TitleWeb Prescription drug updates
Professional; Facility; Ancillary
June 1, 2016
Page Content [ For commercial members enrolled in an AmeriHealth 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 drug | Generic
drug | Formulary chapter | Effective date |
| Adynovate® | Not available | 4. Heart, Blood Pressure, & Cholesterol | November 30, 2015 |
| Alecensa® | Not available | 2. Cancer & Organ Transplant Drugs | December 21, 2015 |
| BelbucaTM 75 mcg, 150 mcg, 330 mcg, 450 mcg,
600 mcg, 750 mcg, 900 mcg |
Not available | 3. Pain, Nervous System, & Psych | November 30, 2015 |
| Coagadex® | Not available | 4. Heart, Blood Pressure, & Cholesterol | November 30, 2015 |
| CotellicTM |
Not available |
2. Cancer & Organ Transplant Drugs |
November 16, 2015 |
| Enstilar® 0.005-.064 foam | Not available | 5. Skin Medications | January 11, 2016 |
| Ferriprox® 100 mg/ml solution | Not available | 15. Diagnostics & Miscellaneous Agents | December 7, 2015 |
| Narcan® 4 mg/actuation spray | Not available | 3. Pain, Nervous System, & Psych | December 7, 2015 |
| Ninlaro® | Not available | 2. Cancer & Organ Transplant Drugs | November 30, 2015 |
| Nuwiq® | Not available | 4. Heart, Blood Pressure, & Cholesterol | November 2, 2015 |
| Riastap® | Not available | 4. Heart, Blood Pressure, & Cholesterol | June 1, 2016 |
| StrensiqTM | Not available | 15. Diagnostics & Miscellaneous Agents | November 2, 2015 |
| TagrissoTM | Not available | 2. Cancer & Organ Transplant Drugs | November 23, 2015 |
| Uptravi® | Not available | 4. Heart, Blood Pressure, & Cholesterol | January 4, 2016 |
| UtibronTM Neohaler | Not available | 12. Allergy, Cough & Cold, Lung Meds | November 16, 2015 |
| ZepatierTM | Not available | 1. Antibiotics & Other Drugs Used for Infection | February 8, 2016 |
Effective July 1, 2016, the following non-formulary drugs will be
added to the list of drugs requiring prior authorization:
| Brand drug | Generic
drug | Formulary chapter |
| Acanya® | Not available | 5. Skin Medications |
| Adderall® | dextroamphetamine-amphetamine | 3. Pain, Nervous System, & Psych |
| Brand prenatal vitamins | various | 14. Vitamins & Electrolytes |
| Concerta® | methylphenidate er | 5. Skin Medications |
| Desoxyn® | methamphetamine hcl | 3. Pain, Nervous System, & Psych |
| Dexedrine® | dextroamphetamine sulfate | 3. Pain, Nervous System, & Psych |
Focalin® XR 5 mg, 10 mg, 15 mg,
20
mg, 30 mg, 40 mg | dexmethylphenidate hcl er | 3. Pain, Nervous System, & Psych |
| Metadate® CD | methylphenidate hcl cd | 3. Pain, Nervous System, & Psych |
| Ritalin® LA 20 mg, 30 mg, 40 mg | methylphenidate er | 3. 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 drug | Generic
drug | Quantity limit | Effective date |
| BelbucaTM |
Not available | 30 films per 30 days | November 30, 2015 |
| Dyanavel® XR | Not available | 240 ml per 30 days | January 25, 2016 |
| Narcan® 4 mg/actuation spray | Not available | 4 units per 30 days | December 7, 2015 |
For additional information on pharmacy policies and programs, go to the
Pharmacy Information page for AmeriHealth New Jersey or the
Pharmacy
Information page for AmeriHealth Pennsylvania.
Upcoming transition of pharmacy claims
AmeriHealth 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
AmeriHealth members and should not affect their access to care.
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