2023 - 2nd quarter Form

1 Pharmacy Specialty Overview by Prior Authorization Approval or Denial 2nd Quarter 2023 00122.04.02-0823 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 HEMATOLOGY & ONCOLOGY ABIRATERONE ANTINEOPLASTICS Approval 1 3956 UROLOGY ABIRATERONE ANTINEOPLASTICS Approval 1 3956 INTERNAL MEDICINE ACTEMRA SQ 162MG SYRINGE/ACTPEN AUTOIN­ JECTOR IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY ACTEMRA SQ 162MG SYRINGE/ACTPEN AUTOIN­ JECTOR IMMUNOSUPPRESSIVES/DMARDS Denial 2 3956 UNSPECIFIED ACTEMRA SQ 162MG SYRINGE/ACTPEN AUTOIN­ JECTOR IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 INTERNAL MEDICINE ACTHAR GEL ANTICONVULSANTS Denial 1 3964 PULMONARY DISEASES ADCIRCA 20MG OR TABS PULMONARY HYPERTENSION No Response 1 3956 CARDIOLOGY ADEMPAS OTHER ANTIHYPERTENSIVES Approval 1 3956 CARDIOLOGY ADEMPAS PULMONARY ARTERIAL HYPERTENSION Approval 1 3956 INTERNAL MEDICINE ADEMPAS OTHER ANTIHYPERTENSIVES Approval 1 3956 INTERNAL MEDICINE ADEMPAS PULMONARY ARTERIAL HYPERTENSION Approval 1 3965 UNSPECIFIED ALIROCUMAB 150 MG/ML SUBCUTANEOUS PEN INJECTOR (PRALUENT) ANTILIPEMIC AGENT No Response 1 3956 CARDIOLOGY AMBRISENTAN DERMATOLOGICAL AGENTS Approval 1 3951 CARDIOLOGY AMBRISENTAN DERMATOLOGICAL AGENTS No Response 1 3962 CARDIOLOGY, PEDIATRIC AMBRISENTAN DERMATOLOGICAL AGENTS Approval 1 3956 UNSPECIFIED AMBRISENTAN DERMATOLOGICAL AGENTS Denial 1 3963 UNSPECIFIED AMBRISENTAN DERMATOLOGICAL AGENTS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED AMJEVITA ANTIRHEUMATIC Approval 1 3956 PEDIATRICS ARANESP HEMATINICS & BLOOD CELL STIMULATORS Denial 1 3956 PEDIATRICS ARANESP HEMATOPOIETIC AGENT Denial 1 3963 UNSPECIFIED ARCALYST 220MG SC SOLR INTERLEUKIN-1 INHIBITOR No Response 1 3963 PULMONARY DISEASES ARIKAYCE ANTIBIOTIC Approval 1 3956 NEUROLOGY AUBAGIO MULTIPLE SCLEROSIS Denial 1 3963 NEUROLOGY AUBAGIO MULTIPLE SCLEROSIS Approval 3 3956 NEUROLOGY AUBAGIO MULTIPLE SCLEROSIS Approval 2 3951 NEUROLOGY AUBAGIO MULTIPLE SCLEROSIS Approval 1 3956 NEUROLOGY AUBAGIO MULTIPLE SCLEROSIS No Response 1

2 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 NURSE PRACTITIONER, UNSPECIFIED AUBAGIO MULTIPLE SCLEROSIS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED AUBAGIO MULTIPLE SCLEROSIS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED AUBAGIO MULTIPLE SCLEROSIS No Response 1 3956 UNSPECIFIED AUBAGIO MULTIPLE SCLEROSIS Approval 1 3963 UNSPECIFIED AUBAGIO MULTIPLE SCLEROSIS Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED BENLYSTA MISCELLANEOUS Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED BENLYSTA LUPUS THERAPY Approval 1 3963 RHEUMATOLOGY BENLYSTA MISCELLANEOUS Approval 2 3963 RHEUMATOLOGY BENLYSTA LUPUS THERAPY Approval 2 3963 UNSPECIFIED BENLYSTA MISCELLANEOUS Approval 1 3963 UNSPECIFIED BENLYSTA LUPUS THERAPY Approval 1 3963 NEUROLOGY BETASERON MISCELLANEOUS No Response 1 3963 UNSPECIFIED BETASERON MISCELLANEOUS Approval 1 3963 NEUROLOGY BETASERON (INTERFERON BETA-1B) 0.3 MG SUBCU­ TANEOUS EACH MISCELLANEOUS No Response 2 3956 DERMATOLOGY BEXAROTENE ANTINEOPLASTICS No Response 1 3956 DERMATOLOGY BEXAROTENE ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED BEXAROTENE (TARGRETIN) 75 MG CAPS ANTINEOPLASTICS No Response 1 3963 UNSPECIFIED BEXAROTENE CAPSULE ANTINEOPLASTICS Denial 1 3963 UNSPECIFIED BEXAROTENE CAPSULE ANTINEOPLASTICS Approval 1 3964 UNSPECIFIED BEXAROTENE CAPSULE ANTINEOPLASTICS No Response 1 3951 MEDICAL ONCOLOGY BRAFTOVI ANTINEOPLASTICS Approval 1 3951 MEDICAL ONCOLOGY BRAFTOVI ANTINEOPLASTICS No Response 1 3951 HEMATOLOGY & ONCOLOGY CABOMETYX ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY CABOMETYX ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY CABOMETYX ANTINEOPLASTICS Approval 1 3961 HEMATOLOGY & ONCOLOGY CABOMETYX ANTINEOPLASTICS Approval 1 3963 INTERNAL MEDICINE CABOMETYX ANTINEOPLASTICS No Response 1 3963 INTERNAL MEDICINE CABOMETYX ANTINEOPLASTICS Approval 1 3963 MEDICAL ONCOLOGY CABOMETYX ANTINEOPLASTICS Approval 1 3951 UNSPECIFIED CABOMETYX ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY CALQUENCE CAPSULE ANTINEOPLASTICS Approval 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL CALQUENCE CAPSULE ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY CALQUENCE TABLET ANTINEOPLASTICS Approval 1 3956 PHYSICIAN, ONCOLOGY, MEDICAL CALQUENCE TABLET ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY CAPECITABINE ANTINEOPLASTICS Approval 5 3956 HEMATOLOGY & ONCOLOGY CAPECITABINE ANTINEOPLASTICS Approval 1

3 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 HEMATOLOGY & ONCOLOGY CAPECITABINE ANTINEOPLASTICS Approval 2 3963 HEMATOLOGY & ONCOLOGY CAPECITABINE ANTINEOPLASTICS No Response 1 3969 HEMATOLOGY & ONCOLOGY CAPECITABINE ANTINEOPLASTICS Approval 1 3956 INTERNAL MEDICINE CAPECITABINE ANTINEOPLASTICS No Response 1 3951 INTERNAL MEDICINE CAPECITABINE ANTINEOPLASTICS Approval 2 3963 INTERNAL MEDICINE CAPECITABINE ANTINEOPLASTICS Approval 1 3956 INTERNAL MEDICINE CAPECITABINE ANTINEOPLASTICS Approval 3 3961 INTERNAL MEDICINE CAPECITABINE ANTINEOPLASTICS Approval 1 3956 MEDICAL ONCOLOGY CAPECITABINE ANTINEOPLASTICS Approval 3 3963 MEDICAL ONCOLOGY CAPECITABINE ANTINEOPLASTICS Denial 1 3956 PHYSICIAN, ONCOLOGY, MEDICAL CAPECITABINE ANTINEOPLASTICS Denial 1 3956 PHYSICIAN, ONCOLOGY, MEDICAL CAPECITABINE ANTINEOPLASTICS Approval 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL CAPECITABINE ANTINEOPLASTICS Approval 1 3965 UNSPECIFIED CAPECITABINE ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED CAPECITABINE ANTINEOPLASTICS No Response 1 3963 UNSPECIFIED CAPECITABINE ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED CAPECITABINE ANTINEOPLASTICS Approval 5 3956 MEDICAL ONCOLOGY CAPECITABINE 500MG OR TABS ANTINEOPLASTICS No Response 1 3956 PHYSICIAN, ONCOLOGY, MEDICAL CAPECITABINE 500MG OR TABS ANTINEOPLASTICS No Response 1 3956 INTERNAL MEDICINE CAPRELSA ANTINEOPLASTICS Approval 1 3956 PULMONARY DISEASES CAYSTON OTHER ANTIBIOTICS Approval 1 3956 PULMONARY DISEASES CAYSTON ANTIBIOTIC Approval 1 3969 ENDOCRINOLOGY, DIABETES & METABOLISM CINACALCET THYROID PRODUCT No Response 1 3969 ENDOCRINOLOGY, DIABETES & METABOLISM CINACALCET THYROID PRODUCT Approval 1 3956 INTERNAL MEDICINE CINACALCET THYROID PRODUCT Approval 2 3956 INTERNAL MEDICINE CINACALCET THYROID PRODUCT No Response 1 3956 INTERNAL MEDICINE CINACALCET THYROID PRODUCT Denial 1 3961 NEPHROLOGY / RENAL MEDICINE CINACALCET THYROID PRODUCT Approval 1 3956 NEPHROLOGY / RENAL MEDICINE CINACALCET THYROID PRODUCT No Response 1 3951 NEPHROLOGY / RENAL MEDICINE CINACALCET THYROID PRODUCT Denial 1 3951 NEPHROLOGY / RENAL MEDICINE CINACALCET THYROID PRODUCT Approval 1 3963 NEPHROLOGY / RENAL MEDICINE CINACALCET THYROID PRODUCT Approval 2 3963 NEPHROLOGY / RENAL MEDICINE CINACALCET THYROID PRODUCT No Response 1 3956 NEPHROLOGY / RENAL MEDICINE CINACALCET THYROID PRODUCT Approval 1 3963 UNSPECIFIED CINACALCET THYROID PRODUCT Approval 1 3956 UNSPECIFIED CINACALCET THYROID PRODUCT Approval 1

4 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 NEUROLOGY COPAXONE (GLATIRAMER ACETATE) 40 MG/ML SUBCUTANEOUS MILLILITER MULTIPLE SCLEROSIS No Response 1 3963 FAMILY PRACTICE COPAXONE 20MG MULTIPLE SCLEROSIS Approval 1 3956 UNSPECIFIED COPAXONE 20MG MULTIPLE SCLEROSIS Approval 1 3963 NEUROLOGY COPAXONE 40MG MULTIPLE SCLEROSIS Approval 2 3956 NEUROLOGY COPAXONE 40MG MULTIPLE SCLEROSIS Approval 2 3967 NEUROLOGY COPAXONE 40MG MULTIPLE SCLEROSIS Approval 1 3963 UNSPECIFIED COPAXONE 40MG MULTIPLE SCLEROSIS Denial 1 3956 DERMATOLOGY COSENTYX ALL OTHER DERMATOLOGICALS Denial 4 3963 DERMATOLOGY COSENTYX ALL OTHER DERMATOLOGICALS No Response 2 3962 DERMATOLOGY COSENTYX ALL OTHER DERMATOLOGICALS Approval 1 3969 DERMATOLOGY COSENTYX ALL OTHER DERMATOLOGICALS Approval 1 3963 DERMATOLOGY COSENTYX ALL OTHER DERMATOLOGICALS Denial 3 3951 DERMATOLOGY COSENTYX ALL OTHER DERMATOLOGICALS No Response 1 3951 DERMATOLOGY COSENTYX ALL OTHER DERMATOLOGICALS Approval 1 3963 INTERNAL MEDICINE COSENTYX ALL OTHER DERMATOLOGICALS No Response 1 3963 INTERNAL MEDICINE COSENTYX ALL OTHER DERMATOLOGICALS Denial 1 3956 NURSE PRACTITIONER, FAMILY HEALTH COSENTYX ALL OTHER DERMATOLOGICALS Denial 3 3951 NURSE PRACTITIONER, FAMILY HEALTH COSENTYX ALL OTHER DERMATOLOGICALS Denial 1 3956 NURSE PRACTITIONER, FAMILY HEALTH COSENTYX ALL OTHER DERMATOLOGICALS No Response 1 3956 NURSE PRACTITIONER, UNSPECIFIED COSENTYX ALL OTHER DERMATOLOGICALS Denial 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED COSENTYX ALL OTHER DERMATOLOGICALS No Response 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED COSENTYX ALL OTHER DERMATOLOGICALS Approval 1 3965 PHYSICIAN ASSISTANT, UNSPECIFIED COSENTYX ALL OTHER DERMATOLOGICALS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED COSENTYX ALL OTHER DERMATOLOGICALS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED COSENTYX ALL OTHER DERMATOLOGICALS Denial 2 3956 PHYSICIAN ASSISTANT, UNSPECIFIED COSENTYX ALL OTHER DERMATOLOGICALS Denial 2 3965 PHYSICIAN ASSISTANT, UNSPECIFIED COSENTYX ALL OTHER DERMATOLOGICALS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED COSENTYX ALL OTHER DERMATOLOGICALS Approval 1 3956 RHEUMATOLOGY COSENTYX ALL OTHER DERMATOLOGICALS Approval 2 3963 RHEUMATOLOGY COSENTYX ALL OTHER DERMATOLOGICALS Approval 6 3963 RHEUMATOLOGY COSENTYX ALL OTHER DERMATOLOGICALS No Response 2 3951 RHEUMATOLOGY COSENTYX ALL OTHER DERMATOLOGICALS Approval 1 3956 RHEUMATOLOGY COSENTYX ALL OTHER DERMATOLOGICALS No Response 1 3951 RHEUMATOLOGY COSENTYX ALL OTHER DERMATOLOGICALS No Response 1 3956 UNSPECIFIED COSENTYX ALL OTHER DERMATOLOGICALS Denial 4 3956 UNSPECIFIED COSENTYX ALL OTHER DERMATOLOGICALS Approval 5

5 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 UNSPECIFIED COSENTYX ALL OTHER DERMATOLOGICALS Approval 2 3965 UNSPECIFIED COSENTYX ALL OTHER DERMATOLOGICALS Approval 2 3963 UNSPECIFIED COSENTYX ALL OTHER DERMATOLOGICALS Denial 2 3963 UNSPECIFIED COSENTYX ALL OTHER DERMATOLOGICALS Approval 3 3965 UNSPECIFIED COSENTYX ALL OTHER DERMATOLOGICALS No Response 1 3963 UNSPECIFIED COSENTYX ALL OTHER DERMATOLOGICALS No Response 3 3956 UNSPECIFIED COSENTYX ALL OTHER DERMATOLOGICALS No Response 2 3963 INTERNAL MEDICINE COSENTYX 150MG/ML PEN 2PK IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED COSENTYX 150MG/ML PEN 2PK IMMUNOSUPPRESSIVES/DMARDS No Response 1 3961 DERMATOLOGY COSENTYX PEN 300 MG/2 PENS (150 MG/ML) SUBCUTANEOUS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, UNSPECIFIED COSENTYX PEN 300 MG/2 PENS (150 MG/ML) SUBCUTANEOUS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY COSENTYX SENSOREADY (300 MG) 150MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 4 3963 DERMATOLOGY COSENTYX SENSOREADY (300 MG) 150MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 FAMILY PRACTICE COSENTYX SENSOREADY (300 MG) 150MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH COSENTYX SENSOREADY (300 MG) 150MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED COSENTYX SENSOREADY (300 MG) 150MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 2 3951 UNSPECIFIED COSENTYX SENSOREADY (300 MG) 150MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 HEMATOLOGY & ONCOLOGY COTELLIC ANTINEOPLASTICS No Response 1 3963 HEMATOLOGY & ONCOLOGY COTELLIC ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED CRYSVITA ANTINEOPLASTICS No Response 1 3963 NEUROLOGY DALFAMPRIDINE ER MULTIPLE SCLEROSIS Denial 1 3963 NEUROLOGY DALFAMPRIDINE ER MULTIPLE SCLEROSIS Approval 3 3963 NEUROLOGY DALFAMPRIDINE ER MULTIPLE SCLEROSIS No Response 2 3956 UNSPECIFIED DALFAMPRIDINE ER MULTIPLE SCLEROSIS Approval 2 3956 UNSPECIFIED DALFAMPRIDINE ER MULTIPLE SCLEROSIS No Response 2 3963 NEUROLOGY DALFAMPRIDINE ER (DALFAMPRIDINE) 10 MG ORAL TABLET MULTIPLE SCLEROSIS No Response 1 3963 NEUROLOGY DIMETHYL FUMARATE MULTIPLE SCLEROSIS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED DIMETHYL FUMARATE MULTIPLE SCLEROSIS Approval 1 3951 UNSPECIFIED DIMETHYL FUMARATE MULTIPLE SCLEROSIS Approval 1 3956 UNSPECIFIED DIMETHYL FUMARATE MULTIPLE SCLEROSIS No Response 1 3956 UNSPECIFIED DIMETHYL FUMARATE MULTIPLE SCLEROSIS Denial 1 3956 UNSPECIFIED DIMETHYL FUMARATE MULTIPLE SCLEROSIS Approval 1

6 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 UNSPECIFIED DIMETHYL FUMARATE 120MG DR CAP MULTIPLE SCLEROSIS No Response 1 3956 CARDIOLOGY DOFETILIDE OTHER CARDIOVASCULAR PREPS Approval 2 3956 CARDIOLOGY DOFETILIDE CARDIOVASCULAR AGENTS Approval 2 3956 NURSE PRACTITIONER, UNSPECIFIED DOFETILIDE OTHER CARDIOVASCULAR PREPS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED DOFETILIDE CARDIOVASCULAR AGENTS Approval 1 3956 PHYSICIAN, CARDIAC ELECTROPHYSIOLOGY DOFETILIDE OTHER CARDIOVASCULAR PREPS Approval 3 3956 PHYSICIAN, CARDIAC ELECTROPHYSIOLOGY DOFETILIDE CARDIOVASCULAR AGENTS Approval 3 3951 INTERNAL MEDICINE DOPTELET HEMATOPOIETIC AGENT Approval 1 3951 INTERNAL MEDICINE DOPTELET HEMATOPOIETIC AGENT Denial 1 3956 UNSPECIFIED DOPTELET HEMATOPOIETIC AGENT Approval 1 3964 ALLERGY & IMMUNOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3956 ALLERGY & IMMUNOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 6 3956 ALLERGY & IMMUNOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 5 3963 ALLERGY & IMMUNOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 8 3963 ALLERGY & IMMUNOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3951 ALLERGY & IMMUNOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 ALLERGY & IMMUNOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 2 3965 ALLERGY & IMMUNOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3956 ALLERGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3956 ALLERGY & IMMUNOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 DERMATOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 7 3963 DERMATOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 16 3963 DERMATOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 3 3956 DERMATOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 12 3956 DERMATOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 7 3964 DERMATOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3956 DERMATOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3951 DERMATOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3969 DERMATOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3951 DERMATOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 2 3956 FAMILY PRACTICE DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 FAMILY PRACTICE DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 2 3964 FAMILY PRACTICE DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3965 FAMILY PRACTICE DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3965 FAMILY PRACTICE DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 4 3963 FAMILY PRACTICE DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3951 FAMILY PRACTICE DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1

7 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 GASTROENTEROLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 GASTROENTEROLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3969 GASTROENTEROLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3962 GASTROENTEROLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 INTERNAL MEDICINE DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3956 INTERNAL MEDICINE DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3961 INTERNAL MEDICINE DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 NEUROLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 NEUROLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 NURSE PRACTITIONER, ACUTE CARE DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3956 NURSE PRACTITIONER, ACUTE CARE DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 4 3951 NURSE PRACTITIONER, FAMILY HEALTH DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 3 3965 NURSE PRACTITIONER, FAMILY HEALTH DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 NURSE PRACTITIONER, UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 NURSE PRACTITIONER, UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3951 NURSE PRACTITIONER, UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3956 OTOLARYNGOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 6 3956 OTOLARYNGOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 2 3965 OTOLARYNGOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3965 OTOLARYNGOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 OTOLARYNGOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 4 3963 OTOLARYNGOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3963 OTOLARYNGOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 6 3961 OTOLARYNGOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3951 OTOLARYNGOLOGY DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3962 PEDIATRICS DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 2 3951 PEDIATRICS DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3951 PEDIATRICS DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3956 PEDIATRICS DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 8 3969 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 11 3956 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 4 3956 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 7

8 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 6 3963 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3965 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3969 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3964 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3962 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3962 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3964 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3956 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3956 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3963 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3956 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 PULMONARY DISEASES DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3963 PULMONARY DISEASES DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 3 3963 PULMONARY DISEASES DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3963 PULMONARY DISEASES DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3956 UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 17 3956 UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 18 3963 UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 20 3963 UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 15 3963 UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 8 3951 UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 4 3969 UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 2 3965 UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 3 3965 UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 4 3964 UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3956 UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 6 3951 UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3969 UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3962 UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3962 UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3964 UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Approval 1 3965 UNSPECIFIED DUPIXENT IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 5 3965 UNSPECIFIED DUPIXENT 200MG/1.14ML PEN 2 PK IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2

9 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT 200MG/1.14ML PFS 2 PK IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT 300 MG/2 ML SUBCUTANEOUS PEN INJECTOR IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 UNSPECIFIED DUPIXENT 300 MG/2 ML SUBCUTANEOUS PEN INJECTOR IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 DERMATOLOGY DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 3 3963 DERMATOLOGY DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 FAMILY PRACTICE DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 INTERNAL MEDICINE 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 4 3956 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3969 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 UNSPECIFIED DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 4 3951 UNSPECIFIED DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 UNSPECIFIED DUPIXENT 300MG/2ML PEN 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3951 DERMATOLOGY DUPIXENT 300MG/2ML PFS 2X2ML IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 ALLERGY & IMMUNOLOGY DUPIXENT 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 3 3963 ALLERGY & IMMUNOLOGY DUPIXENT 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 DERMATOLOGY DUPIXENT 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 GASTROENTEROLOGY DUPIXENT 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 NURSE PRACTITIONER, FAMILY HEALTH DUPIXENT 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 OTOLARYNGOLOGY DUPIXENT 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS Denial 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED DUPIXENT 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 PULMONARY DISEASES DUPIXENT 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 UNSPECIFIED DUPIXENT 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3951 UNSPECIFIED DUPIXENT 300MG/2ML SC SOPN IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3963 DERMATOLOGY DUPIXENT 300MG/2ML SC SOSY IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 2 3956 DERMATOLOGY DUPIXENT 300MG/2ML SC SOSY IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3951 NURSE PRACTITIONER, FAMILY HEALTH DUPIXENT 300MG/2ML SC SOSY IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 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 3963 UNSPECIFIED DUPIXENT 300MG/2ML SC SOSY IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3956 ALLERGY & IMMUNOLOGY DUPIXENT PEN 300 MG/2 MLMG/ML PEN INJECTOR IMMUNOGLOBULINS/DERMATOLOGICAL AGENTS No Response 1 3965 UNSPECIFIED ELIGARD ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED EMFLAZA CORTICOSTEROID No Response 1 3956 UNSPECIFIED EMFLAZA CORTICOSTEROID Approval 1

10 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 UNSPECIFIED ENBREL 25MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED ENBREL 25MG IMMUNOSUPPRESSIVES/DMARDS Denial 2 3956 NURSE PRACTITIONER, FAMILY HEALTH ENBREL 25MG/0.5ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 FAMILY PRACTICE ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 ALLERGY & IMMUNOLOGY ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 DERMATOLOGY ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Denial 2 3963 DERMATOLOGY ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 FAMILY PRACTICE ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 INTERNAL MEDICINE ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Denial 6 3962 INTERNAL MEDICINE ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3964 INTERNAL MEDICINE ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 INTERNAL MEDICINE ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 INTERNAL MEDICINE ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS No Response 4 3956 INTERNAL MEDICINE ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3951 INTERNAL MEDICINE ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 INTERNAL MEDICINE ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 INTERNAL MEDICINE ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3969 INTERNAL MEDICINE ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3969 INTERNAL MEDICINE ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 NURSE PRACTITIONER, FAMILY HEALTH ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 NURSE PRACTITIONER, FAMILY HEALTH ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3965 NURSE PRACTITIONER, UNSPECIFIED ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3961 RHEUMATOLOGY ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 RHEUMATOLOGY ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 11 3951 RHEUMATOLOGY ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 3 3956 RHEUMATOLOGY ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Denial 5 3956 RHEUMATOLOGY ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 17 3964 RHEUMATOLOGY ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 4 3951 RHEUMATOLOGY ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3964 RHEUMATOLOGY ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 RHEUMATOLOGY ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Denial 2 3969 RHEUMATOLOGY ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS No Response 2

11 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3969 RHEUMATOLOGY ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 RHEUMATOLOGY ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS No Response 2 3965 RHEUMATOLOGY ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 UNSPECIFIED ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS No Response 10 3956 UNSPECIFIED ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 12 3951 UNSPECIFIED ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 UNSPECIFIED ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 UNSPECIFIED ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 6 3965 UNSPECIFIED ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3969 UNSPECIFIED ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3962 UNSPECIFIED ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 UNSPECIFIED ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 UNSPECIFIED ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Denial 3 3964 UNSPECIFIED ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3951 UNSPECIFIED ENBREL 50MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED ENBREL 50MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 DERMATOLOGY ENBREL SURECLICK 50MG/ML INJ IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 NURSE PRACTITIONER, FAMILY HEALTH ENBREL SURECLICK 50MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED ENBREL SURECLICK 50MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 GASTROENTEROLOGY ENTECAVIR ANTIVIRALS Approval 1 3956 GASTROENTEROLOGY ENTECAVIR ANTIVIRAL Approval 1 3963 GASTROENTEROLOGY ENTECAVIR ANTIVIRALS Approval 1 3963 GASTROENTEROLOGY ENTECAVIR ANTIVIRAL Approval 1 3956 NURSE PRACTITIONER, ACUTE CARE ENTECAVIR ANTIVIRALS Approval 1 3956 NURSE PRACTITIONER, ACUTE CARE ENTECAVIR ANTIVIRAL Approval 1 3951 NURSE PRACTITIONER, FAMILY HEALTH ENTECAVIR ANTIVIRALS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH ENTECAVIR ANTIVIRALS Approval 1 3951 NURSE PRACTITIONER, FAMILY HEALTH ENTECAVIR ANTIVIRAL Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH ENTECAVIR ANTIVIRAL Approval 1 3956 UNSPECIFIED ENTECAVIR ANTIVIRALS Denial 1 3956 UNSPECIFIED ENTECAVIR ANTIVIRAL Denial 1 3963 FAMILY PRACTICE EPIDIOLEX ANTICONVULSANTS Denial 1 3969 NEUROLOGY, PEDIATRIC EPIDIOLEX ANTICONVULSANTS Denial 1 3963 NEUROLOGY, PEDIATRIC EPIDIOLEX ANTICONVULSANTS Denial 2 3963 NEUROLOGY, PEDIATRIC EPIDIOLEX ANTICONVULSANTS Approval 1 3956 HEMATOLOGY ERBITUX ANTINEOPLASTICS Approval 1

12 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 DERMATOLOGY ERIVEDGE ANTINEOPLASTICS Approval 1 3956 INTERNAL MEDICINE ERIVEDGE ANTINEOPLASTICS Approval 1 3956 INTERNAL MEDICINE ERIVEDGE 150MG OR CAPS ANTINEOPLASTICS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH ERLEADA ANTINEOPLASTICS Approval 1 3965 UNSPECIFIED ERLEADA ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED ERLOTINIB ANTINEOPLASTICS Denial 1 3956 UNSPECIFIED ERLOTINIB ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY EVEROLIMUS 10 MG ANTINEOPLASTICS Approval 1 3965 UNSPECIFIED EVEROLIMUS 10 MG ANTINEOPLASTICS No Response 2 3956 HEMATOLOGY & ONCOLOGY EVEROLIMUS 5 MG ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY EVEROLIMUS 5 MG ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED EXTAVIA MULTIPLE SCLEROSIS AGENT No Response 2 3956 ALLERGY & IMMUNOLOGY FASENRA RESPIRATORY AGENTS No Response 1 3956 ALLERGY & IMMUNOLOGY FASENRA RESPIRATORY AGENTS Denial 1 3956 INTERNAL MEDICINE FASENRA RESPIRATORY AGENTS Denial 2 3963 NURSE PRACTITIONER, UNSPECIFIED FASENRA RESPIRATORY AGENTS Approval 2 3963 NURSE PRACTITIONER, UNSPECIFIED FASENRA RESPIRATORY AGENTS No Response 1 3951 PULMONARY DISEASES FASENRA RESPIRATORY AGENTS Approval 1 3963 PULMONARY DISEASES FASENRA RESPIRATORY AGENTS No Response 1 3963 PULMONARY DISEASES FASENRA RESPIRATORY AGENTS Denial 3 3964 PULMONARY DISEASES FASENRA RESPIRATORY AGENTS Denial 1 3951 PULMONARY DISEASES FASENRA RESPIRATORY AGENTS Denial 1 3956 PULMONARY DISEASES FASENRA RESPIRATORY AGENTS Approval 1 3956 UNSPECIFIED FASENRA RESPIRATORY AGENTS No Response 1 3956 UNSPECIFIED FASENRA RESPIRATORY AGENTS Approval 3 3964 UNSPECIFIED FASENRA RESPIRATORY AGENTS No Response 1 3963 UNSPECIFIED FASENRA RESPIRATORY AGENTS No Response 1 3951 UNSPECIFIED FASENRA RESPIRATORY AGENTS Denial 1 3956 UNSPECIFIED FASENRA 30MG/ML INJ RESPIRATORY AGENTS Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED FASENRA PEN 30MG/ML INJ RESPIRATORY AGENTS Approval 1 3963 PULMONARY DISEASES FASENRA PEN 30MG/ML SC SOAJ RESPIRATORY AGENTS No Response 1 3961 NEUROLOGY FINGOLIMOD MULTIPLE SCLEROSIS AGENT Approval 1 3956 NEUROLOGY FINGOLIMOD MULTIPLE SCLEROSIS AGENT Approval 1 3964 NEUROLOGY FINGOLIMOD MULTIPLE SCLEROSIS AGENT No Response 1 3951 UNSPECIFIED FINGOLIMOD MULTIPLE SCLEROSIS AGENT No Response 1 3951 UNSPECIFIED FINGOLIMOD MULTIPLE SCLEROSIS AGENT Approval 1 3963 UNSPECIFIED FINGOLIMOD MULTIPLE SCLEROSIS AGENT Approval 2

13 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3969 ENDOCRINOLOGY, DIABETES & METABOLISM FORTEO MISCELLANEOUS Approval 1 3969 ENDOCRINOLOGY, DIABETES & METABOLISM FORTEO OSTEOPOROSIS Approval 1 3963 FAMILY PRACTICE FORTEO MISCELLANEOUS Approval 1 3963 FAMILY PRACTICE FORTEO OSTEOPOROSIS Approval 1 3963 INTERNAL MEDICINE FORTEO MISCELLANEOUS Denial 1 3963 INTERNAL MEDICINE FORTEO MISCELLANEOUS Approval 1 3963 INTERNAL MEDICINE FORTEO OSTEOPOROSIS Denial 1 3963 INTERNAL MEDICINE FORTEO OSTEOPOROSIS Approval 1 3963 PHYSICIAN, ENDOCRINOLOGY FORTEO MISCELLANEOUS Denial 1 3963 PHYSICIAN, ENDOCRINOLOGY FORTEO MISCELLANEOUS Approval 1 3963 PHYSICIAN, ENDOCRINOLOGY FORTEO OSTEOPOROSIS Denial 1 3963 PHYSICIAN, ENDOCRINOLOGY FORTEO OSTEOPOROSIS Approval 1 3965 UNSPECIFIED FORTEO MISCELLANEOUS Approval 1 3965 UNSPECIFIED FORTEO OSTEOPOROSIS Approval 1 3963 UNSPECIFIED FORTEO MISCELLANEOUS Approval 2 3963 UNSPECIFIED FORTEO MISCELLANEOUS No Response 1 3963 UNSPECIFIED FORTEO OSTEOPOROSIS Approval 2 3963 UNSPECIFIED FORTEO OSTEOPOROSIS No Response 1 3956 HEMATOLOGY & ONCOLOGY FULVESTRANT ANTINEOPLASTICS Approval 3 3956 UNSPECIFIED FULVESTRANT ANTINEOPLASTICS No Response 1 3956 ENDOCRINOLOGY, DIABETES & METABOLISM GENOTROPIN OTHER HORMONES No Response 1 3956 ENDOCRINOLOGY, DIABETES & METABOLISM GENOTROPIN GROWTH HORMONE THERAPY No Response 1 3963 ENDOCRINOLOGY, DIABETES & METABOLISM GENOTROPIN OTHER HORMONES Denial 1 3963 ENDOCRINOLOGY, DIABETES & METABOLISM GENOTROPIN GROWTH HORMONE THERAPY Denial 1 3963 ENDOCRINOLOGY, PEDIATRIC GENOTROPIN OTHER HORMONES Denial 1 3963 ENDOCRINOLOGY, PEDIATRIC GENOTROPIN OTHER HORMONES Approval 1 3963 ENDOCRINOLOGY, PEDIATRIC GENOTROPIN GROWTH HORMONE THERAPY Denial 1 3963 ENDOCRINOLOGY, PEDIATRIC GENOTROPIN GROWTH HORMONE THERAPY Approval 1 3956 PEDIATRICS GENOTROPIN OTHER HORMONES Denial 1 3951 PEDIATRICS GENOTROPIN OTHER HORMONES Denial 1 3956 PEDIATRICS GENOTROPIN GROWTH HORMONE THERAPY Denial 1 3951 PEDIATRICS GENOTROPIN GROWTH HORMONE THERAPY Denial 1 3951 PEDIATRICS GENOTROPIN OTHER HORMONES No Response 1 3951 PEDIATRICS GENOTROPIN GROWTH HORMONE THERAPY No Response 1 3963 UNSPECIFIED GENOTROPIN 5MG SC CART GROWTH HORMONE THERAPY No Response 2 3956 NEUROLOGY GILENYA MISCELLANEOUS Approval 1 3956 NEUROLOGY GILENYA MULTIPLE SCLEROSIS Approval 1

14 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 UNSPECIFIED GILENYA MISCELLANEOUS Denial 1 3951 UNSPECIFIED GILENYA MULTIPLE SCLEROSIS Denial 1 3963 UNSPECIFIED GILENYA 0.5MG OR CAPS MULTIPLE SCLEROSIS No Response 2 3963 UNSPECIFIED GLATIRAMER ACETATE 20MG MULTIPLE SCLEROSIS No Response 1 3963 INTERNAL MEDICINE GLATIRAMER ACETATE 40MG MULTIPLE SCLEROSIS Approval 1 3964 NEUROLOGY GLATIRAMER ACETATE 40MG MULTIPLE SCLEROSIS Approval 1 3963 NEUROLOGY GLATIRAMER ACETATE 40MG MULTIPLE SCLEROSIS Denial 1 3956 NEUROLOGY GLATIRAMER ACETATE 40MG MULTIPLE SCLEROSIS Approval 3 3963 NEUROLOGY GLATIRAMER ACETATE 40MG MULTIPLE SCLEROSIS Approval 1 3963 UNSPECIFIED GLATIRAMER ACETATE 40MG MULTIPLE SCLEROSIS No Response 2 3962 UNSPECIFIED GLATIRAMER ACETATE 40MG MULTIPLE SCLEROSIS Approval 1 3956 UNSPECIFIED GLATIRAMER ACETATE 40MG MULTIPLE SCLEROSIS Approval 1 3963 UNSPECIFIED GLATIRAMER ACETATE 40MG MULTIPLE SCLEROSIS Approval 2 3951 UNSPECIFIED GLATIRAMER ACETATE 40MG MULTIPLE SCLEROSIS Denial 1 3962 UNSPECIFIED GLATIRAMER ACETATE 40MG MULTIPLE SCLEROSIS No Response 1 3963 UNSPECIFIED HEMLIBRA HEMOPHILIA AGENT Approval 3 3969 ALLERGY & IMMUNOLOGY HIZENTRA BIOLOGICALS Approval 1 3963 ALLERGY & IMMUNOLOGY HIZENTRA BIOLOGICALS Approval 1 3969 ALLERGY & IMMUNOLOGY HIZENTRA IMMUNE GLOBULIN Approval 1 3963 ALLERGY & IMMUNOLOGY HIZENTRA IMMUNE GLOBULIN Approval 1 3963 PEDIATRICS HIZENTRA BIOLOGICALS Denial 1 3963 PEDIATRICS HIZENTRA IMMUNE GLOBULIN Denial 1 3963 UNSPECIFIED HIZENTRA BIOLOGICALS Approval 1 3963 UNSPECIFIED HIZENTRA IMMUNE GLOBULIN Approval 1 3963 UNSPECIFIED HIZENTRA BIOLOGICALS No Response 1 3963 UNSPECIFIED HIZENTRA IMMUNE GLOBULIN No Response 1 3963 ALLERGY & IMMUNOLOGY HIZENTRA 2GM/10ML SC SOSY IMMUNE GLOBULIN No Response 1 3963 RHEUMATOLOGY HUMIRA 10 MG ANTIARTHRITICS Approval 1 3963 DERMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 9 3963 DERMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 5 3956 DERMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 4 3963 DERMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 2 3951 DERMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 FAMILY PRACTICE HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 FAMILY PRACTICE HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 FAMILY PRACTICE HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1

15 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 FAMILY PRACTICE HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 FAMILY PRACTICE HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 GASTROENTEROLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 9 3956 GASTROENTEROLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 6 3963 GASTROENTEROLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 7 3961 GASTROENTEROLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 2 3961 GASTROENTEROLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3965 GASTROENTEROLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3965 GASTROENTEROLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 GASTROENTEROLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 3 3964 GASTROENTEROLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3964 GASTROENTEROLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 GASTROENTEROLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 2 3963 GASTROENTEROLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 2 3961 GASTROENTEROLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 GASTROENTEROLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3951 GASTROENTEROLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 GASTROENTEROLOGY, PEDIATRIC HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 GENERAL PRACTICE HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 GENERAL PRACTICE HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 INTERNAL MEDICINE HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 4 3956 INTERNAL MEDICINE HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 5 3963 INTERNAL MEDICINE HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 INTERNAL MEDICINE HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 4 3956 INTERNAL MEDICINE HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 INTERNAL MEDICINE HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3951 INTERNAL MEDICINE HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, ACUTE CARE HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3964 NURSE PRACTITIONER, FAMILY HEALTH HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 4 3963 NURSE PRACTITIONER, FAMILY HEALTH HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 NURSE PRACTITIONER, FAMILY HEALTH HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 3 3951 NURSE PRACTITIONER, FAMILY HEALTH HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 4 3956 NURSE PRACTITIONER, FAMILY HEALTH HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3964 NURSE PRACTITIONER, FAMILY HEALTH HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 NURSE PRACTITIONER, UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 NURSE PRACTITIONER, UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 3

16 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3962 NURSE PRACTITIONER, UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 PEDIATRICS HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 PEDIATRICS HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3951 PHYSICIAN ASSISTANT, UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3951 PSYCHIATRY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 RHEUMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 8 3963 RHEUMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 21 3965 RHEUMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 RHEUMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 28 3963 RHEUMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 4 3964 RHEUMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 5 3951 RHEUMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 RHEUMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 4 3961 RHEUMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 2 3961 RHEUMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3969 RHEUMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 RHEUMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 4 3962 RHEUMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 2 3962 RHEUMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3951 RHEUMATOLOGY HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 13 3963 UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 30 3956 UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 18 3965 UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 6 3951 UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 5 3963 UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 12 3951 UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 3 3961 UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3961 UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 7 3956 UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 5

17 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 2 3964 UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3965 UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 3 3962 UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 2 3962 UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3965 UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3969 UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3969 UNSPECIFIED HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3964 RHEUMATOLOGY HUMIRA 40MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 RHEUMATOLOGY HUMIRA 40MG/0.4ML SC PSKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 FAMILY PRACTICE HUMIRA 40MG/0.8ML SC PSKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 DERMATOLOGY HUMIRA 80 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 DERMATOLOGY HUMIRA 80 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 FAMILY PRACTICE HUMIRA 80 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 INTERNAL MEDICINE HUMIRA 80 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH HUMIRA 80 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 NURSE PRACTITIONER, UNSPECIFIED HUMIRA 80 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED HUMIRA 80 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED HUMIRA 80 MG IMMUNOSUPPRESSIVES/DMARDS Approval 3 3951 PHYSICIAN ASSISTANT, UNSPECIFIED HUMIRA 80 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED HUMIRA 80 MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 UNSPECIFIED HUMIRA 80 MG IMMUNOSUPPRESSIVES/DMARDS Denial 2 3956 UNSPECIFIED HUMIRA 80 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 UNSPECIFIED HUMIRA 80 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED HUMIRA 80 MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 UNSPECIFIED HUMIRA 80 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 UNSPECIFIED HUMIRA 80 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED HUMIRA CD/UC/HS PACK CF 80MG IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 UNSPECIFIED HUMIRA CD/UC/HS PACK CF 80MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED HUMIRA CD/UC/HS PACK CF 80MG IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 UNSPECIFIED HUMIRA CROHN?S/UC/HS STARTER PACK + HUMI­ RA 80 MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 UNSPECIFIED HUMIRA CROHN?S/UC/HS STARTER PACK + HUMI­ RA 80 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 DERMATOLOGY HUMIRA CROHNS/UC/HS STARTER PACK + HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 DERMATOLOGY HUMIRA CROHNS/UC/HS STARTER PACK + HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1

18 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 GASTROENTEROLOGY HUMIRA CROHNS/UC/HS STARTER PACK + HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 3 3963 INTERNAL MEDICINE HUMIRA CROHNS/UC/HS STARTER PACK + HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, ACUTE CARE HUMIRA CROHNS/UC/HS STARTER PACK + HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH HUMIRA CROHNS/UC/HS STARTER PACK + HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 NURSE PRACTITIONER, FAMILY HEALTH HUMIRA CROHNS/UC/HS STARTER PACK + HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED HUMIRA CROHNS/UC/HS STARTER PACK + HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 UNSPECIFIED HUMIRA CROHNS/UC/HS STARTER PACK + HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 3 3956 UNSPECIFIED HUMIRA CROHNS/UC/HS STARTER PACK + HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 UNSPECIFIED HUMIRA CROHNS/UC/HS STARTER PACK + HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 DERMATOLOGY HUMIRA CROHNS/UC/HS STARTER PACK + HUMIRA 80 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3951 GASTROENTEROLOGY HUMIRA CROHNS/UC/HS STARTER PACK + HUMIRA 80 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED HUMIRA CROHNS/UC/HS STARTER PACK + HUMIRA 80 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 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 2 3963 UNSPECIFIED HUMIRA PED. CROHNS STARTER PACK + HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3964 UNSPECIFIED HUMIRA PED. CROHNS STARTER PACK + HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 DERMATOLOGY HUMIRA PED. UC STARTER PACK + 80 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED HUMIRA PED. UC STARTER PACK + 80 MG IMMUNOSUPPRESSIVES/DMARDS No Response 7 3963 UNSPECIFIED HUMIRA PED. UC STARTER PACK + 80 MG IMMUNOSUPPRESSIVES/DMARDS No Response 4 3965 UNSPECIFIED HUMIRA PED. UC STARTER PACK + 80 MG IMMUNOSUPPRESSIVES/DMARDS No Response 3 3964 UNSPECIFIED HUMIRA PED. UC STARTER PACK + 80 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 UNSPECIFIED HUMIRA PEDIATRIC CROHNS START 80 MG/0.8ML &40MG/0.4ML SC PSKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED HUMIRA PEN 40 MG/0.4ML NO CITR IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 FAMILY PRACTICE HUMIRA PEN 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 GASTROENTEROLOGY HUMIRA PEN 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 3 3963 INTERNAL MEDICINE HUMIRA PEN 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 INTERNAL MEDICINE HUMIRA PEN 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1

19 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3951 INTERNAL MEDICINE HUMIRA PEN 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 2 3951 NURSE PRACTITIONER, FAMILY HEALTH HUMIRA PEN 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY HUMIRA PEN 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 UNSPECIFIED HUMIRA PEN 40MG/0.4ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 NURSE PRACTITIONER, FAMILY HEALTH HUMIRA PEN 40MG/0.8ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3964 UNSPECIFIED HUMIRA PEN 40MG/0.8ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY HUMIRA PEN 80MG/0.8ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY HUMIRA PEN-CD/UC/HS STARTER 80MG/0.8ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 GASTROENTEROLOGY HUMIRA PEN-CD/UC/HS STARTER 80MG/0.8ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED HUMIRA PEN-CD/UC/HS STARTER 80MG/0.8ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED HUMIRA PEN-CD/UC/HS STARTER 80MG/0.8ML SC PNKT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 DERMATOLOGY HUMIRA PSO/UV/ADOLESCENT HS + HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 DERMATOLOGY HUMIRA PSO/UV/ADOLESCENT HS + HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3969 INTERNAL MEDICINE HUMIRA PSO/UV/ADOLESCENT HS + HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 RHEUMATOLOGY HUMIRA PSO/UV/ADOLESCENT HS + HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED HUMIRA PSO/UV/ADOLESCENT HS + HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 UNSPECIFIED HUMIRA PSO/UV/ADOLESCENT HS + HUMIRA 40 MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 UNSPECIFIED HUMIRA(CF) PEN 40 MG/0.4 ML SUBCUTANEOUS KIT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED HUMIRA(CF) PEN CROHN’S-ULC COLITIS-HID SUP STRT 80 MG/0.8 ML SUBCUT KT IMMUNOSUPPRESSIVES/DMARDS No Response 1 3964 ALLERGY & IMMUNOLOGY HYQVIA BIOLOGICALS Approval 1 3964 ALLERGY & IMMUNOLOGY HYQVIA IMMUNE GLOBULIN Approval 1 3963 ALLERGY & IMMUNOLOGY HYQVIA BIOLOGICALS Approval 2 3956 ALLERGY & IMMUNOLOGY HYQVIA BIOLOGICALS No Response 1 3963 ALLERGY & IMMUNOLOGY HYQVIA IMMUNE GLOBULIN Approval 2 3956 ALLERGY & IMMUNOLOGY HYQVIA IMMUNE GLOBULIN No Response 1 3956 ALLERGY & IMMUNOLOGY HYQVIA BIOLOGICALS Denial 1 3956 ALLERGY & IMMUNOLOGY HYQVIA BIOLOGICALS Approval 1 3956 ALLERGY & IMMUNOLOGY HYQVIA IMMUNE GLOBULIN Denial 1 3956 ALLERGY & IMMUNOLOGY HYQVIA IMMUNE GLOBULIN Approval 1 3964 UNSPECIFIED HYQVIA BIOLOGICALS No Response 1

20 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3964 UNSPECIFIED HYQVIA BIOLOGICALS Approval 1 3964 UNSPECIFIED HYQVIA IMMUNE GLOBULIN No Response 1 3964 UNSPECIFIED HYQVIA IMMUNE GLOBULIN Approval 1 3956 HEMATOLOGY & ONCOLOGY IBRANCE ANTINEOPLASTICS Approval 2 3964 HEMATOLOGY & ONCOLOGY IBRANCE ANTINEOPLASTICS Denial 1 3956 HEMATOLOGY & ONCOLOGY IBRANCE ANTINEOPLASTICS No Response 1 3969 HEMATOLOGY & ONCOLOGY IBRANCE ANTINEOPLASTICS No Response 2 3969 HEMATOLOGY & ONCOLOGY IBRANCE ANTINEOPLASTICS Approval 1 3963 INTERNAL MEDICINE IBRANCE ANTINEOPLASTICS No Response 1 3964 UNSPECIFIED IBRANCE ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY IBRANCE 100MG OR TABS ANTINEOPLASTICS No Response 1 3963 UNSPECIFIED ILARIS ANTIRHEUMATIC Approval 1 3951 UNSPECIFIED ILARIS ANTIRHEUMATIC Denial 1 3951 UNSPECIFIED ILARIS ANTIRHEUMATIC Approval 1 3956 HEMATOLOGY & ONCOLOGY IMATINIB MESYLATE ANTINEOPLASTICS No Response 1 3956 HEMATOLOGY & ONCOLOGY IMATINIB MESYLATE ANTINEOPLASTICS Approval 1 3951 UNSPECIFIED IMATINIB MESYLATE ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED IMATINIB MESYLATE ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED IMATINIB MESYLATE ANTINEOPLASTICS No Response 1 3956 UNSPECIFIED IMATINIB MESYLATE ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY IMBRUVICA ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY IMBRUVICA ANTINEOPLASTICS Approval 1 3963 MEDICAL ONCOLOGY IMBRUVICA ANTINEOPLASTICS No Response 1 3965 UNSPECIFIED IMBRUVICA ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED IMBRUVICA ANTINEOPLASTICS No Response 1 3956 UNSPECIFIED IMBRUVICA ANTINEOPLASTICS Approval 1 3961 UNSPECIFIED IMBRUVICA 280MG ANTINEOPLASTICS Approval 1 3951 UNSPECIFIED INFLIXIMAB ANTIRHEUMATIC Denial 1 3963 NURSE PRACTITIONER, PSYCHIATRIC INGREZZA PSYCHOTHERAPEUTIC Denial 1 3963 NURSE PRACTITIONER, PSYCHIATRIC INGREZZA PSYCHOTHERAPEUTIC Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED INGREZZA PSYCHOTHERAPEUTIC No Response 1 3963 NURSE PRACTITIONER, UNSPECIFIED INGREZZA PSYCHOTHERAPEUTIC Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED INGREZZA PSYCHOTHERAPEUTIC Denial 1 3963 NURSE PRACTITIONER, UNSPECIFIED INGREZZA 80MG OR CAPS VESICULAR MONOAMINE TRANSPORTER 2 INHIB­ ITOR No Response 1 3963 NURSE PRACTITIONER, UNSPECIFIED INGREZZA 80MG OR CAPS VMAT2 INHIBITOR No Response 1 3963 HEMATOLOGY & ONCOLOGY INLYTA ANTINEOPLASTICS No Response 2

21 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 HEMATOLOGY & ONCOLOGY INLYTA ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY INLYTA ANTINEOPLASTICS Approval 1 3963 INTERNAL MEDICINE INLYTA ANTINEOPLASTICS Approval 1 3951 HEMATOLOGY & ONCOLOGY JAKAFI ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY JAKAFI ANTINEOPLASTICS Approval 2 3963 INTERNAL MEDICINE JAKAFI ANTINEOPLASTICS Approval 1 3956 MEDICAL ONCOLOGY JAKAFI ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED JAKAFI ANTINEOPLASTICS Approval 1 3965 UNSPECIFIED JAKAFI ANTINEOPLASTICS Approval 1 3965 UNSPECIFIED JYNARQUE KIDNEY AGENT No Response 1 3963 NEUROLOGY KESIMPTA MULTIPLE SCLEROSIS AGENT Denial 1 3963 NURSE PRACTITIONER, GERONTOLOGY KESIMPTA MULTIPLE SCLEROSIS AGENT Denial 1 3963 NURSE PRACTITIONER, GERONTOLOGY KESIMPTA MULTIPLE SCLEROSIS AGENT Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED KESIMPTA MULTIPLE SCLEROSIS AGENT Approval 1 3963 UNSPECIFIED KESIMPTA MULTIPLE SCLEROSIS AGENT No Response 1 3963 UNSPECIFIED KESIMPTA MULTIPLE SCLEROSIS AGENT Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED KESIMPTA 20MG/0.4ML SC SOAJ MULTIPLE SCLEROSIS AGENT No Response 1 3956 INTERNAL MEDICINE KEVZARA IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 RHEUMATOLOGY KEVZARA IMMUNOSUPPRESSIVES/DMARDS Denial 2 3956 RHEUMATOLOGY KEVZARA IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 RHEUMATOLOGY KEVZARA IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 RHEUMATOLOGY KEVZARA IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 RHEUMATOLOGY KEVZARA IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 RHEUMATOLOGY KEVZARA IMMUNOSUPPRESSIVES/DMARDS No Response 1 3969 RHEUMATOLOGY KEVZARA IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 HEMATOLOGY & ONCOLOGY KISQALI ANTINEOPLASTICS Approval 2 3956 HEMATOLOGY & ONCOLOGY KISQALI ANTINEOPLASTICS Approval 1 3963 INTERNAL MEDICINE KISQALI ANTINEOPLASTICS Approval 1 3956 MEDICAL ONCOLOGY KISQALI ANTINEOPLASTICS Approval 1 3964 HEMATOLOGY & ONCOLOGY KISQALI PAK FEMARA ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY LENALIDOMIDE ANTINEOPLASTICS No Response 2 3956 HEMATOLOGY LENALIDOMIDE ANTINEOPLASTICS No Response 1 3956 HEMATOLOGY & ONCOLOGY LENALIDOMIDE ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY LENALIDOMIDE ANTINEOPLASTICS Approval 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL LENALIDOMIDE ANTINEOPLASTICS No Response 1 3956 UNSPECIFIED LENALIDOMIDE ANTINEOPLASTICS No Response 1 3965 UNSPECIFIED LENALIDOMIDE ANTINEOPLASTICS Approval 1

22 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 HEMATOLOGY & ONCOLOGY LENVIMA ANTINEOPLASTICS No Response 1 3963 HEMATOLOGY & ONCOLOGY LENVIMA ANTINEOPLASTICS Approval 3 3956 OBSTETRICS & GYNECOLOGY LENVIMA ANTINEOPLASTICS Approval 1 3956 ONCOLOGY, GYNECOLOGIC LENVIMA ANTINEOPLASTICS No Response 1 3963 UNSPECIFIED LEUPROLIDE 1 MG/0.2 MLMG/ML KIT HORMONES No Response 1 3956 UNSPECIFIED LEUPROLIDE KIT HORMONES No Response 6 3961 UNSPECIFIED LEUPROLIDE KIT HORMONES No Response 1 3963 UNSPECIFIED LEUPROLIDE KIT HORMONES No Response 4 3969 UNSPECIFIED LEUPROLIDE KIT HORMONES No Response 1 3964 HEMATOLOGY & ONCOLOGY LONSURF ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY LONSURF ANTINEOPLASTICS Approval 2 3962 HEMATOLOGY & ONCOLOGY LONSURF ANTINEOPLASTICS Approval 1 3963 OBSTETRICS & GYNECOLOGY LUPRON DEPOT 3.75 MG HORMONES/HORMONE MODIFIERS Approval 2 3963 OBSTETRICS & GYNECOLOGY LUPRON DEPOT 3.75 MG HORMONES/HORMONE MODIFIERS No Response 1 3956 OBSTETRICS & GYNECOLOGY LUPRON DEPOT 3.75 MG HORMONES/HORMONE MODIFIERS Approval 2 3963 UNSPECIFIED LUPRON DEPOT 3.75 MG HORMONES/HORMONE MODIFIERS No Response 1 3956 HEMATOLOGY & ONCOLOGY LYNPARZA ANTINEOPLASTICS Denial 1 3951 HEMATOLOGY & ONCOLOGY LYNPARZA ANTINEOPLASTICS No Response 1 3963 HEMATOLOGY & ONCOLOGY LYNPARZA ANTINEOPLASTICS Denial 1 3963 HEMATOLOGY & ONCOLOGY LYNPARZA ANTINEOPLASTICS Approval 1 3963 INTERNAL MEDICINE LYNPARZA ANTINEOPLASTICS No Response 1 3963 INTERNAL MEDICINE LYNPARZA ANTINEOPLASTICS Denial 1 3963 INTERNAL MEDICINE LYNPARZA ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED LYNPARZA ANTINEOPLASTICS Approval 1 3956 NEUROLOGY MAVENCLAD MULTIPLE SCLEROSIS AGENT Denial 1 3956 NEUROLOGY MAVENCLAD MULTIPLE SCLEROSIS AGENT Approval 1 3956 UNSPECIFIED MAVENCLAD MULTIPLE SCLEROSIS AGENT Approval 1 3956 UNSPECIFIED MAVENCLAD MULTIPLE SCLEROSIS AGENT No Response 1 3956 HEMATOLOGY & ONCOLOGY MEKINIST ANTINEOPLASTICS Denial 1 3956 HEMATOLOGY & ONCOLOGY MEKINIST ANTINEOPLASTICS Approval 1 3956 INTERNAL MEDICINE MEKINIST ANTINEOPLASTICS Approval 1 3951 UNSPECIFIED MEKINIST ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED MEKINIST ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY MEKINIST 2MG OR TABS ANTINEOPLASTICS No Response 1 3951 MEDICAL ONCOLOGY MEKTOVI ANTINEOPLASTICS Approval 1 3951 MEDICAL ONCOLOGY MEKTOVI ANTINEOPLASTICS No Response 1 3963 UNSPECIFIED MYCAPSSA 20MG OR CPDR SOMATOSTATIN ANALOG No Response 1

23 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 INTERNAL MEDICINE NEULASTA ONPRO 6MG/0.6ML SC PSKT HEMATOPOIETIC AGENT Denial 1 3969 UNSPECIFIED NEULASTA ONPRO 6MG/0.6ML SC PSKT HEMATOPOIETIC AGENT Denial 1 3956 HEMATOLOGY & ONCOLOGY NIVESTYM COLONY STIMULATING FACTORS Approval 2 3963 ENDOCRINOLOGY, PEDIATRIC NORDITROPIN OTHER HORMONES Approval 2 3963 ENDOCRINOLOGY, PEDIATRIC NORDITROPIN GROWTH HORMONE THERAPY Approval 2 3963 NURSE PRACTITIONER, FAMILY HEALTH NORDITROPIN OTHER HORMONES No Response 1 3963 NURSE PRACTITIONER, FAMILY HEALTH NORDITROPIN GROWTH HORMONE THERAPY No Response 1 3963 PEDIATRICS NORDITROPIN OTHER HORMONES Approval 2 3963 PEDIATRICS NORDITROPIN OTHER HORMONES Denial 2 3951 PEDIATRICS NORDITROPIN OTHER HORMONES Denial 1 3963 PEDIATRICS NORDITROPIN GROWTH HORMONE THERAPY Approval 2 3963 PEDIATRICS NORDITROPIN GROWTH HORMONE THERAPY Denial 2 3951 PEDIATRICS NORDITROPIN GROWTH HORMONE THERAPY Denial 1 3951 PEDIATRICS NORDITROPIN OTHER HORMONES Approval 1 3951 PEDIATRICS NORDITROPIN GROWTH HORMONE THERAPY Approval 1 3963 REGISTERED NURSE, PEDIATRICS NORDITROPIN OTHER HORMONES Denial 1 3963 REGISTERED NURSE, PEDIATRICS NORDITROPIN GROWTH HORMONE THERAPY Denial 1 3951 UNSPECIFIED NORDITROPIN OTHER HORMONES No Response 2 3951 UNSPECIFIED NORDITROPIN GROWTH HORMONE THERAPY No Response 2 3951 UNSPECIFIED NORDITROPIN OTHER HORMONES Approval 1 3951 UNSPECIFIED NORDITROPIN GROWTH HORMONE THERAPY Approval 1 3963 UNSPECIFIED NORDITROPIN OTHER HORMONES Approval 1 3963 UNSPECIFIED NORDITROPIN OTHER HORMONES No Response 1 3956 UNSPECIFIED NORDITROPIN OTHER HORMONES Denial 1 3963 UNSPECIFIED NORDITROPIN GROWTH HORMONE THERAPY Approval 1 3963 UNSPECIFIED NORDITROPIN GROWTH HORMONE THERAPY No Response 1 3956 UNSPECIFIED NORDITROPIN GROWTH HORMONE THERAPY Denial 1 3963 REGISTERED NURSE, PEDIATRICS NORDITROPIN FLEXPRO 10 MG/1.5 ML(6.7 MG/ML) PEN INJECTOR OTHER HORMONES No Response 1 3951 PEDIATRICS NORDITROPIN FLEXPRO 15MG/1.5ML SC SOPN GROWTH HORMONE THERAPY No Response 1 3951 UNSPECIFIED NORDITROPIN FLEXPRO 15MG/1.5ML SC SOPN GROWTH HORMONE THERAPY No Response 1 3956 HEMATOLOGY & ONCOLOGY NPLATE HEMATOPOIETIC AGENT No Response 1 3963 HEMATOLOGY & ONCOLOGY NPLATE HEMATOPOIETIC AGENT No Response 1 3956 HEMATOLOGY & ONCOLOGY NPLATE ANTINEOPLASTICS No Response 1 3963 HEMATOLOGY & ONCOLOGY NPLATE ANTINEOPLASTICS No Response 1 3956 UNSPECIFIED NPLATE HEMATOPOIETIC AGENT No Response 1 3956 UNSPECIFIED NPLATE ANTINEOPLASTICS No Response 1

24 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 HEMATOLOGY & ONCOLOGY NUBEQA ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED NUBEQA ANTINEOPLASTICS No Response 1 3965 ALLERGY & IMMUNOLOGY NUCALA MISCELLANEOUS Approval 1 3951 NEUROLOGY NUCALA MISCELLANEOUS Approval 1 3951 NEUROLOGY NUCALA MISCELLANEOUS No Response 1 3963 NEUROLOGY NUCALA MISCELLANEOUS Approval 1 3963 NEUROLOGY NUCALA MISCELLANEOUS Denial 1 3965 PULMONARY DISEASES NUCALA MISCELLANEOUS No Response 1 3965 PULMONARY DISEASES NUCALA MISCELLANEOUS Approval 1 3967 PULMONARY DISEASES NUCALA MISCELLANEOUS No Response 1 3963 PULMONARY DISEASES NUCALA MISCELLANEOUS Denial 1 3965 UNSPECIFIED NUCALA MISCELLANEOUS No Response 2 3965 UNSPECIFIED NUCALA MISCELLANEOUS Approval 1 3961 PEDIATRICS NUTROPIN AQ GROWTH HORMONE No Response 1 3956 PEDIATRICS NUTROPIN AQ GROWTH HORMONE No Response 1 3963 INTERNAL MEDICINE OCTREOTIDE ACETATE OTHER HORMONES Approval 1 3956 MEDICAL ONCOLOGY OCTREOTIDE ACETATE OTHER HORMONES Approval 1 3963 MEDICAL ONCOLOGY OCTREOTIDE ACETATE OTHER HORMONES Denial 2 3956 DERMATOLOGY ODOMZO ANTINEOPLASTICS Approval 1 3956 INTERNAL MEDICINE OFEV MISCELLANEOUS No Response 1 3956 INTERNAL MEDICINE OFEV MISCELLANEOUS Denial 1 3956 INTERNAL MEDICINE OFEV MISCELLANEOUS Approval 2 3956 INTERNAL MEDICINE OFEV TYROSINE KINASE INHIBITOR No Response 1 3956 INTERNAL MEDICINE OFEV TYROSINE KINASE INHIBITOR Denial 1 3956 INTERNAL MEDICINE OFEV TYROSINE KINASE INHIBITOR Approval 2 3956 NURSE PRACTITIONER, FAMILY HEALTH OFEV MISCELLANEOUS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH OFEV TYROSINE KINASE INHIBITOR Approval 1 3951 PULMONARY DISEASES OFEV MISCELLANEOUS Approval 1 3951 PULMONARY DISEASES OFEV TYROSINE KINASE INHIBITOR Approval 1 3963 PULMONARY DISEASES OFEV MISCELLANEOUS No Response 1 3963 PULMONARY DISEASES OFEV TYROSINE KINASE INHIBITOR No Response 1 3951 UNSPECIFIED OFEV MISCELLANEOUS Approval 1 3951 UNSPECIFIED OFEV TYROSINE KINASE INHIBITOR Approval 1 3956 UNSPECIFIED OFEV MISCELLANEOUS Approval 3 3956 UNSPECIFIED OFEV TYROSINE KINASE INHIBITOR Approval 3 3956 INTERNAL MEDICINE OFEV 150MG OR CAPS MISCELLANEOUS No Response 3 3956 CARDIOLOGY OPSUMIT OTHER ANTIHYPERTENSIVES Approval 1

25 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 CARDIOLOGY OPSUMIT PULMONARY ARTERIAL HYPERTENSION Approval 1 3956 INTERNAL MEDICINE OPSUMIT OTHER ANTIHYPERTENSIVES No Response 1 3956 INTERNAL MEDICINE OPSUMIT OTHER ANTIHYPERTENSIVES Approval 1 3956 INTERNAL MEDICINE OPSUMIT PULMONARY ARTERIAL HYPERTENSION No Response 1 3956 INTERNAL MEDICINE OPSUMIT PULMONARY ARTERIAL HYPERTENSION Approval 1 3963 PULMONARY DISEASES OPSUMIT OTHER ANTIHYPERTENSIVES Approval 1 3963 PULMONARY DISEASES OPSUMIT PULMONARY ARTERIAL HYPERTENSION Approval 1 3956 UNSPECIFIED OPSUMIT OTHER ANTIHYPERTENSIVES Approval 1 3956 UNSPECIFIED OPSUMIT PULMONARY ARTERIAL HYPERTENSION Approval 1 3963 CARDIOLOGY ORENITRAM VASODILATORS Approval 1 3963 FAMILY PRACTICE OTEZLA 10 & 20 & 30MG OR TBPK IMMUNOSUPPRESSIVES/DMARDS No Response 4 3965 RHEUMATOLOGY 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 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 DERMATOLOGY OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 3 3956 DERMATOLOGY OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 DERMATOLOGY OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 2 3956 DERMATOLOGY OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 9 3956 FAMILY PRACTICE OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 3 3956 FAMILY PRACTICE OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 FAMILY PRACTICE OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 3 3963 FAMILY PRACTICE OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3964 FAMILY PRACTICE OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3964 FAMILY PRACTICE OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3964 FAMILY PRACTICE OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3964 INTERNAL MEDICINE OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3964 INTERNAL MEDICINE OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3964 INTERNAL MEDICINE OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3965 NURSE PRACTITIONER, FAMILY HEALTH OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3951 NURSE PRACTITIONER, FAMILY HEALTH OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 3 3956 NURSE PRACTITIONER, UNSPECIFIED OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 NURSE PRACTITIONER, UNSPECIFIED OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 6 3963 PHYSICIAN ASSISTANT, UNSPECIFIED OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS No Response 1

26 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 RHEUMATOLOGY OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 2 3963 RHEUMATOLOGY OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 9 3956 RHEUMATOLOGY OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 5 3965 RHEUMATOLOGY OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3961 RHEUMATOLOGY OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 RHEUMATOLOGY OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3965 RHEUMATOLOGY OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 4 3963 UNSPECIFIED OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 UNSPECIFIED OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 4 3951 UNSPECIFIED OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3951 UNSPECIFIED OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 UNSPECIFIED OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 3 3956 UNSPECIFIED OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS No Response 4 3956 UNSPECIFIED OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 7 3969 PHYSICIAN ASSISTANT, UNSPECIFIED OTEZLA 30MG OR TABS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED OTEZLA 30MG OR TABS IMMUNOSUPPRESSIVES/DMARDS No Response 4 3961 PHYSICIAN ASSISTANT, UNSPECIFIED OTEZLA 30MG OR TABS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY OTEZLA 30MG OR TABS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 FAMILY PRACTICE OTEZLA STARTER PACK + OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 3 3963 FAMILY PRACTICE OTEZLA STARTER PACK + OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 FAMILY PRACTICE OTEZLA STARTER PACK + OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 FAMILY PRACTICE OTEZLA STARTER PACK + OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3965 INTERNAL MEDICINE OTEZLA STARTER PACK + OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, UNSPECIFIED OTEZLA STARTER PACK + OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, UNSPECIFIED OTEZLA STARTER PACK + OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED OTEZLA STARTER PACK + OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3969 PHYSICIAN ASSISTANT, UNSPECIFIED OTEZLA STARTER PACK + OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED OTEZLA STARTER PACK + OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3961 PHYSICIAN ASSISTANT, UNSPECIFIED OTEZLA STARTER PACK + OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 RHEUMATOLOGY OTEZLA STARTER PACK + OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 2 3965 RHEUMATOLOGY OTEZLA STARTER PACK + OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 UNSPECIFIED OTEZLA STARTER PACK + OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3964 UNSPECIFIED OTEZLA STARTER PACK + OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED OTEZLA STARTER PACK + OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3967 UNSPECIFIED OTEZLA STARTER PACK + OTEZLA 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 INTERNAL MEDICINE PIQRAY ANTINEOPLASTICS Denial 1

27 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 HEMATOLOGY POMALYST ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY POMALYST ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY POMALYST ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY POMALYST ANTINEOPLASTICS No Response 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL POMALYST ANTINEOPLASTICS Approval 1 3956 FAMILY PRACTICE PRALUENT LIPOTROPICS Denial 9 3956 CARDIOLOGY PRALUENT LIPOTROPICS No Response 3 3956 CARDIOLOGY PRALUENT LIPOTROPICS Approval 9 3956 CARDIOLOGY PRALUENT LIPOTROPICS Denial 17 3963 CARDIOLOGY PRALUENT LIPOTROPICS Approval 3 3963 CARDIOLOGY PRALUENT LIPOTROPICS Denial 18 3963 CARDIOLOGY PRALUENT LIPOTROPICS No Response 4 3951 CARDIOLOGY PRALUENT LIPOTROPICS No Response 1 3951 CARDIOLOGY PRALUENT LIPOTROPICS Approval 1 3951 CARDIOLOGY PRALUENT LIPOTROPICS Denial 2 3964 CARDIOLOGY PRALUENT LIPOTROPICS Denial 1 3965 CARDIOLOGY PRALUENT LIPOTROPICS No Response 1 3962 CARDIOLOGY PRALUENT LIPOTROPICS Denial 1 3963 CARDIOLOGY, INTERVENTIONAL PRALUENT LIPOTROPICS Denial 2 3951 CARDIOLOGY, INTERVENTIONAL PRALUENT LIPOTROPICS Denial 1 3963 CARDIOLOGY, INTERVENTIONAL PRALUENT LIPOTROPICS No Response 1 3963 FAMILY PRACTICE PRALUENT LIPOTROPICS Denial 4 3956 FAMILY PRACTICE PRALUENT LIPOTROPICS No Response 2 3956 FAMILY PRACTICE PRALUENT LIPOTROPICS Approval 1 3963 FAMILY PRACTICE PRALUENT LIPOTROPICS No Response 1 3951 FAMILY PRACTICE PRALUENT LIPOTROPICS Denial 1 3956 HOSPITALIST PRALUENT LIPOTROPICS Denial 1 3963 HOSPITALIST PRALUENT LIPOTROPICS Approval 1 3963 INTERNAL MEDICINE PRALUENT LIPOTROPICS Denial 4 3956 INTERNAL MEDICINE PRALUENT LIPOTROPICS Denial 7 3951 INTERNAL MEDICINE PRALUENT LIPOTROPICS Denial 2 3963 INTERNAL MEDICINE PRALUENT LIPOTROPICS No Response 1 3963 INTERNAL MEDICINE PRALUENT LIPOTROPICS Approval 3 3965 INTERNAL MEDICINE PRALUENT LIPOTROPICS Denial 4 3956 INTERNAL MEDICINE PRALUENT LIPOTROPICS Approval 1 3965 INTERNAL MEDICINE PRALUENT LIPOTROPICS Approval 1 3963 NURSE PRACTITIONER, ACUTE CARE PRALUENT LIPOTROPICS Approval 1

28 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 NURSE PRACTITIONER, ACUTE CARE PRALUENT LIPOTROPICS Denial 2 3956 NURSE PRACTITIONER, ACUTE CARE PRALUENT LIPOTROPICS Denial 1 3956 NURSE PRACTITIONER, ACUTE CARE PRALUENT LIPOTROPICS No Response 1 3963 NURSE PRACTITIONER, FAMILY HEALTH PRALUENT LIPOTROPICS Denial 5 3963 NURSE PRACTITIONER, FAMILY HEALTH PRALUENT LIPOTROPICS Approval 4 3956 NURSE PRACTITIONER, FAMILY HEALTH PRALUENT LIPOTROPICS No Response 2 3956 NURSE PRACTITIONER, FAMILY HEALTH PRALUENT LIPOTROPICS Denial 3 3951 NURSE PRACTITIONER, UNSPECIFIED PRALUENT LIPOTROPICS Denial 1 3956 NURSE PRACTITIONER, UNSPECIFIED PRALUENT LIPOTROPICS Denial 3 3963 NURSE PRACTITIONER, UNSPECIFIED PRALUENT LIPOTROPICS No Response 1 3963 NURSE PRACTITIONER, UNSPECIFIED PRALUENT LIPOTROPICS Denial 1 3963 PEDIATRICS PRALUENT LIPOTROPICS Denial 1 3963 PEDIATRICS PRALUENT LIPOTROPICS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED PRALUENT LIPOTROPICS Approval 1 3963 PHYSICIAN, ENDOCRINOLOGY PRALUENT LIPOTROPICS Approval 1 3956 UNSPECIFIED PRALUENT LIPOTROPICS Denial 20 3963 UNSPECIFIED PRALUENT LIPOTROPICS Denial 18 3951 UNSPECIFIED PRALUENT LIPOTROPICS Denial 3 3965 UNSPECIFIED PRALUENT LIPOTROPICS Approval 1 3965 UNSPECIFIED PRALUENT LIPOTROPICS Denial 3 3963 UNSPECIFIED PRALUENT LIPOTROPICS Approval 5 3965 UNSPECIFIED PRALUENT LIPOTROPICS No Response 1 3956 UNSPECIFIED PRALUENT LIPOTROPICS No Response 3 3956 UNSPECIFIED PRALUENT LIPOTROPICS Approval 7 3951 UNSPECIFIED PRALUENT LIPOTROPICS Approval 1 3964 UNSPECIFIED PRALUENT LIPOTROPICS Denial 1 3964 UNSPECIFIED PRALUENT LIPOTROPICS No Response 1 3956 CARDIOLOGY PRALUENT 150MG/ML SC SOAJ LIPOTROPICS No Response 3 3963 CARDIOLOGY PRALUENT 150MG/ML SC SOAJ LIPOTROPICS No Response 1 3963 CARDIOLOGY, INTERVENTIONAL PRALUENT 150MG/ML SC SOAJ LIPOTROPICS No Response 1 3963 FAMILY PRACTICE PRALUENT 150MG/ML SC SOAJ LIPOTROPICS No Response 1 3956 FAMILY PRACTICE PRALUENT 150MG/ML SC SOAJ LIPOTROPICS No Response 2 3956 NURSE PRACTITIONER, FAMILY HEALTH PRALUENT 150MG/ML SC SOAJ LIPOTROPICS No Response 1 3963 UNSPECIFIED PRALUENT 150MG/ML SC SOAJ LIPOTROPICS No Response 5 3956 FAMILY PRACTICE PRALUENT 75MG/ML SC SOAJ LIPOTROPICS No Response 1 3956 CARDIOLOGY PRALUENT 75MG/ML SC SOAJ LIPOTROPICS No Response 3 3963 CARDIOLOGY PRALUENT 75MG/ML SC SOAJ LIPOTROPICS No Response 4

29 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 FAMILY PRACTICE PRALUENT 75MG/ML SC SOAJ LIPOTROPICS No Response 3 3963 HOSPITALIST PRALUENT 75MG/ML SC SOAJ LIPOTROPICS No Response 1 3963 INTERNAL MEDICINE PRALUENT 75MG/ML SC SOAJ LIPOTROPICS No Response 2 3963 NURSE PRACTITIONER, FAMILY HEALTH PRALUENT 75MG/ML SC SOAJ LIPOTROPICS No Response 2 3956 NURSE PRACTITIONER, FAMILY HEALTH PRALUENT 75MG/ML SC SOAJ LIPOTROPICS No Response 2 3956 NURSE PRACTITIONER, UNSPECIFIED PRALUENT 75MG/ML SC SOAJ LIPOTROPICS No Response 1 3963 NURSE PRACTITIONER, UNSPECIFIED PRALUENT 75MG/ML SC SOAJ LIPOTROPICS No Response 1 3956 UNSPECIFIED PRALUENT 75MG/ML SC SOAJ LIPOTROPICS No Response 2 3965 UNSPECIFIED PRALUENT 75MG/ML SC SOAJ LIPOTROPICS No Response 2 3963 UNSPECIFIED PRALUENT 75MG/ML SC SOAJ LIPOTROPICS No Response 4 3963 UNSPECIFIED PRALUENT 75MG/ML SC SOAJ LIPOTROPICS Denial 1 3965 UNSPECIFIED PRALUENT PEN 75 MG/ML SUBCUTANEOUS PEN INJECTOR (ALIROCUMAB) LIPOTROPICS No Response 1 3956 FAMILY PRACTICE PROCRIT 10000UNIT/ML IJ SOLN HEMATOPOIETIC AGENT No Response 1 3956 NURSE PRACTITIONER, UNSPECIFIED PROLASTIN-C RESPIRATORY AGENTS Approval 1 3951 FAMILY PRACTICE PROLIA MISCELLANEOUS Denial 1 3951 FAMILY PRACTICE PROLIA MISCELLANEOUS Approval 2 3951 FAMILY PRACTICE PROLIA BONE-MODIFYING AGENT Denial 1 3951 FAMILY PRACTICE PROLIA BONE-MODIFYING AGENT Approval 2 3963 EMERGENCY MEDICINE PROLIA MISCELLANEOUS Approval 1 3963 EMERGENCY MEDICINE PROLIA BONE-MODIFYING AGENT Approval 1 3956 FAMILY PRACTICE PROLIA MISCELLANEOUS Approval 6 3956 FAMILY PRACTICE PROLIA BONE-MODIFYING AGENT Approval 6 3963 FAMILY PRACTICE PROLIA MISCELLANEOUS No Response 1 3963 FAMILY PRACTICE PROLIA MISCELLANEOUS Approval 2 3963 FAMILY PRACTICE PROLIA BONE-MODIFYING AGENT No Response 1 3963 FAMILY PRACTICE PROLIA BONE-MODIFYING AGENT Approval 2 3961 FAMILY PRACTICE PROLIA MISCELLANEOUS Denial 1 3961 FAMILY PRACTICE PROLIA BONE-MODIFYING AGENT Denial 1 3956 FAMILY PRACTICE PROLIA MISCELLANEOUS Denial 4 3956 FAMILY PRACTICE PROLIA BONE-MODIFYING AGENT Denial 4 3956 FAMILY PRACTICE PROLIA MISCELLANEOUS No Response 1 3956 FAMILY PRACTICE PROLIA BONE-MODIFYING AGENT No Response 1 3956 HEMATOLOGY & ONCOLOGY PROLIA MISCELLANEOUS Approval 1 3956 HEMATOLOGY & ONCOLOGY PROLIA BONE-MODIFYING AGENT Approval 1 3956 INTERNAL MEDICINE PROLIA MISCELLANEOUS Approval 1 3956 INTERNAL MEDICINE PROLIA BONE-MODIFYING AGENT Approval 1

30 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 INTERNAL MEDICINE PROLIA MISCELLANEOUS No Response 1 3963 INTERNAL MEDICINE PROLIA MISCELLANEOUS Approval 1 3963 INTERNAL MEDICINE PROLIA BONE-MODIFYING AGENT No Response 1 3963 INTERNAL MEDICINE PROLIA BONE-MODIFYING AGENT Approval 1 3951 NURSE PRACTITIONER, FAMILY HEALTH PROLIA MISCELLANEOUS Approval 1 3951 NURSE PRACTITIONER, FAMILY HEALTH PROLIA BONE-MODIFYING AGENT Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH PROLIA MISCELLANEOUS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH PROLIA BONE-MODIFYING AGENT Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED PROLIA MISCELLANEOUS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED PROLIA BONE-MODIFYING AGENT Approval 1 3963 OBSTETRICS & GYNECOLOGY PROLIA MISCELLANEOUS Denial 1 3963 OBSTETRICS & GYNECOLOGY PROLIA BONE-MODIFYING AGENT Denial 1 3963 OBSTETRICS & GYNECOLOGY PROLIA MISCELLANEOUS Approval 1 3963 OBSTETRICS & GYNECOLOGY PROLIA BONE-MODIFYING AGENT Approval 1 3956 ORTHOPEDIC SURGERY PROLIA MISCELLANEOUS Approval 1 3956 ORTHOPEDIC SURGERY PROLIA BONE-MODIFYING AGENT Approval 1 3961 PEDIATRICS PROLIA MISCELLANEOUS No Response 1 3961 PEDIATRICS PROLIA BONE-MODIFYING AGENT No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED PROLIA MISCELLANEOUS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED PROLIA BONE-MODIFYING AGENT No Response 1 3956 PHYSICIAN, ONCOLOGY, MEDICAL PROLIA MISCELLANEOUS Approval 1 3956 PHYSICIAN, ONCOLOGY, MEDICAL PROLIA BONE-MODIFYING AGENT Approval 1 3956 UNSPECIFIED PROLIA MISCELLANEOUS Denial 2 3956 UNSPECIFIED PROLIA BONE-MODIFYING AGENT Denial 2 3956 UNSPECIFIED PROLIA MISCELLANEOUS Approval 2 3961 UNSPECIFIED PROLIA MISCELLANEOUS No Response 1 3961 UNSPECIFIED PROLIA MISCELLANEOUS Approval 1 3956 UNSPECIFIED PROLIA BONE-MODIFYING AGENT Approval 2 3961 UNSPECIFIED PROLIA BONE-MODIFYING AGENT No Response 1 3961 UNSPECIFIED PROLIA BONE-MODIFYING AGENT Approval 1 3963 UNSPECIFIED PROLIA MISCELLANEOUS Denial 1 3963 UNSPECIFIED PROLIA MISCELLANEOUS Approval 2 3963 UNSPECIFIED PROLIA BONE-MODIFYING AGENT Denial 1 3963 UNSPECIFIED PROLIA BONE-MODIFYING AGENT Approval 2 3963 UNSPECIFIED PROLIA MISCELLANEOUS No Response 1 3963 UNSPECIFIED PROLIA BONE-MODIFYING AGENT No Response 1 3956 ORTHOPEDIC SURGERY PROLIA 60MG/ML SC SOSY OSTEOPOROSIS AGENTS No Response 1

31 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 HEMATOLOGY & ONCOLOGY PROMACTA HEMOSTATICS Denial 1 3963 INTERNAL MEDICINE PROMACTA HEMOSTATICS No Response 1 3951 PHYSICIAN, ONCOLOGY, MEDICAL PROMACTA HEMOSTATICS No Response 1 3963 UNSPECIFIED PROMACTA HEMOSTATICS Denial 1 3964 UNSPECIFIED PROMACTA HEMOSTATICS No Response 1 3964 UNSPECIFIED PROMACTA HEMOSTATICS Approval 1 3956 INTERNAL MEDICINE PROMACTA 50MG OR TABS HEMOSTATICS No Response 1 3956 UNSPECIFIED PROMACTA 50MG OR TABS HEMOSTATICS No Response 1 3969 PULMONARY DISEASES PULMOZYME MISCELLANEOUS Approval 1 3969 PULMONARY DISEASES PULMOZYME MUCOLYTIC AGENT Approval 1 3965 NEUROLOGY REBIF MISCELLANEOUS Approval 1 3965 NEUROLOGY REBIF MULTIPLE SCLEROSIS AGENT Approval 1 3965 NURSE PRACTITIONER, UNSPECIFIED REBIF MISCELLANEOUS Approval 1 3965 NURSE PRACTITIONER, UNSPECIFIED REBIF MULTIPLE SCLEROSIS AGENT Approval 1 3956 FAMILY PRACTICE RETACRIT HEMATOPOIETIC AGENT Approval 1 3956 HEMATOLOGY & ONCOLOGY RETACRIT HEMATOPOIETIC AGENT Denial 2 3956 HEMATOLOGY & ONCOLOGY RETACRIT HEMATOPOIETIC AGENT Approval 1 3963 INTERNAL MEDICINE RETACRIT HEMATOPOIETIC AGENT Approval 1 3956 HEMATOLOGY & ONCOLOGY RETACRIT 40000UNIT/ML IJ SOLN HEMATOPOIETIC AGENT No Response 1 3963 HEMATOLOGY REVLIMID ANTINEOPLASTICS Approval 4 3956 HEMATOLOGY REVLIMID ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY REVLIMID ANTINEOPLASTICS Approval 4 3951 HEMATOLOGY & ONCOLOGY REVLIMID ANTINEOPLASTICS Approval 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL REVLIMID ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED REVLIMID ANTINEOPLASTICS Approval 3 3956 UNSPECIFIED REVLIMID ANTINEOPLASTICS Approval 1 3965 PHYSICIAN ASSISTANT, UNSPECIFIED RINVOQ 15 MG ER TABLET IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 RHEUMATOLOGY RINVOQ 15 MG ER TABLET IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3951 DERMATOLOGY RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 DERMATOLOGY RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 DERMATOLOGY RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3965 DERMATOLOGY RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 GASTROENTEROLOGY RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 INTERNAL MEDICINE RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 INTERNAL MEDICINE RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 NURSE PRACTITIONER, FAMILY HEALTH RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 1

32 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 NURSE PRACTITIONER, UNSPECIFIED RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 NURSE PRACTITIONER, UNSPECIFIED RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 NURSE PRACTITIONER, UNSPECIFIED RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3965 PHYSICIAN ASSISTANT, UNSPECIFIED RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 RHEUMATOLOGY RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Denial 8 3956 RHEUMATOLOGY RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 8 3951 RHEUMATOLOGY RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 RHEUMATOLOGY RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 4 3951 RHEUMATOLOGY RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 RHEUMATOLOGY RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Denial 2 3965 RHEUMATOLOGY RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 RHEUMATOLOGY RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 RHEUMATOLOGY RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3961 RHEUMATOLOGY RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3969 RHEUMATOLOGY RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 RHEUMATOLOGY RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 3 3951 UNSPECIFIED RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3961 UNSPECIFIED RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 7 3961 UNSPECIFIED RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3961 UNSPECIFIED RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Denial 2 3956 UNSPECIFIED RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS Denial 2 3965 UNSPECIFIED RINVOQ 15MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 RHEUMATOLOGY RINVOQ 15MG OR TB24 IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY RINVOQ 15MG OR TB24 IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 GASTROENTEROLOGY RINVOQ 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 GASTROENTEROLOGY RINVOQ 30MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 GASTROENTEROLOGY RINVOQ 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 GASTROENTEROLOGY RINVOQ 45MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 GASTROENTEROLOGY RINVOQ 45MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 GASTROENTEROLOGY RINVOQ 45MG IMMUNOSUPPRESSIVES/DMARDS Denial 2 3956 NURSE PRACTITIONER, FAMILY HEALTH RINVOQ 45MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 RHEUMATOLOGY RINVOQ 45MG IMMUNOSUPPRESSIVES/DMARDS Approval 1

33 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 UNSPECIFIED RINVOQ 45MG IMMUNOSUPPRESSIVES/DMARDS Denial 2 3963 GASTROENTEROLOGY RINVOQ 45MG + 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 GASTROENTEROLOGY RINVOQ 45MG + 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3961 GASTROENTEROLOGY RINVOQ 45MG + 15MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 GASTROENTEROLOGY RINVOQ 45MG + 15MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 GASTROENTEROLOGY RINVOQ 45MG + 30MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 UNSPECIFIED RINVOQ 45MG + 30MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 GASTROENTEROLOGY RINVOQ 45MG OR TB24 IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 GASTROENTEROLOGY RINVOQ 45MG OR TB24 IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 UNSPECIFIED RINVOQ 45MG OR TB24 IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED RYDAPT ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED RYDAPT ANTINEOPLASTICS Denial 1 3961 PHYSICIAN ASSISTANT, UNSPECIFIED SAPROPTERIN ENZYME COFACTOR Approval 1 3963 FAMILY PRACTICE SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET VASODILATORS No Response 2 3951 NURSE PRACTITIONER, FAMILY HEALTH SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET VASODILATORS No Response 1 3963 PEDIATRICS SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET VASODILATORS No Response 1 3963 UNSPECIFIED SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET VASODILATORS No Response 2 3951 NURSE PRACTITIONER, FAMILY HEALTH SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET (REVATIO) VASODILATORS No Response 1 3956 FAMILY PRACTICE SILDENAFIL 20MG TABLETS VASODILATORS Denial 4 3951 CARDIOLOGY SILDENAFIL 20MG TABLETS VASODILATORS Approval 1 3963 EMERGENCY MEDICINE SILDENAFIL 20MG TABLETS VASODILATORS Denial 1 3963 FAMILY PRACTICE SILDENAFIL 20MG TABLETS VASODILATORS Denial 8 3951 FAMILY PRACTICE SILDENAFIL 20MG TABLETS VASODILATORS Denial 1 3962 FAMILY PRACTICE SILDENAFIL 20MG TABLETS VASODILATORS Denial 2 3969 FAMILY PRACTICE SILDENAFIL 20MG TABLETS VASODILATORS Denial 1 3956 INTERNAL MEDICINE SILDENAFIL 20MG TABLETS VASODILATORS Approval 3 3956 INTERNAL MEDICINE SILDENAFIL 20MG TABLETS VASODILATORS Denial 2 3963 INTERNAL MEDICINE SILDENAFIL 20MG TABLETS VASODILATORS Approval 1 3961 INTERNAL MEDICINE SILDENAFIL 20MG TABLETS VASODILATORS Denial 1 3963 INTERNAL MEDICINE SILDENAFIL 20MG TABLETS VASODILATORS Denial 1 3956 NURSE PRACTITIONER, UNSPECIFIED SILDENAFIL 20MG TABLETS VASODILATORS Denial 2 3963 NURSE PRACTITIONER, UNSPECIFIED SILDENAFIL 20MG TABLETS VASODILATORS Approval 2 3951 NURSE PRACTITIONER, UNSPECIFIED SILDENAFIL 20MG TABLETS VASODILATORS Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED SILDENAFIL 20MG TABLETS VASODILATORS Denial 1

34 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 PHYSICIAN ASSISTANT, UNSPECIFIED SILDENAFIL 20MG TABLETS VASODILATORS Denial 1 3963 RHEUMATOLOGY SILDENAFIL 20MG TABLETS VASODILATORS Approval 1 3963 UROLOGY SILDENAFIL 20MG TABLETS VASODILATORS Denial 2 3963 UNSPECIFIED SILDENAFIL 20MG TABLETS VASODILATORS Denial 7 3969 UNSPECIFIED SILDENAFIL 20MG TABLETS VASODILATORS Denial 1 3956 UNSPECIFIED SILDENAFIL 20MG TABLETS VASODILATORS Denial 2 3963 UNSPECIFIED SILDENAFIL 20MG TABLETS VASODILATORS Approval 1 3965 UNSPECIFIED SILDENAFIL 20MG TABLETS VASODILATORS Denial 1 3956 UNSPECIFIED SILDENAFIL 20MG TABLETS VASODILATORS Approval 1 3951 UNSPECIFIED SILDENAFIL 20MG TABLETS VASODILATORS Denial 1 3956 NURSE PRACTITIONER, FAMILY HEALTH SILDENAFIL CITRATE (SILDENAFIL CITRATE (PUL­ MONARY HYPERTENSION)) 20 MG ORAL TABLET VASODILATORS No Response 1 3963 CARDIOLOGY SILDENAFIL CITRATE 20MG OR TABS VASODILATORS No Response 1 3956 FAMILY PRACTICE SILDENAFIL CITRATE 20MG OR TABS VASODILATORS No Response 1 3956 INTERNAL MEDICINE SILDENAFIL CITRATE 20MG OR TABS VASODILATORS No Response 2 3963 UROLOGY SILDENAFIL CITRATE 20MG OR TABS VASODILATORS No Response 1 3956 UNSPECIFIED SILDENAFIL CITRATE 20MG OR TABS VASODILATORS No Response 3 3963 UNSPECIFIED SILDENAFIL CITRATE 20MG OR TABS VASODILATORS No Response 2 3951 RHEUMATOLOGY SIMPONI 50MG ANTIARTHRITICS Denial 1 3956 RHEUMATOLOGY SIMPONI 50MG ANTIARTHRITICS Approval 1 3963 DERMATOLOGY SKYRIZI 150 MG/ML SUBCUTANEOUS PEN INJEC­ TOR SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3963 UNSPECIFIED SKYRIZI 150 MG/ML SUBCUTANEOUS PEN INJEC­ TOR SYSTEMIC ANTIPSORIASIS AGENTS No Response 2 3956 UNSPECIFIED SKYRIZI 150 MG/ML SUBCUTANEOUS PEN INJEC­ TOR SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3963 DERMATOLOGY SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 11 3956 DERMATOLOGY SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3956 DERMATOLOGY SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 7 3956 DERMATOLOGY SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3963 DERMATOLOGY SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Denial 2 3961 DERMATOLOGY SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3965 DERMATOLOGY SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 DERMATOLOGY SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3956 EMERGENCY MEDICINE SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 EMERGENCY MEDICINE SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3963 FAMILY PRACTICE SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3963 GASTROENTEROLOGY SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 GENERAL PRACTICE SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1

35 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 INTERNAL MEDICINE SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3963 NURSE PRACTITIONER, ACUTE CARE SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS No Response 2 3963 NURSE PRACTITIONER, ACUTE CARE SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3956 NURSE PRACTITIONER, FAMILY HEALTH SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 3 3956 NURSE PRACTITIONER, FAMILY HEALTH SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Denial 2 3956 NURSE PRACTITIONER, FAMILY HEALTH SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS No Response 2 3963 NURSE PRACTITIONER, FAMILY HEALTH SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3963 NURSE PRACTITIONER, UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3963 NURSE PRACTITIONER, UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3964 NURSE PRACTITIONER, UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 PEDIATRICS SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 3 3962 PHYSICIAN ASSISTANT, UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3965 PHYSICIAN ASSISTANT, UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3963 PHYSICIAN ASSISTANT, UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3956 PHYSICIAN ASSISTANT, UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 5 3962 PHYSICIAN ASSISTANT, UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3961 PHYSICIAN ASSISTANT, UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 PSYCHIATRY SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 RHEUMATOLOGY SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3963 RHEUMATOLOGY SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 3 3956 RHEUMATOLOGY SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Denial 2 3963 RHEUMATOLOGY SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3951 RHEUMATOLOGY SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 14 3961 UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS No Response 2 3956 UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 7 3951 UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3963 UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3951 UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3956 UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Denial 2 3963 UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS No Response 4

36 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3964 UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3964 UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3965 UNSPECIFIED SKYRIZI 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 DERMATOLOGY SKYRIZI 150MG/ML PEN SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3956 EMERGENCY MEDICINE SKYRIZI 150MG/ML PEN SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3963 UNSPECIFIED SKYRIZI 150MG/ML PEN SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3956 UNSPECIFIED SKYRIZI 150MG/ML SC SOSY SYSTEMIC ANTIPSORIASIS AGENTS No Response 2 3956 GASTROENTEROLOGY SKYRIZI 360MG + 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3963 GASTROENTEROLOGY SKYRIZI 360MG + 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 2 3951 GASTROENTEROLOGY SKYRIZI 360MG + 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3951 GASTROENTEROLOGY SKYRIZI 360MG + 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3951 NURSE PRACTITIONER, FAMILY HEALTH SKYRIZI 360MG + 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 UNSPECIFIED SKYRIZI 360MG + 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 GASTROENTEROLOGY SKYRIZI 360MG + 180MG + 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3961 GASTROENTEROLOGY SKYRIZI 360MG + 180MG + 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3951 GASTROENTEROLOGY SKYRIZI 360MG + 180MG + 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3963 UNSPECIFIED SKYRIZI 360MG + 180MG + 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 UNSPECIFIED SKYRIZI 360MG + 180MG + 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 GASTROENTEROLOGY SKYRIZI 600MG + 360MG + 180MG + 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 INTERNAL MEDICINE SKYRIZI 600MG + 360MG + 180MG + 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Denial 1 3956 INTERNAL MEDICINE SKYRIZI 600MG + 360MG + 180MG + 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED SKYRIZI 600MG + 360MG + 180MG + 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3951 UNSPECIFIED SKYRIZI 600MG + 360MG + 180MG + 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3963 UNSPECIFIED SKYRIZI 600MG + 360MG + 180MG + 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 UNSPECIFIED SKYRIZI 600MG + 360MG + 180MG + 150MG + 75MG SYSTEMIC ANTIPSORIASIS AGENTS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH SKYRIZI PEN 150MG/ML SC SOAJ SYSTEMIC ANTIPSORIASIS AGENTS No Response 2 3963 PHYSICIAN ASSISTANT, UNSPECIFIED SKYRIZI PEN 150MG/ML SC SOAJ SYSTEMIC ANTIPSORIASIS AGENTS No Response 2 3956 RHEUMATOLOGY SKYRIZI PEN 150MG/ML SC SOAJ SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3951 UNSPECIFIED SKYRIZI PEN 150MG/ML SC SOAJ SYSTEMIC ANTIPSORIASIS AGENTS No Response 2 3956 UNSPECIFIED SKYRIZI PEN 150MG/ML SC SOAJ SYSTEMIC ANTIPSORIASIS AGENTS No Response 3 3963 UNSPECIFIED SKYRIZI PEN 150MG/ML SC SOAJ SYSTEMIC ANTIPSORIASIS AGENTS No Response 1 3963 HEMATOLOGY & ONCOLOGY SOMATULINE DEPOT HORMONE/HORMONE MODIFIER Approval 1 3963 HEMATOLOGY & ONCOLOGY SOMATULINE DEPOT SOMATOSTATIN ANALOG Approval 1

37 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 HEMATOLOGY & ONCOLOGY SOMATULINE DEPOT HORMONE/HORMONE MODIFIER No Response 1 3956 HEMATOLOGY & ONCOLOGY SOMATULINE DEPOT SOMATOSTATIN ANALOG No Response 1 3956 INTERNAL MEDICINE SOMATULINE DEPOT HORMONE/HORMONE MODIFIER Denial 1 3956 INTERNAL MEDICINE SOMATULINE DEPOT SOMATOSTATIN ANALOG Denial 1 3956 UNSPECIFIED SOMATULINE DEPOT HORMONE/HORMONE MODIFIER Approval 1 3956 UNSPECIFIED SOMATULINE DEPOT SOMATOSTATIN ANALOG Approval 1 3956 PHYSICIAN, ONCOLOGY, MEDICAL SORAFENIB ANTINEOPLASTICS Denial 1 3956 PHYSICIAN, ONCOLOGY, MEDICAL SORAFENIB ANTINEOPLASTICS Approval 1 3951 NURSE PRACTITIONER, FAMILY HEALTH SPRAVATO ANTIDEPRESSANT No Response 1 3963 NURSE PRACTITIONER, FAMILY HEALTH SPRAVATO ANTIDEPRESSANT Denial 2 3964 NURSE PRACTITIONER, FAMILY HEALTH SPRAVATO ANTIDEPRESSANT Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH SPRAVATO ANTIDEPRESSANT Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED SPRAVATO ANTIDEPRESSANT Approval 2 3969 PSYCHIATRY SPRAVATO ANTIDEPRESSANT Approval 1 3963 PSYCHIATRY SPRAVATO ANTIDEPRESSANT Approval 2 3963 UNSPECIFIED SPRAVATO ANTIDEPRESSANT Denial 3 3963 UNSPECIFIED SPRAVATO ANTIDEPRESSANT Approval 8 3951 UNSPECIFIED SPRAVATO ANTIDEPRESSANT Approval 1 3964 UNSPECIFIED SPRAVATO ANTIDEPRESSANT Approval 3 3964 UNSPECIFIED SPRAVATO ANTIDEPRESSANT Denial 1 3963 UNSPECIFIED SPRAVATO ANTIDEPRESSANT No Response 1 3951 UNSPECIFIED SPRAVATO ANTIDEPRESSANT Denial 1 3965 UNSPECIFIED SPRAVATO ANTIDEPRESSANT Approval 2 3964 NURSE PRACTITIONER, FAMILY HEALTH SPRAVATO (56 MG DOSE) 28MG/DEVICE NA SOPK ANTIDEPRESSANT No Response 1 3963 PSYCHIATRY SPRAVATO (56 MG DOSE) 28MG/DEVICE NA SOPK ANTIDEPRESSANT No Response 1 3964 UNSPECIFIED SPRAVATO (84 MG DOSE) 28MG/DEVICE NA SOPK ANTIDEPRESSANT No Response 2 3956 HEMATOLOGY & ONCOLOGY SPRYCEL ANTINEOPLASTICS No Response 1 3956 HEMATOLOGY & ONCOLOGY SPRYCEL ANTINEOPLASTICS Approval 2 3963 HEMATOLOGY & ONCOLOGY SPRYCEL ANTINEOPLASTICS Approval 3 3963 HEMATOLOGY & ONCOLOGY SPRYCEL ANTINEOPLASTICS Denial 1 3963 HEMATOLOGY & ONCOLOGY SPRYCEL ANTINEOPLASTICS No Response 1 3963 INTERNAL MEDICINE SPRYCEL ANTINEOPLASTICS Approval 1 3956 INTERNAL MEDICINE SPRYCEL ANTINEOPLASTICS Approval 1 3956 INTERNAL MEDICINE SPRYCEL ANTINEOPLASTICS No Response 1 3963 UNSPECIFIED SPRYCEL ANTINEOPLASTICS Approval 2 3956 UNSPECIFIED SPRYCEL ANTINEOPLASTICS Approval 2 3956 UNSPECIFIED SPRYCEL ANTINEOPLASTICS No Response 1

38 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 UNSPECIFIED SPRYCEL ANTINEOPLASTICS Denial 1 3963 UNSPECIFIED SPRYCEL ANTINEOPLASTICS No Response 1 3963 UNSPECIFIED STELARA 45MG/0.5 INJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3961 DERMATOLOGY STELARA 90MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY STELARA 90MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED STELARA 90MG/ML SC SOSY IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, UNSPECIFIED STELARA IV + STELARA SQ 45MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 GASTROENTEROLOGY STELARA IV + STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED STELARA PLQE IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 INTERNAL MEDICINE STELARA SQ 45 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3965 DERMATOLOGY STELARA SQ 45MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 DERMATOLOGY STELARA SQ 45MG IMMUNOSUPPRESSIVES/DMARDS Approval 3 3963 DERMATOLOGY STELARA SQ 45MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 DERMATOLOGY STELARA SQ 45MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 DERMATOLOGY STELARA SQ 45MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 FAMILY PRACTICE STELARA SQ 45MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 GASTROENTEROLOGY STELARA SQ 45MG IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 GASTROENTEROLOGY STELARA SQ 45MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 NURSE PRACTITIONER, FAMILY HEALTH STELARA SQ 45MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, UNSPECIFIED STELARA SQ 45MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3969 NURSE PRACTITIONER, UNSPECIFIED STELARA SQ 45MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3969 NURSE PRACTITIONER, UNSPECIFIED STELARA SQ 45MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED STELARA SQ 45MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 UNSPECIFIED STELARA SQ 45MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 DERMATOLOGY STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Approval 3 3963 DERMATOLOGY STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS No Response 2 3951 DERMATOLOGY STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 DERMATOLOGY STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3961 DERMATOLOGY STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 GASTROENTEROLOGY STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3951 GASTROENTEROLOGY STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS No Response 3 3951 GASTROENTEROLOGY STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 GASTROENTEROLOGY STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Approval 7 3963 GASTROENTEROLOGY STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 GASTROENTEROLOGY STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Denial 4 3962 GASTROENTEROLOGY STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 GASTROENTEROLOGY STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Denial 2

39 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 GASTROENTEROLOGY STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS No Response 2 3965 GASTROENTEROLOGY STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 INTERNAL MEDICINE STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 INTERNAL MEDICINE STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 INTERNAL MEDICINE STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3961 NURSE PRACTITIONER, FAMILY HEALTH STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3961 NURSE PRACTITIONER, FAMILY HEALTH STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3951 NURSE PRACTITIONER, FAMILY HEALTH STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 NURSE PRACTITIONER, FAMILY HEALTH STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3962 NURSE PRACTITIONER, UNSPECIFIED STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 RHEUMATOLOGY STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 UNSPECIFIED STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 UNSPECIFIED STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 UNSPECIFIED STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Denial 2 3961 UNSPECIFIED STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 UNSPECIFIED STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Approval 6 3969 UNSPECIFIED STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 UNSPECIFIED STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS No Response 2 3964 UNSPECIFIED STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS No Response 2 3951 UNSPECIFIED STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS No Response 2 3961 UNSPECIFIED STELARA SQ 90MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 HEMATOLOGY & ONCOLOGY STIVARGA ANTINEOPLASTICS Approval 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL STIVARGA ANTINEOPLASTICS Denial 1 3963 UNSPECIFIED STIVARGA ANTINEOPLASTICS Denial 1 3963 UNSPECIFIED STIVARGA ANTINEOPLASTICS Approval 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL STIVARGA 40MG OR TABS ANTINEOPLASTICS No Response 2 3956 UNSPECIFIED SUTENT ANTINEOPLASTICS Approval 1 BCBSAR PEDIATRICS SYNAGIS RESPIRATORY AGENT Denial 1 BCBSAR PEDIATRICS SYNAGIS RESPIRATORY AGENT Approval 1 3956 CARDIOLOGY TADALAFIL 20MG VASODILATORS Approval 3 3963 FAMILY PRACTICE TADALAFIL 20MG VASODILATORS Denial 2 3963 INTERNAL MEDICINE TADALAFIL 20MG VASODILATORS Approval 1 3964 PULMONARY DISEASES TADALAFIL 20MG VASODILATORS No Response 1

40 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3964 PULMONARY DISEASES TADALAFIL 20MG VASODILATORS Approval 1 3956 UNSPECIFIED TADALAFIL 20MG VASODILATORS Approval 1 3963 UNSPECIFIED TADALAFIL 20MG VASODILATORS Approval 1 3956 HEMATOLOGY & ONCOLOGY TAFINLAR ANTINEOPLASTICS Approval 1 3956 INTERNAL MEDICINE TAFINLAR ANTINEOPLASTICS Approval 1 3951 UNSPECIFIED TAFINLAR ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED TAFINLAR ANTINEOPLASTICS Approval 1 3956 HEMATOLOGY & ONCOLOGY TAFINLAR 50MG OR CAPS ANTINEOPLASTICS No Response 1 3965 HEMATOLOGY & ONCOLOGY TAGRISSO ANTINEOPLASTICS Denial 1 3965 HEMATOLOGY & ONCOLOGY TAGRISSO ANTINEOPLASTICS Approval 1 3963 MEDICAL ONCOLOGY TAGRISSO ANTINEOPLASTICS Approval 1 3963 DERMATOLOGY TALTZ ALL OTHER DERMATOLOGICALS Approval 4 3963 DERMATOLOGY TALTZ ALL OTHER DERMATOLOGICALS Denial 2 3956 DERMATOLOGY TALTZ ALL OTHER DERMATOLOGICALS Approval 4 3956 DERMATOLOGY TALTZ ALL OTHER DERMATOLOGICALS No Response 5 3961 DERMATOLOGY TALTZ ALL OTHER DERMATOLOGICALS No Response 1 3956 DERMATOLOGY TALTZ ALL OTHER DERMATOLOGICALS Denial 2 3963 EMERGENCY MEDICINE TALTZ ALL OTHER DERMATOLOGICALS Approval 1 3963 FAMILY PRACTICE TALTZ ALL OTHER DERMATOLOGICALS Approval 2 3963 FAMILY PRACTICE TALTZ ALL OTHER DERMATOLOGICALS Denial 1 3961 INTERNAL MEDICINE TALTZ ALL OTHER DERMATOLOGICALS Approval 1 3956 INTERNAL MEDICINE TALTZ ALL OTHER DERMATOLOGICALS No Response 2 3956 INTERNAL MEDICINE TALTZ ALL OTHER DERMATOLOGICALS Approval 1 3956 INTERNAL MEDICINE TALTZ ALL OTHER DERMATOLOGICALS Denial 1 3963 INTERNAL MEDICINE TALTZ ALL OTHER DERMATOLOGICALS Approval 1 3956 NURSE PRACTITIONER, ACUTE CARE TALTZ ALL OTHER DERMATOLOGICALS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH TALTZ ALL OTHER DERMATOLOGICALS Denial 2 3956 NURSE PRACTITIONER, FAMILY HEALTH TALTZ ALL OTHER DERMATOLOGICALS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED TALTZ ALL OTHER DERMATOLOGICALS Approval 2 3956 PHYSICIAN ASSISTANT, UNSPECIFIED TALTZ ALL OTHER DERMATOLOGICALS Approval 18 3956 PHYSICIAN ASSISTANT, UNSPECIFIED TALTZ ALL OTHER DERMATOLOGICALS Denial 2 3956 PHYSICIAN ASSISTANT, UNSPECIFIED TALTZ ALL OTHER DERMATOLOGICALS No Response 7 3961 PHYSICIAN ASSISTANT, UNSPECIFIED TALTZ ALL OTHER DERMATOLOGICALS Approval 2 3963 PHYSICIAN ASSISTANT, UNSPECIFIED TALTZ ALL OTHER DERMATOLOGICALS Denial 2 3963 PHYSICIAN ASSISTANT, UNSPECIFIED TALTZ ALL OTHER DERMATOLOGICALS Approval 2 3956 RHEUMATOLOGY TALTZ ALL OTHER DERMATOLOGICALS Denial 2 3963 RHEUMATOLOGY TALTZ ALL OTHER DERMATOLOGICALS No Response 1

41 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 RHEUMATOLOGY TALTZ ALL OTHER DERMATOLOGICALS Approval 1 3956 RHEUMATOLOGY TALTZ ALL OTHER DERMATOLOGICALS Approval 5 3956 RHEUMATOLOGY TALTZ ALL OTHER DERMATOLOGICALS No Response 3 3963 RHEUMATOLOGY TALTZ ALL OTHER DERMATOLOGICALS Denial 1 3963 UNSPECIFIED TALTZ ALL OTHER DERMATOLOGICALS Approval 4 3956 UNSPECIFIED TALTZ ALL OTHER DERMATOLOGICALS Approval 14 3956 UNSPECIFIED TALTZ ALL OTHER DERMATOLOGICALS No Response 5 3961 UNSPECIFIED TALTZ ALL OTHER DERMATOLOGICALS No Response 2 3961 UNSPECIFIED TALTZ ALL OTHER DERMATOLOGICALS Approval 2 3956 UNSPECIFIED TALTZ ALL OTHER DERMATOLOGICALS Denial 1 3951 UNSPECIFIED TALTZ ALL OTHER DERMATOLOGICALS Approval 1 3956 DERMATOLOGY TALTZ 80MG/ML CF AUTO INJ 1ML IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 EMERGENCY MEDICINE TALTZ 80MG/ML CF AUTO INJ 1ML IMMUNOSUPPRESSIVES/DMARDS No Response 2 3961 INTERNAL 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 3 3963 PHYSICIAN ASSISTANT, UNSPECIFIED TALTZ 80MG/ML CF AUTO INJ 1ML IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 RHEUMATOLOGY TALTZ 80MG/ML CF AUTO INJ 1ML IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 RHEUMATOLOGY 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 2 3961 PHYSICIAN ASSISTANT, UNSPECIFIED TALTZ 80MG/ML CF PFS 1ML IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 DERMATOLOGY TALTZ 80MG/ML INJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 INTERNAL MEDICINE TALTZ 80MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, ACUTE CARE TALTZ 80MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED TALTZ 80MG/ML SC SOAJ IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 RHEUMATOLOGY TAVNEOS COMPLEMENT INHIBITOR Denial 2 3963 RHEUMATOLOGY TAVNEOS COMPLEMENT INHIBITOR Approval 1 3963 RHEUMATOLOGY TAVNEOS 10MG OR CAPS COMPLEMENT INHIBITOR No Response 2 3963 HEMATOLOGY TEMOZOLOMIDE ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY TEMOZOLOMIDE ANTINEOPLASTICS Approval 5 3963 HEMATOLOGY & ONCOLOGY TEMOZOLOMIDE ANTINEOPLASTICS No Response 1 3956 MEDICAL ONCOLOGY TEMOZOLOMIDE ANTINEOPLASTICS Approval 1 3963 MEDICAL ONCOLOGY TEMOZOLOMIDE ANTINEOPLASTICS No Response 1 3956 PHYSICIAN, ONCOLOGY, MEDICAL TEMOZOLOMIDE ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED TEMOZOLOMIDE ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED TEMOZOLOMIDE ANTINEOPLASTICS No Response 2 3956 UNSPECIFIED TEMOZOLOMIDE ANTINEOPLASTICS Approval 1 3956 GENERAL PRACTICE TETRABENAZINE MISCELLANEOUS Approval 1

42 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 GENERAL PRACTICE TETRABENAZINE VESICULAR MONOAMINE TRANSPORTER 2 INHIB­ ITOR Approval 1 3956 NEUROLOGY TETRABENAZINE MISCELLANEOUS Approval 2 3956 NEUROLOGY TETRABENAZINE VESICULAR MONOAMINE TRANSPORTER 2 INHIB­ ITOR Approval 2 3956 NEUROLOGY TETRABENAZINE MISCELLANEOUS No Response 1 3956 NEUROLOGY TETRABENAZINE VESICULAR MONOAMINE TRANSPORTER 2 INHIB­ ITOR No Response 1 3951 UNSPECIFIED TETRABENAZINE MISCELLANEOUS Approval 1 3951 UNSPECIFIED TETRABENAZINE MISCELLANEOUS Denial 1 3951 UNSPECIFIED TETRABENAZINE VESICULAR MONOAMINE TRANSPORTER 2 INHIB­ ITOR Approval 1 3951 UNSPECIFIED TETRABENAZINE VESICULAR MONOAMINE TRANSPORTER 2 INHIB­ ITOR Denial 1 3956 PSYCHIATRY TETRABENAZINE 12.5 MG TABLET VESICULAR MONOAMINE TRANSPORTER 2 INHIB­ ITOR No Response 1 3965 HEMATOLOGY THALOMID OTHER ANTIBIOTICS Approval 1 3965 HEMATOLOGY THALOMID ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY THALOMID OTHER ANTIBIOTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY THALOMID ANTINEOPLASTICS Approval 1 3956 PHYSICIAN, ONCOLOGY, MEDICAL THALOMID OTHER ANTIBIOTICS Approval 1 3956 PHYSICIAN, ONCOLOGY, MEDICAL THALOMID ANTINEOPLASTICS Approval 1 3963 INTERNAL MEDICINE TIBSOVO ANTINEOPLASTICS Approval 1 3956 CARDIOLOGY TIKOSYN OTHER CARDIOVASCULAR PREPS No Response 1 3956 CARDIOLOGY TIKOSYN ANTIARRHYTHMIC AGENT No Response 1 3956 UNSPECIFIED TIKOSYN OTHER CARDIOVASCULAR PREPS No Response 1 3956 UNSPECIFIED TIKOSYN ANTIARRHYTHMIC AGENT No Response 1 3967 PULMONARY DISEASES TOBI PODHALER STREPTOMYCINS Denial 1 3951 PULMONARY DISEASES TOBRAMYCIN INHALATION SOLUTION RESPIRATORY AGENTS Approval 1 3963 UNSPECIFIED TOBRAMYCIN INHALATION SOLUTION RESPIRATORY AGENTS No Response 1 3965 UNSPECIFIED TOLVAPTAN VASOPRESSIN ANTAGONIST Denial 1 3956 DERMATOLOGY TREMFYA IMMUNOSUPPRESSIVES/DMARDS Approval 10 3963 DERMATOLOGY TREMFYA IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 DERMATOLOGY TREMFYA IMMUNOSUPPRESSIVES/DMARDS Approval 9 3965 DERMATOLOGY TREMFYA IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 DERMATOLOGY TREMFYA IMMUNOSUPPRESSIVES/DMARDS Denial 3 3956 DERMATOLOGY TREMFYA IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 DERMATOLOGY TREMFYA IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 DERMATOLOGY TREMFYA IMMUNOSUPPRESSIVES/DMARDS Denial 1

43 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3961 DERMATOLOGY TREMFYA IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 FAMILY PRACTICE TREMFYA IMMUNOSUPPRESSIVES/DMARDS Approval 1 3964 FAMILY PRACTICE TREMFYA IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 INTERNAL MEDICINE TREMFYA IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 INTERNAL MEDICINE TREMFYA IMMUNOSUPPRESSIVES/DMARDS No Response 3 3963 INTERNAL MEDICINE TREMFYA IMMUNOSUPPRESSIVES/DMARDS Approval 4 3956 INTERNAL MEDICINE TREMFYA IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 INTERNAL MEDICINE TREMFYA IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH TREMFYA IMMUNOSUPPRESSIVES/DMARDS No Response 2 3956 NURSE PRACTITIONER, FAMILY HEALTH TREMFYA IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 NURSE PRACTITIONER, FAMILY HEALTH TREMFYA IMMUNOSUPPRESSIVES/DMARDS Approval 4 3963 NURSE PRACTITIONER, FAMILY HEALTH TREMFYA IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 NURSE PRACTITIONER, FAMILY HEALTH TREMFYA IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS Approval 2 3956 NURSE PRACTITIONER, UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS Approval 7 3963 PHYSICIAN ASSISTANT, UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS No Response 3 3951 PHYSICIAN ASSISTANT, UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS Denial 1 3951 PHYSICIAN ASSISTANT, UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS Approval 1 3965 REGISTERED NURSE, GENERAL PRACTICE TREMFYA IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 RHEUMATOLOGY TREMFYA IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS Approval 10 3963 UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS Approval 9 3956 UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS No Response 4 3951 UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS Approval 5 3951 UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS Denial 1 3963 UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS No Response 5 3956 UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS Denial 1 3951 UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS No Response 1 3962 UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS Denial 1 3965 UNSPECIFIED TREMFYA IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 DERMATOLOGY TREMFYA 100 MG/ML ONE-PRESS IMMUNOSUPPRESSIVES/DMARDS No Response 1

44 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 DERMATOLOGY TREMFYA 100 MG/ML ONE-PRESS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED TREMFYA 100 MG/ML PFS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3951 UNSPECIFIED TREMFYA 100MG/ML SC SOPN IMMUNOSUPPRESSIVES/DMARDS No Response 2 3963 UNSPECIFIED TREMFYA 100MG/ML SC SOPN IMMUNOSUPPRESSIVES/DMARDS No Response 1 3969 PEDIATRICS TRIKAFTA CYSTIC FIBROSIS AGENTS Approval 1 3956 PULMONARY DISEASES TRIKAFTA CYSTIC FIBROSIS AGENTS No Response 1 3967 PULMONARY DISEASES TRIKAFTA CYSTIC FIBROSIS AGENTS Approval 1 3956 PULMONARY DISEASES TRIKAFTA CYSTIC FIBROSIS AGENTS Approval 1 3963 PULMONARY DISEASES TRIKAFTA CYSTIC FIBROSIS AGENTS Approval 2 3961 UNSPECIFIED TRIKAFTA CYSTIC FIBROSIS AGENTS Approval 1 3962 UNSPECIFIED TRIKAFTA CYSTIC FIBROSIS AGENTS Approval 1 3969 UNSPECIFIED TRIKAFTA CYSTIC FIBROSIS AGENTS No Response 1 3956 INTERNAL MEDICINE TYMLOS OSTEOPOROSIS AGENTS Approval 1 3963 INTERNAL MEDICINE TYMLOS OSTEOPOROSIS AGENTS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH TYMLOS OSTEOPOROSIS AGENTS Approval 1 3956 NURSE PRACTITIONER, UNSPECIFIED TYMLOS OSTEOPOROSIS AGENTS Approval 1 3961 ORTHOPEDIC SURGERY TYMLOS OSTEOPOROSIS AGENTS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED TYMLOS OSTEOPOROSIS AGENTS Approval 1 3963 UNSPECIFIED TYMLOS OSTEOPOROSIS AGENTS Approval 4 3964 UNSPECIFIED TYMLOS OSTEOPOROSIS AGENTS No Response 1 3963 UNSPECIFIED TYMLOS OSTEOPOROSIS AGENTS Denial 1 3956 UNSPECIFIED TYMLOS OSTEOPOROSIS AGENTS No Response 2 3956 UNSPECIFIED TYMLOS OSTEOPOROSIS AGENTS Approval 1 3956 UNSPECIFIED TYMLOS OSTEOPOROSIS AGENTS Denial 2 3956 UNSPECIFIED UPADACITINIB ER 45 MG TABLET,EXTENDED RE­ LEASE 24 HR ANTIRHEUMATIC No Response 1 3956 CARDIOLOGY UPTRAVI OTHER ANTIHYPERTENSIVES Approval 1 3956 CARDIOLOGY UPTRAVI PULMONARY ARTERIAL HYPERTENSION Approval 1 3963 INTERNAL MEDICINE UPTRAVI OTHER ANTIHYPERTENSIVES Approval 1 3963 INTERNAL MEDICINE UPTRAVI PULMONARY ARTERIAL HYPERTENSION Approval 1 3951 PULMONARY DISEASES UPTRAVI OTHER ANTIHYPERTENSIVES Approval 1 3951 PULMONARY DISEASES UPTRAVI PULMONARY ARTERIAL HYPERTENSION Approval 1 3956 GASTROENTEROLOGY VALGANCICLOVIR ANTIVIRALS Denial 1 3956 INTERNAL MEDICINE VALGANCICLOVIR ANTIVIRALS Approval 4 3956 PULMONARY DISEASES VALGANCICLOVIR ANTIVIRALS Approval 1 3956 UNSPECIFIED VALGANCICLOVIR ANTIVIRALS Approval 1 3956 UNSPECIFIED VALGANCICLOVIR ANTIVIRALS No Response 1

45 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 UNSPECIFIED VEMLIDY ANTIVIRALS Approval 1 3956 FAMILY PRACTICE VEMLIDY 25MG OR TABS ANTIVIRALS No Response 1 3963 HEMATOLOGY & ONCOLOGY VENCLEXTA ANTINEOPLASTICS No Response 2 3961 HEMATOLOGY & ONCOLOGY VENCLEXTA ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY VENCLEXTA ANTINEOPLASTICS Approval 1 3956 INTERNAL MEDICINE VENCLEXTA ANTINEOPLASTICS Approval 1 3965 UNSPECIFIED VENCLEXTA ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED VENCLEXTA ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED VENCLEXTA STARTING PACK 10 & 50 & 100MG OR TBPK ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY VERZENIO ANTINEOPLASTICS Approval 1 3951 INTERNAL MEDICINE VERZENIO ANTINEOPLASTICS No Response 1 3963 PHYSICIAN, ONCOLOGY, MEDICAL VERZENIO ANTINEOPLASTICS Approval 2 3963 UNSPECIFIED VERZENIO ANTINEOPLASTICS Approval 1 3963 NEUROLOGY, PEDIATRIC VIGABATRIN POWDER ANTICONVULSANTS Approval 1 3963 UNSPECIFIED VIGABATRIN POWDER ANTICONVULSANTS Approval 1 3962 UNSPECIFIED VIGABATRIN POWDER ANTICONVULSANTS Approval 1 3956 MEDICAL ONCOLOGY VOTRIENT ANTINEOPLASTICS Approval 1 3956 MEDICAL ONCOLOGY VOTRIENT ANTINEOPLASTICS Denial 1 3965 UNSPECIFIED VOTRIENT ANTINEOPLASTICS Approval 1 3962 UNSPECIFIED VUMERITY MULTIPLE SCLEROSIS No Response 1 3962 UNSPECIFIED VUMERITY MULTIPLE SCLEROSIS Approval 1 3963 UNSPECIFIED VUMERITY MULTIPLE SCLEROSIS Approval 1 3956 GASTROENTEROLOGY XELJANZ 5 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3963 INTERNAL MEDICINE XELJANZ 5 MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 INTERNAL MEDICINE XELJANZ 5 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 INTERNAL MEDICINE XELJANZ 5 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 INTERNAL MEDICINE XELJANZ 5 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3961 NEUROLOGY XELJANZ 5 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 RHEUMATOLOGY XELJANZ 5 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 RHEUMATOLOGY XELJANZ 5 MG IMMUNOSUPPRESSIVES/DMARDS Denial 3 3956 UNSPECIFIED XELJANZ 5 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED XELJANZ 5 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3969 UNSPECIFIED XELJANZ 5 MG IMMUNOSUPPRESSIVES/DMARDS Denial 1 3956 INTERNAL MEDICINE XELJANZ 5MG OR TABS IMMUNOSUPPRESSIVES/DMARDS No Response 1 3963 NURSE PRACTITIONER, FAMILY HEALTH XELJANZ XR 11 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3961 PEDIATRICS XELJANZ XR 11 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1

46 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 RHEUMATOLOGY XELJANZ XR 11 MG IMMUNOSUPPRESSIVES/DMARDS Approval 7 3963 RHEUMATOLOGY XELJANZ XR 11 MG IMMUNOSUPPRESSIVES/DMARDS Approval 6 3964 RHEUMATOLOGY XELJANZ XR 11 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3964 RHEUMATOLOGY XELJANZ XR 11 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED XELJANZ XR 11 MG IMMUNOSUPPRESSIVES/DMARDS Approval 2 3963 UNSPECIFIED XELJANZ XR 11 MG IMMUNOSUPPRESSIVES/DMARDS Approval 1 3956 UNSPECIFIED XELJANZ XR 11 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 UNSPECIFIED XELJANZ XR 22 MG IMMUNOSUPPRESSIVES/DMARDS No Response 1 3956 INTERNAL MEDICINE XELODA ANTINEOPLASTICS Denial 1 3963 HEMATOLOGY & ONCOLOGY XGEVA OSTEOPOROSIS AGENTS Approval 2 3963 PHYSICIAN, SURGERY, GENERAL XGEVA OSTEOPOROSIS AGENTS Approval 1 3963 ALLERGY & IMMUNOLOGY XOLAIR MISCELLANEOUS Denial 4 3963 ALLERGY & IMMUNOLOGY XOLAIR RESPIRATORY AGENTS Denial 4 3963 ALLERGY & IMMUNOLOGY XOLAIR MISCELLANEOUS Approval 14 3963 ALLERGY & IMMUNOLOGY XOLAIR RESPIRATORY AGENTS Approval 14 3963 ALLERGY & IMMUNOLOGY XOLAIR MISCELLANEOUS No Response 3 3956 ALLERGY & IMMUNOLOGY XOLAIR MISCELLANEOUS No Response 2 3963 ALLERGY & IMMUNOLOGY XOLAIR RESPIRATORY AGENTS No Response 3 3956 ALLERGY & IMMUNOLOGY XOLAIR RESPIRATORY AGENTS No Response 2 3956 ALLERGY & IMMUNOLOGY XOLAIR MISCELLANEOUS Approval 11 3961 ALLERGY & IMMUNOLOGY XOLAIR MISCELLANEOUS Approval 1 3956 ALLERGY & IMMUNOLOGY XOLAIR RESPIRATORY AGENTS Approval 11 3961 ALLERGY & IMMUNOLOGY XOLAIR RESPIRATORY AGENTS Approval 1 3956 ALLERGY XOLAIR MISCELLANEOUS Approval 1 3956 ALLERGY XOLAIR RESPIRATORY AGENTS Approval 1 3969 ALLERGY & IMMUNOLOGY XOLAIR MISCELLANEOUS Denial 1 3969 ALLERGY & IMMUNOLOGY XOLAIR MISCELLANEOUS Approval 1 3969 ALLERGY & IMMUNOLOGY XOLAIR RESPIRATORY AGENTS Denial 1 3969 ALLERGY & IMMUNOLOGY XOLAIR RESPIRATORY AGENTS Approval 1 3951 ALLERGY & IMMUNOLOGY XOLAIR MISCELLANEOUS Approval 1 3951 ALLERGY & IMMUNOLOGY XOLAIR RESPIRATORY AGENTS Approval 1 3963 DERMATOLOGY XOLAIR MISCELLANEOUS Denial 1 3963 DERMATOLOGY XOLAIR RESPIRATORY AGENTS Denial 1 3963 DERMATOLOGY XOLAIR MISCELLANEOUS Approval 1 3963 DERMATOLOGY XOLAIR RESPIRATORY AGENTS Approval 1 3963 FAMILY PRACTICE XOLAIR MISCELLANEOUS Approval 1 3963 FAMILY PRACTICE XOLAIR RESPIRATORY AGENTS Approval 1

47 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3956 INTERNAL MEDICINE XOLAIR MISCELLANEOUS Denial 1 3956 INTERNAL MEDICINE XOLAIR RESPIRATORY AGENTS Denial 1 3956 NEUROLOGY XOLAIR MISCELLANEOUS No Response 1 3956 NEUROLOGY XOLAIR RESPIRATORY AGENTS No Response 1 3956 NURSE PRACTITIONER, FAMILY HEALTH XOLAIR MISCELLANEOUS Denial 1 3956 NURSE PRACTITIONER, FAMILY HEALTH XOLAIR MISCELLANEOUS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH XOLAIR RESPIRATORY AGENTS Denial 1 3956 NURSE PRACTITIONER, FAMILY HEALTH XOLAIR RESPIRATORY AGENTS Approval 1 3963 PEDIATRICS XOLAIR MISCELLANEOUS Approval 1 3963 PEDIATRICS XOLAIR RESPIRATORY AGENTS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED XOLAIR MISCELLANEOUS Approval 4 3956 PHYSICIAN ASSISTANT, UNSPECIFIED XOLAIR RESPIRATORY AGENTS Approval 4 3963 PHYSICIAN ASSISTANT, UNSPECIFIED XOLAIR MISCELLANEOUS Approval 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED XOLAIR RESPIRATORY AGENTS Approval 1 3956 PHYSICIAN ASSISTANT, UNSPECIFIED XOLAIR MISCELLANEOUS No Response 2 3956 PHYSICIAN ASSISTANT, UNSPECIFIED XOLAIR RESPIRATORY AGENTS No Response 2 3963 PHYSICIAN ASSISTANT, UNSPECIFIED XOLAIR MISCELLANEOUS Denial 2 3963 PHYSICIAN ASSISTANT, UNSPECIFIED XOLAIR RESPIRATORY AGENTS Denial 2 3963 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC XOLAIR MISCELLANEOUS Approval 3 3963 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC XOLAIR MISCELLANEOUS Denial 3 3951 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC XOLAIR MISCELLANEOUS Approval 1 3963 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC XOLAIR RESPIRATORY AGENTS Approval 3 3963 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC XOLAIR RESPIRATORY AGENTS Denial 3 3951 PHYSICIAN, ALLERGY & IMMUNOLOGY, PEDIATRIC XOLAIR RESPIRATORY AGENTS Approval 1 3963 PULMONARY DISEASES XOLAIR MISCELLANEOUS Approval 1 3963 PULMONARY DISEASES XOLAIR RESPIRATORY AGENTS Approval 1 3963 UNSPECIFIED XOLAIR MISCELLANEOUS Denial 2 3963 UNSPECIFIED XOLAIR MISCELLANEOUS Approval 3 3956 UNSPECIFIED XOLAIR MISCELLANEOUS No Response 1 3956 UNSPECIFIED XOLAIR MISCELLANEOUS Approval 4 3963 UNSPECIFIED XOLAIR RESPIRATORY AGENTS Denial 2 3963 UNSPECIFIED XOLAIR RESPIRATORY AGENTS Approval 3 3956 UNSPECIFIED XOLAIR RESPIRATORY AGENTS No Response 1 3956 UNSPECIFIED XOLAIR RESPIRATORY AGENTS Approval 4 3963 UNSPECIFIED XOLAIR MISCELLANEOUS No Response 1 3963 UNSPECIFIED XOLAIR RESPIRATORY AGENTS No Response 1 3969 UNSPECIFIED XOLAIR MISCELLANEOUS Approval 1

48 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3969 UNSPECIFIED XOLAIR RESPIRATORY AGENTS Approval 1 3956 UNSPECIFIED XOLAIR MISCELLANEOUS Denial 1 3956 UNSPECIFIED XOLAIR RESPIRATORY AGENTS Denial 1 3963 ALLERGY & IMMUNOLOGY XOLAIR 150 MG/ML SUBCUTANEOUS SYRINGE RESPIRATORY AGENTS No Response 1 3963 PEDIATRICS XOLAIR 150MG/ML SC SOSY RESPIRATORY AGENTS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED XOLAIR 150MG/ML SC SOSY RESPIRATORY AGENTS No Response 1 3951 HEMATOLOGY & ONCOLOGY XTANDI ANTINEOPLASTICS Approval 1 3963 HEMATOLOGY & ONCOLOGY XTANDI ANTINEOPLASTICS Approval 2 3956 INTERNAL MEDICINE XTANDI ANTINEOPLASTICS Approval 1 3963 INTERNAL MEDICINE XTANDI ANTINEOPLASTICS Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH XTANDI ANTINEOPLASTICS Approval 1 3951 NURSE PRACTITIONER, FAMILY HEALTH XTANDI ANTINEOPLASTICS Approval 1 3956 NURSE PRACTITIONER, FAMILY HEALTH XTANDI ANTINEOPLASTICS No Response 1 3963 PHYSICIAN ASSISTANT, UNSPECIFIED XTANDI ANTINEOPLASTICS Approval 1 3956 PHYSICIAN, ONCOLOGY, MEDICAL XTANDI ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED XTANDI ANTINEOPLASTICS Denial 1 3956 UNSPECIFIED XTANDI ANTINEOPLASTICS Approval 1 3963 UNSPECIFIED XTANDI ANTINEOPLASTICS No Response 1 3965 UNSPECIFIED XTANDI ANTINEOPLASTICS Denial 1 3951 HEMATOLOGY & ONCOLOGY XTANDI 40MG OR TABS ANTINEOPLASTICS No Response 2 3965 NEUROLOGY XYREM SEDATIVE NON-BARBITURATE Approval 1 3965 NEUROLOGY XYREM CENTRAL NERVOUS SYSTEM DEPRESSANT Approval 1 3965 NEUROLOGY XYREM CNS DEPRESSANT Approval 1 3963 NEUROLOGY XYREM SEDATIVE NON-BARBITURATE Approval 1 3963 NEUROLOGY XYREM CENTRAL NERVOUS SYSTEM DEPRESSANT Approval 1 3963 NEUROLOGY XYREM CNS DEPRESSANT Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED XYREM SEDATIVE NON-BARBITURATE Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED XYREM CENTRAL NERVOUS SYSTEM DEPRESSANT Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED XYREM CNS DEPRESSANT Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH XYWAV CENTRAL NERVOUS SYSTEM DEPRESSANT Approval 1 3963 NURSE PRACTITIONER, FAMILY HEALTH XYWAV CNS DEPRESSANT Approval 1 3962 NURSE PRACTITIONER, UNSPECIFIED XYWAV CENTRAL NERVOUS SYSTEM DEPRESSANT Approval 1 3962 NURSE PRACTITIONER, UNSPECIFIED XYWAV CNS DEPRESSANT Approval 1 3951 NURSE PRACTITIONER, UNSPECIFIED XYWAV CENTRAL NERVOUS SYSTEM DEPRESSANT Approval 1 3969 NURSE PRACTITIONER, UNSPECIFIED XYWAV CENTRAL NERVOUS SYSTEM DEPRESSANT Approval 1 3951 NURSE PRACTITIONER, UNSPECIFIED XYWAV CNS DEPRESSANT Approval 1 3969 NURSE PRACTITIONER, UNSPECIFIED XYWAV CNS DEPRESSANT Approval 1

49 Carrier Prescriber Primary Specialty Description Drug Standard Code Description Decision Count 3963 NURSE PRACTITIONER, UNSPECIFIED XYWAV CENTRAL NERVOUS SYSTEM DEPRESSANT Approval 1 3963 NURSE PRACTITIONER, UNSPECIFIED XYWAV CNS DEPRESSANT Approval 1 3963 UNSPECIFIED XYWAV CENTRAL NERVOUS SYSTEM DEPRESSANT Denial 2 3963 UNSPECIFIED XYWAV CNS DEPRESSANT Denial 2 3965 UNSPECIFIED XYWAV CENTRAL NERVOUS SYSTEM DEPRESSANT Approval 1 3965 UNSPECIFIED XYWAV CNS DEPRESSANT Approval 1 3956 INTERNAL MEDICINE ZEJULA ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED ZEJULA ANTINEOPLASTICS Approval 1 3956 UNSPECIFIED ZEJULA ANTINEOPLASTICS Denial 1 3963 HEMATOLOGY & ONCOLOGY ZELBORAF ANTINEOPLASTICS Approval 1 3961 HEMATOLOGY & ONCOLOGY ZELBORAF ANTINEOPLASTICS No Response 1 3961 HEMATOLOGY & ONCOLOGY ZELBORAF ANTINEOPLASTICS Approval 1 3965 NEUROLOGY ZEPOSIA MULTIPLE SCLEROSIS AGENT Approval 1 3963 UNSPECIFIED ZEPOSIA MULTIPLE SCLEROSIS AGENT Approval 1 3956 GASTROENTEROLOGY ZEPOSIA 0.92MG OR CAPS MULTIPLE SCLEROSIS AGENT No Response 1 3963 UNSPECIFIED ZEPOSIA 0.92MG OR CAPS MULTIPLE SCLEROSIS AGENT No Response 1 3963 HEMATOLOGY & ONCOLOGY ZIEXTENZO HEMATINICS & BLOOD CELL STIMULATORS Approval 6 3956 HEMATOLOGY & ONCOLOGY ZIEXTENZO HEMATINICS & BLOOD CELL STIMULATORS Denial 1 3956 HEMATOLOGY & ONCOLOGY ZIEXTENZO HEMATINICS & BLOOD CELL STIMULATORS Approval 2 3963 HEMATOLOGY & ONCOLOGY ZIEXTENZO HEMATINICS & BLOOD CELL STIMULATORS Denial 1 3951 INTERNAL MEDICINE ZIEXTENZO HEMATINICS & BLOOD CELL STIMULATORS Denial 1 3956 UNSPECIFIED ZIEXTENZO HEMATINICS & BLOOD CELL STIMULATORS Denial 1 3956 UNSPECIFIED ZOLEDRONIC ACID 5MG OSTEOPOROSIS AGENTS Approval 1