Prior Authorization & Medication Quantity Limits

RegenceRx

Medication Quantity Limits
Certain medications are FDA approved for short-term use.
Others may have adverse effects when overused. By using
information from the FDA, practicing doctors and pharmacists,
and scientific publications, our doctors and pharmacists
have established maximum quantities for the following medications.
Medications that Require Prior
Authorization if Prescribed Above the Maximum Quantity |
Maximum Quantity Per Month
Unless Otherwise Specified |
| Ambien CR™ |
14 tablets |
| Edluar™ |
14 tablets |
| Exalgo™ |
120 tablets |
| Imitrex® injection |
6 injections |
| Imitrex® Nasal Spray |
6 canisters |
| Infergen® |
12 injections (per month) |
| Intermezzo® |
14 tablets |
| Lunesta® |
14 tablets |
| Opana® ER |
80 mg per day |
Relenza® |
10 discs (2 treatment courses) per 6 months |
| 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 |
| zolpidem tartrate CR (Ambien CR™) |
14 tablets |
Effective March 9, 2012
Updated April 4, 2012
*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 dosages.

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 |
Cholesterol
atorvastatin, Crestor® |
simvastatin (Zocor®), pravastatin (Pravachol®), lovastatin (Mevacor®) |
| Lipitor®, Livalo®, Vytorin® |
simvastatin (Zocor®), pravastatin (Pravachol®), lovastatin (Mevacor®) or Crestor® |
Depression
Cymbalta®, Pristiq™, Viibryd™ |
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®,
Bydureon™, Byetta®,
Duetact™, Janumet®, Janumet® XR, Januvia™,
Jentadueto™, Juvisync™, Kombiglyze™ XR, Onglyza™, Tradjenta™, Victoza® |
metformin (Glucophage®), glimepiride (Amaryl®), glipizide (Glucotrol®), glyburide (Diabeta®), insulin |
High Blood Pressure Benicar®, Benicar HCT®, Micardis®, Micardis HCT® |
Benazepril/HCT (Lotensin/HCT®), captopril/HCT(Capoten/Captozide®) enalapril /HCT(Vasotec/Vaseretic®), fosinopril/HCT (Monopril/HCT®), lisinopril/HCT (Zestril/Zestoretic®, Prinivil/Prinzide®), losartan/HCT (Cozaar/Hyzaar®), moexipril/HCT (Univasc/Uniretic®), quinapril/HCT (Accupril/Accuretic®), trandolapril (Mavik®) |
| Amturnide™, Atacand®, Atacand-HCT®, Avalide®, Avapro®, Azor®, Diovan®, Diovan HCT®, Edarbi™, Exforge®, Exforge HCT®, Tekamlo™, Tekturna®, Tekturna HCT®, Teveten®, Teveten HCT®, Tribenzor™, Twynsta®, Valturna® |
Benazepril/HCT (Lotensin/HCT®), captopril /HCT(Capoten/Captozide®) enalapril/HCT (Vasotec/Vaseretic®), fosinopril/HCT (Monopril/HCT®), lisinopril/HCT (Zestril/Zestoretic®, Prinivil/Prinzide®), losartan/HCT (Cozaar/Hyzaar®), moexipril/HCT (Univasc/Uniretic®), quinapril/HCT (Accupril/Accuretic®), trandolapril (Mavik®), Benicar®, Benicar HCT®, Micardis®, Micardis HCT® |
Mental Health
Abilify®, Fanapt®, Geodon®, Invega®, Latuda®, Saphris®, ziprasidone |
clozapine (Clozaril®), olanzapine (Zyprexa®), risperidone (Risperdal®), Seroquel®, Seroquel XR® |
Migraines
Maxalt®, Maxalt-MLT®, Relpax® |
sumatriptan (Imitrex®) |
| Alsuma™, Amerge®, Axert®, Frova®, naratriptan, Sumavel™ DosePro™, Treximet™, Zomig®, Zomig-ZMT® |
sumatriptan (Imitrex®), Maxalt®, Maxalt-MLT®, Relpax® |
Multiple Sclerosis
Betaseron®, Extavia® |
Avonex®, Copaxone®, Rebif® |
Nasal Steroids
Beconase AQ®, Nasonex®, Omnaris®, Qnasl™, Rhinocort Aqua®, Veramyst®
|
flunisolide (Nasalide®), fluticasone (Flonase®), triamcinolone acetonide (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
Dexilant™, Kapidex™, lansoprazole |
omeprazole (Prilosec®) |
| Aciphex, Nexium®, Prevacid®, Vimovo™ |
omeprazole (Prilosec®), Dexilant™, Kapidex™ |
| Other Medications
that Have Limited Uses, May Not be a Covered Benefit
or Require Medical Diagnostic Tests |
Abstral®
Actiq®
Actonel®
Actonel® with Calcium
Adcirca™
Afinitor®
amphetamine/dextroamphetamine
ER capsule (Mfgs: Global, Barr/Teva)
Ampyra™
Arcalyst™
Atelvia™
Blood Glucose test strips and meters
(Mfgs: Lifescan/JJ, Abbott and Roche)
Caprelsa®
ciclopirox (topical solution)
Cimzia®
CNL 8™
Doryx®
Egrifta™
Embeda™ |
Enbrel®
Erivedge™
Fentora™
Firazyr®
Forteo®
Gilenya™
Gleevec®
Growth Hormone
Humira®
Incivek™
Increlex™
Inlyta®
Itraconazole
Jakafi™
Kalydeco™
Kineret®
Lamisil®
Lazanda®
Letairis®
Lyrica™
Modafinil
|
Nexavar®
Nuvigil®
Onsolis™
Orencia® SQ injection
OxyContin®
Pedipirox-4™
Pegasys®
PEG-Intron®
PenLac®
Promacta®
Provigil®
Qualaqun™
Raptiva®
Relistor™
Revatio™
Revlimid®
Savella™
Simponi™
Solodyn®
Sporanox®
Sprycel® |
Subsys™
Sutent®
Sylatron™
Tarceva™
Tasigna®
terbinafine
Tracleer®
Tykerb®
Tyvaso®
Vandetanib
Ventavis®
Victrelis™
Votrient™
Xalkori®
Xenazine®
Xyrem®
Zavesca®
Zelboraf™
Zolinza™
ZolpiMist™
Zytiga™ |
|

Effective April 6, 2012
Updated April 25, 2012
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. |