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Prior Authorization & Medication Quantity Limits

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Regence BlueCross BlueShield of Utah

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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® tablets 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® 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
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.

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Prior Authorization Medication List

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™, Victoza® 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™, lansoprazole, 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)
Ampyra™
Anzemet®
Arcalyst™
Boniva®
Cialis®
ciclopirox (topical solution)
Cimzia®
CNL 8T
Embeda™
Enbrel®
Fentora™
Forteo®
Gleevec®
Growth Hormone
Humira®
Increlex™
Itraconazole
Kineret®
Kuvan™
Lamisil®
Levitra®
Lyrica®
Nexavar®
Nuvigil®
OnsolisT
Oral Contraceptives (some plans approve only for medical conditions and not for contraception)
Pegasys®
PEG-Intron®
PenLac®
Promacta®
Provigil®
Qualaquin™
Raptiva®
Relistor™
Retin-A®/Renova®
Revatio™
Revlimid®
Sancuso®
Savella™
Simponi™
Sporanox®
Sprycel®
Sutent®
Tarceva®
Tasigna®
terbinafine
Tykerb®
Viagra®
Votrient™
Xenazine®
Xyrem®
Zavesca®
Zolinza™

Effective March 1, 2010
Updated March 1, 2010

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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:

Actemra®
Amevive®
Arzerra™,
Boniva® IV
botulinum toxin (Botox®, Dysport™, Myobloc®)
Cerezyme®
Cimzia®
Cinryze™
Erbitux®
Folotyn™
Growth Hormone

ILaris®
intravenous immune globulin
(IVIG)
Nplate®
Orencia™
Reclast®
Remicade®
Stelara™
Synagis®
Tysabri®
Velcade®
Xolair®

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.

Effective February 12, 2010
Updated February 17, 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.