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 by Anthem s National Pharmacy and Therapeutics Committee. These edits have also been approved by your health plan to help ensure that you have access to safe, appropriate and effective drug benefits. Simply stated, these edits are defined below: : may require that approval be obtained before you can receive benefits to cover the medication Quantity Limit: may affect the quantity of a certain medication you may receive benefits for each month : may require that you use another type of medication first before you will receive benefits for another medication. We have prepared the following table for you so that if your physician prescribes any of the medications listed below, you may determine which edits or guidelines apply. With the new P&T process, not all edits are clinical, all are reviewed for clinical issues, but if no clinical issues or barriers exist, edits can be implemented that are cost based. Medication Accupril (all strengths except 40mg) Accuretic 10/12.5mg Accutane Aciphex Actos Actonel Aceon (all strengths except 8mg) Aciphex Adalat CC 30mg Aerobid /Aerobid M inhaler Quantity Limit - 30 day supply. No refills allowed. Not filled in mail order. Quantity Limit 4 tablets per 30 days 35mg - 1 tablet per day 5mg or 30mg Age/gender The male only edit applies to impotency, benign prostatic hypertrophy, propecia, and androgen medications. The female only edit applies to vaginal products, estrogen, progestational agents, follicle stimulating/ lutenizing hormone, contraceptive agents, Diflucan 150mg, prenatal vitamins, and Zelnorm. Alamast Aldara TM Allegra, Allegra-D Alocril Alomide Altace (all strengths except 10mg) The age edit applies to Cognex, Aricept, Exelon, Reminyl, Namenda, Feldene, Zelnorm and the tetracycline class of antibiotics. Quantity Limit 12 packets per 28 days Quantity Limit 1 tablet per day 180mg - 2 tablets per day 30mg, 60mg, or D Page 1 of 6
Altoprev (formerly Altocor) 10mg, 20mg Alupent inhaler Amerge Androderm AndroGel Android Anzemet 50mg tablets Anzemet 100mg tablets Arava Atacand (all strengths except 32mg) Atrovent inhaler Atrovent nebulizer solution Atrovent.03% nasal spray Atrovent.06% nasal spray Augmentin tablets; suspension Avandamet Avandia Avapro (all strengths except 300mg) Axert Azmacort Beconase AQ nasal inhaler Benicar 20mg Benicar HCT 20/12.5mg Bextra Cardizem CD 120mg, LA 120mg, LA 180mg Ceftin tablets and suspension Celebrex 100 mg Celebrex 200 mg Celebrex 400 mg Celexa 10mg, 20mg Cialis /Alpha Blockers Cialis /Nitrate Clarinex Combivent inhaler Cozaar 25mg, 50mg Crestor 5mg, 10mg, 20mg Crolom Delatestryl Depo-Testosterone Quantity Limit 9 tablets per 30 days Quantity Limit 60 patches per 30 days 2.5mg - 30 patches per 30 days 5mg Quantity Limit 60 packets per 30 days 2.5mg - 30 packets per 30 days 5mg Quantity Limit 10 tablets per 30 days Quantity Limit 5 tablets per 30 days Quantity Limit 150 unit dose vials (2.5ml ea.) per 30 days Quantity Limit 2 bottles per 30 days Quantity Limit 3 bottles per 30 days Quantity Limit 60 days every 3 months Quantity Limit 4 tablets per day 1/500mg or 2/500mg - 2 tablets per day 2/1000, 4/500, 4/1000mg Quantity Limit 2 tablets per day 2mg or 4 mg - 1 tablet per day - 8mg Quantity Limit 6 tablets per 30 days Quantity Limit 60 days every 3 months Quantity Limit 120 tablets per 30 days Quantity Limit 60 tablets per 30 days Quantity Limit 30 tablets per 30 days Quantity Limit Cialis will reject at the point of sale if alpha blockers (except Flomax) are in the member s prescription profile in the last 90 days. Cialis will reject at the point of sale if nitrates are in the member s prescription profile in the last 90 days. Quantity Limit 1 tablet per day 5mg or Reditabs - 300ml per 30 days Syrup Quantity Limit Page 2 of 6
Diflucan 150mg tablets Dilacor XR 120mg Diovan (all strength except 320mg) Diovan HCT 80/12.5mg Effexor XR 37.5mg, 75mg Elastat Emadine Emend 80mg Emend 125mg Emend Therapy Pack Enbrel Flonase nasal inhaler Flovent 44 inhaler, 110 inhaler Flovent 220 inhaler Flovent Rotadisk 50 mcg, 100mcg Flovent Rotadisk 250mcg Fluoxetine 10mg cap, tab Foradil Foradil /Advair Diskus Forteo Fosamax Frova Gleevec Halotestin Humira Hyzaar 50/12.5mg Imitrex injection Imitrex tablets Imitrex nasal inhaler Infergen Intron A Iressa Kineret Kytril 1mg tablets Kytril susp Lescol 20mg, 40mg Levitra /Alpha Blockers Levitra /Nitrate Lexapro 5mg, 10mg Lipitor 10mg, 20mg, 40mg Livostin Lortab 10 Lotensin (all strengths except 40mg) Quantity Limit 2 tablets per 30 days for females Quantity Limit 8 capsules per 30 days Quantity Limit 4 capsules per 30 days Quantity Limit 4 Packs (12 capsules) per 30 days Quantity Limit - 8 vials 25mg per 28 days - 4 vials 50mg per 28 days Quantity Limit 1 inhaler (13gm) per 30 days Quantity Limit 2 inhalers (13gm) per 30 days Quantity Limit 4 inhalers per 30 days Foradil will reject at the point of sale if Advair is in the member s prescription profile in the last 90 days. Quantity Limit 1 pen per 30 days Quantity Limit 4 tablets per 30 days 35mg or 70mg - 1 tablet per day 5mg, 10mg, or 40mg Quantity Limit 9 tablets per 30 days Quantity Limit 2 vials every 28 days Quantity Limit 4 injections per 30 days Quantity Limit 9 tablets per 30 days Quantity Limit 6 nasal inhalers per 30 days Quantity Limit 8 tablets per 30 days Quantity Limit 40ml per 30 days Levitra will reject at the point of sale if alpha blockers (except Flomax) are in the member s prescription profile in the last 90 days. Levitra will reject at the point of sale if nitrates are in the member s prescription history in the last 90 days. Quantity Limit 8 tablets per day Page 3 of 6
Lotensin HCT (all strengths except 20/12.5mg) Luvox 25mg Luvox 50mg Malarone Mavik (all strengths except 4mg) Maxair Autohaler Maxalt-MLT tablet Maxalt tablets Mepron Methitest Mevacor 10mg Mevacor 20mg Miacalcin Micardis (all strengths except 80mg) Migranal nasal inhaler Mobic Monopril (all strengths except 40mg) Nasacort nasal inhaler Nasacort AQ nasal inhaler Nasalide nasal inhaler Nasarel nasal inhaler Nasonex nasal inhaler Nexium Norvasc 2.5mg, 5mg Opticrom Optivar Panretin Patanol Paxil 10mg, 20mg, CR 12.5mg Pegasys Peg-Intron Penlac Pexeva 10mg, 20mg Plan B Plendil (all strengths except 10mg) Pravachol 10mg, 20mg, 40mg Pregnancy Category X Prevacid Capsules Preven kit Prilosec 40mg Primaxin injection Prinivil (all strengths except 40mg) Prinzide 10/12.5mg Procardia XL 30mg Protonix Proventil (albuterol) Provigil Prozac 10mg cap Pulmicort inhaler Quantity Limit 12 tablets per 30 days Quantity Limit 12 tablets per 30 days 1 bottle(3.7ml) per 30 days Quantity Limit 1 kit = 4 canisters per 30 days Quantity Limlit 1 bottle per month Quantity Limit Quantity Limit 4 tablets per 30 days, 1 copay per 2 tablets Claim will reject at point of sale for Category X drugs when member is also receiving prenatal vitamins. Warning message will be transmitted to pharmacy for members receiving prenatal vitamins and Category C & D drugs. Quantity Limit 2 kits per 30 days, 1 copay per kit Quantity Limit 30 days every 3 months Quantity Limit 200mg per day and Quantity Limit 1 inhaler per 25 days Page 4 of 6
Pulmicort respules QVAR inhaler Rebetron Relenza inhaler Relpax Rhinocort nasal inhaler Rhinocort Aqua nasal inhaler Rocephin injection Roferon A Serevent Diskus (28 & 60 each) Serevent Diskus (28 & 60 each)/advair Diskus Singulair Spiriva Stadol nasal spray Sular 10mg, 20mg Suprax Tamiflu Testim Testopel Testosterone Cream /Ointment Testim Testred Thalomid Tiazac 120mg, 180mg Topamax Toradol injections Toradol tablets Uniretic 7.5/12.5mg Univasc 7.5mg Ventolin (albuterol) Verelan PM 100mg Viagra /Nitrate Vytorin Zaditor Zestoretic 10/12.5mg Zestril (all strengths except 40mg) Zetia Zithromax 250mg tablets Zithromax 500mg tablets Zithromax 600mg tablets Zithromax Suspension 100mg/5ml Zithromax Suspension 200mg/5ml Zithromax Packets 1 gram Quantity Limit 2 boxes per 30 days Quantity Limit 1 carton (5-day supply) per member per prescription. Adults age 7 and older. No mail service for this drug. Quantity Limit 6 tablets per 30 days Quantity Limit 30 days every 3 months Quantity Limit 3 inhalers per month on the 28 each package Quantity Limit 2 inhalers per month on the 60 each package Serevent will reject at the point of sale if Advair is in the member s prescription profile in the last 90 days. Quantity Limit 1 inhaler per 30days Quantity Limit - 1 bottle per 30 days Quantity Limit 60 days every 3 months Quantity Limit 1 package per member per prescription fill and 2 packages per year. Age 1 and older. No mail service for this drug. Daily Dose 1 tube per day Quantity Limit 1 injection per 30 days Quantity Limit 20 tablets per 30 days Viagra will reject at the point of sale if nitrates are in the member s prescription history in the last 90 days. Quantity Limit 6 tablets per fill, 5 day therapy Quantity Limit 3 tablets per fill Quantity Limit 8 tablets per 30 days Quantity Limit 75ml per fill Quantity Limit 37.5ml per fill Quantity Limit 2 packets per fill Page 5 of 6
Zocor 5mg, 10mg, 20mg, 40mg Zofran /Zofran ODT 4mg tablets Zofran /Zofran ODT 8mg tablets Zofran 24mg tablets Zofran Susp Zoloft 25mg, 50mg Zomig tablets Zomig nasal spray Zyrtec, Zyrtec-D Quantity Limit 48 tablets per 30 days Quantity Limit 24 tablets per 30 days Quantity Limit 8 tablets per 30 days Quantity Limit 240ml per 30 days Quantity Limit 6 tablets per 30 days Quantity Limit 6 inhalers per 30 days Quantity Limit 1 tablet per day 5mg or 10mg - 2 tablets per day Zyrtec-D - 300ml per 30 days - syrup * Note: Due to varying health benefit plans, inclusion of a drug and related items on the formulary is not a guarantee of coverage. Please refer to your prescription drug benefit description of coverage, limitations and exclusions. Page 6 of 6