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

Medical Prior-Authorization Medication
List (Medical Benefit)
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® |
Effective February 12, 2010
Updated February 12, 2010
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. |