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Prescription drug updates

February 29, 2016

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 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 Addyi® Not available 10. Female, Hormone Replacement, & Birth Control September 28, 2015 Durlaza® Not available 4. Heart, Blood Pressure, & Cholesterol September 28, 2015 Keveyis™ Not available 15. Diagnostics & Miscellaneous Agents September 21, 2015 Lonsurf® Not available 2. Cancer & Organ Transplant Drugs October 5, 2015 Odomzo® Not available 2. Cancer & Organ Transplant Drugs October 5, 2015 Oxaydo™ Not available 3. Pain, Nervous System, & Psych September 21, 2015 Synjardy® Not available 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones September 7, 2015 Zecuity® Not available 3. Pain, Nervous System, & Psych August 31, 2015

Effective April 1, 2016, the following non-formulary drugs will be added to the list of drugs requiring prior authorization: Brand drug Generic drug Formulary chapter Aczone® Not available 5. Skin Medications Amrix® Not available 9. Bone, Joint, & Muscle Arthrotec® diclofenac sodium/misoprostol 9. Bone, Joint, & Muscle Atralin® tretinoin 5. Skin Medications Avita® tretinoin 5. Skin Medications Azelex® Not available 5. Skin Medications Benzaclin® 1-5% gel clindamycin phos/benzoyl peroxide 5. Skin Medications Benzaclin® Pump Not available 5. Skin Medications Benzamycin® gel erythromycin/benzoyl peroxide 5. Skin Medications Benzamycinpak® Not available 5. Skin Medications Cleocin T® clindamycin phosphate 5. Skin Medications Clindagel® Not available 5. Skin Medications Daypro® oxaprozin 9. Bone, Joint, & Muscle Duac® clindamycin phos/benzoyl peroxide 5. Skin Medications Evoclin® foam clindamycin phosphate 5. Skin Medications Keppra® levetiracetam 3. Pain, Nervous System, & Psych Lamictal® lamotrigine 3. Pain, Nervous System, & Psych Lamictal ODT™ lamotrigine odt 3. Pain, Nervous System, & Psych Lorzone® Not available 9. Bone, Joint, & Muscle Mobic® meloxicam 9. Bone, Joint, & Muscle Onexton™ Not available 5. Skin Medications Prozac® fluoxetine hcl 3. Pain, Nervous System, & Psych Retin-A® and Retin-A Micro® tretinoin 5. Skin Medications Skelaxin® metaxalone 9. Bone, Joint, & Muscle Soma® carisoprodol 9. Bone, Joint, & Muscle Veltin™ Not available 5. Skin Medications Voltaren-XR® diclofenac sodium 9. Bone, Joint, & Muscle Zanaflex® tizanidine hcl 9. Bone, Joint, & Muscle Ziana® Not available 5. Skin Medications Zipsor™ Not available 9. Bone, Joint, & Muscle

Drugs requiring prior authorization with new criteria

Effective April 1, 2016, members currently taking these medications will require a new prior authorization: Brand drug Generic drug Formulary chapter Duexis® Not available 9. Bone, Joint, & Muscle Vimovo® Not available 9. Bone, Joint, & Muscle Zecuity® Not available 9. Bone, Joint, & Muscle

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 Butrans® 5 mcg patch Not available 4 patches per 28 days April 1, 2016 Hycofenix™ Not available 450 ml per 30 days August 17, 2015 Oxaydo™ Not available 180 tablets per 30 days September 21, 2015 Zecuity® Not available 4 patches per 30 days August 31, 2015

Drugs no longer requiring prior authorization

Effective February 1, 2016, the prior authorization requirement was removed for the following drugs: Brand drug Generic drug Formulary chapter Tivorbex™ Not available 9. Bone, Joint, & Muscle Zorvolex® Not available 9. Bone, Joint, & Muscle

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

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