TitleWeb Prescription drug updates
Professional; Facility; Ancillary
December 1, 2016
Page Content For commercial members enrolled in an Independence prescription drug program, prior authorization and quantity limitrequirements will be applied to certain drugs. The purpose of prior authorization is to ensure that drugs are medicallynecessary and are being used appropriately. Quantity limits are designed to allow a sufficient supply of medicationbased upon the maximum daily dose and length of therapy approved by the U.S. Food and Drug Administration for aparticular drug. The most recent updates are reflected below. Drugs requiring prior authorizationThe prior authorization requirement for the following non-formulary drugs was effective at the time the drugs becameavailable in the marketplace: Brand drug | Generic drug | Quantity limit | Effective date |
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Afstyla® | Not available | 4. Heart, Blood Pressure, & Cholesterol | June 13, 2016 | Bevespi aerosphere™ | Not available | 12. Allergy, Cough & Cold, Lung Meds | July 11, 2016 | Briviact® | Not available | 3. Pain, Nervous System, & Psych | May 23, 2016 | Cabometyx™ | Not available | 2. Cancer & Organ Transplant Drugs | May 2, 2016 | Epclusa® | Not available | 1. Antibiotics & Other Drugs Used for Infection | July 4, 2016 | Nuplazid™ | Not available | 3. Pain, Nervous System, & Psych | May 16, 2016 | Nuvigil® | armodafinil* | 3. Pain, Nervous System, & Psych | June 6, 2016 | Ocaliva™ | Not available | 15. Diagnostics & Miscellaneous Agents | June 6, 2016 | Stelara®† | Not available | 9. Bone, Joint, & Muscle | October 1, 2016 | Vonvendi® | Not available | 4. Heart, Blood Pressure, & Cholesterol | July 11, 2016 | Xiidra™ | Not available | 11. Eye Medications July 25, 2016 | July 25, 2016 | Xtampza™ ER | Not available | 3. Pain, Nervous System, & Psych | May 16, 2016 | Zinbryta™ | Not available | 1. Antibiotics & Other Drugs Used for Infection | July 11, 2016 |
*Generic requires prior authorization. †Covered under pharmacy and medical benefit. Effective January 1, 2017, the following non-formulary drugs will be added to the list of drugs requiring priorauthorization: Brand drug | Generic drug | Formulary chapter |
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Abilify® | aripiprazole | 3. Pain, Nervous System, & Psych | Beyaz® | Not available | 10. Female, Hormone Replacement, & Birth Control | Capex® | Not available | 5. Skin Medications | Clobex® | clobetasol propionate | 5. Skin Medications | Cloderm® | clocortolone pivalate | 5. Skin Medications | Cordran® | flurandrenolide | 5. Skin Medications | Crestor® | rosuvastatin calcium | 4. Heart, Blood Pressure, & Cholesterol | Cuprimine® | Not available | 9. Bone, Joint, & Muscle | Cutivate® | fluticasone propionate | 5. Skin Medications | Derma-Smoothe FS® | fluocinolone acetonide | 5. Skin Medications | Dermasorb™ HC, TA | Not available | 5. Skin Medications | Desonate® | Not available | 5. Skin Medications | Desowen® | desonide | 5. Skin Medications | Dibenzyline® | phenoxybenzamine* | 4. Heart, Blood Pressure, & Cholesterol | Diclegis® | Not available | 8. Stomach, Ulcer, & Bowel Meds | Dymista® | Not available | 6. Ear, Nose, Throat Medications | Ecoza™ | Not available | 5. Skin Medications | Effexor XR® | venlafaxine er | 3. Pain, Nervous System, & Psych | Ertaczo® | Not available | 5. Skin Medications | Exelderm® | Not available | 5. Skin Medications | Extina® | ketoconazole | 5. Skin Medications | Glumetza® | metformin er* | 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones | Halog® | Not available | 5. Skin Medications | Kenalog™ | triamcinolone acetonide | 5. Skin Medications | Lexapro® | escitalopram oxalate | 3. Pain, Nervous System, & Psych | Locoid® [lipocream] | hydrocortisone butyrate/emoll | 5. Skin Medications | Loprox® | ciclopirox | 5. Skin Medications | Luxiq® | betamethasone valerate | 5. Skin Medications | Luzu® | Not available | 5. Skin Medications | Minastrin® FE | Not available | 10. Female, Hormone Replacement, & Birth Control | Olux® [E] | clobetasol propionate/emoll | 5. Skin Medications | Oxistat® | oxiconazole nitrate | 5. Skin Medications | Pandel® | Not available | 5. Skin Medications | Psorcon® | diflorasone diacetate | 5. Skin Medications | Rayos® | Not available | 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones | Safyral® | Not available | 10. Female, Hormone Replacement, & Birth Control | Synalar® | fluocinolone acetonide | 5. Skin Medications | Syprine® | Not available | 15. Diagnostics & Miscellaneous Agents | Topicort® | desoximetasone | 5. Skin Medications | Ultravate® | halobetasol propionate | 5. Skin Medications | Valtrex™ | valacyclovir hcl | 1. Antibiotics & Other Drugs Used for Infection | Vanos™ | fluocinonide | 5. Skin Medications | Vusion® | Not available | 5. Skin Medications | Xartemis® XR | Not available | 3. Pain, Nervous System, & Psych | Xolegel® | Not available | 5. Skin Medications | Zoloft® | sertraline hcl | 3. Pain, Nervous System, & Psych |
*Generic requires prior authorization. Drugs with quantity limitsQuantity limits were/will be added or updated for the following drugs as of the date indicated below: Brand drug | Generic drug | Quantity limit | Effective date |
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Denavir® | Not available | 1 tube per 30 days | January 1, 2017 | Xtampza™ ER | Not available | 60 caps per 30 days | May 16, 2016 |
Drugs no longer requiring prior authorizationEffective January 1, 2017, the prior authorization requirement was removed for the following drugs: Brand drug | Generic drug | Formulary chapter |
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Invokamet® | Not available | 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones | Invokana® | Not available | 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones | PegIntron®, Pegasys® | Not available | 3. Pain, Nervous System, & Psych | various | ribavirin | 1. Antibiotics & Other Drugs Used for Infection | For additional information on pharmacy policies and programs, please visit our website.
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