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 1000-20MG ADVICOR 500-20MG, 750-20MG 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
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
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
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
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
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
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