Highlights of This Issue Identity Protection

HIGHLIGHTS OF THIS ISSUE

IDENTITY PROTECTION SERVICES AVAILABLE FOR ELIGIBLE HIGHMARK MEMBERS 1095 FORMS FOR REPORTING MINIMUM ESSENTIAL COVERAGE HEALTH CARE REFORM UPDATE: DEFINITION OF SMALL GROUP NOT CHANGING ALLEGHENY HEALTH NETWORK FACILITY EARNS NATIONAL RECOGNITION FOR ITS PULMONARY HYPERTENSION PROGRAM WHAT’S NEW IN WOMEN’S HEALTH CARE AT ALLEGHENY HEALTH NETWORK? CREATING A NEW APPROACH TO CANCER CARE COVERAGE FOR 3D MAMMOGRAMS CHANGES TO 2016 PHARMACY NETWORKS CHANGES TO Rx CLINICAL MANAGEMENT PROGRAMS IDENTITY PROTECTION SERVICES AVAILABLE FOR ELIGIBLE HIGHMARK MEMBERS

Earlier this year, in response to growing concerns about data security, the Blue Cross and Blue Shield Association announced that identity protection services would be available at no cost to all eligible Blue members, beginning Jan. 1, 2016.

Highmark has selected AllClear ID as the vendor for this new service, and we are giving employers the option of making this service available to their Highmark members.

If you have not yet elected this service for your Highmark members, you can learn more by visiting highmarkprotect.com. This site has detailed information about AllClear Secure identity repair service. If you elect this protection for your eligible Highmark members, it will automatically be available to them. You can also learn about AllClear Pro credit monitoring service, additional protection that eligible members can choose — all at no cost to the member.

A Frequently Asked Questions section on the site addresses questions employers are likely to have about this initiative, including possible income tax implications and resulting employer responsibilities. If you have not yet done so, please visit this site. Then, if you want this protection for your Highmark members, use the interactive feature to indicate your agreement. The deadline to provide protection for your Highmark members in 2016 is Dec. 18, 2015.

The Affordable Care Act (ACA) requires individuals to have basic health insurance coverage (“minimum essential coverage”) for themselves and their dependents. Individuals who do not maintain minimum essential coverage may have to pay tax penalties.

Health insurers and plan sponsors of self-funded group benefit plans must report data on their covered members to the Internal Revenue Service (IRS) for all benefit plans providing minimum essential coverage. That data is reported to the IRS on Form 1095-b or Form 1095-c and includes:

• Members’ names, addresses and Tax Identification Numbers (TINs) • Names and TINs of each members’ dependents • Identification about the health insurer or other entity providing coverage • Months that each member was enrolled in the benefit plan

A copy of the applicable form must also be sent to each responsible individual, which generally means the primary insured. As a health insurer, Highmark is required to issue Form 1095-b to our fully insured members. Depending upon their size, Highmark’s self-funded group customers are responsible for their own reporting on Form 1095-b or Form 1095-c.

Highmark’s Responsibilities for Form 1095-b Reporting Beginning in 2016, Highmark must file Form 1095-b with the IRS for each primary insured covered under an insured Highmark benefit plan providing minimum essential coverage. Highmark will file these forms with the IRS by the required due date and mail a separate copy to the primary insured by Jan. 31, 2016, for the 2015 tax year. IRS regulations do not require Highmark to send a Form 1095-b to primary insured’s dependents, including spouses. Primary insureds may receive multiple forms. A different form will be mailed for each group number in which the primary insured was enrolled.

Under the ACA, certain types of benefit plans are exempt from reporting requirements, including:

• Dental and vision coverage that is not part of a comprehensive health insurance plan • Accident and disability coverage • Workers’ compensation coverage • Medicare complement coverage

Highmark will not be reporting or issuing a Form 1095-b for these types of coverage.

Highmark is required to make reasonable attempts to obtain TINs for all covered individuals, including dependents. If we do not have a TIN (either a Social Security Number or Individual Tax Identification Number) on file for a member, we will send the primary insured a letter to ask for that information.

Self-Funded Clients Self-funded (ASO, ASC and Cost Plus) group customers are responsible for reporting information for their benefit plans providing minimum essential coverage.

We have created several enrollment reports to help self-funded clients with their reporting requirements:

• A missing SSN/TIN Report, which identifies all members for whom Highmark does not have a SSN/TIN on file. Plan sponsors that provide minimum essential coverage are required to solicit this information from all enrollees in their plans. Plan sponsors should contact their Highmark representatives to request these reports. Regulations do not require Highmark to collect or solicit member SSN/TIN information on behalf of our self-funded customers.

• A Minimum Essential Coverage (MEC) Report, which provides enrollment information for self-funded medical plan sponsors. The MEC Report, which contains member TINs, will be delivered via the Employer Portal. To retrieve these reports, plan administrators will need access to the MEC Reports tab of the Employer Portal. Plan sponsors should contact their Highmark representatives if they are having problems with accessing these reports.

Highmark is committed to protecting SSNs/TINs and other personal data. We maintain extensive safeguards to reduce the risk of unauthorized use of, or access to, personal data.

Government-Sponsored Plans The Federal government will report minimum essential coverage for government- sponsored plans, including Medicare (including Medicare Advantage), Medicaid and Children’s Health Insurance Program (CHIP) and issue Form 1095-b. Highmark will not report information on members enrolled in Medicare Advantage products, such as Freedom BlueSM and Security BlueSM. In addition, minimum essential coverage that supplements Medicare, such as Signature 65®, is not subject to reporting.

Have Questions? Primary insureds who receive a Form 1095-b from us with information they think is incorrect should call the toll-free number on the back of their member ID cards. You should consult with your tax advisers or visit irs.gov for tax-related questions.

Freedom Blue and Security Blue are service marks of the Blue Cross and Blue Shield Association. Signature 65 is a registered mark of Highmark Inc.

The definition of small group for Pennsylvania, West Virginia and Delaware remains 50 and fewer.

Bipartisan legislation (HR 1624 and S. 1099) was passed unanimously by Congress and signed into law by President Barack Obama on Oct. 7, 2015. Referred to as the “Protecting Affordable Coverage for Employees Act,” it amends the Affordable Care Act (ACA) and lets states decide whether to maintain their current definition for small employer.

Highmark supported this legislation. The amendment represents an important step toward maintaining affordability and stability of coverage for millions of employees and their families.

For the purposes of health insurance, states have traditionally determined their own definition of a small group, with almost all states defining a small group as an employer with no greater than 50 employees. States know their specific health insurance market and are ultimately best suited to make this determination.

Allegheny General Hospital (AGH), part of the Allegheny Health Network, has earned an accreditation that places it in exclusive company as one of just 29 health care facilities in the United States — and the only one in western Pennsylvania — to be recognized for the quality of its pulmonary hypertension (PH) program. AGH joins the University of Pennsylvania as the only medical centers in the state to receive Pulmonary Hypertension Care Center (PHCC) accreditation by the Pulmonary Hypertension Association (PHA).

This accreditation means a health care facility’s PH program excels in its diagnostic capabilities and has the capacity to appropriately and comprehensively manage PH patients through a set of criteria established by the PHA. As part of the PHCC accreditation process, the PHA is developing a registry of patients with pulmonary hypertension. This will allow researchers to track diagnostic and treatment patterns at the national level, ultimately demonstrating improvements in quality of care and life for PH patients.

What Is Pulmonary Hypertension? Pulmonary hypertension is a debilitating disease of the lungs that affects the functioning of the heart and can lead to heart failure. It occurs when the pressure in the blood vessels leading from the heart to the lungs is too high. The heart pumps blood from the right ventricle to the lungs to get oxygen. Because the blood does not have to travel very far, the pressure in this side of the heart and in the artery taking blood from the right ventricle to the lungs is normally low. But when the pressure in this artery gets too high, the arteries in the lungs can narrow and then the blood does not flow as well as it should. This results in less oxygen in the blood.

AHN’s Approach to Treating Pulmonary Hypertension AHN’s cardiovascular specialists use a careful evaluation process to determine the cause, severity and prognosis of each patient’s PH, as there are various types of the disease that require different treatments. This includes a rare form known as chronic thromboembolic pulmonary hypertension (CTEPH), in which blood clots become stuck to the lung’s blood vessel wall and block blood flow. AGH is one of about 10 medical centers in the country that performs a highly complex procedure called pulmonary thromboendarterectomy (PTE) for patients with CTEPH. In this delicate surgery, which can actually cure a CTEPH patient’s PH, doctors remove the clots from the pulmonary arteries to restore blood flow.

For CTEPH patients who are not candidates for PTE, doctors at AGH are able to perform a non-surgical procedure called balloon pulmonary angioplasty (BPA) that is offered at only a handful of medical centers around the world.

AHN’s cardiovascular disease program at AGH is recognized by CareChex®, a division of leading health care industry analyst Comparion Medical Analytics, as the best in western Pennsylvania in 2015 for medical excellence, patient safety and patient satisfaction. AHN’s heart transplant program is ranked in the nation’s top 10 programs by Comparion based on the same measures.

Learn More Visit the AHN Cardiovascular Institute site to learn more about AHN’s capabilities in cardiovascular care and expertise in treating pulmonary hypertension.

New Postpartum Unit and Family Waiting Room at West Penn Within a progressive maternity culture, West Penn Hospital provides family-friendly, personalized women’s care that promotes mother-child and family bonding. Couplet care ensures that the mother and baby remain together as much as possible while in the hospital, to help the new mother learn about her baby’s needs and to promote stronger family bonding. “Stork nurses” ensure that mothers, particularly those having Cesarean deliveries, get skin-to-skin contact with their babies, which is essential to mother-child bonding. West Penn offers a birthing center atmosphere, birthing tubs and more mobility and comfort for mothers, increasing the demand for West Penn’s women’s and infants’ services.

Recently, Allegheny Health Network (AHN) unveiled a new postpartum unit and family waiting room at West Penn Hospital, further advancing the hospital’s patient- centered approach to obstetrics care and the comprehensive needs of mothers and families.

In addition to postpartum beds and nursery beds, the renovation includes a new family waiting area that provides increased privacy and comfort for those awaiting the new arrival. The waiting area is bigger and offers more conveniences, such as a children’s play area.

The new postpartum unit includes a multipurpose educational room where families can watch educational videos or learn more about baby-care topics, such as car seats or breast-feeding. The new waiting room and postpartum unit are among many significant investments made by Highmark and AHN in facilities and programs to enhance women’s health over the past two years.

Midwives at West Penn AHN is now offering midwifery services to mothers-to-be seeking an alternative birth experience within the additional security of a hospital environment. Midwives are health care professionals who specialize in pregnancy and childbirth, developing a relationship of trust with their clients and centering on a woman’s intuitive knowledge of pregnancy, labor and delivery. Midwives provide comprehensive prenatal care and education, guide labor and birth, and address complications and care for newborns.

Certified nurse midwives Lisa Ferrill and Nicky Rawson of Allegheny Nurse Midwives have joined AHN and will attend births at AHN’s West Penn Hospital. With more than 48 years combined midwifery experience, they offer women hands-on care before, during and after childbirth. They perform gynecologic and obstetric exams, offer contraceptive services and support breast-feeding efforts.

Although they focus on dealing with pain during childbirth by using natural methods, Ferrill and Rawson will also order pain medications or even epidural anesthesia when requested. They will collaborate with the obstetrician/gynecologists of Allegheny Women’s Health in the event of complications prenatally or during labor.

Midwives now attend about 8 percent of births nationwide, up from 3 percent in 1989, according to the U.S. Department of Health and Human Services. Using a midwife appeals to women who are looking for a more natural, less medicalized approach to childbirth.

Reproductive Endocrinology and Infertility Treatment AHN is an affiliate of the Jones Institute of Reproductive Medicine at Eastern Virginia Medical School, a national leader in scientific advances in infertility treatment worldwide. The Jones Institute offers in vitro fertilization, ovulation induction, intrauterine insemination, embryo cryopreservation (freezing), assisted embryo hatching, intracytoplasmic sperm injection and pre-implantation genetic diagnosis. A comprehensive donor egg program at the Institute enables eligible women to donate their eggs to other women anonymously, helping them realize their dreams of having a family.

Lori Homa, MD, a board-certified obstetrician/gynecologist and fellowship-trained reproductive endocrinologist, has joined AHN’s Jones Institute.

Dr. Homa offers clinical expertise in the evaluation and treatment of female fertility problems, fibroids, hormone disorders including polycystic ovarian syndrome, disorders of sexual development, and pediatric and adolescent gynecology. She also performs reproductive surgery and in vitro fertilization. Dr. Homa joins Bryan Hecht, MD, medical director of the Jones Institute at AHN.

Infertility affects approximately 14 percent of American couples. However, 85 percent of those who seek treatment will conceive and deliver a healthy baby. The Jones Institute provides the most advanced level of diagnosis and treatment for infertility through a multidisciplinary approach, with laboratory, psychological and genetics support.

Postpartum Depression Research The Alexis Joy D’Achille Foundation for Postpartum Depression (PPD) has awarded $100,000 to AHN to explore new ways to boost awareness of postpartum depression, make it easier for women to seek treatment and examine emerging models of care for this disease.

PPD is a treatable medical illness that affects 15 to 20 percent of women after giving birth. Symptoms may start shortly after delivery and continue for weeks or months. PPD can be hard to spot, because symptoms are similar to the “baby blues,” a short- lived state that affects up to 70 percent of new mothers. Only 15 percent of all women with perinatal mood and anxiety disorders, including PPD, ever receive professional treatment.

The Alexis Joy D’Achille Foundation was created to raise awareness of PPD, to assist women and their families in spotting warning signs, and to support mental health care providers in Pittsburgh and beyond.

Alexia D’Achille and her husband Steven welcomed their daughter Adriana in August 2013. Alexia soon felt overwhelmed by symptoms of PPD that she couldn’t control and took her own life in October 2013. Steven decided to make it his mission to do what he could to stop such tragedies from happening again and to create a legacy for Adriana to carry on in her mother’s name.

“We honor Alexis by using her story to make people more aware of PPD and help women have access to the right treatment to get them through the crisis they face,” Steven D’Achille said. “Alexis’ legacy will be one that makes a difference in the lives of countless women in search of hope and support.

“We’ve spent a great deal of time trying to determine the best way to utilize all the money that we have raised, and our prayers were answered with Highmark and Allegheny Health Network. They have brought just the sort of energy and focus we need to fulfill our mission,” D’Achille added. A group known as Alexis’ Army meets weekly at AHN’s West Penn Hospital to brainstorm and discuss new models being used to treat PPD.”

“We are very proud and grateful to be a part of Alexis’ Army, and to work in partnership with the Foundation to make a difference in the lives of women suffering from postpartum depression,” said Debbi Linhart, vice president for women’s health initiatives at AHN. “Our vision is to bring this relatively common condition to the forefront and design a new model of care to improve access, early detection and safety, and ultimately to work toward prevention.”

About Allegheny Health Network AHN is a regional and national leader in advanced obstetric and gynecologic care. West Penn Hospital, Jefferson Hospital in Pittsburgh’s South Hills, Forbes Hospital in Monroeville and Saint Vincent Hospital in Erie provide inpatient obstetric care, as well as neonatal intensive care for premature infants. West Penn Hospital’s obstetrics program is recognized by CareChex® a division of leading health care industry analyst Comparion Medical Analytics Inc., as the best in western Pennsylvania for high-quality care, superior outcomes and exceptional patient experience. In addition, state-of-the-art gynecologic care is provided for women of all ages at numerous locations around the region.

CareChex is a registered trademark of Comparion Medical Analytics, Inc.

Today’s cancer care, compared to just a few years ago, is truly amazing. We celebrate with all those who are surviving cancer and living longer, thanks to advancements in technology and treatment. In many ways, cancer has become a chronic disease.

When patients are being treated for cancer, their only concern should be their health. Yet the stress of choosing the right doctors and the right courses of treatment, along with the financial burden of care and trying to tie together all the different parts of their overall care, can get in the way. That’s why we’re working to give our members who are facing cancer a different and better experience with real results: higher quality standards, better health outcomes and lower costs.

Over the next few months, we will share more details on how we will:

• Focus on a patient-centered approach to cancer care across the continuum • Build a team with our network hospitals and world-class clinicians here in our region and, via telemedicine, with those outside the region • Improve quality and value by embracing efforts to decrease unwarranted variation in practice • Further advance care pathways and protocols that promote the best possible outcomes • Provide access to early-phase clinical trials and cutting-edge care with world- renowned clinicians

Watch for more information over the next few months.

A directive issued by the state of Pennsylvania requires 3D mammograms, or “Digital Breast Tomosynthesis (DBT)” mammograms, to be covered by insurance under existing state law. These mammograms must be provided to women in accordance with the terms of your coverage.

DBT is a three-dimensional (3D) view of the breast using X-ray technology, where the X-ray tube moves in an arc around the stabilized breast, and these images (slices) are then sent to a computer to produce the three-dimensional image.

Both 3D and standard mammograms must be covered in the same way under this directive according to your benefits and Highmark’s latest medical policy.

For members who had a 3D mammogram from Oct. 5, 2015 forward, claims may be denied until our systems are updated. We are now working to update our systems. Claims for 3D mammograms will be adjusted in the near future, subject to your benefit plan, to reflect the new directive. Your employees do not need to call Member Service.

Screening and Diagnostic Mammograms Screening mammography is an X-ray of the breast used to detect possible breast cancer in patients with no signs or symptoms of disease.

Diagnostic mammography is an X-ray used to look more closely at a finding in a screening mammography or used when a patient has other signs or symptoms or a history of cancer.

We encourage your employees to talk to their doctors for recommendation about which type of mammogram is right for their needs. Have Questions? Contact your Highmark representative with any questions. Your employees can call the toll-free number on the back of their member ID cards with questions.

On Jan. 1, 2016, our pharmacy network is changing. We’re making these changes to align our network more closely with national industry standards and give us greater buying power for greater cost savings for most of our clients.

What’s Changing? Premier is becoming National Plus network.

• This is our broadest network, open to any pharmacy that agrees to our terms and pricing. • There will be no major changes for 2016, although some smaller independent pharmacies will no longer be in-network.

Premier 2012 is becoming National network.

• This broad network includes most large chain pharmacies, as well as many independent pharmacies. • The most significant change is that Target will be part of the National network. The impact of this is still unknown in light of the recent CVS acquisition of Target pharmacies. More details will be provided as they become available. • Some smaller independent pharmacies will no longer be in-network.

Focused is becoming Advantage network.

• We anticipate that members in this network will experience the most disruption. • The most significant change is that Target and Rite Aid will be in-network and CVS and The Medicine Shoppe will no longer be in-network. Again, at this time we are not sure of the impact that the CVS acquisition of Target will have, as well as the proposed Walgreen’s acquisition of Rite Aid. We will provide more information as it becomes available. • Some smaller independent pharmacies will no longer be in-network.

How These Changes Affect You and Your Employees As mentioned earlier, these changes mean that some pharmacies your employees currently use for their prescriptions will no longer be in-network. These individuals will need to switch to in-network pharmacies to get the most savings on their prescriptions.

We are sending letters to your employees who are affected by this change to let them know that our network is changing and that they should consider switching to in-network pharmacies, as well as give directions to help them find new pharmacies online.

All they need to do is call or visit their new network pharmacy and provide the pharmacist with their information to transfer their prescriptions. They will not have to go to their doctors for new prescriptions.

If you have any questions, contact your Highmark representative.

Highmark Blue Cross Blue Shield continues to address the rising costs and utilization of prescription drugs through its Prescription Drug Clinical Management programs. These programs are critical to your group’s effective management of its prescription drug benefit as they contribute to health care quality and accessibility to drug coverage for your group members.

The changes listed below affect your group members enrolled in the following health care plans, if they have drug benefits with management programs administered by Highmark Health Services: Keystone Blue HMO, PPO Blue, BCBS PPO (BlueCard® PPO), Direct Blue®, EPO Blue, BCBS EPO (BlueCard EPO), Classic Blue® Traditional, Classic Blue Comprehensive, Security BlueSM HMO and Freedom BlueSM PPO.

Prior Authorization Program* The following policies have been added to the Prior Authorization Program:

Effective Oct. 15, 2015, for all Commercial Products and Upon Centers for Medicare & Medicaid Services (CMS) Approval for all Medicare Products

• Entresto™: Sacubitril/valsartan (Entresto) is indicated to reduce the risk of cardiovascular death and hospitalization for heart failure in patients with chronic heart failure (HF) (NYHA Class II-IV) and reduced ejection fraction. Approval criteria include parameters such as systolic dysfunction, concomitant beta- blocker use, and no concomitant use of ACE inhibitors or another ARB.

• Orkambi™: Lumacaftor/ivacaftor (Orkambi) is indicated for the treatment of cystic fibrosis in patients 12 years and older who are homozygous for the F508del mutation in the CFTR gene. • Odomzo®: Sonidegib (Odomzo) is indicated for the treatment of adult patients with locally advanced basal cell carcinoma (IaBCC) that has recurred following surgery or radiation therapy, or those who are not candidates for surgery or radiation therapy.

• Viberzi™: Eluxadoline (Viberzi) is a mu-opioid receptor antagonist, indicated for the treatment of adults with irritable bowel syndrome with diarrhea (IBS-D). Approval criteria include parameters to ensure members do not have hepatic impairment and who have abstained from alcohol or illicit drug use in the past six months.

• Keveyis™: Dichlorphenamide (Keveyis) is indicated for primary hyperkalemic or hypokalemic periodic paralysis, and related variants in adult patients.

• Addyi™: Filbanserin (Addyi) is indicated for the treatment of premenopausal women with acquired, generalized hypoactive sexual desire disorder (HSDD). Approval criteria include parameters that ensure appropriate use, and that HSDD is not related to coexisting medical or psychiatric conditions, substance abuse or relationship issues, and requirement of trial and failure of behavioral therapy for HSDD, if a covered benefit.

Effective Upon CMS Approval for all Medicare Products

• Entyvio®: Vedolizumab (Entyvio) is indicated for Ulcerative Colitis (UC) and Crohn’s Disease (CD). Approval criteria include trial and failure of one preferred subcutaneous TNF-blocker biologic agent (Humira or Remicade).

• Cerdelga®: Eliglustat (Cerdelga) is indicated for the treatment of adults with type 1 Gaucher disease (GD1) who are CYP2D6 extensive metabolizers (Ems), intermediate metabolizers (IMs) or poor metabolizers (PMs) as determined by an FDA-cleared test. This new policy for all Medicare products was created due to more restrictive changes made to the old combination commercial and Medicare policy. Approval criteria include appropriate quantity limits based on type of metabolizer.

The following represent policy revisions:

Effective Oct. 15, 2015, for all Commercial Products and Upon CMS Approval for all Medicare Products

• Testosterone (Androgens): The Commercial and Medicare policies for testosterone (Androgens) products were updated to include recently approved testosterone kit (Testone CIK), and to clarify that lab values are not required for members with double orchiectomy.

• EGFR Tyrosine Kinase Inhibitors: The policy was updated to include criteria for gefitinib (Iressa), indicated as first-line treatment for patients with metastatic non-small cell lung cancer (NSCLC) whose tumors have epidermal growth factor receptor (EGFR) exon 19 deletion or exon 21 (L858R) substitution mutations as detected by an FDA-approved test.

• Thrombopoiesis Stimulating Agents: The policy was updated with an additional indication for eltrombopag (Promacta) use in pediatric patients age 1 year and older, for the treatment of idiopathic thrombocytopenia purpura and inclusion of the newly approved oral suspension formulation.

• Movantik™ (naloxegol): The policy will be removed, as utilization review reflects appropriate prescribing and use with low risk of abuse potential and off- label use, given the specific FDA-approved indication for use of opioid-induced constipation (OIC) in adult patients with chronic non-cancer related pain.

Effective Immediately for all Commercial and Medicare Products

• Cerdelga® (eliglustat): The policy was revised for all commercial products to include appropriate quantity limits based on type of metabolizer. Eliglustat (Cerdelga) is indicated for the treatment of adults with type 1 Gaucher disease (GD1) who are CYP2D6 extensive metabolizers (EMs), intermediate metabolizers (IMs) or poor metabolizers (PMs) as determined by an FDA- cleared test.

• Zydelig® (idelalisib): The policy was revised to be in line with FDA-approved labeling that member should be at least 18 years of age for use of idelalisib. Idelalisib (Zydelig) is indicated for relapsed chronic lymphocytic leukemia (CLL), relapsed follicular B-cell non-Hodgkin lymphoma (FL) and relapsed small lymphocytic lymphoma (SLL).

• Kalydeco® (ivacaftor): The policy was updated to reflect the expanded indication for patients 2 years of age and older with cystic fibrosis (CF) who have one of the following mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, as confirmed by an FDA-accepted CF mutation test: G551D, G1244E, G1349D, G178R, G551S, S1251N, S1255P, S549N or S549R.

• Hetlioz® (tasmelton): The policy was updated with approval duration of six months for commercial members, requiring renewal of authorization after six months, with clinical information that the medication is effective and has minimal side effects. Hetlioz is indicated for the treatment of Non-24-hour Sleep-Wake Disorder.

• Hepatitis C Products: The Commercial and Medicare policies for hepatitis C products were updated with added criteria for Technivie, a new hepatitis C medication, indicated in combination with ribavirin for the treatment of chronic hepatitis C genotype 4 infection without cirrhosis. In addition, coverage criteria were added for Harvoni plus ribavirin for genotype 3. • PCSK9 Inhibitors: The Commercial and Medicare policies were updated based on FDA-approved indications for alirocumab (Praluent) and evolocumab (Repatha). Alirocumab (Praluent) is indicated as adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease (ASCVD), who require additional lowering of LDL cholesterol (LDL-C). Evolocumab (Rapatha) is indicated as adjunct to diet and maximally tolerated statin therapy for the treatment of adults with homozygous familial hypercholesterolemia, heterozygous familial hypercholesterolemia or clinical ASCVD who require additional lowering of LDL-C.

• Homozygous Familial Hypercholesterolemia (HoFH): The Commercial and Medicare policies were updated to require step therapy through evolocumab (Repatha) prior to use of lomitapide (Juxtapid) or mipomersen (Kynamro). Lomitapide (Juxtapid) is indicated as an adjunct to a low-fat diet and other lipid- lowering treatments, including LDL apheresis where available, to reduce low- density lipoprotein cholesterol (LDL-C), total cholesterol (TC), apolipoprotein B (apo B) and non-high-density lipoprotein cholesterol (non-HDL-C) in patients with homozygous familial hypercholesterolemia (HoFH). Mipomersen (Kynamro) is indicated as an adjunct to a low-fat diet and other lipid-lowering medications to reduce LDL-C, TC, apo B and non-HDL-C in patients with HoFH.

Effective upon CMS Approval for all Medicare Products

• New to Market Drug Policy: The New to Market Drug Policy defines the criteria under which coverage for a new to market drug will be considered under the prior authorization request process. The criteria for Medicare products were updated to clarify that for Medicare Part D, approval under this policy is pending CMS RxCUI Submission.

Effective Date to be Determined for all Commercial Products

• Pulmonary Arterial Hypertension: This policy was revised to include step therapy criteria for trial and failure of sidenafil 20 mg prior to Revatio (sildenafil) and Adcirca (tadalafil) use for new start members.

Effective Immediately for all Commercial Products

•Humira® (adalimumab): Policy quantity limitations were revised to include added approval criteria of weekly dosing for rheumatoid arthritis (RA) patients not receiving methotrexate.

• Fertility: The policy was revised to remove language that male partners must be fertile and potent for certain fertility products indicated for the treatment of ovulatory failure in infertile women under the age of 35, unable to conceive after 12 months of regular unprotected intercourse (or six months for women over 35 years of age).

• Fertility (ASO Groups): The policy was updated to mirror the policy for the fully insured business, which will be used for all ASO groups.

Managed Rx Coverage (MRxC) Program*

New policy additions:

Effective Dec. 1, 2015, for all Commercial Products and Jan. 1, 2016, for all Commercial Health Care Reform (HCR ) Products

• New policies were created to promote the use of generic alternatives for these products: ◦ Naproxen/esomeprazole (Vimovo®) ◦ Ibuprofen/famotidine (Duexis®) ◦ Cyclobenzaprine (Amrix® & Fexmid®) ◦ Prednisone (Rayos®) ◦ Brand Metformin

Policy revisions:

Effective Oct. 15, 2015, for all Commercial Products and upon CMS Approval for all Medicare Products

• Atypical Antipsychotics: The policy was revised to add brexipiprazole (Rexulti) based on FDA-approved and medically accepted indications, for the treatment of schizophrenia and as adjunctive treatment of major depressive disorder (MDD).

Effective Immediately for all Commercial and Medicare Products

•Egrifta® (tesamorelin): The duration of approvals was changed from a lifetime authorization to 12 months. Tesamorelin (Egrifta) is indicated for reduction of excess abdominal fat in HIV-infected patients with lipodystrophy.

Quantity Level Limit Program*

• Effective Oct. 15, 2015, for Commercial products: Adipx-P, Addyi, benzphetamine, Bontril, Daklinza, diethylpropion, diethylpropion ER, Egrifta®, Entresto, Iressa, Keveyis, Orkambi, Praluent, Qsymia, Rapatha, Rexulti, Ritalin, Saxenda, Suprenza, Technivie, Viberzi, Xenical • Effective Nov. 1, 2015, for Medicare products: Daklinza, Entresto, Iressa, Keveyis, Orkambi, Praluent, Rapatha, Rexulti, Technivie, Viberzi, Xenical

Formulary Updates — Product Removals Effective Jan. 1, 2016

Commercial Comprehensive and Comprehensive Health Care Reform (HCR):

All Commercial Comprehensive Products

Actonel®, Acular® LS, Aggrenox®, Analpram-HC®, Antabuse®, Aricept®, Aricept® ODT, Atelvia®, Avodart®, Betapace AF®, Canasa®, Catapres-TTS®, Delatestryl®, Depo®-Testosterone, Finacea®, Fioricet®, Imdur® ER, Imitrex® vial, Iopidine®, Isochron™, Mepron® suspension, Methergine®, Miacalcin®, Namenda®, Nexium®, Prevpac®, Rosula®, Rythmol®, Suprax® oral susp, Targretin®, Vfend®, Vospire ER®, Zyvox®

Commercial Comprehensive Products with Incentive Formulary:

Fuzeon®

Commercial Comprehensive Products With Closed Formulary:

Venlafaxine ER tablets

All Commercial Comprehensive — HCR Products:

Accolate®, Aldactazide®, Avandamet®, Avandaryl®, Avandia®, Dibenzyline®, Elixophyllin®, Glyset®, PrandiMet®, Surmontil®

Progressive and Progressive Health Care Reform (HCR)

All Commercial Progressive Products:

FML® eye drops, Fuzeon®, Gastrocrom®, Rilutek®, Suprax® oral susp., Temodar®, venlafaxine HCl ER

All Commercial Progressive — HCR Products:

Acitretin, aminocaproic acid, Anucort-HC™, atovaquone, Avar™ cleanser, calcipotriene cream and ointment, calcipotriene-betamethasone DP ointment, calcitrene ointment, calcitriol ointment, carbidopa-levodopa-entacapone, cefpodoxime proxetil, ceftibuten, clindamycin palmitate, clindamycin pediatric, clobetasole emulsion, clobetasol propionate foam/cream/shampoo/spray, clomipramine HCl, Compro, diflorasone diacetate cream/ointment, dihydroergotamine mesylate, doxercalciferol, dronabinol, entacapone, ergoloid mesylates, felbamate, Gris-Peg®, GRX® Hicort 25, hydrocodone/acetaminophen solution, isomethept-caffeine-acetaminophen, ketoconazole, Ketodan™, lansoprazole-amoxicillin-clarithromycin, levalbuterol vial, lidocaine HC Kit, lidocaine patch, malathion, mefenamic acid, mesalamine kit, metformin ER 1000mg, methamphetamine HCl, methylergonovine maleate, Migergot®, modafinil, moxifloxacin HCl, Myorisan™, paromomycin sulfate, prochlorperazine maleate suppositories, propafenone, sevelame, carbonate, sirolimus, sulfadiazine, sumatriptan cartridges/injectors/spray/vials, tiagabine, tinidazole, tranexamic acid, tretinoin microsphere gel, vancomycin capsules, Zenatane™.

*All effective dates are tentative and subject to delay pending internal review or CMS approval. Policies will not become effective earlier than the dates listed above.

BlueCard®, Direct Blue® and Classic Blue® are registered marks of the Blue Cross and Blue Shield Association.

Keystone Blue, PPO Blue, EPO Blue, Security Blue and Freedom Blue are service marks of the Blue Cross and Blue Shield Association.

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Highmark Blue Cross Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association.