DRUG QUANTITY MANAGEMENT LIST (SUBECT TO CHANGE) MEDICATION (* = SPECIALTY DRUGS)
|
|
- Kimberly Crawford
- 5 years ago
- Views:
Transcription
1 DRUG QUANTITY MANAGEMENT LIST (SUBECT TO CHANGE) MEDICATION (* = SPECIALTY DRUGS) MODULE ABSTRAL ACIPHEX SPRINKLE ACTIQ ACTONEL ACTOPLUS MET ACTOPLUS MET XR ACTOS ADCIRCA* PULMONARY HYPERTENSION ADLYXIN ADRENACLICK ANAPHYLAXIS ADVAIR DISKUS ADVAIR HFA (120) ADVAIR HFA (60) ADVICOR AEROSPAN AIMOVIG AIRDUO AKYNZEO ALBENZA ALENDRONATE ALINIA ALLEGRA ALLEGRA ALLERGY 12 HOUR ALLEGRA ALLERGY 24 HOUR ALLEGRA CHILDREN S ALLERGY ALLEGRA-D 12 HOUR ALLEGRA-D 12 HOUR ALLERGY AND CONGESTION ALLEGRA-D 24 HOUR ALLEGRA-D 24 HOUR ALLERGY AND CONGESTION ALORA ALSUMA ALTOPREV ALVESCO AMBIEN AMBIEN CR AMERGE ANDRODERM ANDROGEL 1% ANDROGEL 1.62% ANORO ELLIPTA ANZEMET
2 ARAVA ARCAPTA NEOHALER ARMONAIR RESPICLICK ARNUITY ELLIPTA ASMANEX HFA ASMANEX TWISTHALER ASTELIN READY SPRAY NASAL SPRAY ATELVIA ATROVENT HFA ATROVENT INHALER ATROVENT NASAL SPRAY AUVI-Q AVANDAMET AVANDARYL AVANDIA AVINZA AVONEX PEN* AVONEX* AXERT AXIRON AZMACORT BAXDELA BECONASE AQ BELBUCA BELSOMRA BENLYSTA* BENZNIDAZOLE BETASERON* BETHKIS* BEVESPI AEROSPHERE BEVYXXA BINOSTO BONIVA BONJESTA BREO ELLIPTA BROVANA INHALATION SOLUTION BUNAVAIL BYDUREON BYDUREON BCISE BYDUREON PEN BYETTA CABERGOLINE CADUET CALCIPOTRIENE CALCITRENE CAMBIA CARDURA INFLAMMATORY CONDITIONS ANAPHYLAXIS SPECIALTY BLOOD CELL DEFICIENCY PREGNANCY HIGH BLOOD PRESSURE
3 CARDURA XL CATAPRES CAVERJECT CAVERJECT IMPULSE CAYSTON* CESAMET CHILDREN'S QNASL CHOLBAM* CHORIONIC GONADOTROPIN* CIALIS CICLOPIROX CIMZIA* CLARINEX CLARINEX D 12 HOUR CLARINEX D 24 HOUR CLARITIN CLARITIN-D 12 HOUR CLARITIN-D 24 HOUR CLIMARA CLIMARA PRO CLOBETASOL CLOTRIMAZOLE COARTEM COLLAGENASE SANTYL COMBIVENT COMBIVENT RESPIMAT CONZIP ER CONZIP ER (TRAMADOL ER -BRAND) COPAXONE* COPAXONE/GLATOPA* CRESTOR DAKLINZA* DALIRESP DALMANE DEPO-PROVERA CONTRACEPTIVE INJECTION DEPO-SUBQ PROVERA 104 DEXILANT DICLEGIS DIFLUCAN DIVIGEL DOPTELET* DORAL DOSTINEX DOVONEX DUETACT HIGH BLOOD PRESSURE HIGH BLOOD PRESSURE SPECIALTY FERTILITY WOUND CARE WOMEN'S HEALTH - CONTRACEPTIVES & NON-PREGNANCY RELATED CONDITIONS WOMEN'S HEALTH - CONTRACEPTIVES & NON-PREGNANCY RELATED CONDITIONS PREGNANCY ORAL ANTIFUNGAL BLOOD CELL DEFICIENCY
4 DULERA DUONEB DUPIXENT* DURAGESIC DYMISTA ECONAZOLE ECOZA EDEX EDLUAR ELESTRIN GEL ELIDEL CREAM ELLA EMBEDA EMEND EMVERM ENBREL* ENSTILAR EPCLUSA* EPINEPHRINE EPIPEN EPIPEN JR ERTACZO ESBRIET* ESOMEPRAZOLE STRONTIUM ESTRADERM ESTRASORB ESTROGEL EUCRISA EVAMIST EVZIO EXALGO EXELDERM EXTAVIA* EXTINA FAMVIR FARXIGA FENTORA FLECTOR FLOLIPID FLONASE FLONASE ALLERGY RELIEF FLONASE ALLERGY RELIEF 50 MCG SPRAY FLOVENT DISKUS FLOVENT HFA FLUNISOLIDE WOMEN'S HEALTH - CONTRACEPTIVES & NON-PREGNANCY RELATED CONDITIONS ANAPHYLAXIS ANAPHYLAXIS ANAPHYLAXIS RESPIRATORY MISCELLANEOUS
5 FLUOCINONIDE OINTMENT GEL, SOLUTION, OR CREAM EMULSIFIED BASE FORADIL FORTAMET FORTEO* FORTESTA FOSAMAX FOSAMAX PLUS D FROVA GELNIQUE OVERACTIVE BLADDER GLUCOPHAGE XR GLUMETZA GLYXAMBI GRANISOL HALCION HARVONI* HETLIOZ* HUMIRA* HYSINGLA ER HYTRIN HIGH BLOOD PRESSURE ILUMYA* IMITREX IMITREX (SUMATRIPTAN) IMPAVIDO INCRUSE ELLIPTA INTERMEZZO INVOKAMET INVOKANA JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR JUVISYNC JYNARQUE KADIAN KALYDECO RESPIRATORY MISCELLANEOUS KAZANO KETOCONAZOLE KEVZARA * KEVZARA* KITABIS PACK TOBRAMYCIN PAK* (BRAND, SPECIALTY ALSO BY SAME MANU: PARI ) KOMBIGLYZE XR KYTRIL (GRANISETRON)
6 LAZANDA LESCOL LESCOL XL (FLUVASTATIN ER) LEVITRA LEVONORGESTREL (BRAND NAME PLAN B NOW OBSOLETE) NEXT CHOICE LIDOCAINE JELLY LIDOCAINE OINTMENT LIDOCAINE/PRILOCAINE CREAM LIPITOR LIPTRUZET LIVALO LONHALA MAGNAIR LOPROX LOTRISONE LUCEMYRA LUNESTA LUZU MALARONE MAVYRET* MAXAIR AUTOHALER MAXALT MAXALT MLT MEFLOQUINE MENOSTAR MENTAX MEPHTYON METHERGINE MEVACOR MIGRANAL MINIVELLE MOBIC MORPHABOND ER MS CONTIN MUSE NAFTIN NARCAN NASACORT ALLERGY 24HR (OTC) NASACORT AQ NASONEX NATESTO NEBUPENT NESINA NEULASTA* NEXIUM NIZORAL WOMEN'S HEALTH - CONTRACEPTIVES & NON-PREGNANCY RELATED CONDITIONS TOPICAL TOPICAL TOPICAL BLOOD CELL DEFICIENCY BLOOD CELL DEFICIENCY
7 NOCTIVA NOVAREL* NUCALA* NUCYNTA NUCYNTA ER NYSTATIN NYSTATIN-TRIAMCINOLONE OCALIVA* OFEV* OLUMIANT* OLYSIO* OMECLAMOX -PAK OMNARIS ONGLYZA ONMEL ONSOLIS ONZETRA XSAIL OPANA ER ORAMORPH SR ORKAMBI* OSENI OTIPRIO OXISTAT OXYCONTIN OXYTROL OZEMPIC PALYNZIQ* PATANASE PEG INTRON* PEGASYS* PENNSAID PENNSAID AND KLOFENSAID PERFOROMIST PLAN B ONE-STEP (LEVONORGESTREL) AFTERA ECONTRA EZ FALLBACK SOLO MY WAY NEXT CHOICE ONE DOSE OPCICON ONE-STEP TAKE ACTION PLEGRIDY* PLIAGLIS PRANDIMET (REPAGLINIDE/METFORMIN) PRAVACHOL OVERACTIVE BLADDER FERTILITY ASTHMA SPECIALTY RESPIRATORY MISCELLANEOUS ORAL ANTIFUNGAL RESPIRATORY MISCELLANEOUS OVERACTIVE BLADDER TOPICAL TOPICAL WOMEN'S HEALTH - CONTRACEPTIVES & NON-PREGNANCY RELATED CONDITIONS TOPICAL
8 PREGNYL PREVACID PREVPAC PREVYMIS PRILOSEC PRIMAQUINE PROAIR HFA PROAIR RESPICLICK PROSOM PROTONIX PROTOPIC OINTMENT PROVENTIL HFA PULMICORT FLEXHALER PULMICORT RESPULES QNASL QUALAQUIN QVAR HFA QVAR REDIHALER REBIF* REGRANEX RELENZA RELPAX RESTASIS RESTORIL REVATIO* RHINOCORT ALLERGY SPRAY RHINOCORT AQ ROZEREM RYBIX ODT RYZOLT ER SAMSCA* SANCUSO SECONAL SEEBRI NEOHALER SEGLUROMET SEREVENT SILENOR SILIQ* SIMCOR SITAVIG SOLARAZE SOLIQUA SOLOSEC SONATA SORILUX SOVALDI* SPINRAZA* FERTILITY WOUND CARE ANTI-INFLUENZA EYE CONDITIONS PULMONARY HYPERTENSION TOPICAL
9 SPIRIVA SPIRIVA RESPIMAT SPORANOX SPRIX* STADOL (BUTORPHANOL NASAL SPRAY ) STAXYN STEGLATRO STEGLUJAN STENDRA STIOLTO RESPIMAT STRIANT STRIVERDI RESPIMAT STROMECTOL SUBOXONE SUBSYS SUMAVEL DOSEPRO SYMBICORT SYMDEKO* SYMLIN SYNJARDY SYNJARDY XR TACLONEX TAMIFLU TANZEUM TAVALISSE TECHNIVIE* TESTIM TINDAMAX TIVORBEX TOBI PODHALER* TOBI* TORADOL TRADJENTA TRAMADOL ER TRELEGY ELLIPTA TREXIMET TRULICITY TUDORZA PRESSAIR TYMLOS* ULTRACET ULTRAM ULTRAM ER UTIBRON NEOHALER VALTREX VARUBI VENTOLIN HFA ORAL ANTIFUNGAL RESPIRATORY MISCELLANEOUS ANTI-INFLUENZA BLOOD CELL DEFICIENCY SPECIALTY SPECIALTY
10 VERAMYST VIAGRA VICTOZA VIEKIRA PAK* VIEKIRA XR* VIVELLE-DOT VIVLODEX VOGELXO VOLTAREN VOSEVI* VUSION VYTORIN XELJANZ XR* XELJANZ* XHANCE NASAL SPRAY XIFAXAN XIGDUO XR XIIDRA XOLAIR* XOLEGEL XTAMPZA ER XULTOPHY XYZAL ZECUITY TDS* ZEGERID ZEMBRACE ZETONNA ZINBRYTA* ZOCOR ZOFRAN (ONDANSETRON) ZOFRAN ODT (ONDANSETRON) ZOHYDRO ER ZOLPIMIST ZOMIG ZOMIG ZMT ZONALON/PRUDOXIN ZORVOLEX ZOVIRAX ZUBSOLV ZUPLENZ ZYPITAMAG ZYRTEC ZYRTEC-D 12 HOUR TOPICAL EYE CONDITIONS ASTHMA SPECIALTY
Data Class: Internal. 1 inhaler (30 blisters OR 14 blisters institutional pack) per presciption
To help make the use of prescription drugs safer and more affordable, our plan is now using a Drug Quantity Management program. That is, for certain medications, you can receive an amount to last you a
More informationDrug Target Maximum Quantity Internal
To help make the use of prescription drugs safer and more affordable, our plan is now using a Drug Quantity Management program. That is, for certain medications, you can receive an amount to last you a
More informationQuantity Management. October 2017
Quantity Management October 2017 What Is Quantity Management? It s a quality and safety program that promotes the safe use of medications. The program limits the amount of some medications we cover. We
More informationPequot Health Care Smart Quantity Program*
Pequot Health Care 1 Annie George Drive Mashantucket, CT 06338 Phone: 1-888-779-6638 Fax: 1-860-396-6494 Pequot Health Care Smart Quantity Program* Updated January 2018 *Quantity Program limits apply to
More information2013 Quantity Level Limits (QLL) Criteria
Certain drugs covered through your EmblemHealth Medicare PDP Medicare Plan are covered for only a limited quantity. We do this to ensure compliance with the US Food and Drug Administration and manufacturer
More information2013 Quantity Level Limits (QLL) Criteria
Certain drugs covered through your EmblemHealth Medicare PDP Medicare Plan are covered for only a limited quantity. We do this to ensure compliance with the US Food and Drug Administration and manufacturer
More informationManagement. Quantity. What Is Quantity Management? What Happens at the Pharmacy? Which Medications Are Included? January 2017
Quantity January 2017 Management What Is Quantity Management? It s a quality and safety program that promotes the safe use of medications. The program limits the amount of some medications that we cover.
More informationBB&T Drug Quantity Program List
BB&T Drug Quantity Program List To help make the use of prescription drugs safer and more affordable, our plan is now using a Drug Quantity Management program. That is, for certain medications, you can
More informationABILIFY ABILIFY DISCMELT ACTONEL ACTOPLUS MET ACTOPLUS MET XR ACTOS ADCIRCA ADVAIR DISKUS ADVAIR HFA
Quantity Limits Paramount Medicare Formulary 2012 Formulary ID 12112, Version 22. CMS Approved 10-23-2012. ABILIFY Abilify TABS ABILIFY DISCMELT Abilify Discmelt ACTONEL Actonel TABS 150MG Actonel TABS
More informationManagement. Quantity. What Is Quantity Management? What Happens at the Pharmacy? Which Medications Are Included? January 2016
January 2016 Quantity Management What Is Quantity Management? It s a quality and safety program that promotes the safe use of medications. The program limits the amount of some medications that we cover.
More informationNational Preferred Formulary Quantity Limits Drug List Helpful Tip: To search for a specific drug, use the find feature (Ctrl + F)
Page 1 of 6 Allergies Anaphylaxis Antifungal Anti-infective Anti-infective - Specialty Anti-Influenza Asthma - Specialty Asthma/COPD National Preferred Formulary Quantity Limits Drug List Helpful Tip:
More informationUniversity System of Georgia Prior Authorization, Step Therapy and Quantity Limit List (Updated 1/1/2016)
University System of Georgia, Step Therapy and Quantity Limit List (Updated 1/1/2016) (PA) Your doctor will need to obtain a prior authorization for the drugs listed below, before your prescription drug
More informationHealth Net Health Plan of Oregon, Inc. Oregon Drugs with a quantity limit Effective January 1, 2015 (Published December 15, 2014)
Health Net Health Plan of Oregon, Inc. Oregon Drugs with a quantity limit Effective January 1, 2015 (Published December 15, 2014) Abstral SL Actonel 35mg Limited to 4 s per month. Actonel 5,30mg adapalene
More informationMichigan Department of Health & Human Services Quantity Limitations
Abstral (fentanyl) sl tab all strength Acetaminophen Actonel Actonel 35mg Adderall XR 5mg, 10mg, 15mg Advair Diskus Advair HFA Aero Chambers and Spacers Aerobid Aerobid M Albuterol HFA 90mcg Akynzeo Aldara
More informationResponsible Quantity Program Effective 4/1/10. Abilify oral solution
Abilify Abilify Discmelt Abilify oral solution Aciphex Actiq Page 1 of 9 750 ml 120 units Actonel 5 mg, 30 mg Actonel 35 mg 4 tabs Actonel 75 mg 2 tabs Actonel 150 mg 1 tab Actonel with Calcium Adcirca
More informationDrug / Pregnancy Conflicts Excessive Daily Doses Ingredient Duplication Insufficient Daily Doses
Drug Utilization Review (DUR) ations (QL), Age, Gender Edits The Health Net DUR program evaluates a prescription when the pharmacy provider electronically submits the prescription. As the prescription
More informationPain Oral-Intranasal Fentanyl (Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys)
Pennsylvania Employees Benefit Trust Fund (PEBTF) and n- Medicare Eligible Retired Employees Health Program (REHP), Step Therapy and Quantity Limit List Your doctor needs to get prior authorization for
More informationMichigan Department of Health & Human Services Quantity Limitations
Quantity s Abstral (fentanyl) sl tab all strength acetaminophen Actonel Actonel 35mg Adderall XR 5mg, 10mg, 15mg Advair Diskus Advair HFA Aero Chambers and Spacers Aerobid Aerobid M albuterol HFA 90mcg
More informationMichigan Department of Community Health Quantity Limitations
Abstral (fentanyl) sl tab all strength Acetaminophen Actonel Actonel 35mg Adderall XR 5mg, 10mg, 15mg 240 per 34 days 3 gm/day 2 every 28 days 4 every 28 days Advair Diskus. No more than 180 every 30 days
More informationOptumRx Focused Utilization Management Program
Utilization management updates - January 1, 2019 OptumRx Focused Utilization Management Program OptumRx focused step therapy with quantity limits programs If you have a prescription for any of the Step
More informationAnthem Prescription Management s Clinical Connections Program
Anthem Prescription Management s Clinical Connections Program Anthem Prescription is committed to helping you manage your health care benefits. Prior Authorization, Quantity Limits and are edits recommended
More informationQuantity Limits Drug List Updated: February 2018 Helpful Tip: To search fo a specific drug, use the find feature (Ctrl + F)
Azithromycin Oral Susp. 100 2 bottles Antibiotics 200 3 bottles Factive 320 mg 7 tabs Antidepressantes- SSRIs, SNRIs, other Zmax Aplenzin Budeprion SR Budeprion XL Bupropion SR/ER Celexa Citalopram Cymbalta
More informationMichigan Department of Community Health Co-pay and Quantity Limitations
Michigan Department of Community Health Co-pay and Quantity Limitations Benefit Plan Co-pay Information Group ID Coverage Co-pay INCARCE Incarcerated Medicaid No coverage No coverage patients SHPDUAL CSHCSCAID
More informationMedPerform Medium Preferred Drug List (PDL)
What is the MedImpact Preferred Drug List (PDL)? The PDL is a list of commonly prescribed medications within select classes of drugs covered by your prescription drug plan. The PDL was created to promote
More informationQuantity Limits Drug List
Updated: October 2018 Helpful Tip: To search fo a specific drug, use the find feature (Ctrl + F) Category Brand Name Drug (Generic) Quantity Limit Azithromycin Oral Susp. 100 2 bottles 200 3 bottles Factive
More informationPrescription Drug Benefit Rider
Prescription Drug Benefit Rider Your Certificate of Coverage is amended as described in this document. This Rider becomes a part of your Certificate of Coverage and is subject to all provisions of your
More informationThree-Tier Prescription Drug Benefit Rider A
Three-Tier Prescription Drug Benefit Rider A Your Certificate of Coverage is amended as described in this document. This Rider becomes a part of your Certificate of Coverage and is subject to all provisions
More informationThree-Tier Prescription Drug Benefits Rider
Three-Tier Prescription Drug Benefits Rider Your Certificate of Coverage is amended as described in this document. This Rider becomes a part of your Certificate of Coverage and is subject to all provisions
More information2016 PRESCRIPTION DRUG LIST UPDATES
2016 PRESCRIPTION DRUG LIST UPDATES Evergreen Health 1 st Quarter Below are key updates to the four-tier EHB Prescription Formulary, effective January 1, 2016. Please consult the full formulary for more
More informationFirstCarolinaCare Preferred Drug List (PDL)
FirstCarolinaCare Preferred Drug List (PDL) 2-tier Drug Plan Members What is the MedImpact Preferred Drug List (PDL)? The PDL is a list of commonly prescribed medications within select classes of drugs
More informationFirstCarolinaCare Preferred Drug List (PDL)
FirstCarolinaCare Preferred Drug List (PDL) 2-tier Drug Plan Member What is the MedImpact Preferred Drug List (PDL)? The PDL is a list of commonly prescribed medications within select classes of drugs
More informationAGGRENOX. Products Affected. Details. Open 1 Last Updated: 10/01/2018. Aggrenox
Open 1 Last Updated: 10/01/2018 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_3742 09/2014 Formulary ID: 19076: version 7 1 ANTIDEPRESSANTS
More information2014 Quantity Limits (QL) Criteria
2014 Quantity Limits (QL) Criteria Certain drugs covered through your EmblemHealth Medicare HMO/PPO Medicare Plan are covered for only a limited quantity. We do this to ensure compliance with the US Food
More informationDiabetes Fortamet (metformin ER), Glumetza (metformin ER) generic of Glucophage XR (metformin ER) preferred
Pennsylvania Employees Benefit Trust Fund (PEBTF) and n-medicare Eligible Retired Employees Health Program (REHP), Step Therapy and Quantity Limit List Your doctor needs to get prior authorization for
More informationFirstCarolinaCare Preferred Drug List (PDL)
3-tier Drug Plan Members What is the MedImpact Preferred Drug List (PDL)? The PDL is a list of commonly prescribed medications within select classes of drugs covered by your prescription drug plan. The
More informationDrugs Requiring Prior Authorization When certain medications require prior authorization
Drugs Requiring Prior Authorization When certain medications require prior authorization Express Scripts is required to review prescriptions for certain medications with your doctor before they can be
More informationAGGRENOX. Products Affected. Details. Open 1 Last Updated: 12/01/2018. Aggrenox
Open 1 Last Updated: 12/01/2018 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_3742 09/2014 Formulary ID: 18066: version 17 1 ANTICONVULSANTS
More informationGenerics. Lead with. Prescription Step Therapy Program
Lead with Generics Prescription Step Therapy Program WWW.BCBSLA.COM 04HQ3972 R11/10 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company GENERIC DRUGS: A
More informationMEDICAID QUANTITY LIMIT DRUG LIST
MEDICAID QUANTITY LIMIT DRUG LIST PH51-R-02162018 Brand Name Generic Name Dosage Form Tier Quantity Limit Details Cambia Diclofenac Potassium PACK Tier 2 QL: 9 per 30 days Fentanyl (12 Mcg/Hr, 25 Mcg/
More informationMedPerform High Preferred Drug List (PDL)
What is the MedImpact Preferred Drug List (PDL)? The PDL is a list of commonly prescribed medications within select classes of drugs covered by your prescription drug plan. The PDL was created to promote
More informationMDI Bonanza. Dwayne Griffin, DO
MDI Bonanza Dwayne Griffin, DO Bonanza 3. A MDI costing $200 - $500 per month SISYPHUS MDI Griffin Mountain Evolution of Deliver Systems for COPD in the US 2003 2009 2011 2013 2004 2012 2014 Prescribing
More informationStep Therapy Criteria
Tier 5 Formulary Step Therapy 2016 Updated: 05/24/2016 Effective: 06/01/2016 What is Step Therapy? Some prescription drugs require step therapy (ST). In some cases, the plan requires you to first try certain
More informationDrug Class Excluded Product Clinical Alternative(s) ABSORICA ONEXTON GEL ANDRODERM FORTESTA VOGELXO MENTHOCIN PAD LIDOCAINE SCAR PATCH
Value Formulary Key Exclusions and Their Alternatives Catamaran offers diverse formulary alternatives that help our clients select what works best for them. The Value Formulary is a partially-closed formulary
More informationRecommended Exclusion of Selected Discretionary Drugs
7100 N High Street Office Suite 305 Worthington, Ohio 43085 pharmaceuticalhorizons.com p 614.781.6500 f 614.781.6503 FROM: RE: Allan Zaenger R.Ph., MS Pharmaceutical Horizons, Inc. Recommended Exclusion
More informationFee-for-Service Pharmacy Provider Notice #216 ** March 2016 PDL Changes ** Existing Drug Classes
Fee-for-Service Pharmacy Provider Notice #216 ** March 2016 PDL Changes ** December 19, 2016 Please be advised that the Department for Medicaid Services (DMS) is making changes to the Kentucky Medicaid
More informationHospitality Rx Step Therapy
agents may not be a generic medication. Second line agent may not be a brand medication. Some Step Therapy category may require trial of more than one medication. CLINDAMYCIN/BENZOYL PEROX Acne Combo Antibiotic
More informationQuantity limits This program helps keep you safe by making sure you get the amount of medicine that s right for you.
Member education Quantity limits This program helps keep you safe by making sure you get the amount of medicine that s right for you. Member education What are quantity limits? Taking too much medicine
More information1, 2014 PHARMACY BENEFIT
Effective 01/01/2007City of Plano Employee Benefit Design Summary Effective Date: January 1, 2014 PHARMACY BENEFIT CVS/CAREMARK TOLLFREE: 888-850-8245 ID CARD & NETWORK PHARMACIES: Identification Card
More informationREVISED RESPIRATORY MEDICATION USE QUESTIONNAIRE
REVISED RESPIRATORY MEDICATION USE QUESTIONNAIRE ID NUMBER: 0a) Date of Collection / / 0b) Staff Code Instructions: This form should be completed during the participant s clinic visit. 1) Are you regularly
More informationYour Drug Coverage Will Change as of Jan. 1, 2017
Your Drug Coverage Will Change as of Jan. 1, 2017 October, 2016 Dear Member: Thank you for choosing us for your health and drug coverage. We at Blue Cross and Blue Shield of Louisiana and HMO Louisiana,
More informationQuantity limits on medications are established to maximize the dosing regimen and decrease cost.
Drug Quantity Limits 2011 Quantity limits on medications are established to maximize the dosing regimen and decrease cost. Quantity limits are commonly placed on once daily drugs available in multiple
More informationStep Therapy Information... 4 Prior Authorization Information ACE Inhibitors and ACE Inhibitor Combinations...60 Acne Therapy...
Step Therapy Information... 4 Prior Authorization Information... 27 ACE Inhibitors and ACE Inhibitor Combinations...60 Acne Therapy...62 Acne Therapy Topical...64 Alcoholism Treatment Agents... 66 Analgesic
More informationYour Group s Drug Coverage Will Change as of Jan. 1, 2017 Notice of modification of drug coverage of a particular product
Your Group s Drug Coverage Will Change as of Jan. 1, 2017 Notice of modification of drug coverage of a particular product October, 2016 Dear Group Leader: Thank you for choosing us for your health and
More informationANTICONVULSANT THERAPY
Network Health Insurance Corporation NetworkCares Step Therapy Last Updated: 7/2017 ANTICONVULSANT THERAPY Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200
More informationTRELEGY ELLIPTA (fluticasone-umeclidinium-vilanterol) aerosol powder
TRELEGY ELLIPTA (fluticasone-umeclidinium-vilanterol) aerosol powder Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific
More informationMedication and Dose 10/04/ /05/2016 Total % Change Since 10/2012 ABILIFY 10 MG TABLET $18.76 $ %
Table Comparing NADAC prices for select brand name prescription medications on October 4, 2012 and October 5, 2016 to show how much prices have gone up for these medications. These medications increased
More informationDrug Quantity Limits Quantity limits (QL) on medications are established to maximize the dosing regimen and decrease cost
Drug Quantity Limits- 2011 Quantity limits (QL) on medications are established to maximize the dosing regimen and decrease cost QLs are commonly placed on once daily drugs available in multiple strengths.
More informationSTATE OF NEW YORK DEPARTMENT OF HEALTH
STATE OF NEW YORK DEPARTMENT OF HEALTH Corning Tower The Governor Nelson A. Rockefeller Empire State Plaza Albany, New York 12237 Antonia C. Novello, M.D., M.P.H., Dr.P.H. Commissioner Dennis P. Whalen
More informationRelative Cost/Month. Less than $10. Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL*
Allergy Chlorpheniramine Tablet* Diphenhydramine Tablet* Diphenhydramine Liquid* Loratadine Tablet* Cetirizine Tablet* Loratadine 10mg ODT* Less than $10 Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL*
More informationStep Therapy Requirements. Effective: 12/01/2016
Effective: 12/01/2016 H2986_PD_049 Updated 11/2016 ALPHA 1-PROTEINASE INHIBITOR GLASSIA PRIOR CLAIM FOR ARALAST NP OR ZEMAIRA WITHIN THE PAST 120 DAYS. ANALGESICS, NARCOTICS KADIAN MORPHINE SULFATE ER
More informationPA Start Date Therapeutic Class P&T Review Date 1/1/17 TOP$ (New Classes) include: Ophthalmics, Anti-Inflammatory/Immunomodulator
Maryland Department of Health and Mental Hygiene PDL Prior Authorization Implementation Schedule PA Start Therapeutic Class P&T Review 1/1/17 TOP$ (New Classes) include: Ophthalmics, Anti-Inflammatory/Immunomodulator
More informationDrug Therapy Guidelines
Classes of medications may be targeted for preferred products when there are multiple entries into the market in the same therapeutic category. Coverage of any non-preferred medication can be granted when
More informationSTATE OF NEW YORK DEPARTMENT OF HEALTH
STATE OF NEW YORK DEPARTMENT OF HEALTH Corning Tower The Governor Nelson A. Rockefeller Empire State Plaza Albany, New York 12237 Antonia C. Novello, M.D., M.P.H., Dr.P.H. Commissioner Dennis P. Whalen
More informationMedications Requiring Prior Authorization for Medical Necessity
Medications Requiring Prior Medical Necessity January 2016 Below is a list of medicines by drug class that will not be covered without a prior authorization for medical necessity. If you continue using
More informationTEST ANTICONVULSANT THERAPY. Products Affected. Step 2: Network Health Insurance Corporation NetworkCares Step Therapy Criteria Last Updated 11/2018
TEST Network Health Insurance Corporation NetworkCares Step Therapy Last Updated 11/2018 ANTICONVULSANT THERAPY Aptiom Banzel Briviact Celontin Dilantin 30 Mg Capsule Equetro Fycompa 0.5 Mg/ml Oral Susp
More informationMedications Requiring Prior Authorization for Medical Necessity
Medications Requiring Prior Medical Necessity January 2016 Below is a list of medicines by drug class that will not be covered without a prior authorization for medical necessity, effective January 1,
More informationMercy Care Plan. Acyclovir Ointment. Products Affected. acyclovir ointment 5 % external Details. Criteria. Requires use of oral Acyclovir
Acyclovir Ointment Mercy Care Plan acyclovir ointment 5 % external Requires use of oral Acyclovir 1 Adcirca ADCIRCA TABLET 20 MG ORAL Requires use of Sildenafil 2 Albenza ALBENZA TABLET 200 MG ORAL Requires
More informationStep Therapy Program Precision Formulary
Step Therapy Program Precision Formulary Physician Guidelines Failure of previous steps in the Step Therapy Program: For most therapies, Magellan Rx Management will review the most recent 180 days of claim
More informationDrug coverage reviews
Drug coverage reviews Drugs requiring prior authorization and step therapy 2018 Aetna Premier plan 05.03.478.1 E (8/17) aetna.com The drugs on this list require coverage reviews, like prior authorization
More informationPrescription Drugs with Dispensing Limits or Prior Authorization Requirements
Prescription Drugs with s or Requirements MHBP provides benefits for most covered prescription drugs for up to a 30-day supply when purchased at a retail pharmacy, and receive up to a 90 day supply for
More informationConnecticut Medicaid P&T Meeting Minutes September 2, 2010
Connecticut Medicaid P&T Meeting Minutes September 2, 2010 The meeting started at 6:30 pm Attendance Present Members: Carl Sherter, MD Peggy Manning Memoli, Pharm D Eric Einstein, MD Ezra Griffith, MD
More informationTRICARE Uniform Formulary. Pre-Authorization Requirements
TRICARE Uniform Formulary Pre-Authorization Requirements The Department of Defense (DoD) requires pre-authorization on select medications. These medications are on the DoD s pre-authorization list because
More informationStep Therapy Medications
Step Therapy Medications Step Therapy (ST PA ) is an automated form of prior authorization. It encourages the use of therapies that should be tried first, before other treatments are covered, based on
More informationHow to Search. For PC Users: Hold down the Ctrl and F keys at the same time, or click on the Binoculars icon, to open the search pane.
To help make the use of prescription drugs safer and more affordable, our plan is now using a Drug Quantity Management program (Quantity Limits or QL). That is, for certain medications, you can receive
More informationSelect Inhaled Respiratory Agents
Applies to all products administered or underwritten by Blue Cross and Blue Shield of Louisiana and its subsidiary, HMO Louisiana, Inc.(collectively referred to as the Company ), unless otherwise provided
More informationThe Medical Letter. on Drugs and Therapeutics
The Medical Letter publications are protected by US and international copyright laws. Forwarding, copying or any other distribution of this material is strictly prohibited. For further information call:
More informationPDL Implementation Date 1/1/18 TOP$ (New Classes) include: Epinephrine, Self-Injecting
Maryland Department of Health Preferred Drug List (PDL) Implementation Schedule PDL Implementation Therapeutic Class Date 1/1/18 TOP$ (New Classes) include: Epinephrine, Self-Injecting Acne Agents, Topical
More informationCigna Drug and Biologic Coverage Policy
Cigna Drug and Biologic Coverage Policy Subject Step Therapy Individual and Family Plan Table of Contents Coverage Policy... 1 General Background... 5 References... 5 Effective Date... 3/15/2018 Next Review
More informationQuantity Limits 2016 Paramount Medicare Formulary Formulary ID: Version 26 Updated: 11/1/2016
Quantity Limits 2016 Paramount Medicare Formulary Formulary ID: 16162 Version 26 Updated: 11/1/2016 ANALGESICS acetaminophen w/ codeine (300-15 mg, 300-30 mg, 300-60 mg) acetaminophen w/ codeine soln 120-12
More informationFormulary Medical Necessity Program
BENEFIT APPLICATION Formulary Medical Necessity Program DRUG POLICY Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations
More informationPDL DOSAGE CONSOLIDATION LIST
Last update 7/11 PDL DOSAGE CONSOLIDATION LIST Tabs/Caps/Patches: Quantities in units Shaded areas are non-preferred agents - Quantities of these Sprays/Inhalers/Nebulizers: Quantities in GM, ML, OR MCG
More informationCigna Drug and Biologic Coverage Policy
Cigna and Biologic Coverage Policy Subject Quantity Limitations Table of Contents Coverage Policy... 1 General Background... 6 Coding/Billing Information... 11 References... 11 Effective Date...2/15/2018
More informationAGGRENOX. Products Affected. Details. First Health Part D Value Plus (PDP) Last Updated: 10/01/2017. Aggrenox
First Health Part D Value Plus (PDP) Last Updated: 10/01/2017 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_3742 09/2014 Formulary ID: 18059:
More informationStep Therapy Criteria
ADCIRCA 1772-D ADCIRCA Coverage will be provided if the member has filled a prescription for sildenafil (at least a 30 day supply within the past 365 AMYLIN ANALOG 676-D SYMLINPEN 120, SYMLINPEN 60 rapid-acting
More informationPlan Year CCHP Senior Program (HMO) Step Therapy Criteria (ST)
Plan Year 2016 CCHP Senior Program (HMO) Step Therapy Criteria (ST) Step Therapy: In some cases, CCHP Senior Program (HMO) requires you to first try certain drugs to treat your medical condition before
More informationPrescription benefit updates Individual/small group
Prescription benefit updates Individual/small group Moda Health s prescription program is a pharmacy benefit that offers members a choice of safe and effective medication treatments. The program also helps
More informationMedications Requiring Prior Authorization for Medical Necessity for The University of Nebraska
January 2017 Medications Requiring Prior Medical Necessity for The University of Nebraska Below is a list of medicines by drug class that will not be covered without a prior authorization for medical necessity,
More informationQuantity limits This program helps keep you safe by making sure you get the amount of medicine that s right for you.
Member education Quantity limits This program helps keep you safe by making sure you get the amount of medicine that s right for you. Member education What are quantity limits? Taking too much medicine
More informationSecretary for Health and Family Services Selections for Preferred Products
Secretary for Health and Family Services Selections for Preferred Products This is a summary of the final Preferred Drug List (PDL) selections made by the Secretary for Health and Family Services based
More informationDrug coverage reviews
Drug coverage reviews Drugs requiring prior authorization and step therapy Aetna Premier Plus plan aetna.com The drugs on this list require coverage reviews like prior authorization or step therapy* under
More information2013 Preferred Drug List An evidence-based pharmacy program that works for you
2013 Preferred Drug List An evidence-based pharmacy program that works for you What is the Moda Health Preferred Drug Program? The Moda Health Preferred Drug Program is a pharmacy program that is designed
More information2013 Preferred Drug List An evidence-based pharmacy program that works for you
2013 Preferred Drug List An evidence-based pharmacy program that works for you What is the Moda Health Preferred Drug Program? The Moda Health Preferred Drug Program is a pharmacy program that is designed
More information2013 Preferred Drug List An evidence-based pharmacy program that works for you
2013 Preferred Drug List An evidence-based pharmacy program that works for you What is the Moda Health Preferred Drug Program? The Moda Health Preferred Drug Program is a pharmacy program that is designed
More informationIf you have questions about the Step Therapy Program, contact ClearScript Member Services at the number on the back of your ID Card.
Step Therapy The ClearScript Step Therapy program promotes the cost-effective use of clinically appropriate medications when more than one drug is available to treat a medical condition. What is Step Therapy?
More informationHigh-Cost Drug Exclusions
PHARMACY SERVICES High-Cost Exclusions The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at
More information