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 |
Acticlate™ | Not available | 1.
Antibiotics & Other Drugs Used for Infection | August 11, 2014 |
Bunavail™ | Not available | 3. Pain,
Nervous System, & Psych | August 4, 2014 |
Cerdelga™ | Not available | 15.
Diagnostics & Miscellaneous Agents | September 1, 2014 |
Contrave ER® | Not available | 3. Pain,
Nervous System, & Psych | September 22, 2014 |
Esbriet® | Not available | 12. Allergy,
Cough & Cold, Lung Meds | October 27, 2014 |
Harvoni™ | Not available | 1. Antibiotics
& Other Drugs Used for Infection | October 20, 2014 |
Invokamet™ | Not available | 7. Diabetes,
Thyroid, Steroids, & Other Miscellaneous Hormones | August 18,
2014 |
Jardiance® | Not available | 7. Diabetes,
Thyroid, Steroids, & Other Miscellaneous Hormones | August 11,
2014 |
Ofev® | Not available | 12. Allergy, Cough &
Cold, Lung Med | October 27, 2014 |
Trulicity™ | Not available | 7. Diabetes,
Thyroid, Steroids, & Other Miscellaneous Hormones | October 6,
2014 |
Zydelig® | Not available | 2. Cancer & Organ
Transplant Drugs | August 4, 2014 |
Effective April 1, 2015, the following non-formulary drugs
have been added to the list of drugs requiring prior authorization:
Brand drug | Generic drug | Formulary chapter |
Ativan® | lorazepam | 3. Pain, Nervous
System, & Psych |
Ciclodan® 8% solution, 0.77% cream | Not
available | 5. Skin Medications |
Evzio™ | Not available | 3. Pain, Nervous
System, & Psych |
Jublia® | Not available | 5. Skin
Medications |
Kerydin™ | Not available | 5. Skin
Medications |
Lipitor® | atorvastatin | 4. Heart, Blood
Pressure, & Cholesterol |
Migranal® | dihydroergotamine | 3. Pain,
Nervous System, & Psych |
Northera™ | Not available | 4. Heart,
Blood Pressure, & Cholesterol |
Onmel™ | Not available | 1. Antibiotics &
Other Drugs Used for Infection |
Penlac® | ciclopirox | 5. Skin
Medications |
Percocet® | oxycodone/acetaminophen | 3.
Pain, Nervous System, & Psych |
Valium® | diazepam | 3. Pain, Nervous
System, & Psych |
Xanax® | alprazolam | 3. 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 drug | Generic drug | Formulary chapter |
Levitra® | Not available | 13. Urinary &
Prostate Meds |
Staxyn® | Not available | 13. Urinary &
Prostate Meds |
Stendra™ | Not available | 13. Urinary &
Prostate Meds |
Viagra® | Not available | 13. Urinary &
Prostate Meds |
Drugs with quantity limits
Effective April 1, 2015, quantity limits will be added or
updated for the following drugs:
Brand drug | Generic drug | Quantity limit |
Bunavail™ 2.1-0.3 mg | Not
available | 120 tabs per 30 days |
Bunavail™ 4.2-0.7 mg | Not available | 90
tabs per 30 days |
Bunavail™ 6.3-1 mg | Not available | 30
tabs per 30 days |
Plegridy™ | Not available | 1 box per 28
days |
Suboxone® 8-2 mg | buprenorphine/naloxone 8-2
mg | 90 tabs per 30 days |
Suboxone® 12-3 mg | buprenorphine/naloxone 12-3
mg | 60 tabs per 30 days |
Zubsolve® 5.7-1.4 mg | Not available | 90
tabs per 30 days |
Drug no longer requiring prior authorization
Effective February 1, 2015, prior authorization has been
removed for the following drug:
Brand drug | Generic drug | Formulary chapter |
Plegridy™ | Not available | 3. Pain,
Nervous System, & Psych |
For additional information on pharmacy policies and programs, please visit
the Pharmacy Information page.