For members enrolled in an IBC prescription drug program, prior authorization and quantity limit requirements will be applied to certain drugs. The purpose of prior authorization is to ensure that drugs are medically necessary and are being used appropriately. Quantity limits are designed to allow a sufficient supply of medication based upon the maximum daily dose and length of therapy approved by the U.S. Food and Drug Administration for a particular drug. The most recent updates are reflected below.

Drugs requiring prior authorization

The prior authorization requirement for the following non-formulary drugs was effective at the time the drugs became available in the marketplace: Brand Generic drug Drug category Effective date Actemra^® SC Not available Bone, Joint, & Muscle November 1, 2013 Adempas^® Not available Heart, Blood Pressure, & Cholesterol October 11, 2013 Breo? Ellipta? Not available Allergy, Cough & Cold, Lung Meds July 12, 2013 Brintellix^® Not available Pain, Nervous System, & Psych October 11, 2013 Gilotrif? Not available Cancer & Organ Transplant Drugs August 23, 2013 Opsumit^® Not available Heart, Blood Pressure, & Cholesterol October 25, 2013

The following drugs have been added to the list of drugs requiring prior authorization. Members taking these drugs prior to the effective date are not affected. Brand drug Generic drug Drug category Effective date Advate^® Not available Diagnostics & Miscellaneous Agents April 1, 2014 Alphanate^® Not available Diagnostics & Miscellaneous Agents April 1, 2014 Alphanine^® SD Not available Diagnostics & Miscellaneous Agents April 1, 2014 Androgel^® Not available Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones April 1, 2014 Bebulin^® Not available Diagnostics & Miscellaneous Agents April 1, 2014 Belviq^® Not available Pain, Nervous System, & Psych April 1, 2014 BeneFIX^® Not available Diagnostics & Miscellaneous Agents April 1, 2014 Feiba^® Not available Diagnostics & Miscellaneous Agents April 1, 2014 Helixate^® FS Not available Diagnostics & Miscellaneous Agents April 1, 2014 Hemofil^® M Not available Diagnostics & Miscellaneous Agents April 1, 2014 Humate-P^® Not available Diagnostics & Miscellaneous Agents April 1, 2014 Koate^®-DVI Not available Diagnostics & Miscellaneous Agents April 1, 2014 Kogenate^® FS Not available Diagnostics & Miscellaneous Agents April 1, 2014 Letairis^® Not available Heart, Blood Pressure, & Cholesterol April 1, 2014 Monoclate-P^® Not available Diagnostics & Miscellaneous Agents April 1, 2014 Mononine^® Not available Diagnostics & Miscellaneous Agents April 1, 2014 Novoseven^® RT Not available Diagnostics & Miscellaneous Agents April 1, 2014 Profilnine^® SD Not available Diagnostics & Miscellaneous Agents April 1, 2014 Recombinate? Not available Diagnostics & Miscellaneous Agents April 1, 2014 Rixubis? Not available Diagnostics & Miscellaneous Agents April 1, 2014 Tracleer^® Not available Heart, Blood Pressure, & Cholesterol April 1, 2014 Tyvaso^® Not available Heart, Blood Pressure, & Cholesterol April 1, 2014 Valchlor? Not available Cancer & Organ Transplant Drugs April 1, 2014 Ventavis^® Not available Heart, Blood Pressure, & Cholesterol April 1, 2014 Wilate^® Not available Diagnostics & Miscellaneous Agents April 1, 2014 Xyntha^® Not available Diagnostics & Miscellaneous Agents April 1, 2014 Zohydro? ER Not available Pain, Nervous System, & Psych When drug becomes available

Drug no longer requiring prior authorization

Effective February 1, 2014, prior authorization was removed for the following drug: Brand drug Generic drug Drug category Rozerem^® ramelteon Pain, Nervous System, & Psych

Drugs with quantity limits

Effective April 1, 2014, quantity limits will be added for the following drugs: Brand drug Generic drug Quantity limit Actemra^® SC Not available 3.6 ml per 30 days Depo-Provera^®
104 mg, 150 mg medroxyprogesterone
acetate 1 vial/syringe per 90 days (applies to both brand and generic) Esomeprazole
Strontium Not available 30 caps per 30 days Nuvaring^® Not available 1 ring per 30 days Ortho Evra^® Patch Not available 3 patches per 30 days Zohydro? ER Not available 6 per 30 days (when drug becomes available)