2023 - 1st quarter Form

1 Pharmacy Specialty Overview by Prior Authorization Approval or Denial 1st Quarter 2023 00122.04.01-0623 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 INTERNAL MEDICINE abiraterone 250 mg ANTINEOPLASTICS Denial 1 3964 UNSPECIFIED abiraterone 250 mg ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED abiraterone 250 mg ANTINEOPLASTICS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Actemra SQ 162mg syringe/Actpen autoinjector IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 RHEUMATOLOGY Actemra SQ 162mg syringe/Actpen autoinjector IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 RHEUMATOLOGY Actemra SQ 162mg syringe/Actpen autoinjector IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED Actemra SQ 162mg syringe/Actpen autoinjector IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 INTERNAL MEDICINE Acthar Gel ANTICONVULSANTS Denial 2 3963 INTERNAL MEDICINE Adempas PULMONARY ARTERIAL HYPERTENSION Approval 1 3956 INTERNAL MEDICINE Adempas PULMONARY ARTERIAL HYPERTENSION Approval 1 3956 UNSPECIFIED Adempas PULMONARY ARTERIAL HYPERTENSION Approval 1 3951 UNSPECIFIED Adempas PULMONARY ARTERIAL HYPERTENSION Approval 1 3963 HEMATOLOGY & ONCOLOGY, PEDIATRIC Afinitor Disperz 5 mg IMMUNOSUPPRESSANT AGENT Denial 1 3965 HEMATOLOGY & ONCOLOGY Alunbrig Antineoplastics Approval 1 3963 HEMATOLOGY & ONCOLOGY Alunbrig Antineoplastics No Response 1 3963 HEMATOLOGY & ONCOLOGY Alunbrig Antineoplastics Approval 1 3963 CARDIOLOGY ambrisentan DERMATOLOGICAL AGENTS Approval 1 3951 CARDIOLOGY ambrisentan DERMATOLOGICAL AGENTS Denial 1 3951 CARDIOLOGY ambrisentan DERMATOLOGICAL AGENTS Approval 1 3956 UNSPECIFIED Ambrisentan 5MG OR TABS DERMATOLOGICAL AGENTS No Response 1 3963 PHYSICIAN, PHYSICAL MEDICINE & REHABILITA­ TION / PHYSIATRY Ampyra MULTIPLE SCLEROSIS AGENT Denial 1 3956 UNSPECIFIED Apokyn PARKINSON’S AGENT Approval 1 3956 UNSPECIFIED Aranesp HEMATOPOIETIC AGENT Denial 1 3963 PULMONARY DISEASES Arikayce ANTIBIOTIC No Response 2 3956 NEUROLOGY Aubagio MULTIPLE SCLEROSIS Approval 6 3956 NEUROLOGY Aubagio MULTIPLE SCLEROSIS No Response 2 3963 NEUROLOGY Aubagio MULTIPLE SCLEROSIS Approval 1 3961 NEUROLOGY Aubagio MULTIPLE SCLEROSIS Approval 1 3956 NURSE PRACTITIONER, GERONTOLOGY Aubagio MULTIPLE SCLEROSIS No Response 1

2 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 UNSPECIFIED Aubagio MULTIPLE SCLEROSIS No Response 2 3956 UNSPECIFIED Aubagio MULTIPLE SCLEROSIS Approval 4 3961 UNSPECIFIED Aubagio MULTIPLE SCLEROSIS No Response 1 3964 UNSPECIFIED Aubagio MULTIPLE SCLEROSIS Approval 1 3956 NEUROLOGY Aubagio 14MG OR TABS MULTIPLE SCLEROSIS No Response 1 3963 NEUROLOGY Avonex MULTIPLE SCLEROSIS AGENT Approval 3 3963 NEUROLOGY Bafiertam MULTIPLE SCLEROSIS Approval 1 3963 INTERNAL MEDICINE Benlysta LUPUS THERAPY Approval 1 3963 RHEUMATOLOGY Benlysta LUPUS THERAPY Approval 2 3969 RHEUMATOLOGY Benlysta LUPUS THERAPY Approval 1 3963 RHEUMATOLOGY Benlysta LUPUS THERAPY No Response 1 3963 RHEUMATOLOGY Benlysta LUPUS THERAPY Denial 1 3969 UNSPECIFIED Benlysta LUPUS THERAPY Approval 1 3963 UNSPECIFIED Benlysta LUPUS THERAPY No Response 1 3963 UNSPECIFIED Benlysta LUPUS THERAPY Approval 1 3963 UNSPECIFIED Benlysta LUPUS THERAPY Denial 1 3963 INTERNAL MEDICINE Bosulif ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY Braftovi ANTINEOPLASTICS Approval 1 3969 INTERNAL MEDICINE Braftovi ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY Cabometyx ANTINEOPLASTICS Approval 1 3956 INTERNAL MEDICINE Cabometyx ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED Cabometyx ANTINEOPLASTICS Approval 1 3951 HEMATOLOGY & ONCOLOGY Calquence ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY Calquence Capsule ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY Calquence Tablet ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY Calquence Tablet ANTINEOPLASTICS Approval 1 3963 INTERNAL MEDICINE Calquence Tablet ANTINEOPLASTICS Approval 1 3956 INTERNAL MEDICINE Calquence Tablet ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY capecitabine ANTINEOPLASTICS Denial 1 3964 HEMATOLOGY & ONCOLOGY capecitabine ANTINEOPLASTICS No Response 1 3963 HEMATOLOGY & ONCOLOGY capecitabine ANTINEOPLASTICS Approval 6 3956 HEMATOLOGY & ONCOLOGY capecitabine ANTINEOPLASTICS Approval 11 3956 HEMATOLOGY & ONCOLOGY capecitabine ANTINEOPLASTICS Denial 1 3956 HEMATOLOGY & ONCOLOGY capecitabine ANTINEOPLASTICS No Response 1 3963 HEMATOLOGY & ONCOLOGY capecitabine ANTINEOPLASTICS No Response 1 3964 HEMATOLOGY & ONCOLOGY capecitabine ANTINEOPLASTICS Approval 1 3951 HEMATOLOGY & ONCOLOGY capecitabine ANTINEOPLASTICS Denial 1

3 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 INTERNAL MEDICINE capecitabine ANTINEOPLASTICS Approval 2 3956 INTERNAL MEDICINE capecitabine ANTINEOPLASTICS Approval 1 3963 INTERNAL MEDICINE capecitabine ANTINEOPLASTICS No Response 1 3956 INTERNAL MEDICINE capecitabine ANTINEOPLASTICS Denial 1 3956 MEDICAL ONCOLOGY capecitabine ANTINEOPLASTICS Approval 3 3956 MEDICAL ONCOLOGY capecitabine ANTINEOPLASTICS No Response 1 3963 MEDICAL ONCOLOGY capecitabine ANTINEOPLASTICS No Response 1 3951 MEDICAL ONCOLOGY capecitabine ANTINEOPLASTICS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH capecitabine ANTINEOPLASTICS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED capecitabine ANTINEOPLASTICS Approval 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL capecitabine ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED capecitabine ANTINEOPLASTICS Approval 3 3956 UNSPECIFIED capecitabine ANTINEOPLASTICS Approval 2 3951 UNSPECIFIED capecitabine ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY Capecitabine 500MG OR TABS ANTINEOPLASTICS No Response 1 3956 HEMATOLOGY & ONCOLOGY Capecitabine 500MG OR TABS ANTINEOPLASTICS No Response 1 3956 HEMATOLOGY & ONCOLOGY Capecitabine 500MG OR TABS ANTINEOPLASTICS Denial 1 3963 UNSPECIFIED Capecitabine 500MG OR TABS ANTINEOPLASTICS Approval 1 3956 PULMONOLOGY, PEDIATRIC Cayston ANTIBIOTIC No Response 1 3956 PULMONOLOGY, PEDIATRIC Cayston ANTIBIOTIC Approval 1 3963 FAMILY PRACTICE cinacalcet THYROID PRODUCT Denial 1 3969 INTERNAL MEDICINE cinacalcet THYROID PRODUCT Approval 1 3951 NEPHROLOGY / RENAL MEDICINE cinacalcet THYROID PRODUCT Approval 1 3963 NEPHROLOGY / RENAL MEDICINE cinacalcet THYROID PRODUCT Denial 2 3956 NEPHROLOGY / RENAL MEDICINE cinacalcet THYROID PRODUCT Approval 4 3965 NEPHROLOGY / RENAL MEDICINE cinacalcet THYROID PRODUCT Denial 2 3964 NEPHROLOGY / RENAL MEDICINE cinacalcet THYROID PRODUCT No Response 1 3951 PHYSICIAN, ENDOCRINOLOGY cinacalcet THYROID PRODUCT Approval 1 3956 UNSPECIFIED cinacalcet THYROID PRODUCT No Response 1 3963 UNSPECIFIED cinacalcet THYROID PRODUCT Denial 1 3956 UNSPECIFIED cinacalcet THYROID PRODUCT Approval 1 3963 UNSPECIFIED cinacalcet THYROID PRODUCT Approval 1 3956 UNSPECIFIED cinacalcet THYROID PRODUCT Denial 1 3956 NEPHROLOGY / RENAL MEDICINE Cinacalcet HCl 30MG OR TABS THYROID PRODUCT No Response 2 3956 NEUROLOGY Copaxone 40mg MULTIPLE SCLEROSIS No Response 2 3963 NEUROLOGY Copaxone 40mg MULTIPLE SCLEROSIS Denial 2 3963 NEUROLOGY Copaxone 40mg MULTIPLE SCLEROSIS Approval 1

4 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3964 NEUROLOGY Copaxone 40mg MULTIPLE SCLEROSIS Approval 1 3956 DERMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Denial 6 3969 DERMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3963 DERMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Approval 4 3963 DERMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS No Response 4 3963 DERMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Denial 5 3951 DERMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS No Response 1 3951 DERMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3961 DERMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3956 DERMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3969 FAMILY PRACTICE Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3956 FAMILY PRACTICE Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3963 FAMILY PRACTICE Cosentyx ALL OTHER DERMATOLOGICALS No Response 1 3961 FAMILY PRACTICE Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3956 INTERNAL MEDICINE Cosentyx ALL OTHER DERMATOLOGICALS No Response 1 3963 INTERNAL MEDICINE Cosentyx ALL OTHER DERMATOLOGICALS No Response 1 3956 INTERNAL MEDICINE Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3951 NURSE PRACTITIONER, FAMILY HEALTH Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3961 NURSE PRACTITIONER, UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3951 PEDIATRICS Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3965 PHYSICIAN ASSISTANT, UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3961 PHYSICIAN ASSISTANT, UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Denial 3 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS No Response 2 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3963 RHEUMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS No Response 5 3956 RHEUMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Denial 3 3963 RHEUMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Approval 6 3956 RHEUMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Approval 7 3951 RHEUMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS No Response 1 3951 RHEUMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3963 RHEUMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3956 RHEUMATOLOGY Cosentyx ALL OTHER DERMATOLOGICALS No Response 1

5 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Approval 5 3956 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Approval 2 3964 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3964 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Approval 2 3956 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Denial 3 3963 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Denial 3 3963 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS No Response 4 3951 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3965 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS No Response 3 3965 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Denial 1 3965 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS Approval 1 3956 UNSPECIFIED Cosentyx ALL OTHER DERMATOLOGICALS No Response 1 3963 UNSPECIFIED Cosentyx (300 MG Dose) 150MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY COSENTYX 150MG/ML PEN 2PK IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 DERMATOLOGY COSENTYX 150MG/ML PEN 2PK IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY COSENTYX 150MG/ML PEN 2PK IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 DERMATOLOGY Cosentyx Sensoready (300 MG) 150MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 DERMATOLOGY Cosentyx Sensoready (300 MG) 150MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 INTERNAL MEDICINE Cosentyx Sensoready (300 MG) 150MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS Denial 1 3965 DERMATOLOGY Cosentyx Sensoready Pen 150MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 INTERNAL MEDICINE Cosentyx Sensoready Pen 150MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 RHEUMATOLOGY Cosentyx Sensoready Pen 150MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 HEMATOLOGY Cotellic ANTINEOPLASTICS Approval 1 3963 NEUROLOGY dalfampridine ER MULTIPLE SCLEROSIS Approval 1 3956 NEUROLOGY dalfampridine ER MULTIPLE SCLEROSIS Approval 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED dalfampridine ER MULTIPLE SCLEROSIS Approval 1 3961 PHYSICIAN ASSISTANT, UNSPECIFIED dalfampridine ER MULTIPLE SCLEROSIS Approval 1 3963 PHYSICIAN, PHYSICAL MEDICINE & REHABILITA­ TION / PHYSIATRY dalfampridine ER MULTIPLE SCLEROSIS Approval 1 3963 PHYSICIAN, PHYSICAL MEDICINE & REHABILITA­ TION / PHYSIATRY dalfampridine ER MULTIPLE SCLEROSIS No Response 1 3963 NEUROLOGY Dalfampridine ER (Dalfampridine) 10 MG Oral Tablet MULTIPLE SCLEROSIS No Response 1 3956 UNSPECIFIED Dalfampridine ER 10MG OR TB12 MULTIPLE SCLEROSIS Approval 1 3962 NURSE PRACTITIONER, GERONTOLOGY deferasirox CHELATING AGENT Approval 1 3956 HEMATOLOGY & ONCOLOGY deferiprone CHELATING AGENT Denial 1 3956 NEUROLOGY dimethyl fumarate Multiple Sclerosis Approval 2 3963 NEUROLOGY dimethyl fumarate Multiple Sclerosis Approval 1 3951 NEUROLOGY dimethyl fumarate Multiple Sclerosis Approval 1

6 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 UNSPECIFIED dimethyl fumarate Multiple Sclerosis Approval 1 3951 UNSPECIFIED dimethyl fumarate Multiple Sclerosis No Response 1 3956 CARDIOLOGY dofetilide CARDIOVASCULAR AGENTS Approval 4 3951 CARDIOLOGY dofetilide CARDIOVASCULAR AGENTS Approval 2 3963 CARDIOLOGY dofetilide CARDIOVASCULAR AGENTS No Response 1 3963 CARDIOLOGY dofetilide CARDIOVASCULAR AGENTS Approval 1 3963 FAMILY PRACTICE dofetilide CARDIOVASCULAR AGENTS Denial 1 3956 INTERNAL MEDICINE dofetilide CARDIOVASCULAR AGENTS Approval 1 3963 INTERNAL MEDICINE dofetilide CARDIOVASCULAR AGENTS Approval 1 3961 NURSE PRACTITIONER, UNSPECIFIED dofetilide CARDIOVASCULAR AGENTS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED dofetilide CARDIOVASCULAR AGENTS Approval 1 3951 NURSE PRACTITIONER, UNSPECIFIED dofetilide CARDIOVASCULAR AGENTS No Response 1 3963 PHYSICIAN, CARDIAC ELECTROPHYSIOLOGY dofetilide CARDIOVASCULAR AGENTS No Response 1 3963 PHYSICIAN, CARDIAC ELECTROPHYSIOLOGY dofetilide CARDIOVASCULAR AGENTS Approval 1 3956 PHYSICIAN, CARDIAC ELECTROPHYSIOLOGY dofetilide CARDIOVASCULAR AGENTS Approval 2 3963 HEMATOLOGY & ONCOLOGY Doptelet HEMATOPOIETIC AGENT Approval 1 3964 UNSPECIFIED Doptelet HEMATOPOIETIC AGENT Approval 1 3963 UNSPECIFIED Doptelet HEMATOPOIETIC AGENT Denial 1 3963 UNSPECIFIED Doptelet 20MG OR TABS HEMATOPOIETIC AGENT No Response 1 3951 NEUROLOGY Duopa ANTIPARKINSON AGENT Approval 4 3963 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 6 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 Approval 6 3963 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 5 3956 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 3 3969 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3956 ALLERGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 ALLERGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3951 ALLERGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 ALLERGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3951 ALLERGY & IMMUNOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3963 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 4 3956 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 13 3951 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 2 3951 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 3

7 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3965 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3963 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 10 3961 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3956 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 7 3962 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3969 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3961 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 4 3969 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3956 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3951 DERMATOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 EMERGENCY MEDICINE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 EMERGENCY MEDICINE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 FAMILY PRACTICE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3963 FAMILY PRACTICE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3956 FAMILY PRACTICE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3964 FAMILY PRACTICE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3964 FAMILY PRACTICE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3956 GASTROENTEROLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 GENERAL PRACTICE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 GENERAL PRACTICE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3956 GENERAL PRACTICE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3956 INTERNAL MEDICINE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 2 3956 INTERNAL MEDICINE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 INTERNAL MEDICINE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3956 INTERNAL MEDICINE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 INTERNAL MEDICINE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3951 INTERNAL MEDICINE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3962 NURSE PRACTITIONER, ACUTE CARE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 NURSE PRACTITIONER, ACUTE CARE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 2 3962 NURSE PRACTITIONER, ACUTE CARE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 NURSE PRACTITIONER, ACUTE CARE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3951 NURSE PRACTITIONER, FAMILY HEALTH Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 3 3956 NURSE PRACTITIONER, FAMILY HEALTH Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3956 NURSE PRACTITIONER, FAMILY HEALTH Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 3

8 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 NURSE PRACTITIONER, FAMILY HEALTH Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 NURSE PRACTITIONER, PEDIATRIC CARE Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3951 NURSE PRACTITIONER, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3956 OTOLARYNGOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 9 3963 OTOLARYNGOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 5 3965 OTOLARYNGOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 OTOLARYNGOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 3 3956 OTOLARYNGOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 5 3951 OTOLARYNGOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 3 3956 OTOLARYNGOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 3 3961 OTOLARYNGOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3962 OTOLARYNGOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 OTOLARYNGOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3951 OTOLARYNGOLOGY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 PEDIATRICS Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3963 PEDIATRICS Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 2 3956 PEDIATRICS Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 3 3951 PEDIATRICS Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 12 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 16 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 3 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 3 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 5 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 17 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 11 3964 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3962 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3956 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 3 3956 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3961 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 PSYCHIATRY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 PSYCHIATRY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3956 PSYCHIATRY Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 PULMONARY DISEASES Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 3 3956 PULMONARY DISEASES Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3956 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 20

9 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 4 3963 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 11 3956 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 9 3961 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3951 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 3 3963 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 16 3963 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 20 3951 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 7 3956 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 9 3965 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3962 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3962 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3969 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 3 3965 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 3 3964 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3964 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3962 UNSPECIFIED Dupixent IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3956 INTERNAL MEDICINE Dupixent 200MG/1.14ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3961 OTOLARYNGOLOGY Dupixent 300 MG/2ML Subcutaneous Solution Pen-in­ jector (Dupilumab) IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 DERMATOLOGY DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3951 DERMATOLOGY DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3965 DERMATOLOGY DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 DERMATOLOGY DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3951 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 2 3964 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 UNSPECIFIED DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 3 3963 INTERNAL MEDICINE DUPIXENT 300MG/2ML PFS 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 ALLERGY & IMMUNOLOGY Dupixent 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3965 EMERGENCY MEDICINE Dupixent 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 FAMILY PRACTICE Dupixent 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 INTERNAL MEDICINE Dupixent 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3963 OTOLARYNGOLOGY Dupixent 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 OTOLARYNGOLOGY Dupixent 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3963 PEDIATRICS Dupixent 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1

10 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 3 3963 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC Dupixent 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3969 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 3956 UNSPECIFIED Dupixent 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 FAMILY PRACTICE Dupixent 300MG/2ML SC SOSY IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3969 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent 300MG/2ML SC SOSY IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Dupixent 300MG/2ML SC SOSY IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 UNSPECIFIED Dupixent 300MG/2ML SC SOSY IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 UROLOGY Eligard 22.5MG SC KIT ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY Eligard 30mg ANTINEOPLASTICS Approval 1 3963 DERMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 DERMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 FAMILY PRACTICE Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 FAMILY PRACTICE Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 INTERNAL MEDICINE Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 6 3963 INTERNAL MEDICINE Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 3 3963 INTERNAL MEDICINE Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 INTERNAL MEDICINE Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 3 3961 INTERNAL MEDICINE Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 NURSE PRACTITIONER, FAMILY HEALTH Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 NURSE PRACTITIONER, FAMILY HEALTH Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 NURSE PRACTITIONER, UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3961 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Denial 6 3956 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 19 3961 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 20 3951 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 5 3963 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 9 3956 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 5 3963 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3964 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 1

11 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 RHEUMATOLOGY Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 9 3963 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 4 3956 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Denial 3 3956 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 10 3965 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 13 3951 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3951 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3961 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3964 UNSPECIFIED Enbrel 50mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED Enbrel 50MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 DERMATOLOGY ENBREL SURECLICK 50MG/ML INJ IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 FAMILY PRACTICE Enbrel SureClick 50MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 RHEUMATOLOGY Enbrel SureClick 50MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 RHEUMATOLOGY Enbrel SureClick 50MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED Enbrel SureClick 50MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 5 3963 RHEUMATOLOGY ENBREL SURECLICK PEN 50 MG/ML IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 GASTROENTEROLOGY entecavir ANTIVIRALS Approval 2 3963 GASTROENTEROLOGY entecavir ANTIVIRALS Approval 1 3951 INTERNAL MEDICINE entecavir ANTIVIRALS No Response 1 3951 INTERNAL MEDICINE entecavir ANTIVIRALS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH entecavir ANTIVIRALS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED entecavir ANTIVIRALS Denial 1 3956 NURSE PRACTITIONER, UNSPECIFIED entecavir ANTIVIRALS Approval 1 3956 UNSPECIFIED entecavir ANTIVIRALS Approval 2 3951 FAMILY PRACTICE Epidiolex ANTICONVULSANTS Denial 2 3969 NEUROLOGY, PEDIATRIC Epidiolex ANTICONVULSANTS Denial 2 3963 NEUROLOGY, PEDIATRIC Epidiolex ANTICONVULSANTS Approval 2 3963 UNSPECIFIED Epidiolex ANTICONVULSANTS Denial 2 3961 UNSPECIFIED Erleada ANTINEOPLASTICS Approval 1 3964 UNSPECIFIED Erleada ANTINEOPLASTICS No Response 1 3964 UNSPECIFIED Erleada ANTINEOPLASTICS Approval 2 3956 NURSE PRACTITIONER, FAMILY HEALTH Erleada 60MG OR TABS ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY erlotinib ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED erlotinib ANTINEOPLASTICS Denial 1

12 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 UNSPECIFIED Erlotinib HCl 25MG OR TABS ANTINEOPLASTICS No Response 1 3963 ORTHOPEDIC SURGERY Euflexxa ANTIRHEUMATIC Approval 1 3963 MEDICAL ONCOLOGY everolimus 10 mg ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED everolimus 10 mg ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY everolimus 5 mg ANTINEOPLASTICS Approval 1 3951 HEMATOLOGY & ONCOLOGY everolimus 5 mg ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY everolimus 7.5 mg ANTINEOPLASTICS No Response 1 3965 HEMATOLOGY & ONCOLOGY everolimus 7.5 mg ANTINEOPLASTICS No Response 1 3963 HEMATOLOGY & ONCOLOGY, PEDIATRIC everolimus 7.5 mg ANTINEOPLASTICS Approval 1 3963 INTERNAL MEDICINE everolimus 7.5 mg ANTINEOPLASTICS No Response 1 3963 UNSPECIFIED Extavia MULTIPLE SCLEROSIS AGENT No Response 8 3963 ALLERGY & IMMUNOLOGY Fasenra RESPIRATORY AGENTS Approval 1 3963 INTERNAL MEDICINE Fasenra RESPIRATORY AGENTS Approval 1 3969 INTERNAL MEDICINE Fasenra RESPIRATORY AGENTS Denial 1 3951 INTERNAL MEDICINE Fasenra RESPIRATORY AGENTS Approval 1 3956 INTERNAL MEDICINE Fasenra RESPIRATORY AGENTS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Fasenra RESPIRATORY AGENTS Approval 1 3951 PULMONARY DISEASES Fasenra RESPIRATORY AGENTS No Response 1 3956 PULMONARY DISEASES Fasenra RESPIRATORY AGENTS Denial 2 3956 PULMONARY DISEASES Fasenra RESPIRATORY AGENTS Approval 2 3963 PULMONARY DISEASES Fasenra RESPIRATORY AGENTS Denial 1 3951 PULMONARY DISEASES Fasenra RESPIRATORY AGENTS Denial 1 3963 PULMONARY DISEASES Fasenra RESPIRATORY AGENTS Approval 1 3956 UNSPECIFIED Fasenra RESPIRATORY AGENTS Approval 2 3956 UNSPECIFIED Fasenra RESPIRATORY AGENTS No Response 1 3963 UNSPECIFIED Fasenra RESPIRATORY AGENTS Denial 1 3951 UNSPECIFIED Fasenra RESPIRATORY AGENTS Approval 2 3951 UNSPECIFIED Fasenra RESPIRATORY AGENTS No Response 1 3956 UNSPECIFIED Fasenra RESPIRATORY AGENTS Denial 1 3951 UNSPECIFIED Fasenra RESPIRATORY AGENTS Denial 1 3963 UNSPECIFIED Fasenra RESPIRATORY AGENTS No Response 1 3963 UNSPECIFIED Fasenra RESPIRATORY AGENTS Approval 1 3956 PULMONARY DISEASES FASENRA PEN 30MG/ML INJ RESPIRATORY AGENTS Approval 1 3951 UNSPECIFIED fingolimod MULTIPLE SCLEROSIS AGENT Approval 1 3963 INTERNAL MEDICINE Forteo OSTEOPOROSIS Denial 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Forteo OSTEOPOROSIS Approval 1 3963 OBSTETRICS & GYNECOLOGY Forteo OSTEOPOROSIS Denial 1

13 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 UNSPECIFIED Forteo OSTEOPOROSIS Approval 1 3963 UNSPECIFIED Forteo OSTEOPOROSIS No Response 1 3956 MEDICAL ONCOLOGY Fulphila 6MG/0.6ML SC SOSY HEMATOPOIETIC AGENT No Response 1 3951 HEMATOLOGY & ONCOLOGY fulvestrant ANTINEOPLASTICS Approval 2 3956 HEMATOLOGY & ONCOLOGY fulvestrant ANTINEOPLASTICS Approval 4 3963 UNSPECIFIED Galafold PHARMACOLOGIC CHAPERONE Approval 1 3963 UNSPECIFIED Gavreto ANTINEOPLASTICS Approval 1 3956 EMERGENCY MEDICINE, PEDIATRIC Genotropin GROWTH HORMONE THERAPY Denial 1 3956 EMERGENCY MEDICINE, PEDIATRIC Genotropin GROWTH HORMONE THERAPY Approval 1 3963 ENDOCRINOLOGY, PEDIATRIC Genotropin GROWTH HORMONE THERAPY Approval 2 3963 PEDIATRICS Genotropin GROWTH HORMONE THERAPY Denial 1 3963 PHYSICIAN, ENDOCRINOLOGY Genotropin GROWTH HORMONE THERAPY Approval 1 3963 UNSPECIFIED Genotropin GROWTH HORMONE THERAPY Approval 2 3963 UNSPECIFIED Genotropin GROWTH HORMONE THERAPY No Response 1 3956 UNSPECIFIED Genotropin GROWTH HORMONE THERAPY Denial 1 3964 UNSPECIFIED Genotropin GROWTH HORMONE THERAPY Approval 3 3961 UNSPECIFIED Genotropin GROWTH HORMONE THERAPY Approval 1 3964 UNSPECIFIED Genotropin GROWTH HORMONE THERAPY No Response 1 3963 UNSPECIFIED Genotropin GROWTH HORMONE THERAPY Denial 1 3963 NEUROLOGY Gilenya MULTIPLE SCLEROSIS Approval 2 3963 NEUROLOGY Gilenya MULTIPLE SCLEROSIS No Response 1 3956 NEUROLOGY Gilenya MULTIPLE SCLEROSIS Denial 1 3956 NEUROLOGY Gilenya MULTIPLE SCLEROSIS Approval 1 3951 UNSPECIFIED Gilenya MULTIPLE SCLEROSIS Approval 1 3963 NEUROLOGY glatiramer acetate 20mg MULTIPLE SCLEROSIS Denial 1 3963 NEUROLOGY glatiramer acetate 20mg MULTIPLE SCLEROSIS Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED glatiramer acetate 20mg MULTIPLE SCLEROSIS No Response 1 3963 UNSPECIFIED glatiramer acetate 20mg MULTIPLE SCLEROSIS Approval 1 3956 FAMILY PRACTICE glatiramer acetate 40mg MULTIPLE SCLEROSIS Approval 1 3963 NEUROLOGY glatiramer acetate 40mg MULTIPLE SCLEROSIS Approval 4 3963 NEUROLOGY glatiramer acetate 40mg MULTIPLE SCLEROSIS Denial 1 3963 NEUROLOGY glatiramer acetate 40mg MULTIPLE SCLEROSIS No Response 1 3956 NEUROLOGY glatiramer acetate 40mg MULTIPLE SCLEROSIS Approval 1 3956 NEUROLOGY glatiramer acetate 40mg MULTIPLE SCLEROSIS No Response 1 3962 NEUROLOGY glatiramer acetate 40mg MULTIPLE SCLEROSIS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED glatiramer acetate 40mg MULTIPLE SCLEROSIS Approval 1 3963 UNSPECIFIED glatiramer acetate 40mg MULTIPLE SCLEROSIS No Response 3

14 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 UNSPECIFIED glatiramer acetate 40mg MULTIPLE SCLEROSIS Approval 3 3956 UNSPECIFIED glatiramer acetate 40mg MULTIPLE SCLEROSIS Approval 1 3956 UNSPECIFIED glatiramer acetate 40mg MULTIPLE SCLEROSIS No Response 1 3961 UNSPECIFIED glatiramer acetate 40mg MULTIPLE SCLEROSIS No Response 1 3963 NEUROLOGY Glatiramer Acetate 40MG/ML SC SOSY MULTIPLE SCLEROSIS No Response 2 3963 NEUROLOGY Glatiramer Acetate 40MG/ML SC SOSY MULTIPLE SCLEROSIS Approval 1 3961 NEUROLOGY Glatopa MULTIPLE SCLEROSIS AGENT Approval 1 3956 NEUROLOGY Glatopa MULTIPLE SCLEROSIS AGENT Approval 1 3963 HEMATOLOGY & ONCOLOGY Gleevec ANTINEOPLASTICS Denial 1 3963 PEDIATRICS Hemlibra HEMOPHILIA AGENT No Response 1 3963 UNSPECIFIED Hemlibra HEMOPHILIA AGENT Denial 1 3963 NURSE PRACTITIONER, PSYCHIATRIC Hetlioz SEDATIVES/HYPNOTICS Denial 1 3963 ALLERGY & IMMUNOLOGY Hizentra IMMUNE GLOBULIN Approval 2 3963 UNSPECIFIED Hizentra IMMUNE GLOBULIN Approval 1 3956 RHEUMATOLOGY Humira ANTIARTHRITICS Approval 1 3956 UNSPECIFIED Humira ANTIARTHRITICS Approval 1 3963 UNSPECIFIED Humira 10 mg ANTIARTHRITICS Approval 1 3963 DERMATOLOGY Humira 20 mg ANTIRHEUMATIC No Response 1 3963 DERMATOLOGY Humira 20 mg ANTIRHEUMATIC Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Humira 20 mg ANTIRHEUMATIC Denial 1 3956 RHEUMATOLOGY Humira 20 mg ANTIRHEUMATIC Denial 1 3963 UNSPECIFIED Humira 20 mg ANTIRHEUMATIC Approval 1 3963 FAMILY PRACTICE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3963 FAMILY PRACTICE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 CLINICAL NURSE SPECIALIST, FAMILY HEALTH Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 DERMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 DERMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3962 DERMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3962 DERMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 DERMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3951 DERMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 FAMILY PRACTICE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 FAMILY PRACTICE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3956 FAMILY PRACTICE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 FAMILY PRACTICE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 FAMILY PRACTICE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3964 FAMILY PRACTICE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1

15 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 6 3963 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 13 3956 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 17 3956 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 6 3961 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 8 3964 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3961 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3969 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3969 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3965 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3964 GASTROENTEROLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 GENERAL PRACTICE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 GENERAL PRACTICE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 INTERNAL MEDICINE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 3 3963 INTERNAL MEDICINE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 8 3963 INTERNAL MEDICINE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 3 3956 INTERNAL MEDICINE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 3 3962 INTERNAL MEDICINE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 INTERNAL MEDICINE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 5 3962 INTERNAL MEDICINE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 INTERNAL MEDICINE Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 3 3963 NURSE PRACTITIONER, ADULT HEALTH Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 4 3956 NURSE PRACTITIONER, FAMILY HEALTH Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 5 3956 NURSE PRACTITIONER, FAMILY HEALTH Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 NURSE PRACTITIONER, FAMILY HEALTH Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 NURSE PRACTITIONER, UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3951 NURSE PRACTITIONER, UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 PEDIATRICS Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 PEDIATRICS Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2

16 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3961 PHYSICIAN ASSISTANT, UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3951 PSYCHIATRY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 PSYCHIATRY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 35 3965 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3965 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3956 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 27 3963 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 11 3956 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 7 3964 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 4 3951 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 4 3963 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 11 3956 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 6 3961 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 3 3961 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3961 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3964 RHEUMATOLOGY Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 19 3963 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 11 3956 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 11 3965 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3965 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 26 3963 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 7 3956 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 6 3964 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3964 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3965 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3962 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 4 3951 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3951 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3961 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3961 UNSPECIFIED Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY Humira 40MG/0.4ML SC PSKT IMMUNOSUPPRESSIVES/DMARDS No Response 1

17 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 DERMATOLOGY Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3969 DERMATOLOGY Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 GASTROENTEROLOGY Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 INTERNAL MEDICINE Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3962 NURSE PRACTITIONER, FAMILY HEALTH Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 RHEUMATOLOGY Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3964 UNSPECIFIED PHYSICIAN, INTERN/RESIDENT/FEL­ LOW, UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Denial 3 3963 UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Denial 3 3951 UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 NURSE PRACTITIONER, ACUTE CARE HUMIRA CD/UC/HS PACK CF 80MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3962 DERMATOLOGY Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 GASTROENTEROLOGY Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 NURSE PRACTITIONER, ACUTE CARE Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 NURSE PRACTITIONER, FAMILY HEALTH Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3963 UNSPECIFIED Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3963 UNSPECIFIED Humira Crohn?s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS No Response 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 Approval 1 3963 INTERNAL MEDICINE 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 3956 UNSPECIFIED Humira Crohns/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED Humira Crohns/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 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 Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Humira Crohn’s/UC/HS Starter Pack + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY Humira Crohns/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1

18 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 DERMATOLOGY Humira Crohns/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 GASTROENTEROLOGY Humira Crohns/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Humira Crohns/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED Humira Crohns/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Humira Crohn’s/UC/HS Starter Pack + Humira 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 NURSE PRACTITIONER, UNSPECIFIED Humira Ped. Crohn’s 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 3956 GASTROENTEROLOGY Humira Ped. UC Starter Pack + 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED Humira Ped. UC Starter Pack + 80 mg IMMUNOSUPPRESSIVES/DMARDS No Response 10 3964 UNSPECIFIED Humira Ped. UC Starter Pack + 80 mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 UNSPECIFIED Humira Ped. UC Starter Pack + 80 mg IMMUNOSUPPRESSIVES/DMARDS No Response 11 3951 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 3951 UNSPECIFIED Humira Ped. UC Starter Pack + 80 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 RHEUMATOLOGY HUMIRA PEN 40 MG/0.4ML NO CITR IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 RHEUMATOLOGY HUMIRA PEN 40 MG/0.4ML NO CITR IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 DERMATOLOGY Humira Pen 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 FAMILY PRACTICE Humira Pen 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3969 GASTROENTEROLOGY Humira Pen 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 INTERNAL MEDICINE Humira Pen 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 3 3956 INTERNAL MEDICINE Humira Pen 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 PEDIATRICS Humira Pen 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 RHEUMATOLOGY Humira Pen 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 RHEUMATOLOGY Humira Pen 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 RHEUMATOLOGY Humira Pen 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED Humira Pen 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED 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 No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Humira Pen-CD/UC/HS Starter 80MG/0.8ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED Humira Pen-CD/UC/HS Starter 80MG/0.8ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 UNSPECIFIED Humira Pen-CD/UC/HS Starter 80MG/0.8ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 UNSPECIFIED Humira Pen-Psor/Uveit Starter 80 MG/0.8ML &40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 DERMATOLOGY HUMIRA PS/UV/ADOL HS KIT CF IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY Humira PsO/UV/Adolescent HS + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3951 NURSE PRACTITIONER, FAMILY HEALTH Humira PsO/UV/Adolescent HS + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Humira PsO/UV/Adolescent HS + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1

19 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 NURSE PRACTITIONER, FAMILY HEALTH Humira PsO/UV/Adolescent HS + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3965 UNSPECIFIED Humira PsO/UV/Adolescent HS + Humira 40 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 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 2 3956 ALLERGY & IMMUNOLOGY HyQvia IMMUNE GLOBULIN Approval 1 3963 ALLERGY & IMMUNOLOGY HyQvia IMMUNE GLOBULIN No Response 1 3956 ALLERGY & IMMUNOLOGY HyQvia IMMUNE GLOBULIN No Response 1 3956 PEDIATRICS HyQvia IMMUNE GLOBULIN Denial 1 3963 PEDIATRICS HyQvia IMMUNE GLOBULIN No Response 1 3963 UNSPECIFIED HyQvia IMMUNE GLOBULIN Approval 1 3956 ALLERGY & IMMUNOLOGY Hyqvia 20GM/200ML SC KIT IMMUNE GLOBULIN No Response 1 3956 HEMATOLOGY Ibrance ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY Ibrance ANTINEOPLASTICS Approval 6 3963 HEMATOLOGY & ONCOLOGY Ibrance ANTINEOPLASTICS Approval 2 3956 HEMATOLOGY & ONCOLOGY Ibrance ANTINEOPLASTICS No Response 1 3964 HEMATOLOGY & ONCOLOGY Ibrance ANTINEOPLASTICS No Response 1 3956 INTERNAL MEDICINE Ibrance ANTINEOPLASTICS No Response 1 3963 INTERNAL MEDICINE Ibrance ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED Ibrance ANTINEOPLASTICS No Response 1 3963 UNSPECIFIED Ibrance ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED Ilaris ANTIRHEUMATIC Approval 4 3951 HEMATOLOGY imatinib mesylate ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY imatinib mesylate ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY imatinib mesylate ANTINEOPLASTICS No Response 2 3956 HEMATOLOGY & ONCOLOGY imatinib mesylate ANTINEOPLASTICS Approval 2 3963 HEMATOLOGY & ONCOLOGY imatinib mesylate ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY imatinib mesylate ANTINEOPLASTICS Denial 1 3963 HEMATOLOGY & ONCOLOGY imatinib mesylate ANTINEOPLASTICS No Response 1 3951 UNSPECIFIED imatinib mesylate ANTINEOPLASTICS No Response 1 3956 UNSPECIFIED imatinib mesylate ANTINEOPLASTICS Denial 1 3951 UNSPECIFIED imatinib mesylate ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED imatinib mesylate ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY Imbruvica ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY Imbruvica ANTINEOPLASTICS Approval 2 3963 HEMATOLOGY & ONCOLOGY Imbruvica ANTINEOPLASTICS No Response 1 3965 INTERNAL MEDICINE Imbruvica ANTINEOPLASTICS Approval 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL Imbruvica ANTINEOPLASTICS Approval 1

20 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3965 UNSPECIFIED Imbruvica ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED Imbruvica ANTINEOPLASTICS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH infliximab ANTIRHEUMATIC Approval 1 3956 UNSPECIFIED infliximab ANTIRHEUMATIC Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED Ingrezza 80MG OR CAPS VESICULAR MONOAMINE TRANSPORTER 2 INHIB­ ITOR No Response 4 3956 HEMATOLOGY & ONCOLOGY Inlyta ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY Inlyta ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED Inlyta ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY Jakafi ANTINEOPLASTICS Approval 3 3963 HEMATOLOGY & ONCOLOGY Jakafi ANTINEOPLASTICS Denial 2 3963 HEMATOLOGY & ONCOLOGY Jakafi ANTINEOPLASTICS No Response 1 3965 INTERNAL MEDICINE Jakafi ANTINEOPLASTICS Approval 1 3956 PHYSICIAN, ONCOLOGY, MEDICAL Jakafi ANTINEOPLASTICS Denial 1 3963 NEPHROLOGY / RENAL MEDICINE Jynarque KIDNEY AGENT Approval 1 3963 NURSE PRACTITIONER, PEDIATRIC CARE Kalydeco MISCELLANEOUS Approval 1 3951 FAMILY PRACTICE Kesimpta MULTIPLE SCLEROSIS AGENT Approval 1 3956 NEUROLOGY Kesimpta MULTIPLE SCLEROSIS AGENT Denial 2 3967 NEUROLOGY Kesimpta MULTIPLE SCLEROSIS AGENT Approval 1 3963 NEUROLOGY Kesimpta MULTIPLE SCLEROSIS AGENT Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Kesimpta MULTIPLE SCLEROSIS AGENT No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Kesimpta MULTIPLE SCLEROSIS AGENT Approval 1 3951 UNSPECIFIED Kesimpta MULTIPLE SCLEROSIS AGENT Approval 1 3956 UNSPECIFIED Kesimpta MULTIPLE SCLEROSIS AGENT Denial 1 3963 UNSPECIFIED Kesimpta MULTIPLE SCLEROSIS AGENT Approval 1 3964 UNSPECIFIED Kesimpta MULTIPLE SCLEROSIS AGENT No Response 1 3963 NEUROLOGY Kesimpta 20MG/0.4ML SC SOAJ MULTIPLE SCLEROSIS AGENT Approval 1 3956 NEUROLOGY Kesimpta 20MG/0.4ML SC SOAJ MULTIPLE SCLEROSIS AGENT No Response 2 3956 INTERNAL MEDICINE Kevzara IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 INTERNAL MEDICINE Kevzara IMMUNOSUPPRESSIVES/DMARDS Denial 1 3969 NURSE PRACTITIONER, UNSPECIFIED Kevzara IMMUNOSUPPRESSIVES/DMARDS Approval 1 3962 RHEUMATOLOGY Kevzara IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 RHEUMATOLOGY Kevzara IMMUNOSUPPRESSIVES/DMARDS Approval 3 3963 RHEUMATOLOGY Kevzara IMMUNOSUPPRESSIVES/DMARDS Approval 3 3956 RHEUMATOLOGY Kevzara IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 RHEUMATOLOGY Kevzara IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 UNSPECIFIED Kevzara IMMUNOSUPPRESSIVES/DMARDS No Response 1

21 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 INTERNAL MEDICINE Kevzara 200MG/1.14ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED kineret ANTIRHEUMATIC Denial 1 3956 HEMATOLOGY & ONCOLOGY Kisqali ANTINEOPLASTICS Approval 3 3963 HEMATOLOGY & ONCOLOGY Kisqali ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED Kisqali ANTINEOPLASTICS Approval 1 3962 HEMATOLOGY lenalidomide ANTINEOPLASTICS No Response 1 3956 HEMATOLOGY lenalidomide ANTINEOPLASTICS No Response 1 3956 HEMATOLOGY & ONCOLOGY lenalidomide ANTINEOPLASTICS Approval 2 3956 HEMATOLOGY & ONCOLOGY lenalidomide ANTINEOPLASTICS No Response 2 3963 HEMATOLOGY & ONCOLOGY Lenvima ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY Lenvima ANTINEOPLASTICS No Response 1 3956 INTERNAL MEDICINE Lenvima ANTINEOPLASTICS No Response 1 3963 INTERNAL MEDICINE Lenvima ANTINEOPLASTICS No Response 1 3963 INTERNAL MEDICINE Lenvima ANTINEOPLASTICS Approval 1 3963 MEDICAL ONCOLOGY Lenvima ANTINEOPLASTICS Denial 2 3963 UNSPECIFIED Lenvima ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED Lenvima ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED Lenvima (20 MG Daily Dose) 2 x 10MG OR CPPK ANTINEOPLASTICS No Response 1 3963 UNSPECIFIED leuprolide kit HORMONES No Response 4 3963 UNSPECIFIED leuprolide kit HORMONES Denial 1 3964 UNSPECIFIED leuprolide kit HORMONES No Response 1 3951 UNSPECIFIED leuprolide kit HORMONES Denial 1 3956 UNSPECIFIED leuprolide kit HORMONES No Response 2 3951 UNSPECIFIED leuprolide kit HORMONES No Response 1 3965 HEMATOLOGY & ONCOLOGY Lonsurf ANTINEOPLASTICS Approval 2 3963 HEMATOLOGY & ONCOLOGY Lonsurf ANTINEOPLASTICS Approval 2 3963 INTERNAL MEDICINE Lonsurf ANTINEOPLASTICS Approval 1 3956 CLINICAL NURSE SPECIALIST, FAMILY HEALTH Lupron Depot 3.75 mg HORMONES/HORMONE MODIFIERS Denial 1 3956 OBSTETRICS & GYNECOLOGY Lupron Depot 3.75 mg HORMONES/HORMONE MODIFIERS Approval 1 3963 UNSPECIFIED Lupron Depot 3.75 mg HORMONES/HORMONE MODIFIERS Approval 1 3956 HEMATOLOGY & ONCOLOGY Lynparza ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY Lynparza ANTINEOPLASTICS Approval 2 3951 HEMATOLOGY & ONCOLOGY Lynparza ANTINEOPLASTICS Denial 1 3956 MEDICAL ONCOLOGY Lynparza ANTINEOPLASTICS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Lynparza ANTINEOPLASTICS Denial 2 3963 NURSE PRACTITIONER, FAMILY HEALTH Lynparza ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED Lynparza ANTINEOPLASTICS Approval 1

22 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 UNSPECIFIED Lynparza ANTINEOPLASTICS No Response 1 3956 UNSPECIFIED Lynparza ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED Lynparza ANTINEOPLASTICS Denial 1 3963 UNSPECIFIED Mavenclad MULTIPLE SCLEROSIS AGENT Approval 2 3956 INTERNAL MEDICINE Mekinist ANTINEOPLASTICS No Response 1 3963 HEMATOLOGY & ONCOLOGY Mektovi ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY Neulasta Onpro 6MG/0.6ML SC PSKT HEMATOPOIETIC AGENT Denial 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL Ninlaro ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED Ninlaro ANTINEOPLASTICS Approval 1 3963 DERMATOLOGY Nivestym COLONY STIMULATING FACTORS Denial 1 3956 GASTROENTEROLOGY Nivestym COLONY STIMULATING FACTORS Denial 1 3963 HEMATOLOGY & ONCOLOGY Nivestym COLONY STIMULATING FACTORS Approval 1 3956 HEMATOLOGY & ONCOLOGY Nivestym COLONY STIMULATING FACTORS Approval 1 3963 INTERNAL MEDICINE Nivestym COLONY STIMULATING FACTORS Denial 1 3956 ENDOCRINOLOGY, DIABETES & METABOLISM Norditropin GROWTH HORMONE THERAPY Approval 1 3963 ENDOCRINOLOGY, PEDIATRIC Norditropin GROWTH HORMONE THERAPY No Response 2 3963 ENDOCRINOLOGY, PEDIATRIC Norditropin GROWTH HORMONE THERAPY Approval 3 3969 ENDOCRINOLOGY, PEDIATRIC Norditropin GROWTH HORMONE THERAPY Approval 2 3969 ENDOCRINOLOGY, PEDIATRIC Norditropin GROWTH HORMONE THERAPY No Response 1 3951 ENDOCRINOLOGY, PEDIATRIC Norditropin GROWTH HORMONE THERAPY Approval 1 3963 FAMILY PRACTICE Norditropin GROWTH HORMONE THERAPY Approval 1 3956 FAMILY PRACTICE Norditropin GROWTH HORMONE THERAPY Denial 1 3956 FAMILY PRACTICE Norditropin GROWTH HORMONE THERAPY Approval 1 3963 GENERAL PRACTICE Norditropin GROWTH HORMONE THERAPY Approval 1 3956 GENERAL PRACTICE Norditropin GROWTH HORMONE THERAPY Denial 1 3961 INTERNAL MEDICINE Norditropin GROWTH HORMONE THERAPY Denial 1 3963 PEDIATRICS Norditropin GROWTH HORMONE THERAPY Approval 2 3956 PEDIATRICS Norditropin GROWTH HORMONE THERAPY Denial 1 3963 PEDIATRICS Norditropin GROWTH HORMONE THERAPY No Response 1 3951 PEDIATRICS Norditropin GROWTH HORMONE THERAPY No Response 2 3963 PSYCHIATRY Norditropin GROWTH HORMONE THERAPY Approval 1 3956 PSYCHIATRY Norditropin GROWTH HORMONE THERAPY Denial 1 3951 UNSPECIFIED Norditropin GROWTH HORMONE THERAPY No Response 2 3963 UNSPECIFIED Norditropin GROWTH HORMONE THERAPY No Response 3 3963 UNSPECIFIED Norditropin GROWTH HORMONE THERAPY Approval 3 3963 UNSPECIFIED Norditropin GROWTH HORMONE THERAPY Denial 1 3956 UNSPECIFIED Norditropin GROWTH HORMONE THERAPY No Response 1

23 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 UNSPECIFIED Norditropin GROWTH HORMONE THERAPY Approval 1 3951 HEMATOLOGY & ONCOLOGY Nplate HEMATOPOIETIC AGENT No Response 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Nubeqa ANTINEOPLASTICS Approval 1 3963 UROLOGY Nubeqa ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED Nubeqa ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED Nubeqa 300MG OR TABS ANTINEOPLASTICS No Response 1 3963 ALLERGY & IMMUNOLOGY Nucala MISCELLANEOUS Denial 2 3963 INTERNAL MEDICINE Nucala MISCELLANEOUS Approval 1 3963 INTERNAL MEDICINE Nucala MISCELLANEOUS Denial 1 3963 INTERNAL MEDICINE Nucala MISCELLANEOUS No Response 1 3963 NURSE PRACTITIONER, UNSPECIFIED Nucala MISCELLANEOUS Denial 1 3963 OTOLARYNGOLOGY Nucala MISCELLANEOUS Denial 2 3963 PULMONARY DISEASES Nucala MISCELLANEOUS Denial 2 3963 PULMONARY DISEASES Nucala MISCELLANEOUS No Response 1 3963 PULMONARY DISEASES Nucala MISCELLANEOUS Approval 2 3965 UNSPECIFIED Nucala MISCELLANEOUS No Response 1 3963 ALLERGY & IMMUNOLOGY Nucala 100MG/ML SC SOAJ RESPIRATORY AGENTS No Response 1 3963 ENDOCRINOLOGY, PEDIATRIC Nutropin AQ GROWTH HORMONE No Response 2 3951 UNSPECIFIED Nutropin AQ GROWTH HORMONE No Response 1 3963 UNSPECIFIED Nutropin AQ GROWTH HORMONE No Response 1 3961 UNSPECIFIED Nutropin AQ GROWTH HORMONE No Response 1 3956 UNSPECIFIED Nutropin AQ GROWTH HORMONE No Response 2 3951 PEDIATRICS Nutropin AQ NuSpin 10 10MG/2ML SC SOPN GROWTH HORMONE Denial 1 3963 GASTROENTEROLOGY Ocaliva PRIMARY BILIARY CHOLANGITIS Denial 1 3963 UNSPECIFIED Ocaliva PRIMARY BILIARY CHOLANGITIS No Response 1 3964 UNSPECIFIED Ocaliva PRIMARY BILIARY CHOLANGITIS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Odomzo ANTINEOPLASTICS Approval 1 3969 INTERNAL MEDICINE Ofev TYROSINE KINASE INHIBITOR Approval 1 3956 PULMONARY DISEASES Ofev TYROSINE KINASE INHIBITOR Approval 1 3963 UNSPECIFIED Ofev TYROSINE KINASE INHIBITOR Approval 1 3956 UNSPECIFIED Ofev TYROSINE KINASE INHIBITOR Approval 2 3956 INTERNAL MEDICINE Omnitrope GROWTH HORMONE Denial 1 3963 UNSPECIFIED Onureg ANTINEOPLASTICS Denial 1 3963 UNSPECIFIED Onureg ANTINEOPLASTICS Approval 1 3956 CARDIOLOGY Opsumit PULMONARY ARTERIAL HYPERTENSION Approval 1 3963 CARDIOLOGY Opsumit PULMONARY ARTERIAL HYPERTENSION Approval 1 3963 INTERNAL MEDICINE Opsumit PULMONARY ARTERIAL HYPERTENSION Approval 2

24 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 INTERNAL MEDICINE Opsumit PULMONARY ARTERIAL HYPERTENSION Approval 1 3956 PULMONARY DISEASES Opsumit PULMONARY ARTERIAL HYPERTENSION Approval 1 3964 PULMONARY DISEASES Opsumit PULMONARY ARTERIAL HYPERTENSION Approval 1 3956 UNSPECIFIED Opsumit PULMONARY ARTERIAL HYPERTENSION Denial 1 3956 UNSPECIFIED Opsumit PULMONARY ARTERIAL HYPERTENSION Approval 3 3956 UNSPECIFIED Opsumit 10MG OR TABS VASODILATORS No Response 1 3961 NURSE PRACTITIONER, PEDIATRIC CARE Orkambi CYSTIC FIBROSIS AGENTS Approval 1 3963 FAMILY PRACTICE Otezla 10 & 20 & 30MG OR TBPK IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY OTEZLA 30 MG TABLET 60 IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 DERMATOLOGY OTEZLA 30 MG TABLET 60 IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 DERMATOLOGY OTEZLA 30 MG TABLET 60 IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY OTEZLA 30 MG TABLET 60 IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 9 3963 DERMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 DERMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 3 3961 DERMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3965 DERMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 DERMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 4 3951 DERMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 DERMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3951 DERMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 DERMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 DERMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 FAMILY PRACTICE Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 FAMILY PRACTICE Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3963 FAMILY PRACTICE Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 INTERNAL MEDICINE Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 INTERNAL MEDICINE Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3963 INTERNAL MEDICINE Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 INTERNAL MEDICINE 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 3965 NURSE PRACTITIONER, FAMILY HEALTH Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3951 NURSE PRACTITIONER, FAMILY HEALTH Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 NURSE PRACTITIONER, FAMILY HEALTH Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 3

25 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3969 NURSE PRACTITIONER, FAMILY HEALTH Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 NURSE PRACTITIONER, UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 6 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3961 PHYSICIAN ASSISTANT, UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 3 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 RHEUMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 RHEUMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 6 3956 RHEUMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 5 3964 RHEUMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3964 RHEUMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3965 RHEUMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3961 RHEUMATOLOGY Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3951 UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3964 UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 3 3963 UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3964 UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3965 UNSPECIFIED Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 DERMATOLOGY Otezla 30MG OR TABS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 FAMILY PRACTICE Otezla 30MG OR TABS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Otezla 30MG OR TABS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Otezla 30MG OR TABS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 DERMATOLOGY Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3965 DERMATOLOGY Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 DERMATOLOGY Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 FAMILY PRACTICE Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 FAMILY PRACTICE Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 INTERNAL MEDICINE Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1

26 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 UNSPECIFIED Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3969 UNSPECIFIED Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED Otezla Starter Pack + Otezla 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 FAMILY PRACTICE Otrexup ANTIARTHRITICS Denial 1 3963 NURSE PRACTITIONER, UNSPECIFIED Otrexup ANTIARTHRITICS Approval 1 3963 RHEUMATOLOGY Otrexup ANTIARTHRITICS Denial 1 3963 HEMATOLOGY & ONCOLOGY Piqray ANTINEOPLASTICS Approval 1 3951 INTERNAL MEDICINE Piqray ANTINEOPLASTICS Approval 1 3965 NURSE PRACTITIONER, UNSPECIFIED pirfenidone ANTIFIBROTIC AGENT Approval 1 3963 PULMONARY DISEASES pirfenidone ANTIFIBROTIC AGENT Denial 1 3963 PULMONARY DISEASES pirfenidone ANTIFIBROTIC AGENT Approval 1 3956 PULMONARY DISEASES pirfenidone ANTIFIBROTIC AGENT Approval 1 3956 UNSPECIFIED pirfenidone ANTIFIBROTIC AGENT Approval 1 3965 NURSE PRACTITIONER, UNSPECIFIED pirfenidone IDIOPATHIC PULMONARY FIBROSIS Approval 1 3963 PULMONARY DISEASES pirfenidone IDIOPATHIC PULMONARY FIBROSIS Denial 1 3963 PULMONARY DISEASES pirfenidone IDIOPATHIC PULMONARY FIBROSIS Approval 1 3956 PULMONARY DISEASES pirfenidone IDIOPATHIC PULMONARY FIBROSIS Approval 1 3956 UNSPECIFIED pirfenidone IDIOPATHIC PULMONARY FIBROSIS Approval 1 3956 HEMATOLOGY & ONCOLOGY Pomalyst ANTINEOPLASTICS No Response 1 3965 NEUROLOGY Ponvory MULTIPLE SCLEROSIS Denial 1 3956 CARDIOLOGY Praluent LIPOTROPICS Denial 18 3956 CARDIOLOGY Praluent LIPOTROPICS Approval 6 3965 CARDIOLOGY Praluent LIPOTROPICS No Response 2 3965 CARDIOLOGY Praluent LIPOTROPICS Approval 1 3963 CARDIOLOGY Praluent LIPOTROPICS Approval 10 3963 CARDIOLOGY Praluent LIPOTROPICS No Response 2 3963 CARDIOLOGY Praluent LIPOTROPICS Denial 20 3956 CARDIOLOGY Praluent LIPOTROPICS No Response 1 3962 CARDIOLOGY Praluent LIPOTROPICS Approval 1 3964 CARDIOLOGY Praluent LIPOTROPICS Approval 1 3964 CARDIOLOGY Praluent LIPOTROPICS No Response 1 3964 CARDIOLOGY Praluent LIPOTROPICS Denial 1 3965 CARDIOLOGY Praluent LIPOTROPICS Denial 2 3951 CARDIOLOGY Praluent LIPOTROPICS Denial 2 3961 CARDIOLOGY Praluent LIPOTROPICS Approval 1 3951 CARDIOLOGY Praluent LIPOTROPICS Approval 1 3964 CARDIOLOGY, INTERVENTIONAL Praluent LIPOTROPICS Denial 1

27 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 CARDIOLOGY, INTERVENTIONAL Praluent LIPOTROPICS Denial 1 3951 CARDIOLOGY, INTERVENTIONAL Praluent LIPOTROPICS No Response 1 3951 CARDIOLOGY, INTERVENTIONAL Praluent LIPOTROPICS Denial 1 3951 CARDIOLOGY, INTERVENTIONAL Praluent LIPOTROPICS Approval 1 3956 FAMILY MEDICINE Praluent LIPOTROPICS Denial 2 3956 FAMILY PRACTICE Praluent LIPOTROPICS Denial 6 3963 FAMILY PRACTICE Praluent LIPOTROPICS Denial 4 3956 FAMILY PRACTICE Praluent LIPOTROPICS Approval 1 3956 GENERAL PRACTICE Praluent LIPOTROPICS Denial 1 3956 HOSPITALIST Praluent LIPOTROPICS Denial 1 3963 HOSPITALIST Praluent LIPOTROPICS Denial 1 3956 HOSPITALIST Praluent LIPOTROPICS Approval 1 3962 HOSPITALIST Praluent LIPOTROPICS Denial 1 3951 HOSPITALIST Praluent LIPOTROPICS Denial 1 3951 INTERNAL MEDICINE Praluent LIPOTROPICS Denial 1 3963 INTERNAL MEDICINE Praluent LIPOTROPICS Denial 4 3956 INTERNAL MEDICINE Praluent LIPOTROPICS Denial 2 3963 INTERNAL MEDICINE Praluent LIPOTROPICS No Response 1 3963 INTERNAL MEDICINE Praluent LIPOTROPICS Approval 1 3963 NURSE PRACTITIONER, ACUTE CARE Praluent LIPOTROPICS Denial 1 3963 NURSE PRACTITIONER, ACUTE CARE Praluent LIPOTROPICS No Response 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Praluent LIPOTROPICS Approval 2 3963 NURSE PRACTITIONER, FAMILY HEALTH Praluent LIPOTROPICS Denial 3 3963 NURSE PRACTITIONER, FAMILY HEALTH Praluent LIPOTROPICS No Response 1 3956 NURSE PRACTITIONER, UNSPECIFIED Praluent LIPOTROPICS Denial 3 3963 NURSE PRACTITIONER, UNSPECIFIED Praluent LIPOTROPICS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED Praluent LIPOTROPICS No Response 1 3956 PEDIATRICS Praluent LIPOTROPICS Denial 1 3963 PEDIATRICS Praluent LIPOTROPICS Denial 4 3969 PHYSICIAN ASSISTANT, UNSPECIFIED Praluent LIPOTROPICS Denial 1 3956 PHYSICIAN, ENDOCRINOLOGY Praluent LIPOTROPICS Approval 1 3963 PHYSICIAN, ENDOCRINOLOGY Praluent LIPOTROPICS Denial 3 3963 PHYSICIAN, ENDOCRINOLOGY Praluent LIPOTROPICS Approval 1 3963 PHYSICIAN, ENDOCRINOLOGY Praluent LIPOTROPICS No Response 1 3956 PSYCHIATRY Praluent LIPOTROPICS Denial 1 3963 UNSPECIFIED Praluent LIPOTROPICS Denial 21 3956 UNSPECIFIED Praluent LIPOTROPICS Approval 3

28 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 UNSPECIFIED Praluent LIPOTROPICS Denial 2 3963 UNSPECIFIED Praluent LIPOTROPICS Approval 5 3956 UNSPECIFIED Praluent LIPOTROPICS Denial 9 3965 UNSPECIFIED Praluent LIPOTROPICS Denial 2 3962 UNSPECIFIED Praluent LIPOTROPICS Denial 1 3963 UNSPECIFIED Praluent LIPOTROPICS No Response 2 3963 CARDIOLOGY Praluent 150MG/ML SC SOAJ LIPOTROPICS No Response 2 3956 CARDIOLOGY Praluent 150MG/ML SC SOAJ LIPOTROPICS No Response 3 3963 CARDIOLOGY Praluent 150MG/ML SC SOAJ LIPOTROPICS Denial 1 3963 CARDIOLOGY, INTERVENTIONAL Praluent 150MG/ML SC SOAJ LIPOTROPICS No Response 2 3956 FAMILY MEDICINE Praluent 150MG/ML SC SOAJ LIPOTROPICS No Response 2 3964 FAMILY PRACTICE Praluent 150MG/ML SC SOAJ LIPOTROPICS No Response 1 3963 INTERNAL MEDICINE Praluent 150MG/ML SC SOAJ LIPOTROPICS No Response 2 3963 NURSE PRACTITIONER, FAMILY HEALTH Praluent 150MG/ML SC SOAJ LIPOTROPICS No Response 1 3963 PEDIATRICS Praluent 150MG/ML SC SOAJ LIPOTROPICS No Response 1 3963 UNSPECIFIED Praluent 150MG/ML SC SOAJ LIPOTROPICS No Response 2 3956 UNSPECIFIED Praluent 150MG/ML SC SOAJ LIPOTROPICS No Response 3 3956 CARDIOLOGY Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 4 3963 CARDIOLOGY Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 3 3962 CARDIOLOGY Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 2 3951 CARDIOLOGY, INTERVENTIONAL Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 1 3956 FAMILY PRACTICE Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 1 3963 INTERNAL MEDICINE Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 1 3956 INTERNAL MEDICINE Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 2 3963 NURSE PRACTITIONER, FAMILY HEALTH Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Praluent 75MG/ML SC SOAJ LIPOTROPICS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 1 3969 PHYSICIAN ASSISTANT, UNSPECIFIED Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 2 3962 UNSPECIFIED Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 1 3963 UNSPECIFIED Praluent 75MG/ML SC SOAJ LIPOTROPICS No Response 1 3963 PEDIATRICS Praluent Pen 150 mg/mL subcutaneous pen injector LIPOTROPICS No Response 1 3956 FAMILY PRACTICE Procrit 10000UNIT/ML IJ SOLN HEMATOPOIETIC AGENT No Response 1 3956 CLINICAL NURSE SPECIALIST, EMERGENCY Prolia BONE-MODIFYING AGENT Approval 1 3963 FAMILY PRACTICE Prolia BONE-MODIFYING AGENT Approval 2 3956 FAMILY PRACTICE Prolia BONE-MODIFYING AGENT Approval 4 3956 FAMILY PRACTICE Prolia BONE-MODIFYING AGENT No Response 1 3956 FAMILY PRACTICE Prolia BONE-MODIFYING AGENT Denial 1

29 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 HEMATOLOGY & ONCOLOGY Prolia BONE-MODIFYING AGENT Approval 1 3956 INTERNAL MEDICINE Prolia BONE-MODIFYING AGENT Denial 1 3963 INTERNAL MEDICINE Prolia BONE-MODIFYING AGENT No Response 1 3956 NEPHROLOGY / RENAL MEDICINE Prolia BONE-MODIFYING AGENT Approval 1 3956 NURSE PRACTITIONER, ACUTE CARE Prolia BONE-MODIFYING AGENT Approval 1 3956 NURSE PRACTITIONER, ADULT HEALTH Prolia BONE-MODIFYING AGENT Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED Prolia BONE-MODIFYING AGENT Approval 2 3956 OBSTETRICS & GYNECOLOGY Prolia BONE-MODIFYING AGENT Approval 2 3963 OBSTETRICS & GYNECOLOGY Prolia BONE-MODIFYING AGENT Denial 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Prolia BONE-MODIFYING AGENT No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Prolia BONE-MODIFYING AGENT Approval 1 3964 UROLOGY Prolia BONE-MODIFYING AGENT Approval 1 3963 UNSPECIFIED Prolia BONE-MODIFYING AGENT Denial 1 3956 UNSPECIFIED Prolia BONE-MODIFYING AGENT No Response 1 3956 UNSPECIFIED Prolia BONE-MODIFYING AGENT Approval 3 3956 FAMILY PRACTICE Prolia 60MG/ML SC SOSY OSTEOPOROSIS AGENTS No Response 1 3963 HEMATOLOGY & ONCOLOGY Promacta HEMOSTATICS Denial 1 3963 HEMATOLOGY & ONCOLOGY Promacta HEMOSTATICS No Response 2 3963 HEMATOLOGY & ONCOLOGY Promacta HEMOSTATICS Approval 1 3951 HEMATOLOGY & ONCOLOGY Promacta HEMOSTATICS No Response 1 3951 HEMATOLOGY & ONCOLOGY Promacta HEMOSTATICS Approval 1 3963 INTERNAL MEDICINE Promacta HEMOSTATICS Approval 2 3963 PHYSICIAN, ONCOLOGY, MEDICAL Promacta HEMOSTATICS Approval 1 3956 UNSPECIFIED Promacta 50MG OR TABS HEMOSTATICS No Response 2 3962 PEDIATRICS Pulmozyme MUCOLYTIC AGENT No Response 1 3962 PEDIATRICS Pulmozyme MUCOLYTIC AGENT Approval 1 3963 PULMONARY DISEASES Pulmozyme MUCOLYTIC AGENT Approval 1 3963 PULMONOLOGY, PEDIATRIC Pulmozyme MUCOLYTIC AGENT Approval 1 3951 UNSPECIFIED Rasuvo ANTIARTHRITICS No Response 1 3969 NEUROLOGY Rebif MULTIPLE SCLEROSIS AGENT Approval 1 3963 UNSPECIFIED Rebif MULTIPLE SCLEROSIS AGENT No Response 1 3963 GASTROENTEROLOGY Remicade 100MG IV SOLR ANTIRHEUMATIC No Response 1 3963 GASTROENTEROLOGY Renflexis 100MG IV SOLR ANTIRHEUMATIC No Response 2 3963 DERMATOLOGY Retacrit HEMATOPOIETIC AGENT Denial 1 3956 FAMILY PRACTICE Retacrit HEMATOPOIETIC AGENT Denial 1 3969 HEMATOLOGY & ONCOLOGY Retacrit HEMATOPOIETIC AGENT Approval 1 3956 HEMATOLOGY & ONCOLOGY Retacrit HEMATOPOIETIC AGENT Approval 2

30 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 HEMATOLOGY & ONCOLOGY Retacrit HEMATOPOIETIC AGENT Denial 1 3963 INTERNAL MEDICINE Retacrit HEMATOPOIETIC AGENT Approval 1 3956 PHYSICIAN, ONCOLOGY, MEDICAL Retacrit HEMATOPOIETIC AGENT Denial 1 3963 UNSPECIFIED Retacrit HEMATOPOIETIC AGENT No Response 1 3965 UNSPECIFIED Retacrit HEMATOPOIETIC AGENT No Response 1 3965 UNSPECIFIED Retacrit HEMATOPOIETIC AGENT Approval 1 3956 FAMILY PRACTICE Retacrit 10000UNIT/ML IJ SOLN HEMATOPOIETIC AGENT No Response 1 3963 HEMATOLOGY & ONCOLOGY, PEDIATRIC Retevmo ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY Revlimid ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY Revlimid ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY Revlimid ANTINEOPLASTICS Approval 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL Revlimid ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED Revlimid ANTINEOPLASTICS Approval 2 3951 PHYSICIAN ASSISTANT, UNSPECIFIED RINVOQ 15 MG ER TABLET IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 RHEUMATOLOGY RINVOQ 15 MG ER TABLET IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 DERMATOLOGY rinvoq 15 mg tablet extended release 24 hr IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 DERMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3965 DERMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 DERMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 INTERNAL MEDICINE Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 INTERNAL MEDICINE Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3969 PHYSICIAN ASSISTANT, UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 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 Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3951 RHEUMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3956 RHEUMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 6 3956 RHEUMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Denial 3 3963 RHEUMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Denial 3 3963 RHEUMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 5 3963 RHEUMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS No Response 1

31 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 RHEUMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3961 RHEUMATOLOGY Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 4 3963 UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 7 3951 UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3961 UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3961 UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS No Response 6 3956 UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Denial 3 3963 UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 UNSPECIFIED Rinvoq 15mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 INTERNAL MEDICINE Rinvoq 15MG OR TB24 IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 RHEUMATOLOGY Rinvoq 15MG OR TB24 IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY Rinvoq 15MG OR TB24 IMMUNOSUPPRESSIVES/DMARDS No Response 1 3969 GASTROENTEROLOGY Rinvoq 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3964 NURSE PRACTITIONER, UNSPECIFIED Rinvoq 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3969 UNSPECIFIED Rinvoq 30mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3961 UNSPECIFIED Rinvoq 30mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 UNSPECIFIED Rinvoq 30mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED Rinvoq 30MG OR TB24 IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED Rinvoq 45mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 UNSPECIFIED Rinvoq 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED Rinvoq 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3964 UNSPECIFIED Rinvoq 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 RHEUMATOLOGY Rinvoq 45mg + 15mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 GASTROENTEROLOGY Rinvoq 45MG OR TB24 IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Rinvoq 45MG OR TB24 IMMUNOSUPPRESSIVES/DMARDS Approval 1 3961 UNSPECIFIED Rydapt ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY Sandostatin SOMATOSTATIN ANALOG Approval 1 3961 PHYSICIAN ASSISTANT, UNSPECIFIED sapropterin ENZYME COFACTOR Approval 1 3963 UNSPECIFIED sapropterin ENZYME COFACTOR No Response 1 3963 UNSPECIFIED sapropterin ENZYME COFACTOR Approval 2 3951 UNSPECIFIED sapropterin ENZYME COFACTOR Denial 1 3956 FAMILY PRACTICE sildenafil (pulm.hypertension) 20 mg tablet VASODILATORS No Response 1 3965 FAMILY PRACTICE sildenafil (pulmonary hypertension) 20 mg tablet VASODILATORS No Response 1 3956 FAMILY PRACTICE sildenafil (pulmonary hypertension) 20 mg tablet VASODILATORS No Response 3 3963 FAMILY PRACTICE sildenafil (pulmonary hypertension) 20 mg tablet VASODILATORS No Response 1

32 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 NURSE PRACTITIONER, FAMILY HEALTH sildenafil (pulmonary hypertension) 20 mg tablet VASODILATORS No Response 1 3963 PHYSICIAN, GERIATRIC MEDICINE sildenafil (pulmonary hypertension) 20 mg tablet VASODILATORS No Response 1 3956 UNSPECIFIED sildenafil (pulmonary hypertension) 20 mg tablet VASODILATORS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED sildenafil (Revatio) 20 MG tablet VASODILATORS No Response 1 3963 CARDIOLOGY sildenafil 20mg tablets VASODILATORS Approval 1 3963 CARDIOLOGY, INTERVENTIONAL sildenafil 20mg tablets VASODILATORS Approval 1 3963 FAMILY PRACTICE sildenafil 20mg tablets VASODILATORS Denial 1 3956 FAMILY PRACTICE sildenafil 20mg tablets VASODILATORS Denial 1 3956 INTERNAL MEDICINE sildenafil 20mg tablets VASODILATORS Approval 1 3956 INTERNAL MEDICINE sildenafil 20mg tablets VASODILATORS Denial 1 3963 INTERNAL MEDICINE sildenafil 20mg tablets VASODILATORS Denial 1 3951 NURSE PRACTITIONER, FAMILY HEALTH sildenafil 20mg tablets VASODILATORS Denial 1 3956 RHEUMATOLOGY sildenafil 20mg tablets VASODILATORS Approval 2 3951 UNSPECIFIED sildenafil 20mg tablets VASODILATORS Approval 1 3965 UNSPECIFIED sildenafil 20mg tablets VASODILATORS Denial 1 3965 NURSE PRACTITIONER, FAMILY HEALTH Sildenafil Citrate (Sildenafil Citrate (Pulmonary Hyper­ tension)) 20 MG Oral 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 3956 FAMILY PRACTICE Sildenafil Citrate 20MG OR TABS VASODILATORS No Response 3 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Sildenafil Citrate 20MG OR TABS VASODILATORS No Response 1 3963 UNSPECIFIED Sildenafil Citrate 20MG OR TABS VASODILATORS No Response 1 3962 CARDIOLOGY, PEDIATRIC sildenafil suspension VASODILATORS No Response 1 3962 CARDIOLOGY, PEDIATRIC sildenafil suspension VASODILATORS Approval 1 3956 CARDIOLOGY, PEDIATRIC sildenafil tablets VASODILATORS Denial 1 3963 FAMILY PRACTICE sildenafil tablets VASODILATORS Denial 3 3965 FAMILY PRACTICE sildenafil tablets VASODILATORS Denial 3 3956 FAMILY PRACTICE sildenafil tablets VASODILATORS Denial 6 3964 FAMILY PRACTICE sildenafil tablets VASODILATORS Denial 1 3956 INTERNAL MEDICINE sildenafil tablets VASODILATORS Denial 1 3963 INTERNAL MEDICINE sildenafil tablets VASODILATORS Approval 1 3963 INTERNAL MEDICINE sildenafil tablets VASODILATORS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH sildenafil tablets VASODILATORS Denial 2 3956 NURSE PRACTITIONER, FAMILY HEALTH sildenafil tablets VASODILATORS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED sildenafil tablets VASODILATORS Approval 2 3951 RHEUMATOLOGY sildenafil tablets VASODILATORS Denial 1

33 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 RHEUMATOLOGY sildenafil tablets VASODILATORS Approval 1 3963 UROLOGY sildenafil tablets VASODILATORS Denial 1 3963 UNSPECIFIED sildenafil tablets VASODILATORS Denial 6 3963 UNSPECIFIED sildenafil tablets VASODILATORS Approval 2 3956 UNSPECIFIED sildenafil tablets VASODILATORS Denial 1 3964 UNSPECIFIED sildenafil tablets VASODILATORS Denial 1 3956 UNSPECIFIED sildenafil tablets VASODILATORS Approval 1 3956 INTERNAL MEDICINE Simponi 100mg ANTIARTHRITICS Denial 2 3956 FAMILY PRACTICE Simponi 50mg ANTIARTHRITICS Approval 2 3956 GENERAL PRACTICE Simponi 50mg ANTIARTHRITICS Approval 2 3956 PEDIATRICS Simponi 50mg ANTIARTHRITICS Approval 2 3956 PSYCHIATRY Simponi 50mg ANTIARTHRITICS Approval 2 3956 UNSPECIFIED Simponi 50mg ANTIARTHRITICS Approval 2 3963 UNSPECIFIED Simponi 50MG/0.5ML SC SOAJ ANTIARTHRITICS Denial 1 3963 RHEUMATOLOGY Skyrizi (150 MG Dose) 75MG/0.83ML SC PSKT SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 FAMILY PRACTICE Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 DERMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 8 3956 DERMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 9 3963 DERMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3951 DERMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3951 DERMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3956 DERMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 2 3969 DERMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3961 DERMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3961 DERMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 DERMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3956 EMERGENCY MEDICINE Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 3 3956 EMERGENCY MEDICINE Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Denial 2 3956 FAMILY PRACTICE Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3956 FAMILY PRACTICE Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 GASTROENTEROLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 INTERNAL MEDICINE Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3956 INTERNAL MEDICINE Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3963 NURSE PRACTITIONER, ACUTE CARE Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3956 NURSE PRACTITIONER, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3963 NURSE PRACTITIONER, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 2

34 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 NURSE PRACTITIONER, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 OBSTETRICS & GYNECOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 2 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 11 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Denial 2 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 4 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3964 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3964 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3965 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3965 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3961 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3951 RHEUMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 RHEUMATOLOGY Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 14 3965 UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3963 UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 11 3951 UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3961 UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3963 UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 7 3963 UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Denial 4 3956 UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 2 3962 UNSPECIFIED Skyrizi 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3951 DERMATOLOGY SKYRIZI 150MG/ML PEN SYSTEMIC ANTIPSORIASIS AGENTS No Response 2 3956 DERMATOLOGY SKYRIZI 150MG/ML PEN SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3956 EMERGENCY MEDICINE SKYRIZI 150MG/ML PEN SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3956 INTERNAL MEDICINE SKYRIZI 150MG/ML PEN SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 UNSPECIFIED SKYRIZI 150MG/ML PFS SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Skyrizi 150MG/ML SC SOSY SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3961 GASTROENTEROLOGY Skyrizi 360mg + 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 GASTROENTEROLOGY Skyrizi 360mg + 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3956 GASTROENTEROLOGY Skyrizi 360mg + 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 3 3963 GASTROENTEROLOGY Skyrizi 360mg + 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3965 GASTROENTEROLOGY Skyrizi 360mg + 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 UNSPECIFIED Skyrizi 360mg + 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS No Response 1

35 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 UNSPECIFIED Skyrizi 360mg + 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 GASTROENTEROLOGY Skyrizi 360mg + 180mg + 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3962 GASTROENTEROLOGY Skyrizi 360mg + 180mg + 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 GASTROENTEROLOGY Skyrizi 360MG/2.4ML SC SOCT SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3956 GASTROENTEROLOGY Skyrizi 600mg + 360mg + 180mg + 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3951 GASTROENTEROLOGY Skyrizi 600mg + 360mg + 180mg + 150mg + 75mg SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3956 DERMATOLOGY SKYRIZI PEN 150MG/ML INJ SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3965 PHYSICIAN ASSISTANT, 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 1 3963 UNSPECIFIED Skyrizi Pen 150MG/ML SC SOAJ SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3963 ENDOCRINOLOGY, DIABETES & METABOLISM Somatuline Depot SOMATOSTATIN ANALOG Denial 1 3963 ENDOCRINOLOGY, DIABETES & METABOLISM Somatuline Depot SOMATOSTATIN ANALOG Approval 1 3963 FAMILY PRACTICE Spravato ANTIDEPRESSANT Denial 12 3951 FAMILY PRACTICE Spravato ANTIDEPRESSANT Approval 12 3963 GENERAL PRACTICE Spravato ANTIDEPRESSANT Denial 36 3951 INTERNAL MEDICINE Spravato ANTIDEPRESSANT Denial 12 3951 INTERNAL MEDICINE Spravato ANTIDEPRESSANT Approval 24 3963 NURSE PRACTITIONER, FAMILY HEALTH Spravato ANTIDEPRESSANT Denial 12 3963 NURSE PRACTITIONER, PSYCHIATRIC Spravato ANTIDEPRESSANT Denial 12 3963 NURSE PRACTITIONER, UNSPECIFIED Spravato ANTIDEPRESSANT Denial 12 3963 NURSE PRACTITIONER, UNSPECIFIED Spravato ANTIDEPRESSANT Approval 12 3963 PEDIATRICS Spravato ANTIDEPRESSANT Denial 12 3963 PSYCHIATRY Spravato ANTIDEPRESSANT Denial 12 3965 PSYCHIATRY Spravato ANTIDEPRESSANT Approval 12 3969 PSYCHIATRY Spravato ANTIDEPRESSANT Approval 24 3963 UNSPECIFIED Spravato ANTIDEPRESSANT Approval 48 3963 UNSPECIFIED Spravato ANTIDEPRESSANT Denial 24 3951 UNSPECIFIED Spravato ANTIDEPRESSANT Denial 36 3964 UNSPECIFIED Spravato ANTIDEPRESSANT Denial 12 3951 UNSPECIFIED Spravato ANTIDEPRESSANT Approval 24 3963 HEMATOLOGY & ONCOLOGY Sprycel ANTINEOPLASTICS Denial 1 3963 HEMATOLOGY & ONCOLOGY Sprycel ANTINEOPLASTICS Approval 3 3956 HEMATOLOGY & ONCOLOGY Sprycel ANTINEOPLASTICS Approval 3 3956 HEMATOLOGY & ONCOLOGY Sprycel ANTINEOPLASTICS Denial 1 3956 INTERNAL MEDICINE Sprycel ANTINEOPLASTICS Approval 1 3956 INTERNAL MEDICINE Sprycel ANTINEOPLASTICS Denial 1 3956 MEDICAL ONCOLOGY Sprycel ANTINEOPLASTICS Approval 1

36 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 UNSPECIFIED Sprycel ANTINEOPLASTICS No Response 4 3956 UNSPECIFIED Sprycel ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED Sprycel ANTINEOPLASTICS No Response 2 3963 GASTROENTEROLOGY Stelara IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 GASTROENTEROLOGY Stelara 45mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 GASTROENTEROLOGY STELARA 45MG/0.5 INJ IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 FAMILY PRACTICE Stelara 45MG/0.5ML SC SOLN IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED STELARA 90 MG/ML SYRINGE IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY Stelara 90MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 GASTROENTEROLOGY Stelara 90MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 5 3963 GASTROENTEROLOGY Stelara 90MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, ACUTE CARE Stelara 90MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 1 3961 NURSE PRACTITIONER, FAMILY HEALTH Stelara 90MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED Stelara 90MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 UNSPECIFIED Stelara 90MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 GASTROENTEROLOGY Stelara IV + Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 INTERNAL MEDICINE Stelara IV + Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED Stelara IV + Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 DERMATOLOGY Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 DERMATOLOGY Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 FAMILY PRACTICE Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 GASTROENTEROLOGY Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3963 GASTROENTEROLOGY Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 GASTROENTEROLOGY Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 INTERNAL MEDICINE Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, UNSPECIFIED Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, WOMEN’S HEALTH Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, WOMEN’S HEALTH Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Denial 3 3956 UNSPECIFIED Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS Denial 2

37 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 UNSPECIFIED Stelara SQ 45mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 DERMATOLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 12 3956 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Denial 4 3963 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 10 3963 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Denial 4 3961 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3961 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 3 3951 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3964 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3963 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS No Response 2 3951 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3961 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Denial 2 3964 GASTROENTEROLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 INTERNAL MEDICINE Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 INTERNAL MEDICINE Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 INTERNAL MEDICINE Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 INTERNAL MEDICINE Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, ACUTE CARE Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, ACUTE CARE Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3961 NURSE PRACTITIONER, FAMILY HEALTH Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 RHEUMATOLOGY Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 4 3963 UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 5 3951 UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3969 UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3964 UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3964 UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED Stelara SQ 90mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 HEMATOLOGY & ONCOLOGY Stivarga ANTINEOPLASTICS Approval 1 3963 INTERNAL MEDICINE Stivarga ANTINEOPLASTICS Approval 1

38 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 INTERNAL MEDICINE Stivarga ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY SUNItinib Malate 37.5MG OR CAPS ANTINEOPLASTICS No Response 1 3963 ENDOCRINOLOGY, PEDIATRIC Supprelin LA 50MG SC KIT ANTINEOPLASTICS No Response 1 3956 HEMATOLOGY Sutent ANTINEOPLASTICS Approval 1 3965 HEMATOLOGY & ONCOLOGY Sutent ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED Sutent ANTINEOPLASTICS Approval 1 BCBSAR PEDIATRICS Synagis RESPIRATORY AGENT Denial 1 BCBSAR PEDIATRICS Synagis RESPIRATORY AGENT Approval 2 3956 CARDIOLOGY tadalafil 20mg VASODILATORS Approval 1 3964 PULMONARY DISEASES tadalafil 20mg VASODILATORS Approval 1 3956 INTERNAL MEDICINE Tafinlar ANTINEOPLASTICS No Response 1 3965 HEMATOLOGY & ONCOLOGY Tagrisso ANTINEOPLASTICS Approval 1 3963 INTERNAL MEDICINE Tagrisso ANTINEOPLASTICS Approval 1 3963 DERMATOLOGY Taltz ALL OTHER DERMATOLOGICALS Approval 4 3956 DERMATOLOGY Taltz ALL OTHER DERMATOLOGICALS Approval 13 3956 DERMATOLOGY Taltz ALL OTHER DERMATOLOGICALS Denial 1 3956 DERMATOLOGY Taltz ALL OTHER DERMATOLOGICALS No Response 3 3963 DERMATOLOGY Taltz ALL OTHER DERMATOLOGICALS No Response 1 3961 DERMATOLOGY Taltz ALL OTHER DERMATOLOGICALS Approval 1 3956 EMERGENCY MEDICINE Taltz ALL OTHER DERMATOLOGICALS Approval 1 3956 FAMILY PRACTICE Taltz ALL OTHER DERMATOLOGICALS Approval 1 3956 INTERNAL MEDICINE Taltz ALL OTHER DERMATOLOGICALS No Response 1 3956 INTERNAL MEDICINE Taltz ALL OTHER DERMATOLOGICALS Approval 2 3963 INTERNAL MEDICINE Taltz ALL OTHER DERMATOLOGICALS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Taltz ALL OTHER DERMATOLOGICALS Approval 2 3956 NURSE PRACTITIONER, UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS No Response 5 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Approval 17 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Approval 4 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Denial 4 3961 PHYSICIAN ASSISTANT, UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS No Response 2 3961 PHYSICIAN ASSISTANT, UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Approval 2 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Denial 1 3956 RHEUMATOLOGY Taltz ALL OTHER DERMATOLOGICALS Denial 4 3956 RHEUMATOLOGY Taltz ALL OTHER DERMATOLOGICALS Approval 3

39 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 RHEUMATOLOGY Taltz ALL OTHER DERMATOLOGICALS No Response 1 3963 UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Approval 9 3956 UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Approval 24 3956 UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Denial 6 3956 UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS No Response 8 3961 UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Approval 2 3963 UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS No Response 1 3963 UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Denial 1 3951 UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS Approval 1 3961 UNSPECIFIED Taltz ALL OTHER DERMATOLOGICALS No Response 1 3956 DERMATOLOGY TALTZ 80MG/ML CF AUTO INJ 1ML IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 EMERGENCY MEDICINE TALTZ 80MG/ML CF AUTO INJ 1ML IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED TALTZ 80MG/ML CF AUTO INJ 1ML IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 UNSPECIFIED TALTZ 80MG/ML CF AUTO INJ 1ML IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 UNSPECIFIED TALTZ 80MG/ML CF AUTO INJ 1ML IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED TALTZ 80MG/ML CF AUTO INJ 1ML IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED TALTZ 80MG/ML CF PFS 1ML IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY Taltz 80MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 INTERNAL MEDICINE Taltz 80MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, UNSPECIFIED Taltz 80MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Taltz 80MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY Taltz 80MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED Taltz 80MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED Taltz 80MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED Tecfidera MULTIPLE SCLEROSIS AGENT Denial 1 3956 HEMATOLOGY & ONCOLOGY temozolomide ANTINEOPLASTICS Approval 2 3951 HEMATOLOGY & ONCOLOGY temozolomide ANTINEOPLASTICS No Response 1 3951 HEMATOLOGY & ONCOLOGY temozolomide ANTINEOPLASTICS Approval 1 3956 MEDICAL ONCOLOGY temozolomide ANTINEOPLASTICS Approval 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL temozolomide ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED temozolomide ANTINEOPLASTICS Approval 3 3956 UNSPECIFIED temozolomide ANTINEOPLASTICS Approval 1 3951 NEUROLOGY tetrabenazine VESICULAR MONOAMINE TRANSPORTER 2 INHIB­ ITOR Approval 1 3961 NEUROLOGY tetrabenazine VESICULAR MONOAMINE TRANSPORTER 2 INHIB­ ITOR Approval 1 3956 NEUROLOGY tetrabenazine VESICULAR MONOAMINE TRANSPORTER 2 INHIB­ ITOR Approval 1

40 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 PEDIATRICS tetrabenazine VESICULAR MONOAMINE TRANSPORTER 2 INHIB­ ITOR Approval 1 3951 UNSPECIFIED tetrabenazine VESICULAR MONOAMINE TRANSPORTER 2 INHIB­ ITOR No Response 1 3951 UNSPECIFIED tetrabenazine VESICULAR MONOAMINE TRANSPORTER 2 INHIB­ ITOR Approval 2 3956 UNSPECIFIED tetrabenazine VESICULAR MONOAMINE TRANSPORTER 2 INHIB­ ITOR No Response 1 3951 UNSPECIFIED Tetrabenazine 12.5MG OR TABS VESICULAR MONOAMINE TRANSPORTER 2 INHIB­ ITOR No Response 1 3963 HEMATOLOGY Thalomid ANTINEOPLASTICS Approval 1 3951 HEMATOLOGY Thalomid ANTINEOPLASTICS Approval 1 3956 CARDIOLOGY Tikosyn ANTIARRHYTHMIC AGENT No Response 1 3956 NURSE PRACTITIONER, UNSPECIFIED Tikosyn ANTIARRHYTHMIC AGENT No Response 2 3956 PHYSICIAN, CARDIAC ELECTROPHYSIOLOGY Tikosyn ANTIARRHYTHMIC AGENT Denial 1 3951 PULMONARY DISEASES Tobramycin inhalation solution RESPIRATORY AGENTS Approval 1 3964 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3961 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Denial 1 3961 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Denial 4 3956 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 8 3963 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 5 3956 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 2 3965 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 1 3962 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 1 3962 DERMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 FAMILY PRACTICE Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 FAMILY PRACTICE Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 INTERNAL MEDICINE Tremfya IMMUNOSUPPRESSIVES/DMARDS Denial 2 3956 INTERNAL MEDICINE Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 INTERNAL MEDICINE Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 INTERNAL MEDICINE Tremfya IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 6 3956 NURSE PRACTITIONER, FAMILY HEALTH Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 3 3963 NURSE PRACTITIONER, FAMILY HEALTH Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1

41 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3961 PEDIATRICS Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 4 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 9 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 12 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 PHYSICIAN ASSISTANT, UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 PHYSICIAN ASSISTANT, UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Denial 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 RHEUMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 RHEUMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 RHEUMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3965 RHEUMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3961 RHEUMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Denial 1 3961 RHEUMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3969 RHEUMATOLOGY Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 12 3962 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 1 3962 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 12 3951 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 2 3965 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 5 3963 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 5 3963 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Denial 3 3961 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3969 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 1 3961 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS No Response 1 3964 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Approval 1 3964 UNSPECIFIED Tremfya IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 DERMATOLOGY TREMFYA 100 MG/ML ONE-PRESS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 DERMATOLOGY TREMFYA 100 MG/ML ONE-PRESS IMMUNOSUPPRESSIVES/DMARDS No Response 1

42 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 PHYSICIAN ASSISTANT, UNSPECIFIED TREMFYA 100 MG/ML ONE-PRESS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 DERMATOLOGY Tremfya 100MG/ML SC SOPN IMMUNOSUPPRESSIVES/DMARDS No Response 2 3964 FAMILY PRACTICE Tremfya 100MG/ML SC SOPN IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 INTERNAL MEDICINE Tremfya 100MG/ML SC SOPN IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Tremfya 100MG/ML SC SOPN IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 RHEUMATOLOGY Tremfya 100MG/ML SC SOPN IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 RHEUMATOLOGY Tremfya 100MG/ML SC SOPN IMMUNOSUPPRESSIVES/DMARDS No Response 3 3956 UNSPECIFIED Tremfya 100MG/ML SC SOPN IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY Tremfya 100MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Tremfya 100MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 3 3956 UNSPECIFIED Tremfya 100MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 2 3961 INTERNAL MEDICINE Trikafta CYSTIC FIBROSIS AGENTS No Response 1 3961 INTERNAL MEDICINE Trikafta CYSTIC FIBROSIS AGENTS Approval 1 3956 PULMONARY DISEASES Trikafta CYSTIC FIBROSIS AGENTS Approval 1 3963 PULMONOLOGY, PEDIATRIC Trikafta CYSTIC FIBROSIS AGENTS Approval 1 3963 UNSPECIFIED Trikafta CYSTIC FIBROSIS AGENTS Approval 1 3956 PULMONARY DISEASES Trikafta 100-50-75 & 150MG OR TBPK CYSTIC FIBROSIS AGENTS No Response 1 3963 HEMATOLOGY & ONCOLOGY Tukysa ANTINEOPLASTICS Approval 1 3963 CLINICAL NURSE SPECIALIST, FAMILY HEALTH Tymlos OSTEOPOROSIS AGENTS Approval 1 3956 FAMILY PRACTICE Tymlos OSTEOPOROSIS AGENTS Approval 2 3956 INTERNAL MEDICINE Tymlos OSTEOPOROSIS AGENTS Approval 2 3963 ORTHOPEDIC SURGERY Tymlos OSTEOPOROSIS AGENTS Denial 2 3956 UNSPECIFIED Tymlos OSTEOPOROSIS AGENTS No Response 2 3951 UNSPECIFIED Tymlos OSTEOPOROSIS AGENTS Approval 1 3963 UNSPECIFIED Tymlos OSTEOPOROSIS AGENTS No Response 2 3961 UNSPECIFIED Tymlos OSTEOPOROSIS AGENTS Approval 1 3965 UNSPECIFIED Tymlos OSTEOPOROSIS AGENTS Approval 1 3963 CARDIOLOGY Tyvaso Dry Powder Inhaler (DPI) VASODILATORS Approval 1 3963 CARDIOLOGY Uptravi PULMONARY ARTERIAL HYPERTENSION No Response 1 3963 INTERNAL MEDICINE Uptravi PULMONARY ARTERIAL HYPERTENSION Approval 1 3963 INTERNAL MEDICINE Uptravi PULMONARY ARTERIAL HYPERTENSION No Response 1 3951 PULMONARY DISEASES Uptravi PULMONARY ARTERIAL HYPERTENSION No Response 1 3963 UNSPECIFIED Uptravi PULMONARY ARTERIAL HYPERTENSION Approval 1 3956 NURSE PRACTITIONER, ACUTE CARE valganciclovir ANTIVIRALS Approval 1 3956 PULMONARY DISEASES valganciclovir ANTIVIRALS Approval 1 3956 UNSPECIFIED valganciclovir ANTIVIRALS Approval 3 3963 UNSPECIFIED valganciclovir ANTIVIRALS Approval 1

43 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 UNSPECIFIED valganciclovir ANTIVIRALS Approval 1 3956 NURSE PRACTITIONER, ACUTE CARE valGANciclovir HCl 450MG OR TABS ANTIVIRALS Approval 1 3956 FAMILY PRACTICE Vemlidy Antivirals Denial 2 3956 GASTROENTEROLOGY Vemlidy Antivirals No Response 2 3956 GASTROENTEROLOGY Vemlidy Antivirals Approval 2 3956 INTERNAL MEDICINE Vemlidy Antivirals Approval 1 3956 FAMILY PRACTICE Vemlidy 25 mg tablet Antivirals No Response 1 3956 HEMATOLOGY & ONCOLOGY Venclexta ANTINEOPLASTICS Approval 1 3965 HEMATOLOGY & ONCOLOGY Venclexta ANTINEOPLASTICS Denial 1 3961 HEMATOLOGY & ONCOLOGY Venclexta ANTINEOPLASTICS No Response 1 3961 HEMATOLOGY & ONCOLOGY Venclexta ANTINEOPLASTICS Approval 1 3965 HEMATOLOGY & ONCOLOGY Venclexta ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY Venclexta ANTINEOPLASTICS No Response 1 3956 INTERNAL MEDICINE Venclexta ANTINEOPLASTICS Approval 1 3963 MEDICAL ONCOLOGY Venclexta ANTINEOPLASTICS Approval 1 3965 UNSPECIFIED Venclexta ANTINEOPLASTICS Approval 2 3964 UNSPECIFIED Venclexta ANTINEOPLASTICS Denial 1 3956 UNSPECIFIED Venclexta ANTINEOPLASTICS No Response 1 3963 UNSPECIFIED Venclexta ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED Venclexta ANTINEOPLASTICS Approval 2 3965 HEMATOLOGY & ONCOLOGY Venclexta 100MG OR TABS ANTINEOPLASTICS No Response 1 3956 HEMATOLOGY & ONCOLOGY Venclexta 100MG OR TABS ANTINEOPLASTICS Approval 1 3964 UNSPECIFIED Venclexta 50MG OR TABS ANTINEOPLASTICS No Response 1 3963 HEMATOLOGY & ONCOLOGY Verzenio ANTINEOPLASTICS Approval 2 3963 UNSPECIFIED Verzenio ANTINEOPLASTICS No Response 1 3963 NEUROLOGY, PEDIATRIC vigabatrin powder ANTICONVULSANTS Approval 2 3963 UNSPECIFIED vigabatrin powder ANTICONVULSANTS Approval 4 3963 UNSPECIFIED vigabatrin powder ANTICONVULSANTS Denial 2 3962 UNSPECIFIED vigabatrin powder ANTICONVULSANTS Approval 2 3963 UNSPECIFIED vigabatrin powder ANTICONVULSANTS No Response 2 3963 HEMATOLOGY & ONCOLOGY Votrient ANTINEOPLASTICS No Response 1 3956 HEMATOLOGY & ONCOLOGY Votrient ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY Votrient ANTINEOPLASTICS Approval 1 3964 UNSPECIFIED Votrient ANTINEOPLASTICS Approval 1 3963 NEUROLOGY Vumerity MULTIPLE SCLEROSIS Approval 2 3951 UNSPECIFIED Vumerity MULTIPLE SCLEROSIS Approval 1 3956 UNSPECIFIED Xeljanz 10 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1

44 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 GASTROENTEROLOGY Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 INTERNAL MEDICINE Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 INTERNAL MEDICINE Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 INTERNAL MEDICINE Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3961 RHEUMATOLOGY Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3964 RHEUMATOLOGY Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 RHEUMATOLOGY Xeljanz 5 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 GASTROENTEROLOGY Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, UNSPECIFIED Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 RHEUMATOLOGY Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Approval 8 3963 RHEUMATOLOGY Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Approval 6 3951 RHEUMATOLOGY Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 RHEUMATOLOGY Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Denial 3 3964 RHEUMATOLOGY Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 RHEUMATOLOGY Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 UNSPECIFIED Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS No Response 3 3956 UNSPECIFIED Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 UNSPECIFIED Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED Xeljanz XR 11 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 RHEUMATOLOGY XELJANZ XR 11 MG TABLET IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 RHEUMATOLOGY Xeljanz XR 11MG OR TB24 IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 GASTROENTEROLOGY Xeljanz XR 22 mg IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL Xeloda ANTINEOPLASTICS Denial 1 3963 HEMATOLOGY & ONCOLOGY Xgeva OSTEOPOROSIS AGENTS Approval 1 3963 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Denial 2 3956 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Approval 5 3963 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Approval 11 3961 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS No Response 1 3956 ALLERGY Xolair RESPIRATORY AGENTS Approval 1 3951 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Denial 1 3951 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Approval 3 3956 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Denial 1 3969 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS No Response 1

45 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS No Response 1 3951 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS No Response 1 3967 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Approval 1 3967 ALLERGY & IMMUNOLOGY Xolair RESPIRATORY AGENTS Denial 1 3963 DERMATOLOGY Xolair RESPIRATORY AGENTS Approval 2 3956 DERMATOLOGY Xolair RESPIRATORY AGENTS Approval 1 3956 FAMILY PRACTICE Xolair RESPIRATORY AGENTS Denial 1 3956 NURSE PRACTITIONER, ADULT HEALTH Xolair RESPIRATORY AGENTS Denial 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Xolair RESPIRATORY AGENTS Denial 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Xolair RESPIRATORY AGENTS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Xolair RESPIRATORY AGENTS No Response 1 3956 NURSE PRACTITIONER, UNSPECIFIED Xolair RESPIRATORY AGENTS No Response 1 3956 NURSE PRACTITIONER, UNSPECIFIED Xolair RESPIRATORY AGENTS Approval 1 3956 PEDIATRICS Xolair RESPIRATORY AGENTS Approval 1 3961 PEDIATRICS Xolair RESPIRATORY AGENTS No Response 1 3961 PEDIATRICS Xolair RESPIRATORY AGENTS Approval 1 3964 PHYSICIAN ASSISTANT, UNSPECIFIED Xolair RESPIRATORY AGENTS Denial 2 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Xolair RESPIRATORY AGENTS Denial 2 3964 PHYSICIAN ASSISTANT, UNSPECIFIED Xolair RESPIRATORY AGENTS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Xolair RESPIRATORY AGENTS Approval 5 3956 PHYSICIAN ASSISTANT, UNSPECIFIED Xolair RESPIRATORY AGENTS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Xolair RESPIRATORY AGENTS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED Xolair RESPIRATORY AGENTS Approval 1 3963 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC Xolair RESPIRATORY AGENTS Approval 2 3963 PULMONARY DISEASES Xolair RESPIRATORY AGENTS No Response 1 3963 PULMONARY DISEASES Xolair RESPIRATORY AGENTS Approval 4 3956 PULMONARY DISEASES Xolair RESPIRATORY AGENTS No Response 1 3956 PULMONARY DISEASES Xolair RESPIRATORY AGENTS Denial 1 3963 PULMONARY DISEASES Xolair RESPIRATORY AGENTS Denial 1 3963 UNSPECIFIED Xolair RESPIRATORY AGENTS No Response 3 3963 UNSPECIFIED Xolair RESPIRATORY AGENTS Approval 4 3962 UNSPECIFIED Xolair RESPIRATORY AGENTS Approval 2 3956 UNSPECIFIED Xolair RESPIRATORY AGENTS Approval 2 3962 UNSPECIFIED Xolair RESPIRATORY AGENTS No Response 1 3951 UNSPECIFIED Xolair RESPIRATORY AGENTS No Response 1 3956 UNSPECIFIED Xolair RESPIRATORY AGENTS No Response 1 3956 UNSPECIFIED Xolair RESPIRATORY AGENTS Denial 1

46 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 ALLERGY & IMMUNOLOGY Xolair 150MG/ML SC SOSY RESPIRATORY AGENTS No Response 1 3956 ALLERGY & IMMUNOLOGY Xolair 150MG/ML SC SOSY RESPIRATORY AGENTS Approval 1 3965 INTERNAL MEDICINE Xtandi ANTINEOPLASTICS Approval 1 3963 INTERNAL MEDICINE Xtandi ANTINEOPLASTICS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH Xtandi ANTINEOPLASTICS Approval 1 3951 UROLOGY Xtandi ANTINEOPLASTICS No Response 1 3956 UROLOGY Xtandi ANTINEOPLASTICS No Response 1 3963 UROLOGY Xtandi ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED Xtandi ANTINEOPLASTICS No Response 2 3964 UNSPECIFIED Xtandi ANTINEOPLASTICS Approval 1 3969 NEUROLOGY Xyrem CENTRAL NERVOUS SYSTEM DEPRESSANT Approval 1 3964 NURSE PRACTITIONER, FAMILY HEALTH Xyrem CENTRAL NERVOUS SYSTEM DEPRESSANT Approval 1 3963 PULMONARY DISEASES Xyrem CENTRAL NERVOUS SYSTEM DEPRESSANT No Response 1 3963 PULMONARY DISEASES Xyrem CENTRAL NERVOUS SYSTEM DEPRESSANT Approval 1 3964 NURSE PRACTITIONER, UNSPECIFIED Xywav CENTRAL NERVOUS SYSTEM DEPRESSANT Approval 1 3963 UNSPECIFIED Zejula ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY Zelboraf ANTINEOPLASTICS Approval 1 3951 FAMILY PRACTICE Zeposia MULTIPLE SCLEROSIS AGENT Approval 1 3962 GASTROENTEROLOGY Zeposia MULTIPLE SCLEROSIS AGENT Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED Zeposia MULTIPLE SCLEROSIS AGENT Approval 1 3963 GASTROENTEROLOGY Zeposia 0.92MG OR CAPS MULTIPLE SCLEROSIS AGENT No Response 1 3951 FAMILY PRACTICE Zeposia Starter Kit 0.23MG & 0.46MG& 0.92MG OR CPPK MULTIPLE SCLEROSIS AGENT No Response 1 3963 GASTROENTEROLOGY Zeposia Starter Kit 0.23MG & 0.46MG& 0.92MG OR CPPK MULTIPLE SCLEROSIS AGENT No Response 1 3956 HEMATOLOGY & ONCOLOGY Ziextenzo HEMATINICS & BLOOD CELL STIMULATORS Approval 4 3963 HEMATOLOGY & ONCOLOGY Ziextenzo HEMATINICS & BLOOD CELL STIMULATORS Denial 2 3956 HEMATOLOGY & ONCOLOGY Ziextenzo HEMATINICS & BLOOD CELL STIMULATORS Denial 1 3963 HEMATOLOGY & ONCOLOGY Ziextenzo HEMATINICS & BLOOD CELL STIMULATORS Approval 1 3951 HEMATOLOGY & ONCOLOGY Ziextenzo HEMATINICS & BLOOD CELL STIMULATORS Approval 1 3951 INTERNAL MEDICINE Ziextenzo HEMATINICS & BLOOD CELL STIMULATORS Approval 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL Ziextenzo HEMATINICS & BLOOD CELL STIMULATORS Approval 1