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 |
Afrezza® | Not available | 7. Diabetes,
Thyroid, Steroids, & Other Miscellaneous
Hormones | December 29, 2014 |
Arnuity Ellipta® | Not available | 12.
Allergy, Cough & Cold, Lung Meds | December 22, 2014 |
Belsomra® | Not available | 3. Pain, Nervous
System, & Psych | December 8, 2014 |
Embeda® 60-2.4 mg,
80-3.2 mg, 100-4 mg | Not available | 3. Pain, Nervous System, &
Psych | January 19, 2015 |
HysinglaTM | Not available | 3. Pain, Nervous
System, & Psych | December 15, 2014 |
LynparzaTM | Not available | 2. Cancer & Organ
Transplant Drugs | December 29, 2014 |
Viekira PakTM | Not available | 1. Antibiotics &
Other Drugs Used for Infection | December 29, 2014 |
Xigduo XRTM | Not available | 7. Diabetes,
Thyroid, Steroids, & Other Miscellaneous
Hormones | November 3, 2014 |
Effective July 1, 2015, the following non-formulary drugs
will be added to the list of drugs requiring prior
authorization:
Brand drug | Generic drug | Formulary chapter |
Differin® Cream/Gel | adapalene
cream/gel | 5. Skin Medications |
Embeda® 20-0.8 mg,
30-1.2 mg, 50-2 mg | Not available | 3. Pain, Nervous System, &
Psych |
Solaraze® Gel | diclofenac gel* | 5. Skin
Medications |
*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 in the following:
Brand drug | Generic drug | Quantity Limit | Effective date |
Belsomra® | Not available | 30 tabs per 30
days | July 1, 2015 |
Embeda® | Not available | 60 caps per 30
days | January 19, 2015 |
Hysingla? | Not available | 30 tabs per 30
days | December 15, 2014 |
Obredon® | Not available | 450 ml per 30
days | January 19, 2015 |
Suboxone® Film 2-0.5 mg, 4-1 mg | Not
available | 720 films per 365 days | June 1, 2015 |
Suboxone® Film 8-2 mg | Not available | 540
films per 365 days | June 1, 2015 |
Suboxone® Film 12-3 mg | Not available | 360
films per 365 days | June 1, 2015 |
Trezix® | Not available | 180 caps per 30
days | December 15, 2014 |
Vituz® | Not available | 450 ml per 30
days | July 1, 2015 |
Drug no longer requiring prior
authorization
Effective May 1, 2015, prior authorization was removed for
the following drug:
Brand drug | Generic drug | Formulary chapter |
Suboxone® Film | Not available | 3. Pain,
Nervous System, & Psych |
For additional information on pharmacy policies and programs, please visit
the Pharmacy Information page.