QUANTITY LEVEL LIMIT (QLL) GUIDELINE

Transcription

1 PENNSYLVANIA Last Review: 10/2010 QUANTITY LEVEL LIMIT (QLL) GUIDELINE Requirements Appropriate dose of medication based on age (e.g., pediatric and elderly populations) and indication AND Appropriate dosage for diagnosis/indication for requested medication as documented by medical records AND Documented trial and failure of quantity level limit (QLL) for an adequate duration have not been effective or tolerated OR 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 FDA-approved dosage level. Initial Approval If the above requirements are met, the request will be approved for a minimum of 1 month or course of therapy depending upon the diagnosis and usual treatment. If the above conditions are not met, the request will be referred to a Medical Director for medical necessity review and for final determination. Renewal Minimum of 1 month per medical records documenting treatment response OR Rx history showing compliance Drug Compendia 1. FDA-approved drug monographs 2. American Medical Hospital Formulary Service Drug Information 3. Drug Facts and Comparisons 4. American Medical Association Drug Evaluations 5. Clinical Pharmacology Primary Reference Policy Pharmacy Prior Authorization

2 PENNSYLVANIA Last Review: 10/2010 ANTIINFECTIVES CEPHALOSPORINS REFERENCE NAME 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 clavulanate Augmentin QLL=28/30 days QUINOLONES ciprofloxacin er Cipro XR QLL=3 tabs/rx ciprofloxacin hcl Cipro QLL=28 tabs/30 days LEVAQUIN QLL=14 tabs/90 days ORAL ANTIFUNGALS fluconazole Diflucan 150 MG QLL=1 tab/rx terbinafine Lamisil QLL=84 tabs/year OTHER ANTIVIRAL S 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 valacyclovir Valtrex 500 mg tablet=60 tabs/30 days 1 gram tablet: QLL=30 tabs/30 days 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= up to 4 grams APAP/day 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

3 REFERENCE NAME 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 Tylenol #3 QLL= up to 4 grams APAP/day CLASS III NARCOTICS acetaminophencodeine hydrocodoneacetaminophen Vicodin QLL= up to 4 grams APAP/day hydrocodone bitibuprofen Vicoprofen QLL=240 tabs/30 days S TO PREVENT AND TREAT HEADACHES butorphanol nasal Stadol QLL=1 bottle/30 days spray 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 QLL=90 tabs/30 days DIASTAT QLL=2 pkgs/30 days SEDATIVE/HYPNOTIC S chloral hydrate QLL=300 ml/30 days; 30 suppositories/30 days estazolam flurazepam hcl Dalmane QLL=30 caps/30 days temazepam Restoril QLL=30 caps/30 days ROZEREM zaleplon Sonata QLL=30 caps/30 days zolpidem Ambien 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

4 fluvoxamine maleate REFERENCE NAME 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 SR bupropion, xl, sr Wellbutrin QLL=90 tabs/30 days Wellbutrin XL mirtazapine Remeron ANTIVERTIGO AND ANTIEMETIC S granisetron Kytril QLL=2 tabs/rx OTHER ANTIPARKINSON S COMTAN QLL=120 tabs/30 days ropinirole Requip QLL=90 tabs/30 days STALEVO QLL=270 tabs/30 days ANTIPSYCHOTIC S risperidone, ODT SEROQUEL CNS STIMULANT S amphetamine/ dextroamphetamine methylin chewable Risperdal Risperdal M-Tab Adderall, Adderall XR Ritalin QLL=90 tabs/30 days; 300 mg=60 tabs/30 days Immediate release QLL=90 tabs/30 days; Extended release QLL=60 caps/30 days QLL=120 tabs/30 days tabs, suspension methylphenidate hcl Ritalin QLL=120 tabs/30 days METADATE CD QLL=30 caps/30 days ANTIDEMENTIA S ARICEPT, ODT galantamine, -ER rivastigmine capsules Razadyne, Razadyne ER Exelon galantamine galantamine ER QLL=30 caps/30 days QLL=60 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 hcl Cardizem QLL=120 tabs/30 days nifedical xl QLL=90 tabs/30 days nifedipine, er Procardia Procardia XL Extended Release QLL=90/30 days

5 REFERENCE NAME nisoldipine Sular verapamil, er Verelan/Calan/Calan SR QLL for Immediate Release=120 units/30days; QLL for Extended Release=60 units/30 days 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 S ADCIRCA ; HYPOLIPOPROTEINEMICS gemfibrozil Lopid HMG-COA REDUCTASE INHIBITORS* lovastatin Mevacor ; 40 mg=60 tabs/30 days pravastatin Pravachol simvastatin Zocor LESCOL LESCOL XL QLL=60 caps/30 days DERMATOLOGICAL MEDICATIONS ANTIACNE S tretinoin Avita/Retin-A QLL=20 gram tube/30days TOPICAL DERMATOLOGICAL S ELIDEL EAR-NOSE-THROAT MEDICATIONS S AFFECTING THE NOSE QLL=30 gm/30 days azelastine Astelin QLL= 2 bottles/30 days NASONEX QLL=2 bottles/30 days ENDOCRINE MEDICATIONS INSULIN SENSITIZERS ACTOPLUS MET ACTOS AVANDAMET AVANDARYL AVANDIA QLL=90 tabs/30 days

6 REFERENCE NAME DUETACT OTHER ENDOCRINE S 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 GASTROINTESTINAL MEDICATIONS PROTON PUMP INHIBITORS omeprazole, OTC omeprazole, QLL=1 bottle/30 days; QLL=90 tabs/30 days QLL=120 tabs and caps /30 days OTC PRILOSEC pantoprazole Protonix LAXATIVES AND CATHARTICS OTC MIRALAX QLL=510 g/30 days OTHER GI S AMITIZA IMMUNOLOGICALS AND VACCINES FLUMIST QLL=60 caps/30 days MUSCULOSKELETAL MEDICATIONS ketorolac Toradol QLL=20 tabs/30 days and 2 Rxs per 90 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 metaxalone Skelaxin QLL=120 tabs/30 days NUTRITION, BLOOD MODIFIERS, ELECTROLYTES LOW-MOLECULAR WEIGHT HEPARINS (LMWH) enoxaparin [inj] Lovenox 10 DAYS W/O PA FRAGMIN [inj] ANTIPLATELET S 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 (10 DAYS=20 SYRINGES) 10 DAYS W/O PA (10 DAYS=10 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

7 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 S estradiol transdermal patch REFERENCE NAME Climara SELECTIVE ESTROGEN RECEPTOR MODULATOR EVISTA PROGESTIN S medroxyprogesterone acetate (inj) Provera RESPIRATORY MEDICATIONS BETA-2 ADRENERGIC S albuterol sulfate (inhalation soln, syrup, tablet) PROAIR HFA PROVENTIL HFA VENTOLIN HFA INHALED CORTICOSTEROIDS budesonide Pulmicort Respules respules 0.25 mg/1 ml, 0.50 mg/1 ml PULMICORT RESPULES1 MG/1 ML RESPULES PULMICORT FLEXHALER/ INHALER LEUKOTRIENE MODIFIERS QLL=4 patches/30 days QLL for injection=1/90 days QLL=375 ml/30 days for inhalation soln QLL= 2 inhalers/30 days QLL= 2 inhalers/30 days QLL= 2 inhalers/30 days QLL=120 ml/30 days (60 respules/30 days) QLL=120 ml/30 days (60 respules/30 days) QLL=1 inhaler or flexhaler/30 days

8 REFERENCE NAME ACCOLATE SINGULAIR OTHER RESPIRATORY S SPIRIVA QLL=30 caps/30 days (pkg size=30); 6 caps/30 days (pkg size=6); 1 pkg/30 days (pkg size=5); ANTIHISTAMINES OTC cetirizine tablets, solution; OTC cetirizine-d tablets OTC Zyrtec OTC Zyrtec-D cetirizine-d cetirizine soln QLL=150 ml/30 days OTC loratadine D OTC Claritin-D ANTITUSSIVE AND EXPECTORANT S benzonatate Tessalon QLL= 90 capsules/ 30days UROLOGICAL MEDICATIONS ANTICHOLINERGIC ANTISPASMODICS S trospium Sanctura MEDICAL (MISCELLANEOUS) SUPPLIES DIABETIC SUPPLIES: Combined QLL for test strips=204/month ACCU-CHEK ACCU-CHEK III ACCU-CHEK AVIVA GLUCOMETER/ TEST STRIPS ACCU-CHEK ACTIVE GLUCOMETER/ TEST STRIPS ACCU-CHEK ADVANTAGE GLUCOMETER/ TEST STRIPS ACCU-CHEK COMFORT CURVE TEST STRIPS ONE TOUCH ULTRA2, UKTRALINK, ULTRAMINI, ULTRASMART ONE TOUCH SELECT ONE TOUCH TEST STRIPS OTHER SUPPLIES AEROCHAMBER, MICROCHAMBER

9 ASSESS PEAK FLOW METER MICROLIFE PEAK FLOW METER PERSONAL BEST PEAK FLOW METER REFERENCE NAME