Guardian Coverage Management

Transcription

1 What is Coverage Management? Coverage Management is a review of certain prescribed drugs, or drug quantities to verify that they are covered according to plan rules. Plan rules are based on FDA approved prescribing and safety information, clinical guidelines, and uses that are considered reasonable, safe and effective. Please note that this program is not intended to limit the doctor s ability to treat his/her patient s healthcare needs, but rather to ensure the coverage of medications based on accepted medical uses. Refer to the accompanying list of drugs that require prior authorization, or visit and select the Prescription Drug link under the Resources heading. Or, speak with a Member Services representative by calling for assistance. The list of drugs requiring prior authorization may be updated periodically, so be sure to visit the site occasionally to stay informed of any changes. Obtaining Prior Authorization for your Save time get the process started early! To initiate the process, ask your doctor to call Medco at before you leave his or her office. Medco will review the information with your doctor. In certain cases, a Utilization Review Agent, other than Medco, may also review the information with your doctor. Based on the review outcome, coverage for your will be approved or denied. If your doctor has not previously contacted Medco, the process of initiating the review will vary, depending on how you choose to fill your. This is described in more detail below. Medco By Mail Depending on the prior authorization your is subject to, either a mail-order pharmacist will perform the review before filling the, or you will receive up to the maximum amount allowed by your plan. When your medication is not subject to dispensing limits, the mail-order pharmacist will initiate the review with your doctor. When your medication is subject to dispensing limits, your will be filled up to the allowable quantity and you will be asked to call your doctor to begin a coverage review for the remaining amount. If the remaining amount is approved, you should submit a new for the full quantity to avoid paying an additional cost-share for the remaining amount. Participating retail pharmacy The pharmacist will tell you if a needs prior authorization. Either you or the pharmacist may call your doctor to initiate the process. nparticipating retail pharmacy The pharmacist will fill your. When you submit your claim for reimbursement and your requires prior authorization, you will be notified to initiate the process and resubmit your claim. If coverage is limited to a smaller quantity or shorter duration, you will only be reimbursed for the authorized amount and you will be asked to contact your doctor to initiate the authorization process for the non-authorized amount. If coverage is approved, you must submit a claim for the additional amount to be reimbursed, less your cost-share. Additional Information You and your doctor will be informed if coverage for your is approved or denied. If coverage is denied, you will have the right to appeal. For additional information on Coverage Management, refer to the Coverage Management FAQ. If you have questions on Coverage Management or how to file an appeal, please contact Medco Member Services at Representatives are available to assist you 24 hours a day, 7 a week. Page 1 of 23

2 Prescription Drugs Requiring Prior Authorization Guardian Coverage Management Drug Class Brand Name Chemical Name Generic Androgens & Anabolic Steroids Androgel testosterone gel Testim Androderm testosterone transdermal system Striant testosterone buccal system First TM -testosterone ointment testosterone propionate First TM -testosterone Moisturizing Cream Methitest methyltestosterone tablets Testred methyltestosterone Android capsules Androxy fluoxymesterone Yes Tesamone testosterone aqueous injection Depo-Testosterone testosterone cypionate injection Delatestryl testosterone enanthate injection Testopel testosterone pellets Anadrol-50 oxymetholone Winstrol stanozolol Oxandrin oxandrolone Yes Nandrolone decanoate nandrolone decanoate Yes Testosterone propionate testosterone propionate Yes Anticonvulsants* (2) Lyrica pregabalin Anti-Narcoleptic Agents (1) Provigil modafinil (used to promote wakefulness) Nuvigil armodafinil Antipsychotic Agents* (3) Antiviral Agents* (used to treat hepatitis B and C) Abilify aripiprazole Invega paliperidone Saphris asenapine maleate Copegus, Rebetol, ribavirin Yes (1) * Prior claim history is used to initiate the coverage evaluation process in this drug class. If the claim history meets the review criteria, coverage consideration is not subject to prior authorization. All medications in this class are subject to the dispensing limitations rules listed on page 15 in this document. (2) This medication is subject to dispensing limitation rules listed on page 12 of this document. (3) This medication is subject to dispensing limitation rules listed on page 13 of this document. Page 2 of 23

3 Prescription Drugs Requiring Prior Authorization Guardian Coverage Management Drug Class Brand Name Chemical Name Generic Appetite Suppressants and Weight Loss Agents Didrex benzphetamine Yes Tenuate, Tenuate Dospan diethylpropion Yes Bontril phendimetrazine Yes Adipex-P, Fastin phentermine Yes Ionamin phentermine Meridia sibutramine Xenical orlistat Asthmatic Agents (used to treat allergic asthma caused by Immunoglobulin type E (IgE) only) Calcium Regulators (used to lower parathyroid hormone levels) Cancer Therapy Xolair omalizumab Sensipar cinacalcet hydrochloride Gleevec imatinib mesylate Nexavar sorafenib tosylate Sprycel dasatinib Sutent sunitinib malate Tarceva erlotinib Tasigna nilotinib hydrochloride Temodar temozolomide Tykerb lapatinib ditosylate CNS Stimulant-type Agents (attention deficit or ADHD) Adderall amphetamine/ dextroamphetamine Yes Adderall XR amphetamine/ dextroamphetamine Cylert pemoline Yes Dexedrine, Dexedrine dextroamphetamine Yes Spansules, DextroStat Desoxyn methamphetamine Yes Focalin dexmethylphenidate Yes Focalin XR dexmethylphenidate * Prior claim history is used to initiate the coverage evaluation process in this drug class. If the claim history meets the review criteria, coverage consideration is not subject to prior authorization. Page 3 of 23

4 Prescription Drugs Requiring Prior Authorization Drug Class Brand Name Chemical Name Generic CNS stimulant-type Agents (attention deficit or ADHD) (continued) ProCentra TM dextroamphetamine Ritalin methylphenidate Yes Daytrana TM Ritalin-LA, Metadate CD, Concerta methylphenidate transdermal patch methylphenidate extended release Methylin ER, Metadate ER methylphenidate extended Yes release Ritalin-SR methylphenidate sustained release Intuniv guanfacine extendedrelease tablet Strattera atomoxetine Vyvanse lisdexamfetamine dimesylate Constipation Agents Relistor methylnaltrexone bromide Cosmetic Agents Botox onabotulinumtoxina COX-2 inhibitors* (commonly used for arthritis pain and inflammation) Myobloc rimabotulinumtoxinb Celebrex celecoxib Crohn s Disease Cimzia certolizumab Cystic Fibrosis Pulmozyme dornase alfa Dermatologicals (used to treat diseases of the skin) Diabetic Agents Erythroid Stimulants (to boost red blood cell count) Cayston aztreonam lysine Tobi tobramycin Amnesteem, Claravis, Sotret isotretinoin Yes Penlac ciclopirox Yes Elidel pimecrolimus Protopic tacrolimus Regranex becaplermin Retin-A, Avita, Tretin-X, tretinoin Yes Atralin, Altinac Solodyn minocycline HCl Yes Tazorac tazarotene Fortamet, Glucophage XR metformin hydrochloride Yes extended release Byetta * (1) exenatide Symlin (1) pramlintide Procrit, Epogen erythropoietin (epoetin) Aranesp darbepoetin *Prior claim history is used to initiate the coverage evaluation process in this drug class. If the claim history meets the review criteria, coverage consideration is not subject to prior authorization. (1) This medication is subject to dispensing limitation rules listed on page 20 of this document. Page 4 of 23

5 Prescription Drugs Requiring Prior Authorization Drug Class Brand Name Chemical Name Generic Fertility Agents Growth Hormones ** (used to treat hormone deficiencies in children) Growth Hormone Receptor Antagonists** (used to treat conditions caused by excessive growth hormone production) Clomid Serophene clomiphene citrate Yes Pergonal menotropin Humegon Repronex Fertinex urofollitropin Bravelle Gonal-F follitropin alfa Follistim AQ follitropin beta Luveris lutropin alfa Profasi, Profasi HP, Chorex- human chorionic 5, Chorex-10, Gonic, Pregnyl. Ovidrel gonadotropin Factrel gonadorelin hydrochloride Lupron leuprolide Yes Synarel nafarelin acetate FollistimAntagon Kit follitropin beta/ganirelix acetate Cetrotide cetrorelix acetate Ganirelix acetate ganirelix acetate Crinone Prochieve progesterone progesterone progesterone Yes Genotropin, Humatrope somatropin rditropin, Nutropin, Saizen, Tev-Tropin, Zorbtive, Omnitrope, Serostim Geref sermorelin Increlex mecasermin (rdna origin) Somavert pegvisomant HIV Agents Selzentry maraviroc Immunomodulatory Agents Thalomid thalidomide (used to treat certain cancers and blood cell disorders) Revlimid lenalidomide ** Accredo is the preferred specialty pharmacy to dispense growth hormones. Page 5 of 23

6 Prescription Drugs Requiring Prior Authorization Drug Class Brand Name Chemical Name Generic Interferons (used to treat hepatitis and certain cancers) Alferon-N interferon alpha-n3 Actimmune interferon gamma-1b Intron A interferon alpha-2b Infergen interferon alpha-con Pegasys pegylated Interferon alpha-2a Pegintron peginterferon alpha-2b Leukotriene Receptor Antagonist Agents* (1) (allergy and asthma relief) Singulair montelukast Accolate zafirlukast Zyflo CR zileuton Zyflo zileuton Multiple Sclerosis Ampyra dalfampridine Avonex interferon beta-1a Rebif interferon beta-1a Gilenya fingolimod HCl Betaseron interferon beta-1b Copaxone glatiramer acetate Tysabri natalizumab Myeloid Stimulants (to boost white blood cell counts) Neupogen filgrastim Neulasta pegfilgrastim Leukine sargramostim Neumega oprelvekin Nplate romiplostim Promacta eltrombopag Narcotic Analgesics* (used to treat breakthrough pain) Actiq fentanyl Yes Fentora fentanyl Opthalmic Therapy Restasis cyclosporine ** Accredo is the preferred specialty pharmacy to dispense growth hormones. (1) All medications in this class are subject to the dispensing limitations rules listed on page 22 in this document Page 6 of 23

7 Prescription Drugs Requiring Prior Authorization Drug Class Brand Name Chemical Name Osteoporosis Therapy* Forteo teriparatide Pain Management Voltaren Gel diclofenac Onsolis fentanyl citrate Flector Patch diclofenac epolamine Parkinson's Therapy Apokyn apomorphine hydrochloride Generic Pulmonary Arterial Hypertension Therapy* (treats pulmonary arterial hypertension) Rheumatoid Arthritis Agents* (used to treat rheumatoid arthritis and other specific types of arthritis) Respiratory Syncytial Virus (RSV) Agents (to prevent lower respiratory tract disease caused by respiratory syncytial virus) Revatio sildenafil Tracleer bosentan Ventavis iloprost Letairis ambrisentan Arava leflunomide Yes Enbrel etanercept Actemra tocilizumab Humira adalimumab Kineret anakinra Orencia abatacept Remicade Infliximab Rituxan rituximab Simponi golimumab Synagis palivizumab Smoking Deterrents Nicotine Transdermal, Nicotrol NS, Nicotrol Inhaler, nicotine Zyban bupropion Yes Chantix varenicline Page 7 of 23

8 Prescription Drugs Subject to Coverage Review The drugs listed below as "Covered brand" or "Covered generic" are covered without coverage review. "Targeted brand" drugs require a review and may or may not be covered depending on the outcome of the review and may be subject to a higher copay. The targeted drugs listed may or may not be covered depending on the outcome of the review. All medications listed below are subject to the existing coverage management rules for that particular drug class listed elsewhere in this document. If you are prescribed a targeted medication, your doctor should contact Medco at to initiate a review. This telephone number is for your doctor s use only. Prescription Drugs Subject to Coverage Review Drug Class Brand Name Chemical Name Generic Angiotensin II Receptor Blockers (ARB's) (blood pressure) Antisecretory Agents- Proton Pump Inhibitors (ulcer) (1) Drug Status Micardis telmisartan Covered brand Micardis HCT telmisartan Covered brand hydrochlorothiazde Diovan valsartan Covered brand Diovan HCT valsartan Covered brand hydrochorothiazide losartan losartan Yes Covered generic losartan losartan Yes Covered generic hydrochorothiazide hydrochorothiazide Atacand candesartan Targeted brand Atacand HCT candesartan Targeted brand hydrochlorothiazide Avalide irbesartan Targeted brand hydrochlorothiazide Avapro irbesartan Targeted brand Benicar olmesartan Targeted brand Benicar HCT olmesartan Targeted brand hydrochlorothiazide Teveten eprosartan Targeted brand Teveten HCT eprosartan Targeted brand hydrochorothiazide Tekturna aliskiren Targeted brand Tekturna HCT aliskiren Targeted brand hydrochorothiazde omeprazole omeprazole Yes Covered generic Nexium esomeprazole Covered brand Aciphex rabeprazole Targeted brand Zegerid omeprazole Targeted brand Prevacid lansoprazole Yes Targeted brand Protonix pantoprazole Yes Targeted brand Dexilant dexlansoprazole Targeted brand Prilosec packets omeprazole Targeted brand (1) Generic omeprazole and branded Nexium are covered Proton Pump Inhibitors; members that have active claims for Plavix in history will not be targeted. All medications in this class are subject to the dispensing limitations rules listed on page 14 in this document. Page 8 of 23

9 Prescription Drugs Subject to Coverage Review Drug Class Brand Name Chemical Name Generic Antidepressants (depression and other mental health disorders) (2) SSRI Drug Status fluvoxamine fluvoxamine Yes Covered generic fluoxetine fluoxetine Yes Covered generic paroxetine paroxetine Yes Covered generic sertraline sertraline Yes Covered generic Lexapro escitalopram Targeted brand Luvox CR fluvoxamine Targeted brand SNRI venlafaxine venlafaxine Yes Covered generic Wellbutrin XL bupropion extended release (24-hour) Yes Covered generic Wellbutrin SR bupropion extended release (12-hour) Yes Covered generic Cymbalta duloxetine Covered brand Pristiq desvenlafaxine Targeted brand Effexor XR venlafaxine extended release capsules Targeted brand (2) Generics and branded Cymbalta are the covered Antidepressants; Applies to new users only. SSRIs in this class are subject to the dispensing limitations rules listed on page 13 in this document. Page 9 of 23

10 Prescription Drugs Subject to Coverage Review Drug Class Brand Name Chemical Name Generic Hypnotic Agents (used to treat insomnia, short term) (3) Drug Status zolpidem zolpidem Yes Covered generic zaleplon zaleplon Yes Covered generic Ambien CR zolpidem Targeted brand Lunesta eszopiclone Targeted brand Rozerem ramelteon Targeted brand Sonata zaleplon Yes Targeted brand Intranasal Steroids (used to treat allergic rhinitis) flunisolide flunisolide Yes Targeted generic fluticasone fluticasone Yes Targeted generic Beconase AQ beclomethasone Targeted brand Nasacort AQ triamcinolone Targeted brand Nasonex mometasone Targeted brand Omnaris ciclesonide Targeted brand Rhinocort Aqua budesonide Targeted brand Veramyst fluticasone furoate Targeted brand Migraine Therapy (5) sumatriptan sumatriptan Yes Covered generic Relpax eletriptan Covered Brand Amerge naratriptan Targeted Brand Axert almotriptan Targeted brand Frova frovatriptan Targeted brand Maxalt / Maxalt-MLT rizatriptan Targeted brand Sumavel sumatriptan Yes Targeted brand Treximet Sumatriptan/naproxen Targeted brand Zomig / Zomig ZMT zolmatriptan Targeted brand Osteoporosis Therapy (Bisphosphonates) (used to treat bone loss) (4) alendronate alendronate Yes Covered generic Boniva ibandronate Covered brand Actonel risedronate Targeted brand Actonel with Calcium risedronate wih calcium Targeted brand Fosamax D alendronate with vitamin D Targeted brand (3) Generic zolpidem, zaleplon and branded Ambien are covered hypnotics. All medications in this class are subject to the dispensing limitations rules listed on page 16 in this document. (4) Generic alendronate and branded Boniva are covered bisphosphonates (5) All medications in this class are subject to the dispensing limitations rules listed on page 17 in this document Page 10 of 23

11 Prescription Drugs Subject to Dispensing Limitations There are quantity limitations on the medications listed below. If your doctor prescribes a medication from this list, for a quantity above the limit, they should contact Medco at to initiate a review. This telephone number is for your doctor s use only. Prescription Drugs Subject to Dispensing Limitations Drug Class Brand Name Chemical Name Generic Dispensing Limit** ACE Inhibitors (1) ACE Inhibitors (2) Combination Accupril quinapril Yes 60 tablets/ (1) Altace ramipril Yes 60 tablets/ (1) Capoten captopril Yes 90 tablets/ Lotensin benazepril Yes 60 tablets/ (1) Mavik trandolapril Yes 60 tablets/ (1) Monopril fosinopril Yes 60 tablets/ (1) Prinivil 2.5mg, 5mg, 10mg, 20mg, 40mg Zestril 2.5mg, 5mg, 10mg, 20mg, 30mg, 40mg lisinopril (60) 40mg tablets/ (1) Yes (30) 10mg, 20mg, 30mg tablets/ Univasc moexipril Yes 60 tablets/ (1) Vasotec enalapril Yes 60 tablets/ (1) Aceon perindopril Yes 60 tablets/ (1) Accuretic quinapril/ HCTZ Yes (30) mg, mg 20-25mg tablets/ Capozide Captopril/ HCTZ Yes 30 tablets/ Lotensin HCT benazepril/ HCTZ Yes 30 tablets/ Lotrel mg, 5- amlodipine/hctz Yes 30 tablets/ (2) 40mg Monopril HCT fosinopril/ HCTZ Yes (30) mg, mg tablets/ Prinzide Zestorectic lisinopril/hctz Tarka Trandolapril/ HCTZ Yes Uniretic moexipril/ HCTZ Yes Vaseretic enalapril/ HCTZ Yes (30) mg, mg tablets/ (60) 20-25mg tablets/ (2) (30) 2-80mg, 1-240mg, 2-240mg tablets/ (60) 4-240mg tablets/ (2) (30) mg, mg tablets/ (60) 15-25mg tablets/ (2) (30) mg tablets/ (60) 10-25mg tablets/ **Quantities reflect limits available at a retail pharmacy. Mail order quantities are generally available at 3 times the retail pharmacy limit (max. 90-day supply). State and plan variations apply. See your Certificate of Coverage for benefit information (1) Additional quantities of Accupril 40mg, Altace 10mg, Lotensin 40mg, Mavik 4mg, Monopril 40mg, Prinivil/ Zestril 40mg, Univasc 15mg, Vasotec 20mg, and Aceon 4mg are not available through coverage review (2) Additional quantities of Lotrel 5-10mg, 5-20mg, 10-20mg, 10-40mg, Prinzide 20-25mg, Zestoretic 20-25mg, Unirectic15-25mg, and Tarka 4-240mg are not available through coverage review. Page 11 of 23

12 Prescription Drugs Subject to Dispensing Limitations Drug Class Brand Name Chemical Name Generic Dispensing Limit** ARBs/Renin Atacand candesartan (60) 16mg tablets/ Inhibitor (1) (30) 4mg, 8mg, 32mg tablets/ Avapro irbesartan 30 tablets/ Benicar olmesartan (30) 20mg, 40mg tablets/ Cozaar losartan Yes (60) 5mg tablets/ (60) 25mg, 50mg tablets/ Diovan valsartan (30) 100mg tablets/ (60) 40mg, 160mg tablets/ (30) 80mg, 320mg tablets/ Micardis telmisartan 30 tablets/ Teveten eprosartan (60) 400mg tablets/ (30) 600mg tablets/ Tekturna aliskiren 30 tablets/ (1) ARB Combination (2) Atacand candesartan/ HCTZ 30 tablets/ HCT Avalide irbesartan/ HCTZ 30 tablets/ (2) Benicar HCT olmesartan/hctz 30 tablets/ (2) Hyzaar losartan/ HCTZ Yes 30 tablets/ (2) Diovan HCT valsartan/hctz 30 tablets/ Micardis telmisartan/ HCTZ (30) mg, 80-25mg HCT tablets/ (60) mg tablets/ (2) Tekamlo aliskiren/amlodipine 30 tablets/ (2) Tribenzor amlodipine/olmesartan/hydrochlorothiazide 30 tablets/ (2) Teveten HCT eprosartan l/ HCTZ 30 tablets/ (2) Anti-Infectives Alinia nitazoxanide (6) 500mg tablets/ at retail and mail (3 bottles) 100mg/ 5ml suspension/ at retail and mail Xifaxan rifaximin (9) 200mg tab;ets per 23 or (27) 200mg tablets per 69 Zyvox linezolid Maximum of 14 of therapy per 30 Anticonvulsant (3) xafil Lyrica posaconazole pregabalin Maximum of 10 of therapy per 30 (90) 25mg, 50mg, 100mg, 150mg, 200mg tablets/ (60) 75mg, 225mg, 300mg tablets/ **Quantities reflect limits available at a retail pharmacy. Mail order quantities are generally available at 3 times the retail pharmacy limit (max. 90-day supply). State and plan variations apply. See your Certificate of Coverage for benefit information (1) Additional quantities of Tekturna are not available through coverage review (2) Additional quantities of Atacand HCT mg, Avalide mg, Benicar HCT, Hyzaar mg, mg, Micardis HCT mg, 80-25mg, Teveten HCT are not available through coverage review (3) Additional quantities of Lyrica 25mg, 150mg, 200mg, 225mg, 300mg are not available through coverage review. Page 12 of 23

13 Prescription Drugs Subject to Dispensing Limitations Drug Class Antidepressants (depression and other mental health disorders) Atypical Antipsychotics (1) Brand Name Chemical Name Celexa citalopram Yes Generic Dispensing Limit** (60) 10mg or, (90) 20mg or, (30) 40mg tablets/ Lexapro escitalopram 30 tablets/ Luvox CR fluvoxamine 60 tablets/ Paxil paroxetine Yes (60) 10mg or, (30) 20mg or, (60) 30mg or, (30) 40mg tablets/ Paxil CR paroxetine Yes (60) 12.5mg or, (90) 25mg or, (60) 37.5mg tablets/ Pexeva paroxetine mesylate (60) 10mg or, (30) 20mg or, (60) 30mg or, (30) 40mg tablets/ Prozac fluoxetine Yes (60) 10mg or, (90) 20mg or, (60) 40mg tablets/ Zoloft sertraline Yes (60) 25mg or, (90) 50mg or, (60) 100mg tablets/ Prozac Weekly fluoxetine 4 capsules/ Sarafem fluoxetine 14 capsules/ Symbyax olanzapine/ 30 tablets/ (1) fluoxetine Fanapt iloperidone (2) 1mg, 2mg, 4mg tablets/ (60) 6mg, 8mg, 10mg, 12mg tablets/ (1) Titration pack/ Zyprexa Zyprexa Zydis olanzapine 30 tablets/ (1) Seroquel quetiapine (60) 400mg, 25mg, 150mg, 300mg tablets/ (1) Seroquel XR Risperdal risperidone Yes (90) 50mg, 100mg, 200mg tablets/ 60 tablets/ Risperdal M- Tab 8 bottles oral solution Geodon ziprasidone 60 tablets/ (1) Saphris asenapine maleate (60) 5mg, 10mg, 15mg tablets/ (1) Abilify aripirazole (42) 5mg, 10mg, 15mg tablets/ (1) Abilify Discmelt Invega paliperidone (30) 20mg, 30mg tablets/ (30) 3mg, 9mg tablets/ (60) 1.5mg, 6mg tablets/ Antiplatelet (2) Pletal cilostazol Yes 60 tablets/ (2) Effient prasugrel (30) 5mg tablets/ (36) 10mg tablets/ Plavix clopidogrel 37 tablets/ Ticlid ticlopidine Yes 60 tablets/ (2) Aggrenox dipyridamole/ 60 capsules/ (2) aspirin Agrylin anagrelide Yes 120 capsules/ (2) **Quantities reflect limits available at a retail pharmacy. Mail order quantities are generally available at 3 times the retail pharmacy limit (max. 90- day supply). State and plan variations apply. See your Certificate of Coverage for benefit information (1) Additional quantities of Fanapt 6mg, 8mg, 10mg, 12mg, and Titration pack, Symbyax 6/50mg, 12/25mg, 12/50mg, Zyprexa/Zyprexa Zydis 15mg, 20mg, Seroquel/ Seroquel XR 300mg, 400mg, Geodon 40mg, 60mg, 80mg, and Invega are not available through coverage review (2) Additional quantities of Pletal, Ticlid, Aggrenox, Agrylin 0.5mg are not available through coverage review. Page 13 of 23

14 Prescription Drugs Subject to Dispensing Limitations Drug Class Brand Name Chemical Name Generic Antidiabetic Agents (1) Antisecretory Agents- Proton Pump Inhibitors (2) and H 2 Antagonists (ulcer) Dispensing Limit** Avandia (1) rosiglitazone (30) 8mg tablets/ (60) 2mg, 4mg tablets/ Actos (1) pioglitazone 30 tablets/ Avandamet (1) rosiglitazone/metformin (60) 4-500mg, mg, mg tablets/ Metaglip glipizide/ metformin Yes (60) 1-500mg, 2-500mg tablets/ (60) mg tablets/ Glucovance (1) glyburide/ metformin Yes (60) mg, 5-500mg tablets/ (60) mg, mg tablets/ Glucophage XR (1) metformin extended Yes (120) 5-500mg tablets/ (60) 750mg tablets/ Fortamet (1) release metformin extended Yes (120) 500mg tablets/ (150) 500mg tablets/ Glucotrol XL release glipizide Yes (60) 1000mg tablets/ (30) 2.5mg, 5mg tablets/ Amaryl glimepiride Yes (60) 10mg (1) tablets/ (30) 1mg, 2mg (1) tablets/ Glynase Prestab glyburide, micronized Yes (60) 4mg tablets/ (30) 1.5mg, 3mg tablets/ Prandin (1) repaglinide (60) 6mg (1) tablets/ (120) 0.5mg, 1mg tablets/ (240) 2mg (1) tablets/ Starlix (1) nateglinide Yes 90 tablets/ Symlin (1) pramlintide 4 vials/ Duetact (1) glimepiride/pioglitazone 30 tablets/ Januvia (1) sitagliptin 30 tablets/ Prilosec, omeprazole Yes Ulcer healing doses for first 90 of therapy Zegerid, omeprazole Aciphex rabeprazole Nexium esomeprazole Prevacid lansoprazole Yes Protonix pantoprazole Yes Tagamet cimetidine Yes Zantac ranitidine Yes Pepcid famotidine Yes Axid nizatidine Yes H2 Antagonists: > 800mg/ day of Tagamet > 300mg/day of Axid/ Zantac > 40mg/day of Pepcid PPIs: > 20 mg/day of Aciphex > 40 mg/day of Nexium > 30 mg/day of Prevacid > 20 mg/day of Prilosec (includes packets) > 40 mg/day of Protonix > 20mg/day of Zegerid > 30 mg/day of Dexilant **Quantities reflect limits available at a retail pharmacy. Mail order quantities are generally available at 3 times the retail pharmacy limit (max. 90-day supply). State and plan variations apply. See your Certificate of Coverage for benefit information. (1) Additional quantities of Avandia, Actos, Avandamet, Metaglip,Glucovance, Glucophage XR, Fortamet, Glucotrol XL 10mg, Amaryl 2mg, Glynase Prestab 6mg, Prandin, Starlix, Symlin, Duetact, Januvia are not available through coverage review. (2) Certain drugs in this class maybe subject to Coverage Review rules. See page 8 for specific details. Page 14 of 23

15 Prescription Drugs Subject to Dispensing Limitations Drug Class Brand Name Chemical Name Generic Antiemetic Agents (used to treat nausea and vomiting) Anzemet ondansetron Emend aprepitant Dispensing Limit** Quantities sufficient for seven (7) treatment per 30 day period Anzemet: 700 mg in 30 or 2100 mg in 90 Emend 125 mg: 2 capsule in 26 or 4 capsules in 84 Emend 40mg: 1 capsule in 30 or 2 capsules in 90 Emend 80mg: 8 capsules in 26 or 16 capsules in 84 Emend trifold pack: 2 pack (6 caps) in 26 or 4 packs (12 caps) in 84 Kytril granisetron Yes Kytril: 14 mg in 30 or 42 mg in 90 Antifungal Agents (1) Zofran, Zuplenz ondansetron Yes Zofran (all forms): 168 mg in 30 or 504 mg in 90 Sancuso granisetron 2 patches in 30 or 6 patches in 90 Diflucan fluconazole Yes Lamisil (1) terbinafine Yes (30) 50mg, 100mg tablets/ (1) (2) 150mg tablets/ (60) 200mg tablets/ (30) 250mg (60) 125mg packets/ (30) 187.5mg packets/ Sporanox (1) itraconazole Yes 120 capsules/ Antiviral Agents (used to treat herpes infections) Famvir famciclovir Yes Quantities sufficient to treat one (1) acute episode or three (3) preventative regimens per 90 day period Famvir: 50,000 mgs in any 90 day period Valtrex valacyclovir Yes Valtrex: 100,000 mgs in any 90 day period Zovirax acyclovir Yes Zovirax: 80,000 mgs in any 90 day period For recurrent genital herpes, quantities greater than approved suppression regimens and 1 acute treatment in 90 require prior authorization. Anti-Narcoleptic Agents (used to promote wakefulness) (2) Provigil Nuvigil modafinil armodafinil 6000 mg in 23 or mg in mg in 23 or mg in 68!" "## (1) Additional quantities of Diflucan 50mg, 100mg, Lamisil, Sporanox are not available through coverage review (2) This class of medications is subject to prior authorization. See page 2 for specific details. Page 15 of 23

16 Prescription Drugs Subject to Dispensing Limitations Drug Class Brand Name Chemical Name Calcium Regulators (used to lower parathyroid hormone levels) Cancer Agents Sensipar cinacalcet hydrochloride Generic Dispensing Limit** 5400 mg in 23 or mg in 69 Sprycel dasatinib 4200 mg in 23 or mg in 68 Sutent sunitinib malate 1500 mg in 23 or 4500 mg in 69 Tarceva erlotinib 4500 mg in 23 or mg in 69 Tasigna nilotinib hydrochloride 22400mg in 21 or mg in 63 *based on 28-day regimen Tykerb lapatinib ditosylate 45000mg in 23 or mg in vials in 23 or 45 vials in 69 bromide Constipation Agents Relistor methylnaltrexone Cystic Fibrosis Cayston aztreonam lysine 84ml(1 kit) in 56 or 168ml(2 kits) in 112 Fertility Agents Hypnotic Agents (used to treat insomnia, short term) (3) Clomid, Serophene clomiphene citrate Yes 4500 units in 30 or units in 90 Pergonal menotropin 4500 units in 30 or units in 90 Humegon, Repronex Fertinex, Bravelle urofollitropin 4500 units in 30 or units in 90 Gonal-F follitropin alfa 4500 units in 30 or units in 90 Follistim AQ follitropin beta 4500 units in 30 or units in 90 Luveris lutropin alfa 4500 units in 30 or units in 90 Profasi, Profasi HP, Chorex-5, Chorex-10, Gonic, Pregnyl. Ovidrel Factrel human chorionic gonadotropin 4500 units in 30 or units in 90 gonadorelin 4500 units in 30 or units in 90 hydrochloride Lupron leuprolide Yes 4500 units in 30 or units in 90 Synarel nafarelin acetate 4500 units in 30 or units in 90 FollistimAntagon Kit follitropin beta/ganirelix acetate 4500 units in 30 or units in 90 Cetrotide cetrorelix acetate 4500 units in 30 or units in 90 Ganirelix Acetate ganirelix acetate 4500 units in 30 or units in 90 Crinone, Prochieve progesterone 4500 units in 30 or units in 90 progesterone progesterone Yes 4500 units in 30 or units in 90 Ambien zolpidem Yes Ambien CR zolpidem Yes Edluar zolpidem Lunesta eszopiclone Rozerem ramelteon Silenor doxepin Hcl Sonata zaleplon Yes Zolpimist zolpidem Doses consistent with the treatment of short term insomnia Ambien, Ambien CR, Edluar, Lunesta, Rozerem, Silenor, Sonata, Zolpimist: 60 supply in 90!" "## (3) Certain drugs in this class may be subject to Coverage Review rules. See page 10 for specific details. Page 16 of 23

17 Prescription Drugs Subject to Dispensing Limitations Drug Class Brand Name Chemical Name Generic Dispensing Limit** Inhaled Corticosteroids (1) Qvar beclomethasone 3 inhalers/ Pulmicor Flexhalert budesonide 2 inhalers/ Dulera Aerobid Aerobid-M Flovent Flovent HFA Flovent Rotadisk mometasone furoate/ formoterol fumarate 1 inhaler/ flunisolide 3 inhalers at retail and 8 inhalers at mail fluticasone propionate 2 inhalers/ 240 doses (16 blisters) Advair HFA fluticasone/ salmeterol 1 inhaler/ Azmacort triamcinolone 2 inhalers/ Symbicort (1) budesonide/ formoterol 1 inhaler/ Migraine Therapy (headache treatment) Alsuma, Imitrex, sumatriptan Yes 900mg/ 30 Sumavel Zomig, Zomig-ZMT zolmitriptan 40mg/ 30 Amerge naratriptan 20mg/ 30 Maxalt, rizatriptan 120mg/ 30 Maxalt-MLT Axert almotriptan 100mg/ 30 Frova frovatriptan 30mg/ 30 Treximet sumatriptan/naproxen 900mg(sumatriptan)/ 30 Relpax eletriptan 320mg/ 30 Migranal NS dihydroergotamine nasal 8 amps/ 30 Misc Hormones Acthar Gel Maximum quantity of 5 ml (1 vial) in 30 or 15 ml (3 vials) in 90 **Quantities reflect limits available at a retail pharmacy. Mail order quantities are generally available at 3 times the retail pharmacy limit (max. 90-day supply). State and plan variations apply. See your Certificate of Coverage for benefit information. (1) Additional quantities of Symbicort are not available through coverage review. (2) Drugs in this class may be subject to Coverage Review rules. See page 10 for specific details. Page 17 of 23

18 Prescription Drugs Subject to Dispensing Limitations Drug Class Brand Name Chemical Name Generic Oral Estrogens (estrogen replacement) Prempro, Premphase conjugated estrogens, medroxyprogesterone Dispensing Limit** 28 day pack/ Activella 1-0.5mg estradiol,norethindrone Yes Activella 0.5mg-0.1mg estradiol,norethindrone Cenestin conjugated estrogen (30) 0.625mg or (30) 0.3mg or 0.9mg tablets/ Menest esterified estrogen 30 tablets/ Premarin, Enjuvia conjugated estrogens Femtrace estradiol acetate Ortho-Prefest estradiol, norgestimate Estratest, Estratest HS esterified estrogens, methyltestosterone Yes 30 tablets/ Ortho-Est, Ogen estropipate Yes Estrace estradiol Yes Femhrt ethinyl estradiol,norethindrone Syntest DS, Syntest HS esterified estrogen, methyltestosterone Yes Pain Management Actiq fentanyl citrate Yes 120 units in 23 or 360 units in 68 Fentora fentanyl citrate Fentora 300,400,600,800 mcg: 120 tabs in 23 or 360 tabs in 68 Onsolis fentanyl citrate Onsolis 400, 600, 800, 1200 mcg: 120 units in 23 or 360 units in 68 Stadol Nasal Spray butorphanol Yes 10 ml in 30 or 30 ml in 90 Voltaren Gel diclofenac 500gm in 23 or 1500gm in 68 Parkinson's Therapy Apokyn apomorphine hydrochloride 60ml (20 cartridges) in 23 or 180ml (60 cartridges) in 68 Psoriatic Therapy (2) Enbrel etanercept 200 mg/ 30 (used to treat psoriasis) Raptiva efalizumab 4 kits/ 30 Pulmonary Arterial Hypertension Amevive alefacept 60 mg/ 30 (2) Adcirca tadalafil 60 tablets in 23 or 180 tablets in 68 Revatio sildenafil citrate 90 tablets in 23 or 270 tablets in 68 Tyvaso treprostinil **Quantities reflect limits available at a retail pharmacy. Mail order quantities are generally available at 3 times the retail pharmacy limit (max. 90-day supply). State and plan variations apply. See your Certificate of Coverage for benefit information (2) Additional quantities of Amevive are not available through coverage review. Page 18 of 23

19 Prescription Drugs Subject to Dispensing Limitations Drug Class Brand Name Chemical Name Generic Rheumatoid Arthritis Agents Dispensing Limit** Enbrel etanercept Enbrel 50 mg prefilled SureClick autoinjector (Carton of 4): 1 carton (4 doses) in 30 or 3 cartons (12 doses) in 90 Enbrel 50 mg pre-filled syringe (carton of 4) 1 carton (4 doses) in 30 or 3 cartons (12 doses) in 90 Cimzia certolizumab pegol 1 carton contains #2 200 mg vials 1 carton/ 30 3 cartons/ 90 Humira adalimumab Humira Syringe carton (2 prefilled syringes; 40 mg/0.8 ml): 1 syringe carton (2 pre-filled syringes) in 30 or 3 syringe carton (6 pre-filled syringes) in 90 Humira Pediatric prefilled syringe carton (2 prefilled 20 mg syringes): 1 syringe carton (2 pre-filled syringes) in 30 or 3 syringe carton (6 pre-filled syringes) in 90 Humira Pen carton: each kit contains 2 - single use pens providing 40 mg (0.8mL) of Humira: 1 kit in 30 or 3 kits in 90 **Quantities reflect limits available at a retail pharmacy. Mail order quantities are generally available at 3 times the retail pharmacy limit (max. 90-day supply). State and plan variations apply. See your Certificate of Coverage for benefit information Page 19 of 23

20 Prescription Drugs Subject to Dispensing Limitations no review Quantities are subject to the dispensing limit shown. Refills may be obtained for these quantities in accordance with the -supply listed for each prescribed drug. Prescription Drugs Subject to Dispensing Limitations no review Drug Class Brand Name Chemical Generic Dispensing Limit** Name Leukotriene Receptor Antagonist Agents (Allergy & Asthma) Alpha1 Blockers Antihistamines Xolair omalizumab 6 vials in 23 or 18 vials in 68 Minipress prazosin Yes (120) 1mg, 2mg, 5mg capsules/ Hytrin terazosin Yes 60 capsules/ Cardura doxazosin Yes 60 tablets/ Cardura XL doxazosin Yes 30 tablets/ Flomax tamsulosin 60 capsules/ Jalyn dutasteride/tamsulosin 30 tablets/ Rapaflo silodosin 30 tablets/ Clarinex desloratadine (30) 2.5mg, 5mg, 5-240mg tablets/ Clarinex-D desloratadine/ pseudoephedrine (60) mg tablets/ Allegra fexofenadine Yes (60) 30-60mg tablets/ (60) 60mg capsules/ (30) 180mg tablets/ Allegra-D fexofenadine/ pseudoephedrine Yes (60) mg tablets/ (30) mg tablets/ BPH Agents Cancer Therapy Cholesterol Lowering Agents Xyzal levocetirizine 30 tablets/ Proscar finasteride Yes 30 tablets/ Avodart dutasteride 30 tablets/ Uroxatral alfuzosin 30 tablets/ Gleevec imatinib mesylate 24000mg in 23 or 72000mg in 68 Nexavar sorafenib tosylate mg in 23 or mg in 68 Omacor (Lovaza ) omega-3-acid ethyl 120 capsules in 23 or 360 capsules esters in 69 Diabetic Agents Erectile Dysfunction Agents Byetta exenatide 3 ml in 23 or 8 ml in 68 Symlin pramlintide acetate 12000mcg in 23 or 33000mcg in 68 Viagra sildenafil 6 tablets(or units)/30 Levitra vardenafil Cialis (10mg, 20mg) tadalafil Muse, Edex, alprostadil Caverject Cialis 2.5mg tadalafil 15 tablets/ 60 Cialis 5.mg **Quantities reflect limits available at a retail pharmacy. Mail order quantities are generally available at 3 times the retail pharmacy limit (max. 90- day supply). State and plan variations apply. See your Certificate of Coverage for benefit information. Page 20 of 23

21 Prescription Drugs Subject to Dispensing Limitations no review Drug Class Brand Name Chemical Name Estrogens - Topical Estrogen Receptor Modulator (selective) Bronchodilators HIV Agents Immunomodulatory Agents (used to treat certain cancers and blood cell disorders) Generic Dispensing Limit** Vivelle, Vivelle-Dot Alora Esclim estradiol 8 systems/ Estraderm Climara estradiol Yes Climara-Pro 4 systems/ estradiol/ levonorgestrel CombiPatch estradiol/ norethrindone 8 systems/ Menostar estradiol 4 systems/ Estrogel 93gm 1 at retail and mail estradiol 50gm 1 at retail; 3 at mail Elestrin estradiol 1 pump at retail; 2 pumps at mail Divigel estradiol 30 Evista Ventolin, Ventolin HFA Proventil, Proventil HFA ProAir Atrovent Atrovent HFA raloxifene 30 tablets/ albuterol 2 inhalers/ ipratropium Yes 2 inhalers/ Combivent albuterol/ 2 inhalers/ ipratropium Maxair Autohaler pirbuterol 2 inhalers/ Serevent 2 inhalers/ Serevent Diskus salmeterol 56 blisters or 60 blisters based on package size Foradil formoterol 60 blisters/ Spiriva tiotropium 30 units in 23 or 90 units in 68 Selzentry maraviroc Revlimid lenalidomide 36000mg in 23 and mg in 68 Revlimid 5mg, 10mg, & 15mg: 28 capsules in 23 at both retail and mail Revlimid 25 mg: 21 capsules in 21 at both retail and mail **Quantities reflect limits available at a retail pharmacy. Mail order quantities are generally available at 3 times the retail pharmacy limit (max. 90- day supply). State and plan variations apply. See your Certificate of Coverage for benefit information. Page 21 of 23

22 Prescription Drugs Subject to Dispensing Limitations no review Drug Class Brand Name Chemical Name Generic Intranasal Corticosteroids Leukotriene Antagonists HMG-CoA Inhibitors (cholesterol-lowering) Dispensing Limit** Nasarel flunisolide Yes 3 inhalers at retail and 8 inhalers at mail Beconase AQ beclomethasone 2 inhalers at retail and 4 inhalers at mail Nasacort AQ triamcinolone 2 inhalers/ Rhinocort Aqua budesonide 2 inhalers/ Flonase fluticasone Yes 1 inhaler/ Nasonex mometasone 1 inhaler/ Omnaris ciclesonide 1 inhaler/ Veramyst fluticasone 1 inhaler/ Accolate zafirlukast 60 tablets/ Singulair montelukast 30 tablets/ Zyflo, Zyflo CR zileuton 120 tablets/ Mevacor lovastatin Yes (30) 10mg tablets/ or, (60) 20mg or 40-mg tablets/ Zocor simvastatin Yes (30) tablets/ Lipitor atorvastatin Pravachol pravastatin Yes Altoprev lovastatin Lescol fluvastatin Crestor rosuvastatin Zetia ezetimibe Pain Management Psoriatic Therapy (used to treat psoriasis) Pulmonary Arterial Hypertension Vytorin simvastatin/ ezetimibe Caduet amlodipine/ atorvastatin Fentora fentanyl citrate Fentora 100mcg, 200mcg: 240 tabs in 23 or 720 tabs in 68 Flector Patch diclofenac 60 patches in 30 or 180 patches in epolamine 90 Lidoderm Patch lidocaine 90 patches in 30 or 270 patches in 90. Pennsaid diclofenac sodium 300 ml per 23 or 900 ml in 68 Amevive alefacept 60 mg/ 30 Letairis ambrisentan 30 tablets in 23 or 90 tablets in 68 **Quantities reflect limits available at a retail pharmacy. Mail order quantities are generally available at 3 times the retail pharmacy limit (max. 90- day supply). State and plan variations apply. See your Certificate of Coverage for benefit information. Page 22 of 23

23 Prescription Drugs Subject to Dispensing Limitations no review Drug Class Brand Name Chemical Name Generic Rheumatoid Arthritis Agents Dispensing Limit** Arava leflunomide Yes 30 tablets in 23 or 90 tablets in 69 Enbrel etanercept Enbrel 25 mg prefilled syringe (Carton of 4): 2 cartons (8 doses) in 30 or 6 cartons (24 doses) in 90 Enbrel 25 mg Multiple use vial carton (4 doses per carton): 2 cartons (8 doses) in 30 or 6 cartons (24 doses) in 90 Smoking Deterrents Humira adalimumab Crohn's Disease or Psoriasis Starter Kit (6 pens; 40 mg/0.8 ml) 1 starter kit in 30 or 1 starter kit in 90 Kineret anakinra 21ml (31 syringes) in 23 or 61ml (91 syringes) in 69 Simponi golimumab 1 vial in 30 or 3 vials in 90 Nicotrol NS nicotine 90 supply in any 365 day period Nicotrol Inhaler nicotine 90 supply in any 365 day period Zyban buproprion Yes 90 supply in any 365 day period Chantix varenicline 180 supply in any 365 day period Urinary Antispasmodics Detrol tolterondine 60 tablets/ Detrol LA tolterondine 30 tablets/ extended release Ditropan XL oxybutynin Yes (30) 5mg tablets/ Ditropan XL oxybutynin Yes (60) 10mg, 15mg tablets/ Oxytrol oxybutynin 10 patches/ Enablex darifenacin 30 tablets/ Sanctura trospium 60 tablets/ Sanctura XR trospium chloride 30 tablets/ Vesicare solifenacin 30 tablets/ **Quantities reflect limits available at a retail pharmacy. Mail order quantities are generally available at 3 times the retail pharmacy limit (max. 90- day supply). State and plan variations apply. See your Certificate of Coverage for benefit information. Page 23 of 23