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Prescription drug updates

December 1, 2014

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For commercial members enrolled in an Independence prescription drug program, prior authorization and quantitylimit requirements will be applied to certain drugs. The purpose of prior authorization is to ensure that drugs aremedically necessary and are being used appropriately. Quantity limits are designed to allow a sufficient supplyof medication based upon the maximum daily dose and length of therapy approved by the U.S. Food and DrugAdministration 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 becameavailable in the marketplace:

Brand drugGeneric drugFormulary chapterEffective date
EloctateTMNot available4. Heart, Blood Pressure, & CholesterolJuly 14, 2014
RasuvoTM Not available9. Bone, Joint, & MuscleAugust 27, 2014
SivextroTMNot available1. Antibiotics & Other Drugs Used for InfectionJune 30, 2014
TanzeumTMNot available7. Diabetes, Thyroid, Steroids, & Other Miscellaneous HormonesJune 16, 2014
ZykadiaTMNot available2. Cancer & Organ Transplant DrugsMay 5, 2014

Effective January 1, 2015, the following non-formulary drugs have been added to the list of drugs requiringprior authorization:

Brand drugGeneric drugFormulary chapter
Ambien® 5 mg, 10 mg zolpidem 5 mg, 10 mg*3. Pain, Nervous System, & Psych
Ambien CR® 12.5 mg zolpidem ER 12.5 mg*3. Pain, Nervous System, & Psych
Avinza® 120 mgmorphine sulfate ER 120 mg*3. Pain, Nervous System, & Psych
Corifact®Not available 4. Heart, Blood Pressure, & Cholesterol
Dilaudid® 4 mg, 8 mghydromorphone 4 mg*, 8 mg*3. Pain, Nervous System, & Psych
Diovan® valsartan 4. Heart, Blood Pressure, & Cholesterol
Diovan HCT® valsartan/hctz4. Heart, Blood Pressure, & Cholesterol
Doral® quazepam3. Pain, Nervous System, & Psych
Duragesic® 25 mcg, 50 mcg, 75 mcg, 100 mcg fentanyl patches 25 mcg*, 50 mcg*, 75 mcg*, 100 mcg* 3. Pain, Nervous System, & Psych
First Testosterone®Not available7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones
Halcion®triazolam 3. Pain, Nervous System, & Psych
Kadian® 60 mg, 80 mg, 100 mgmorphine sulfate ER 60 mg*,80 mg*, 100 mg*3. Pain, Nervous System, & Psych
Kadian® 200 mg Not available 3. Pain, Nervous System, & Psych
Lunesta® 1 mg, 2 mg, 3 mg eszopiclone 1 mg, 2 mg, 3 mg* 3. Pain, Nervous System, & Psych
Not available morphine sulfate IR 30 mg* 3. Pain, Nervous System, & Psych
MS Contin® 60 mg,100 mg, 200 mgmorphine sulfate ER 60 mg*,100 mg*, 200 mg* 3. Pain, Nervous
Nasonex®Not available6. Ear, Nose, Throat Medications
Opana® 10 mg oxymorphone 10 mg* 3. Pain, Nervous System, & Psych
Opana ER® 20 mg, 30 mg, 40 mgNot available3. Pain, Nervous System, & Psych
Oxycontin® 30 mg, 40 mg, 60 mg, 80 mgoxycodone ER 30 mg*, 40 mg*, 60 mg*, 80 mg*3. Pain, Nervous System, & Psych
Regimex®Not available3. Pain, Nervous System, & Psych
Restoril®temazepam 3. Pain, Nervous System, & Psych
Roxicodone® 30 mg oxycodone 30 mg* 3. Pain, Nervous System, & Psych
Saphris®Not available 3. Pain, Nervous System, & Psych
Sonata®zaleplon 3. Pain, Nervous System, & Psych
Targretin® Gel Not available 2. Cancer & Organ Transplant Drugs
*Generic requires prior authorization.

Effective January 1, 2015, the following drug categories have been added to the list of drugs requiring priorauthorization, and these requirements apply to all members:

Category
Compound products containing any prescription bulk chemical
Compound products with total ingredient cost equal to or greater than $150 per prescription

Drugs requiring prior authorization with new criteria

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

Brand drugGeneric drugFormulary chapter
Exalgo®hydromorphone ER*3. Pain, Nervous System, & Psych
Nucynta® 100 mgNot available3. Pain, Nervous System, & Psych
Nucynta ER® 150 mg, 200 mg, 250 mgNot available3. Pain, Nervous System, & Psych
*Generic requires prior authorization.

Drugs with quantity limits

Effective January 1, 2015, quantity limits will be added for the following drugs:

Brand drugGeneric drugQuantity limit
Ambien CR®zolpidem tartrate ER30 tabs per 30 days
Conzip®Not available30 caps per 30 days
EvzioTMNot available4 units per 30 days
Nuvaring®Not available1 ring per 28 days
Rozerem®Not available30 tabs per 30 days
SivextroTMNot available6 tabs per 6 days
Ultracet® tramadol/acetaminophen40 tabs per 5 days
Ultram®tramadol 240 tabs per 30 days
Ultram ER®tramadol ER30 tabs per 30 days
Zutripro®hydrocodone/chlorpheniramine/pseudoephedrine450 ml per 30 days; 15 ml per day

Drugs no longer requiring prior authorization

Effective November 1, 2014, prior authorization was removed for the following drugs:

Brand drug Generic drugFormulary chapter
Actoplus Met XR®pioglitazone hcl/metformin hcl7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones
Nucynta® 50 mg, 75 mgNot available 3. Pain, Nervous System, & Psych
Nucynta ER® 50 mg, 100 mgNot available 3. Pain, Nervous System, & Psych

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

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