Prior Authorization & Medication Quantity Limits

Regence BlueCross BlueShield of Oregon

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® |
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® |
8 tablets |
| Kytril® Solution |
30 ml |
| 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 |
| 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 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 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 – 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™ |
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™, 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)
Anzemet®
Arcalyst™
Boniva®
ciclopirox (topical solution)
Cimzia®
CNL 8T |
Embeda™
Enbrel®
Fentora™
Forteo®
Gleevec®
Growth Hormone
Humira®
Increlex™
Itraconazole
Kineret®
Kuvan™
Lamisil®
Lyrica™
Nexavar® |
Nuvigil®
Onsolis™
PEG-Intron®
Pegasys®
PenLac®
Promacta®
Provigil®
Qualaqun™
Raptiva®
Relistor™
Revatio™
Revlimid®
Sancuso®
Savella™
Simponi™ |
Sporanox®
Sprycel®
Sutent®
Tarceva™
Tasigna®
terbinafine
Tykerb®
Votrient™
Xenazine®
Xyrem®
Zavesca®
Zolinza™ |
|
Effective February 1, 2010
Updated February 1, 2010

Prior-Authorization List for Medications
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®
Boniva® IV
botulinum toxin (Botox®, Myobloc®)
Cerezyme®
Cimzia®
Cinryze™
Erbitux®
Growth Hormone
ILaris® |
intravenous immune globulin (IVIG)
Nplate®
Orencia™
Reclast®
Remicade®
Stelara™
Synagis®
Tysabri®
Velcade®
Xolair® |
Phone: 1 (800) 643-5918
Fax: 1 (888) 437-1510
- Before requesting prior authorization, please verify
eligibility, benefits and medically managed delegation
services through Customer Services.
- Verification of member eligibility is valid if obtained
within five business days of the service except in the
case of a misrepresentation.
NOTE: Verification of eligibility within five days of
service does not guarantee payment on Preferred Choice
Sixty-Five, First Choice Sixty-Five, Medicare supplements,
policies issued outside of Oregon and Washington, or
self-funded employer plans.
- Member contracts determine benefits. Contract exclusions
will not be prior authorized. Denials may be appealed
through Customer Service.
- Prior authorization obtained within 90 business days
prior to the service is valid except in the case of a
misrepresentation.
- Medical policies related to specific prior authorization
requirements may be available online.

Effective February 1, 2010
Updated January 29, 2010
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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