For commercial members enrolled in an Independence 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 drug
Generic drug
Formulary chapter
Effective date
Addyi®
Not available
10. Female, Hormone Replacement, & Birth Control
September 28, 2015
Durlaza®
Not available
4. Heart, Blood Pressure, & Cholesterol
September 28, 2015
Keveyis™
Not available
15. Diagnostics & Miscellaneous Agents
September 21, 2015
Lonsurf®
Not available
2. Cancer & Organ Transplant Drugs
October 5, 2015
Odomzo®
Not available
2. Cancer & Organ Transplant Drugs
October 5, 2015
Oxaydo™
Not available
3. Pain, Nervous System, & Psych
September 21, 2015
Synjardy®
Not available
7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones
September 7, 2015
Zecuity®
Not available
3. Pain, Nervous System, & Psych
August 31, 2015
Effective April 1, 2016, the following non-formulary drugs
will be added to the list of drugs requiring prior authorization:
Brand drug
Generic drug
Formulary chapter
Aczone®
Not available
5. Skin Medications
Amrix®
Not available
9. Bone, Joint, & Muscle
Arthrotec®
diclofenac sodium/misoprostol
9. Bone, Joint, & Muscle
Atralin®
tretinoin
5. Skin Medications
Avita®
tretinoin
5. Skin Medications
Azelex®
Not available
5. Skin Medications
Benzaclin® 1-5% gel
clindamycin phos/benzoyl peroxide
5. Skin Medications
Benzaclin® Pump
Not available
5. Skin Medications
Benzamycin® gel
erythromycin/benzoyl peroxide
5. Skin Medications
Benzamycinpak®
Not available
5. Skin Medications
Cleocin T®
clindamycin phosphate
5. Skin Medications
Clindagel®
Not available
5. Skin Medications
Daypro®
oxaprozin
9. Bone, Joint, & Muscle
Duac®
clindamycin phos/benzoyl peroxide
5. Skin Medications
Evoclin® foam
clindamycin phosphate
5. Skin Medications
Keppra®
levetiracetam
3. Pain, Nervous System, & Psych
Lamictal®
lamotrigine
3. Pain, Nervous System, & Psych
Lamictal ODT™
lamotrigine odt
3. Pain, Nervous System, & Psych
Lorzone®
Not available
9. Bone, Joint, & Muscle
Mobic®
meloxicam
9. Bone, Joint, & Muscle
Onexton™
Not available
5. Skin Medications
Prozac®
fluoxetine hcl
3. Pain, Nervous System, & Psych
Retin-A® and Retin-A Micro®
tretinoin
5. Skin Medications
Skelaxin®
metaxalone
9. Bone, Joint, & Muscle
Soma®
carisoprodol
9. Bone, Joint, & Muscle
Veltin™
Not available
5. Skin Medications
Voltaren-XR®
diclofenac sodium
9. Bone, Joint, & Muscle
Zanaflex®
tizanidine hcl
9. Bone, Joint, & Muscle
Ziana®
Not available
5. Skin Medications
Zipsor™
Not available
9. Bone, Joint, & Muscle
Drugs requiring prior authorization with new
criteria
Effective April 1, 2016, members currently taking these
medications will require a new prior authorization:
Brand drug
Generic drug
Formulary chapter
Duexis®
Not available
9. Bone, Joint, & Muscle
Vimovo®
Not available
9. Bone, Joint, & Muscle
Zecuity®
Not available
9. Bone, Joint, & Muscle
Drugs with quantity limits
Quantity 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
Butrans® 5 mcg patch
Not available
4 patches per 28 days
April 1, 2016
Hycofenix™
Not available
450 ml per 30 days
August 17, 2015
Oxaydo™
Not available
180 tablets per 30 days
September 21, 2015
Zecuity®
Not available
4 patches per 30 days
August 31, 2015
Drugs no longer requiring prior
authorization
Effective February 1, 2016, the prior authorization requirement was removed
for the following drugs:
Brand drug
Generic drug
Formulary chapter
Tivorbex™
Not available
9. Bone, Joint, & Muscle
Zorvolex®
Not available
9. Bone, Joint, & Muscle
For additional information on pharmacy policies and programs, please visit
our Pharmacy Information page.