TitleWeb Prescription drug updates
Professional; Facility; Ancillary
December 1, 2014
Page Content [ 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 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 | Formulary chapter | Effective date | EloctateTM | Not available | 4. Heart, Blood Pressure, & Cholesterol | July 14, 2014 | RasuvoTM | Not available | 9. Bone, Joint, & Muscle | August 27, 2014 | SivextroTM | Not available | 1. Antibiotics & Other Drugs Used for Infection | June 30, 2014 | TanzeumTM | Not available | 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones | June 16, 2014 | ZykadiaTM | Not available | 2. Cancer & Organ Transplant Drugs | May 5, 2014 |
Effective January 1, 2015, the following non-formulary drugs have been added to the list of drugs requiringprior authorization: Brand drug | Generic drug | Formulary 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 mg | morphine sulfate ER 120 mg* | 3. Pain, Nervous System, & Psych | Corifact® | Not available | 4. Heart, Blood Pressure, & Cholesterol | Dilaudid® 4 mg, 8 mg | hydromorphone 4 mg*, 8 mg* | 3. Pain, Nervous System, & Psych | Diovan® | valsartan | 4. Heart, Blood Pressure, & Cholesterol | Diovan HCT® | valsartan/hctz | 4. Heart, Blood Pressure, & Cholesterol | Doral® | quazepam | 3. 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 available | 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones | Halcion® | triazolam | 3. Pain, Nervous System, & Psych | Kadian® 60 mg, 80 mg, 100 mg | morphine 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 mg | morphine sulfate ER 60 mg*,100 mg*, 200 mg* | 3. Pain, Nervous | Nasonex® | Not available | 6. Ear, Nose, Throat Medications | Opana® 10 mg | oxymorphone 10 mg* | 3. Pain, Nervous System, & Psych | Opana ER® 20 mg, 30 mg, 40 mg | Not available | 3. Pain, Nervous System, & Psych | Oxycontin® 30 mg, 40 mg, 60 mg, 80 mg | oxycodone ER 30 mg*, 40 mg*, 60 mg*, 80 mg* | 3. Pain, Nervous System, & Psych | Regimex® | Not available | 3. 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 criteriaEffective January 1, 2015, current members taking these medications will require a new prior authorization: Brand drug | Generic drug | Formulary chapter | Exalgo® | hydromorphone ER* | 3. Pain, Nervous System, & Psych | Nucynta® 100 mg | Not available | 3. Pain, Nervous System, & Psych | Nucynta ER® 150 mg, 200 mg, 250 mg | Not available | 3. Pain, Nervous System, & Psych | *Generic requires prior authorization.Drugs with quantity limitsEffective January 1, 2015, quantity limits will be added for the following drugs: Brand drug | Generic drug | Quantity limit | Ambien CR® | zolpidem tartrate ER | 30 tabs per 30 days | Conzip® | Not available | 30 caps per 30 days | EvzioTM | Not available | 4 units per 30 days | Nuvaring® | Not available | 1 ring per 28 days | Rozerem® | Not available | 30 tabs per 30 days | SivextroTM | Not available | 6 tabs per 6 days | Ultracet® | tramadol/acetaminophen | 40 tabs per 5 days | Ultram® | tramadol | 240 tabs per 30 days | Ultram ER® | tramadol ER | 30 tabs per 30 days | Zutripro® | hydrocodone/chlorpheniramine/pseudoephedrine | 450 ml per 30 days; 15 ml per day |
Drugs no longer requiring prior authorizationEffective November 1, 2014, prior authorization was removed for the following drugs: Brand drug | Generic drug | Formulary chapter | Actoplus Met XR® | pioglitazone hcl/metformin hcl | 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones | Nucynta® 50 mg, 75 mg | Not available | 3. Pain, Nervous System, & Psych | Nucynta ER® 50 mg, 100 mg | Not available | 3. Pain, Nervous System, & Psych |
For additional information on pharmacy policies and programs, please visit the Pharmacy Information page. ]
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