TitleWeb Prescription drug updates
Professional; Facility; Ancillary
September 1, 2015
Page Content 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 |
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| Cholbam® | Not available | 8. Stomach, Ulcer, & Bowel Meds | April 6, 2015 | | Corlanor® | Not available | 4. Heart, Blood Pressure, & Cholesterol | April 27, 2015 | | Cosentyx™ | Not available | 5. Skin Medications | February 9, 2015 | | Cresemba® | Not available | 1. Antibiotics & Other Drugs Used for Infection | March 30, 2015 | | Entresto™ | Not available | 4. Heart, Blood Pressure, & Cholesterol | July 13, 2015 | | Evekeo™ | Not available | 3. Pain, Nervous System, & Psych | February 2, 2015 | | Farydak® | Not available | 2. Cancer & Organ Transplant Drugs | March 9, 2015 | | Glyxambi® | Not available | 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones | February 9, 2015 | | Ibrance® | Not available | 2. Cancer & Organ Transplant Drugs | February 9, 2015 | | Jadenu™ | Not available | 15. Diagnostics & Miscellaneous Agents | April 13, 2015 | | Lenvima? | Not available | 2. Cancer & Organ Transplant Drugs | February 23, 2015 | | N/A | fentanyl 37.5 mcg, 62.5 mcg, 87.5 mcg/hr patch | 3. Pain, Nervous System, & Psych | March 2, 2015 | | Natesto™ | Not available | 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones | March 16, 2015 | | Natpara® | Not available | 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones | April 6, 2015 | | Novoeight® | Not available | 4. Heart, Blood Pressure, & Cholesterol | March 16, 2015 | | Saxenda® | Not available | 3. Pain, Nervous System, & Psych | April 13, 2015 | | Zubsolv® 8.6-2.1 mg | Not available | 3. Pain, Nervous System, & Psych | February 9, 2015 |
Effective October 1, 2015, the following non-formulary drugs will be added to the list of drugs requiring prior authorization: | Brand drug | Generic drug | Formulary chapter |
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| Inderal® LA | propranolol er | 4. Heart, Blood Pressure, & Cholesterol | | Oracea® | doxycycline ir-dr | 1. Antibiotics & Other Drugs Used for Infection | | Pennsaid® 2% drops | Not available | 9. Bone, Joint, & Muscle | | Tenoretic® | atenolol/chlorthalidone | 4. Heart, Blood Pressure, & Cholesterol | | Tenormin® | atenolol | 4. Heart, Blood Pressure, & Cholesterol | | Viibryd® | Not available | 3. Pain, Nervous System, & Psych | | Wellbutrin® XL | bupropion hcl xl | 3. Pain, Nervous System, & Psych | | Zorvolex® | Not available | 9. Bone, Joint, & Muscle |
Effective October 1, 2015, the following drug category has been added to the list of drugs requiring prior authorization, and these requirements apply to all members: | Category |
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| Compound products with total ingredient cost equal to or greater than $75 per prescription* |
*All compounds will be covered at the appropriate non-formulary brand level of cost-sharing.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 |
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| Aciphex® tabs | rabeprazole tabs | 60 tabs per 30 days | October 1, 2015 | | Cresemba® | Not available | 68 caps per 30 days | March 30, 2015 | | Dexilant® | Not available | 60 caps per 30 days | October 1, 2015 | | Dilaudid® 1 mg/ml liquid | hydromorphone 1 mg/ml liquid | 360 ml per 30 days | October 1, 2015 | | Entresto? | Not available | 60 tabs per 30 days | July 13, 2015 | | Evekeo? 5 mg | Not available | 90 tabs per 30 days | February 2, 2015 | | Evekeo? 10 mg | Not available | 180 tabs per 30 days | February 2, 2015 | | N/A | fentanyl 37.5 mcg, 62.5 mcg, 87.5 mcg/hr patch | 15 patches per 30 days | March 2, 2015 | | Nexium® caps | esomeprazole caps | 60 caps per 30 days | October 1, 2015 | | Prevacid® caps | lansoprazole caps | 60 caps per 30 days | October 1, 2015 | | Prilosec® caps | omeprazole caps | 60 caps per 30 days | October 1, 2015 | | Protonix® tabs | pantoprazole tabs | 60 tabs per 30 days | October 1, 2015 | | Restasis® | Not available | 60 droperettes per 30 days | October 1, 2015 | | Tussionex® ER susp | hydrocodone/chlorpheniramine ER susp | 120 ml per 30 days | October 1, 2015 | | Zubsolv® 8.6-2.1 mg | Not available | 60 tabs per 30 days | February 9, 2015 |
Drugs no longer requiring prior authorization Effective July 1, 2015, the prior authorization requirement was removed for the following drugs: | Brand drug | Generic drug | Formulary chapter |
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| Chantix® | Not available | 15. Diagnostics & Miscellaneous Agents | | Toujeo Solostar® | Not available | 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones | | various | nicotine gum, lozenges, patches, and sprays | 15. Diagnostics & Miscellaneous Agents | | Zyban® | bupropion | 15. Diagnostics & Miscellaneous Agents |
For additional information on pharmacy policies and programs, please visit the Pharmacy Information page.
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