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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
Generic drug
Drug category
Effective date
Mekinist?
Not available
Cancer & Organ Transplant Drugs
June 21, 2013
Tafinlar?
Not available
Cancer & Organ Transplant Drugs
June 14, 2013
VecamylTM
Not available
Heart, Blood Pressure, & Cholesterol
May 3, 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 January
1, 2014.
Brand drug
Generic drug
Drug category
Adrenaclick?, Auvi-Q?
epinephrine pen
Allergy, Cough & Cold, Lung Meds
Alodox?
doxycycline
Antibiotics & Other Drugs Used for Infection
AvidoxyTM, Monodox?, Adoxa?
doxycycline monohydrate
Antibiotics & Other Drugs Used for Infection
Doryx? DR, Vibramycin?
doxycycline hyclate
Antibiotics & Other Drugs Used for Infection
Esomeprazole Strontium
Not available
Heart, Blood Pressure, & Cholesterol
Minocin?
minocycline hcl
Antibiotics & Other Drugs Used for Infection
Novarel?, Pregnyl?
chorionic gonadotropin, human
Diagnostics & Miscellaneous
Rescula?
Not available
Eye Medications
Drug no longer requiring prior authorization
Effective November 1, 2013, prior authorization was removed for the
following drug:
Brand drug
Generic drug
Drug category
Vascepa?
Not available
Heart, Blood Pressure, & Cholesterol
Drugs with quantity limits
Effective January 1, 2014, quantity limits will be added for the following
drugs:
Brand drug
Generic drug
Quantity limit (per 30 days)
All applicable products
blood glucose monitors
1 per year
All applicable products
diabetic test strips
200 per 30 days
All applicable products
lancets
200 per 30 days
All applicable products
insulin injecting devices
2 per year
All applicable products
insulin syringes and pen needles
200 per 30 days
Ella?
ulipristal acetate
3 per 30 days
Firazyr?
Not available
27 ml per 30 days (9 syringes)
My Way?, Next Choice? One
Dose, Plan B? One-Step
levonorgestrel 1.5 mg
3 per 30 days
Not available
hydrocodone/chlorpheniramine
450 ml per 30 days
Nicotrol?
NS nicotine nasal spray
80 ml per 30 days
Plan B?
levonorgestrel .075 mg
6 per 30 days