Drug / Pregnancy Conflicts Excessive Daily Doses Ingredient Duplication Insufficient Daily Doses
|
|
- Victor Spencer
- 6 years ago
- Views:
Transcription
1 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 is submitted, a quality assurance review is preformed based on rational drug therapy, referenced interaction information; suggested dosage limits; and recommended length of therapy as indicated by the drug manufacturer s FDA-approved package insert and primary medical literature. The prior authorization process may also be used to request a dosing regimen that is outside the usual recommended DUR and edits. DUR edits used to assist the pharmacist in the provision of quality care are: Drug / Age Conflicts Drug / Disease Conflicts Drug / Drug Interactions Drug / Gender Conflicts Drug / Pregnancy Conflicts Excessive Daily Doses Ingredient Duplication Insufficient Daily Doses Insufficient Duration Refill Too Late Refill Too Soon Therapeutic Duplication Please refer to the Preferred Drug List for the formulary status of these agents. Drug Name ABILIFY ABILIFY DISCMELT ABILIFY SOLUTION Max 900 ml per month ACIPHEX ACTIQ Max 3 lozenges per day ACTONEL 150MG Max 1 tablet per month ACTONEL 35MG ACTONEL 75MG Max 2 tablets per month ACTOPLUS MET ACTOS ADDERALL XR ADRENACLICK Max 2 injectors per RX ADVAIR DISKUS ADVAIR HFA ADVICOR MG ADVICOR MG, MG ALDARA Max 24 packets per month alendronate 35mg, 70mg alendronate 5mg, 10mg, 40mg ALLEGRA Authorization not required for generic ALORA ALTOPREV AMBIEN AMBIEN CR AMERGE anastrozole ANDRODERM Males only ANDROGEL Males only ANZEMET Max 4 tablets per month APLENZIN ARALEN Page 1 of 7
2 ARAVA ARICEPT 23MG ARIMIDEX AROMASIN ASACOL ASACOL HD ASMANEX ASTELIN ASTEPRO ATRALIN ATRIPLA AVANDIA 2MG, 4MG AVANDIA 8MG AVINZA AVITA AVODART AXERT azithromycin 250mg azithromycin 500mg azithromycin 600mg azithromycin powder pak 1gm AZMACORT BONIVA BROVANA bupropion xl 150mg bupropion xl 300mg butorphanol tartrate BYETTA BYSTOLIC 10MG BYSTOLIC 2.5MG, 5MG BYSTOLIC 20MG CADUET CAMPRAL carbidopa/levodopa cr 50/200 CAVERJECT CELEBREX CELEXA 10MG CELEXA 20MG CELEXA 40MG chloroquine CIALIS CIPRO XR 1000MG CIPRO XR 500MG ciprofloxacin sr 1000mg ciprofloxacin sr 500mg citalopram 10mg citalopram 20mg citalopram 40mg CLIMARA CLINDAREACH KIT COMBIVENT CONCERTA 18MG, 27MG, 54MG CONCERTA 36MG Max 12 tablets per day Max 6 tablets per day Max 2 spray bottles per month Max 2 spray bottles per month Max one 45gm tube per month, Max 1 tube per month, Males Only Max 3 tablets per month Max 2 packets per RX, Max 1 RX per month Max 1 tablet per month Max 60 vials per month Max 1 pen device per month Max 6 tablets per day Max 8 tablets per day Age 40 or older. Max 6 doses per month Max 1 and ½ tablets per day Age 40 or older. Max 4 tablets per month (cumulative total in this drug class) Max 14 tablets per course of therapy Max 3 tablets per course of therapy Max 14 tablets per course of therapy Max 3 tablets per course of therapy Max 1 and ½ tablets per day Max 1 unit per month Page 2 of 7
3 COREG CR CRESTOR 10MG, 20MG, 40MG CRESTOR 5MG CYMBALTA DAYTRANA DIFFERIN CREAM, GEL DIFFERIN PADS DIFFERIN SOLUTION DIFLUCAN 150MG DORYX DOSTINEX DUAC CS DUETACT DURAGESIC 100MCG DURAGESIC 12.5MCG, 25MCG DURAGESIC 50MCG, 75MCG EDEX EFFIENT EMEND 40MG EMEND TRI-FOLD EMSAM ENABLEX EPIDUO EPIPEN EPIPEN JR EPIVIR 300MG ESCLIM ESTRADERM estradiol patch estradiol patch ESTRASORB ESTROGEL EVISTA FACTIVE FEMARA FEMRING fentanyl lozenge fentanyl patch 100mcg fentanyl patch 12.5mcg, 25mcg fentanyl patch 50mcg, 75mcg FENTORA fexofenadine FIBRICOR finasteride FLONASE FLOVENT HFA fluconazole 150mg fluticasone nasal spray FOCALIN XR FORTEO fortical FOSAMAX 35MG, 70MG FOSAMAX 5MG, 10MG 40MG FOSAMAX PLUS D Max 1 patch per day Max one 45gm tube per month, Max 60 pads per month, Max one 30ml bottle per month, Max 2 tablets per Rx Max 16 tablets per month Max one 45gm tube per month Max 3 patches every 3 days Age 40 or older, Max 6 doses per month Max 1 capsule per Rx Max 4 combination packs per month Max 1 patch per day Max 2 injectors per RX Max 2 injectors per RX Max 1 carton (56 pouches) per month Max 1 pump every 2 months Max 7 tablets per Rx Females Only Max 3 lozenges per day Max 3 patches every 3 days Max 4 buccal tablets per day Authorization not required for generic Males Only, Age 50 or older Max 2 tablets per Rx Max 1 pen per month Page 3 of 7
4 FOSAMAX SOLUTION FROVA GEODON GLUCAGON granisetron IMITREX INJ STATDOSE IMITREX INJ VIALS IMITREX SPRAY IMITREX TABLETS INTAL INHALER INTUNIV INVEGA 1.5MG, 3MG, 9MG INVEGA 6MG JANUMET JANUVIA KADIAN KAPIDEX KETEK ketorolac KYTRIL LAMICTAL STARTER KIT lansoprazole LARIAM leflunomide LETAIRIS LEVITRA levonorgestrel LEXAPRO 10MG LEXAPRO 5MG, 20MG LEXAPRO ORAL SOLUTION LIDODERM LIPITOR LOTRONEX lovastatin LOVENOX LUMIGAN LUNESTA LYRICA 150MG, 200MG LYRICA 225MG, 300MG LYRICA 25MG, 50MG LYRICA 75MG, 100MG MAXAIR AUTOHALER MAXALT MAXALT MLT mefloquine meloxicam MENOSTAR METADATE CD MEVACOR MIACALCIN minocycline sr MOBIC MUSE Max 4 bottles (300ml) per month Max 2 kits per month Max 4 kits per month Max 10 vials per month Max 6 nasal spray units per month Max 1 tablets per day, Max 20 tablets per Rx Max 20 tablets per 6 months Max 1 kit per year Age 40 or older.max 4 tablets per month (cumulative total in this drug class) Max 2 tabs (1 box) per Rx Max 1 and ½ tablets per day Max 600ml per month Max 3 patches per day Females Only Max 2 syringes per day Max 5ml per month Max 6 suppositories per month, Age 40 or older Page 4 of 7
5 NASACORT AQ NASONEX NEXIUM NUCYNTA NUVARING NUVIGIL ondansetron ondansetron odt ondansetron oral solution ONGLYZA ONSOLIS OPANA ER ORACEA ORTHO EVRA OXYCONTIN 10MG, 20MG OXYCONTIN 15MG, 30MG OXYCONTIN 40MG, 80MG OXYCONTIN 60MG PANRETIN GEL pantoprazole PLAN-B PLAVIX PRAVACHOL pravastatin PREVACID PREVACID NAPRAPAC PREVACID SOLUTAB PREVPAC PREZISTA 150MG PREZISTA 300MG PREZISTA 400MG, 600MG PREZISTA 75MG PROAIR HFA PROQUIN XR PROSCAR PROTONIX PROVENTIL HFA PROVIGIL PROZAC WEEKLY PULMICORT FLEXHALER QVAR RANEXA 1000MG RANEXA 500MG REBIF REGRANEX RELENZA RELPAX RESTORIL RETIN-A RETIN-A MICRO GEL RETIN-A MICRO PUMP REYATAZ 100MG,150MG, 200MG REYATAZ 300MG RHINOCORT AQ Max 2 spray pump units per month Max 6 tablets per day Max 1 ring per month Max 100ml per month Max 3 films per day Max 3 patches per month Max 1 tube (60gm) per month Max 2 tabs (1 box) per Rx Max 1 pack per month Max 1 solutab per day Max 14 packs per RX Max 8 tablets per day Max 16 tablets per day Max 3 tablets per Rx Males Only, Age 50 or older Max 8 capsules per month Max 12 syringes per month Max 1 tube (15gm) per Rx Max 1 unit per Rx Max 2 spray bottles per month Page 5 of 7
6 RISPERDAL RISPERDAL CONSTA RISPERDAL SOLUTION RISPERDAL-M risperidone risperidone odt risperidone solution ROZEREM RYZOLT SANCTURA XR SANCUSO SAPHRIS SAVELLA SENSIPAR 30MG, 60MG SENSIPAR 90MG SEROQUEL 100MG, 200MG SEROQUEL 25MG, 50MG SEROQUEL XR 150MG, 200MG, SEROQUEL XR 50MG, 300MG, 400MG simvastatin SINEMET CR 50/200 SINGULAIR SOLODYN SONATA 10MG SONATA 5MG SPIRIVA STADOL STRATTERA 40MG STRATTERA 60MG STRATTERA 80MG, 100MG sumatriptan inj statdose sumatriptan inj vials sumatriptan spray sumatriptan tablets SYMBICORT SYMBYAX TAMIFLU TAMIFLU SUSPENSION TAZORAC temazepam TESTIM TORADOL tramadol er 100mg tramadol er 200mg tretinoin TREXIMET TRICOR TRILIPIX TWINJECT ULTRAM ER 100MG ULTRAM ER 200MG VENTOLIN HFA VERAMYST VESICARE Max 2 dose kits per month Max 480ml per month Max 480ml per month Max 8 tablets per day Max 2 capsule per day Max 4 kits per month Max 10 vials per month Max 6 nasal spray units per month Max 10 capsules per Rx Max 3 bottles per Rx Max one 30gm tube per month. Males Only Max 20 tablets per 6 months Max 1 package per Rx Page 6 of 7
7 VIAGRA VIVELLE VIVELLE-DOT VYTORIN 10/10 VYTORIN 10/20, 10/40, 10/80 VYVANSE WELLBUTRIN XL 150MG WELLBUTRIN XL 300MG XALATAN XIFAXIN XOPENEX HFA XYZAL zaleplon 10mg zaleplon 5mg ZEGERID ZETIA ZIPSOR ZITHROMAX 250MG ZITHROMAX 500MG ZITHROMAX 600MG ZITHROMAX POWDER PAK 1GM ZMAX ZOCOR ZOFRAN ZOFRAN ODT ZOFRAN ORAL SOLUTION zolpidem ZOMIG ZOMIG NASAL SPRAY ZOMIG ZMT ZYPREXA ZYPREXA 15MG, 20MG Age 40 or older. Max 4 tablets per month (cumulative total in this drug class) Max 2 bottles per month Max 9 tablets per year Max 2 capsule per day Max 1 capsule or packet per day Max 4 tabs per day for 7 days Max 3 tablets per month Max 2 packets per RX, Max 1 RX per month Max 1 dose (bottle) per month Max 100ml per month Max 6 single use nasal spray units per month Page 7 of 7
Responsible 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 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 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 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 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 informationData 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 informationDrugs That Have Quantitiy Limits (QL)
Drugs That Have Quantitiy Limits (QL) There are Quantity Limits set by your UA Medicare Group Part D Prescription Drug Plan for the drugs listed below. The UA Medicare Group Part D Prescription Drug Plan
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 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 information2014 Preferred Drug List An evidence-based pharmacy program that works for you
2014 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 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 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 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 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 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 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 informationCost Effectiveness Recommendations For Kentucky Retirement Systems MTM Plan 2011
Medication Tier 2 options Tier 1 options Nexium- Tier 3 Aciphex Lansoprazole Omeprazole Pantoprazole Crestor- Tier 3 Lipitor Simvastatin Vytorin- Tier 3 Atacand- Tier 3 Avapro Benicar Cozaar Micardis Tevetan
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 informationGenerics. Lead with. P r e s c r i p t i o n S t e p T h e r a p y P r o g r a m
Lead with Generics P r e s c r i p t i o n S t e p T h e r a p y P r o g r a m WWW.BCBSLA.COM 04HQ3972 5/09 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity
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 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 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 informationSTEP THERAPY ALGORITHMS PUP Select Formulary
The Step Therapy drug will be dispensed if the drug has been dispensed within 120 days of current fill or if alternative (Step 1) drugs have been used first. If the member s prescription claim fails the
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 informationQuantity per Dispensing Level Limits/Allowances
An independent licensee of the Blue Cross and Blue Shield Association. Quantity per Dispensing Level Limits/Allowances All covered prescription medications are available at a participating pharmacy for
More informationRxBlue 2010 ST Criteria
RxBlue 2010 ST Criteria ANTIDEPRESSANTS - SARAFEM... 10 FLUOXETINE HCL... 10 SARAFEM... 10 SELFEMRA... 10 ANTIDEPRESSANTS- SSRI, SNRI... 11 CELEXA... 11 CITALOPRAM... 11 CYMBALTA... 11 EFFEXOR XR... 11
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 informationPrimary/Preferred Drug List
July 2009 Primary/Preferred Drug List The CVS Caremark Primary/Preferred Drug List is a guide within select therapeutic categories for clients, plan participants and health care providers. Generics should
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 informationPerformance Drug List
January 2011 Performance Drug List The CVS Caremark Performance Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered
More informationDrug Bill As Unit Common Directions Common Day Supply Common Billing Errors Oral Tablets/Capsules
Note: This is a guide for commonly misbilled medications. Please submit the claims according to directions for use indicated on the prescription order. Drug Bill As Unit Common Directions Common Day Supply
More informationADHD STIMULANTS-S(SHC)
Step Therapy Simply Health Care 2014 Formulary ID: 14406 Version: 14 Last Updated: 08/01/2014 ADHD STIMULANTS-S(SHC) Daytrana Focalin Xr Strattera Patient needs to have a paid claim for one Step 1 drug
More informationHow do I request an exception to the Liberty Health Advantage s Formulary?
QUANTITY LIMITATIONS How do I request an exception to the Liberty Health Advantage s Formulary? You can ask Liberty Health Advantage to make an exception to our coverage rules. There are several types
More informationU T I L I Z A T I O N E D I T S
I N D I A N A H E A L T H C O V E R A G E P R O G R A M S U T I L I Z A T I O N E D I T S A P R I L 1 9, 2 0 1 2 s for s Refer to Provider Bulletin BT200709 for additional information regarding the Mental
More informationPharmacy Costs: Can I Make a Difference?
Pharmacy Costs: Can I Make a Difference? Pharmaceutical Market Dynamics What is driving Rx cost up? No New Blockbusters Patent Expirations OTC Market Dynamics Availability Pharmaceutical Companies Unfortunately,
More informationAGGRENOX. Products Affected. Details. GRP B2 Last Updated: 09/01/2018. Aggrenox
GRP B2 Last Updated: 09/01/2018 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_3742 09/2014 Formulary ID: 18066: version 15 1 ANTICONVULSANTS
More informationANTICHOLINERGIC BRONCHODILATORS ANTICHOLINERGIC BETA-AGONIST COMBO'S CORTICOSTEROID / BRONCHODILATOR COMBO'S NASAL STEROIDS LEUKOTRIENE MODIFIERS
1 of 5 ALLERGY / ASTHMA THERAPIES ANTIHISTAMINES, MINIMALLY SEDATING cetirizine fexofenadine loratadine ANTIHISTAMINE/DECONGESTANT COMBINATIONS cetirizine/pseudoephedrine fexofenadine/pseudoephedrine loratadine/pseudoephedrine
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 informationAmitriptyline Hydrochloride Heart Health & BP Amlodipine Besylate 5mg Norvasc Antibiotics Amoxicillin 500 mg Amoxil
School Corp Formulary Antiviral Acyclovir 400mg Zovirax Asthma Advair Diskus Diskus 250/50 Fluticasone/Salmeterol Asthma Albuterol Sulfate 2.5 mg/3 ml Proventil Arthritis and Pain Allendronate Sodium 70
More informationSmithRx Standard Formulary Step Therapy List
SmithRx Standard Formulary Step Therapy List Revised: January 27, 2017 The following medications require prior use of at least one other medication for coverage. Please note that any plan-specific customizations
More informationAlprazolam 0.25mg, 0.5mg, 1mg tablets
Presbyterian Senior Care (HMO) / Presbyterian MediCare PPO Quantity Limits Effective November 1, 2014 For the most recent list of drugs or other questions, please contact the Presbyterian Customer Service
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 informationAmitriptyline Hydrochloride Heart Health & BP Amlodipine Besylate 5mg Norvasc Antibiotics Amoxicillin 500 mg Amoxil
Antiviral Acyclovir 400mg Zovirax Asthma Advair Diskus Diskus 250/50 Fluticasone/Salmeterol Asthma Albuterol Sulfate 2.5 mg/3 ml Proventil Arthritis and Pain Allendronate Sodium 70 mg Fosamax Arthritis
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 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 informationMedication Guide April 2010
Blue Cross and Blue Shield of Florida Medication Guide April 2010 CONTENTS This Medication Guide was current at time of printing and is subject to change. Please visit our web site, www.bcbsfl.com, for
More informationUniversity of Virginia Drug List
July 2010 University of Virginia Drug List The University of Virginia Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered
More information2015 Chinese Community Health Plan Senior Program (HMO) Step Therapy Criteria Last Updated 11/1/2015
2015 Chinese Community Health Plan Senior Program (HMO) Step Therapy Last Updated 11/1/2015 APLENZIN TAB 174MG, 348MG, 522MG Step Therapy requires trial of bupropion SR or bupropion XL in previous 180
More informationPreferred Drug List (Formulary) CareFirst BlueCross BlueShield
Prescription drugs can account for a large percentage of your health care costs. By using the (CareFirst) preferred drug list, also called a formulary, you can discuss with your physician and your pharmacist
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 informationBeneficiary Advisory Panel Handout Uniform Formulary Decisions 24 June 2010
Beneficiary Advisory Panel Handout Uniform Formulary Decisions 24 June 2010 PURPOSE: The purpose of this handout is to provide BAP Committee members with a reference document for the relative clinical
More informationUF Decision Report FY06-07 Beneficiary Advisory Panel 10 Jan 2008
UF Decision Report FY06-07 Beneficiary Advisory Panel 10 Jan 2008 Promoting high quality, cost effective drug therapy throughout the Military Health System UF Decisions, May 07 Class FY05 rank, total $
More informationAvoid paying too much for your prescriptions
Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2017 Aetna Rx Step Program Medicine List Avoid paying too much for your prescriptions It s important to try to
More informationOHIO MEDICAID PHARMACY COVERAGE
OHIO MEDICAID PHARMACY COVERAGE This information is intended for use by providers to help select the most appropriate cost-effective medication and formulation for their patients. Prescribers should utilize
More informationPrimary/Preferred Drug List
January 2012 Primary/Preferred Drug List The CVS Caremark Primary/Preferred Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should
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 informationANTIDEPRESSANT THERAPY
Step Therapy Paramount Medicare Enhanced Formulary 2011 Formulary ID 11110, Ver 23. CMS Approved 10-25-2011. Last Updated: 10-05-2011 ANTIDEPRESSANT THERAPY Celexa Pristiq Cymbalta Prozac Effexor Prozac
More information+-Quantity per Dispensing Level Limits/Allowances
An independent licensee of the Blue Cross and Blue Shield Association. +-Quantity per Dispensing Level Limits/Allowances All covered prescription medications are available at a participating pharmacy for
More informationQUANTITY LEVEL LIMIT (QLL) GUIDELINE
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
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 informationBlue Cross Complete Pharmacy Prior Authorization Guidelines
Pharmacy Guidelines Medications that require prior authorization are identified as requiring prior authorization on the Blue Cross Complete List. Prior authorization helps ensure that safe, high-quality,
More informationTable 1: Price increases for Brand Name Drugs with Generic Equivalents
Table 1: Price increases for Brand Name Drugs with Generic Equivalents Brand Name Medication and Dose Total % Change Since 10/2012 ACTOS 15 MG TABLET 6.36 11.03 73.39% ACTOS 30 MG TABLET 9.7 16.80 73.23%
More informationSouth Carolina Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina
South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina 29202-8206 Pharmacy and Therapeutics (P&T) Committee Meeting MINUTES 1. Call to Order A meeting of the
More informationBLUE SHIELD OF CALIFORNIA JUNE 2016 PLUS DRUG FORMULARY CHANGES
BLUE SHIELD OF CALIFORNIA JUNE 2016 PLUS DRUG FORMULARY CHANGES Blue Shield is committed to covering safe, effective and affordable medications, so we regularly review and update our drug formularies.
More informationCARDIOVASCULAR ACE INHIBITORS fosinopril lisinopril quinapril ramipril ACE INHIBITOR / DIURETIC COMBINATIONS fosinoprilhydrochlorothiazide
April 2012 CalPERS Drug List The CalPERS Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing.
More informationCommissioner for the Department for Medicaid Services Selections for Preferred Products
Commissioner for the Department for Medicaid Services Selections for Preferred Products This is a summary of the final Preferred Drug List (PDL) selections made by the Commissioner for the Department for
More informationCerner Bulletin Providers Issued: October 2, 2014
Alert Warfarin Ordered without INR CPOE, Nursing and Pharmacy 10/13/14 S B A R Prescribers currently do NOT get a warning if warfarin is actively ordered and there has not been an INR result in the past
More informationStep Therapy Requirements
An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 12/01/2017 Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/2014 1 ABILIFY Abilify 10 mg tablet
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 informationAETNA BETTER HEALTH Prior Authorization guideline for Quantity Level-Limits
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
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 information2015 Step Therapy Prior Authorization Medical Necessity Guidelines
Tufts Health Unify 2015 Step Therapy Prior Authorization Medical Necessity Guidelines Effective: 01/01/2015 Updated: 10/01/2015 Tufts Health Plan P.O. Box 9194 Watertown, MA 02471-9194 Phone: 855-393-3154
More informationPrimary/Preferred Drug List
April 2012 Primary/Preferred Drug List The CVS Caremark Primary/Preferred Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should
More informationAttention: Behavioral Health Providers, Pharmacists and Prescribers N.C. Medicaid and N.C. Health Choice Preferred Drug List Changes - UPDATE
Attention: Behavioral Health Providers, Pharmacists and Prescribers N.C. Medicaid and N.C. Health Choice Drug List Changes - UPDATE Note: This article was previously published in the December 2014 Medicaid
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 informationGuide to Prescription Drug Benefits
Guide to Prescription Drug Benefits Understanding your prescription drug benefits can help you get the most out of your health care dollar. Table of Contents 1 Contact Us Phone Number Website 2-3 Using
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 informationCHICAGO REGIONAL COUNCIL OF CARPENTERS WELFARE FUND RETIREE PRESCRIPTION DRUG BENEFITS October 2013
CHICAGO REGIONAL COUNCIL OF CARPENTERS WELFARE FUND RETIREE PRESCRIPTION DRUG BENEFITS October 2013 How to Use the Prescription Drug Program The Chicago Regional Council of Carpenters Welfare Fund has
More informationQuarterly pharmacy formulary change notice
Quarterly pharmacy formulary change notice Provider update Summary: The formulary changes listed in the table below were reviewed and approved at our fourth-quarter Pharmacy and Therapeutics Committee
More information