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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)
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