Prior Authorization & Medication Quantity Limits

Regence BlueCross BlueShield of Oregon

• Retail Medication Quantity Limits
• Prior Authorization Medication List (Retail Pharmacy Benefit)
• Medical Prior-Authorization Medication List (Medical Benefit)
• Medical Medication Maximum Billing Unit Limits

Retail 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.

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 Pharmacy 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.

Effective April 6, 2012
Updated April 25, 2012

Medical Prior-Authorization Medication List (Medical Benefit)

This list applies to injectable medications covered as part of the medical benefit. Prior authorization is required for the following medications:

Phone: 1 (800) 643-5918
Fax: 1 (888) 437-1510

1. Before requesting prior authorization, please verify eligibility, benefits and medically managed delegation services through Customer Services.
2. 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 Medicare supplements, policies issued outside of Oregon and Washington, or self-funded employer plans.
3. Member contracts determine benefits. Contract exclusions will not be prior authorized. Denials may be appealed through Customer Service.
4. Prior authorization obtained within 90 business days prior to the service is valid except in the case of a misrepresentation.
5. Medical policies related to specific prior authorization requirements may be available online.

Effective December 1, 2011
Updated December 1, 2011

Medical Medication Maximum Billing Unit Limits

Effective September 1, RegenceRx® will cover up to the maximum safe dose for some medications that are usually administered in a provider's office and covered under the member's medical benefit.

RegenceRx will provide reimbursement for the listed medications up to the recognized maximum safe and effective dose. Doses exceeding the maximum dose limit will only be reimbursed up to the medication maximum billing unit limits, unless documentation has been provided for the medical necessity of higher dosing.

Specific medications with maximum safe and effective dose limits are listed in the following Medication Policy.

Please note: Some medications may require prior authorization, please also see the Medical Prior-Authorization Medication List (Medical Benefit).

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.