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Prescription drug updates

August 31, 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 drugGeneric drugFormulary chapterEffective date
Alprolix® 250 mg, VialNot available4. Heart, Blood Pressure, & CholesterolMarch 28, 2016
Idelvion®Not available15. Diagnostics & Miscellaneous AgentsMarch 14, 2016
Onzetra Xsail?Not available3. Pain, Nervous System, & PsychApril 25, 2016
Sernivo?Not available5. Skin Medications April 4, 2016
Taltz Autoinjector®Not available5. Skin MedicationsApril 4, 2016
Venclexta®Not available2. Cancer & Organ Transplant DrugsApril 18, 2016
Vraylar?Not available3. Pain, Nervous System, & PsychFebruary 22, 2016
Wilate® 500 Unit - 500 Unit, 1,000 Unit - 1,000 Unit, VialNot available4. Heart, Blood Pressure, & CholesterolApril 18, 2016
Xuriden?Not available15. Diagnostics & Miscellaneous AgentsFebruary 8, 2016
Zembrace Symtouch?Not available3. Pain, Nervous System, & PsychMarch 28, 2016
Zepatier?Not available1. Antibiotics & Other Drugs Used for InfectionFebruary 8, 2016

Effective October 1, 2016, the following non-formulary drugs will be added to the list of drugs requiring prior authorization:

Brand drugGeneric drugFormulary chapter
Amitiza®Not available8. Stomach, Ulcer, & Bowel Meds
Butrans? 15 mcg/hr and 20 mcg/hr patchNot available3. Pain, Nervous System, & Psych
Elmiron®Not available13. Urinary & Prostate Meds
Kadian® 50 mgmorphine sulfate er 50 mg*3. Pain, Nervous System, & Psych
Not availablemorphine sulfate er 90 mg*3. Pain, Nervous System, & Psych
Nascobal®Not available14. Vitamins & Electrolytes
Relistor®Not available8. Stomach, Ulcer, & Bowel Meds
Tracleer®Not available4. Heart, Blood Pressure, & Cholesterol
Viberzi?Not available8. Stomach, Ulcer, & Bowel Meds
Xifaxan® 550 mgNot available1. Antibiotics & Other Drugs Used for Infection

*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 drugGeneric drugQuantity limitEffective date
Adzenys? XR-ODTNot available30 tablets per 30 daysMarch 28, 2016
Brand Bowel Prep Agents
(PEG 3350/Electrolytes and PEG Prep Kits)
Generic Bowel Prep Agents
(PEG 3350/Electrolytes and PEG Prep Kits)
2 units per 365 daysOctober 1, 2016
Impavido®Not available84 capsules per 28 daysOctober 1, 2016
Narcan® Nasal SprayNot available6 sprays per 30 daysOctober 1, 2016
Onzetra Xsail?Not available16 capsules per 30 daysApril 25, 2016
Quillichew ER? 20 mg and 30 mgNot available60 tablets per 30 daysFebruary 1, 2016
Quillichew ER? 40 mgNot available30 tablets per 30 daysFebruary 1, 2016
Xifaxan® 200 mgNot available9 tablets per 90 daysOctober 1, 2016
Zembrace Symtouch?Not available9 tablets per 90 daysMarch 28, 2016

Drugs no longer requiring prior authorization

Effective September 1, 2016, the prior authorization requirement was removed for the following drugs:

Brand drugGeneric drugFormulary chapter
Not availableclonidine3. Pain, Nervous System, & Psych
Not availableguanfacine3. Pain, Nervous System, & Psych

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


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