2022 - 3rd quarter Form

1 Pharmacy Specialty Overview by Prior Authorization Approval or Denial 3rd Quarter 2022 00122.03.03-1122 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 HEMATOLOGY & ONCOLOGY abiraterone 250 mg ANTINEOPLASTICS Approval 1 3961 HEMATOLOGY & ONCOLOGY abiraterone 250 mg ANTINEOPLASTICS Approval 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL abiraterone 250 mg ANTINEOPLASTICS No Response 1 3965 UNSPECIFIED abiraterone 250 mg ANTINEOPLASTICS No Response 1 3965 UNSPECIFIED abiraterone 250 mg ANTINEOPLASTICS Approval 1 3963 MEDICAL ONCOLOGY abiraterone 500 mg ANTINEOPLASTICS Approval 1 3956 RHEUMATOLOGY Actemra 162MG/0.9ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 RHEUMATOLOGY Actemra SQ 162mg syringe/Actpen autoinjector IMMUNOSUPPRESSIVES/DMARDS Denial 3 3963 RHEUMATOLOGY Actemra SQ 162mg syringe/Actpen autoinjector IMMUNOSUPPRESSIVES/DMARDS Denial 3 3963 RHEUMATOLOGY Actemra SQ 162mg syringe/Actpen autoinjector IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 RHEUMATOLOGY Actemra SQ 162mg syringe/Actpen autoinjector IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 GENERAL PRACTICE Adcirca PULMONARY ARTERIAL HYPERTENSION Denial 1 3956 CARDIOLOGY Adempas PULMONARY ARTERIAL HYPERTENSION No Response 1 3963 CARDIOLOGY Adempas PULMONARY ARTERIAL HYPERTENSION Approval 1 3956 CARDIOLOGY Adempas PULMONARY ARTERIAL HYPERTENSION Approval 2 3956 INTERNAL MEDICINE Adempas PULMONARY ARTERIAL HYPERTENSION No Response 1 3956 INTERNAL MEDICINE Adempas PULMONARY ARTERIAL HYPERTENSION Approval 1 3965 INTERNAL MEDICINE Adempas PULMONARY ARTERIAL HYPERTENSION Approval 1 3963 INTERNAL MEDICINE Afinitor 10 mg ANTINEOPLASTICS No Response 1 3956 UNSPECIFIED Afinitor 10 mg ANTINEOPLASTICS Denial 1 3965 UNSPECIFIED Afinitor 10 mg ANTINEOPLASTICS No Response 1 3956 PULMONARY DISEASES ambrisentan DERMATOLOGICAL AGENTS Approval 1 3963 UNSPECIFIED ambrisentan DERMATOLOGICAL AGENTS Approval 1 3956 UNSPECIFIED ambrisentan DERMATOLOGICAL AGENTS No Response 1 3956 UNSPECIFIED Aranesp HEMATOPOIETIC AGENT Approval 1 3956 FAMILY PRACTICE Aubagio MULTIPLE SCLEROSIS Approval 1 3956 INTERNAL MEDICINE Aubagio MULTIPLE SCLEROSIS No Response 1 3956 INTERNAL MEDICINE Aubagio MULTIPLE SCLEROSIS Approval 1 3963 NEUROLOGY Aubagio MULTIPLE SCLEROSIS Approval 4

2 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 NEUROLOGY Aubagio MULTIPLE SCLEROSIS Denial 1 3956 NEUROLOGY Aubagio MULTIPLE SCLEROSIS No Response 1 3956 NEUROLOGY Aubagio MULTIPLE SCLEROSIS Approval 4 3963 UNSPECIFIED Aubagio MULTIPLE SCLEROSIS Approval 1 3956 NEUROLOGY Aubagio 14MG OR TABS MULTIPLE SCLEROSIS No Response 3 3956 UNSPECIFIED Aubagio 14MG OR TABS MULTIPLE SCLEROSIS Approval 1 3956 NEUROLOGY Aubagio 7MG OR TABS MULTIPLE SCLEROSIS No Response 1 3963 PSYCHIATRY Austedo NEUROLOGICAL AGENTS Approval 1 3963 PSYCHIATRY Austedo 6MG OR TABS NEUROLOGICAL AGENTS Denial 1 3961 PHYSICIAN ASSISTANT, UNSPECIFIED Avonex MULTIPLE SCLEROSIS AGENT Denial 1 3963 UNSPECIFIED Avonex MULTIPLE SCLEROSIS AGENT Approval 1 3961 PHYSICIAN ASSISTANT, UNSPECIFIED Avonex Pen 30MCG/0.5ML IM AJKT MULTIPLE SCLEROSIS No Response 3 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Bafiertam MULTIPLE SCLEROSIS No Response 1 3969 RHEUMATOLOGY Benlysta LUPUS THERAPY Approval 1 3951 UNSPECIFIED Benlysta LUPUS THERAPY Approval 1 3963 DERMATOLOGY bexarotene ANTINEOPLASTICS Approval 1 3963 FAMILY PRACTICE bosentan 62.5 mg VASODILATORS No Response 1 3963 GENERAL PRACTICE bosentan 62.5 mg VASODILATORS No Response 1 3963 PEDIATRICS bosentan 62.5 mg VASODILATORS No Response 1 3963 PSYCHIATRY bosentan 62.5 mg VASODILATORS No Response 1 3956 HEMATOLOGY & ONCOLOGY Bosulif ANTINEOPLASTICS Approval 1 3969 HEMATOLOGY & ONCOLOGY Bosulif ANTINEOPLASTICS No Response 1 3969 HEMATOLOGY & ONCOLOGY Bosulif ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED Bosulif ANTINEOPLASTICS No Response 1 3963 UNSPECIFIED Bosulif ANTINEOPLASTICS Approval 1 3963 MEDICAL ONCOLOGY Braftovi ANTINEOPLASTICS No Response 1 3963 MEDICAL ONCOLOGY Braftovi ANTINEOPLASTICS Approval 2 3963 HEMATOLOGY & ONCOLOGY Cabometyx ANTINEOPLASTICS Approval 2 3951 HEMATOLOGY & ONCOLOGY Cabometyx ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY Cabometyx ANTINEOPLASTICS No Response 1 3963 HEMATOLOGY & ONCOLOGY Cabometyx ANTINEOPLASTICS Denial 1 3963 UNSPECIFIED Cabometyx ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED Cabometyx ANTINEOPLASTICS Approval 2 3956 HEMATOLOGY & ONCOLOGY capecitabine ANTINEOPLASTICS No Response 2 3962 HEMATOLOGY & ONCOLOGY capecitabine ANTINEOPLASTICS No Response 1 3963 HEMATOLOGY & ONCOLOGY capecitabine ANTINEOPLASTICS No Response 2 3956 HEMATOLOGY & ONCOLOGY capecitabine ANTINEOPLASTICS Approval 4

3 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 HEMATOLOGY & ONCOLOGY capecitabine ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY capecitabine ANTINEOPLASTICS Approval 2 3963 INTERNAL MEDICINE capecitabine ANTINEOPLASTICS Approval 4 3951 INTERNAL MEDICINE capecitabine ANTINEOPLASTICS Approval 1 3956 INTERNAL MEDICINE capecitabine ANTINEOPLASTICS Approval 2 3956 LEGAL MEDICINE capecitabine ANTINEOPLASTICS Approval 1 3951 MEDICAL ONCOLOGY capecitabine ANTINEOPLASTICS No Response 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL capecitabine ANTINEOPLASTICS Approval 1 3956 PHYSICIAN, ONCOLOGY, MEDICAL capecitabine ANTINEOPLASTICS Approval 2 3964 UNSPECIFIED capecitabine ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED capecitabine ANTINEOPLASTICS Approval 4 3956 UNSPECIFIED capecitabine ANTINEOPLASTICS Approval 2 3951 HEMATOLOGY & ONCOLOGY Capecitabine 150MG OR TABS ANTINEOPLASTICS No Response 2 3951 HEMATOLOGY & ONCOLOGY Capecitabine 150MG OR TABS ANTINEOPLASTICS Approval 1 3951 HEMATOLOGY & ONCOLOGY Capecitabine 500MG OR TABS ANTINEOPLASTICS No Response 2 3956 HEMATOLOGY & ONCOLOGY Capecitabine 500MG OR TABS ANTINEOPLASTICS Approval 1 3963 INTERNAL MEDICINE Capecitabine 500MG OR TABS ANTINEOPLASTICS No Response 1 3964 UNSPECIFIED Capecitabine 500MG OR TABS ANTINEOPLASTICS No Response 1 3956 INTERNAL MEDICINE cinacalcet THYROID PRODUCT Approval 2 3956 INTERNAL MEDICINE cinacalcet THYROID PRODUCT Denial 1 3963 INTERNAL MEDICINE cinacalcet THYROID PRODUCT Approval 1 3963 INTERNAL MEDICINE cinacalcet THYROID PRODUCT No Response 1 3956 NEPHROLOGY / RENAL MEDICINE cinacalcet THYROID PRODUCT Approval 2 3962 UNSPECIFIED cinacalcet THYROID PRODUCT Approval 1 3951 UNSPECIFIED cinacalcet THYROID PRODUCT Approval 1 3963 UNSPECIFIED cinacalcet THYROID PRODUCT Denial 1 3963 UNSPECIFIED cinacalcet THYROID PRODUCT Approval 1 3963 NEUROLOGY Copaxone 40mg MULTIPLE SCLEROSIS Approval 1 3951 NURSE PRACTITIONER, FAMILY HEALTH Copaxone 40mg MULTIPLE SCLEROSIS No Response 1 3956 UNSPECIFIED Copaxone 40mg MULTIPLE SCLEROSIS Approval 1 3963 UNSPECIFIED Copaxone 40mg MULTIPLE SCLEROSIS Approval 1 3951 NEUROLOGY Copaxone 40MG/ML SC SOSY MULTIPLE SCLEROSIS No Response 1 3956 UNSPECIFIED Copaxone 40MG/ML SC SOSY MULTIPLE SCLEROSIS No Response 1 3969 DERMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS No Response 1 3969 DERMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3956 DERMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Denial 2 3963 DERMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Approval 2

4 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3961 DERMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3951 DERMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3963 DERMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS No Response 1 3963 DERMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Denial 2 3956 INTERNAL MEDICINE Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3956 INTERNAL MEDICINE Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3963 INTERNAL MEDICINE Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Cosentyx ALL OTHER DERMATOLOGICALS Denial 2 3951 NURSE PRACTITIONER, FAMILY HEALTH Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3962 PHYSICIAN ASSISTANT, UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS No Response 2 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Approval 4 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Approval 3 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Denial 2 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3963 RHEUMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Approval 3 3956 RHEUMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Approval 4 3951 RHEUMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Approval 2 3956 RHEUMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS No Response 1 3951 RHEUMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3961 RHEUMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3963 RHEUMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3963 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Approval 4 3956 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Denial 3 3964 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3961 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3956 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Approval 2 3951 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3951 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Denial 2 3963 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS No Response 1 3965 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3956 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS No Response 1 3965 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS No Response 1 3956 INTERNAL MEDICINE COSENTYX 150MG/ML PEN 2PK IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 RHEUMATOLOGY COSENTYX 150MG/ML PEN 2PK IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Cosentyx Sensoready (300 MG) 150MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1

5 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 NEUROLOGY dalfampridine ER MULTIPLE SCLEROSIS Approval 2 3963 NEUROLOGY dalfampridine ER MULTIPLE SCLEROSIS No Response 2 3963 NEUROLOGY dalfampridine ER MULTIPLE SCLEROSIS Approval 3 3956 UNSPECIFIED dalfampridine ER MULTIPLE SCLEROSIS Approval 2 3963 UNSPECIFIED dalfampridine ER MULTIPLE SCLEROSIS Approval 2 3963 UNSPECIFIED dalfampridine ER MULTIPLE SCLEROSIS No Response 2 3962 NURSE PRACTITIONER, PRIMARY CARE deferasirox CHELATING AGENT Approval 1 3956 FAMILY PRACTICE dimethyl fumarate Multiple Sclerosis Approval 1 3951 NEUROLOGY dimethyl fumarate Multiple Sclerosis Denial 1 3951 NEUROLOGY dimethyl fumarate Multiple Sclerosis Approval 2 3965 UNSPECIFIED dimethyl fumarate Multiple Sclerosis Approval 1 3963 UNSPECIFIED dimethyl fumarate Multiple Sclerosis Approval 2 3956 FAMILY PRACTICE Dimethyl Fumarate 120MG OR CPDR Multiple Sclerosis No Response 1 3956 CARDIOLOGY dofetilide CARDIOVASCULAR AGENTS Approval 2 3951 CARDIOLOGY dofetilide CARDIOVASCULAR AGENTS Approval 1 3956 CARDIOLOGY, INTERVENTIONAL dofetilide CARDIOVASCULAR AGENTS No Response 1 3956 CARDIOLOGY, INTERVENTIONAL dofetilide CARDIOVASCULAR AGENTS Denial 1 3956 CARDIOLOGY, INTERVENTIONAL dofetilide CARDIOVASCULAR AGENTS Approval 1 3961 NURSE PRACTITIONER, FAMILY HEALTH dofetilide CARDIOVASCULAR AGENTS Approval 1 3963 PHYSICIAN, CARDIAC ELECTROPHYSIOLOGY dofetilide CARDIOVASCULAR AGENTS No Response 1 3956 PHYSICIAN, CARDIAC ELECTROPHYSIOLOGY dofetilide CARDIOVASCULAR AGENTS No Response 1 3956 PHYSICIAN, CARDIAC ELECTROPHYSIOLOGY dofetilide CARDIOVASCULAR AGENTS Approval 1 3961 PHYSICIAN, CARDIAC ELECTROPHYSIOLOGY dofetilide CARDIOVASCULAR AGENTS No Response 1 3956 UNSPECIFIED dofetilide CARDIOVASCULAR AGENTS No Response 1 3956 UNSPECIFIED Dofetilide 250MCG OR CAPS CARDIOVASCULAR AGENTS Approval 1 3963 PHYSICIAN, CARDIAC ELECTROPHYSIOLOGY Dofetilide 500MCG OR CAPS CARDIOVASCULAR AGENTS No Response 1 3963 PHYSICIAN, CARDIAC ELECTROPHYSIOLOGY Dofetilide 500MCG OR CAPS CARDIOVASCULAR AGENTS Approval 1 3964 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 8 3956 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 4 3969 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3961 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3969 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3961 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3951 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3956 ALLERGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 ALLERGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2

6 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3964 ALLERGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3956 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 4 3963 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 3 3962 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3964 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3965 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3963 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 9 3956 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3956 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 8 3956 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 3 3963 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 7 3961 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3961 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 3 3969 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 2 3965 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3969 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3951 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3951 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 4 3961 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3951 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3965 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3965 EMERGENCY MEDICINE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 2 3956 EMERGENCY MEDICINE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3951 FAMILY PRACTICE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3951 FAMILY PRACTICE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3964 FAMILY PRACTICE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3956 GASTROENTEROLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 GASTROENTEROLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 2 3963 GASTROENTEROLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 GASTROENTEROLOGY, PEDIATRIC Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3956 INTERNAL MEDICINE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 2 3956 INTERNAL MEDICINE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3951 INTERNAL MEDICINE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 2 3963 INTERNAL MEDICINE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 INTERNAL MEDICINE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1

7 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3962 NURSE PRACTITIONER, ACUTE CARE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 NURSE PRACTITIONER, ACUTE CARE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 3 3956 NURSE PRACTITIONER, ACUTE CARE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 NURSE PRACTITIONER, ACUTE CARE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3956 NURSE PRACTITIONER, FAMILY HEALTH Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 2 3956 NURSE PRACTITIONER, FAMILY HEALTH Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3951 NURSE PRACTITIONER, FAMILY HEALTH Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3951 NURSE PRACTITIONER, FAMILY HEALTH Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 NURSE PRACTITIONER, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3956 NURSE PRACTITIONER, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3956 OTOLARYNGOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 OTOLARYNGOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 6 3963 OTOLARYNGOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3951 OTOLARYNGOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3963 OTOLARYNGOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 OTOLARYNGOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3956 OTOLARYNGOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3951 PEDIATRICS Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3956 PEDIATRICS Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 4 3956 PEDIATRICS Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3951 PEDIATRICS Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3951 PEDIATRICS Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3962 PEDIATRICS Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 PEDIATRICS Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3969 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 6 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 7 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 12 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 10 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 10 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 4 3964 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3965 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3962 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2

8 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3961 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3956 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3956 PULMONARY DISEASES Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 PULMONARY DISEASES Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 PULMONARY DISEASES Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 PULMONARY DISEASES Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 8 3956 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 8 3956 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 13 3963 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 15 3956 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 5 3969 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3951 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 10 3963 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 12 3951 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 4 3965 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 3 3962 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3962 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3965 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3951 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 5 3965 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3964 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3951 UNSPECIFIED Dupixent 200MG/1.14ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 DERMATOLOGY Dupixent 200MG/1.14ML SC SOSY ALL OTHER DERMATOLOGICALS Denial 2 3956 DERMATOLOGY Dupixent 200MG/1.14ML SC SOSY ALL OTHER DERMATOLOGICALS Denial 1 3963 DERMATOLOGY DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3956 DERMATOLOGY DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 NURSE PRACTITIONER, ACUTE CARE DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 NURSE PRACTITIONER, ACUTE CARE DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 UNSPECIFIED DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3963 UNSPECIFIED DUPIXENT 300MG/2ML PFS 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 ALLERGY & IMMUNOLOGY Dupixent 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1

9 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 ALLERGY & IMMUNOLOGY Dupixent 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 INTERNAL MEDICINE Dupixent 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 NURSE PRACTITIONER, UNSPECIFIED Dupixent 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 3 3963 OTOLARYNGOLOGY Dupixent 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 PEDIATRICS Dupixent 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 3 3956 UNSPECIFIED Dupixent 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 UNSPECIFIED Dupixent 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3963 ALLERGY & IMMUNOLOGY Dupixent 300MG/2ML SC SOSY IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 ALLERGY & IMMUNOLOGY Dupixent 300MG/2ML SC SOSY IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 DERMATOLOGY Dupixent 300MG/2ML SC SOSY IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3969 DERMATOLOGY Dupixent 300MG/2ML SC SOSY IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Dupixent 300MG/2ML SC SOSY IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3963 NURSE PRACTITIONER, FAMILY HEALTH Dupixent 300MG/2ML SC SOSY IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 OTOLARYNGOLOGY Dupixent 300MG/2ML SC SOSY IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent 300MG/2ML SC SOSY IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent 300MG/2ML SC SOSY IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent 300MG/2ML SC SOSY IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 UNSPECIFIED Dupixent 300MG/2ML SC SOSY IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 ALLERGY & IMMUNOLOGY dupixent pen 300 mg/2 mLmg/ml pen injector IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 INTERNAL MEDICINE dupixent pen 300 mg/2 mLmg/ml pen injector IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3964 ALLERGY & IMMUNOLOGY Dupixent Syn 300 IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3951 UNSPECIFIED Eligard 7.5MG SC KIT ANTINEOPLASTICS Denial 1 3963 DERMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 DERMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 FAMILY PRACTICE Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 FAMILY PRACTICE Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 INTERNAL MEDICINE Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 5 3956 INTERNAL MEDICINE Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 5 3956 INTERNAL MEDICINE Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3951 INTERNAL MEDICINE Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 12 3956 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 24 3956 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Denial 4 3963 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 4 3963 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3951 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 3

10 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 5 3961 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3964 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3965 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3956 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 8 3969 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3964 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3965 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 5 3951 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3969 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Denial 4 3963 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 4 3956 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 7 3962 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY Enbrel SureClick 50MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3969 NEUROLOGY, PEDIATRIC Epidiolex ANTICONVULSANTS Denial 2 3963 NEUROLOGY, PEDIATRIC Epidiolex ANTICONVULSANTS Approval 2 3963 UNSPECIFIED Epidiolex ANTICONVULSANTS Denial 4 3951 UNSPECIFIED Epidiolex ANTICONVULSANTS Approval 2 3956 DERMATOLOGY Erivedge ANTINEOPLASTICS No Response 1 3964 UNSPECIFIED Erleada ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED Erleada ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY everolimus 10 mg ANTINEOPLASTICS Approval 1 3963 INTERNAL MEDICINE everolimus 10 mg ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED everolimus 10 mg ANTINEOPLASTICS Approval 1 3965 UNSPECIFIED everolimus 10 mg ANTINEOPLASTICS Denial 1 3965 UNSPECIFIED everolimus 10 mg ANTINEOPLASTICS Approval 1 3964 HEMATOLOGY & ONCOLOGY everolimus 5 mg ANTINEOPLASTICS Approval 1 3951 PULMONARY DISEASES Fasenra RESPIRATORY AGENTS Approval 1 3963 PULMONARY DISEASES Fasenra RESPIRATORY AGENTS Denial 2 3951 UNSPECIFIED Fasenra RESPIRATORY AGENTS No Response 1 3951 UNSPECIFIED Fasenra RESPIRATORY AGENTS Denial 1 3951 UNSPECIFIED Fasenra RESPIRATORY AGENTS Approval 2 3963 NURSE PRACTITIONER, UNSPECIFIED Forteo OSTEOPOROSIS Approval 1

11 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Forteo OSTEOPOROSIS Approval 1 3963 UNSPECIFIED Forteo OSTEOPOROSIS No Response 1 3951 HEMATOLOGY & ONCOLOGY fulvestrant ANTINEOPLASTICS Approval 2 3963 HEMATOLOGY & ONCOLOGY fulvestrant ANTINEOPLASTICS Approval 2 3963 ENDOCRINOLOGY, PEDIATRIC Genotropin GROWTH HORMONE THERAPY No Response 1 3963 ENDOCRINOLOGY, PEDIATRIC Genotropin GROWTH HORMONE THERAPY Approval 1 3963 PEDIATRICS Genotropin GROWTH HORMONE THERAPY Approval 2 3961 NEUROLOGY Gilenya MULTIPLE SCLEROSIS Approval 1 3963 NEUROLOGY Gilenya MULTIPLE SCLEROSIS Approval 1 3963 UNSPECIFIED Gilenya MULTIPLE SCLEROSIS Approval 2 3961 UNSPECIFIED Gilenya MULTIPLE SCLEROSIS Approval 1 3963 UNSPECIFIED Gilenya MULTIPLE SCLEROSIS No Response 1 3956 UNSPECIFIED Gilenya MULTIPLE SCLEROSIS Approval 1 3963 UNSPECIFIED Gilenya 0.5MG OR CAPS MULTIPLE SCLEROSIS No Response 1 3956 NEUROLOGY glatiramer 40 mg/mLmg/ml syringe MULTIPLE SCLEROSIS No Response 1 3956 NEUROLOGY glatiramer acetate 40mg MULTIPLE SCLEROSIS No Response 2 3956 NEUROLOGY glatiramer acetate 40mg MULTIPLE SCLEROSIS Approval 2 3961 NEUROLOGY glatiramer acetate 40mg MULTIPLE SCLEROSIS Denial 1 3951 NEUROLOGY glatiramer acetate 40mg MULTIPLE SCLEROSIS Approval 1 3956 UNSPECIFIED glatiramer acetate 40mg MULTIPLE SCLEROSIS Approval 3 3956 UNSPECIFIED glatiramer acetate 40mg MULTIPLE SCLEROSIS No Response 1 3956 NEUROLOGY Glatiramer Acetate 40MG/ML SC SOSY MULTIPLE SCLEROSIS Approval 1 3956 UNSPECIFIED Glatiramer Acetate 40MG/ML SC SOSY MULTIPLE SCLEROSIS No Response 1 3963 UNSPECIFIED Glatopa MULTIPLE SCLEROSIS AGENT Approval 1 3956 NURSE PRACTITIONER, ADULT HEALTH Hetlioz SEDATIVES/HYPNOTICS Denial 1 3956 PSYCHIATRY Hetlioz SEDATIVES/HYPNOTICS Denial 1 3956 UNSPECIFIED Hetlioz SEDATIVES/HYPNOTICS Denial 3 3963 ALLERGY & IMMUNOLOGY Hizentra IMMUNE GLOBULIN Approval 1 3963 ALLERGY & IMMUNOLOGY Hizentra IMMUNE GLOBULIN No Response 1 3969 ALLERGY & IMMUNOLOGY Hizentra IMMUNE GLOBULIN Approval 1 3963 UNSPECIFIED Hizentra IMMUNE GLOBULIN Denial 1 3963 UNSPECIFIED Hizentra IMMUNE GLOBULIN Approval 1 3961 DERMATOLOGY Humira ANTIARTHRITICS Approval 1 3956 DERMATOLOGY Humira ANTIARTHRITICS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Humira ANTIARTHRITICS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Humira ANTIARTHRITICS Approval 1 3963 RHEUMATOLOGY Humira ANTIARTHRITICS Approval 1

12 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 RHEUMATOLOGY Humira ANTIARTHRITICS Approval 2 3963 UNSPECIFIED Humira ANTIARTHRITICS Approval 2 3963 GASTROENTEROLOGY Humira 20 mg ANTIRHEUMATIC Denial 1 3963 DERMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3956 DERMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 4 3956 DERMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 4 3963 DERMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3951 DERMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3961 DERMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 EMERGENCY MEDICINE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 EMERGENCY MEDICINE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 FAMILY PRACTICE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 FAMILY PRACTICE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3951 FAMILY PRACTICE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 FAMILY PRACTICE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 FAMILY PRACTICE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 6 3963 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 4 3956 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 15 3951 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 3 3963 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 5 3956 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 4 3951 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3964 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3964 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3951 GASTROENTEROLOGY, PEDIATRIC Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3964 INTERNAL MEDICINE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 INTERNAL MEDICINE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 INTERNAL MEDICINE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 INTERNAL MEDICINE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 INTERNAL MEDICINE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 INTERNAL MEDICINE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 NEPHROLOGY / RENAL MEDICINE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3956 NURSE PRACTITIONER, FAMILY HEALTH Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 4 3956 NURSE PRACTITIONER, FAMILY HEALTH Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 3

13 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 NURSE PRACTITIONER, FAMILY HEALTH Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 NURSE PRACTITIONER, FAMILY HEALTH Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3951 NURSE PRACTITIONER, UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3951 NURSE PRACTITIONER, UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3964 NURSE PRACTITIONER, UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3969 NURSE PRACTITIONER, UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 NURSE PRACTITIONER, UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3969 NURSE PRACTITIONER, UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3961 PHYSICIAN ASSISTANT, UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 10 3963 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 6 3956 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 5 3956 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 19 3963 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 23 3965 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3961 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3951 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 7 3951 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 9 3969 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 3 3965 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3962 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3962 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3962 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3951 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 3 3956 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 16 3963 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 4 3963 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 20 3965 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3951 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 11 3956 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 8 3969 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1

14 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3969 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 4 3961 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 3 3951 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3961 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3964 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3962 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3965 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 GASTROENTEROLOGY Humira 40mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 FAMILY PRACTICE Humira 40MG/0.4ML SC PSKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED Humira 40MG/0.8ML SC PSKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 DERMATOLOGY Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3961 GASTROENTEROLOGY Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 NURSE PRACTITIONER, FAMILY HEALTH Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Denial 3 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3961 PHYSICIAN ASSISTANT, UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS No Response 3 3956 UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3961 UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 DERMATOLOGY Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 GASTROENTEROLOGY Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3956 GASTROENTEROLOGY Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 GASTROENTEROLOGY Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 OBSTETRICS & GYNECOLOGY Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3965 PHYSICIAN ASSISTANT, UNSPECIFIED Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3961 PHYSICIAN ASSISTANT, UNSPECIFIED Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3961 PHYSICIAN ASSISTANT, UNSPECIFIED Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3964 UNSPECIFIED PHYSICIAN, INTERN/RESIDENT/FEL­ LOW, UNSPECIFIED Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Denial 2

15 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 UNSPECIFIED Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 UNSPECIFIED Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3951 UNSPECIFIED Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 UNSPECIFIED Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 UNSPECIFIED Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 DERMATOLOGY Humira Crohns/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 DERMATOLOGY Humira Crohns/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 GASTROENTEROLOGY Humira Crohns/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3961 GASTROENTEROLOGY Humira Crohns/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 NURSE PRACTITIONER, FAMILY HEALTH Humira Crohns/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Humira Crohns/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3965 PHYSICIAN ASSISTANT, UNSPECIFIED Humira Crohns/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 UNSPECIFIED Humira Crohns/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3951 UNSPECIFIED Humira Crohns/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED Humira Crohns/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3956 UNSPECIFIED Humira Crohns/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3964 UNSPECIFIED Humira Crohns/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED Humira Crohns/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 UNSPECIFIED Humira Crohns/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3962 UNSPECIFIED Humira Crohns/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 GASTROENTEROLOGY Humira Crohn’s/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 GASTROENTEROLOGY Humira Crohn’s/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3964 RHEUMATOLOGY Humira Ped. Crohns Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED Humira Ped. Crohn’s Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3969 UNSPECIFIED Humira Ped. Crohn’s Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 UNSPECIFIED Humira Ped. Crohn’s Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED Humira Ped. UC Starter Pack + 80 mg IMMUNOSUPPRESSIVES/DMARDS No Response 3 3963 UNSPECIFIED Humira Ped. UC Starter Pack + 80 mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3965 UNSPECIFIED Humira Ped. UC Starter Pack + 80 mg IMMUNOSUPPRESSIVES/DMARDS No Response 3 3962 UNSPECIFIED Humira Ped. UC Starter Pack + 80 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3964 UNSPECIFIED Humira Ped. UC Starter Pack + 80 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3961 UNSPECIFIED Humira Ped. UC Starter Pack + 80 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 GASTROENTEROLOGY Humira Pen 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 3 3951 GASTROENTEROLOGY, PEDIATRIC Humira Pen 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 NURSE PRACTITIONER, FAMILY HEALTH Humira Pen 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY Humira Pen 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 RHEUMATOLOGY Humira Pen 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 3

16 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 UNSPECIFIED Humira Pen 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 UNSPECIFIED Humira Pen 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS Approval 1 3969 UNSPECIFIED Humira Pen 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Humira Pen 40MG/0.8ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 GASTROENTEROLOGY Humira Pen 80MG/0.8ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 GASTROENTEROLOGY Humira Pen-CD/UC/HS Starter 80MG/0.8ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS Denial 2 3951 NURSE PRACTITIONER, FAMILY HEALTH Humira Pen-CD/UC/HS Starter 80MG/0.8ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 OBSTETRICS & GYNECOLOGY Humira Pen-CD/UC/HS Starter 80MG/0.8ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 DERMATOLOGY Humira Pen-Psor/Uveit Starter 80 MG/0.8ML &40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 DERMATOLOGY Humira Pen-Psor/Uveit Starter 80 MG/0.8ML &40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Humira Pen-Psor/Uveit Starter 80 MG/0.8ML &40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY Humira PsO/UV/Adolescent HS + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 DERMATOLOGY Humira PsO/UV/Adolescent HS + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 FAMILY PRACTICE Humira PsO/UV/Adolescent HS + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Humira PsO/UV/Adolescent HS + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED Humira PsO/UV/Adolescent HS + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED Humira PsO/UV/Adolescent HS + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 DERMATOLOGY Humira(CF) Pen 40 mg/0.4 mL subcutaneous kit IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Humira(CF) Pen 40 mg/0.4 mL subcutaneous kit IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 ALLERGY & IMMUNOLOGY HyQvia IMMUNE GLOBULIN Approval 1 3956 ALLERGY & IMMUNOLOGY HyQvia IMMUNE GLOBULIN Approval 2 3956 ALLERGY & IMMUNOLOGY HyQvia IMMUNE GLOBULIN No Response 1 3963 ALLERGY & IMMUNOLOGY HyQvia IMMUNE GLOBULIN No Response 1 3956 HEMATOLOGY & ONCOLOGY HyQvia IMMUNE GLOBULIN Approval 1 3956 HEMATOLOGY & ONCOLOGY HyQvia IMMUNE GLOBULIN Denial 1 3956 PEDIATRICS HyQvia IMMUNE GLOBULIN Approval 1 3963 HEMATOLOGY Ibrance ANTINEOPLASTICS No Response 1 3956 HEMATOLOGY Ibrance ANTINEOPLASTICS No Response 1 3956 HEMATOLOGY Ibrance ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY Ibrance ANTINEOPLASTICS Approval 1 3951 HEMATOLOGY & ONCOLOGY Ibrance ANTINEOPLASTICS Approval 2 3963 HEMATOLOGY & ONCOLOGY Ibrance ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY Ibrance ANTINEOPLASTICS Approval 1 3969 HEMATOLOGY & ONCOLOGY Ibrance ANTINEOPLASTICS Approval 1 3963 INTERNAL MEDICINE Ibrance ANTINEOPLASTICS Approval 1

17 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3964 UNSPECIFIED Ibrance ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY, PEDIATRIC Iclusig ANTINEOPLASTICS Approval 1 3963 RHEUMATOLOGY Ilaris ANTIRHEUMATIC Approval 4 3951 UNSPECIFIED Ilaris ANTIRHEUMATIC Denial 4 3951 UNSPECIFIED Ilaris 150MG/ML SC SOLN ANTIRHEUMATIC Denial 1 3951 HEMATOLOGY imatinib mesylate ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY imatinib mesylate ANTINEOPLASTICS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH imatinib mesylate ANTINEOPLASTICS Approval 1 3951 UNSPECIFIED imatinib mesylate ANTINEOPLASTICS Denial 1 3951 UNSPECIFIED imatinib mesylate ANTINEOPLASTICS Approval 2 3956 UNSPECIFIED imatinib mesylate ANTINEOPLASTICS Approval 3 3963 UNSPECIFIED imatinib mesylate ANTINEOPLASTICS Approval 1 3964 UNSPECIFIED imatinib mesylate ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED imatinib mesylate ANTINEOPLASTICS No Response 2 3951 UNSPECIFIED imatinib mesylate ANTINEOPLASTICS No Response 1 3951 UNSPECIFIED Imatinib Mesylate 400MG OR TABS ANTINEOPLASTICS No Response 2 3951 HEMATOLOGY & ONCOLOGY Imbruvica ANTINEOPLASTICS Approval 2 3964 HEMATOLOGY & ONCOLOGY Imbruvica ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY Imbruvica ANTINEOPLASTICS Approval 2 3963 HEMATOLOGY & ONCOLOGY Imbruvica ANTINEOPLASTICS No Response 1 3956 HEMATOLOGY & ONCOLOGY Imbruvica ANTINEOPLASTICS Approval 4 3961 HEMATOLOGY & ONCOLOGY Imbruvica ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY Imbruvica 420MG OR TABS ANTINEOPLASTICS No Response 1 3964 HEMATOLOGY & ONCOLOGY Inlyta ANTINEOPLASTICS No Response 1 3963 HEMATOLOGY & ONCOLOGY Inlyta ANTINEOPLASTICS Approval 1 3951 MEDICAL ONCOLOGY Inlyta ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY Jakafi ANTINEOPLASTICS Approval 1 3961 HEMATOLOGY & ONCOLOGY Jakafi ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY Jakafi ANTINEOPLASTICS Approval 2 3963 HEMATOLOGY & ONCOLOGY Jakafi ANTINEOPLASTICS Approval 2 3956 HEMATOLOGY & ONCOLOGY Jakafi ANTINEOPLASTICS No Response 1 3956 INTERNAL MEDICINE Jakafi ANTINEOPLASTICS Approval 2 3956 PHYSICIAN, ONCOLOGY, MEDICAL Jakafi ANTINEOPLASTICS Approval 2 3963 UNSPECIFIED Jakafi ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED Kalydeco MISCELLANEOUS Approval 1 3963 UNSPECIFIED Kalydeco 150MG OR TABS MISCELLANEOUS No Response 2 3963 NEUROLOGY Kesimpta MULTIPLE SCLEROSIS AGENT Approval 1

18 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 NEUROLOGY Kesimpta MULTIPLE SCLEROSIS AGENT Approval 1 3963 UNSPECIFIED Kesimpta MULTIPLE SCLEROSIS AGENT Approval 3 3956 NEUROLOGY Kesimpta 20MG/0.4ML SC SOAJ MULTIPLE SCLEROSIS AGENT No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Kesimpta 20MG/0.4ML SC SOAJ MULTIPLE SCLEROSIS AGENT No Response 2 3956 INTERNAL MEDICINE Kevzara IMMUNOSUPPRESSIVES/DMARDS Denial 2 3969 RHEUMATOLOGY Kevzara IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY Kevzara IMMUNOSUPPRESSIVES/DMARDS No Response 1 3969 RHEUMATOLOGY Kevzara IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 RHEUMATOLOGY Kevzara IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 RHEUMATOLOGY Kevzara IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 RHEUMATOLOGY Kevzara IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 UNSPECIFIED Kevzara IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED Kevzara 150MG/1.14ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 HEMATOLOGY & ONCOLOGY Kisqali ANTINEOPLASTICS Approval 1 3956 PHYSICIAN, ONCOLOGY, MEDICAL Kisqali ANTINEOPLASTICS Approval 1 3951 PHYSICIAN, ONCOLOGY, MEDICAL Kisqali ANTINEOPLASTICS No Response 1 3956 PHYSICIAN, ONCOLOGY, MEDICAL Kisqali ANTINEOPLASTICS No Response 1 3956 UNSPECIFIED Kisqali ANTINEOPLASTICS Approval 1 3964 PHYSICIAN, ONCOLOGY, MEDICAL Kisqali Pak Femara ANTINEOPLASTICS Approval 1 3964 UNSPECIFIED lapatinib ANTINEOPLASTICS Approval 1 3964 UNSPECIFIED Lapatinib Ditosylate 250MG OR TABS ANTINEOPLASTICS No Response 1 3963 HEMATOLOGY lenalidomide ANTINEOPLASTICS Approval 1 3951 HEMATOLOGY & ONCOLOGY lenalidomide ANTINEOPLASTICS No Response 1 3962 UNSPECIFIED lenalidomide ANTINEOPLASTICS No Response 1 3956 HEMATOLOGY & ONCOLOGY Lenvima ANTINEOPLASTICS Approval 2 3963 HEMATOLOGY & ONCOLOGY Lenvima ANTINEOPLASTICS Approval 1 3964 HEMATOLOGY & ONCOLOGY Lenvima ANTINEOPLASTICS Approval 1 3951 HEMATOLOGY & ONCOLOGY Lenvima ANTINEOPLASTICS No Response 1 3956 UNSPECIFIED leuprolide 1 mg/0.2 mLmg/ml kit HORMONES No Response 1 3963 UNSPECIFIED leuprolide kit HORMONES No Response 5 3956 UNSPECIFIED leuprolide kit HORMONES No Response 2 3961 UNSPECIFIED leuprolide kit HORMONES No Response 1 3963 INTERNAL MEDICINE Lonsurf 20-8.19MG OR TABS ANTINEOPLASTICS No Response 1 3951 OBSTETRICS & GYNECOLOGY Lupron Depot (1-Month) 3.75MG IM KIT HORMONES/HORMONE MODIFIERS No Response 1 3956 OBSTETRICS & GYNECOLOGY Lupron Depot (3-Month) 11.25MG IM KIT HORMONES/HORMONE MODIFIERS Denial 1 3951 OBSTETRICS & GYNECOLOGY Lupron Depot 3.75 mg HORMONES/HORMONE MODIFIERS Approval 1 3963 OBSTETRICS & GYNECOLOGY Lupron Depot 3.75 mg HORMONES/HORMONE MODIFIERS No Response 1

19 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 HEMATOLOGY & ONCOLOGY Lynparza ANTINEOPLASTICS Approval 1 3956 MEDICAL ONCOLOGY Lynparza ANTINEOPLASTICS No Response 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL Lynparza ANTINEOPLASTICS No Response 1 3963 UNSPECIFIED Lynparza ANTINEOPLASTICS No Response 1 3963 UNSPECIFIED Lynparza ANTINEOPLASTICS Approval 2 3956 UNSPECIFIED Lynparza ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED Mavenclad MULTIPLE SCLEROSIS AGENT Denial 1 3963 UNSPECIFIED Mavenclad MULTIPLE SCLEROSIS AGENT Approval 1 3956 UNSPECIFIED Mavenclad (6 Tabs) 10MG OR TBPK MULTIPLE SCLEROSIS AGENT No Response 1 3965 UNSPECIFIED Mavenclad (6 Tabs) 10MG OR TBPK MULTIPLE SCLEROSIS AGENT Denial 1 3963 MEDICAL ONCOLOGY Mektovi ANTINEOPLASTICS No Response 1 3963 MEDICAL ONCOLOGY Mektovi ANTINEOPLASTICS Approval 2 3951 HEMATOLOGY & ONCOLOGY Nexavar ANTINEOPLASTICS Denial 1 3956 PHYSICIAN, ONCOLOGY, MEDICAL Nexavar ANTINEOPLASTICS Approval 1 3951 HEMATOLOGY Nivestym COLONY STIMULATING FACTORS Approval 1 3963 INTERNAL MEDICINE Nivestym COLONY STIMULATING FACTORS Denial 1 3963 OBSTETRICS & GYNECOLOGY Nivestym COLONY STIMULATING FACTORS Denial 1 3956 UNSPECIFIED Nivestym COLONY STIMULATING FACTORS Approval 1 3956 EMERGENCY MEDICINE Norditropin GROWTH HORMONE THERAPY Denial 1 3967 ENDOCRINOLOGY, PEDIATRIC Norditropin GROWTH HORMONE THERAPY Approval 1 3956 INTERNAL MEDICINE Norditropin GROWTH HORMONE THERAPY Approval 1 3956 PEDIATRICS Norditropin GROWTH HORMONE THERAPY Approval 1 3963 UNSPECIFIED Norditropin GROWTH HORMONE THERAPY Approval 2 3962 UNSPECIFIED Norditropin GROWTH HORMONE THERAPY Approval 1 3964 UNSPECIFIED Norditropin GROWTH HORMONE THERAPY No Response 1 3956 UNSPECIFIED Norditropin GROWTH HORMONE THERAPY Approval 1 3964 UNSPECIFIED Norditropin GROWTH HORMONE THERAPY Approval 1 3951 UNSPECIFIED Norditropin GROWTH HORMONE THERAPY No Response 2 3963 MEDICAL ONCOLOGY Nubeqa ANTINEOPLASTICS Approval 1 3956 ALLERGY & IMMUNOLOGY Nucala MISCELLANEOUS Denial 1 3963 ALLERGY & IMMUNOLOGY Nucala MISCELLANEOUS Denial 1 3951 ALLERGY & IMMUNOLOGY Nucala MISCELLANEOUS No Response 1 3961 ALLERGY & IMMUNOLOGY Nucala MISCELLANEOUS Denial 1 3956 INTERNAL MEDICINE Nucala MISCELLANEOUS Denial 1 3963 INTERNAL MEDICINE Nucala MISCELLANEOUS Denial 1 3963 NEUROLOGY Nucala MISCELLANEOUS Approval 1 3956 NEUROLOGY Nucala MISCELLANEOUS Denial 1

20 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 OTOLARYNGOLOGY Nucala MISCELLANEOUS Denial 1 3963 PULMONARY DISEASES Nucala MISCELLANEOUS Approval 1 3963 PULMONARY DISEASES Nucala MISCELLANEOUS Denial 1 3956 PULMONARY DISEASES Nucala MISCELLANEOUS Denial 1 3956 PULMONARY DISEASES Nucala MISCELLANEOUS No Response 1 3956 PULMONARY DISEASES Nucala MISCELLANEOUS Approval 1 3967 PULMONARY DISEASES Nucala MISCELLANEOUS Approval 1 3951 PULMONARY DISEASES Nucala MISCELLANEOUS Denial 1 3963 UNSPECIFIED Nucala MISCELLANEOUS Denial 1 3951 UNSPECIFIED Nucala MISCELLANEOUS Denial 2 3963 UNSPECIFIED Nucala MISCELLANEOUS No Response 3 3956 UNSPECIFIED Nucala MISCELLANEOUS No Response 2 3956 UNSPECIFIED Nucala MISCELLANEOUS Denial 1 3956 INTERNAL MEDICINE Nucala 100MG SC SOLR MISCELLANEOUS Denial 1 3956 PULMONARY DISEASES Nucala 100MG/ML SC SOSY MISCELLANEOUS No Response 1 3963 GASTROENTEROLOGY Ocaliva PRIMARY BILIARY CHOLANGITIS Denial 1 3963 GASTROENTEROLOGY Ocaliva PRIMARY BILIARY CHOLANGITIS Approval 1 3956 INTERNAL MEDICINE Ofev TYROSINE KINASE INHIBITOR Approval 1 3963 PULMONARY DISEASES Ofev TYROSINE KINASE INHIBITOR Approval 2 3956 PULMONARY DISEASES Ofev TYROSINE KINASE INHIBITOR Denial 3 3963 PULMONARY DISEASES Ofev TYROSINE KINASE INHIBITOR No Response 1 3963 UNSPECIFIED Ofev TYROSINE KINASE INHIBITOR Approval 1 3963 UNSPECIFIED Onureg ANTINEOPLASTICS Approval 1 3963 CARDIOLOGY Opsumit PULMONARY ARTERIAL HYPERTENSION Approval 2 3951 CARDIOLOGY Opsumit PULMONARY ARTERIAL HYPERTENSION Approval 1 3956 CARDIOLOGY Opsumit PULMONARY ARTERIAL HYPERTENSION Approval 1 3963 GENERAL PRACTICE Opsumit PULMONARY ARTERIAL HYPERTENSION No Response 1 3963 GENERAL PRACTICE Opsumit PULMONARY ARTERIAL HYPERTENSION Approval 1 3963 INTERNAL MEDICINE Opsumit PULMONARY ARTERIAL HYPERTENSION Approval 2 3956 INTERNAL MEDICINE Opsumit PULMONARY ARTERIAL HYPERTENSION Approval 1 3963 PULMONARY DISEASES Opsumit PULMONARY ARTERIAL HYPERTENSION Approval 1 3956 PULMONARY DISEASES Opsumit PULMONARY ARTERIAL HYPERTENSION Approval 1 3951 PULMONARY DISEASES Opsumit PULMONARY ARTERIAL HYPERTENSION Approval 1 3963 UNSPECIFIED Opsumit PULMONARY ARTERIAL HYPERTENSION No Response 1 3956 CARDIOLOGY Orenitram VASODILATORS Approval 1 3962 NURSE PRACTITIONER, PEDIATRIC CARE Orkambi CYSTIC FIBROSIS AGENTS Approval 1 3963 UNSPECIFIED Otezla (Apremilast) 30 MG Oral Tablet IMMUNOSUPPRESSIVES/DMARDS No Response 1

21 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 CLINICAL NURSE SPECIALIST, FAMILY HEALTH Otezla 10 & 20 & 30MG OR TBPK IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 DERMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3956 DERMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 7 3956 DERMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3964 DERMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 DERMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 DERMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 6 3956 FAMILY PRACTICE Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 INTERNAL MEDICINE Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 INTERNAL MEDICINE Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 INTERNAL MEDICINE Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3951 INTERNAL MEDICINE Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 INTERNAL MEDICINE Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 NURSE PRACTITIONER, FAMILY HEALTH Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3951 NURSE PRACTITIONER, UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 NURSE PRACTITIONER, UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 4 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 RHEUMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 4 3956 RHEUMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3962 RHEUMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3964 RHEUMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 5 3963 RHEUMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 8 3956 UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 5 3961 UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3965 UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 2

22 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3965 UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3962 UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 DERMATOLOGY Otezla 30MG OR TABS IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 INTERNAL MEDICINE Otezla 30MG OR TABS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 INTERNAL MEDICINE Otezla 30MG OR TABS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Otezla 30MG OR TABS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, UNSPECIFIED Otezla 30MG OR TABS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Otezla 30MG OR TABS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 RHEUMATOLOGY Otezla 30MG OR TABS IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED Otezla 30MG OR TABS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 DERMATOLOGY Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 FAMILY PRACTICE Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 FAMILY PRACTICE Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 FAMILY PRACTICE Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3961 NURSE PRACTITIONER, FAMILY HEALTH Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 UNSPECIFIED Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3951 UNSPECIFIED Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 UNSPECIFIED Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 RHEUMATOLOGY Otrexup ANTIARTHRITICS Denial 1 3956 UNSPECIFIED pirfenidone IDIOPATHIC PULMONARY FIBROSIS Approval 1 3951 UNSPECIFIED pirfenidone IDIOPATHIC PULMONARY FIBROSIS Denial 1 3951 UNSPECIFIED pirfenidone IDIOPATHIC PULMONARY FIBROSIS Approval 1 3963 NEUROLOGY Plegridy MULTIPLE SCLEROSIS AGENT Denial 1 3963 UNSPECIFIED Plegridy MULTIPLE SCLEROSIS AGENT Approval 1 3963 HEMATOLOGY & ONCOLOGY Pomalyst ANTINEOPLASTICS No Response 2 3963 HEMATOLOGY & ONCOLOGY Pomalyst ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY Pomalyst ANTINEOPLASTICS Approval 2 3951 NURSE PRACTITIONER, ACUTE CARE Pomalyst ANTINEOPLASTICS Approval 1 3956 CARDIOLOGY Praluent LIPOTROPICS Denial 12 3956 CARDIOLOGY Praluent LIPOTROPICS No Response 1 3951 CARDIOLOGY Praluent LIPOTROPICS Denial 6 3963 CARDIOLOGY Praluent LIPOTROPICS No Response 2

23 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 CARDIOLOGY Praluent LIPOTROPICS Denial 7 3963 CARDIOLOGY Praluent LIPOTROPICS Approval 5 3956 CARDIOLOGY Praluent LIPOTROPICS Approval 2 3965 CARDIOLOGY Praluent LIPOTROPICS No Response 1 3965 CARDIOLOGY Praluent LIPOTROPICS Approval 1 3951 CARDIOLOGY Praluent LIPOTROPICS No Response 2 3961 CARDIOLOGY Praluent LIPOTROPICS Denial 4 3951 CARDIOLOGY Praluent LIPOTROPICS Approval 1 3956 CARDIOLOGY, INTERVENTIONAL Praluent LIPOTROPICS No Response 1 3956 CARDIOLOGY, INTERVENTIONAL Praluent LIPOTROPICS Approval 1 3956 CARDIOLOGY, INTERVENTIONAL Praluent LIPOTROPICS Denial 1 3963 CARDIOLOGY, INTERVENTIONAL Praluent LIPOTROPICS Approval 1 3963 CARDIOLOGY, INTERVENTIONAL Praluent LIPOTROPICS Denial 2 3964 FAMILY PRACTICE Praluent LIPOTROPICS Denial 5 3963 FAMILY PRACTICE Praluent LIPOTROPICS No Response 1 3963 FAMILY PRACTICE Praluent LIPOTROPICS Denial 4 3951 FAMILY PRACTICE Praluent LIPOTROPICS Denial 2 3956 FAMILY PRACTICE Praluent LIPOTROPICS Approval 1 3956 FAMILY PRACTICE Praluent LIPOTROPICS Denial 1 3961 FAMILY PRACTICE Praluent LIPOTROPICS Denial 1 3962 FAMILY PRACTICE Praluent LIPOTROPICS Denial 1 3963 INTERNAL MEDICINE Praluent LIPOTROPICS Approval 1 3956 INTERNAL MEDICINE Praluent LIPOTROPICS Approval 1 3963 INTERNAL MEDICINE Praluent LIPOTROPICS Denial 5 3951 INTERNAL MEDICINE Praluent LIPOTROPICS Denial 2 3956 INTERNAL MEDICINE Praluent LIPOTROPICS Denial 3 3964 INTERNAL MEDICINE Praluent LIPOTROPICS Approval 1 3956 NURSE PRACTITIONER, ACUTE CARE Praluent LIPOTROPICS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Praluent LIPOTROPICS Denial 5 3963 NURSE PRACTITIONER, FAMILY HEALTH Praluent LIPOTROPICS Approval 1 3956 NURSE PRACTITIONER, PRIMARY CARE Praluent LIPOTROPICS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED Praluent LIPOTROPICS Denial 1 3956 NURSE PRACTITIONER, UNSPECIFIED Praluent LIPOTROPICS No Response 1 3963 NURSE PRACTITIONER, UNSPECIFIED Praluent LIPOTROPICS Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED Praluent LIPOTROPICS Denial 1 3961 PHYSICIAN ASSISTANT, UNSPECIFIED Praluent LIPOTROPICS No Response 1 3963 UNSPECIFIED Praluent LIPOTROPICS Denial 9

24 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 UNSPECIFIED Praluent LIPOTROPICS Denial 10 3969 UNSPECIFIED Praluent LIPOTROPICS Approval 1 3964 UNSPECIFIED Praluent LIPOTROPICS Denial 3 3963 UNSPECIFIED Praluent LIPOTROPICS Approval 4 3965 UNSPECIFIED Praluent LIPOTROPICS Denial 1 3956 UNSPECIFIED Praluent LIPOTROPICS No Response 1 3956 UNSPECIFIED Praluent LIPOTROPICS Approval 2 3956 CARDIOLOGY Praluent 150MG/ML SC SOAJ LIPOTROPICS No Response 1 3963 CARDIOLOGY Praluent 150MG/ML SC SOAJ LIPOTROPICS No Response 2 3963 CARDIOLOGY, INTERVENTIONAL Praluent 150MG/ML SC SOAJ LIPOTROPICS No Response 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Praluent 150MG/ML SC SOAJ LIPOTROPICS No Response 1 3951 NURSE PRACTITIONER, UNSPECIFIED Praluent 150MG/ML SC SOAJ LIPOTROPICS No Response 1 3951 NURSE PRACTITIONER, UNSPECIFIED Praluent 150MG/ML SC SOAJ LIPOTROPICS Approval 1 3963 UNSPECIFIED Praluent 150MG/ML SC SOAJ LIPOTROPICS No Response 1 3956 UNSPECIFIED Praluent 150MG/ML SC SOAJ LIPOTROPICS No Response 1 3956 CARDIOLOGY Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 2 3963 CARDIOLOGY Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 3 3956 CARDIOLOGY Praluent 75MG/ML SC SOAJ LIPOTROPICS Denial 1 3951 CARDIOLOGY Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 1 3963 CARDIOLOGY, INTERVENTIONAL Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 4 3963 EMERGENCY MEDICINE Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 1 3956 FAMILY PRACTICE Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 1 3964 FAMILY PRACTICE Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 1 3963 INTERNAL MEDICINE Praluent 75MG/ML SC SOAJ LIPOTROPICS Approval 1 3956 INTERNAL MEDICINE Praluent 75MG/ML SC SOAJ LIPOTROPICS Approval 1 3964 INTERNAL MEDICINE Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 1 3963 NURSE PRACTITIONER, UNSPECIFIED Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 1 3969 UNSPECIFIED Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 1 3964 UNSPECIFIED Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 4 3956 UNSPECIFIED Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 2 3969 UNSPECIFIED Praluent Pen 75 mg/mL subcutaneous pen injector LIPOTROPICS No Response 1 3956 PULMONARY DISEASES Prolastin-C RESPIRATORY AGENTS No Response 1 3956 PULMONARY DISEASES Prolastin-C RESPIRATORY AGENTS Approval 4 3956 FAMILY PRACTICE Prolia BONE-MODIFYING AGENT Approval 6 3956 FAMILY PRACTICE Prolia BONE-MODIFYING AGENT No Response 2 3956 FAMILY PRACTICE Prolia BONE-MODIFYING AGENT Denial 2 3956 INTERNAL MEDICINE Prolia BONE-MODIFYING AGENT Approval 1

25 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 NURSE PRACTITIONER, UNSPECIFIED Prolia BONE-MODIFYING AGENT Approval 2 3956 OBSTETRICS & GYNECOLOGY Prolia BONE-MODIFYING AGENT Denial 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Prolia BONE-MODIFYING AGENT Approval 1 3956 UNSPECIFIED Prolia BONE-MODIFYING AGENT Denial 2 3956 UNSPECIFIED Prolia BONE-MODIFYING AGENT Approval 4 3961 UNSPECIFIED Prolia BONE-MODIFYING AGENT Denial 1 3956 UNSPECIFIED Prolia BONE-MODIFYING AGENT No Response 1 3956 HEMATOLOGY & ONCOLOGY Promacta HEMOSTATICS No Response 1 3956 HEMATOLOGY & ONCOLOGY Promacta HEMOSTATICS Approval 2 3951 HEMATOLOGY & ONCOLOGY Promacta HEMOSTATICS Approval 1 3963 HEMATOLOGY & ONCOLOGY Promacta HEMOSTATICS No Response 1 3963 HEMATOLOGY & ONCOLOGY Promacta HEMOSTATICS Denial 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL Promacta HEMOSTATICS Approval 1 3956 UNSPECIFIED Promacta HEMOSTATICS Denial 1 3963 UNSPECIFIED Promacta HEMOSTATICS No Response 1 3956 HEMATOLOGY & ONCOLOGY Promacta 75MG OR TABS HEMOSTATICS No Response 1 3965 NURSE PRACTITIONER, UNSPECIFIED Rebif MULTIPLE SCLEROSIS AGENT Approval 1 3965 PHYSICIAN ASSISTANT, UNSPECIFIED Rebif MULTIPLE SCLEROSIS AGENT No Response 1 3965 PHYSICIAN ASSISTANT, UNSPECIFIED Rebif MULTIPLE SCLEROSIS AGENT Approval 1 3961 UNSPECIFIED Rebif MULTIPLE SCLEROSIS AGENT No Response 3 3963 HEMATOLOGY & ONCOLOGY Retacrit HEMATOPOIETIC AGENT Approval 1 3956 NURSE PRACTITIONER, ACUTE CARE Retacrit HEMATOPOIETIC AGENT Approval 1 3951 NURSE PRACTITIONER, FAMILY HEALTH Retacrit HEMATOPOIETIC AGENT Denial 1 3956 UNSPECIFIED Retacrit HEMATOPOIETIC AGENT Denial 1 3965 UNSPECIFIED Retacrit HEMATOPOIETIC AGENT Approval 1 3962 HEMATOLOGY Revlimid ANTINEOPLASTICS No Response 1 3962 HEMATOLOGY Revlimid ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY Revlimid ANTINEOPLASTICS Approval 1 3951 HEMATOLOGY & ONCOLOGY Revlimid ANTINEOPLASTICS Approval 1 3956 INTERNAL MEDICINE Revlimid ANTINEOPLASTICS Approval 1 3963 INTERNAL MEDICINE Revlimid ANTINEOPLASTICS Approval 1 3964 NURSE PRACTITIONER, UNSPECIFIED Revlimid ANTINEOPLASTICS Approval 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL Revlimid ANTINEOPLASTICS No Response 1 3951 UNSPECIFIED Revlimid ANTINEOPLASTICS Approval 1 3965 UNSPECIFIED Revlimid ANTINEOPLASTICS Approval 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED RINVOQ 15 MG ER TABLET IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 RHEUMATOLOGY RINVOQ 15 MG ER TABLET IMMUNOSUPPRESSIVES/DMARDS Approval 1

26 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 DERMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 DERMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3965 INTERNAL MEDICINE Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 RHEUMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3965 RHEUMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 RHEUMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 6 3963 RHEUMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS No Response 3 3956 RHEUMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 RHEUMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3964 RHEUMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 RHEUMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 RHEUMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 13 3964 UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3964 UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3961 UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS No Response 3 3963 UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Denial 4 3956 UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3965 UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 RHEUMATOLOGY Rinvoq 15MG OR TB24 IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 GASTROENTEROLOGY Rinvoq 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED Rinvoq 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3963 UNSPECIFIED Rinvoq 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 UNSPECIFIED Rinvoq 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 UNSPECIFIED Rinvoq 30MG OR TB24 IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 GASTROENTEROLOGY Rinvoq 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3963 GASTROENTEROLOGY Rinvoq 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 GASTROENTEROLOGY Rinvoq 45mg + 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 GASTROENTEROLOGY Rinvoq 45mg + 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 UNSPECIFIED Rinvoq 45mg + 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1

27 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 GASTROENTEROLOGY Rinvoq 45MG OR TB24 IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED Rinvoq 45MG OR TB24 IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 UNSPECIFIED Rydapt ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED Sabril powder ANTICONVULSANTS No Response 2 3961 PHYSICIAN ASSISTANT, UNSPECIFIED sapropterin ENZYME COFACTOR Approval 1 3963 UNSPECIFIED sapropterin ENZYME COFACTOR Denial 1 3963 UNSPECIFIED sapropterin ENZYME COFACTOR Approval 1 3956 INTERNAL MEDICINE Sensipar CALCIMIMETIC Approval 1 3956 FAMILY PRACTICE sildenafil (pulm.hypertension) 20 mg tablet VASODILATORS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Sildenafil Citrate (Sildenafil Citrate (Pulmonary Hyper­ tension)) 20 MG Oral Tablet VASODILATORS No Response 1 3963 UNSPECIFIED Sildenafil Citrate (Sildenafil Citrate (Pulmonary Hyper­ tension)) 20 MG Oral Tablet VASODILATORS No Response 1 3951 CARDIOLOGY Sildenafil Citrate 20MG OR TABS VASODILATORS No Response 1 3963 FAMILY PRACTICE Sildenafil Citrate 20MG OR TABS VASODILATORS No Response 1 3965 FAMILY PRACTICE Sildenafil Citrate 20MG OR TABS VASODILATORS Denial 1 3964 FAMILY PRACTICE Sildenafil Citrate 20MG OR TABS VASODILATORS Denial 1 3963 UNSPECIFIED Sildenafil Citrate 20MG OR TABS VASODILATORS No Response 4 3956 UNSPECIFIED Sildenafil Citrate 20MG OR TABS VASODILATORS No Response 1 3965 UNSPECIFIED Sildenafil Citrate 20MG OR TABS VASODILATORS No Response 1 3963 UNSPECIFIED Sildenafil Citrate 20MG OR TABS VASODILATORS Denial 1 3956 FAMILY PRACTICE sildenafil tablets VASODILATORS Denial 8 3956 FAMILY PRACTICE sildenafil tablets VASODILATORS Approval 2 3956 CARDIOLOGY sildenafil tablets VASODILATORS Denial 1 3963 FAMILY PRACTICE sildenafil tablets VASODILATORS Denial 8 3951 FAMILY PRACTICE sildenafil tablets VASODILATORS Denial 2 3961 FAMILY PRACTICE sildenafil tablets VASODILATORS Denial 2 3963 INTERNAL MEDICINE sildenafil tablets VASODILATORS Denial 4 3956 INTERNAL MEDICINE sildenafil tablets VASODILATORS Denial 1 3963 INTERNAL MEDICINE sildenafil tablets VASODILATORS Approval 2 3951 INTERNAL MEDICINE sildenafil tablets VASODILATORS Denial 1 3956 NURSE PRACTITIONER, FAMILY HEALTH sildenafil tablets VASODILATORS Denial 1 3963 NURSE PRACTITIONER, UNSPECIFIED sildenafil tablets VASODILATORS Denial 1 3956 NURSE PRACTITIONER, UNSPECIFIED sildenafil tablets VASODILATORS Approval 1 3965 PHYSICIAN ASSISTANT, UNSPECIFIED sildenafil tablets VASODILATORS Denial 1 3956 REGISTERED NURSE, UNSPECIFIED sildenafil tablets VASODILATORS Denial 1 3951 RHEUMATOLOGY sildenafil tablets VASODILATORS Approval 1 3956 RHEUMATOLOGY sildenafil tablets VASODILATORS Approval 1

28 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 UROLOGY sildenafil tablets VASODILATORS Denial 1 3956 UNSPECIFIED sildenafil tablets VASODILATORS Denial 3 3963 UNSPECIFIED sildenafil tablets VASODILATORS Denial 2 3951 UNSPECIFIED sildenafil tablets VASODILATORS Denial 1 3956 UNSPECIFIED sildenafil tablets VASODILATORS Approval 1 3956 UNSPECIFIED sildenafil tablets VASODILATORS No Response 1 3956 GASTROENTEROLOGY Simponi 100mg ANTIARTHRITICS Approval 2 3956 GASTROENTEROLOGY Simponi 50mg ANTIARTHRITICS No Response 2 3956 INTERNAL MEDICINE Simponi 50mg ANTIARTHRITICS No Response 2 3956 RHEUMATOLOGY Simponi 50mg ANTIARTHRITICS Denial 2 3956 RHEUMATOLOGY Simponi 50mg ANTIARTHRITICS No Response 2 3956 RHEUMATOLOGY Simponi 50mg ANTIARTHRITICS Approval 2 3963 RHEUMATOLOGY Simponi Aria ANTIARTHRITICS Approval 1 3963 RHEUMATOLOGY Simponi Aria 50MG/4ML IV SOLN ANTIARTHRITICS No Response 1 3956 CLINICAL NURSE SPECIALIST, FAMILY HEALTH Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3956 DERMATOLOGY Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS No Response 2 3956 DERMATOLOGY Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS Approval 4 3951 DERMATOLOGY Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3963 DERMATOLOGY Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3956 DERMATOLOGY Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3963 DERMATOLOGY Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3951 DERMATOLOGY Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3963 INTERNAL MEDICINE Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 NURSE PRACTITIONER, ACUTE CARE Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3951 NURSE PRACTITIONER, FAMILY HEALTH Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3951 NURSE PRACTITIONER, UNSPECIFIED Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS Approval 4 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3963 UNSPECIFIED Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS Approval 4 3956 UNSPECIFIED Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3964 UNSPECIFIED Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 UNSPECIFIED Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3964 UNSPECIFIED Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS No Response 2 3956 UNSPECIFIED Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3956 UNSPECIFIED Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS Approval 3 3951 UNSPECIFIED Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS No Response 1

29 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3965 UNSPECIFIED Skyrizi SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3951 RHEUMATOLOGY Skyrizi (150 MG Dose) 75MG/0.83ML SC PSKT SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 NURSE PRACTITIONER, ACUTE CARE Skyrizi 150 mg/1.66 mL(75 mg/0.83 mL x 2) subcutane­ ous syringe kit SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Skyrizi 150 mg/mL subcutaneous pen injector SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3961 DERMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3964 DERMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 DERMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 7 3963 DERMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3963 DERMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3956 DERMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3956 DERMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3965 DERMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 DERMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3963 FAMILY PRACTICE Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 INTERNAL MEDICINE Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 INTERNAL MEDICINE Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3963 NURSE PRACTITIONER, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3964 NURSE PRACTITIONER, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 RHEUMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3956 RHEUMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 3 3956 UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3965 UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3951 UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3965 UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3956 DERMATOLOGY SKYRIZI 150MG/ML PEN SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED SKYRIZI 150MG/ML PFS SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3951 UNSPECIFIED Skyrizi 150MG/ML SC SOSY SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3956 GASTROENTEROLOGY Skyrizi 600mg + 360mg + 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 GASTROENTEROLOGY Skyrizi 600mg + 360mg + 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3964 NURSE PRACTITIONER, FAMILY HEALTH Skyrizi Pen 150MG/ML SC SOAJ SYSTEMIC ANTIPSORIASIS AGENTS Approval 1

30 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 NURSE PRACTITIONER, UNSPECIFIED Skyrizi Pen 150MG/ML SC SOAJ SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi Pen 150MG/ML SC SOAJ SYSTEMIC ANTIPSORIASIS AGENTS No Response 2 3964 RHEUMATOLOGY Skyrizi Pen 150MG/ML SC SOAJ SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 UNSPECIFIED Skyrizi Pen 150MG/ML SC SOAJ SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3956 UNSPECIFIED Skyrizi Pen 150MG/ML SC SOAJ SYSTEMIC ANTIPSORIASIS AGENTS No Response 2 3956 HEMATOLOGY & ONCOLOGY Somatuline Depot SOMATOSTATIN ANALOG Approval 3 3963 INTERNAL MEDICINE Somatuline Depot SOMATOSTATIN ANALOG Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Somatuline Depot SOMATOSTATIN ANALOG Denial 1 3963 PEDIATRICS sorafenib ANTINEOPLASTICS Approval 1 3963 NURSE PRACTITIONER, PEDIATRIC CARE Spravato ANTIDEPRESSANT Denial 12 3964 NURSE PRACTITIONER, PSYCHIATRIC Spravato ANTIDEPRESSANT No Response 12 3951 NURSE PRACTITIONER, PSYCHIATRIC Spravato ANTIDEPRESSANT Denial 12 3964 NURSE PRACTITIONER, PSYCHIATRIC Spravato ANTIDEPRESSANT Approval 12 3969 PSYCHIATRY Spravato ANTIDEPRESSANT Approval 24 3962 PSYCHIATRY Spravato ANTIDEPRESSANT Denial 12 3963 PSYCHIATRY Spravato ANTIDEPRESSANT Denial 12 3963 UNSPECIFIED Spravato ANTIDEPRESSANT Approval 48 3951 UNSPECIFIED Spravato ANTIDEPRESSANT Denial 12 3951 UNSPECIFIED Spravato ANTIDEPRESSANT Approval 12 3964 UNSPECIFIED Spravato ANTIDEPRESSANT Approval 12 3964 UNSPECIFIED Spravato ANTIDEPRESSANT Denial 12 3963 UNSPECIFIED Spravato ANTIDEPRESSANT Denial 24 3967 UNSPECIFIED Spravato ANTIDEPRESSANT Denial 12 3951 HEMATOLOGY & ONCOLOGY Sprycel ANTINEOPLASTICS Denial 1 3951 HEMATOLOGY & ONCOLOGY Sprycel ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY Sprycel ANTINEOPLASTICS Approval 2 3956 HEMATOLOGY & ONCOLOGY Sprycel ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY Sprycel ANTINEOPLASTICS No Response 1 3956 HEMATOLOGY & ONCOLOGY Sprycel ANTINEOPLASTICS Denial 1 3956 INTERNAL MEDICINE Sprycel ANTINEOPLASTICS No Response 1 3956 INTERNAL MEDICINE Sprycel ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED Sprycel ANTINEOPLASTICS Approval 1 3951 UNSPECIFIED Sprycel ANTINEOPLASTICS Approval 1 3951 UNSPECIFIED Sprycel ANTINEOPLASTICS No Response 1 3963 UNSPECIFIED Stelara 45MG/0.5ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 GASTROENTEROLOGY STELARA 90MG/ML INJ IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 GASTROENTEROLOGY Stelara 90MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 1

31 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Stelara 90MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED Stelara 90MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 1 3961 DERMATOLOGY Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 DERMATOLOGY Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 DERMATOLOGY Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3964 DERMATOLOGY Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 DERMATOLOGY Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3963 EMERGENCY MEDICINE Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 GASTROENTEROLOGY Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3969 GASTROENTEROLOGY Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 UNSPECIFIED Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3956 UNSPECIFIED Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3964 UNSPECIFIED Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 DERMATOLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 DERMATOLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3961 DERMATOLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3964 DERMATOLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 EMERGENCY MEDICINE Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3963 EMERGENCY MEDICINE Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Denial 3 3956 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3963 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Denial 3 3963 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3956 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3951 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3965 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 INTERNAL MEDICINE Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 INTERNAL MEDICINE Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 PEDIATRICS Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 1

32 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3963 RHEUMATOLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS No Response 6 3956 UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 4 3963 UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3951 UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3951 UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS No Response 5 3963 UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3956 HEMATOLOGY & ONCOLOGY Stivarga ANTINEOPLASTICS Approval 2 3964 HEMATOLOGY & ONCOLOGY Stivarga ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY Stivarga ANTINEOPLASTICS Denial 1 3956 INTERNAL MEDICINE Sutent ANTINEOPLASTICS Approval 1 BCBSAR FAMILY PRACTICE Synagis RESPIRATORY AGENT Denial 1 BCBSAR PEDIATRICS Synagis RESPIRATORY AGENT Approval 9 BCBSAR PEDIATRICS Synagis RESPIRATORY AGENT Denial 7 BCBSAR UNSPECIFIED Synagis RESPIRATORY AGENT Denial 1 3956 CARDIOLOGY Tadalafil (PAH) 20MG OR TABS VASODILATORS No Response 1 3963 CARDIOLOGY tadalafil 20mg VASODILATORS No Response 1 3963 CARDIOLOGY tadalafil 20mg VASODILATORS Approval 1 3956 CARDIOLOGY tadalafil 20mg VASODILATORS Approval 2 3956 CARDIOLOGY tadalafil 20mg VASODILATORS No Response 1 3956 FAMILY PRACTICE tadalafil 20mg VASODILATORS Denial 1 3951 PULMONARY DISEASES tadalafil 20mg VASODILATORS Approval 1 3963 UNSPECIFIED tadalafil 20mg VASODILATORS Denial 1 3956 UNSPECIFIED tadalafil 20mg VASODILATORS Approval 1 3963 HEMATOLOGY & ONCOLOGY Tagrisso ANTINEOPLASTICS Approval 1 3951 HEMATOLOGY & ONCOLOGY Tagrisso ANTINEOPLASTICS No Response 1 3951 HEMATOLOGY & ONCOLOGY Tagrisso ANTINEOPLASTICS Approval 1 3963 DERMATOLOGY Taltz ALL OTHER DERMATOLOGICALS Denial 1 3963 DERMATOLOGY Taltz ALL OTHER DERMATOLOGICALS No Response 2 3951 DERMATOLOGY Taltz ALL OTHER DERMATOLOGICALS Approval 1 3951 DERMATOLOGY Taltz ALL OTHER DERMATOLOGICALS Denial 1 3956 DERMATOLOGY Taltz ALL OTHER DERMATOLOGICALS Approval 11 3956 DERMATOLOGY Taltz ALL OTHER DERMATOLOGICALS Denial 4

33 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 DERMATOLOGY Taltz ALL OTHER DERMATOLOGICALS No Response 4 3963 DERMATOLOGY Taltz ALL OTHER DERMATOLOGICALS Approval 1 3956 FAMILY PRACTICE Taltz ALL OTHER DERMATOLOGICALS Approval 1 3956 INTERNAL MEDICINE Taltz ALL OTHER DERMATOLOGICALS Denial 1 3963 INTERNAL MEDICINE Taltz ALL OTHER DERMATOLOGICALS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Taltz ALL OTHER DERMATOLOGICALS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Taltz ALL OTHER DERMATOLOGICALS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Taltz ALL OTHER DERMATOLOGICALS Denial 1 3963 NURSE PRACTITIONER, UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Approval 26 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS No Response 6 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Denial 2 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Approval 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Approval 2 3961 PHYSICIAN ASSISTANT, UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Approval 1 3956 RHEUMATOLOGY Taltz ALL OTHER DERMATOLOGICALS Denial 6 3956 RHEUMATOLOGY Taltz ALL OTHER DERMATOLOGICALS No Response 1 3956 RHEUMATOLOGY Taltz ALL OTHER DERMATOLOGICALS Approval 2 3956 UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS No Response 6 3956 UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Approval 15 3961 UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Approval 1 3956 UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Denial 3 3963 UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Denial 2 3963 UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Approval 1 3951 UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Approval 2 3963 UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS No Response 1 3956 DERMATOLOGY TALTZ 80 MG/ML AUTO INJ 1ML IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY TALTZ 80MG/ML CF AUTO INJ 1ML IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED TALTZ 80MG/ML CF AUTO INJ 1ML IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED TALTZ 80MG/ML CF AUTO INJ 1ML IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 INTERNAL MEDICINE TALTZ 80MG/ML INJ IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED TALTZ 80MG/ML INJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY Taltz 80MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 DERMATOLOGY Taltz 80MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Taltz 80MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 3 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Taltz 80MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 UNSPECIFIED Taltz 80MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1

34 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 DERMATOLOGY Taltz Autoinjector 80 mg/mL subcutaneous IMMUNOSUPPRESSIVES/DMARDS No Response 1 3964 HEMATOLOGY & ONCOLOGY Tavalisse ANTINEOPLASTICS Approval 1 3964 HEMATOLOGY & ONCOLOGY Tavalisse ANTINEOPLASTICS Denial 1 3963 INTERNAL MEDICINE Tecfidera MULTIPLE SCLEROSIS AGENT No Response 1 3956 HEMATOLOGY & ONCOLOGY temozolomide ANTINEOPLASTICS No Response 1 3956 HEMATOLOGY & ONCOLOGY temozolomide ANTINEOPLASTICS Approval 2 3951 MEDICAL ONCOLOGY temozolomide ANTINEOPLASTICS Approval 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL temozolomide ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED temozolomide ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED temozolomide ANTINEOPLASTICS Approval 3 3951 MEDICAL ONCOLOGY Temozolomide 180MG OR CAPS ANTINEOPLASTICS No Response 1 3956 INTERNAL MEDICINE tetrabenazine VESICULAR MONOAMINE TRANSPORTER 2 INHIB­ ITOR Approval 1 3956 NEUROLOGY tetrabenazine VESICULAR MONOAMINE TRANSPORTER 2 INHIB­ ITOR Denial 1 3951 UNSPECIFIED tetrabenazine VESICULAR MONOAMINE TRANSPORTER 2 INHIB­ ITOR Denial 1 3963 DERMATOLOGY Thalomid ANTINEOPLASTICS No Response 1 3963 HEMATOLOGY Thalomid ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY Thalomid ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY Thalomid ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY Thalomid ANTINEOPLASTICS Denial 2 3963 HEMATOLOGY & ONCOLOGY Thalomid ANTINEOPLASTICS Approval 1 3951 HEMATOLOGY & ONCOLOGY Thalomid ANTINEOPLASTICS No Response 1 3963 UNSPECIFIED Thalomid ANTINEOPLASTICS Denial 1 3956 HEMATOLOGY & ONCOLOGY Thalomid 100MG OR CAPS ANTINEOPLASTICS No Response 1 3965 UNSPECIFIED TOBI STREPTOMYCINS Denial 1 3969 UNSPECIFIED Tobi Podhaler 28MG IN CAPS CYSTIC FIBROSIS AGENTS No Response 1 3965 UNSPECIFIED Tobramycin inhalation solution RESPIRATORY AGENTS Approval 1 3963 UNSPECIFIED Tobramycin inhalation solution RESPIRATORY AGENTS Approval 2 3963 UNSPECIFIED Tobramycin inhalation solution RESPIRATORY AGENTS Denial 1 3963 UNSPECIFIED tolvaptan VASOPRESSIN ANTAGONIST No Response 1 3963 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 7 3963 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 5 3963 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 1 3962 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3964 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1

35 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3965 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 3 3963 NURSE PRACTITIONER, FAMILY HEALTH Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 NURSE PRACTITIONER, FAMILY HEALTH Tremfya IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 NURSE PRACTITIONER, UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 3 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 3 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 3 3956 RHEUMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Denial 2 3956 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 8 3963 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY Tremfya 100 mg/mL subcutaneous auto-injector IMMUNOSUPPRESSIVES/DMARDS No Response 1 3962 DERMATOLOGY Tremfya 100MG/ML SC SOPN IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Tremfya 100MG/ML SC SOPN IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 NURSE PRACTITIONER, FAMILY HEALTH Tremfya 100MG/ML SC SOPN IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 UNSPECIFIED Tremfya 100MG/ML SC SOPN IMMUNOSUPPRESSIVES/DMARDS No Response 1 3962 PEDIATRICS Trikafta CYSTIC FIBROSIS AGENTS Approval 1 3956 PULMONARY DISEASES Trikafta CYSTIC FIBROSIS AGENTS Approval 3 3969 PULMONARY DISEASES Trikafta CYSTIC FIBROSIS AGENTS Approval 1 3963 PULMONARY DISEASES Trikafta CYSTIC FIBROSIS AGENTS Approval 1 3963 PULMONOLOGY, PEDIATRIC Trikafta CYSTIC FIBROSIS AGENTS Approval 2 3956 PULMONOLOGY, PEDIATRIC Trikafta CYSTIC FIBROSIS AGENTS Approval 1 3951 PULMONOLOGY, PEDIATRIC Trikafta CYSTIC FIBROSIS AGENTS Approval 1 3956 UNSPECIFIED Trikafta CYSTIC FIBROSIS AGENTS No Response 1 3956 UNSPECIFIED Trikafta CYSTIC FIBROSIS AGENTS Approval 1 3961 UNSPECIFIED Trikafta CYSTIC FIBROSIS AGENTS Approval 1 3963 UNSPECIFIED Trikafta CYSTIC FIBROSIS AGENTS No Response 1 3956 UNSPECIFIED Trikafta 100-50-75 & 150MG OR TBPK CYSTIC FIBROSIS AGENTS Denial 1 3963 HEMATOLOGY & ONCOLOGY Tukysa ANTINEOPLASTICS Approval 1 3956 FAMILY PRACTICE Tymlos OSTEOPOROSIS AGENTS Approval 1

36 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 FAMILY PRACTICE Tymlos OSTEOPOROSIS AGENTS Denial 1 3963 FAMILY PRACTICE Tymlos OSTEOPOROSIS AGENTS Approval 1 3963 INTERNAL MEDICINE Tymlos OSTEOPOROSIS AGENTS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Tymlos OSTEOPOROSIS AGENTS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Tymlos OSTEOPOROSIS AGENTS Approval 1 3956 ORTHOPEDIC SURGERY Tymlos OSTEOPOROSIS AGENTS Approval 2 3963 PEDIATRICS Tymlos OSTEOPOROSIS AGENTS No Response 1 3963 PEDIATRICS Tymlos OSTEOPOROSIS AGENTS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Tymlos OSTEOPOROSIS AGENTS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Tymlos OSTEOPOROSIS AGENTS Denial 2 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Tymlos OSTEOPOROSIS AGENTS Approval 1 3956 RHEUMATOLOGY Tymlos OSTEOPOROSIS AGENTS Denial 1 3956 RHEUMATOLOGY Tymlos OSTEOPOROSIS AGENTS Approval 1 3956 UNSPECIFIED Tymlos OSTEOPOROSIS AGENTS No Response 3 3956 UNSPECIFIED Tymlos OSTEOPOROSIS AGENTS Denial 1 3963 UNSPECIFIED Tymlos OSTEOPOROSIS AGENTS Denial 1 3956 UNSPECIFIED Tymlos OSTEOPOROSIS AGENTS Approval 3 3963 UNSPECIFIED Tymlos OSTEOPOROSIS AGENTS Approval 1 3961 PULMONARY DISEASES Tyvaso Starter 0.6MG/ML IN SOLN VASODILATORS Denial 1 3964 CARDIOLOGY Uptravi PULMONARY ARTERIAL HYPERTENSION Approval 1 3951 CARDIOLOGY Uptravi PULMONARY ARTERIAL HYPERTENSION No Response 1 3963 GENERAL PRACTICE Uptravi PULMONARY ARTERIAL HYPERTENSION Approval 1 3964 UNSPECIFIED Valchlor ANTINEOPLASTICS Approval 1 3951 UNSPECIFIED Valchlor ANTINEOPLASTICS Approval 1 3964 UNSPECIFIED Valchlor 0.016% EX GEL ANTINEOPLASTICS No Response 2 3956 GASTROENTEROLOGY valganciclovir ANTIVIRALS Approval 1 3956 HEMATOLOGY & ONCOLOGY valganciclovir ANTIVIRALS Approval 1 3963 NURSE PRACTITIONER, ACUTE CARE valganciclovir ANTIVIRALS Approval 1 3956 NURSE PRACTITIONER, ACUTE CARE valganciclovir ANTIVIRALS Approval 3 3956 PHYSICIAN, SURGERY, GENERAL valganciclovir ANTIVIRALS Approval 1 3951 UNSPECIFIED valganciclovir ANTIVIRALS Approval 3 3956 UNSPECIFIED valganciclovir ANTIVIRALS Approval 1 3956 NURSE PRACTITIONER, ACUTE CARE valGANciclovir HCl 450MG OR TABS ANTIVIRALS No Response 1 3956 FAMILY PRACTICE Vemlidy Antivirals No Response 1 3951 NURSE PRACTITIONER, FAMILY HEALTH Vemlidy Antivirals No Response 1 3951 NURSE PRACTITIONER, UNSPECIFIED Vemlidy Antivirals Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED Vemlidy Antivirals No Response 1

37 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 NURSE PRACTITIONER, UNSPECIFIED Vemlidy Antivirals Approval 2 3961 HEMATOLOGY & ONCOLOGY Venclexta ANTINEOPLASTICS Approval 1 3965 HEMATOLOGY & ONCOLOGY Venclexta ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY Venclexta ANTINEOPLASTICS Approval 2 3956 HEMATOLOGY & ONCOLOGY Venclexta ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED Venclexta ANTINEOPLASTICS Denial 2 3961 UNSPECIFIED Venclexta ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED Venclexta ANTINEOPLASTICS No Response 1 3961 INTERNAL MEDICINE Venclexta 100MG OR TABS ANTINEOPLASTICS No Response 1 3965 HEMATOLOGY & ONCOLOGY Venclexta 50MG OR TABS ANTINEOPLASTICS No Response 1 3963 HEMATOLOGY & ONCOLOGY Venclexta Starting Pack 10 & 50 & 100MG OR TBPK ANTINEOPLASTICS No Response 1 3963 HEMATOLOGY Verzenio ANTINEOPLASTICS No Response 1 3963 HEMATOLOGY Verzenio ANTINEOPLASTICS Approval 1 3951 HEMATOLOGY & ONCOLOGY Verzenio ANTINEOPLASTICS Approval 1 3951 INTERNAL MEDICINE Verzenio ANTINEOPLASTICS Approval 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL Verzenio ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED vigabatrin powder ANTICONVULSANTS Approval 4 3956 FAMILY PRACTICE Vivitrol SUBSTANCE ABUSE AGENTS Approval 1 3961 FAMILY PRACTICE Vivitrol SUBSTANCE ABUSE AGENTS Approval 1 3956 GENERAL PRACTICE Vivitrol SUBSTANCE ABUSE AGENTS Approval 5 3956 NURSE PRACTITIONER, FAMILY HEALTH Vivitrol SUBSTANCE ABUSE AGENTS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Vivitrol SUBSTANCE ABUSE AGENTS Approval 1 3956 NURSE PRACTITIONER, PSYCHIATRIC Vivitrol SUBSTANCE ABUSE AGENTS No Response 2 3951 NURSE PRACTITIONER, PSYCHIATRIC Vivitrol SUBSTANCE ABUSE AGENTS Approval 4 3956 NURSE PRACTITIONER, PSYCHIATRIC Vivitrol SUBSTANCE ABUSE AGENTS Approval 5 3956 NURSE PRACTITIONER, UNSPECIFIED Vivitrol SUBSTANCE ABUSE AGENTS No Response 2 3956 PHYSICIAN, PSYCHIATRY & NEUROLOGY Vivitrol SUBSTANCE ABUSE AGENTS Approval 1 3956 PSYCHIATRY Vivitrol SUBSTANCE ABUSE AGENTS No Response 2 3956 PSYCHIATRY Vivitrol SUBSTANCE ABUSE AGENTS Approval 2 3951 PSYCHIATRY, ADDICTION Vivitrol SUBSTANCE ABUSE AGENTS Approval 1 3956 PSYCHIATRY, ADDICTION Vivitrol SUBSTANCE ABUSE AGENTS Approval 1 3951 UNSPECIFIED Vivitrol SUBSTANCE ABUSE AGENTS Approval 2 3956 UNSPECIFIED Vivitrol SUBSTANCE ABUSE AGENTS Approval 15 3956 UNSPECIFIED Vivitrol SUBSTANCE ABUSE AGENTS No Response 1 3961 UNSPECIFIED Vivitrol SUBSTANCE ABUSE AGENTS No Response 1 3956 NURSE PRACTITIONER, PSYCHIATRIC Vivitrol 380MG IM SUSR SUBSTANCE ABUSE AGENTS No Response 2 3956 NURSE PRACTITIONER, PSYCHIATRIC Vivitrol 380MG IM SUSR SUBSTANCE ABUSE AGENTS Approval 1

38 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 UNSPECIFIED Votrient ANTINEOPLASTICS Approval 1 3963 NEUROLOGY Vumerity MULTIPLE SCLEROSIS Denial 1 3963 NEUROLOGY Vumerity MULTIPLE SCLEROSIS Approval 1 3963 NURSE PRACTITIONER, GERONTOLOGY Vumerity MULTIPLE SCLEROSIS No Response 1 3963 NURSE PRACTITIONER, GERONTOLOGY Vumerity MULTIPLE SCLEROSIS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED Vumerity MULTIPLE SCLEROSIS Denial 1 3963 UNSPECIFIED Vumerity MULTIPLE SCLEROSIS Approval 2 3961 NURSE PRACTITIONER, FAMILY HEALTH Vumerity 231MG OR CPDR MULTIPLE SCLEROSIS No Response 1 3956 UNSPECIFIED Vumerity 231MG OR CPDR MULTIPLE SCLEROSIS No Response 1 3962 UNSPECIFIED Vyndamax AMYLOID CARDIOMYOPATHY Approval 1 3962 UNSPECIFIED Vyndamax TRANSTHYRETIN STABILIZER Approval 1 3963 DERMATOLOGY Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS Denial 3 3956 INTERNAL MEDICINE Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 INTERNAL MEDICINE Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 INTERNAL MEDICINE Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 PHYSICIAN, GERIATRIC MEDICINE Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 RHEUMATOLOGY Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3964 RHEUMATOLOGY Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 RHEUMATOLOGY Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3951 UNSPECIFIED Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 UNSPECIFIED Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 GASTROENTEROLOGY Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 INTERNAL MEDICINE Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 INTERNAL MEDICINE Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 RHEUMATOLOGY Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3961 RHEUMATOLOGY Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 RHEUMATOLOGY Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 RHEUMATOLOGY Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Approval 5 3963 RHEUMATOLOGY Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3951 RHEUMATOLOGY Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 UNSPECIFIED Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3951 UNSPECIFIED Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1

39 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 NEUROLOGY Xenazine MISCELLANEOUS Denial 1 3956 NEUROLOGY Xenazine 12.5MG OR TABS MISCELLANEOUS No Response 1 3963 INTERNAL MEDICINE Xermelo TRYPTOPHAN HYDROXYLASE INHIBITOR No Response 2 3963 INTERNAL MEDICINE Xermelo TRYPTOPHAN HYDROXYLASE INHIBITOR Approval 2 3963 UROLOGY Xgeva OSTEOPOROSIS AGENTS Approval 1 3956 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS No Response 5 3963 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS No Response 1 3956 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Approval 7 3963 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Denial 1 3963 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Approval 7 3961 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Approval 2 3951 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Denial 4 3951 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Approval 2 3962 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Approval 1 3969 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Denial 1 3969 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Approval 1 3967 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Approval 1 3956 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Denial 1 3951 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS No Response 1 3962 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Denial 1 3961 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Denial 1 3956 DERMATOLOGY Xolair RESPIRATORY AGENTS Approval 1 3963 FAMILY PRACTICE Xolair RESPIRATORY AGENTS Approval 2 3956 FAMILY PRACTICE Xolair RESPIRATORY AGENTS Denial 2 3956 NURSE PRACTITIONER, FAMILY HEALTH Xolair RESPIRATORY AGENTS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED Xolair RESPIRATORY AGENTS Approval 1 3951 NURSE PRACTITIONER, UNSPECIFIED Xolair RESPIRATORY AGENTS Approval 1 3963 PEDIATRICS Xolair RESPIRATORY AGENTS Denial 1 3951 PEDIATRICS Xolair RESPIRATORY AGENTS No Response 1 3956 PEDIATRICS Xolair RESPIRATORY AGENTS Approval 1 3961 PEDIATRICS Xolair RESPIRATORY AGENTS No Response 1 3961 PEDIATRICS Xolair RESPIRATORY AGENTS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Xolair RESPIRATORY AGENTS Approval 4 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Xolair RESPIRATORY AGENTS Approval 3 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Xolair RESPIRATORY AGENTS Denial 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Xolair RESPIRATORY AGENTS Denial 1 3963 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC Xolair RESPIRATORY AGENTS Approval 1

40 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 PULMONARY DISEASES Xolair RESPIRATORY AGENTS Approval 3 3963 PULMONARY DISEASES Xolair RESPIRATORY AGENTS Denial 1 3963 UNSPECIFIED Xolair RESPIRATORY AGENTS No Response 3 3963 UNSPECIFIED Xolair RESPIRATORY AGENTS Denial 3 3963 UNSPECIFIED Xolair RESPIRATORY AGENTS Approval 3 3956 UNSPECIFIED Xolair RESPIRATORY AGENTS Approval 1 3951 UNSPECIFIED Xolair RESPIRATORY AGENTS No Response 2 3956 UNSPECIFIED Xolair RESPIRATORY AGENTS No Response 2 3951 UNSPECIFIED Xolair RESPIRATORY AGENTS Denial 1 3951 UNSPECIFIED Xolair RESPIRATORY AGENTS Approval 1 3964 UNSPECIFIED Xolair RESPIRATORY AGENTS Approval 1 3951 ALLERGY & IMMUNOLOGY Xolair 150MG/ML SC SOSY RESPIRATORY AGENTS Approval 1 3951 ALLERGY & IMMUNOLOGY Xolair 150MG/ML SC SOSY RESPIRATORY AGENTS No Response 1 3963 PEDIATRICS Xolair 150MG/ML SC SOSY RESPIRATORY AGENTS Denial 1 3956 HEMATOLOGY & ONCOLOGY Xtandi ANTINEOPLASTICS No Response 1 3956 HEMATOLOGY & ONCOLOGY Xtandi ANTINEOPLASTICS Approval 1 3963 MEDICAL ONCOLOGY Xtandi ANTINEOPLASTICS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Xtandi ANTINEOPLASTICS Approval 1 3963 UROLOGY Xtandi ANTINEOPLASTICS Approval 1 3963 UROLOGY Xtandi ANTINEOPLASTICS Denial 1 3965 UNSPECIFIED Xtandi ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED Xtandi ANTINEOPLASTICS Approval 1 3963 UROLOGY Xtandi 40MG OR CAPS ANTINEOPLASTICS Approval 1 3956 INTERNAL MEDICINE Zejula ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY Ziextenzo HEMATINICS & BLOOD CELL STIMULATORS Approval 2 3961 HEMATOLOGY & ONCOLOGY Ziextenzo HEMATINICS & BLOOD CELL STIMULATORS Denial 1 3961 UNSPECIFIED zoledronic acid 5mg OSTEOPOROSIS AGENTS Approval 1