Prior Authorization & Medication Quantity Limits
Regence BlueShield (Washington)
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 |
| Emend® |
2 capsules of 125mg, plus 4 capsules of 80mg |
| Frova® |
12 tablets |
| granisetron HCL tablet (Kytril®) |
8 tablets |
| Imitrex® |
12 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 |
| OxyContin® |
160 mg per day |
| Relenza® |
10 discs (two treatment courses) per 6
months |
| Relpax® |
12 tablets |
| Rozerem™ |
14 tablets |
| Sonata® |
14 capsules |
| Stadol Nasal Spray® |
1 canister |
| Tamiflu® 30mg |
40 capsules (two treatment courses) per 6 months |
| Tamiflu® 45mg & 75mg |
20 capsules (two treatment courses) per 6 months |
| Tamiflu® 12mg/ml |
150ml (two treatment courses) per 6 months |
| Treximet™ |
12 tablets |
| 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 Pharmacy Benefit)
| Medications that need Prior
Authorization |
Possible Alternatives –
Prior Authorization not necessary |
Cholesterol
Crestor®,
Lipitor®,
Vytorin® |
simvastatin (Zocor®), pravastatin (Pravachol®), lovastatin (Mevacor®) |
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™, Symlin®, SymlinPen™ |
metformin (Glucophage®), insulin |
Multiple Sclerosis
Betaseron®
|
Avonex®, Copaxone®, Rebif® |
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®, Nexium®, Prevacid®, Protonix® |
omeprazole (Prilosec®), Prilosec OTC™ |
| Other Medications that Have Limited
Uses, May Not be a Covered Benefit or Require Medical
Diagnostic Tests |
Actiq®
Aranesp®
ciclopirox (topical solution)
Cimzia®
CNL 8™
Enbrel®
Epogen®
Fentora™
Forteo®
|
Gleevec®
Humira®
Increlex™
Itraconazole
Kineret®
Kuvan™
Lamisil®
Lyrica™
Nexavar®
|
Pegasys®
PEG-Intron®
PenLac®
Procrit®
Provigil®
Raptiva®
Revatio™
Revlimid®
Sporanox® |
Sprycel®
Sutent®
Tarceva™
Tasigna®
terbinafine
Tykerb®
Xyrem®
Zavesca®
Zolinza™ |
|
Effective July 1, 2008
Updated July 14, 2008
Medical Prior-Authorization Medication
List (Medical Benefit)
Amevive®
Aranesp® (implementation 3/14/2008)
botulinum toxin (Botox®, Myobloc®)
Cerezyme®
Epogen® (implementation 3/14/2008)
Growth Hormone
intravenous immune globulin (IVIG)
|
Procrit® (implementation 3/14/2008)
Orencia™
Remicade®
Synagis®
Tysabri®
Xolair® |
Effective April 12, 2007
Updated April 20, 2007
NOTE: Because scientific information changes, our Medication
Prior Authorization List is subject to change. Please call
our Customer Service Department if you have any questions.
NOTE: If the requested medication is authorized, there
may be limits to the amount of medication that is eligible
for coverage. These limits are based on information from
the FDA and scientific literature.
|