Pharmacy Prior Authorizations, Quantity Limits, Specialty Medications, and Step Therapy
for Non-Medicare Members
Pharmacy Prior Authorization
Pharmacy prior authorization (PA) is a medical review that is required for coverage of certain medications such as those that:
-
- Are very high cost
- Have specific prescribing guidelines
- Are generally used for cosmetic purposes
- Have quantity limitations
Follow the steps below to request a prior authorization:
-
- Your physician must call 1-800-753-2851 to request a prior authorization form that must be completed and returned. To request a brand-name exception or non-Preferred medication review, your physician must call the pharmacy benefit manager at 1-800-841-5409.
- Once the completed form is received by the pharmacy benefits manager, a decision is made within 24 hours.
- The pharmacy benefit manager then sends notification of the approval or denial to you and your physician.
- If approved, the prior authorization is entered in the pharmacy benefit manager’s system within 48 hours. Your medication is subject to the applicable pharmacy copay. If the review is denied, you or your physician can file an appeal with HealthChoice.
Types of Prior Authorizations
Traditional Prior Authorization (PA) Medications
Traditional prior authorization reviews typically require that specific medical criteria be met before access to the medication is allowed.
Step Therapy (ST) Medications
Step Therapy prior authorizations require you to first try a designated Preferred drug(s) to treat your medical condition before the Plan covers another drug for that same condition. Some step therapy medications may also be limited in quantity.
Brand-Name Exception and Non-Preferred Medication Review
Reviews are available for brand-name and non-Preferred drugs if you are unable to tolerate the generic or Preferred drugs.
All of these reviews follow the same process as described in the Pharmacy Prior Authorization section.
Medications limited in Quantity (QL)
Quantity limits are based on the recommended duration of therapy and/or routine use of each medication and are less than the standard benefit.
If generics are available or become available for brand-name drugs that are subject to quantity limits, the generics are also limited in quantity.
New medications that become available in the drug categories that are subject to quantity limits will automatically have quantity limits per copay. New drug categories can become subject to quantity limits throughout the year.
Specialty Medications (SM)
Certain specialty medications are covered only if you order them through Accredo Health, the
HealthChoice specialty pharmacy. Specialty medications are generally high-cost medications that are injected. You must pay the applicable copay for each 30-day fill of a specialty medication.
Accredo Health also provides:
- Free supplies, such as needles and syringes
- Free shipping
- Refill reminder calls
- A personal counseling team of registered nurses and pharmacists
Be aware that if you don’t order your specialty medications through Accredo Health, you will be responsible for the full cost.
For more information, contact Accredo Health toll-free 1-800-501-7260. TDD users call toll-free 1-800-759-1089.
Restricted Medication List - This list is not all-inclusive and is subject to change.
| Category/Medication Name | Generic Available | Prior Authorization | Quantity Limits | Specialty Medication | Step Therapy |
| Allergic Reactions | GA | PA | QL | SM | ST |
|
Epipen (epinephrine auto injector) |
 |
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| Anti-Depressive Therapies | GA | PA | QL | SM | ST |
|
Lexapro® (escitalopram oxalate) |
|
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| Anti-Influenza Agents | GA | PA | QL | SM | ST |
|
Relenza® (zanamivir) |
|
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|
Tamiflu® Capsules/Suspensions (osteltamivir) |
|
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| Anti-Narcolepsy Therapies | GA | PA | QL | SM | ST |
|
Nuvigil® |
|
|
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Provigil® |
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| Anti-Nausea Therapies | GA | PA | QL | SM | ST |
|
Anzemet® (dolasetron) |
|
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|
Emend® (aprepitant) |
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Kytril® (granisetron HCL) |
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Sancuso® (granisetron) |
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Zofran® (odansetron) |
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| Asthma Therapies | GA | PA | QL | SM | ST |
|
Accolate® (zafirlukast) |
|
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Singulair® (montelukast) |
|
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|
Zyflo® (zileuton) |
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Zyflo® CR (zileuton) |
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| COX-II Inhibitors | GA | PA | QL | SM | ST |
|
Celebrex® (celecoxib) |
|
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| CNS Stimulants (PA required for age 21 and older) |
GA | PA | QL | SM | ST |
|
Adderall® (amphetamine/dextroamphetamine) |
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Adderall XR® (amphetamine/dextroamphetamine) |
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Concerta® (methylphenidate extended-release tablets) |
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Daytrana® (methylphenidate) |
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Desoxyn® (methamphetamine) |
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Dexedrine® (dextroamphetamine) |
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Dexedrine Spansules® (dextroamphetamine) |
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Dextrostat® (dextroamphetamine) |
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Focalin®(dexmethylphenidate) |
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Focalin XR® (dexmethylphenidate) |
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Metadate CD® (methylphenidate hcl) |
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Methylin ER® (methylphenidate) |
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Ritalin® (methylphenidate) |
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Ritalin SR® (methylphenidate hcl) |
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Ritalin LA® (methylphenidate hcl) |
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Strattera® (atomoxetine) |
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Vyvanse® (lisdexamfetamine) |
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| Erythroid Stimulants | GA | PA | QL | SM | ST |
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Aranesp® (darbepoetin) |
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|
Procrit® /Epogen® (erythropoietin) |
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| Estrogen Therapies (Topical) | GA | PA | QL | SM | ST |
|
Alora® (estradiol transdermal) |
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|
Climara® (estradiol transdermal) |
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ClimaraPro® (estradiol/levonorgestrel transdermal) |
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CombiPatch® (estradiol, norethindrone acetate transdermal) |
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Esclim® (estradiol transdermal) |
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Estrogel® (estradiol transdermal) |
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Estrasorb® (estradiol transdermal) |
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Estraderm® (estradiol transdermal) |
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Generic estrogen patches |
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Menostar® (estradiol transdermal) |
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Vivelle Dot® (estradiol transdermal) |
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| Growth Hormone Therapies | GA | PA | QL | SM | ST |
|
Genotropin® (somatropin) |
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Humatrope® (somatropin) |
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Norditropin® (somatropin) |
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Nutropin® (somatropin) |
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Nutropin AQ® (somatropin) |
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Omnitrope® (somatropin) |
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Protropin® (somatropin) |
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Saizen® (somatropin) |
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Serostim® (somatropin) |
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Somavert® (somatropin) |
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Tev-Tropin® (somatropin) |
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Zorbitive® (somatropin) |
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| Hypertension Therapies | GA | PA | QL | SM | ST |
|
Atacand® (candesartan) |
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Atacand HCT® (candesartan/HCTZ) |
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Avalide® (irbesartan/HCTZ) |
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Avapro® (irbesartan) |
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Benicar® (olmesartan) |
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Benicar HCT® (olmesartan/HCTZ) |
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Cozaar® (losartan) |
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Diovan® (valsartan) |
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Diovan HCT® (valsartan/HCTZ) |
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Hyzaar® (losartan/HCTZ) |
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Micardis® (telmisartan) |
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Micardis HCT® (telmisartan/HCTZ) |
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Teveten® (eprosartan) |
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Teveten HCT® (eprosartan/HCTZ) |
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| Impotency Agents (Prior authorization is approved for use following radical retropubic prostatectomy surgery, otherwise, these medications are not covered) |
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| GA | PA | QL | SM | ST | |
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Caverject® Injection (alprostadil) |
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Cialis® (tadalafil) |
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Edex® Injection (alprostadil) |
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Levitra® (vardenafil) |
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MUSE® (alprostadil) |
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Viagra® (sildenafil) |
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Yohimbine® HCL, both generic and brand-name |
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| Insulin and Supplies | GA | PA | QL | SM | ST |
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Cartridges |
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Insulin, Test Strips, Lancets |
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Needles |
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Pens |
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Syringes |
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Pre-Filled Syringes |
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Diabetic Supplies (over-the-counter) |
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| Migraine Therapies | GA | PA | QL | SM | ST |
|
Amerge® (naratriptan) |
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Axert® (almotriptan malate) |
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Frova® (frovatriptan succinate) |
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Imitrex® (sumatriptan succinate) |
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Imitrex Injection® |
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Imitrex NS® |
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Maxalt® (rizatriptan benzoate) |
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Maxalt-MLT® (rizatriptan benzoate) |
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Migranal® Nasal Spray (dihydroergotamine mesylate) |
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Relpax® (eletriptan hydrobromide) |
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Stadol® Nasal Spray (butorphanol tartrate) |
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Treximet® (sumatriptan and naproxen) |
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Zomig® (zolmitriptan) |
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Zomig NS® |
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Zomig-ZMT® (zolmitriptan) |
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| Miscellaneous Devices | GA | PA | QL | SM | ST |
|
Inhaler spacers (Limited to two per calendar year) |
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| Multiple Sclerosis Therapies | GA | PA | QL | SM | ST |
|
Ampyra® (dalfampridine) |
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Avonex® (interferon beta-1a) |
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Betaseron® (interferon beta-1b) |
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Copaxone® (glatiramer acetate) |
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Extavia® (interferon beta – 1b) |
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Rebif® (interferon beta-1a) |
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| Myeloid Stimulants | GA | PA | QL | SM | ST |
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Leukine® (sargramostim) |
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Neulasta® (pegfilgrastim) |
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Neumega® (oprelvekin) |
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Neupogen® (filgrastim) |
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Nplate® (romiplostim) |
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| Nasal Steroids | GA | PA | QL | SM | ST |
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Beconase® (AQ) (beclomethasone dipropionate) |
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Flonase® (fluticasone propionate) |
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Nasacort® (AQ) (triamcinolone acetonide) |
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Nasarel® (flunisolide) |
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Nasonex Rhinocort® (AQ) (mometasone furoate) |
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Omnaris® (ciclesonide) |
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Rhinocort AQ® (budesonide) |
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Veramyst® (fluticasone furoate) |
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| Oncology | GA | PA | QL | SM | ST |
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Afinitor® (everolimus) |
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Gleevac® (imatinib mesylate) |
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Iressa® (gefitinib) |
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Nexavar® (sorafenib) |
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Revlimid® (lenalidomide) |
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Sprycel® (dasatinib) |
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Sutent® (sunitinib malate) |
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Tasigna® (nilotinib) |
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Tarceva® (erlotinib) |
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Temodar® (oral) (temozolomide) |
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Thalomid® (thalidomide ) |
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Tykerb® (lapatinib) |
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Votrient® (pazopanib) |
|
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Zolinza® (vorinostat) |
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| Ophthalmic Therapies | GA | PA | QL | SM | ST |
|
Restasis® (cyclosporine) |
|
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| Osteoporosis Therapies | GA | PA | QL | SM | ST |
|
Actonel® (risedronate sodium) |
|
|
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Boniva® (ibandronate sodium) |
|
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|
Forteo® (teriparatide, RDNA origin) |
|
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Fosamax® (alendronate sodium) |
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Miacalcin® (calcitonin-salmon) |
|
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| Proton Pump Inhibitors | GA | PA | QL | SM | ST |
|
Aciphex® (rabeprazole) |
|
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|
Dexilant® (dexiansoprazole) |
|
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|
Prilosec® Suspension packets (omeprazole magnesium) |
|
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| Rheumatoid Arthritis Therapies | GA | PA | QL | SM | ST |
|
Arava® (leflunomide) |
|
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Cimzia® (certolizumab pegol) |
|
|
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Enbrel® (etanercept) |
|
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Humira® (adalimumab) |
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Kineret® (anakinra) |
|
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Simponi® (golimumab) |
|
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| Sedative-Hypnotic Therapies | GA | PA | QL | SM | ST |
|
Ambien® (zolpidem tartrate) |
|
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Ambien® CR (zolpidem tartrate) |
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|
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Butisol® (butabarbital sodium) |
|
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chloral hydrate |
|
|
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Dalmane® (flurazepam hydrochloride) |
|
|
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Doral® (quazepam) |
|
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Edluar® (zolpidem tartrate) |
|
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Halcion® (triazolam) |
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Lunesta® (eszopiclone) |
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Prosom® (estazolam) |
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Restoril® (temazepam) |
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|
Rozerem® (ramelteom) |
|
|
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|
Sonata® (zaleplon) |
|
|
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| Select Asthma Inhalers | GA | PA | QL | SM | ST |
|
Intal® (cromolyn sodium aerosol) |
|
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|
Nasalcrom® (cromolyn sodium) |
|
||||
|
Tilade® (nedocromil sodium aerosol) |
|
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| Select Transdermal Patches | GA | PA | QL | SM | ST |
|
Androderm® (testosterone transdermal) |
|
||||
|
Androgel® (testosterone gel) |
|
||||
|
Catapres TTS® (clonidine transdermal) |
|
|
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Daytrana® (methylphenidate transdermal) |
|
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|
Emsam® (selegiline transdermal) |
|
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fentanyl transdermal |
|
|
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|
Lidoderm® (lidocaine transdermal) |
|
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|
nitroglycerin transdermal |
|
|
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|
Ortho-Evra® (norelgestromin/ethinyl estradiol trandsermal) |
|
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|
Oxytrol® (oxybutynin transdermal) |
|
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|
Striant® (testosterone mucoadhesive system) |
|
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|
Testim Gel® (testosterone gel) |
|
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|
Transderm-Scope® (scopolamine transdermal) |
|
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| Topical Retinoid Therapies (Prior authorization required for age 23 and older) |
GA | PA | QL | SM | ST |
|
Differin® (adapalene) All dosage forms |
|
|
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|
Retin-A® (tretinoin) All dosage forms |
|
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|
Tazorac® (tazarotene) All dosage forms |
|
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Last Modified on 09/21/2011