encourages correct prescription drug use for a particular diagnosis, promotes the safe use of prescription drugs, and helps reduce drug costs.

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1 Prior Authorization Your health plan participates in a Prior Authorization (PA) program for specific prescription drugs. This means that Caremark must review certain information provided by your doctor to determine if benefits can be paid for that drug. The PA program: encourages correct prescription drug use for a particular diagnosis, promotes the safe use of prescription drugs, and helps reduce drug costs. How does the PA process work? The PA program includes a list of prescription drugs that require a review of information received from your doctor to determine if benefits can be paid for that drug. You only need to get the prescription, Caremark works with your doctor and pharmacy do the rest. 1. You get a prescription from your doctor for a drug listed below and give it to a retail pharmacy or mail service. 2. The pharmacy submits the prescription claim online to Caremark. 3. Caremark sends a reply message to the pharmacy explaining that authorization is necessary before benefits can be paid. The message also tells the pharmacy to contact Caremark to start the PA process. 4. The pharmacy begins the PA process. 5. Caremark works with your pharmacist and doctor to get the information needed for the review. 6. Your doctor provides the requested information to Caremark. 7. Caremark reviews the information and sends a letter to you and your doctor to let you know if benefits are approved or denied. If benefits are approved, your regular copays and deductibles will apply. If benefits are denied, you can appeal the denial. For questions regarding the PA program, please contact Caremark Customer Care tollfree at (888) TDD (telecommunications device for the deaf) users please call toll-free (800) The drugs listed below are part of the PA program for HealthSelect SM of Texas members. Caremark updates this list periodically, as it is subject to change if your plan changes. Non Specialty Medications Drug Category/Condition Specific Drugs that require a PA Notes Actinic Keratosis Solaraze Antifungal Jublia, Kerydin Clomid Clomid, Milophene, Serophene Compounded Medication Compounded Medication PA required if $300 or more

2 Neuropathic pain Osteoarthritis Pain Influenza prevention Narcolepsy Lidoderm Voltaren 1% Gel, Pennsaid Solution Relenza, Tamiflu Xyrem PA required if additional quantities are required past the quantity limit Pain Management Oxycontin, Stadol, PA required if additional quantities are required past the quantity limit Pain Management Cont Topical Pain Specialty Medications Abstal, Actiq, Fentora, Lazanda, Onsolis, Subsys, Fentanyl Oral EMLA, Lidocaine gel, Lidocaine Ontiment, Lidocaine Solution, Pliaglis, Synera Drug Category/Condition Specific Drugs that require a PA Retinal Disorders Allergic Asthma Bone Disorders Cryopyrin Associated Periodic Syndromes (CAPS) Neutropenia Coagulation Disorders Cystic Fibrosis Anemia Gastrointestinal Disorders Other Avastin, Macugen, Lucentis, Visudyne, Eylea Xolair Strensiq Arcalyst, Kineret, Ilaris Leukine, Neupogen, Neulasta, Granix Ceprotin Pulmozyme, Tobi, Cayston, Kalydeco, Tobi-Podhaler, Bethkis, Orkambi, Kitabis Pak Aranesp, Procrit, Epogen, Omontys Gattex, Zorbtive Growth Hormone and related disorders Genotropin, Increlex, Nutropin, Omnitrope, Humatrope, Norditropin, Nutropin AQ, Tev-Tropin, Saizen Hematopoietics Hemophilia and related bleeding disorders Hepatitis C HIV Mozobil, Neumega Stimate Infergen, Pegasys, Ribavirin (Copegus, Rebetol, Ribasphere), Intron A, PegIntron, Incivek, Victrelis, Olysio, Sovaldi, Harvnoi Fuzeon, Egrifta, Serostim

3 Hormonal Therapies Firmagon, Lupron, Leuprolide Acetate, Trelstar Dep/LA/Mix, Zoladex, Vantas, Lupron Depot, Eligard, Lupaneta, Aveed, Natpara Idiopathic Pulmonary Fibrosis Ofev, Esbriet Inflammatory Bowel Disease Humira, Remicade, Tysabri, Cimzia, Simponi, Entyvio Immune Therapies Carimune NF, Flebogamma, Gammagard, Gamunex, Octagam, Vivaglobin, Rho(D) immune globulin (RhoGAM, HyperRho, Rhophylac, Win Rho), Cytogam, GamaSTAN SD, Gammaplex, Hizentra, Privigen, Hepatitis B immune globulin (HepaGam B, HyperHep B S/D, Nabi-HB), Bivigam, Hyqvia Infertility Chorionic, ganirelex acetate, Gonal-F, Menopur, Repronex, Cetrotide, Follistim AQ, leuprolide acetate (Lupron), Ovidrel Iron Overload Exjade, Desferal, deferoxamine, Ferriprox Lipid Disorders Juxtapid, Kynamro, Repatha Lysosomal Storage Disorders Adagen, Cystagon, Orgadin, Zavesca, Cystaran, Procysbi, Cerdelga Multiple Sclerosis Avonex, Copaxone, Rebif, Extavia, Gilenya, Betaseron, Mitoxantrone, Ampyra, Tysabri, Aubagio, Tecfidera, Lemtrada, Plegridy

4 Oncology Afinitor, Avastin, Dacogen, Erbitux, Gleevec, Herceptin, Hycamtin Capsules, Intron A, Iressa, Ixempra, Nexavar, Mitoxantrone, Proleukin, Revlimid, Rituxan, Sprycel, Sutent, Tarceva, Tasigna, Temodar, Thalomid, Torisel, Treanda, Tykerb, Vectibix, Velcade, Vidaza, Xeloda, Zolinza, Zometa, Folotyn, Votrient, Arzerra, Istodax, Oforta, Thyrogen, Jevtana, Fusilev, Valstar, Xgeva, Halaven, Yervoy, Sylatron, Vandetanib, Zytiga, Adcetris, Xalkori, Zelboraf, Jakafi, Erwinaze, Elspar, Oncaspar, Inlyta, Erivedge, Voraxaze, Targretin, Perjeta, Kyprolis, Zaltrap, Xtandi, Bosulif, Stivarga, Synribo, Cometriq, Iclusig, Pomalyst, Kadcyla, Mekinist, Tafinlar, Gilotrif, Valchlor Gel, Gazyva, Imbruvica, Keytruda, Blincyto, Opdivo, Lynparza, Ibrance, Unituxin, Iressa, Darzalex, Empliciti, Tagrisso, Venclexta, Tecentriq Osteoporosis Phenylketonuria (PKU) Pre-term Birth Forteo, Prolia, Reclast (zoledronic acid) Kuvan Makena Psoriasis Amevive, Humira, Stelara, Enbrel, Remicade, Otrexup, Otezla, Rasuvo Pulmonary Arterial Hypertension Renal RSV (infant respiratory virus) Rheumatoid Arthritis Adcirca, epoprostenol (Flolan, Veletri), Letairis, Remodulin, Revatio (sildenafil), Ventavis, Tyvaso, Tracleer, Adempas, Opsumit, Orenitram, Uptravi Sensipar, Synagis Cimzia, Enbrel, Humira, Kineret, Orencia, Remicade, Actemra, Simponi, Simponi Aria, Rituxan, Xeljanz, Otezla, Otrezup, Rasuvo Seizure Disorders Acthar, Sabril Sleep Disorders Hetlioz Systemic Lupus Erythematosus (SLE) Benlysta Acromegaly Alcohol & Opioid Dependency octreotide acetate (Sando-statin), Sandostatin LAR, Somavert, Somatuline Depot, Signifor Vivitrol

5 Botulinum Toxins Botox, Myobloc, Dysport, Xeomin Cardiac Disorder Tikosyn Dupuytren s contracture Xiaflex Electrolyte Disorders Samsca Idiopathic Thrombocytopenic Purpura (ITP) Nplate, Promacta Lipodystrophy Myalept Infectious Disease Actimmune, Alferon -N Movement Disorders Apokyn, Xenazine, Nuplazid Pain Management Prialt Gout Therapies Urea Cycle Disorders Paroxysmal Nocturnal Hemoglobin-uria (PNH) Cushing s Syndrome Central Precocious Puberty (CPP) Krystexxa Carbiglu, Ravicti, Buphenyl Soliris Korlym, Signifor Leuprolide Acetate (CPP)(Lupron Depot-Ped), Leuprolide Acetate (CPP)(3month)(Leupron Depot-Ped), Supprelin LA

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