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 |
| Emend® |
2 capsules of 125mg, plus 4 capsules of 80mg |
| Frova® |
12 tablets |
| granisetron HCL tablet (Kytril®) |
8 tablets |
| Imitrex® |
12 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 |
| Oxycontin® |
160 mg per day |
| Relenza® |
10 discs (two treatment courses) per
6 months |
| Relpax® |
12 tablets |
| Rozerem™ |
14 tablets |
| Sonata® |
14 capsules |
| Stadol NS® |
1 canister (2.5 ml) |
| Tamiflu® 30mg |
40 capsules (two treatment courses) per 6 months |
| Tamiflu® 45mg & 75mg |
20 capsules (two treatment courses) per 6 months |
| Tamiflu® 12mg/ml |
150ml (two treatment courses) per 6 months |
| Treximet™ |
12 tablets |
| 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 July 1, 2008
Updated July 14, 2008
* 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
Medications that need Prior Authorization |
Possible Alternatives – Prior Authorization not necessary |
Cholesterol
Crestor®,
Lipitor®,
Vytorin® |
simvastatin (Zocor®), pravastatin (Pravachol®), lovastatin (Mevacor®) |
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™,
Symlin®, SymlinPen™ |
metformin (Glucophage®), insulin |
Multiple Sclerosis
Betaseron® |
Avonex®, Copaxone®, Rebif® |
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®, Nexium®, Prevacid®, Protonix® |
omeprazole (Prilosec®), Prilosec OTC™ |
Other Medications that Have Limited Uses, May Not be a Covered Benefit or Require Medical Diagnostic Tests |
Actiq®
Aranesp®
Cialis®
ciclopirox (topical solution)
Cimzia®
CNL 8™
Enbrel®
Epogen®
Fentora™
Forteo®
Gleevec®
|
Humira®
Increlex™
Itraconazole
Kineret®
Kuvan™
Lamisil®
Levitra®
Lyrica®
Nexavar®
Oral Contraceptives (coverage of birth
control is excluded) |
Pegasys®
PEG-Intron®
PenLac®
Procrit®
Provigil®
Raptiva®
Retin-A® (after age 26)
Revatio™
Revlimid®
Sporanox® |
Sprycel®
Sutent®
Tarceva®
Tasigna®
terbinafine
Tykerb®
Viagra®
Xyrem®
Zavesca®
Zolinza™ |
|
Effective July 1, 2008
Updated July 14, 2008
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:
Amevive®
Aranesp® (implementation 3/14/2008)
botulinum toxin (Botox®, Myobloc®)
Cerezyme®
Epogen® (implementation 3/14/2008)
Growth Hormone
intravenous immune globulin (IVIG)
|
Procrit® (implementation 3/14/2008)
Orencia™
Remicade®
Synagis®
Tysabri®
Xolair® |
Effective June 5, 2007
Updated June 5, 2007
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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