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CRP1386903A 204612 EXCL-NPF-26 (08/08/2025) Page 11 Drug Class Excluded Medications Preferred Alternatives HEMATOLOGICAL (continued) Erythropoiesis-Stimulating Agents ARANESP, EPOGEN, MIRCERA PROCRIT, RETACRIT IXINITY, RIXUBIS NOVOSEVEN RT BENEFIX SEVENFACT ADVATE, ADYNOVATE, AFSTYLA, ALTUVIIIO, ELOCTATE, ESPEROCT, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT, XYNTHA, XYNTHA SOLOFUSE Factor Deficiency Agents & Related Products NUWIQ, RECOMBINATE REBINYN ALPROLIX, IDELVION FYLNETRA, NEULASTA, NYVEPRIA, ROLVEDON, RYZNEUTA, STIMUFEND, UDENYCA GRANIX, NEUPOGEN, NYPOZI, RELEUKO, ZARXIO FULPHILA, ZIEXTENZO Granulocyte Colony Stimulating Factors NIVESTYM Hematopoietic & Thrombopoietic Agents APHEXDA plerixafor For Hemophilia A with inhibitors: ALHEMO, HEMLIBRA For Hemophilia A without inhibitors: ALHEMO, HEMLIBRA, HYMPAVZI For Hemophilia B with inhibitors: ALHEMO For Hemophilia B without inhibitors: ALHEMO, HYMPAVZI Hemophilia Agents QFITLIA Hemophilia Gene Therapy Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitors Iron Replacement Agents Sickle Cell Disease Agents BEQVEZ HEMGENIX VAFSEO PROCRIT, RETACRIT MONOFERRIC SIKLOS, XROMI sodium ferric gluconate complex, VENOFER hydroxyurea, DROXIA eltrombopag, NPLATE ALVAIZ Thrombocytopenia Agents MULPLETA DOPTELET Coverage may be approved for the treatment of Myelodysplastic Syndrome with Transfusion- Dependent Anemia under certain conditions

Animal_Sheep

Treatment Options:Single Injection

Regulatory status: investigational and WADA-prohibited TB-500 is not FDA-approved as a drug