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Prior Authorization & Medication Quantity Limits

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Regence BlueShield of Idaho

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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.

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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

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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

  1. Before requesting prior authorization, please verify eligibility, benefits and medically managed delegation services through Customer Services.
  2. Member contracts determine benefits. Contract exclusions will not be prior authorized.  Denials may be appealed through Customer Service.
  3. 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.