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For members enrolled in an IBC 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
Drug category
Effective date
InvokanaTM
Not available
Diabetes, Thyroid, Steroids, & Other
Miscellaneous Hormones
April 5, 2013
Kazano?
Not available
Diabetes, Thyroid, Steroids, & Other
Miscellaneous Hormones
February 1, 2013
Kynamro?
Not available
Heart, Blood Pressure, & Cholesterol
March 1, 2013
Nesina?
Not available
Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones
February 1, 2013
Oseni?
Not available
Diabetes, Thyroid, Steroids, & Other
Miscellaneous Hormones
February 1, 2013
Pomalyst?
Not available
Cancer & Organ Transplant Drugs
February 14, 2013
Signifor?
Not available
Diabetes, Thyroid, Steroids, & Other
Miscellaneous Hormones
March 15, 2013
SirturoTM
Not available
Antibiotics & Other Drugs Used for
Infection
April 26, 2013
TecfideraTM
Not available
Bone, Joint, & Muscle
April 5, 2013
The following non-formulary drugs have been added to the list of drugs
requiring prior authorization.
Members taking these drugs prior to the effective date are not affected:
Effective October 1, 2013.
Brand drug
Generic drug
Drug category
CystaranTM
Not available
Eye Medications
FulyzaqTM
Not available
Stomach, Ulcer, & Bowel Meds
Procysbi?
Not available
Urinary & Prostate Meds
RavictiTM
Not available
Stomach, Ulcer, & Bowel Meds
Drugs requiring prior authorization
The following non-formulary drugs have been added to the list of drugs
requiring prior authorization:
Effective October 1, 2013.
Brand drug
Generic drug
Drug category
Proventil? HFA
Not available
Allergy, Cough & Cold, Lung Meds
Ventolin? HFA
Not available
Allergy, Cough & Cold, Lung Meds
Xoponex? HFA
Not available
Allergy, Cough & Cold, Lung Meds
The following drugs have been added to the list of drugs requiring prior
authorization and apply to all members:
Effective October 1, 2013.
Chantix?
Compound products containing any of the following bulk powders: cholestyramine,
cyclobenzaprine,
gabapentin, or ketamine
Compound products with total ingredient cost equal to or greater than $300 per
prescription
Nicotine patches, nicotine gums, nicotine lozenges, nicotine inhalers, nicotine
sprays
Zyban?, buproprion hcl
Drugs with quantity limits
Quantity limits will be added for the following drugs: Effective October
1, 2013.
Brand drug
Generic drug
Quantity limit (per 30 days)
All applicable products
Female condoms
#15
All applicable products
diaphragms
#1/365 days
All applicable products
nicotine gum
#300
All applicable products
nicotine lozenge
#300
All applicable products
nicotine inhaler cartridges
#300
All applicable products
smoking cessation patches
#30
Chantix?
Not available
#60
CystaranTM
Not available
4 bottles
EdluarTM
Not available
30 tablets
Lunesta? 1mg
Not available
60 tablets
Lunesta? 2mg and 3mg
Not available
30 tablets
Zyban?
buproprion hcl
#60
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