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Prescription drug updates

December 1, 2016

For commercial members enrolled in an Independence prescription drug program, prior authorization and quantity limitrequirements will be applied to certain drugs. The purpose of prior authorization is to ensure that drugs are medicallynecessary and are being used appropriately. Quantity limits are designed to allow a sufficient supply of medicationbased upon the maximum daily dose and length of therapy approved by the U.S. Food and Drug Administration for aparticular 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 becameavailable in the marketplace:

Brand drug Generic drug Quantity limit Effective date
Afstyla®Not available4. Heart, Blood Pressure, & Cholesterol June 13, 2016
Bevespi aerosphereNot available12. Allergy, Cough & Cold, Lung MedsJuly 11, 2016
Briviact®Not available3. Pain, Nervous System, & PsychMay 23, 2016
CabometyxNot available2. Cancer & Organ Transplant DrugsMay 2, 2016
Epclusa®Not available1. Antibiotics & Other Drugs Used for InfectionJuly 4, 2016
Nuplazid Not available3. Pain, Nervous System, & PsychMay 16, 2016
Nuvigil® armodafinil*3. Pain, Nervous System, & PsychJune 6, 2016
Ocaliva Not available15. Diagnostics & Miscellaneous AgentsJune 6, 2016
Stelara®† Not available9. Bone, Joint, & MuscleOctober 1, 2016
Vonvendi® Not available4. Heart, Blood Pressure, & CholesterolJuly 11, 2016
Xiidra Not available11. Eye Medications July 25, 2016July 25, 2016
Xtampza ER Not available3. Pain, Nervous System, & PsychMay 16, 2016
Zinbryta Not available1. Antibiotics & Other Drugs Used for Infection July 11, 2016

*Generic requires prior authorization.
Covered under pharmacy and medical benefit.

Effective January 1, 2017, the following non-formulary drugs will be added to the list of drugs requiring priorauthorization:

Brand drugGeneric drugFormulary chapter
Abilify®aripiprazole3. Pain, Nervous System, & Psych
Beyaz®Not available10. Female, Hormone Replacement, & Birth Control
Capex® Not available 5. Skin Medications
Clobex®clobetasol propionate5. Skin Medications
Cloderm®clocortolone pivalate5. Skin Medications
Cordran®flurandrenolide5. Skin Medications
Crestor®rosuvastatin calcium4. Heart, Blood Pressure, & Cholesterol
Cuprimine® Not available9. Bone, Joint, & Muscle
Cutivate®fluticasone propionate5. Skin Medications
Derma-Smoothe FS®fluocinolone acetonide 5. Skin Medications
Dermasorb HC, TA Not available5. Skin Medications
Desonate®Not available5. Skin Medications
Desowen®desonide5. Skin Medications
Dibenzyline® phenoxybenzamine*4. Heart, Blood Pressure, & Cholesterol
Diclegis® Not available8. Stomach, Ulcer, & Bowel Meds
Dymista®Not available6. Ear, Nose, Throat Medications
EcozaNot available5. Skin Medications
Effexor XR®venlafaxine er3. Pain, Nervous System, & Psych
Ertaczo®Not available5. Skin Medications
Exelderm®Not available5. Skin Medications
Extina®ketoconazole5. Skin Medications
Glumetza® metformin er*7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones
Halog®Not available5. Skin Medications
Kenalogtriamcinolone acetonide5. Skin Medications
Lexapro®escitalopram oxalate3. Pain, Nervous System, & Psych
Locoid® [lipocream]hydrocortisone butyrate/emoll5. Skin Medications
Loprox®ciclopirox5. Skin Medications
Luxiq®betamethasone valerate5. Skin Medications
Luzu® Not available5. Skin Medications
Minastrin® FENot available 10. Female, Hormone Replacement, & Birth Control
Olux® [E]clobetasol propionate/emoll 5. Skin Medications
Oxistat®oxiconazole nitrate5. Skin Medications
Pandel®Not available5. Skin Medications
Psorcon®diflorasone diacetate5. Skin Medications
Rayos®Not available7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones
Safyral®Not available10. Female, Hormone Replacement, & Birth Control
Synalar®fluocinolone acetonide5. Skin Medications
Syprine®Not available15. Diagnostics & Miscellaneous Agents
Topicort®desoximetasone5. Skin Medications
Ultravate®halobetasol propionate5. Skin Medications
Valtrex valacyclovir hcl1. Antibiotics & Other Drugs Used for Infection
Vanos fluocinonide5. Skin Medications
Vusion® Not available5. Skin Medications
Xartemis® XRNot available3. Pain, Nervous System, & Psych
Xolegel®Not available5. Skin Medications
Zoloft®sertraline hcl3. Pain, Nervous System, & Psych

*Generic requires prior authorization.

Drugs with quantity limits

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

Brand drug Generic drug Quantity limit Effective date
Denavir® Not available1 tube per 30 daysJanuary 1, 2017
Xtampza ER Not available60 caps per 30 daysMay 16, 2016

Drugs no longer requiring prior authorization

Effective January 1, 2017, the prior authorization requirement was removed for the following drugs:

Brand drugGeneric drugFormulary chapter
Invokamet® Not available7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones
Invokana®Not available7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones
PegIntron®, Pegasys®Not available3. Pain, Nervous System, & Psych
variousribavirin1. Antibiotics & Other Drugs Used for Infection

For additional information on pharmacy policies and programs, please visit our website.


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