Pharmacy Utilization Management Programs Executive Overview October 2012

1. Pharmacy Utilization Management Programs Executive Overview October 2012

2. Pharmacy Utilization Management • The purpose of this document is to provide an overview of Responsible Rx, Florida Blue’s pharmacy utilization management program. • The document includes following: • Program descriptions • How these programs work • Frequency of program changes • Member notifications, when impacted by program changes • Authorization requests

3. Responsible Rx Programs Responsible Rx is the name of Florida Blue’s pharmacy Utilization Management Program created to support affordable solutions by delivering integrated pharmaceutical and medical services in an optimized manner for our members. Responsible Rx includes the following: • Prior Authorization • Responsible Steps • Responsible Quantity

4. Prior Authorization • The prior authorization program encourages the safe and cost-effective use of medication. Under this program, certain high-cost drugs that have the potential for misuse require prior authorization through Florida Blue before they will be covered under your prescription drug plan. If a member is currently taking or is prescribed a drug that is included in the prior authorization program, the physician will need to submit a prior authorization request in order for the members prescription to be considered for coverage. As always, treatment decisions rest solely with the member and their doctor. • Program savings average $0.50 to $0.75 PMPM

5. If you’ve tried the alternative drugs and your doctor still wants you to use one of the drugs listed in the program, the prescription will be filled. . If you’ve tried the alternative drugs and your doctor still wants you to use one of the drugs listed in the program, the prescription will be filled. . Prior Authorization Program in Action How Prior Authorization Works

6. Responsible Steps • Responsible Steps is a step therapy program that offers a “step” approach to providing medications to ensure the use of a covered alternative or prerequisite drug first before coverage of the drug included in the Responsible Steps program is provided. This means that a member may first need to try a more cost-effective or clinically appropriate medication before certain high-cost medications are approved by Florida Blue. Responsible Steps is based on nationally recognized therapeutic guidelines, clinical evidence, and research. Prescription medications included in the Responsible Steps program are not covered unless a member has tried one or more covered alternative medications first. • Program savings average $1.00 to $1.50 PMPM

7. If you’ve tried the alternative drugs and your doctor still wants you to use one of the drugs listed in the program, the prescription will be filled. . If you’ve tried the alternative drugs and your doctor still wants you to use one of the drugs listed in the program, the prescription will be filled. . Responsible Steps in Action How Step Therapy Works

8. Responsible Steps in Action Potential Member Cost Savings Self Administered

9. Responsible Quantity • The Responsible Quantity Program is a coverage maximum program that encourages the appropriate, safe and cost-effective use of medication by setting a maximum quantity per month for a medication or supply. The program places coverage maximums on select medicines. The quantity limitations used in our Responsible Quantity program are based on the Food and Drug Administration’s guidelines and the manufacturer's dosing recommendations. • Program savings average $0.20 to $0.30 PMPM

10. If you’ve tried the alternative drugs and your doctor still wants you to use one of the drugs listed in the program, the prescription will be filled. . If you’ve tried the alternative drugs and your doctor still wants you to use one of the drugs listed in the program, the prescription will be filled. . Responsible Quantity in Action How Quantity Limits Works

11. Responsible Rx Program Updates and Formulary Changes Our panel of Physicians and Pharmacist review new and existing drugs quarterly and evaluate the following: • Should we cover and what is the appropriate tier for new drugs entering the market? • Are there any safety concerns with any of the drugs on our formulary? There are varying reasons why changes are made to the medications listed in the Medication Guide. • The tier level of a Brand prescription medication included on the Medication List may increase (change from Tier 2 to Tier 3) when an FDA-approved bioequivalent Generic prescription medication becomes available. • Newly marketed Brand prescription medications are usually introduced on Tier 3 until the opportunity exists to review the medication level, at which time a determination will be made as to which tier will apply based on safety, efficacy and the availability of other products within that class of medications • Formulary changes are reflected in the Medication Guide bi-annually (January and July) along with bi-annual update lists (April and October). Both can be found on the Florida BlueL website.

12. Authorization Forms • Prior authorization request forms are available on the provider website at www.bcbsfl.com under For Providers, then Pharmacy, and the Prior Authorization Program Information and Authorization forms link. • Responsible Steps program authorization request forms are available on the provider website at www.bcbsfl.com under For Providers, then Pharmacy, then the Responsible Steps Program Information and Authorization Forms link. • Members requiring a greater monthly quantity than the coverage maximum based on medical necessity can have their physician submit a prior authorization request by filling out the Quantity Limit Prior Authorization Form at www.bcbsfl.com, under For Providers, then Pharmacy then the Quantity Limit Authorization form link. Note: Authorization forms must be completed and submitted by the prescribing physician. Submission of an authorization form does not constitute nor guarantee approval as specific criteria must be met before approvals are granted. Each request is subject to review based on the criteria specific to each program.

13. Sample Member Notification

14. Appendix

15. Accessing Authorization Forms Authorization request forms are available at www.bcbsfl.com under For Providers, then Pharmacy.