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Prescription drug updates

March 2, 2015

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 drugGeneric drugFormulary chapterEffective date
ActiclateNot available1. Antibiotics & Other Drugs Used for InfectionAugust 11, 2014
BunavailNot available3. Pain, Nervous System, & PsychAugust 4, 2014
CerdelgaNot available15. Diagnostics & Miscellaneous AgentsSeptember 1, 2014
Contrave ER®Not available3. Pain, Nervous System, & PsychSeptember 22, 2014
Esbriet®Not available12. Allergy, Cough & Cold, Lung MedsOctober 27, 2014
HarvoniNot available1. Antibiotics & Other Drugs Used for InfectionOctober 20, 2014
InvokametNot available7. Diabetes, Thyroid, Steroids, & Other Miscellaneous HormonesAugust 18, 2014
Jardiance®Not available7. Diabetes, Thyroid, Steroids, & Other Miscellaneous HormonesAugust 11, 2014
Ofev®Not available12. Allergy, Cough & Cold, Lung MedOctober 27, 2014
TrulicityNot available7. Diabetes, Thyroid, Steroids, & Other Miscellaneous HormonesOctober 6, 2014
Zydelig®Not available2. Cancer & Organ Transplant DrugsAugust 4, 2014

Effective April 1, 2015, the following non-formulary drugs have been added to the list of drugs requiring prior authorization:

Brand drugGeneric drugFormulary chapter
Ativan®lorazepam3. Pain, Nervous System, & Psych
Ciclodan® 8% solution, 0.77% creamNot available5. Skin Medications
EvzioNot available3. Pain, Nervous System, & Psych
Jublia®Not available5. Skin Medications
KerydinNot available5. Skin Medications
Lipitor®atorvastatin4. Heart, Blood Pressure, & Cholesterol
Migranal®dihydroergotamine3. Pain, Nervous System, & Psych
NortheraNot available4. Heart, Blood Pressure, & Cholesterol
OnmelNot available1. Antibiotics & Other Drugs Used for Infection
Penlac®ciclopirox5. Skin Medications
Percocet®oxycodone/acetaminophen3. Pain, Nervous System, & Psych
Valium®diazepam3. Pain, Nervous System, & Psych
Xanax®alprazolam3. Pain, Nervous System, & Psych

Drugs requiring prior authorization with new criteria

Effective April 1, 2015, current members taking these medications will require a new prior authorization:

Brand drugGeneric drugFormulary chapter
Levitra®Not available13. Urinary & Prostate Meds
Staxyn®Not available13. Urinary & Prostate Meds
StendraNot available13. Urinary & Prostate Meds
Viagra®Not available13. Urinary & Prostate Meds

Drugs with quantity limits

Effective April 1, 2015, quantity limits will be added or updated for the following drugs:

Brand drugGeneric drugQuantity limit
Bunavail 2.1-0.3 mg Not available120 tabs per 30 days
Bunavail 4.2-0.7 mg Not available90 tabs per 30 days
Bunavail 6.3-1 mg Not available30 tabs per 30 days
PlegridyNot available1 box per 28 days
Suboxone® 8-2 mg buprenorphine/naloxone 8-2 mg90 tabs per 30 days
Suboxone® 12-3 mg buprenorphine/naloxone 12-3 mg60 tabs per 30 days
Zubsolve® 5.7-1.4 mgNot available90 tabs per 30 days

Drug no longer requiring prior authorization

Effective February 1, 2015, prior authorization has been removed for the following drug:

Brand drugGeneric drugFormulary chapter
Plegridy Not available3. Pain, Nervous System, & Psych

For additional information on pharmacy policies and programs, please visit the Pharmacy Information page.


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