Alameda Alliance for Health SPECIALTY PHARMACY PROGRAM FOR ALLIANCE MEDI-CAL AND GROUP CARE MEMBERS PROGRAM DESCRIPTION

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1 Alameda Alliance for Health SPECIALTY PHARMACY PROGRAM FOR ALLIANCE MEDI-CAL AND GROUP CARE MEMBERS PROGRAM DESCRIPTION Contents Page Program Overview 1 Process for Obtaining Authorization 2 Contacts 2 Medication Request Form 3 Specialty Pharmacy Program Drug List 4 Alliance Specialty Pharmacy Program Overview: Effective September 1, 2010, Diplomat Specialty Pharmacy (Diplomat) is the Alliance s specialty pharmacy for Alliance Medi-Cal and Group Care programs. (Specialty drug orders for Alliance CompleteCare members can be filled by Diplomat, or any other Alliance-contracted pharmacy.) Attached to this program description is the list of drugs that Diplomat is providing under this program. Diplomat is the only pharmacy that can fill the drugs on this list for Alliance Medi-Cal and Group Care members. Retail pharmacies may not dispense these drugs. Providers (including physicians, hospitals, infusion centers, and dialysis centers) can, however, continue to purchase specialty drugs directly from manufactures and wholesalers. The benefits of using Diplomat Specialty Pharmacy include: There are no up-front costs for specialty drugs or medication supplies, such as needles. Convenient FREE delivery of specialty drugs to your patients homes or to your office. Diplomat offers proactive renewal on all medications. You can continue to bill the Alliance your administration fee.

2 Process for Obtaining Specialty Drugs from Diplomat for Alliance Medi-Cal and Group Care Members: Starting September 1, 2010, prior authorization is required for new specialty drug orders and for renewals. The same review process is used for specialty drug orders as is used for other drugs that require prior authorization. Please fax the attached Medication Request Form to PerformRx at or call PerformRx at PerformRx will process the request within 72 hours (for urgent requests) or 14 days (for routine requests) and notify your office and Diplomat of the decision. Upon PerformRx s approval, Diplomat will call your office to obtain the prescription and dispense the drug by mail. Diplomat can be reached at Contacts for Additional Information: Call Diplomat toll-free at for: o A complete list of specialty drugs provided by Diplomat o Questions related to dispensing of the drugs Call PerformRx toll-free at for prior authorization-related questions Call Alliance Pharmacy Services at for any other specialty pharmacy related questions Alameda Alliance for Health - Specialty Pharmacy Program Description Last Updated: January

3 Alameda Alliance for Health Medication Request Form Attn: Prior Authorization Department 200 Stevens Drive Philadelphia, PA Phone (Medi-Cal/Group Care): Phone (AllianceSELECT): Fax: Instructions: This form is to be used by participating providers to obtain coverage for a formulary drug with PA guideline, other restrictions, or a nonformulary drug for which there is no suitable alternative available. Please complete this form and fax it to PerformRx at or call with this information. If you have any questions regarding this process, please contact PerformRx s Provider Service Line at for Medi-Cal/Group Care and for AllianceSELECT. Urgent Request (Must be reserved for requests that, in the provider s best professional judgment, are potentially life threatening or pose a significant risk to the continuous care of the patient.) Patient Name Patient DOB Patient ID Number Prescriber Name Specialty Prescriber Phone Prescriber Fax NPI# Prescriber Address Pharmacy Name Pharmacy Phone Pharmacy Fax Medication Name and Strength Requested: Brand Medically Necessary request (Rationale required below) Directions: Quantity Requested: Anticipated Length of Therapy: Days 3 Months 6 Months 12 Months Diagnosis: Preferred Medications tried/previous therapy, please include strength, frequency and duration: Rationale and/or additional information, which may be relevant to the review of this prior authorization request: Prescriber Signature Date Please Fax Completed Form to Alameda Alliance for Health Medication Request Form Revised

4 Alliance Medi-Cal and Group Care Specialty Pharmacy Program Drug List Effective: January 1, 2014 The following list reflects drugs that are a part of the Alameda Alliance for Health Specialty Pharmacy Program. This program applies to Alliance Medi-Cal and Group Care only. Providers (including physicians, hospitals, dialysis centers, and infusion centers) can order the drugs on this list from a drug distributor or from Diplomat Specialty Pharmacy (Diplomat). Retail pharmacies may not dispense these drugs. Diplomat is the only pharmacy that can dispense these drugs. Prior authorization is required for the drugs on this list. Please submit a Prior Authorization Form to PerformRx via fax at or call PerformRx at Upon approval, Diplomat will contact the ordering physicians office for prescription. The list is sorted by drug class and most common brand name. This list is subject to change. Please visit to for updates. Antibacterials Colistimethate Coly-Mycin M Coly-Mycin S Antiemetics Aloxi Anzemet Antifungals Cancidas Vfend Antithrombotic Agents Activase Cathflo Activase Integrilin Blood Cell Deficiency Leukine Neulasta Neumega Neupogen Bones Resorption Inhibitors Prolia Xgeva Zoledronic Acid Zometa CMV Cidofovir Cytovene Valcyte Growth Hormone Genotropin Humatrope CRT Increlex Nordiflex Norditropin Nutropin Nutropin AQ Omnitrope Serostim Tev-Tropin Hemophilia Alphanate AlphaNine SD Bebulin VH BeneFix Feiba NF Hemofil Humate-P Koate DVI Kogenate FS Bio Set Kogenate FS Monoclate-P Mononine NovoSeven RT Profilnine SD Recombinate Recombinate w/baxjet Wilate Xyntha AHF Xyntha Intravenous Kit Xyntha Solofuse Intravenous Hepatitis B Tyzeka Viread Hepatitis C Incivek Infergen Intron A Pegasys Pegasys Proclick PegIntron RediPEN Rebetol RibaPak Ribasphere Ribavirin Victrelis Hormonal Therapy Danazol Delestrogen Immune Deficiencies Carimune NF Flebogamma DIF Gammagard LIQ Gammagard S/D less IgA Gammagard SD Gammaked Gammaplex Gamunex-C Hizentra Octagam Privigen WinRho SDF Liquid Lysosomal Storage Disorders Aldurazyme Elaprase Fabrazyme Multiple Sclerosis (MS) Ampyra Aubagio Avonex Pen Avonex PFS Avonex SDV Celestone Soluspan Copaxone Extavia Gilenya Rebif Rebidose Rebif titration pack Rebif Tecfidera Oncology Abraxane Adcetris Adriamycin Adrucil Alimta Alkeran Amifostine IV Arimidex Aromasin Arranon Arzerra Avastin Bicnu Bleomycin Bosulif Busulfex Camptosar Carboplatin CeeNU Cerubidine Cisplatin Cladribine Clolar Cometriq Cosmegen Cyclophosphamide Cytarabine Dacarbazine Dactinomycin Daunorubicin Dexrazoxane Diplomat is able to provide other drugs that are not listed here. For a complete list of drugs, contact Diplomat at To check the status of prior authorization requests, contact PerformRx at For questions about the specialty pharmacy program, please contact Alliance Pharmacy Services at Pg 1 of 2

5 Alliance Medi-Cal and Group Care Specialty Pharmacy Program Drug List Effective: January 1, 2014 The following list reflects drugs that are a part of the Alameda Alliance for Health's Specialty Pharmacy Program. This program applies to Alliance Medi-Cal and Group Care plans only. Providers (including physicians, hospitals, dialysis centers, and infusion centers) can order the drugs on this list from a drug distributor or from Diplomat Specialty Pharmacy (Diplomat). Retail pharmacies may not dispense these drugs. Diplomat is the only pharmacy that can dispense these drugs. Prior authorization is required for the drugs on this list. Please submit a Prior Authorization Form to PerformRx via fax at or call PerformRx at Upon approval, Diplomat will contact the ordering physicians office for prescription. The list is sorted by drug class and most common brand name. This list is subject to change. Please visit to for updates. Oncology continued Docefrez DOCEtaxel Doxil Doxorubicin Eligard Ellence Eloxatin Elspar Emcyt Epirubicin Erbitux Erivedge Etopophos Etoposide Fareston Faslodex Floxuridine Fludarabine Fluorouracil IV Flutamide Folotyn Gemcitabine HCL Gemzar Gleevec Halaven Idamycin Ifex Irinotecan Jakafi Leukeran Leuprolide Lysodren Melphalan HCL Mercaptopurine Tabs Methotrexate IV Mitomycin Myleran Nexavar Nipent Octreotide Paclitaxel Pamidronate Pentostatin Pomalyst Revlimid Rituxan Sprycel Stivarga Sutent Sylatron Tarceva Temodar Thalomid Oncology continued TheraCys Topotecan Tretinoin Caps Tykerb Xeloda Yervoy Zaltrap Zanosar Zinecard Zolinza Zytiga Other Aminocaproic Acid Syr Aminocaproic Acid Tab Berinert Botox Buphenyl Decavac Deferoxamine Desmopressin Droperidol Elitek Euflexxa Exjade Eylea Hyalgan Kepivance Leucovorin Mannitol Marcaine Mesalamine Pentam RhoGam Ultra Filtered Plus Rhophylac PFS RiaSTAP Supartz Synvisc Zemplar Parenteral Iron Dexferrum Feraheme Infed Venofer Pulmonary Hypertension Adcirca Alprostadil Sildenafil Rheumatoid Arthritis (RA) Actemra Arava Cimzia Enbrel Gengraf Humira Kineret Leflunomide Neoral Orencia Remicade Xeljanz Transplant Atgam Cellcept IV Cyclosporine Inj Mycophenolate Diplomat is able to provide other drugs that are not listed here. Please contact Diplomat at for a complete list of drugs. To check the status of prior authorization requests, contact PerformRx at For questions about the specialty pharmacy program, please contact Alliance Pharmacy Services at Pg 2 of 2

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