Pharmacy Passages

Formulary Update

OptumRx Direct Pharmacy Plans May 2019

The following Formulary decisions and updates apply to OptumRx® direct commercial business.

The OptumRx Business Committee meets monthly to evaluate tier placements and new prescription products approved by the Food and Drug Administration (FDA). This committee makes decisions based on information and recommendations from the OptumRx National Pharmacy & Therapeutics Committee, comprised of independent physician providers and pharmacists.

The following are the strategic clinical decisions made in the past month. Your actual plan's copays may differ from those indicated depending on the selected plan design, which determines coverage and pharmacy provider(s).

Please note: If your plan includes Specialty Pharmacy (SP), your members may obtain specialty products from ® BriovaRx Specialty Pharmacy for your plan’s designated copay. If your plan does not include SP, your members may purchase self-injectable and oral specialty medications from retail pharmacies, or specialty products may be covered under your medical plan. Specialty program medications may be limited to a 30-day supply depending on plan design. Please consult your plan coverage documents.

Available Formularies

Premium Generic drugs are included in Tier 1. All specialty drugs, including injectables, are tiered based on the OptumRx specialty drug list. There are approximately 90 excluded medications. Select Generic drugs are included in Tier 1. All specialty drugs, including injectables, are tiered based on the OptumRx specialty drug list.

Key SP: Specialty Pharmacy PA: Prior Authorization ST: Step Therapy QL: Quantity Limits

Authorized generic insulin Lispro to launch Lispro, an authorized generic of Humalog, is expected to launch soon in both vial and pen versions. Lispro and Humalog are rapid-acting insulins used for the treatment of type 1 and type 2 diabetes. • Effective May 2, 2019, Lispro and Lispro Kwikpen were excluded on OptumRx’s Premium Formulary. On the Select Formulary, both products were dowtiered to Tier 2 with step therapy. • Humalog and Humalog Kwikpen will remain as the preferred products at Tier 2 on the Premium and Select Formularies.

This new strategy will help drive lower net cost products for our clients and members. If you have questions about our authorized generic strategies, contact your OptumRx representative.

Down-tiers

Medications may move to a lower tier throughout the year, helping members take immediate advantage of cost savings.

Brand/ Tier Tier Programs Effective Therapeutic Use Medication Name Generic Premium Select SP PA ST QL Date Hematopoietic Retacrit injection Brand Tier 2 Tier 2 X X ------7/1/19 Agents Metabolic Fabrazyme injection Brand Tier 2 Tier 2 X X------7/1/19 Agents Respiratory Xolair injection Brand Tier 2 Tier 2 X X ------7/1/19 Agents

Up-tiers

Medications typically move to a higher tier on Jan. 1 and July 1 to help reduce member disruption. Brand medications may move to a higher tier at any time when a generic equivalent becomes available.

Therapeutic Brand/ Tier Tier Programs Effective Medication Name Use Generic Premium Select SP PA ST QL Date Hematopoietic Procrit injection Brand Excluded Tier 3 X X ------1/1/20 Agents

New Brand Launches

New brand name medications launch throughout the year. Final coverage status is determined after medications are thoroughly reviewed by the OptumRx National Pharmacy & Therapeutics Committee.

Brand/ Tier Tier Programs Effective Therapeutic Use Medication Name Generic Premium Select SP PA ST QL Date doxycycline Anti-infective delayed-release Brand Excluded Tier 3 ------X --- 7/1/19 Agents + tablet 80mg

Antineoplastic + Balversa tablet Brand Excluded Tier 3 X ------4/15/19 Agents

2 Herceptin Hylecta + Brand Excluded Tier 3 X ------4/4/19 solution 60-1000 Antineoplastic Agents Infugem solution + Brand Excluded Tier 3 X ------4/12/19 1900mg

Dovato tablet 50- Antiviral Agents + Brand Excluded Tier 3 X ------4/30/19 300mg Adapalene pads Brand Tier 3 Tier 3 --- X ------4/12/19 0.1%

Dermatological Duobrii lotion+ Brand Excluded Tier 3 ------`---- 4/29/19 Agent

Skyrizi injection kit+ Brand Excluded Tier 3 X ------4/25/19

Endocrine Evenity injection + Brand Excluded Tier 3 X ------4/16/19 Agents 105mg Hormonal Jynarque tablet Brand Tier 3 Tier 3 X ------X 4/30/19 Agents Multiple Sclerosis Mavenclad pak+ Brand Excluded Tier 3 X ------4/21/19 Agents

Multivitamins Vitafol film 1mg Brand Tier 2 Tier 2 ------4/18/19

Neurological Diacomit capsule + Brand Excluded Tier 3 X ------4/1/19 Agents and packet

+Medication product added on New Drugs to Market.

New Generic Launches

New generic medication launches occur throughout the year. Generic medications will be placed in Tier 1 on the Select and Premium Formularies.

Brand of Therapeutic Tier Tier Programs Effective Generic Medication the generic Use Premium Select Date Medication SP PA ST QL Humalog/ Antidiabetic insulin lispro # Humalog Excluded Tier 2 ------X --- 5/2/19 Agent injection 100/ml KwikPen Suprax cefixime capsule 400mg Tier 1 Tier 1 ------4/30/19 400mg Anti-infective capsule Agents Pentam pentamidine injection injection Tier 1 Tier 1 ------3/18/19 300mg 300mg Valstar Antineoplastic valrubicin solution 40 solution 40 Tier 1 Tier 1 X ------4/23/19 Agents mg/ml mg/ml Cardiovascular Letairis ambrisentan tablet Tier 1 Tier 1 X X --- X 4/11/19 Agents tablet

3 Cardiovascular treprostinil sodium Remodulin Tier 1 Tier 1 X X ------2/28/19 Agents injection injection Genitourinary solifenacin succinate Vesicare Tier 1 Tier 1 ------4/23/19 Agents tablet tablet Yosprala Hematological aspirin/omeprazole #+ tablet 81- Excluded Tier 3 ------X 4/18/19 Agents tablet 81-40mg 40mg Hormonal ganirelix injection Ganirelix Tier 1 Tier 1 X ------2/8/19 Agents 250mcg/0.5ml AC injection Respiratory albuterol sulfate Proventil # Excluded Tier 3 ------X X 4/23/19 Agents HFA ^ HFA

#Medications with a hashtag are authorized generics. ^Medication product added to the Focused UM program. +Medication product added on New Drugs to Market.

New Benefit Coverage (automatically applies to plans that opt into the Premium Formulary)

Therapeutic Brand/ Tier Programs Effective Medication Name Tier Select Use Generic Premium SP PA ST QL Date Hematological Cablivi injection kit Brand Tier 3 Tier 3 X X --- X 6/1/19 agent Hematopoietic Aranesp injection Brand Tier 2 Tier 2 X X ------7/1/19 Agents

Prior Authorization

Prior Authorization requires physicians to provide additional clinical information to verify member benefit coverage.

Tier Effective Therapeutic Use Medication Name Tier Select Premium Add/Remove Date Hematological Cablivi injection kit Tier 3 Tier 3 Add 5/15/19 agent

Step Therapy

Step Therapy directs members to try a lower-cost alternative (Step 1) before a higher-cost medication (Step 2 and/or Step 3) may be eligible for coverage.

Tier Effective Therapeutic Use Medication Name Tier Select Premium Add/Remove Date

ADHD Agents Evekeo tab Tier 3 Tier 3 Remove 6/1/2019

Anti-infective doxycycline delayed-release Excluded Tier 3 Add 4/30/19 Agents tablet 80mg

4 Ophthalmic Agents Rocklatan drops Excluded Tier 3 Add 6/1/2019

Quantity Limits

Quantity Limits establish the maximum quantity of a drug that is covered within a specified timeframe or per copay.

Tier Effective Therapeutic Use Medication Name Tier Select Add/Remove Premium Date

Hematological agent Cablivi injection kit Tier 3 Tier 3 Add 5/15/19

Age Restrictions (this applies to a limited number of clinical programs)

Please note there are no additions or removals for this restriction at this time.

Gender Restrictions

Please note there are no additions or removals for this restriction at this time.

Bulk Chemical Exclusions (only applies to plans that opt into compound exclusions)

As a way to address increasing compound medication costs, OptumRx pharmacy has excluded a number of compound medication ingredients. For groups that do not exclude, a member must go through the prior authorization program in order to receive benefit coverage.

Please note there are no additions to this list at this time.

If you would like additional information that is not listed, please contact your OptumRx representative.

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