AETNA BETTER HEALTH Prior Authorization guideline for Quantity Level-Limits

Transcription

1 AETNA BETTER HEALTH Prior Authorization guideline for Quantity Level-Limits Authorization guidelines For patients who have the following: 1. Appropriate dose of medication based on age (e.g., pediatric and elderly populations) and indication AND 2. Appropriate dosage for diagnosis/indication for requested medication as documented by medical records AND 3. Documented trial and failure of quantity level limit (QLL) for an adequate duration have not been effective or tolerated OR 4. Dosage requested must be based on national established/ recognized guidelines pertaining to the treatment and management of the diagnosis which it is being used to treat. OR 5. FDA-approved dosage level. Authorization and Limitations Initial Approval: 1 year Extended Approval: 3 years Additional Information: Increased quantity levels are NOT covered for members with the following criteria: Use not approved by the FDA; AND The use is unapproved and not supported by the literature or evidence as an accepted off-label use. Medically Necessary A service or benefit is Medically Necessary if it is compensable under the MA Program and if it meets any one of the following standards: The service or benefit will, or is reasonably expected to, prevent the onset of an illness, condition or disability. The service or benefit will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability. The service or benefit will assist the Member to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional

2 capacity of the Member and those functional capacities that are appropriate for Members of the same age. Determination of Medical Necessity for covered care and services, whether made on a Prior Authorization, Concurrent Review, Retrospective Review, or exception basis, must be documented in writing. The determination is based on medical information provided by the Member, the Member s family/caretaker and the Primary Care Practitioner, as well as any other Providers, programs, agencies that have evaluated the Member. All such determinations must be made by qualified and trained Health Care Providers. Any determinations that may result in a denied, request will be made by the Medical Director. A Health Care Provider who makes such determinations of Medical Necessity is not considered to be providing a health care service under this Agreement. COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS ANTIINFECTIVES CEPHALOSPORINS ceftriaxone Rocephin QLL=2 grams/rx SUPRAX QLL= 1 tab/rx OTHER MACROLIDES azithromycin Zithromax QLL for 250 mg=12 tabs/30 days QLL for 600 mg=8 tabs/30 days clarithromycin, er Biaxin, Biaxin XL QLL=14 tabs/30 days for extended-release; QLL=28 tabs/30 days for immediate-release PENICILLINS amox tr-potassium Augmentin QLL=28/30 days clavulanate QUINOLONES ciprofloxacin er Cipro XR QLL=3 tabs/rx ciprofloxacin hcl Cipro QLL=28 tabs/30 days LEVAQUIN QLL=14 tabs/90 days ORAL ANTIFUNGALDRUGS fluconazole Diflucan 150 MG QLL=1 tab/rx terbinafine Lamisil QLL=84 tabs/year OTHER ANTIVIRAL DRUGS acyclovir Zovirax QLL=60 caps or tabs/30 days rimantadine Flumadine QLL=7 tabs/30 days RELENZA QLL/Rx=20 inhalation diskus/rx TAMIFLU QLL/Rx=75mg 10 capsules/rx; 45mg 10 capsules /Rx; 30mg 20 capsules/rx; 12mg/ml oral suspension 3 bottles/rx VALTREX (1 GRAM TABLET ONLY)

3 COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS AUTONOMIC AND CNS MEDICATIONS ANALGESICS OTC acetaminophen tablets, capsules, suppositories, liquids, drops Tylenol QLL= up to 4 grams APAP/day tramadol hcl Ultram QLL=240 tabs/30 days tramadol hclacetaminophen Ultracet QLL= 240 tabs/30 days or daily max dose of 8 tab/day BENZODIAZEPINES alprazolam clonazepam diazepam estrazolam flurazepam QLL =120 tabs/30days 2mg QLL= 60/30days QLL =120 tabs/30days 2mg QLL= 60/30days QLL = 120 tabs/30days, QLL = 30 caps/30 days lorazepam temazepam Restoril QLL =120 tabs/30days 2mg QLL= 60/30days QLL=30 caps/30 days triazolam CLASS II NARCOTICS codeine sulfate fentanyl patches Duragesic QLL=10 patches/30 days fentanyl lozenges Actiq QLL=120 lozenges /30 days hydromorphone hcl Dilaudid QLL for 8 mg=120 tabs/30 days methadone hcl Dolophine QLL=540 tabs/30 days oxycodoneacetaminophen Percocet QLL=240 tabs/30 days or up to 4 grams APAP/day oxycodone-aspirin QLL=240 tabs/30 days oxycodone hcl Oxyir QLL for 5 mg=240 tabs/30 days, 10 mg,15 mg, 20 mg, or 30 mg=150 tabs/30 days CLASS III NARCOTICS acetaminophencodeine Tylenol #3 QLL= up to 4 grams APAP/day hydrocodoneacetaminophen Vicodin QLL= up to 4 grams APAP/day hydrocodone bitibuprofen Vicoprofen QLL=150 tabs/30 days DRUGS TO PREVENT AND TREAT HEADACHES butorphanol nasal spray Stadol QLL=1 bottle/30 days

4 COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS sumatriptan Imitrex QLL=6 nasal sprays/30 days; 9 tabs/30 days sumatriptan (inj) Imitrex QLL=4 vials/30 days; 1 kit/30 days MIGRANAL QLL=8 units/30 days RELPAX QLL=6 tabs/30 days ANXIOLYTICS buspirone hcl Buspar DIASTAT QLL=2 pkgs/30 days SEDATIVE/HYPNOTIC DRUGS chloral hydrate QLL=300 ml/30 days; 30 suppositories/30 days flurazepam hcl Dalmane QLL=30 caps/30 days ROZEREM zaleplon Sonata QLL=30 caps/30 days CARBAMAZEPINES carbamazepine ER Tegretol XR QLL=400 tabs/100 days OTHER ANTICONVULSANTS gabapentin Neurontin QLL=180 units/30 days GABITRIL topiramate Topamax QLL=120 units/30 days zonisamide Zonegran QLL=180 units/30 days SELECTIVE SEROTONIN REUPTAKE INHIBITORS citalopram Celexa or 300 ml/30 days fluoxetine hcl Prozac QLL for 10 mg=30 caps/30 days; 20 mg, 40 mg= 60 tabs/caps/ 30 days; soln=150 ml/30 days fluvoxamine maleate Luvox QLL for 100 mg=90 tabs/30 days; 50 mg=60 tabs/30 days; 25 mg= 30 tabs/30 days paroxetine hcl Paxil ; soln=300 ml/30 days sertraline hcl Zoloft QLL for 25 mg=30 tabs/30 days; 50 mg or 100 mg=60 tabs/30 days; soln=75 ml/30 days OTHER ANTIDEPRESSANTS budeprion sr Wellbutrin XL bupropion, sr Wellbutrin QLL=90 tabs/30 days mirtazapine Remeron OTHER ANTIPARKINSON DRUGS entacopone COMTAN QLL=240 tabs/30 days ropinirole Requip QLL=90 tabs/30 days STALEVO QLL=270 tabs/30 days ANTIPSYCHOTIC DRUGS risperidone Risperdal quetiapine SEROQUEL QLL=90 tabs/30 days; 300 and 400 mg=60 tabs/30 days

5 CNS STIMULANT DRUGS amphetamine/ dextroamphetamine methylin chewable tabs, suspension Adderall, Adderall XR Ritalin Immediate release QLL=90 tabs/30 days; Extended release QLL=60 caps/30 days QLL=120 tabs/30 days QLL suspension= 600ml/30 days methylphenidate hcl Ritalin QLL=120 tabs/30 days METADATE CD QLL=30 caps/30 days ANTIDEMENTIA DRUGS ARICEPT, ODT EXELON QLL=60 caps/30 days galantamine, -ER Razadyne, Razadyne ER galantamine galantamine ER QLL=30 caps/30 days CARDIOVASCULAR MEDICATIONS CALCIUM ANTAGONISTS amlodipine Norvasc QLL= 30 tabs/30 days diltiazem er Tiazac/Taztia XT QLL=30 caps or tabs/30 days diltiazem sr QLL = 60 caps/30days diltiazem hcl Cardizem QLL=4 tabs/day nifedipine er Procardia XL QLL=90 tabs/30 days 90mg QLL = 60 tabs/30days verapamil er Verelan/Calan SR QLL=60 caps or tabs/30days 300mg, 360mg QLL = 30 caps/30days VASODILATOR ANTIHYPERTENSIVES doxazosin mesylate Cardura terazosin hcl Hytrin QLL 1mg, 2mg, 5mg=30/30 days; QLL 10 mg=60/30 days ANGIOTENSIN CONVERTING ENZYME INHIBITORS lisinopril Prinivil/Zestril ; 40 mg=60 tabs/30 days ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR DIOVAN ; OTHER ANTIHYPERTENSIVES BENICAR HCT DIOVAN HCT OTHER VASODILATING DRUGS ADCIRCA HYPOLIPOPROTEINEMICS gemfibrozil Lopid HMG-COA REDUCTASE INHIBITORS* lovastatin Mevacor ; 40 mg=60 tabs/30 days pravastatin Pravachol simvastatin Zocor LESCOL QLL=60 caps/30 days LESCOL XL

6 DERMATOLOGICAL MEDICATIONS ANTIACNE DRUGS tretinoin Avita/Retin-A QLL=20 gram tube/30days TOPICAL DERMATOLOGICAL DRUGS ELIDEL EAR-NOSE-THROAT MEDICATIONS DRUGS AFFECTING THE NOSE ASTELIN NASONEX ENDOCRINE MEDICATIONS INSULIN SENSITIZERS ACTOPLUS MET ACTOS AVANDAMET AVANDARYL AVANDIA DUETACT QLL=30 gm/30 days QLL= 2 bottles/30 days QLL=2 bottles/30 days QLL=90 tabs/30 days 4mg/1mg,4mg/2mg 4mg/4mg,8mg/2mg,8mg/4mg =QLL 30/30 days OTHER ENDOCRINE DRUGS alendronate sodium Fosamax QLL 35 mg or 70 mg=4 tabs/30 days; QLL 5 mg,10 mg, 40 mg=30 tabs/30 days desmopressin acetate DDAVP/Minirin QLL=1 bottle/30 days; QLL=90 tabs/30 days GASTROINTESTINAL MEDICATIONS PROTON PUMP INHIBITORS omeprazole, OTC omeprazole, OTC PRILOSEC QLL=120 tabs and caps /30 days pantoprazole Protonix LAXATIVES AND CATHARTICS OTC MIRALAX QLL=510 g/30 days OTHER GI DRUGS AMITIZA QLL=60 caps/30 days IMMUNOLOGICALS AND VACCINES FLUMIST QLL=#1/YEAR MUSCULOSKELETAL MEDICATIONS ketorolac Toradol QLL=20 tabs/30 days and 2 Rxs per 90 days DIRECT MUSCLE RELAXANTS SKELAXIN QLL=120 tabs/30 days CNS MUSCLE RELAXANTS carisoprodol Soma QLL=120 tabs/30 days cyclobenzaprine hcl Flexeril QLL=120 tabs/30 days methocarbamol Robaxin QLL=120 tabs/30 days

7 NUTRITION, BLOOD MODIFIERS, ELECTROLYTES LOW-MOLECULAR WEIGHT HEPARINS (LMWH) FRAGMIN [inj] LOVENOX [inj] ANTIPLATELET DRUGS PLAVIX OBSTETRICAL & GYNECOLOGICAL MEDICATIONS CONTRACEPTIVES NUVARING ORTHO EVRA OTC NEXT CHOICE OTC PLAN B ONE STEP PRENATAL VITAMINS (LEGEND PRODUCTS) QLL=100 tabs/90 days for all legend prenatal vitamins advanced care plus bp multinatal plus carenatal DHA cal-nate folbecal prenatal advantage (prenatal AD) prenatal low iron prenatal H prenatal U trimesis rx trinate ultra-natal vinatal forte vinate ultra vinate calcium vitafol-ob vitafol-pn vitaspire ESTROGEN DRUGS estradiol transdermal Climara patch SELECTIVE ESTROGEN RECEPTOR MODULATOR EVISTA PROGESTIN DRUGS medroxyprogesterone acetate (inj) RESPIRATORY MEDICATIONS BETA-2 ADRENERGIC DRUGS albuterol sulfate Depo-Provera 10 DAYS W/O PA (10 DAYS=10 SYRINGES) 10 DAYS W/O PA (10 DAYS=20 SYRINGES) QLL=1 ring/month QLL=3 patches/28 days QLL=2 tabs (1 pkg)/1 month; QLL=6 tabs (3 pkg)/year QLL=1 tab (1 pkg)/1 month; QLL=3 tabs (3 pkg)/year QLL=8 patches/30 days QLL for injection=1/90 days QLL=375 ml/30 days for inhalation soln

8 (inhalation soln, PROAIR HFA PROVENTIL HFA VENTOLIN HFA INHALED CORTICOSTEROIDS PULMICORT RESPULES QLL= 2 inhalers/30 days QLL= 2 inhalers/30 days QLL= 2 inhalers/30 days QLL=60 respules30 days PULMICORT FLEXHALER/INHALER LEUKOTRIENE MODIFIERS ACCOLATE SINGULAIR OTHER RESPIRATORY DRUGS SPIRIVA ANTIHISTAMINES OTC cetirizine tablets, solution OTC Zyrtec QLL=1 inhaler or flexhaler/30 days QLL=30 caps/30 days (pkg size=30); 6 caps/30 days (pkg size=6); 1 pkg/30 days (pkg size=5); QLL=1 tabs/day 150 ml/30 days ANTITUSSIVE AND EXPECTORANT DRUGS benzonatate Tessalon QLL= 90 capsules/ 30days UROLOGICAL MEDICATIONS ANTICHOLINERGIC ANTISPASMODICS DRUGS SANCTURA MEDICAL (MISCELLANEOUS) SUPPLIES DIABETIC SUPPLIES: Combined QLL for test strips=150/month ONE TOUCH ULTRA2, UKTRALINK, ULTRAMINI, ULTRASMART ONE TOUCH SELECT ONE TOUCH TEST STRIPS OTHER SUPPLIES AEROCHAMBER, MICROCHAMBER ASSESS PEAK FLOW METER MICROLIFE PEAK FLOW METER PERSONAL BEST PEAK FLOW METER 1 per year 1 per year 1 per year 1 per year