500 Patroon Creek Blvd. Albany, NY 12206-1057 www.cdphp.com June 30, 2010 Russell M Zivkovich MD Russell M. Zivkovich, MD 54 Bedford Street Cohoes, NY 12047 Dear CDPHP Practitions In our efforts to provide high quality, cost-effective health care coverage, CDPHP® continually reviews the medications prescribed to members. These reviews are accomplished through the CDPHP Pharmacy and Therapeutics Committee, comprised of 17 voting member-physicians and two voting member- pharmacists who practice in the community. Reviews are focused on clinical quality, safety, and efficiency. ‘Two of the decisions made at the June 16" Pharmacy and Therapeutics Committee meeting will affect the commercial prescription drug formularies and coverage for drugs in the HMG-CoA reductase inhibitor (Statin) and the proton pump inhibitor (PPI) therapeutic classes. First, brand-name drugs in the proton pump inhibitor class will no longer be covered. Additionally, a step therapy protocol will include the generics in this class. Secondly, a new step therapy protocol in the HMG-CoA reductase inhibitor (statin) class requires use of generics first. There will be only one Tier 2 option, Lipitor 80mg; and only one Tier 3 option: Crestor 40mg. Details are enclosed. Changes in both these classes will affect new prescriptions immediately. Current utilizers of now non- covered brands will need to transition to a formulary product aligned with step therapy by October 10, 2010. Members on Crestor (all strengths) and Lipitor 80mg only will be “grandfathered,” that is, exempt from the required transition, These therapeutic categories represent the Plan's top two most utilized drug classes and therefore we recognize the impact these changes will have on your practice. CDPHP is ready to assist in the transitions in the following ways. If your practice has 10 or more members impacted by these step therapies, CDPHP will pay $50 per telephonic visit during the transition period (July 5 — Oct. 10, 2010) resulting from these formulary actions. These telephonic visits will require no copayment from the member.‘Additionally, CDPHP is providing (under separate cover), practice-level detail regarding your patients affected by these changes. This practice-level information will be a spreadsheet that will include the demographic information for the members, including telephone numbers; the details of the last prescription filled (in our records); and the pharmacy information for the last prescription. This spreadsheet will serve as the tool for reimbursement for telephonic visits as well. Specific information regarding the process for reimbursement will be included with the patient-level information. CDPHP strategic engagement teams are ready to support your efforts to facilitate the necessary prescription changes for your CDPHP patients. If you need assistance or have questions, please contact your Strategic Coordinator by calling our Strategic Engagement Team hotline at (518) 641-4290. We appreciate your assistance during this transition period and your continued partnership as we seek to deliver high value health coverage products to the community. aon Martin R. Symansky, MD Medical Director and Chair, Pharmacy & ‘Therapeutics Committee Capital District Physicians’ Health Plan, Inc. CDPHP Universal Benefits, Inc.Summary for HMG-CoA reductase inhibitors (statins) Class Affects new starts immediately. * Current users of excluded products must transition to a formulary product in alignment with step therapy by Oct 10, 2010. * “Grandfather status” does not defer tier changes for current users, i refills will be at the top copayment amount. any remaining brand-name + Exceptions: Any current user of Crestor (any strength) or Lipitor (80mg) will not have to make a change, however all new starts must follow the step therapy protocol. Lipitor 10mg Excluded Lipitor 20mg Excluded Lipitor 40mg Excluded _| Lipitor 80mg Tier 2, STEP | Step through simvastatin 60mg for 3 months Crestor 5mg Excluded Crestor 10mg Excluded Crestor 20mg Excluded Crestor 40mg Tier 3, STEP ‘Step through Lipitor 80mg for 3 months [ Altoprev (all strengths) Excluded _ LescoV/Lescol XL (all strengths) | Excluded Livalo (all strengths) Excluded ‘Mevacor (all strengths) Excluded Pravachol (ail strengths) Excluded Zocor (all strengths) Excluded simvastatin 80mg Tier 1 No restrictions simvastatin 40mg Tier 1 No restrictions ‘simvastatin 20mg Tier 4 No restrictions ‘simvastatin 10mg Tier 1 No restrictions simvastatin 5mg Tier 1 No restrictions pravastatin 80mg : Tier 1 No restrictions pravastatin 40mg Tier t No restrictions pravastatin 20mg Tier i No restrictions pravastatin 10mg Tier No restrictions lovastatin 40mg Tier t No restrictions lovastatin 20mg Tier t No restrictions [lovastatin 10mg Tier 1 No restrictions Example: Member currently taking Lipitor 10, 20, 40mg must transition to simvastatin or other generic by October 10, 2010.500 Patron Creek Blvd. Albany, NY 12206-1057 www.cdphp.com ‘+ Affects new starts immediately. Summary for PPI Class © Current users of excluded products must transition to a formulary product in alignment with step therapy by Oct 10, 2010. “Grandfather status” does not defer tier changes for current users, i.e., any remaining brand- name refills will be at the top copayment amount. ‘Aciphex (all strengths) Excluded, Quantity limits on omeprazole have been removed. Dexilant/Kapidex (all strengths) Excluded [Nexium (all strengths) Excluded Prevacid (all strengths) Excluded Prilosec (all strengths) Excluded Protonix (all strengths) Excluded Zegerid (all strengths) Excluded | Priloseo OTC. Tier 1 No restrictions or quantity limits [Prevacid OTC Tier 1 No restrictions or quantity limits Zegerid OTC 1 No restrictions or quantity limits ‘omeprazole 40mg Tier No restrictions or quantity limits ‘omeprazole 20mg Tiert ____No restrictions oF quantity limits ‘omeprazole 10mg Tier 1 No restrictions or quantity limits lansoprazole 30mg Tier 1, STEP__ | _ Step through omeprazole 40mg for 30 da lansoprazole 15mg Tier 1, STEP __| _ Step through omeprazole 40mg for 30 days pantoprazole 40mg Tier 1, STEP | Step through lansoprazole 30mg for 30 days {pantoprazole 20mg Tier 1, STEP | Step through lansoprazole 30mg for 30 days’ Example: Member currently on Nexium or any brand PPI must transition to generic omeprazole by October 10, 2010, or follow step therapy to access lansoprazole and pantoprazole. Capital District Physicians’ Health Plan, Inc. { Capital District Physicians’ Healthcare Network, Ine. | CDPHP Univers Form #5300 sal Benefits,” Inc.