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Prescription drug updates

June 1, 2016

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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 (FDA) 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 drugGeneric drugFormulary chapterEffective date
Adynovate®Not available4. Heart, Blood Pressure, & CholesterolNovember 30, 2015
Alecensa®Not available2. Cancer & Organ Transplant DrugsDecember 21, 2015
BelbucaTM 75 mcg, 150 mcg, 330 mcg, 450 mcg, 600 mcg, 750 mcg, 900 mcgNot available3. Pain, Nervous System, & PsychNovember 30, 2015
Coagadex®Not available4. Heart, Blood Pressure, & CholesterolNovember 30, 2015
CotellicTMNot available2. Cancer & Organ Transplant DrugsNovember 16, 2015
Enstilar® 0.005-.064 foamNot available5. Skin MedicationsJanuary 11, 2016
Ferriprox® 100 mg/ml solutionNot available15. Diagnostics & Miscellaneous AgentsDecember 7, 2015
Narcan® 4 mg/actuation sprayNot available3. Pain, Nervous System, & PsychDecember 7, 2015
Ninlaro®Not available2. Cancer & Organ Transplant DrugsNovember 30, 2015
Nuwiq®Not available4. Heart, Blood Pressure, & CholesterolNovember 2, 2015
Riastap®Not available4. Heart, Blood Pressure, & CholesterolJune 1, 2016
StrensiqTMNot available15. Diagnostics & Miscellaneous AgentsNovember 2, 2015
TagrissoTMNot available2. Cancer & Organ Transplant DrugsNovember 23, 2015
Uptravi®Not available4. Heart, Blood Pressure, & CholesterolJanuary 4, 2016
UtibronTM NeohalerNot available12. Allergy, Cough & Cold, Lung MedsNovember 16, 2015
ZepatierTMNot available1. Antibiotics & Other Drugs Used for InfectionFebruary 8, 2016

Effective July 1, 2016, the following non-formulary drugs will be added to the list of drugs requiring prior authorization:

Brand drugGeneric drugFormulary chapter
Acanya®Not available5. Skin Medications
Adderall®dextroamphetamine-amphetamine3. Pain, Nervous System, & Psych
Brand prenatal vitaminsvarious14. Vitamins & Electrolytes
Concerta®methylphenidate er5. Skin Medications
Desoxyn®methamphetamine hcl3. Pain, Nervous System, & Psych
Dexedrine®dextroamphetamine sulfate3. Pain, Nervous System, & Psych
Focalin® XR 5 mg, 10 mg, 15 mg,
20 mg,30 mg, 40 mg
dexmethylphenidate hcl er3. Pain, Nervous System, & Psych
Metadate® CDmethylphenidate hcl cd3. Pain, Nervous System, & Psych
Ritalin® LA 20 mg, 30 mg, 40 mgmethylphenidate er3. Pain, Nervous System, & Psych
Zegerid® 40 mg/1.1 g cap"omeprazole/sodium bicarbonate 40 mg/1.1 g cap*8. Stomach, Ulcer, & Bowel Meds
*Generic requires prior authorization.

According to the FDA, "A generic drug is the same as a brand-name drug in dosage, safety, strength, how it is taken, quality, performance, and intended use." Before approving a generic drug product, the FDA requires many rigorous tests and procedures to assure that the generic drug can be substituted for the brand-name drug. The FDA bases evaluations of substitutability, or "therapeutic equivalence," of generic drugs on scientific evaluations. By law, a generic drug product must contain identical amounts of the same active ingredient(s) as the brand-name product. Drug products evaluated as "therapeutically equivalent" can be expected to have equal effect with no difference when substituted for the brand-name product. Generic equivalents are required to demonstrate bioequivalence, which evaluates the rate and extent of absorption of the drug.

Clinically, it is reasonable to interchange the generic equivalents, which are generally less costly to your patients, for the above-listed brand-name drugs, including ADHD medications (Adderall®, Concerta®, Desoxyn®, Dexedrine®, Focalin® XR, Metadate® CD, Ritalin® LA).

Drugs with quantity limits

Quantity limits were added or updated for the following drugs as of the date indicated below:

Brand drugGeneric drugQuantity limitEffective date
BelbucaTMNot available30 films per 30 daysNovember 30, 2015
Dyanavel® XRNot available240 ml per 30 daysJanuary 25, 2016
Narcan® 4 mg/actuation sprayNot available4 units per 30 daysDecember 7, 2015

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

Upcoming transition of pharmacy claims

Independence will be transitioning its pharmacy claims to a new platform in an effort to streamline claims processes and business operations, while saving on administrative costs. The transition will occur in stages, which are set to begin on July 1, 2016, and be completed by October 1, 2016. Please note that this is not a change in our pharmacy benefits manager, just the platform on which claims are processed. The transition of claims should be seamless to Independence members and should not affect their access to care.

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