Prior Authorization & Medication Quantity Limits

Regence BlueCross BlueShield of Oregon

• Medication Quantity Limits
• Prior-Authorization Medication List - Retail/Prescription Benefit
• Prior-Authorization List for Medications Given in Physician Offices/Clinics

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 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.

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:

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 Preferred Choice Sixty-Five, First Choice Sixty-Five, 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 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.