TitleWeb Prescription drug updates
Professional; Facility; Ancillary
August 31, 2016
Page Content 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 |
Alprolix® 250 mg, Vial | Not available | 4.
Heart, Blood Pressure, & Cholesterol | March 28, 2016 |
Idelvion® | Not available | 15. Diagnostics
& Miscellaneous Agents | March 14, 2016 |
Onzetra Xsail? | Not available | 3. Pain, Nervous System, &
Psych | April 25, 2016 |
Sernivo? | Not available | 5. Skin Medications |
April 4, 2016 |
Taltz Autoinjector® | Not available | 5.
Skin Medications | April 4, 2016 |
Venclexta® | Not available | 2. Cancer &
Organ Transplant Drugs | April 18, 2016 |
Vraylar? | Not available | 3. Pain, Nervous System, &
Psych | February 22, 2016 |
Wilate® 500 Unit - 500 Unit,
1,000 Unit - 1,000 Unit, Vial | Not available | 4. Heart, Blood
Pressure, & Cholesterol | April 18, 2016 |
Xuriden? | Not available | 15. Diagnostics & Miscellaneous
Agents | February 8, 2016 |
Zembrace Symtouch? | Not available | 3. Pain, Nervous
System, & Psych | March 28, 2016 |
Zepatier? | Not available | 1. Antibiotics & Other Drugs
Used for Infection | February 8, 2016 |
Effective October 1, 2016, the following non-formulary
drugs will be added to the list of drugs requiring prior authorization:
Brand drug | Generic drug | Formulary chapter |
Amitiza® | Not available | 8. Stomach,
Ulcer, & Bowel Meds |
Butrans? 15 mcg/hr and
20 mcg/hr patch | Not available | 3. Pain, Nervous System, &
Psych |
Elmiron® | Not available | 13. Urinary &
Prostate Meds |
Kadian® 50 mg | morphine sulfate er 50
mg* | 3. Pain, Nervous System, & Psych |
Not available | morphine sulfate er 90 mg* | 3. Pain,
Nervous System, & Psych |
Nascobal® | Not available | 14. Vitamins &
Electrolytes |
Relistor® | Not available | 8. Stomach,
Ulcer, & Bowel Meds |
Tracleer® | Not available | 4. Heart, Blood
Pressure, & Cholesterol |
Viberzi? | Not available | 8. Stomach, Ulcer, & Bowel
Meds |
Xifaxan® 550 mg | Not available | 1.
Antibiotics & Other Drugs Used for Infection |
*Generic requires prior authorization.
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 |
Adzenys? XR-ODT | Not available | 30 tablets per 30
days | March 28, 2016 |
Brand Bowel Prep Agents
(PEG 3350/Electrolytes
and PEG Prep Kits) | Generic Bowel Prep Agents
(PEG 3350/Electrolytes
and PEG Prep Kits) | 2 units per 365 days | October 1,
2016 |
Impavido® | Not available | 84 capsules per
28 days | October 1, 2016 |
Narcan® Nasal Spray | Not available | 6
sprays per 30 days | October 1, 2016 |
Onzetra Xsail? | Not available | 16 capsules per 30
days | April 25, 2016 |
Quillichew ER? 20 mg
and 30 mg | Not available | 60 tablets per 30 days | February
1, 2016 |
Quillichew ER? 40 mg | Not available | 30 tablets per 30
days | February 1, 2016 |
Xifaxan® 200 mg | Not available | 9 tablets
per 90 days | October 1, 2016 |
Zembrace Symtouch? | Not available | 9 tablets per 90
days | March 28, 2016 |
Drugs no longer requiring prior
authorization
Effective September 1, 2016, the prior authorization
requirement was removed for the following drugs:
Brand drug | Generic drug | Formulary chapter |
Not available | clonidine | 3. Pain, Nervous System, &
Psych |
Not available | guanfacine | 3. Pain, Nervous System, &
Psych |
For additional information on pharmacy policies and programs, please visit
our Pharmacy page.
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