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Prescription drug updates

August 28, 2014

For commercial 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 Formulary Chapter Effective date AlprolixTM Not available 15. Diagnostics & Miscellaneous Agents April 28, 2014 AnoroTM ElliptaTM Not available 12. Allergy, Cough & Cold, Lung Meds March 3, 2014 Grastek® Not available 12. Allergy, Cough & Cold, Lung Meds April 28, 2014 HetliozTM Not available 3. Pain, Nervous System, & Psych March 17, 2014 MyaleptTM Not available 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones April 28, 2014 Oralair® Not available 12. Allergy, Cough & Cold, Lung Meds April 14, 2014 OrenitramTM Not available 4. Heart, Blood Pressure, & Cholesterol March 31, 2014 OtezlaTM Not available 9. Bone, Joint, & Muscle March 31, 2014 RagwitekTM Not available 12. Allergy, Cough & Cold, Lung Meds April 28, 2014 Tretten® Not available 15. Diagnostics & Miscellaneous Agents March 17, 2014

Effective October 1, 2014, the following non-formulary drugs have been added to the list of drugs requiring prior authorization:

Brand drug Generic drug Formulary Chapter AbsoricaTM Not available 5. Skin Medications Factive® Not available 1. Antibiotics & Other Drugs Used for Infection First® Lansoprazole Not available 8. Stomach, Ulcer, & Bowel Meds First® Omeprazole Not available 8. Stomach, Ulcer, & Bowel Meds Khedezla® desvenlafaxine er 3. Pain, Nervous System, & Psych Nexium® Not availble 8. Stomach, Ulcer, & Bowel Meds Prilosec® omeprazole 8. Stomach, Ulcer, & Bowel Meds Qualaquin® quinine sulfate* 1. Antibiotics & Other Drugs Used for Infection Vimovo® Not available 8. Stomach, Ulcer, & Bowel Meds Zavesca® Not available 15. Diagnostics & Miscellaneous Agents

*Generic drug require prior authorization.

Drugs with quantity limits

Quantity limits will be added for the following drugs:

Brand drug Generic drug Quantity limit Effective date Actonel® 150 mg risedronate 1 tab per 28 days October 1, 2014 Actonel® 35 mg Not available 4 tabs per 28 days October 1, 2014 Amerge® 1 mg naratriptan 9 tabs per 30 days October 1, 2014 Atelvia® Not available 4 tabs per 28 days October 1, 2014 Avinza® morphine sulfate er 30 tabs per 30 days February 24, 2014 Binosto® Not available 4 tabs per 28 days October 1, 2014 Boniva® ibandronate 1 tab per 30 days October 1, 2014 First® Lansoprazole Not available 600 ml per 30 days October 1, 2014 First® Omeprazole Not available 600 ml per 30 days October 1, 2014 Not available alendronate solution 300 ml per 28 days October 1, 2014 Fosamax®, Fosamax®
Plus D alendronate 4 tabs per 28 days October 1, 2014 HetliozTM Not available 30 caps per 30 days October 1, 2014 Imitrex® 25 mg, 50 mg tabs sumatriptan 18 tabs per 30 days October 1, 2014 Imitrex® 5 mg nasal spray sumatriptan 36 units per 30 days October 1, 2014 Lunesta® 1 mg eszopiclone 1 mg 60 tabs per 30 days April 21, 2014 Lunesta® 2 mg, 3 mg eszopiclone 2 mg, 3 mg 30 tabs per 30 days April 21, 2014 Maxalt® (MLT) 5 mg rizatriptan 12 tabs per 30 days October 1, 2014 Noxafil® Not available 93 tabs per 30 days October 1, 2014 Ortho Evra® Xulane 3 patches per 28 days April 28, 2014 Relpax® 20 mg Not available 12 tabs per 30 days October 1, 2014 XartemisTM XR Not available 120 tabs per 30 days March 24, 2014 ZenzediTM 10 mg dextroamphetamine 90 tabs per 30 days October 1, 2014 ZenzediTM 15, 20 mg Not available 90 tabs per 30 days October 1, 2014 ZenzediTM 30 mg Not available 60 tabs per 30 days October 1, 2014 Zomig® (ODT) 2.5 mg zolmitriptan 9 tabs per 30 days October 1, 2014

Quantity limits currently exist for brand drugs and will apply to generics at the dates indicated above.

Drugs no longer requiring prior authorization

Effective August 1, 2014, prior authorization was removed for the following drugs:

Brand drug Generic drug Formulary chapter Eliquis® Not available 4. Heart, Blood Pressure, & Cholesterol Pradaxa® Not available 4. Heart, Blood Pressure, & Cholesterol Tracleer® Not available 4. Heart, Blood Pressure, & Cholesterol Victoza® Not available 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones Xarelto® Not available 4. Heart, Blood Pressure, & Cholesterol Zortress® Not available 2. Cancer & Organ Transplant Drugs For additional information on pharmacy policies and programs, please visit our Pharmacy Information web page.

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