TitleWeb Prescription drug updates
Professional; Facility; Ancillary
December 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
|
|---|
| Daklinza™ | Not available | 1.
Antibiotics & Other Drugs Used for Infection | August 3, 2015 |
| Entresto™ | Not available | 4. Heart,
Blood Pressure, & Cholesterol | July 13, 2015 |
| Ixinity® | Not available | 15. Diagnostics
& Miscellaneous Agents | June 1, 2015 |
| Orkambi™ | Not available | 12. Allergy,
Cough & Cold, Lung Meds | July 13, 2015 |
| Rexulti® | Not available | 3. Pain,
Nervous System, & Psych | July 20, 2015 |
| Stiolto Respimat™ | Not available | 12.
Allergy, Cough & Cold, Lung Meds | June 1, 2015 |
| Technivie™ | Not available | 1.
Antibiotics & Other Drugs Used for Infection | August 3, 2015 |
| Tivorbex™ | Not available | 9. Bone,
Joint, & Muscle | May 11, 2015 |
| Zomacton™ 5 mg vial | Not available | 7.
Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones | May 11,
2015 |
Effective January 1, 2016, the following non-formulary
drugs will be added to the list of drugs requiring prior authorization:
| Brand drug | Generic drug | Formulary chapter |
|---|
| Carac® | Not available | 5. Skin
Medications |
| Duexis® | Not available | 8. Stomach,
Ulcer, & Bowel Meds |
| Fortamet® | Not available | 7. Diabetes,
Thyroid, Steroids, & Other Miscellaneous Hormones |
| Janumet® | Not available | 7. Diabetes,
Thyroid, Steroids, & Other Miscellaneous Hormones |
| Janumet® XR | Not available | 7. Diabetes,
Thyroid, Steroids, & Other Miscellaneous Hormones |
| Januvia® | Not available | 7. Diabetes,
Thyroid, Steroids, & Other Miscellaneous Hormones |
| Onglyza® | Not available | 7. Diabetes,
Thyroid, Steroids, & Other Miscellaneous Hormones |
| Proctocort® 30 mg supp | Not available |
5. Skin Medications |
| Relpax® | Not available | 3. Pain, Nervous
System, & Psych |
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
|
|---|
| Aptensio XR™ | Not available | 30
capsules per 30 days | May 11, 2015 |
| Axert® 6.25 mg | almotriptan maleate 6.25 mg
| 12 tablets per 30 days | January 1, 2016 |
| Chantix® | Not available | 180 days supply
per 365 days | January 1, 2016 |
| Evekeo™ 10 mg | Not available | 120
tablets per 30 days | July 1, 2015 |
| Ritalin® LA 60 mg | Not available | 30
capsules per 30 days | July 6, 2015 |
| Tuzistra™ XR | Not available | 240 ml
per 30 days | June 15, 2015 |
| Various | nicotine gum, inhalers, lozenges | 180 days
supply per 365 days | January 1, 2016 |
| Various | nicotine patches | 180 days supply per 365 days
| January 1, 2016 |
| Zegerid® | omeprazole sodium bicarbonate
| 60 capsules per 30 days | January 1, 2016 |
| Zyban® 150 mg | buproprion hcl sr 150 mg
| 180 days supply per 365 days | January 1, 2016 |
Drugs no longer requiring prior
authorization
Effective December 1, 2015, the prior authorization
requirement was removed for the following drug:
| Brand drug | Generic drug | Formulary chapter |
|---|
| Vimpat® | Not available | 3. Pain, Nervous
System, & Psych |
For additional information on pharmacy policies and programs, please visit
the Pharmacy Information page.
|
|