Prior authorization. Member education. Why do some drugs need review and approval? How do I get approval?

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1 Member education Prior authorization Some drugs need to be reviewed before they re covered by your plan. This review helps make sure they re safe and affordable for you. Why do some drugs need review and approval? Most prescriptions are filled right away when you take them to the pharmacy. But, some drugs need to be reviewed by your health plan before they re covered. This process is called prior authorization. It focuses on drugs that may have: Risk of side effects. Risk of harmful effects when taken with other drugs. Potential for incorrect use or abuse. Better options that may cost you less and may work better. Rules for use with certain health conditions. How do I get approval? If your drug needs approval, your pharmacist will receive a message on the pharmacy s computer. This tells them that we need to know a little more about your health. Sometimes, the pharmacist can call us with the information. Then, your prescription is filled. Other times, your doctor calls or faxes us the information. If the information meets your plan s guidelines, the claim is approved. Your doctor or pharmacist lets you know the prescription can be filled. If we need more information, we may contact your doctor directly. If the request to cover your drug is denied, you and your doctor will receive a letter explaining how to appeal it. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association CAMENABC VPOD Rev. 04/14

2 Prior Authorization Drug List Most prescriptions are filled right away when you take them to the pharmacy. But some drugs need to be reviewed by your health plan before they re covered. This process is called prior authorization. Prior authorization focuses on drugs that may have a risk of side effects, a risk of harmful effects when taken with other drugs, potential for incorrect use or abuse, better options that may cost you less and work better, and rules for use with certain health conditions. The drugs listed below need to be reviewed and approved by your health plan before they re covered.* Acromegaly/Cancer treatment Sandostatin Arthritis/Crohn's/Psoriasis Humira Cancer Treatment Blincyto Remicade Cystic Fibrosis Orkambi Arthritis/Psoriasis Enbrel High cholesterol Praluent Simponi Addiction treatment Vivitrol Asthma Xolair Allergy Auvi-Q Benign Prostatic Hyperplasia Cialis Grastek Blood builder Aranesp Oralair Epogen Ragwitek Granix Alpha-1 Proteinase Inhibitor Deficiency Aralast Glassia Leukine Neulasta Prolastin-C Neumega Zemaira Neupogen Anemia Mircera Procrit Antibiotic Xifaxan Blood modifier Nplate Antidiarrheal Fulyzaq Promacta Antihyperlipidemic Juxtapid Blood modifier agent Soliris Antiviral Arthritis Arthritis/Crohn's Disease Kynamro Denavir LidoVir Sitavig Xerese Actemra Euflexxa Hyalgan Kineret Orencia Orthovisc Supartz Synvisc Synvisc-One Xeljanz Xiaflex Cimzia Bone fracture/ Pain due to cancer Cancer treatment Xgeva Adcetris Afinitor Afinitor Disperz Alimta Arimidex Aromasin Arzerra Avastin Beleodaq Bosulif Cometriq Eligard Emcyt Erbitux Erivedge Erwinaze 45233CAMENABC VPOD Rev. 07/15

3 Cancer treatment Femara Cancer treatment Temodar Gazyva Thalomid Gilotrif Trelstar LA, Depot Gleevec Tykerb Gleostine Vantas Implant Halaven Vectibix Herceptin Velcade Hycamtin Votrient Iclusig Xalkori Imbruvica Xeloda Inlyta Xofigo Jakafi Xtandi Jakafi 10 mg Yervoy Jakafi 15 mg Zaltrap Jakafi 20 mg Zelboraf Jakafi 25 mg Zoladex Jakafi 5 mg Zolinza Kadcyla Zykadia Keytruda CAPS/Arthritis Ilaris Kyprolis Cervical Dystonia/Spasticity Botox Lynparza Dysport Mekinist Myobloc Mozobil Xeomin Nexavar Chronic Granulomatous Disease Actimmune Oncaspar Opdivo Perjeta Pomalyst Pomalyst 1 mg Pomalyst 2 mg Pomalyst 3 mg, 4 mg Purixan Revlimid Rituxan Sprycel Stivarga Sutent Tafinlar Tarceva Targretin Tasigna Taxotere Cryopyrin-Associated Periodic Syndrome Cushing s Disease Cushing's Syndrome Cystic Fibrosis Endometriosis Endometriosis /Infertility/ Cancer Excessive sleepiness Eye condition Gastrointestinal Health Gaucher s Disease Arcalyst Signifor Korlym Kalydeco Lupaneta Lupron, Depot Hetlioz Nuvigil Provigil Jetrea Aloxi Cerdelga Ceredase Cerezyme Elelyso Vpriv Zavesca

4 Gout Heart failure Hemophilia Hepatitis Hereditary Angioedema Colcrys Krystexxa Mitigare Corlanor Advate Alphanate Alphanine SD Alprolix Bebulin Benefix Corifact Eloctate Feiba NF Helixate FS Hemofilm Humate-P Koate-DVI Kogenate FS Monoclate-P Mononine Novoeight NovoSeven RT Obizur Profilnine SD Recombinant Recombinate RiaSTAP Rixubis Tretten Wilate Xyntha Harvoni Incivek Intron-A Olysio Pegasys Peg-Intron Sovaldi Victrelis Viekira Berinert Cinryze Firazyr Hereditary Angioedema Kalbitor High cholesterol Simvastatin 80 Hormonal therapy Acthar H.P. AndroGel Axiron Fortesta Testim Androderm 2.5mg Androderm 2mg/24hr Patch Androderm 4mg/24hr Patch Androderm 5mg Osphena Striant Testopel Testosterone Gel/Pump Vogelxo Human Growth Hormone Egrifta Genotropin Humatrope Norditropin Nurtropin AQ Nurtropin AQ NuSpin Nutropin Omnitrope Saizen Serostim Tev-Tropin Zorbtive Huntington's Disease Xenazine Hyperammonemia Agent Ravicti Immune deficiency Increlex Immune system/ Carimune NF Immune globulin Flebogamma GamaSTAN S/D Gammagard liquid, S/D Gamunex Hizentra Octagam Privigen Infection prevention and Cresemba treatment Qualaquin Sivextro

5 Infection prevention and treatment Sporanox Vfend Osteoporosis Zolendronic Acid Forteo Zovirax Cream Prolia Zyvox Pain relief Abstral Interferon Avonex Actiq Kidney transplant Nulojix Embeda Lupus Disease Benlysta Fentora Macular degeneration Eylea Lazanda Lucentis Onsolis Macugen Prialt Macular edema Iluvien Subsys Ozurdex Zohydro Miscellaneous gastrointestinal Gattex Parkinson's Apokyn Miscellaneous respiratory Esbriet Phenylketonuria (PKU) Kuvan Ofev Pompe Disease Lumizyme Mucopolysaccharidosis Aldurazyme Myozyme Elaprase Precocious puberty Supprelin LA Multicentric Castleman's Disease Multiple Sclerosis Multiple Sclerosis Nausea/ vomiting Oncology Opiod dependence Naglazyme Sylvant Ampyra Aubagio Betaseron Copaxone Gilenya Lemtrada Plegridy Tecfidera Tysabri Diclegis Cyramza Zydelig Bunavail Evzio Precocious puberty/ Endometriosis Pre-term delivery prevention Prostate cancer Psoriasis Pulmonary arterial hypertension RSV prevention Seizures/Fibromyalgia/Nerve pain Synarel Makena Provenge Zytiga Stelara Adcirca Flolan Remodulin Revatio Tyvaso Veletri Ventavis Synagis Lyrica Suboxone Zubsolv

6 Skin condition Sleep aid Thyroid cancer Urea Cycle Disorder Treatment Aldara Avage Entyvio Fabior Mirvaso Otezla Picato Solaraze Tazorac Zyclara Xyrem Caprelsa Buphenyl * Due to varying health benefit plans, inclusion of a drug and related items on the drug list is not a guarantee of coverage. Please refer to the prescription drug benefit description of coverage, limitations and exclusions. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.