Commercial Formulary and Utilization Management Program Updates for January 2017 Producer Communication #782 Issued November 10, 2016

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1 Commercial and Utilization Management Program Updates for January 2017 Producer Communication #782 Issued November 10, 2016 Message The Capital BlueCross Pharmacy & Therapeutics (P&T) Committee, consisting of practicing physicians, pharmacists and other health care experts, reviews medications in all therapeutic categories according to safety, efficacy and overall value. development is a dynamic process. The P&T Committee regularly reviews new and existing medications to ensure the remains responsive to the needs of our members and providers. The 2017 updates are results of the most recent Capital BlueCross Pharmacy & Therapeutics (P&T) Committee meetings, held in May 2016 and August These updates include January 1, 2017 changes to the open/closed and selectively closed formularies. members will be notified prior to changes. Details The formulary updates reflect the decisions from quarterly P&T Committee meetings in the following categories (These updates do not apply to Medicare.): Newly Marketed Drugs Products Changing Tier Status Pharmacy Utilization Management Programs: o Prior Authorization o Enhanced Prior Authorization o Quantity Level Limit Effective January 1, 2017, the selectively closed formulary will consist of three tiers of medications: Generic, Brand Preferred, and Brand Nonpreferred. Currently, the selectively closed formulary operates as a two-tier generic formulary but will be changing to a one-tier generic formulary starting January 1, Please note that the open/closed formulary will continue to operate with four tiers of medications: Generic Preferred, Generic Nonpreferred, Brand Preferred, and Brand Nonpreferred. (Not all benefits utilizing the open/closed formulary have separate cost shares for generic drugs. For benefits that have one cost share for generic drugs, that cost share is applied to generic preferred and generic nonpreferred drugs. For generic specialty drugs, one cost share is applied to generic preferred and generic nonpreferred specialty drugs when applicable.) updates are communicated via BenefitFOCUS, Simply-Well, and the Provider Administrative Bulletin. Quarterly Update-Decision Summaries by Quarter for the open/closed formulary and the selectively closed formulary can also be found on the pharmacy page of our website, Attachments Attachment A Commercial Updates May 2016 & August 2016 P&T Questions Contact your Preferred Agency with any questions. Thank you. Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

2 The following formulary updates may affect Commercial members who have prescription drug coverage through Capital BlueCross: Capital BlueCross Update Apply Newly Marketed Drugs Effective Immediately Brand Name Commercial (/) Commercial Indication Preferred Alternatives BRIVIACT (PAR) BNP NC Epilepsy levetiracetam CABOMETYX* (PAR) BNP NC Renal Cell Carcinoma SUTENT* NUPLAZID (PAR) BP BP Parkinson s Disease related psychosis N/A OCALIVA (PAR) BNP NC Primary Biliary Cholangitis ursodiol ODEFSEY BP BP Human Immunodeficiency Virus TALTZ* (PAR) BNP NC Plaque Psoriasis UPTRAVI* (PAR) BNP NC VENCLEXTA* (PAR) BP BP Pulmonary Arterial Hypertension Chronic Lymphocytic Leukemia VISTOGARD BP BP Fluorouracil overdose N/A VRAYLAR (PAR) BNP NC Schizophrenia/Bipolar Disorder XURIDEN* (PAR) BP BP Hereditary Orotic Aciduria N/A N/A ENBREL* (PAR), HUMIRA* (PAR) ORENITRAM* (PAR) N/A aripiprazole, risperidone ZEPATIER* (PAR) BNP NC Hepatitis C KEY: Brand Preferred (BP), Brand Non-Preferred (BNP), Not Covered (NC) * Indicates specialty medication HARVONI* (PAR), SOVALDI* (PAR)

3 Capital BlueCross Update Apply Brand Name Products Changing Tier Status Effective July 1, 2016 (/) Current Tier (/) New Tier ** Current Tier ** New Tier BETASERON* BNP BP NC BP N/A Preferred Alternatives ELIQUIS BNP BP NC BP N/A TECFIDERA* BNP BP NC BP N/A KEY: Brand Preferred (BP), Brand Non-Preferred (BNP), Not Covered (NC) * Indicates specialty medication The following medications have been added to the Prior Authorization (PAR) Program: Pharmacy Utilization Management Program Update Prior Authorization (PAR) Program Effective Immediately BRIVIACT (PAR) CABOMETYX* (PAR) NUPLAZID (PAR) OCALIVA (PAR) Purpose Prescribed as adjunctive therapy in the treatment of partial-onset seizures in a patient 16 years of age or older with epilepsy Treatment for renal cell carcinoma in advanced or metastatic disease w/clear cell histology and member has received/progressed on or after prior treatment w/a vascular endothelial growth factor receptor (VEGFR) targeting tyrosine kinase inhibitor Diagnosis of Parkinson's disease was made prior to the onset of psychotic symptoms with a baseline mini-mental status examination associated w/mild dementia Diagnosis of primary biliary cholangitis (PBC) and a 12 month trial of ursodiol /

4 Pharmacy Utilization Management Program Update TALTZ* (PAR) UPTRAVI* (PAR) VENCLEXTA* (PAR) Prior Authorization (PAR) Program Effective Immediately Purpose Diagnosis of moderate to severe plaque psoriasis and trial and failure of both ENBREL* (PAR) and HUMIRA* (PAR) WHO Group 1 class pulmonary hypertension confirmed by either pretreatment right heart catherization with (mpap 25 mmhg, PCWP 15 mmhg, PVR 5 Wood units) or for infants < 1yr old w/any of the following: Post cardiac surgery, chronic heart disease, chronic lung disease w/prematurity, congenital diaphragmatic hernia; and member has NYHA Class II or III symptoms prior to initiation of UPTRAVI* (PAR) therapy Treatment of Chronic Lymphocytic Leukemia (CLL) w/fda positive test for the 17p chromosome deletion and has tried at least one prior therapy with Imbruvica or other preferred kinase inhibitors / VRAYLAR (PAR) One of the following must be met either demonstrated failure of or intolerance or documented contraindication or adverse reaction to at least 2 generic preferred formulary alternatives XURIDEN* (PAR) Diagnosis of hereditary orotic aciduria ZEPATIER* (PAR) Diagnosis of chronic hepatitis C virus, genotypes 1a,1b, and 4 and must fail SOVALDI* (PAR) or HARVONI* (PAR) * Indicates specialty medication

5 Pharmacy Management Program Updates Brand Migraine Agents (PAR,QLL) (AMERGE, AXERT, FROVA, IMITREX, MAXALT/-MLT, RELPAX, TREXIMET, ZOMIG/- ZMT) # Prior Authorization Program (PAR) Effective January 1, 2017 Purpose/Guidelines alternatives Brand Non-oral Migraine Agents (PAR,QLL) (ALSUMA, IMITREX INJECTION, IMITREX NASAL SPRAY, ONZETRA, SUMAVEL DOSEPRO, ZEMBRACE, ZOMIG NASAL SPRAY) # alternatives of different routes of administration EVZIO (PAR) # Current opioid prescription and trial and failure of NARCAN NASAL SPRAY PRADAXA (PAR) # SAVAYSA (PAR) # # members will be notified prior to change Diagnosis of deep vein thrombosis and pulmonary embolism treatment and prevention, or non valvular atrial fibrillation, or post-operative thromboprophylaxis and trial and failure of both ELIQUIS and XARELTO Diagnosis of deep vein thrombosis and pulmonary embolism treatment and prevention, or non valvular atrial fibrillation, or post-operative thromboprophylaxis and trial and failure of both ELIQUIS and XARELTO

6 Quantity limits have been updated for the following medications: Pharmacy Utilization Management Program Quantity Level Limits (QLL) Program Effective January 1, 2017 Quantity Limits ALSUMA (sumatriptan) 6mg (PAR, QLL) # AMERGE (naratriptan) 1mg (PAR, QLL) # AMERGE (naratriptan) 2.5mg (PAR, QLL) # AXERT (almotriptan) 6.25mg (PAR, QLL) # AXERT (almotriptan) 12.5mg (PAR, QLL) # FROVA (frovatriptan) 2.5mg (PAR, QLL) # IMITREX (sumatriptan) 25mg (PAR, QLL) # IMITREX (sumatriptan) 50mg (PAR, QLL) # IMITREX (sumatriptan) 100mg (PAR, QLL) # IMITREX (sumatriptan) NASAL 5mg (PAR, QLL) # IMITREX (sumatriptan) NASAL 20mg (PAR, QLL) # IMITREX (sumatriptan) INJECTION 4mg (PAR, QLL) # IMITREX (sumatriptan) INJECTION 6mg (PAR, QLL) # MAXALT /-MLT (rizatriptan) 5mg (PAR, QLL) # MAXALT/-MLT (rizatriptan) 10mg (PAR, QLL) # ONZETRA XSAIL (sumatriptan) 11mg (PAR, QLL) # RELPAX 20mg (PAR, QLL) # RELPAX 40mg (PAR, QLL) # SUMAVEL (sumatriptan) INJECTION 4mg (PAR, QLL) # SUMAVEL (sumatriptan) INJECTION 6mg (PAR, QLL) # TREXIMET 85mg/500mg (PAR, QLL) # 12 injections per 30 days 9 tablets per 30 days 24 tablets per 30 days 27 tablets per 30 days 27 tablets per 30 days 9 tablets per 30 days 30 sprays per 30 days 12 sprays per 30 days 10 injections per 30 days 12 injections per 30 days 36 tablets per 30 days 8 doses per 30 days 18 injections per 30 days 12 injections per 30 days 9 tablets per 30 days

7 Pharmacy Utilization Management Program Update Quantity Level Limits (QLL) Program Effective January 1, ZOMIG /-ZMT (zolmitriptan) 2.5mg (PAR, QLL) # ZOMIG/-ZMT (zolmitriptan) 5mg (PAR, QLL) # ZOMIG NASAL 2.5mg (PAR, QLL) # ZOMIG NASAL 5mg (PAR, QLL) # Quantity Limits 18 sprays per 30 days 12 sprays per 30 days # members will be notified prior to Quantity Level Limits apply to both brand and generic medications when available The following medications, effective January 1, 2018, have been added to the Prior Authorization (PAR) Program: Pharmacy Management Program Updates Apply Brand Migraine Agents (PAR,QLL) (FROVA, RELPAX) # Prior Authorization Program (PAR) Effective January 1, 2018 Purpose/Guidelines alternatives EVZIO (PAR) # PRADAXA (PAR) # Current opioid prescription and trial and failure of NARCAN NASAL SPRAY Diagnosis of deep vein thrombosis and pulmonary embolism treatment and prevention, or non valvular atrial fibrillation, or post-operative thromboprophylaxis and trial and failure of both ELIQUIS and XARELTO ZOMIG 2.5mg Nasal Spray (PAR, QLL) # alternatives of different routes of administration # members will be notified prior to change