Prior Authorization &
Medication Quantity Limits

Regence BlueShield of Idaho

Medication Quantity Limits
| Medications that Require Prior Authorization
if Prescribed Above the Maximum Quantity |
Maximum Quantity for a 30-day supply |
| Ambien® |
14 tablets |
| Ambien CR™ |
14 tablets |
| Amerge® |
12 tablets |
| Anzemet® |
4 tablets |
| Axert® |
12 tablets |
| Edluar™ |
14 tablets |
| Emend® |
2 capsules of 125mg, plus 4 capsules of 80mg |
| Frova® |
12 tablets |
| granisetron HCL tablet (Kytril®) |
8 tablets |
| Imitrex® injection |
6 injections |
| Imitrex® Nasal Spray |
6 canisters |
| Infergen® |
12 injections (per month) |
| Kytril® tablets |
8 tablets |
| Kytril® solution |
30 mLs |
| Lunesta® |
14 tablets |
| Maxalt® |
12 tablets |
ondansetron HCL 4mg & 8mg
(Zofran®, Zofran ODT®) |
90 tablets |
| ondansetron HCL 24mg (Zofran®) |
30 tablets |
| ondansetron HCL oral solution (Zofran®) |
360 ml |
| Opana® ER |
80 mg per day |
| oxycodone HCL SR tablet (Oxycontin®) |
160 mg per day |
Relenza® |
10 discs (2 treatment courses) per 6 months |
| Relpax® |
12 tablets |
| Rozerem™ |
14 tablets |
| sumatriptan succinate tablet (Imitrex®) |
12 tablets |
Tamiflu® 30mg |
40 capsules (2 treatment courses) per 6 months |
| Tamiflu® 45mg |
20 capsules (2 treatment courses) per 6 months |
| Tamiflu® 75mg |
20 capsules (2 treatment courses) per 6 months |
| Tamiflu® 12mg/ml |
150ml (2 treatment courses) per 6 months |
| Treximet™ |
12 tablets |
| zaleplon (Sonata®) |
14 capsules |
| Zofran® 4 mg & 8 mg |
90 tablets |
| Zofran® 4 mg/5 ml oral solution |
360 ml |
| Zofran® 24 mg |
30 tablets |
| zolpidem tartrate (Ambien®) |
14 tablets |
| Zomig® |
12 tablets |
| Zomig® Nasal Spray |
6 canisters |
Effective September 11, 2009
Updated October 5, 2009
* This medication is FDA approved for once a week administration
only.
NOTE: In addition to the medications listed above, there
are limits to the amount of medication eligible for coverage
for all prescriptions. These limits are based on your prescription
benefit along with information from the FDA and scientific
literature about maximum, safe, effective dosage.

Prior Authorization Medication List - Retail/Prescription Benefit
Some medications may need prior authorization because better medication values are available.
For example, the generic options listed in bold are the best value for most members.
However, when it comes to medications, we also know that one-size may not fit all. That’s why for certain medications listed below that need prior authorization, we have an automated way to review your previous RegenceRx prescription history and automatically determine coverage for medications when certain criteria are met.
Medications that need Prior Authorization |
Possible Alternatives – Prior Authorization not necessary |
Cholesterol
Crestor® |
simvastatin (Zocor®), pravastatin (Pravachol®), lovastatin (Mevacor®) |
| Lipitor®,
Vytorin® |
simvastatin (Zocor®), pravastatin (Pravachol®), lovastatin (Mevacor®), or Crestor® |
Depression
Cymbalta®,
Effexor XR®,
Lexapro®,
Luvox® CR and Pristiq™ |
bupropion SR (Wellbutrin SR®), bupropion XL 300mg (Wellbutrin XL®), fluoxetine (Prozac®), fluvoxamine maleate, mirtazapine (Remeron®), paroxetine (Paxil®), sertraline (Zoloft®) |
Diabetes
ACTOplus met™,
Actos®, Avandamet®,
Avandaryl™,
Avandia®,
Byetta®,
Duetact™,
Janumet™,
Januvia™,
Onglyza™, Symlin®, SymlinPen™, Victoza® |
metformin (Glucophage®), insulin |
Migraines
Maxalt®, Maxalt-MLT®, Relpax® |
sumatriptan (Imitrex®) |
| Amerge®, Axert®, Frova®, Sumavel™ DosePro™, Treximet™,
Zomig®, Zomig-ZMT® |
sumatriptan (Imitrex®), Maxalt®, Maxalt-MLT®,
Relpax® |
Multiple Sclerosis
Betaseron®, Extavia® |
Avonex®, Copaxone®, Rebif® |
Nasal Steroids
Nasacort® AQ |
flunisolide (Nasalide®), fluticasone (Flonase®) |
| Beconase AQ®, Nasonex®, Omnaris®, Rhinocort Aqua®, Veramyst® |
flunisolide (Nasalide®), fluticasone (Flonase®), Nasacort® AQ |
Pain and Inflammation
Celebrex® |
Generic non-steroidal anti-inflammatory medications (NSAIDs) such as: diclofenac (Voltaren®), etodolac (Lodine®), flurbiprofen (Ansaid®), ibuprofen (Motrin®), indomethacin (Indocin®), ketoprofen (Orudis®), nabumetone (Relafen®), naproxen (Naprosyn®), oxaprozin (Daypro®), piroxicam (Feldene®), salsalate (Disalcid®), sulindac (Clinoril®), tolmetin (Tolectin®) |
Stomach Acid
Aciphex®, Kapidex™, lansoprazole, Nexium®, pantoprazole, Prevacid®, Protonix® |
omeprazole (Prilosec®) |
Other Medications that Have Limited Uses, May Not be a Covered Benefit or Require Medical Diagnostic Tests |
Actiq®
Actonel®
Actonel® with Calcium
Adcirca™
Afinitor®
amphetamine/dextroamphetamine
ER capsule (Mfgs: Global, Barr/Teva)
Ampyra™
Anzemet®
Arcalyst™
Boniva®
Cialis®
ciclopirox (topical solution)
Cimzia®
CNL 8T
Embeda™ |
Fentora™
Forteo®
Gleevec®
Growth Hormone
Humira®
Increlex™
Itraconazole
Kineret®
Kuvan™
Lamisil®
Levitra®
Lyrica®
Nexavar®
Nuvigil®
Onsolis™
Enbrel®
|
Oral Contraceptives
(coverage of birth control
is excluded)
Pegasys®
PEG-Intron®
PenLac®
Promacta®
Provigil®
Qualaquin™
Raptiva®
Relistor™
Retin-A® (after age 26)
Revatio™
Revlimid®
Sancuso®
Savella™
|
Simponi™
Sporanox®
Sprycel®
Sutent®
Tarceva®
Tasigna®
terbinafine
Tykerb®
Viagra®
Votrient™
Xenazine®
Xyrem®
Zavesca®
Zolinza™ |
|
Effective February 8, 2010
Updated February 10, 2010

Prior Authorization Medication List - Given in Physician Offices/Clinics
This list applies to injectable medications covered as part of the medical benefit.
Prior authorization is required for the following medications:
Actemra®
Amevive®
Arzerra™
Boniva® IV
botulinum toxin (Botox®, Dysport™, Myobloc®)
Cerezyme®
Cimzia®
Cinryze™
Erbitux®
Folotyn™
Growth Hormone |
ILaris®
intravenous immune globulin (IVIG)
Nplate®
Orencia™
Reclast®
Remicade®
Stelara™
Synagis®
Tysabri®
Velcade®
Xolair® |
Effective March 1, 2010
Updated March 1, 2010
Phone: 1 (800) 572-0316
Fax: 1 (800) 884-4282
- Before requesting prior authorization, please verify eligibility, benefits and medically managed delegation services through Customer Services.
- Member contracts determine benefits. Contract exclusions will not be prior authorized. Denials may be appealed through Customer Service.
- Medical policies related to specific prior authorization requirements may be available online at www.regence.com/trgmedpol.
NOTE: Because scientific information changes, our medication Prior Authorization List is subject to change.
If the requested medication is authorized, there maybe limits to the amount of medication that is eligible for coverage.
Please call our Customer Service Department if you have any questions.
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