Special Authorization Certain medications in the Reformulary require Special Authorization from your insurance company before your prescription is eligible for coverage. What is Special Authorization? Your drug plan provides you with immediate access to about 10,000 prescription drugs. Certain other medications require Special Authorization before your prescription is eligible for coverage. Will I need to pay for my prescription myself? If the Special Authorization is approved, you will pay the lowest amount (copay) available in your plan for your prescription. If the Special Authorization is not approved, you may need to pay the full price of the prescription yourself. How do I apply for Special Authorization? Your doctor needs to provide a well-documented medical reason why you need to take the Special Authorization drug. Here s how you apply: 1. Complete the Special Authorization (SA) form; you can download the Special Authorization form from your plan administrator s website. Both you and your doctor will need to complete the form. Have your doctor or pharmacist call or fax the Special Authorization (SA) form to your plan administrator. 2. Once your request has been processed, you will be notified and you will also receive a letter in the mail. You will need to have the Special Authorization request approved to pay the lowest amount (co-pay) in your plan. 3. If your plan administrator needs more information, they may contact your doctor directly. 4. If the request is approved, have your prescription filled. If the special authorization request is denied, you and your doctor will be notified. Clinical Conditions in the Reformulary Special Authorization Drugs December 2017 1
What happens to my Special Authorization request once it is sent to my plan administrator? Your request will be confidentially reviewed by a qualified medical reviewer, according to specific criteria. You will receive written notification of the decision, typically within seven to fourteen working days. In cases where a doctor requires an urgent response due to the medical condition, every effort will be made to respond promptly. If your request is approved, the approval will indicate the specified period of time. You will likely need to re-apply for Special Authorization after that specified time period. What if I am already taking a Special Authorization drug? If you are already taking a Special Authorization drug when your new drug plan launches, your drug will be grandfathered. This means that you may continue taking this drug at the lowest amount (co-pay). Please refer to Clinical Conditions in the Reformulary Grandfathered Drugs for more information. Any statement suggesting that you consider a particular drug, indicating that any drug is a preferred drug, or describing the effectiveness of a drug is not intended to be a substitute for your physician's advice, diagnosis or treatment, and should not be used to replace a health care professional, for diagnosis or for treatment. You should not act or rely on any Information provided in this document or in DrugFinder at www.reformulary.com without seeking the advice of a physician or health care professional. Clinical Conditions in the Reformulary Special Authorization Drugs December 2017 2
ACTEMRA (tocilizumab) ADCIRCA (tadalafil) adefovir ADEMPAS (riociguat) AFINITOR, AFINITOR DISPERZ (everolimus) Rheumatoid Arthritis (RA); Juvenile Idiopathic Arthritis (JIA) Hepatitis B ALDURAZYME (laronidase) Mucopolysaccharidosis I (MPS I) ALECENSARO (alectinib hydrochloride) APTIOM (eslicarbazepine) APTIVUS (tipranavir) ARANESP (darbepoetin alfa) AUBAGIO (teriflunomide) AVANDIA (rosiglitazone), AVANDAMET (rosiglitazone/metformin) AVONEX (interferon beta-1a) BANZEL (rufinamide) BENLYSTA (belimumab) BETASERON (interferon beta-1b) bosentan BOSULIF (bosutinib) BOTOX (onabotulinumtoxin A) Brenzys (etanercept) BRIVLERA (brivaracetam) butorphanol nasal spray Epilepsy HIV/AIDS Anemia Diabetes ++ Epilepsy Lupus Miscellaneous Conditions Ankylosing Spondylitis; Rheumatoid Arthritis Epilepsy Migraines CALCIJEX (calcitriol) Kidney Disease ++ Clinical Conditions in the Reformulary Special Authorization Drugs December 2017 3
calcitriol (injectable) Kidney Disease ++ CAPRELSA (vandetanib) CARBAGLU (carglumic acid) CARIPUL (epoprostenol) CAYSTON (aztreonam) CELSENTRI (maraviroc) CEREZYME (imiglucerase) Chlorax (clidinium bromide + chlordiazepoxide hydrochloride) CIMZIA (certolizumab) cinacalcet CINQAIR (reslizumab) COPAXONE (glatiramer) COSENTYX (secukinumab) COTELLIC (cobimetinib) CYSTADANE (betaine) DAKLINZA (daclatasvir) DAXAS (roflumilast) deferasirox DIACOMIT (stiripentol) DIFICID (fidaxomicin) DUODOPA (carbidopa + levodopa) EGRIFTA (tesamorelin) ELAPRASE (idursulfase) Hyperammonaemia HIV/AIDS Gaucher Disease Gastrointestinal (GI) Disorders ++ Rheumatoid Arthritis (RA); Psoriatic Arthritis; Ankylosing Spondylitis Hyperparathyroidism; Hypercalcemia Asthma, COPD Ankylosing Spondylitis; Psoriasis; Psoriatic Arthritis Homocystinuria Asthma, COPD Chronic Iron Overload Epilepsy Antibiotics, Antifungals, Antivirals Parkinson s Disease HIV/AIDS Mucopolysaccharidosis II (MPS II) Clinical Conditions in the Reformulary Special Authorization Drugs December 2017 4
ELELYSO (taliglucerase alfa) ENBREL (etanercept) ENTOCORT (budesonide) ENTRESTO (valsartan + sacubitril) ENTYVIO (vedolizumab) EPCLUSA (sofosbuvir + velpatasvir) EPREX (epoetin alfa) ERIVEDGE (vismodegib) erlotinib ESBRIET (pirfenidone) EXJADE (deferasirox) EXTAVIA (interferon beta-1b) EYLEA (aflibercept) FABRAZYME (agalsidase beta) FAMPYRA (fampridine) FERRIPROX (deferiprone) FIRAZYR (icatibant) FLOLAN (epoprostenol) FLUDARA (fludarabine) FORTEO (teriparatide) FOSRENOL (lanthanum carbonate hydrate) FUZEON (enfuvirtide) FYCOMPA (perampanel) GALEXOS (simeprevir) Gaucher Disease Rheumatoid Arthritis; Psoriatic Arthritis; Psoriasis; Juvenile Idiopathic Arthritis (JIA); Ankylosing Spondylitis Inflammatory Bowel Disease (IBD) Heart and Blood Pressure Conditions Inflammatory Bowel Disease (IBD) Anemia Idiopathic Pulmonary Fibrosis Chronic Iron Overload Other Eye Conditions Fabry Disease Iron Overload Hereditary Antioedema (HAE) Osteoporosis Hyperkalemia; Hyperphosphatemia HIV/AIDS Epilepsy Clinical Conditions in the Reformulary Special Authorization Drugs December 2017 5
gefinitib GENOTROPIN (somatropin) GILENYA (fingolimod) GIOTRIF (afatinib) GLEEVEC (imatinib) Grastofil (filgrastim) HARVONI (ledipasvir + sofosbuvir) HEMANGIOL (propranolol hydrochloride) HEPSERA (adefovir) HOLKIRA PAK (ritonavir + paritaprevir + ombitasvir + dasabuvir) HUMATROPE (somatropin) HUMIRA (adalimumab) IBRANCE (palbociclib) ICLUSIG (ponatinib) ILARIS (canakinumab) imatinib IMBRUVICA (ibrutinib) Growth Hormone Deficiency -related Conditions Miscellaneous Conditions Hepatitis B Growth Hormone Deficiency Rheumatoid Arthritis; Psoriatic Arthritis; Psoriasis; Inflammatory Bowel Disease (IBD); Juvenile Idiopathic Arthritis (JIA); Ankylosing Spondylitis; Hidradenitis Suppurativa; Uveitis Juvenile Idiopathic Arthritis (JIA); Cryopyrin- Associated Periodic Syndrome (CAPS); Familial Mediterranean Fever (FMF); Hyperimmunoglobulin D syndrome (HIDS)/Mevalonate Kinase Deficiency (MKD); Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS) IMUNOVIR (inosine) Antibiotics, Antifungals, Antivirals ++ INCIVEK (telaprevir) Clinical Conditions in the Reformulary Special Authorization Drugs December 2017 6
Inflectra (infliximab) INLYTA (axitinib) INVEGA TRINZA (paliperidone palmitate) IRESSA (gefitinib) JADENU (deferasirox) JAKAVI (ruxolitinib) JETREA (ocriplasmin) JINARC (tolvaptan) JUXTAPID (lomitapide) KALYDECO (ivacaftor) KEVZARA (sarilumab) KINERET (anakinra) KUVAN (sapropterin) LANCORA (ivabradine) LEMTRADA (alemtuzumab) LENVIMA (lenvatinib mesylate) LIBRAX (clidinium bromide + chlordiazepoxide hydrochloride) linezolid LUCENTIS (ranibizumab) MACUGEN (pegaptanib) MEKINIST (trametinib) METOJECT, METOJECT SUBCUTANEOUS (methotrexate) MODERIBA (ribavirin) Rheumatoid Arthritis; Psoriasis ; Psoriatic Arthritis; Ankylosing Spondylitis; Inflammatory Bowel Disease (IBD) Schizophrenia Chronic Iron Overload Other Eye Conditions Autosomal Dominant Polycystic Kidney Disease (ADPKD) Homozygous familial hypercholesterolemia (HoFH) Rheumatoid Arthritis Rheumatoid Arthritis (RA); Juvenile Idiopathic Arthritis (JIA) Phenylketonuria Heart and Blood Pressure Disorders Gastrointestinal (GI) Disorders ++ Antibiotics, Antifungals, Antivirals Other Eye Conditions Other Eye Conditions Rheumatoid Arthritis; Psoriatic Arthritis; Psoriasis; Clinical Conditions in the Reformulary Special Authorization Drugs December 2017 7
MULTAQ (dronedarone) Heart and Blood Pressure Conditions ++ MYOZYME (alglucosidase) NAGLAZYME (galsulfase) NEULASTA (pegfilgrastim) NEUPOGEN (filgrastim) NEUPRO (rotigotine) NEXAVAR (sorafenib) nitisinone NORDITROPIN NORDIFLEX (somatropin) NPLATE (romiplostim) NUCALA (mepolizumab) NUTROPIN AQ (somatropin) OFEV (nintedanib esilate) Omnitrope (somatropin) OPSUMIT (macitentan) ORENCIA (abatacept) ORFADIN (nitisinone) ORKAMBI (ivacaftor + lumacaftor) OTEZLA (apremilast) OZURDEX (dexamethasone) PHEBURANE (sodium phenylbutyrate) PLEGRIDY (peginterferon beta-1a) POMALYST (pomalidomide) POSANOL (posaconazole) Pompe's Disease Mucopolysaccharidosis VI (MPS VI, Maroteaux- Lamy syndrome) -related Conditions -related Conditions Parkinson s Disease Hereditary Tyrosinemia type 1 (HT-1) Growth Hormone Deficiency Refractory chronic immune thrombocytopenia purpura (ITP) Asthma, COPD Growth Hormone Deficiency Idiopathic Pulmonary Fibrosis (IPF) Growth Hormone Deficiency Rheumatoid Arthritis (RA); Juvenile Idiopathic Arthritis (JIA) Hereditary Tyrosinemia type 1 (HT-1) Psoriasis; Psoriatic Arthritis Eye/Ear Inflammation Urea Cycle Disorders Antibiotics, Antifungals, Antivirals Clinical Conditions in the Reformulary Special Authorization Drugs December 2017 8
PRALUENT (alirocumab) PROLASTIN-C (alpha 1-proteinase inhibitor) PULMOZYME (dornase alfa) QUINSAIR (levofloxacin) RASILEZ (aliskiren), RASILEZ HCT (aliskiren/hydrochlorothiazide) RAVICTI (sodium phenylbutyrate) REBIF (interferon beta-1a) REMICADE (infliximab) REMODULIN (treprostinil) RENAGEL (sevelamer hydrochloride) RENVELA (sevelamer carbonate) REPATHA (evolocumab) RESTASIS (ciclosporin) RETISERT (fluocinolone) REVATIO (sildenafil) REVESTIVE (teduglutide) REVLIMID (lenalidomide) REVOLADE (eltrombopag) RILUTEK (riluzole) riluzole RITUXAN (rituximab) SAIZEN (somatropin) High Cholesterol Congenital Alpha 1-Antitrypsin Deficiency Heart and Blood Pressure Conditions ++ Urea Cycle Disorders Rheumatoid Arthritis; Psoriatic Arthritis; Psoriasis; Inflammatory Bowel Disease (IBD); Juvenile Idiopathic Arthritis (JIA); Ankylosing Spondylitis Hyperkalemia; Hyperphosphatemia Hyperkalemia; Hyperphosphatemia High Cholesterol Dry Eye Other Eye Conditions Functional Bowel Disorders ; Refractory chronic immune thrombocytopenia purpura (ITP) Amyotropic Lateral Sclerosis (ALS) Amyotropic Lateral Sclerosis (ALS) Rheumatoid Arthritis (RA); Juvenile Idiopathic Arthritis (JIA) Growth Hormone Deficiency Clinical Conditions in the Reformulary Special Authorization Drugs December 2017 9
SAMSCA (tolvaptan) SAPHRIS (asenapine) SATIVEX (cannabidiol + delta-9- tetrahydrocannabinol) SEBIVO (telbivudine) SENSIPAR (cinacalcet) SIGNIFOR (pasireotide) SIGNIFOR LAR (pasireotide) sildenafil (20 mg) SIMPONI (golimumab) SIMPONI I.V. (golimumab) SOLIRIS (eculizumab) SOMAVERT (pegvisomant) SOVALDI (sofosbuvir) SPRYCEL (dasatinib) STELARA (ustekinumab) STIVARGA (regorafenib) STRENSIQ (asfotase alfa) SUNVEPRA (asunaprevir) SUTENT (sunitinib) tadalafil TAFINLAR (dabrafenib) TAGRISSO (osimertinib) TALTZ (ixekizumab) Hyponatremia Bipolar Disorder Pain Hepatitis B Hyperparathyroidism; Hypercalcemia Cushing's Disease Acromegaly Rheumatoid Arthritis; Psoriatic Arthritis; Inflammatory Bowel Disease (IBD); Ankylosing Spondylitis; Non-Radiographic Axial Spondyloarthritis Rheumatoid Arthritis Hemolytic uremic syndrome (HUS); Paroxysmal nocturnal hemoglobinuria (PNH) Acromegaly Psoriasis; Psoriatic Arthritis; Inflammatory Bowel Disease (IBD) Enzyme Replacement Therapy Psoriasis Clinical Conditions in the Reformulary Special Authorization Drugs December 2017 10
TARCEVA (erlotinib) TASIGNA (nilotinib) TECFIDERA (dimethyl) TECHNIVIE (ritonavir + paritaprevir + ombitasvir) TEMODAL (temozolomide) temozolomide THALOMID (thalidomide) TOBI, TOBI PODHALER (tobramycin) tobramycin (Inhalation Solution) TRACLEER (bosentan) TYKERB (lapatinib) TYSABRI (natalizumab) ULORIC (febuxostat) UPTRAVI (selexipag) VFEND (voriconazole) VICTRELIS (boceprevir) VICTRELIS TRIPLE (boceprevir + peginterferon Alfa- 2B + ribavirin) VIMIZIM (elosulfase alfa) VISUDYNE (verteporfin) VOLIBRIS (ambrisentan) voriconazole (injectable) VOTRIENT (pazopanib) VPRIV (velaglucerase alfa) XALKORI (crizotinib) XELJANZ (tofacitinib) Gout Antibiotics, Antifungals, Antivirals Mucopolysaccharidosis IVA (MPS IVA) Other Eye Conditions Antibiotics, Antifungals, Antivirals Gaucher Disease Rheumatoid Arthritis Clinical Conditions in the Reformulary Special Authorization Drugs December 2017 11
XEOMIN (incobotulinumtoxin A) XIAFLEX (collagenase clostridium histolyticum) XOLAIR (omalizumab) XTANDI (enzalutamide) ZAVESCA (miglustat) ZAXINE (rifaximin) ZELBORAF (vemurafenib) ZEPATIER (elbasvir + grazoprevir) ZINBRYTA (daclizumab beta) ZOLINZA (vorinostat) ZYDELIG (idelalisib) ZYKADIA (ceritinib) ZYTIGA (abiraterone acetate) ZYVOXAM (linezolid) Miscellaneous Conditions Dupuytren's contracture Asthma, COPD; Chronic Idiopathic Urticaria (CIU) Gaucher Disease; Niemann-Pick Disease Type C Hepatic Encephalopathy Antibiotics, Antifungals, Antivirals BRAND drugs are capitalized. Generic drugs are in italics. Symbol denotes grandfathered drugs. Please refer to Clinical Conditions in the Reformulary Grandfathered Drugs for more information ++ Only plan members already taking these drugs may continue to receive coverage for these drugs. Special Authorization will not be given to plan members with a new prescription due to clinical concerns. Clinical Conditions in the Reformulary Special Authorization Drugs December 2017 12