Blue Rx Value Formulary Effective 12/01/2016 INTRODUCTION The Blue Rx Value formulary is a list of drugs covered under your pharmacy benefit and developed to serve as a guide for physicians, pharmacists, healthcare professionals and members in the selection of cost-effective drug therapy. Wellmark recognizes that drug therapy is an integral part of effective health management. The vast availability of drug options, however, warrants a reasonable program for drug selection and use. Wellmark continually reviews new and existing drugs to ensure the formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited to safety, efficacy and cost-effectiveness data, as well as comparison of relevant benefits of similar prescription or over-the-counter (OTC) agents while minimizing potential duplications. The formulary is a continually reviewed and modified document that represents covered drugs under your pharmacy benefit. This dynamic process does not allow this document to be completely accurate at all times. To accommodate regular changes, an updated electronic version of this formulary is available online at www.Wellmark.com. Wellmark welcomes your input and feedback on the information provided in this document. FORMULARY OVERVIEW The Blue Rx Value formulary is continually changing to reflect new advances in drug treatment therapies and current practices of Wellmark providers. Due to the rapidly changing environment, this process ensures appropriate formulary review and tier placement. To continue to provide sustainable pharmacy benefits and access to needed cost-effective treatments, concentrated evaluation and analysis of drug products in formularies is accomplished through this process. Wellmark has developed the Pharmacy and Therapeutics Committee (P&T) to ensure all drugs in the Blue Rx Value formulary and new drugs approved by the United States Food and Drug Administration (FDA) are reviewed by licensed physicians actively practicing medicine in Iowa and South Dakota. In addition, the process allows P&T members the opportunity to receive evidence-based clinical data and make clinical recommendations for formulary placement and utilization management. The entire Wellmark formulary is reviewed annually by P&T including all new drugs approved by the FDA. Wellmark Blue Cross and Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. Revision date 11/30/2016 ©2016 Wellmark, Inc. 1 The P&T includes licensed physicians and pharmacists. These clinicians serve in an evaluation, education and advisory capacity to the Wellmark Pharmacy program specific to the coverage and limitations of drugs on the Wellmark formularies. Through review and discussion, P&T votes whether the drug or drug class is therapeutically unique, similar or inferior to existing treatment options. In addition, the P&T makes utilization management recommendations to Wellmark for consideration when there are therapeutically interchangeable alternatives. The P&T meets quarterly to evaluate drugs requested for addition to the Wellmark formularies, reviews existing drugs in the Wellmark formularies and establishes recommendations for utilization management. HOW TO READ THE FORMULARY All drugs are listed by their generic names and/or most common proprietary (brand) name. Specific drug listings may be accessed either by generic (in lowercase) or brand name (in uppercase) and by therapeutic drug tier. Any drug not found in this formulary listing, or any formulary updates published by Wellmark, shall be considered excluded from your benefit. Once the product is located, the following items can be viewed: Drug Tier: Drugs are categorized within two tiers on the formulary. Each tier is assigned a cost, which is determined by the member's pharmacy benefit plan. Please refer to table below, or reference your summary plan document (SPD). You may refer to the formulary as a guide to select the most appropriate drugs and associated cost share. Tier Designation in Formulary Below Tier 1 Tier 2 Value 2 Tier X X Value 1 Tier X Specialty Drugs (SP-P): Specialty drugs are high-cost injectable, infused, oral or inhaled drugs for the ongoing treatment of a chronic condition. These drugs generally require close supervision and monitoring of the patient's drug therapy. Specialty drugs may be categorized within tiers on the formulary or as drugs covered under your medical benefit. • Specialty Drugs Preferred (SP-P): Drugs in this category will process with the preferred specialty drug cost-share. Specialty pharmacies specialize in the delivery and clinical management of specialty drugs. Wellmark has two preferred specialty pharmacy providers: Caremark Specialty Pharmacy and Hy-Vee Pharmacy Solutions. You can find more information about their services at www.Wellmark.com. Drug Name: This lists the generic name for the product (lowercase) OR the brand name or common reference name for the product (UPPERCASE). Requirements/Limits: This lists Wellmark Pharmacy programs that may Wellmark Blue Cross and Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. Revision date 11/30/2016 ©2016 Wellmark, Inc. 2 impact a particular drug or class of drugs and are described below: • Prior Authorization (PA): This indicates a drug requires prior authorization before it is covered under your benefit. Your health care provider will need to contact our Pharmacy program at 1-800-600-8065. Hours of operation are Monday - Friday: 8 a.m. to 6 p.m. CST Prior authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Wellmark. If the request does not meet the approved criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. A list of edits recommended by Wellmark is available upon request. Members should call Wellmark Customer Service at the number listed on the back of their ID card if they have questions regarding their specific coverage. • Quantity Limits (QL): Wellmark typically covers a 30-day supply for prescriptions per co-pay. Some drugs, however, have a quantity limit. Amounts over the specified quantity limits are not a covered benefit. Quantity limits are in place to ensure the drug is being used correctly and other treatments are not appropriate. Most people would not need to take these drugs more often than what Wellmark allows. No special steps are necessary by the physician or member to have these drugs covered as long as the drugs prescribed do not exceed quantity limits. A few drugs may also require prior authorization (for example, Viagra). If you require one of these drugs in a larger quantity than is allowed, your physician may make a special request for coverage. Your physician may be asked to provide details about your medical condition and treatment plan. After reviewing the information, coverage will be evaluated based on medical necessity. Your benefits certificate, coverage manual, or policy has specific information about your plan's prior authorization requirements. • Preventive Drugs (PV): Preventive drugs are defined by the Internal Revenue Service, and your deductible obligation may be waived for these drugs. Preventive drugs are prescribed to prevent the occurrence of a disease or condition with risk factors such as high blood pressure, high cholesterol, diabetes, asthma, heart attack and stroke, or to prevent the recurrence of the disease or condition for individuals who have recovered. Preventive drugs do not include drugs used to treat an existing illness, injury or condition. For some pharmacy plans that require you to pay a certain amount before the plan coverage begins, preventive drugs may be covered before you reach that amount. To be sure, you should read your enrollment information to see how preventive drugs are covered specific to your plan. Wellmark Blue Cross and Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. Revision date 11/30/2016 ©2016 Wellmark, Inc. 3 • Generic Available (GA): Indicates a generic equivalent is available for a brand name drug. In most cases, when you purchase a brand name drug that has an FDA-approved "A"-rated generic equivalent, Wellmark will pay only what it would have paid for the equivalent generic drug. You will be responsible for your payment obligation for the equivalent generic drug and any remaining cost difference up to the maximum allowed fee for the brand name drug. HEALTH CARE REFORM PREVENTIVE DRUGS Preventive drugs with an "A" or "B" rating in the current recommendations of the United States Preventive Services Task Force (USPSTF) and immunizations as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention are not associated with any cost share for members on plans with this benefit. A complete list of recommendations and guidelines related to preventive services can be found at Healthcare.gov. Recommended preventive items and services are subject to change and are subject to medical management. HOW TO READ YOUR FORMULARY BENEFIT COVERAGE AND LIMITATIONS This printed formulary does not define benefit coverage and limitations. Many members have specific benefit inclusions, exclusions, copayments or a lack of coverage, which are not reflected in the Blue Rx Value formulary. Members should contact their Plan Sponsor or Wellmark Customer Service at the number on the back of their ID card if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes Wellmark Blue Cross and Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. Revision date 11/30/2016 ©2016 Wellmark, Inc. 4 can occur throughout the year. The following topics may or may not be applicable depending on the parameters of your specific benefits. FORMULARY EXCEPTION PROCESS Drugs not included in this list shall be considered non-formulary and are NOT COVERED. In some instances, Wellmark will consider coverage exceptions.