The Specialty Drug Program provides care management services to your members, including:

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1 Aetna Better Health is managed through CVS Health Specialty Pharmacy. The Specialty pharmacies fill prescriptions and ship drugs for complex medical conditions, including multiple sclerosis, rheumatoid arthritis and most cancer drugs. Medications provided through CVS specialty pharmacy include injectable, oral and inhaled drugs. Due to the complexity of these drugs, they require a high level of support and care guidelines for shipment and storage. The provides care management services to your members, including: 24 hours a day, seven days a week access to a pharmacist Disease-specific education and counseling by the CareTeam TM. The CareTeam TM are clinical professionals who review dosing and medication schedules, identify injection issues, provide education of potential side effects and provide information to help your member to manage their medical condition. Care coordination with your member and you Delivery of Specialty drugs to your member s home and/or your office in temperaturecontrolled packaging with the required supplies, i.e. needles, syringes, and alcohol wipes Contact CVS Specialty Pharmacy at from 7:30 a.m. (EST) to 9:00 p.m. (EST) time, Monday Friday. CVS Specialty Pharmacy will assist you in filling your specialty drug. Prior Authorization (PA) still applies to specific specialty drugs that require a clinical review. You can check our health plan website to confirm PA requirements on the below listed medications as well as review of the PA Guideline used in our clinical reviews. Last Update: 04/2017 Page 1

2 ALLERGEN IMMUNOTHERAPY Alpha-1 Antitrypsin Deficiency Alpha-1 Antitrypsin Deficiency Alpha-1 Antitrypsin Deficiency Coagulation Disorders Cryopyrin Associated Periodic Syndromes Cryopyrin Associated Periodic Syndromes Electrolyte Disorders Gastrointestinal Gastrointestinal Gout Hematopoietics Hereditary Angioedema Hereditary Angioedema Hereditary Angioedema OCTREOTIDE ACETATE SANDOSTATIN SANDOSTATIN LAR SOMATULINE SOMATULINE DEPOT SOMAVERT ORALAIR ARALAST NP GLASSIA ZEMAIRA CEPROTIN ARCALYST ILARIS SAMSCA GATTEX SOLESTA KRYSTEXXA GENOTROPIN HUMATROPE INCRELEX NORDITROPIN NUTROPIN OMNITROPE SAIZEN SEROSTIM TEV-TROPIN ZORBTIVE MOZOBIL ADEFOVIR DIPIVOXIL BARACLUDE EPIVIR HBV HEPSERA TYZEKA BERINERT CINRYZE FIRAZYR Last Update: 04/2017 Page 2

3 Hereditary Angioedema Idiopathic Thrombocytopenic Purpura Idiopathic Thrombocytopenic Purpura Infectious Disease Infectious Disease KALBITOR AVEED ELIGARD FIRMAGON LEUPROLIDE ACETATE LUPANETA PACK LUPRON DEPOT LUPRON DEPOT-PED SUPPRELIN SUPPRELIN LA SYNAREL TRELSTAR VANTAS ZOLADEX BIVIGAM CARIMUNE NF NANOFILTERED CYTOGAM FLEBOGAMMA GAMASTAN GAMMAGARD LIQUID GAMMAGARD S-D GAMMAKED GAMMAPLEX GAMUNEX-C HEPAGAM B HIZENTRA HYPERHEP B NABI-HB OCTAGAM PRIVIGEN RHOPHYLAC VIVAGLOBIN NPLATE PROMACTA ACTIMMUNE ALFERON N Last Update: 04/2017 Page 3

4 Inflammatory Bowel Disease Inflammatory Bowel Disease Iron Overload Iron Overload Iron Overload LIPID DISORDER Movement Disorders Movement Disorders Neutropenia Neutropenia Neutropenia CIMZIA ENTYVIO DEFEROXAMINE MESYLATE DESFERAL EXJADE KYNAMRO ALDURAZYME CEREDASE CEREZYME CYSTAGON ELAPRASE FABRAZYME LUMIZYME MYOZYME NAGLAZYME VIMIZIM VPRIV APOKYN XENAZINE AUBAGIO AVONEX BETASERON COPAXONE EXTAVIA GILENYA MITOXANTRONE NOVANTRONE PLEGRIDY REBIF REBIF REBIDOSE TECFIDERA TYSABRI ZINBRYTA GRANIX LEUKINE NEULASTA Last Update: 04/2017 Page 4

5 Neutropenia Oncology - injectable NEUPOGEN ABRAXANE ADCETRIS ALIMTA ARZERRA AVASTIN AZACITIDINE DACOGEN DECITABINE DOCETAXEL ELSPAR ERBITUX FASLODEX FOLOTYN FUSILEV GAZYVA GEMCITABINE HCL HALAVEN HERCEPTIN INTRON A ISTODAX IXEMPRA JEVTANA KADCYLA KYPROLIS ONCASPAR OXALIPLATIN PERJETA PROLEUKIN RITUXAN SYLATRON TEMODAR (Injectable) THYROGEN TORISEL TREANDA VALSTAR Last Update: 04/2017 Page 5

6 VECTIBIX VELCADE VIDAZA XGEVA YERVOY ZALTRAP BENDEKA MDV YONDELIS AFINITOR EMCYT ERIVEDGE ETOPOSIDE GLEEVEC HYCAMTIN JAKAFI MUGARD OFORTA POMALYST REVLIMID TARCEVA TARGRETIN TEMODAR TEMOZOLOMIDE THALOMID XELODA XTANDI ZOLINZA EUFLEXXA GEL-ONE HYALGAN MONOVISC ORTHOVISC SUPARTZ SYNVISC SYNVISC-ONE CERDELGA Last Update: 04/2017 Page 6

7 Paroxysmal Nocturnal Hemoglobinuria Phenylketonuria Psoriasis Psoriasis Psoriasis Psoriasis CIDOFOVIR COLISTIMETHATE SODIUM COLY-MYCIN M ELOXATIN ERAXIS ESBRIET FERRLECIT GANCICLOVIR SODIUM HYPERRAB S/D HYQVIA KEYTRUDA MYCAMINE NORTHERA QUTENZA RUCONEST SDV RUCONEST SANCUSO SIRTURO SOD FERRIC SORIATANE TAXOTERE THYMOGLOBULN SOLIRIS KUVAN ACITRETIN AMEVIVE OTEZLA STELARA ADCIRCA ADEMPAS EPOPROSTENOL LETAIRIS OPSUMIT ORENITRAM ORENITRAM ER REMODULIN Last Update: 04/2017 Page 7

8 RSV Seizure Disorders Seizure Disorders Systemic Lupus Erythematosus Urea Cycle Disorders Urea Cycle Disorders Urea Cycle Disorders REVATIO SILDENAFIL TRACLEER TYVASO VELETRI VENTAVIS EYLEA LUCENTIS MACUGEN OZURDEX RETISERT VISUDYNE ACTEMRA ENBREL HUMIRA ORENCIA OTREXUP REMICADE SIMPONI SIMPONI ARIA XELJANZ SYNAGIS ACTHAR GEL SABRIL BENLYSTA BUPHENYL RAVICTI SODIUM PHENYLBUTYRATE Last Update: 04/2017 Page 8