PRX STANDARD FORMULARY
UTILIZATION MANAGEMENT: OVERVIEW
Partners Rx is committed to helping you manage your prescription drug use and costs. Prior Authorization, Quantity
Limits, Step Therapy, and Age or Gender edits are recommended by the PartnersRx Formulary Review Committee
and may be used by your prescription drug benefit plan to ensure you have access to safe, appropriate, and effective
prescription medications. Please check you plan documents to determine your prescription drug benefit plan’s
approach to utilizing these clinical edits.
The clinical edits are defined as follows:
Prior Authorization
Medications which require pharmacy benefit manager or plan approval before you may receive benefits
Quantity Limits and Daily Dose Limit
Medication whose frequency and dosage are defined by a certain quantity per day
Step Therapy
Medications that require that you first use alternative medications before this medication may be tried or prescribed
Age and Gender Edits
Age edits are designed to ensure that medications are used only in appropriate age groups, e.g. not for use in infants
or the elderly. Gender edits are designed to restrict access to drug therapies which are specific to male or female
populations.
The table below displays the clinical edits that may be associated with the use of your prescription medications.
Medication
Clinical Edits and Guidelines
Abilify
Abilify Disc Tab (orally disintegrating)
Abraxane
Abstral
Quantity Limit – 30 tablets per 30 days, 750ml oral solution per 30 days
Quantity Limit – 5mg and 10mg = 30 tablets for 30 days
Specialty, Prior Authorization
Prior Authorization
Quantity Limit- 120 per 30 days
Quantity Limit- 50G (1 jar) per 30 days
Quantity Limit - 200 per 30 days
Quantity Limit – 30 per 30 days
Quantity Limit – 30 per 30 days
Quantity Limit – 30 per 30 days
Step Therapy, Quantity Limit - 30 tablets per 30 days
Specialty, Prior Authorization
Specialty , Prior Authorization
Prior Authorization, Quantity Limit – 120 per 30 days
Gender edit – female only, Quantity Limit – 30 per 30 days
Quantity Limit - 35mg = 4 tablets per 28 days
Quantity Limit - 5mg & 30mg = 30 per 30 days
Quantity Limit - 15mg, 30mg & 45mg =30 tablets per 30 days
Quantity Limit - 90 tablets per 30 days
Acanya Gel
Accu-Chek testing strips
Accupril (quinipril)
Accuretic 10/2.5
Aceon (perindopril)
Aciphex
Actemra
Acthar HP
Actiq (fentanyl lozenge)
Activella
Actonel
Actos (pioglitazone)
Actos Plus Met 15/500mg, 15/850mg
(pioglitazone- metformin)
ActosPlus Met XR
Quantity Limit - 90 tablets per 30 days
PRX0301_0413
-1-
Medication
Clinical Edits and Guidelines
Acular, Acular LS
Acuvail
Adalat CC (Nifedipine) 30mg
Adderall
(amphetamine/dextroamphetamine)
Adderall XR
(amphetamine/dextroamphetamine)
Adcetris
Adcirca
Adoxa
Quantity Limit -15ml per 30 days, LS = 5ml per 30 days
Quantity Limit – 64 vials per 180 days
Quantity Limit - 30 per 30 days
Quantity Limit: 60 per 30 days
Adrenalclick (epinephrine )
Advair
Advate inj
Advicor
Afeditab 30mg CR (nifedipine)
Afinitor
Alagesic Liq (butalbital-APAP- Caf)
Alamast
Aldara
All Day Allg Tab (cetirizine)
Aldurazyme
Allegra (fexofenadine)
Allegra ODT 30mg
Allegra-D (fexofenadine-D)
Allergy D-12 Tab All Day
Allergy Relief Tab 10mg
Allergy Relief Tab 5-120mg
Aller-Tec 10mg
Aller-Tec D 5-120mg
Allergy Comp D Tab 5-120mg
Almita
Alocril
Alomide
Alora
Alphagan P 0.15%
Alprazolam Intensol
Alsuma
Altace(ramipril)
Altoprev ER
Ambien (zolpidem)
Ambien CR (zolpidem CR)
Amerge (naratriptan)
Quantity Limit - 5mg, 10mg & 15mg = 30 per 30 days, 20mg, 25mg
and 30mg = 60 per 30 days
Specialty, Prior Authorization
Specialty, Quantity Limit- 60 per 30 days, Prior Authorization
Step Therapy
Quantity Limit - 150mg = 30 per 30 days
Quantity Limit - 2 pens per fill
Quantity Limit. Diskus = 1 diskus / 30 days (60 blisters)
Quantity Limit. HFA Inhaler = 1 inhaler per 30 days
Specialty
Quantity Limit – 500/20mg & 1000-40mg = 30 per 30 days, 1000-20mg
& 750-20mg = 60 per days
Quantity Limit – 30 per 30 days
Specialty, Prior Authorization
Quantity Limit - 60 per 30 days
Quantity Limit: 90ml per day ( 2700ml per 30 days)
Quantity Limit - 1 bottle (10ml) per 30 days
Quantity Limit – 48 packets (2 boxes) per 16 weeks
Quantity Limit – 30 per 30 days
Specialty, Prior Authorization
Quantity Limit - 180mg= 30 per 30 days, 30mg & 60mg = 60 per 30
days, suspension = 900ml per 30 days
Quantity Limit - 60 per 30 days
Quantity Limit - 24HR = 30 per 30 days
Quantity Limit - 12HR = 60 per 30 days
Quantity Limit - 60 per 30 days
Quantity Limit - 30 per 30 days
Quantity Limit - 60 per 30 days
Quantity Limit - 30 per 30 days
Quantity Limit - 60 per 30 days
Quantity Limit - 60 per 30 days
Specialty, Prior Authorization
Quantity Limit - 1 bottle per 30 days (5ml)
Quantity Limit - 1 bottle per 30 days (10ml)
Gender Edit, Quantity Limit – 8 per 30 days
Quantity Limit- 10ml per 30 days
Quantity Limit - 300ml per 30 days
Quantity Limit – 5 vials per 30 days
Quantity Limit – 1.25mg, 2.5mg, 5mg = 30 per 30 days
Step Therapy, Quantity Limit – 20mg, 40mg, 60mg = 30 per 30 days
Quantity Limit – 30 tabs per 30 days
Quantity Limit – 30 tabs per 30 days
Quantity Limit - 9 tablets per 30 days
PRX0301_0413
-2-
Medication
Clinical Edits and Guidelines
Amevive
Amethia & Amethia Lo (levonorg-est tab)
Amitiza
Amnesteem (isotretinoin)
Ampyra
Amturnide
Anaprox (naproxen sodium)
Androderm patch
Specialty, Prior Authorization
Max day supply 91
Quantity Limit - 60 per 30 days
Quantity Limit - 30 day supply
Specialty, Prior Authorization, Quantity Limit – 60 per 30 days
Step Therapy, Quantity Limit – 30 per 30 days
Quantity Limit - 275mg = 180 per 30 days, 550mg = 90 per 30 days
Prior Authorization, Gender Edit (males only)
Quantity Limit – 30 patches per 30 days
Prior Authorization, Gender Edit (males only)
Quantity Limit – 1% (25mg) = 75GM per 30 days; 1% (50mg) = 300G
(60 packets) per 30 days ; PUMP = 300G per 30 days
Prior Authorization, Gender Edit (males only)
Quantity Limit – 176G (2 bottles) per 30 days
Gender Edit, Prior Authorization
Gender edit – female only, Quantity Limit – 30 per 30 days
Quantity Limit - 43mg = 60 per 30 days, 130mg= 30 per 30 days
Quantity Limit – 50mg = 10 tablets per 30 days
Quantity Limit – 100mg = 5 tablets per 30 days
Step Therapy
Quantity Limit – 30 per 30 days
Specialty, Prior Authorization
Specialty, Prior Authorization
Specialty, Prior Authorization
Specialty, Prior Authorization
Step Therapy, Quantity Limit – 30 inhaled capsules per 30 days
Age edit – must be over 40 years old
Age Edit, Step Therapy
Step Therapy
Specialty, Prior Authorization
Quantity Limit –1 inhaler per 30 days
Quantity Limit – 2 bottles(60ml) per 30 days
Quantity Limit – 30 per 30 days
Quantity Limit – 16/12.5mg= 60 per 30 days
Quantity Limit – 32/12.5mg & 32-25mg= 30 per 30 days
Step Therapy, Quantity Limit – 4 tablets per 28 days
Quantity Limit – 0.5mg & 1mg = 90 per 30 days, 2mg = 150 per 30
days
Quantity Limit – 3 inhalers per 30 days
Quantity Limit – 2 bottles 0.03% per 30 days
Quantity Limit – 3 bottles 0.06% per 30 days
Quantity Limit – 150 unit dose vials (2.5ml) per 30 days
Specialty, Prior Authorization
Quantity Limit – 900ml per 90 days
AndroGel 1%
AndroGel 1.62%
Android
Angeliq
Antara
Anzemet tablets
Apidra
Aplenzin
Apokyn
Aralast & Aralast NP
Aranesp
Arcalyst
Arcapta
Aricept & ODT (donepezil)
Aricept 23mg
Arthrotec
Arzerra
Asmanex
Astelin Nasal (azelastine)
Atacand
Atacand HCT
Atelva
Ativan (lorazepam)
Atrovent HFA
Atrovent (ipratropium) nasal spray
Atrovent (ipratropium) neb solution
Aubagio
Augmentin (amoxicillin-clavulanate)
suspension
Augmentin (amoxicillin- clavulanate)
tablets
Avalide (irbesartan-HCTZ)
Quantity Limit – 500mg & 875mg=120 per 90 days, XR 12hr products =
240 per 90 days, chew 120 tablets per 90 days
Quantity Limit – 30 per 30 days
PRX0301_0413
-3-
Medication
Clinical Edits and Guidelines
Avandamet
Avandaryl
Avandia
Quantity Limit – 60 per 30 days, Prior Authorization
Quantity Limit – 60 per 30 days, Prior Authorization
Quantity Limit – 2mg= 90 per 30 days, 4mg= 60 per 30 days
Quantity Limit – 8mg= 30 tablets per 30 days
Prior Authorization
Quantity Limit – 30 per 30 days
Specialty, Prior Authorization
Quantity Limit – 21 per fill
Quantity Limit – 5 per fill
Quantity Limit – 30mg, 45mg, 60mg and 75mg = 30 per 30 days,
90mg & 120mg = 60 per 30 days
Age Limit ≥ 45 years, Gender edit – Male only
Quantity Limit – 30 per 30 days
Specialty, Prior Authorization
Quantity Limit – 1 kit (4 syringes) per 30 days
Quantity Limit – 12 tablets per 30 days, Prior Authorization
Gender Edit, Prior Authorization, Quantity Limit – 180ml per 30 days
Quantity Limit – 15ml per 30 days
Quantity Limit – 180 per 30 days
Specialty, Quantity Limit – 20ml per day, tablets: 1 per day (30 per 30
days)
Quantity Limit – 2 inhalers per 30 days
Quantity Limit – 5mg= 2 per day, 20mg & 40mg = 30 per 30 days
Quantity Limit – 30 per 30 days
Specialty, Prior Authorization
Quantity Limit – 50G per 30 days
Avapro (irbesartan)
Avastin
Avelox
Avelox ABC Pak
Avinza
Avodart
Avonex
Axert
Axiron
Azopt
Balacet 325
Baraclude
Beconase AQ nasal
Benicar
Benicar HCT
Benlysta
Benzaclin (benzoyl peroxideclindamycin)
Berinert
Besivance
Betaseron
Beyaz
Biaxin/colchicine
BiDil
Blood Glucose Testing Strips, all brands
Boniva 150mg (ibandronate)
Bosulif
Botox Cosmetic
BP Cleansing EMU
Bravelle
Brilinta
Bromday
Bromfenac Sol
Brovana
Butrans
Bydureon
Specialty, Prior Authorization
Quantity Limit – 5ml per 30 days
Specialty, Prior Authorization, Quantity Limit 14 vials per 30 days
Gender Edit (females only)
Biaxin will reject if colchicine products are in the prescription profile in
the last 120 days. Colchicine products will reject if Biaxin is in the
prescription profile in the last 120 days.
Quantity Limit – 180 per 30 days
Quantity Limit – 200 per 30 days
Quantity Limit – 1 tablet per 28 days
Specialty, Prior Authorization
Specialty, Prior Authorization
Quantity Limit – 473ml (1 bottle) per 30 days
Specialty, Prior Authorization
Quantity Limit – 60 per 30days
Quantity Limit – 1.7ml (1 bottle) per fill
Quantity Limit – 5ml per 30 days
Quantity Limit – 60 doses per 30 days
Prior Authorization
Quantity Limit - 4 patches per 30 days
Step Therapy, Quantity Limit – 4 vials per 30 days
PRX0301_0413
-4-
Medication
Clinical Edits and Guidelines
Byetta 5mcg, 10mcg
Bystolic
Quantity Limit – 1 prefilled pen per 30 days, Step Therapy
Quantity Limit - 2.5 mg = 30 per 30 days, 5 mg &10 mg = 90 per 30
days, 20 mg = 60 per 30 days
Quantity Limit – 30 per 30 days
Quantity Limit - 400mg/4ml= 24ml/day, 800mg/ml= 32ml/day
Specialty, Prior Authorization
Quantity Limit – 1200ml per 30 days
Specialty, Quantity Limit - 100 mg = 60 per 30 days, 300 mg = 30 per
30 days
Quantity Limit - 60 per 30 days
Quantity Limit - 1 per day
Quantity Limit- 120mg, 180mg, 300mg, 360mg & 420mg = 30 per 30
days, 240mg = 60 per 30 days
Caduet (amlodipine/atorvastatin)
Caldolor Injection
Campath
Capital with Codeine
Caprelsa
Cardene SR
Cardizem CD 120mg/24hr
Cardizem LA
Cardura
Cardura XL
Cataflam (diclofenac potassium)
Carimune NF
Cayston inhalation
Ceftin (cefuroxime) 500mg tablets
Ceftin (cefuroxime) suspension
Celebrex 50mg & 200mg
Celebrex 100mg
Celebrex 400 mg
Celexa (citalopram)
Cenestin
Ceredase
Cerezyme
Cesamet
Cetrotide
Chantix
Chlordiazepoxide
Chloral hydrate
Chorionic gonadotropin
Cialis
Ciclodan Kit 0.77%
Ciloxin (ciprofloxacin)
Cimzia
Cinryze
Cipro (ciprofloxacin)
Cipro XR
Claravis (isotretinoin)
Clarinex (desloratadine)
Age Limit ≥ 45 years, Gender edit – Male only
Quantity Limit- 30 per 30 days, Step Therapy
Quantity Limit - 120 tablets per 30 days
Specialty, Prior Authorization
Specialty
Quantity Limit – 120 tablets per 3 months
Quantity Limit – 600mls per 3 months
Quantity Limit – 60 tablets per 30 days
Quantity Limit – 90 tablets per 30 days
Quantity Limit – 30 tablets per 30 days
Safety Edits, Quantity Limit – 10mg & 20 mg = 30 tablets per 30 days,
Oral suspension = 600ml per 30 days
Gender Edit, Quantity Limit – 30 per 30 days
Specialty, Prior Authorization
Specialty, Prior Authorization
Prior Authorization
Gender Edit: Females only
Quantity Limit- 60 per 30 days
Quantity Limit- 5mg = 120 per 30 days, 10mg = 30 per 30 days
Prior Authorization
Specialty, Prior Authorization
Quantity Limit- 2.5 & 5mg = 30 per 30 days, 10mg & 20mg = 6 per 30
days
Gender Edit: males only
Quantity Limit: 544G per fill
Quantity Limit - Drops =10ml per 30days, Oint = 7G per 30 days
Specialty, Prior Authorization
Quantity Limit - Kit= 1 kit per 30 days. Starter Kit- 1 kit per 365 days.
Specialty, Prior Authorization
Quantity Limit – Tablets = 56 per fill, except 1000mg = 14 per fill,
ophthalmic solution = 10ml per 30 day supply
Quantity Limit – 500mg ER = 3 per fill
Quantity Limit – 30 day supply, no refills
Quantity Limit – Syrup= 300ml per 30 days, 5mg = 30 per 30 days
PRX0301_0413
-5-
Medication
Clinical Edits and Guidelines
Clarinex RDT Tab
Quantity Limit – 2.5mg and 5mg = 30 per 30 days
Quantity Limit – 2.5/120mg = 60 per 30 days, 5/240mg = 30 per 30
days
Quantity Limit – 437ml (1 bottle) per 30 days
Gender Edit, Quantity Limit – 4 per 30 days
Quantity Limit- 0.125 mg, 0.25 mg, 0.5 mg, 1 mg = 90 per 30 days,
2 mg = 300 per 30 days
Quantity Limit – 50mg = 90 per 30 days, 400mg = 120 per 30 days
Quantity Limit – 650/30mg 180 per 30 days
Quantity Limit – 650/60mg 180 per 30 days
Quantity Limit – 240 per 30 days
Age Limit - must be > 40 years old
Quantity Limit – 180 per 30 days
Quantity Limit – 10ml (1 bottle) per 30 days
Gender Edit, Quantity Limit 8 patches per 30 days
Quantity Limit – 3 inhalers per 30 days
Quantity Limit- 18mg, 27mg & 36mg = 60 per 30 days; 54mg = 30 per
30 days
Prior Authorization, Quantity Limit – 30 per 30 days
Specialty, Prior Authorization
Quantity Limit - 1 kit (30 syringes) per 30 days
Specialty, Prior Authorization
Quantity Limit – 1 Tape per 30 days
Quantity Limit – 60gm per 30 days
Quantity Limit – 10mg, 20mg & 40mg = 60 per 30 days, 80mg = 30 per
30 days, Step Therapy
Quantity Limit – 100mg = 30 per 30 days, 25mg & 50mg = 60 per 30
days
Quantity Limit – 30 per 30 days
Gender Edit: Females only
Quantity Limit – Max daily dose one
Quantity Limit – 30 per 30 days
Quantity Limit – 180 per 30 days, Prior Authorization
Quantity Limit – 30 per 30 days
Quantity Limit – 30 per 30 days, Prior Authorization
Quantity Limit – 180 per 30 days
Quantity Limit – N-100= 180 per 30 days, N-50= 360 per 30 days
Quantity Limit- 30 patches per 30 days
Gender Edit
Gender Edit
Quantity Limit – 1 vial per prescription
Quantity Limit – Max day supply 90
Quantity Limit – 1 kit (130gm) per 30 days
Quantity Limit – Cream & Ointment = 1 kit (130gm) per 30 days
Quantity Limit – 150 per 30 days
Quantity Limit – 120 per 30 days
Quantity Limit- 5mg = 60 per 30 days; 10mg = 150 per 30 days
Quantity Limit – 30mg & 60mg = 30 per 30 days, Step Therapy
Clarinex D
Claris Wash EMU 10-4%
Climara & Climara Pro
Clonazepam ODT
Clozapine
Cocet
Cocet Plus
Co-Gesic
Cognex
Colcrys (colchicine)
Combigan (brimonidine-timilol)
Combipatch
Combivent
Concerta (methylphenidate sa osm
Conzip
Copaxone
Copegus
Cordran
Cordran SP
Coreg CR
Cozaar (losartan)
Crestor
Crinone Gel
Cromolyn Opth
CVS Allergy Tab
Cycloset Tab
Cymbalta 30mg only
Daliresp
Darvocet A500
Darvocet N-100
Daytrana Dis
Delestrogen inj
Depo- Estradiol inj
Depo-Provera injection 150mg/ml
Depo-SQ injection
Desonil Kit 0.05%
Desonil Plus Kit
Desoxyn (methamphetamine)
Dexedrine Cap 15mg CR
Dexedrine CR (dextroamphetamine SR)
Dexilant (Kapidex)
PRX0301_0413
-6-
Medication
Clinical Edits and Guidelines
Dexrazoxane
dextroamphetamine sulfate
Diabinese (chlorpropamide) 250mg
Diastat Gel (diazepam)
Differin (adapalene)
Specialty, Prior Authorization
Quantity Limit: 5mg= 60 per 30 days; 10mg = 180 per day
Quantity Limit - 90 per 30 days
Quantity Limit – 2 boxes per fill
Quantity Limit – cream & gel = 45gm per 30 days,
lotion = 59ml per 30 days
Prior Authorization
Quantity Limit – 150mg = 2 tabs per 30 days, females only
Quantity Limit – 2mg, 4mg & 8mg = 180 per 30 days
Quantity Limit – 30 per 30 days
Quantity Limit – 30 per 30 days
Quantity Limit – 30 per 30 days
Quantity Limit – 30 per 30 days
Quantity Limit – 30 per 30 days
Specialty
Quantity Limit – 150 per 30 days
Quantity Limit – 30 per 30 days
Quantity Limit – 30 per 30 days
Quantity Limit – 1 kit per 30 days
Quantity Limit – 30 per 30 days
Quantity Limit – 1 inhaler per 30 days
Quantity Limit – 75mcg & 100mcg = 30 per 30 days, 12mcg, 25mcg &
50mcg = 15 per 30 days
Quantity Limit – 60 per 30 days
Quantity Limit – 60 per 30 days
Quantity Limit – 23G (1 bottle) per 30 days
Specialty, Prior Authorization
Prior Authorization, Step Therapy, Quantity Limit – 30 per 30 days
Step Therapy, Quantity Limit – 30 per 30 days
Step Therapy, Quantity Limit – 30 per 30 days
Quantity Limit – 30 tablets per 30 days, Step Therapy
Quantity Limit – 10mg = 35 per 30 days, 5mg = 30 per 30 days
Specialty, Prior Authorization, Quantity Limit – 60 vials (1 box) per 30
days
Specialty, Prior Authorization
Specialty, Prior Authorization
Quantity Limit – 5ml (1 bottle) per 30 days
Quantity Limit – 100gm (1 tube) per 30 days
Age Limitation – Not permitted if member is under 2 years of age
Step Therapy
Specialty, Prior Authorization
Quantity Limit – 1 per fill
Quantity Limit – 5ml (1 bottle) per 30 days
Gender Edit (females only), Quantity Limit – 60 per 30 days
Quantity Limit – 125mg = 4 per 30 days, 40mg = 1 per fill, 80mg = 8 per
30 days, PAK = 12 per 30 days
Specialty, Prior Authorization, Quantity Limit 2 vials per fill
Quantity Limit – 30 per 30 days
Dificid
Diflucan (fluconazole)
Dilaudid (hydromorphone)
Dilt-CD (diltiazem)
Dilt – XR (diltiazem)
Diltzac (diltiazem)
Diovan (valsartan)
Diovan HCT (valsartan/hctz)
Docefrez inj
Dolgic Plus
Doral (quazepam)
Doxycycline
Duac CS Kit 1-5%
Duetact
Dulera
Duragesic (fentanyl patch)
Dutoprol
Dynacirc CR
Dymista Spray
Dysport
Edarbi
Edarbychlor
Edluar Sub
Effexor (venlafaxine) XR
Effient
Egrifta
Elaprase
Elelyso
Elestat (epinastine)
Elidel 1% cream
Eligard
Ella Tab 30mg
Emadine sol 5% OP
Embeda
Emend
Emend inj
Enablex
PRX0301_0413
-7-
Medication
Clinical Edits and Guidelines
Enbrel
Specialty, Prior Authorization
Quantity Limit – 25mg = 8 per 28 days, 50mg = 4 per 30 days
Quantity Limit – 10/325mg, 5/325mg, 7.5/325mg = max daily dose 12,
7.5/500mg = max daily dose 8, 10/650mg = max daily dose 6
Quantity Limit – 30 per 30 days
Quantity Limit – 45gm (1 tube) per 30 days
Quantity Limit – 2 per fill
Safety edit for Hepatitis B duplicate therapy
Specialty, Prior Authorization
Quantity Limit – 30 per 30 days
Quantity Limit – Allergy D= 60 per 30 days, EQL Aller D = 60 per 30
days, EQL All Day – 30 per 30 days
Specialty, Prior Authorization
Specialty, Prior Authorization, Quantity Limit - 30 per 30 days
Erythromycin will reject if colchicine products are in the prescription
profile in the last 120 days. Colchicine products will reject if
erythromycin is in the prescription profile in the last 120 days
Quantity Limit – 180 per 30 days
Endocet (oxycodone/APAP)
Enjuvia
Epiduo
Epipen (epinephrine)
Epivir HBV
Epogen
Eprosartan
EQ Allergy-D, EQL All Day Aller D,
EQL All Day
Erbitux
Erivedge
Erythromycin/colchicine
Esgic & Esgic -Plus (butalbital-APAPcaf)
Estazolam
Estrace (estradiol)
Estraderm
Estrasorb
Estring
Estrogel
Estrogen, Estrogen + Progestin
Euflexxa
Evamist
Evoclin
Exalgo
Exelon (rivastigmine)
Exforge (amlodipine/valsartan)
Exforge HCT (amlodipine/valsartan/HCT)
Extavia
Fabrazyme
Factive
Fanapt & Fanapt PAK
Fazaclo ODT
Feldene (piroxicam)
Felodipine
Femara
Femhrt & Femhrt 1/5
Femring
Femtrace
Fenoglide (fenofibrate)
Quantity Limit – 30 per 30 days
Gender Edit, Quantity Limit – 30 per 30 days
Gender Edit, Quantity Limit – 8 patches per 30 days
Gender Edit, Quantity Limit – 60 pouches per 30 days
Quantity Limit – one ring per 90 days
Gender Edit, Quantity Limit – 93 G ( 1 bottle) per 30 days
Gender Edit – females only
Specialty, Prior Authorization
Gender Edit, Quantity Limit – 16.2ml ( 2 bottles) per 30 days
Quantity Limit – 50gm per 30 days
Quantity Limit- 180 per 30 days, Step Therapy
Age Limit - > 40 years old
Quantity Limit – 30 per 30 days
Quantity Limit – 30 per 30 days
Specialty, Prior Authorization, Quantity Limit – 15 vials per 28 days.
Specialty, Prior Authorization
Quantity Limit – 7 per fill
Quantity Limit – 60 per 30 days, 1 pak (8 tablets) per fill & Step
Therapy
Quantity Limit – 100mg = 270 per 30 days, 12.5mg, 150mg & 200mg =
90 per 30 days
Quantity Limit – 150mg & 200mg = 90 per 30 days
Age Limit < 75 years old
Quantity Limit- 30 per 30 days
Prior Authorization
Gender Edit, Quantity Limit – 30 per 30 days
Gender Edit, Quantity Limit – 1 ring per 84 days
Gender Edit, Quantity Limit – 30 per 30 days
Quantity Limit – 40mg= 60 per 30 days, 120mg = 30 per 30 days
PRX0301_0413
-8-
Medication
Clinical Edits and Guidelines
Fentora
Ferriprox
Fibricor (fenofibric)
Finacea gel
Finacea Kit
Fioricet with Codeine
Fiorinal (butalbital-ASA- caffeine)
Fiorinal/Cod Cap (butalbital-ASA- cafcod)
Firazyr
Firmagon
Flebogamma
Flector Patch
Flolan (epoprostenol)
Flomax (tamsulosin)
Flonase (fluticasone) Nasal Inhaler
Flovent Diskus
Prior Authorization, Quantity Limit – 120 per 30 days
Specialty, Prior Authorization
Quantity Limit – 35mg = 60 per 30 days, 105mg = 30 per 30 days.
Quantity Limit – 50gm per 30 days
Quantity Limit – 1 kit per 30 days, Step Therapy
Quantity Limit – 180 per 30 days
Quantity Limit – 180 per 30 days
Quantity Limit – 180 per 30 days
Flovent HFA Inhaler
Floxin (ofloxacin)
Flunisolide Spray
flurazepam
Focalin (dexmethylphenidate)
Focalin XR
Follistim & Follistim AQ
Folotyn
Foradil
Foradil /Advair
Forteo
Fortesta
Fortamet (Metformin)
Fortical
Fosamax (alendronate)
Fosinopril
Frova
Fuzeon
Gablofen
Gamastan SD
Gammagard, Gammgard SD
Gammaked
Gammaplex
Gamunex, Gamunex C
Gelnique
Specialty, Prior Authorization
Specialty, Prior Authorization
Specialty, Prior Authorization
Quantity Limit – 60 patches per 30 days
Specialty, Prior Authorization
Gender Edit – Males only, Quantity Limit – 60 per 30 days
Quantity Limit – 1 inhaler per 30 days
Quantity Limit - 50mcg & 100mcg= 120 blisters (2 diskus) per 30 days.
250mcg diskus= 240 blisters (4 packs) per 30 days
Quantity Limit – 2 inhalers per 30 days
Quantity Limit – 56 per fill
Quantity Limit – 1 inhaler (25ml) per 30 days
Prior Authorization, Quantity Limit- 30 per 30 days
Quantity Limit – 2.5mg & 5mg = 90 per 30 days, 10mg = 60 per 30
days
Quantity Limit- 5mg, 10mg, 15mg, 25mg, 30mg, 35mg, & 40mg = 30
per 30 days; 20mg = 60 per 30 days
Specialty, Prior Authorization
Specialty, Prior Authorization
Quantity Limit – 2 inhalers (60 capsules) per 30 days
Foradil will reject if Advair is in the prescription profile in the last 90
days.
Specialty, Prior Authorization
Prior Authorization, Gender Edit
Quantity Limit- 120G (2 bottles) per 30 days
Quantity Limit – 500mg = 150 per 30 days, 100mg 60 per 30 days
Quantity Limit – 1 bottle (3.8ml) per 30 days
Quantity Limit – 35mg & 70mg = 4 per 28 days.
Quantity Limit – 5mg, 10mg & 40mg = 30 per 30 days
Quantity Limit – 30 per 30 days
Quantity Limit – 9 tablets per 30 days
Specialty, Quantity Limit - 1 kit per 30 days
Specialty
Specialty, Prior Authorization
Specialty, Prior Authorization
Specialty, Prior Authorization
Specialty, Prior Authorization
Specialty, Prior Authorization
Step Therapy, Quantity Limit – 92 G (1 bottle) per 30 days
PRX0301_0413
-9-
Medication
Clinical Edits and Guidelines
Generess FE
Genotropin
Geodon (ziprasidone)
Gilenya
Glassia
Gleevec
Gender Edit
Specialty, Prior Authorization
Step Therapy, Quantity Limit – 60 per 30 days
Specialty, Prior Authorization, Quantity Limit – 30 per 30 days
Specialty, Prior Authorization
Specialty, Prior Authorization
Quantity Limit – 100mg= 240 per 30 days, 400mg= 60 per 30 days
Quantity Limit – 500mg= 150 per 30 days, 850mg = 90 per 30 days,
1000mg = 60 per 30 days
Quantity Limit – 500mg = 120 per 30 days, 1000mg = 60 per 30 days
Quantity Limit – 1.25-250mg= 240 per 30 days, 2.5-500mg & 5-500mg
= 120 per 30 days
Quantity Limit – 120 per 30 days
Quantity Limit – 90 per 30 days
Quantity Limit – 1 treatment per fill
Specialty, Prior Authorization
Step Therapy
Quantity Limit - 300mg = 30 per 30 days, 600mg = 90 per 30 days.
Quantity Limit – 50ml per 30 days
Quantity Limit- 60 per 30 days
Quantity Limit – 1 treatment per Rx
Specialty, Prior Authorization
Safety edit for Hepatitis B duplicate therapy
Specialty, Prior Authorization
Specialty, Prior Authorization
Step Therapy, Quantity Limit – 30 per 30 days
Specialty, Prior Authorization
Specialty, Prior Authorization, Quantity Limit – 2 vials every 28 days
Specialty, Prior Authorization , Quantity Limit : 1 kit per 30 days;
Psoriasis Kit: 1 (4 pens) per year, Crohn’s Kit: 1 (6 pens) per year
Specialty, Prior Authorization
Quantity Limit – 3,600ml per 30 days
Quantity Limit – 240 per 30 days
Quantity Limit – 50/12.5mg = 60 per 30 days, 100/12.5mg & 100/25mg
= 30 per 30 days
Quantity Limit – 180 per 30 days
Glucophage (metformin)
Glucophage XR (metformin XR)
Glucovance (metformin-glyburide)
Glumetza
Glyset
GoLytely
Gonal- F & Gonal F RFF
Gralise
Granisol
Halcion (triazolam)
HalfLytely
Halaven
Hepsera
Herceptin
Hizentra
Horizant
Humatrope
Humira
Humira Kits
Hyalgan
Hycet (hydrocodone/APAP)
Hydrogesic
Hyzaar (losartan hctz)
Ibudone 5-200mg (hydrocodoneibuprofen)
Ilaris
Imitrex (sumatriptan) injection
Imitrex (sumatriptan) tablets
Imitrex Nasal Spray
Incivek
Increlex
Indocin CR & ER (indomethacin)
Indocin suppository
Infergen
Inlyta
Intelence
Specialty, Prior Authorization, Quantity Limit – 1 vial per 8 weeks
Quantity Limit – 4mg & 6mg injection = 5 per 30 days
Quantity Limit – 9 tablets per 30 days
Quantity Limit – 6 nasal inhalers per 30 days
Specialty, Prior Authorization, Quantity Limit – 180 per 30 days
Specialty, Prior Authorization
Quantity Limit – 75mg = 60 per 30 days
Quantity Limit – 4 per day
Specialty, Prior Authorization
Specialty, Prior Authorization, Quantity Limit - 120 per 30 days
Specialty
PRX0301_0413
- 10 -
Medication
Clinical Edits and Guidelines
Intermezzo Sub
Intorvale
Intuniv
Intron-A
Invega
Iquix
Iressa
Istodax
Jalyn
Jakafi
Janumet
Janumet XR
Quantity Limit – 30 per 30 days
Quantity Limit – max day supply 91
Quantity Limit – 30 per 30 days, Step Therapy
Specialty, Prior Authorization, Safety edit Hepatitis B duplicate therapy
Step Therapy
Quantity Limit – 15ml per 30 days
Specialty, Prior Authorization, Quantity Limit – 250mg = 60 per 30 days
Specialty, Prior Authorization
Quantity Limit – 30 per 30 days
Specialty, Prior Authorization, Quantity Limit- 60 per 30 days
Quantity Limit – 60 per 30 days
Step Therapy, Quantity Limit – 50/1000 & 50/500 = 60 per 30 days,
100/1000 = 30 per 30 days
Quantity Limit – 30 per 30 days
Step Therapy, Quantity Limit - 60 per 30 days
Specialty, Prior Authorization
Quantity Limit – max day supply 91, Gender Edit
Quantity Limit- 30 per 30 days
Quantity Limit -10mg, 20mg, 30mg, 50mg, 60mg, 80mg & 100mg =2
per day, 200mg = 120 per 30 days
Specialty, Prior Authorization
Specialty, Prior Authorization, Quantity Limit – 120 per 30 days
Quantity Limit – 60 per 30 days
Age Edit: 6-18years old only, Step Therapy
Quantity Limit- 250mg= 360 per 30 days, 500mg= 180 per 30 days,
750mg = 120 per 30 days, 1000mg= 90 per 30 days, Solution = 946ml
per 30 days
Quantity Limit- 500mg= 180 per 30 days, 1000mg= 90 per 30 days
Prior Authorization
Specialty, Prior Authorization, Quantity Limit - 1 syringe per day
Quantity Limit- 0.125 mg, 0.25 mg, 0.5 mg, 1 mg = 90 per 30 days,
2 mg = 300 per 30 days
Step Therapy
Quantity Limit- 2.5-1000mg= 60 per 30 days, 5-500mg= 30 per 30 days
Prior Authorization
Specialty, Prior Authorization, Quantity Limit: 4ml (2 vials) per 30 days
Specialty, Prior Authorization
Quantity Limit - 6 per fill, Max days supply= 3
Quantity Limit- 1 box per fill (28 or 35)
Quantity Limit - 25mg & 50mg= 30 per 30 days, 100mg & 200mg = 90
per 30 days
Step Therapy, Quantity Limit - 3ml per 30 days
Step Therapy, Quantity Limit - 30 per 30 days
Prior Authorization, Quantity Limit - 1 bottle (5.3ml) per day
Step Therapy, Quantity Limit – 30 per 30 days
Step Therapy, Quantity Limit – 30 per 30 days
Specialty, Prior Authorization, Quantity Limit- 30 per 30 days
Specialty, Prior Authorization
Januvia
Jentadueto
Jevtana
Jolessa
Juvisync
Kadian (morphine SR)
Kalbitor
Kalydeco
Kapvay
Keppra (levatiracetam)
Keppra XR (levatiracetam)
Ketalar (ketamine) IV
Kineret
Klonipin (clonazepam)
Kombiglyze
Korlym
Krystexxa
Kyprolis
Kytril (ganisetron) tablets
Lamictal Kits ( IR, XR & ODT)
Lamictal XR
Lastacaft
Latuda
Lazanda
Lescol (fluvastatin)20mg, 40mg
Lescol XL 80mg
Letairis
Leukine
PRX0301_0413
- 11 -
Medication
Clinical Edits and Guidelines
Leuprolide
Levaquin
Levaquin Leva-Pak
Levitra
Specialty, Prior Authorization
Quantity Limit – 21 per fill
Quantity Limit – 1 pack per fill
Quantity Limit – 6 per 30 days
Gender Edit – males only
Quantity Limit - 5mg & 10mg = 45 per 30 days, 20mg = 30 per 30 days,
oral solution = 600ml per 30 days
Prior Authorization
Quantity Limit - 90 per 30 days
Quantity Limit - 50mg= 60 per 30 days, 150mg= 30 per 30 days
Step Therapy, Quantity Limit - 30 per 30 days
Quantity Limit - 60ml per day
Quantity Limit- 120ml per day
Step Therapy, Quantity Limit - 30 per 30 days
Quantity Limit – 1 bottle per 30 days (10ml)
Quantity Limit - 54mg & 160mg tablets= 60 per 30 days, 67mg, 134mg,
& 200mg capsules = 30 per 30 days
Quantity Limit - 60 per 30 days
Quantity Limit- 150ml per 30 days
Quantity Limit – 150 per 30 days
Quantity Limit – 180 per 30 days
Quantity Limit – 240 tablets per 30 days, 1200ml per 30 days
Gender Edit (females only)
Lexapro (escitalopram)
Lidocaine inj
Lidoderm Patch
Lipofen
Lipitor (atorvastatin)
Liquadd
Liquicet
Livalo
Livostin
Lofibra (fenofibrate)
Lopid (gemfibrizol) 600mg
Lorazepam Intensol (lorazepam conc)
Lorcet HD (hydrocodone/APAP)
Lorcet, Lorcet Plus (hydrocodone/APAP)
Lortab (hydrocodone/APAP)
Lo-Seasonique (levonorgesterol- Eestradiol)
Lotensin (benazepril)
Lotensin HCT (benazepril/hctz)
Lotrel (amlodipine/benazepril)
Lotronex
Lovaza
Lumigan Sol
Lumizyme
Lunesta
Lupron Depot Products
Lupron Dep- PED
Luvox (fluvoxamine)
Luvox CR
Lyrica
Lysteda
Makena
Malarone
Mavik
Maxair, Maxair Autohaler
Maxalt Tablets & MLT
Maxaquin
Maxidone (hydrocodone/APAP)
Quantity Limit – 5mg, 10mg, & 20mg = 2 per day
Quantity Limit - 5-6.25mg & 10-12.5mg= 1 per day
Quantity Limit - 30 per 30 days for all strengths
Gender Edit: Females greater than 18 years old only
Quantity Limit - 120 per 30 days (4 per day)
Quantity Limit - 2.5ml per 30 days
Specialty, Prior Authorization
Quantity Limit - 30 tablets per 30 days. Step Therapy
Age Edit : 3mg for 64 years of age or younger
Specialty, Prior Authorization
Specialty
Quantity Limit- 25mg & 50mg= 30 per 30 days,100mg = 90 per 30 days
Quantity Limit - 60 per 30 days
Prior Authorization
Quantity Limit - all strengths except 225mg & 300mg= 90 per 30 days,
225mg & 300mg = 60 per 30 days.
Gender Edit, Quantity Limit - 30 per 30 days
Specialty, Prior Authorization
Prior Authorization
Quantity Limit - 1 mg & 2 mg= 1 per day
Quantity Limit – 2 inhalers per 30 days
Quantity Limit – 18 tablets per 30 days
Quantity Limit – 21 per fill
Quantity Limit – 150 per 30 days
PRX0301_0413
- 12 -
Medication
Clinical Edits and Guidelines
Menest
Menostar
Menopur
Meperidine
Meridia
Metadate CD (methylphenidate cr )
Metaglip (glipizide/metformin)
Gender Edit, Quantity Limit – 30 per 30 days
Gender Edit, Quantity Limit – 4 patches per 30 days
Specialty, Prior Authorization
Quantity Limit - 8 per day (240 per 30 days)
Prior Authorization
Quantity Limit- 30 per 30 days
Quantity Limit - 2.5-250mg = 240 per 30 days, 2.5-500mg = 120 per 30
days, 5-500mg= 120 per 30 days
Quantity Limit : 150 per 30 days
Quantity Limit: 2.5mg & 5mg = 90 per 30 days; 10mg = 180 per 30
days.
Quantity Limit: 10mg/5ml= 900ml per 30 days, 5mg/5ml = 1800ml per
30 days
Gender Edit, Prior Authorization
Gender Edit, Prior Authorization
Step Therapy
Quantity Limit-: 12 weeks (180 days) of therapy (10-15mg/day)
Quantity Limit- 30 per 30 days
Quantity Limit – 1 bottle (3.7mL) per 30 days
Quantity Limit - 20mg & 40mg = 1 per day. 80mg = 2 per day
Quantity Limit - 40/12.5mg & 80/25mg =1 per day. Quantity Limit - 8012.5mg = 60 per 30 days
Quantity Limit – 1 kit = 8 canisters per 30 days
Step Therapy, Quantity Limit - 30 per 30 days
Specialty, Prior Authorization
Quantity Limit – 30 tablets per 30 days, suspension = 300ml per 30
days
Quantity Limit- 10 & 20mg = 1 per day
Specialty, Prior Authorization
Quantity Limit - 15mg, 30mg, 60mg, 100mg, & 200mg= 120 per 30
days
Prior Authorization
Specialty, Prior Authorization
Specialty, Prior Authorization
Age Edit: > 40 years old. Specialty, Prior Authorization
Age Edit : > 40 years old
Quantity Limit - 5mg= 3 per day, 10mg = 2 per day, pack = 1 pack per
30 days, Solution: 360ml per 30 days
Quantity Limit – 30 per 30 days
Quantity Limit - 375mg = 120 per 30 days, 500mg = 90 per 30 days,
750mg = 60 per 30 days
Quantity Limit – 1 inhaler per 30 days
Quantity Limit – 1 inhalers per 30 days
Quantity Limit – 2 inhalers per 30 days
Gender Edit
Methylin ER 10mg
Methylin Chew
Methylin Solution (methylphenidate)
Methitest
Meth-test hs /estradiol
Metozolv ODT
Mevacor (lovastatin)
Miacalcin
Micardis
Micardis HCT
Migranal nasal inhaler
Mirapex ER
Mitoxantrone
Mobic (meloxicam)
Monopril (fosinopril)
Mozobil
MS Contin (morphine CR)
Multaq
Myobloc
Myozyme
Naglazyme
Namenda
Namenda XR
Naprelan SR
Nasacort AQ (triamcinolone) nasal
Nasarel (flunisolide) nasal
Nasonex nasal
Natazia
Neulasta
Specialty, Prior Authorization
Quantity Limit – 2 vials per 28 days
PRX0301_0413
- 13 -
Medication
Clinical Edits and Guidelines
Neumega
Neupogen
Nevanac
Nexavar
Nexiclon XR
Niaspan ER
Niravam (alprazolam odt)
Specialty, Prior Authorization
Specialty, Prior Authorization
Quantity Limit – 6ml per 30 days
Specialty, Prior Authorization. Quantity Limit - 120 tablets per 30 days
Quantity Limit - 90 tablets per 30 days, 180ml (suspension) per 30 days
Quantity Limit- 500mg= 90 per 30 days, 750mg & 1G= 60 per 30 days
Quantity Limit - 0.25mg , 0.5mg & 1mg = 120 per 30 days, 2mg =150
per 30days
Quantity Limit – 360 per 30 days
Quantity Limit – 360 per 30 days
Specialty, Prior Authorization
Quantity Limit – 42 per fill
Quantity Limit -1 per day
Specialty, Prior Authorization
Specialty, Prior Authorization
Step Therapy, Quantity Limit - 50mg & 75mg= 360 per 30 days,
100mg= 420 per 30 days
Quantity Limit - 60 per 30 days
Prior Authorization
Specialty, Prior Authorization
Specialty, Prior Authorization
Specialty, Prior Authorization
Gender Edit: Females only
Prior Authorization
Specialty, Prior Authorization
Quantity Limit - 1 kit per prescription
Quantity Limit- 2.5ml per 30 days
Quantity Limit - 10ml per 30 days
Quantity Limit – 400ml/day
Gender Edit, Quantity Limit – 30 per 30 days
Quantity Limit - 30 per 30 days
Quantity Limit – 1 inhaler per 30 days (13Gm)
Specialty, Prior Authorization
Specialty, Prior Authorization
Prior Authorization
Quantity Limit - 30 tablets per 30 days
Prior Authorization, Quantity Limit – 120 films per 30 days
Specialty, Prior Authorization
Quantity Limit – 360 per 30 days
Quantity Limit – 120 per 30 days
Quantity Limit – 1 bottle per month (6ml)
Gender Edit: Females only
Quantity Limit : 15mg, 30mg, 60mg = 120 per 30 days
Quantity Limit : 100mg = 180 per 30 days
Quantity Limit - 14 per prescription
Quantity Limit - 180 per 30 days
Quantity Limit – 180 per 30 days
Specialty, Prior Authorization
Norco (hydrocodone/APAP)
Norco 5-325mg & 7.5-325mg
Norditropin
Noroxin
Norvasc (amlodipine) 2.5mg, 5mg
Novarel
Nplate
Nucynta
Nucynta ER
Nuedexta
Nulojix
Nutropin
Nutropin AQ
Nuvaring
Nuvigil
Octagam
Ocudox
Ocufen (flurbiprofen)
Ocuflox
Ofirmev
Ogen (estropipate)
Oleptro
Omnaris
Omnitrope
Omontys
Onfi
Onglyza
Onsolis
Ontak
Opana (oxymorphone)
Opana ER (oxymorphone ER)
Optivar (azelastine)
Oral contraceptives
Oramorph SR
Oravig
Orbivin
Orbivin CF (butalbital-APAP)
Orencia
PRX0301_0413
- 14 -
Medication
Ortho Evra
Orthovisc
Ovidrel
Oxandrolone & oxymetholone
Oxazepam
Oxycodone (immediate release)
Oxycontin (oxycodone time release)
Oxytrol Dis
Panlor DC
Panlor SS
Patanase
Patanol
Paxil (paroxetine)
Paxil CR (paroxetine)
Pegasys
Peg-Intron
Penlac
Percocet (oxycodone/APAP)
Perforomist
Perjeta
Pexeva
Phrenilin Tab & Forte (butalbital- APAP)
Picato
Plan B One Step (levonorgestrel)
Plan B Next Choice
Plavix (clopidogrel)
Plendil (all strengths except 10mg)
Polygam S/D
Ponstel 250mg
Ponstel (mefenamic)
Potiga
Pradaxa
Prandin
PrandiMet
Pravachol (pravastatin)
Precose (acarbose)
Prefest
Pregnancy Category X
Clinical Edits and Guidelines
Quantity Limit - 4 syringes per 30 days
Gender Edit: Females only
Specialty, Prior Authorization
Specialty, Prior Authorization
Gender Edit: Males only
Quantity Limit - 120 per 30 days
Quantity Limit - 8 per day (240 per 30 days)
Step Therapy, Quantity Limit : 4 per day ( 120 per 30 days)
Quantity Limit: 10 patches per 30 days
Quantity Limit – 330 per 30 days
Quantity Limit - 150 per 30 days
Quantity Limit – 1 inhaler per 30 days (31Gm)
Quantity Limit – 1 bottle per month (5ml)
Quantity Limit – 10mg = 45 per 30 days, 20mg = 30 per 30 days, 30 &
40mg = 60 per 30 days, oral suspension 1260ml per 30 days
Quantity Limit - 12.5mg = 30 per 30 days, 25mg & 37.5mg = 60 per 30
days
Specialty, Prior Authorization, Safety Edit Hepatitis B duplicate therapy
Specialty, Prior Authorization
Prior Authorization
Quantity Limit - 1 bottle per prescription fill
Quantity Limit – 5/500 & 7.5/500= 240 per 30 days, 10/600mg= 180 per
30 days, 2.5/325 5/325 7.5/325 & 10/325 =360 per 30 days
Duplicate Therapy
Quantity Limit – 60 vials (120mls) per 30 days
Specialty, Prior Authorization
Quantity Limit - 20mg= 1 per day.
Quantity Limit for all other strengths: 30 per 30 days
Quantity Limit: 180 per 30 days,
Step Therapy
Quantity Limit - 2 kits per 30 days, 1 copay per kit.
Age Edit. Gender Edit
Quantity Limit - 4 kits per 30 days, 1 copay per kit.
Age Edit. Gender Edit
Quantity Limit - 300mg = 3 per RX fill, 75mg = 30 per 30 days.
Quantity Limit – 30 per 30 days
Prior Authorization
Quantity Limit - 150 per 30 days
Quantity Limit - 150 capsules per 30 days
Quantity Limit - 90 per 30 days
Quantity Limit - 60 per 30 days
Quantity Limit – 0.5mg & 1mg= 120per 30 days, 1mg = 240 per 30days
Quantity Limit - 150 per 30 days
Step Therapy, Quantity Limit – 30 per 30 days
Quantity Limit - 25mg= 360 per 30 days, 50mg= 180 per 30 days,
100mg= 90 per 30 days
Gender Edit, Quantity Limit – 30 per 30 days
Claim will reject for Category X drugs when member is receiving
PRX0301_0413
- 15 -
Medication
Pregnyl
Premarin
Premphase
Prempro
Prenatal
Prevacid (lansoprazole) Capsules or
SoluTab (ODT)
Prilosec (omeprazole)
Primaxin injection
Prinivil (lisinopril)
Prinizide (lisinopril-hctz) 10-12.5mg
Priftin
Pristiq
Privigen
ProAir HFA
Procardia XL (nifedipine) 30mg
Procrit
Profasi
Progestins
Prolastin & Prolastin C
Proleukin
Prolia
Promacta
Promethazine (all products)
Propoxyphene/APAP 65-650mg
Proquin XR
Proscar
Protonix (pantoprazole)
Protopic
Protropin
Provenge
Proventil HFA
Provigil (modafinil)
Prozac (fluoxetine)
Pulmicort inhaler
Pulmicort respules
Pulmozyme
Qnasl Aeresol
Qualaquin (quinine sulfate 324mg)
Clinical Edits and Guidelines
prenatal vitamins. Warning message will be transmitted to pharmacy for
members receiving prenatal vitamins and Category C&D drugs.
Specialty, Prior Authorization
Gender Edit, Quantity Limit - 30 per 30 days
Gender Edit, Quantity Limit - 30 per 30 days
Gender Edit, Quantity Limit - 30 per 30 days
Gender Edit: Females only
Quantity Limit – 30 per 30 days
BRAND Step Therapy
Quantity Limit – 30 per 30 days. BRAND Step Therapy
Quantity Limit – 30 days every 3 months
Quantity Limit – 30 per 30 days
Quantity Limit – 30 per 30 days
Quantity Limit - 32 tablets per 28 days
Quantity Limit – 30 per 30 days
Specialty, Prior Authorization
Quantity Limit – 2 inhalers per 30 days
Quantity Limit – 30 per 30 days
Specialty, Prior Authorization
Gender Edit: Females only
Gender Edit: Females only
Specialty, Prior Authorization
Specialty, Prior Authorization
Specialty, Prior Authorization, Quantity Limit - 1 vial per 180 days
Specialty, Prior Authorization
Age Limitation – Members under 2 years of age are not permitted to get
products containing promethazine
Quantity Limit - 180 per 30 days
Quantity Limit – 3 per fill (Rx)
Age Limit ≥ 45 years
Gender Edit – Males only
Quantity Limit – 30 tablets per 30 days
Age Limitation: Members under 2 years of age are not permitted to get
Step Therapy, Quantity Limit - 100g (1 tube) per 30 days
Specialty, Prior Authorization
Specialty, Prior Authorization
Quantity Limit- 2 inhalers per 30 days
Prior Authorization
Quantity Limit - 30 per 30 days
Quantity Limit - 10mg = 45 per 30 days, 20mg = 120 per 30 days, 40mg
= 60 per 30 days, oral solution = 600mls per 30 days, 90mg weekly = 4
per 28 days
Quantity Limit – 1 inhaler per 25 days
Quantity Limit – 2 boxes per 30 days (60ml)
Specialty
Quantity Limit: 1 inhaler per 30 days
Prior Authorization
Quantity Limit – 42 caps per year
PRX0301_0413
- 16 -
Medication
Clinical Edits and Guidelines
Quixin
QVAR inhaler
Raptiva
Rapaflo
Razadyne & ER (galantamine)
Rebetol Solution
Rebif
Quantity Limit – 10ml per 30 days
Quantity Limit : 40mcg= 2 per 30 days, 80mcg= 3 inhalers per 30 days
Prior Authorization
Quantity Limit – 30 per 30 days
Age Edit: > 40 years old
Specialty, Prior Authorization
Specialty, Prior Authorization
Quantity Limit – 6ml per 30 days, titration = 1 kit (4.2ml) per 365 days
Quantity Limit -12weeks (180 days) of therapy (10-15mg/day)
Quantity Limit -12weeks (180 days) of therapy (10-15mg/day)
Quantity Limit – 1 carton (5-day supply) per member per prescription
and 2 per year. Adults age 7 and older. No mail service for this drug.
Specialty, Prior Authorization
Quantity Limit – 12 tablets per 30 days
Specialty, Prior Authorization
Specialty, Prior Authorization
Quantity Limit – 150/480 per 30 days
Specialty, Prior Authorization
Quantity Limit - 30 per 30 days
Quantity Limit - 30 per 30 days
Prior Authorization
Specialty, Prior Authorization (IV and oral forms)
Quantity Limit - 90 per 30 days
Specialty, Prior Authorization
Quantity Limit – 30 per 30 days
Quantity Limit - 2 inhalers per 30 days (17G)
Specialty, Prior Authorization
Specialty, Prior Authorization
Specialty, Prior Authorization
Specialty, Prior Authorization
Quantity Limit - 750ml per 30 days (oral solution)
Quantity Limit: 20mg = 90 per 30 days
Quantity Limit: 5mg, 10mg & 20mg = 90 per 30 days
Quantity Limit: 10mg, 20mg & 40mg = 30 per 30 days, 30mg = 60 per
30 days
Specialty, Prior Authorization
Quantity Limit - 30 days of therapy every 3 months
Prior Authorization
Quantity Limit - 100G per 30 days, cleanser= 355ml per 30 days, gel=
45ml per 30 days, Kit= 1 kit per 30 days, NS pads= 2 boxes per 30
days, wash= 473ml per 30 days
Quantity Limit – 10ml per day (300ml per 30 days)
Quantity Limit – 240 per 30 days
Quantity Limit – 60ml per day
Quantity Limit - 240 per 30 days
Quantity Limit – 30 tablets per 30 days
Step Therapy
Quantity Limit - 240 per 30 days ( 8 per day)
Reglan (metoclopramide)
Reglan (metoclopramide) oral solution
Relenza inhaler
Relistor
Relpax
Remicade
Remodulin
Reprexain (hydrocodone/APAP)
Repronex
Requip XL (ropinirole)
Restoril (temazepam)
Restasis
Revatio
Revlimid
Rhinocort Aqua nasal inhaler
RibaPak
RibaSphere
RibaTab
Ribavirin 200mg caps
Riomet
Ritalin SR (methylphenidate SR)
Ritalin (methylphenidate)
Ritalin LA
Rituxan
Rocephin (ceftriaxone)
Roferon-A
Rosula Products
Roxanol
Roxicet 5-500
Roxicet Solution
Roxicodone
Rozerem
Rybix
PRX0301_0413
- 17 -
Medication
Clinical Edits and Guidelines
Ryzolt (tramadol SR)
Sabril
Step Therapy, Quantity Limit - 30 per 30 days
Specialty, Prior Authorization
Quantity Limit - 180 units per 30 days (6 units per day)
Gender Edit
Specialty, Prior Authorization
Specialty, Prior Authorization
Quantity Limit - 15mg= 30 per 30 days, 30mg= 60 per 30 days.
Step Therapy, Quantity Limit: 30 per 30 days
Quantity Limit- 1 per fill
Specialty, Prior Authorization
Quantity Limit - 60 per 30 days (2 per day)
Quantity Limit – 10mg= 30 per 30 days, 15mg & 20mg = 60 per 30days
Step Therapy, Quantity Limit- 60 per 30 days
Quantity Limit: 180 per 30 days
Specialty
Quantity Limit - 2 inhalers per month (28 each)
Quantity Limit - 1 inhalers per month (60 each)
Serevent will reject if Advair is in the member’s prescription profile in
the last 90 days.
Specialty, Prior Authorization
Quantity Limit - 1 vial per day
Quantity Limit - 30 per 30 days
Quantity Limit – 30 tabs per 30 days
Step Therapy
Quantity Limit – 30 per 30 days
Specialty, Prior Authorization
Quantity Limit : 1 syringe per month
Quantity Limit - 100 grams per 30 days
Specialty
Specialty, Prior Authorization
Specialty, Prior Authorization
Prior Authorization
Quantity Limit – 30 per 30 days
BRAND Step Therapy
Quantity Limit - 10mg, 17.5mg and 22.5mg capsules= 60 per 30 days,
10mg capsules= 120 per 30 days
Quantity Limit - 1 inhaler per 30 days (30 doses)
Prior Authorization
Quantity Limit - 90 tablets per 30 days
Specialty, Prior Authorization
Quantity Limit - 20mg= 270 per 30 days, 50mg= 90 per 30 days, 70mg
& 80mg = 60 per 30 days, 100mg & 140mg = 30 per 30 days
Quantity Limit - 1 bottle per 30 days (2.5ml)
Gender Edit: Males only
Quantity Limit - 90 per 30 days
Gender Edit. Quantity Limit - 6 tablets per 30 days
Specialty, Prior Authorization
Quantity Limit - 45mg = 0.5ml per 12 weeks, 90mg = 1ml per 12 weeks
Safyral
Saizen
Samsca
Sanctura XR
Sancuso
Sandostatin (octreotide)
Saphris
Sarafem
Savella
Sedapap (butalbital-APAP)
Sensipar
Serevent Diskus (28 & 60 each)
Serevent /Advair
Serostim
Silenor
Simcor
Singulair (montelukast)
Simponi
Solaraze gel
Solesta
Somatuline
Somavert
Somnote (chloral hydrate)
Sonata (zaleplon)
Soritane
Spiriva
Sporanox (itraconazole)
Sprix
Sprycel
Stadol nasal spray
Stanozolol
Starlix (nateglinide)
Staxyn
Stelara
PRX0301_0413
- 18 -
Medication
Clinical Edits and Guidelines
Stivarga
Strattera
Specialty, Prior Authorization
Quantity Limit - 60 per 30 days, except 60mg, 80mg & 100mg = 30 per
30days. Step Therapy
Prior Authorization, Gender Edit
Quantity Limit- 60 buccal systems (1 box) per 30 days
Specialty
Prior Authorization
Quantity Limit - 3 per day
Prior Authorization, Quantity Limit – 12 unit doses per day
Prior Authorization
Quantity Limit - 2mg = 16 per 30 days, 8mg= 8 per 30 days
Quantity Limit - 1 per day
Quantity Limit - 8 units (4ml) per 30 days
Specialty, Prior Authorization
Specialty
Quantity Limit - 1200ml per 3 months
Quantity Limit - 60 days every 3 months
Quantity Limit - 354ml per RX
Specialty, Prior Authorization
Quantity Limit - 12.5mg= 210 per 30days, 25mg = 90 per 30days,
50mg = 30 per 30 days
Specialty, Prior Authorization
Quantity Limit – 1 inhaler per 30 days (11 Gm)
Duplicate Therapy Edit: Foradil and Serevent
Specialty, Prior Authorization
Prior Authorization
Specialty, Prior Authorization
Quantity Limit: 60G per 30 days
Quantity Limit - Capsule=: 1 package per member per prescription fill
and 2 packages per year. Suspension= 120ml per fill and 2 fills per
year. Age 1 and older. No mail service for this drug.
Specialty, Prior Authorization
Quantity Limit - 25mg =180 per 30 days, 100mg & 150mg = 30 per 30
days
Prior Authorization
Specialty, Prior Authorization
Quantity Limit - 120 per 30 days
Quantity Limit: 30G per 30 days
Prior Authorization
Quantity Limit - 30 per 30 days
Quantity Limit - 1 per day. Step Therapy
Quantity Limit - 1 box per prescription
Prior Authorization, Quantity Limit – 60 tubes (300G) per 30 days
Specialty, Prior Authorization
Gender edit: Males only
Gender Edit, Prior Authorization
Quantity Limit - 400mg = 60 per 30days, 600mg = 30 per 30 days
Quantity Limit - 30 per 30 days
Striant
Stribild
Suboxone, Suboxone Mis
Subsys
Subutex
Sular 10mg, 20mg CR (nisoldipine)
Sumavel DosePro
Supartz
Supprelin LA
Suprax (cefixime) suspension
Suprax (cefixime)
Suprep Bowel
Sutent
Sylatron
Symbicort
Synagis
Synarel Nasal Spray
Synvisc, Synvisc ONE
Taclonex
Tamiflu
Tarceva
Targretin capsules
Tasigna
Tazorac
Teflaro
Tekamlo
Tekturna, Tekturna HCT
Terazol
Testim
Testopel
Testosterone
Testred
Teveten (eprosartan)
Teveten HCT
PRX0301_0413
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Medication
Clinical Edits and Guidelines
Tev-tropin
Thalomid
Specialty, Prior Authorization
Specialty, Prior Authorization.
Quantity Limit - 50mg & 100mg= 120 per 30 days, 150mg & 200mg=
240 per 30 days
Quantity Limit – 30 per 30 days
Quantity Limit - 30 per 30 days.
Quantity Limit - 20ml per RX
Quantity Limit - 250mg= 120 per 30 days, 500mg = 60 per 30 days
Quantity Limit - 180 per 30 days
Quantity Limit- 15mg/ml = 40ml per 30 days, 30mg/ml = 20ml per 30
days
Quantity Limit – 20 tablets per 30 days
Specialty, Prior Authorization, Quantity Limit - 8ml per 28 days
Specialty, Prior Authorization
Specialty, Prior Authorization
Quantity Limit- 60 per 30 days
Step Therapy
Quantity Limit - 30 per 30 days
Quantity Limit - 3.75mg = 840 per 30 days, 7.5mg= 360 per 30 days,
15mg = 180 per 30 days
Quantity Limit – 2.5ml ( 1 bottle) per 30 days
Specialty, Prior Authorization
Specialty
Prior Authorization
Quantity Limit – 9 per 23 days
Step Therapy
Quantity Limit - 30 per 30 days
Step Therapy
Quantity Limit - 48mg = 60 per 30 days, 145mg = 30 per 30 days
Quantity Limit - 50mg = 60 per 30 days, 160mg = 30 per 30 days
Quantity Limit - 45mg = 60 per 30 days, 135mg = 30 per 30 days
Specialty, Prior Authorization
Quantity Limit - 2 per prescription
Step Therapy, Quantity Limit - 1 per day
Specialty, Prior Authorization. Quantity Limit - 180 per 30 days
Quantity Limit : 300-30mg= 360 per 30 days, 300-60= 180 per 30 days
Quantity Limit – 240 per 30 days
Specialty, Prior Authorization
Specialty, Prior Authorization, Quantity Limit - 2.9ml per day
Step Therapy, Quantity Limit - 30 per 30 days
Quantity Limit – 240 per 30 days
Quantity Limit – 240 per 30 days
Quantity Limit – 30 per 30 days
Quantity Limit – 30 per 30 days
Quantity Limit – 30 per 30 days
Quantity Limit - 120 per 30 days
Age Limit ≥ 45 years, Gender edit: Male only.
Quantity Limit - 30 per 30 days
Tiazac (diltiazem) 120mg, 180mg
Ticlid (ticlopidine)
Tobradex ST
tolazamide
tolbutamide
Toradol (ketorolac)injection
Toradol (ketorolac) tablets
Torisel
Totec
Tracleer
Tradjenta
Tranxene T (clorazepate)
Travatan Z
Treanda
Trelstar LA, Trelstar Depot & Mix
Tretin X
Treximet
Tribenzor
Tricor
Triglide
Trilipix
Trisenox
Twinject
Twynsta
Tykerb
Tylenol with Codeine
Tylox
Tysabri
Tyvaso
Uloric
Ultracet (tramadol/ acetaminophen)
Ultram (tramadol)
Ultram (tramadol) ER
Univasc (moexipril) 7.5mg
Uniretic (moexipril-hctz) 7.5mg-12.5mg
Uribel
Uroxatral (alfuzosin)
PRX0301_0413
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Medication
Clinical Edits and Guidelines
Valcyte
Valturna
Quantity Limit - 120 per 30 days (4 per day)
Step Therapy
Quantity Limit - 30 per 30 days
Specialty
Specialty, Prior Authorization
Prior Authorization
Specialty, Prior Authorization
Specialty, Prior Authorization
Quantity Limit - 60 G per 30 days
Specialty, Prior Authorization
Quantity Limit - 270ml per 30 days (9ml per day)
Quantity Limit – 2 inhalers per 30 days B378
Quantity Limit – 1 inhaler per 30 days (10Gm)
Quantity Limit – 30 per 30 days
Prior Authorization (IV form only)
Quantity Limit - oral solution= 20ml per day, tablets 4 per day
Prior Authorization
Quantity Limit – 6 per 30 days. Gender Edit – males only
Step Therapy.
Quantity Limit – 240 per 30 days
Quantity Limit – 150 per 30 days
Quantity Limit – 180 per 30 days
Quantity Limit – 480 per 30 days
Specialty, Prior Authorization, Quantity Limit – 360 per 30 days
Step Therapy
Quantity Limit - Injection = 9ml per 30 days (0.3ml per day)
Quantity Limit - 3 ml per fill
Quantity Limit – 30 per 30 days
Quantity Limit - 60 per 30 days
Prior Authorization
Gender Edit, Quantity Limit – 8 patches per 30 days
Specialty
Quantity Limit - 32 grams per day (available in 100 Grams tubes)
Quantity Limit – 7.5ml per 30 days
Quantity Limit – 180 per 30 days
Specialty
Specialty, Prior Authorization. .
Quantity Limit- 120 per 30 days
Prior Authorization
Step Therapy, Quantity Limit - Safety Edits- 30 tablets per 30 days
Prior Authorization needed to continue 80mg simvastatin
Quantity Limit - 1 per day
Quantity Limit - 210 per 30 days ( 7 per day)
Quantity Limit – 30 per 30 days
Specialty, Prior Authorization
Quantity Limit - 60 per 30 days
Quantity Limit – 2.5ml per 30 days
Quantity Limit – 0.25 mg, 0.5 mg & 1 mg = 120 per 30 days, 2mg = 150
Vantas
Vectibix
Vectical
Velcade
Veletri (epoprostenol)
Veltin
Ventavis
Ventolin HFA
Veramyst
Verelan PM (verapamil) 100mg
Vfend (voriconazole)
Viadur Implant
Viagra
Vibativ
Vicodin (hydrocodone/APAP)
Vicodin ES (hydrocodone/APAP)
Vicodin HP (hydrocodone/APAP)
Vicoprofen (hydrocodone/ibuprofen)
Victrelis
Victoza
Vigamox
Viibryd
Vimovo
Vivaglobin
Vivelle Dot
Vivitrol
Voltaren gel
Voltaren (diclofenac) Ophth
Vopac 650-30 (APAP-codiene)
Voraxaze
Votrient
Vpriv
Vytorin (all strengths)
Vyvanse
Welchol
Wellbutrin(bupropion) XL 150mg
Xalkori
Xalatan (latanoprost)
Xanax (alprazolam)
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Medication
Xanax XR (alprazolam SR)
Xarelto
Xeloda
Xenazine
Xenical
Xeomin
Xgeva
Xibrom
Xodol 10-300, 5-300, 7.5-300
Xolair
Xopenex HFA
Xtandi
Xyrem
Xyzal (levocetirizine)
Yervoy
Yohimbine
Zaditor
Zaltrap
Zavesca
Zegerid powder 40-1680
Zelboraf
Zemaira
Zesteril (lisinopril)
Zestoretic (lisinopril-hctz) 10-12.5mg
Zetia
Zetonna Aeresol
Ziana
Zinecard
Zioptan
Zipsor
Zirgan
Zithromax (azithromycin)
Zithromax (azithromycin) Suspension
Zocor (simvastatin)
Zofran (ondansetron)
Zoladex
Zolinza
Zomig
Zorbtive
Zortress
Clinical Edits and Guidelines
per 30 days
Quantity Limit – 0.5 mg & 1 mg = 30 per 30 days,
2mg = 150
per 30 days, 3mg = 90 per 30 days
Prior Authorization, Quantity Limit – 10mg, 15mg & 20 mg = 30 per 30
days
Specialty
Specialty, Prior Authorization
Prior Authorization
Specialty, Prior Authorization
Specialty, Prior Authorization, Quantity Limit - 1.7ml per 21 days
Quantity Limit- 2.5ml per prescription
Quantity Limit – 390 tablets per 30 days
Specialty, Prior Authorization
Quantity Limit – 2 inhalers per 30 days
Specialty, Prior Authorization
Specialty, Prior Authorization,
Quantity Limit - 3 bottles (540ml) per 30 days
Quantity Limit – 30 per 30 days, 300ml/30 days
Specialty, Prior Authorization
Gender Edit: Males only
Quantity Limit - 1 bottle per month (5ml)
Specialty, Prior Authorization
Specialty, Prior Authorization
Quantity Limit – 30 packets per 30 days, Step Therapy
Specialty, Prior Authorization, Quantity Limit - 240 per 30 days
Specialty, Prior Authorization
Quantity Limit – 30 per 30 days
Quantity Limit – 30 per 30 days
Step Therapy. Quantity Limit – 30 tablets per 30 days
Quantity Limit: 6.1G ( 1 inhaler) per 30 days
Quantity Limit - 60 G per 30 days
Specialty, Prior Authorization
Quantity Limit – 1 container (0.3ml) per 30 days
Quantity Limit - 120 tablets per 30 days
Quantity Limit - 5G per 30 days
Quantity Limit – 250mg = 6 tablets per fill, 5 day therapy, 500mg = 5
tablets per fill, 600mg = 8 tablets per 30 days
Quantity Limit – 100mg/5ml = 30ml per fill, 200mg/5ml = 60 ml per fill
Step Therapy, Quantity Limit - Safety Edit: 20mg, 30mg & 40mg = 45
per 30 days, 5mg and 80mg = 30 per 30 days.
Prior Authorization (80mg dose only) to continue 80 mg per day dose.
Quantity Limit- 4mg = 18 per 30 days, 8mg = 60 per 30 days, 24mg =8
per 30 days, oral solution = 600ml per 30 days
Specialty
Specialty, Prior Authorization, Quantity Limit- 120 per 30 days
Quantity Limit 6 per 30 days
Specialty, Prior Authorization, Quantity Limit : 30vials per 30 days
Specialty, Prior Authorization
PRX0301_0413
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Medication
Clinical Edits and Guidelines
Zuplenz
Zyclara
Zyflo
Zyflo CR
Zymaxid
Zyprexa Relprew
Quantity Limit - 4mg= 18 films per 30 days, 8mg= 60 films per 30 days
Quantity Limit - 56 packets per 60 days
Quantity Limit - 120 per 30 days
Quantity Limit - 120 per 30 days
Quantity Limit - 2.5ml per 30 days
Quantity Limit - 210mg & 405mg = 2 vials per 28 days, 300mg = 2 vials
per 28 days
Specialty
Zytiga
Please Note: Due to varying health benefit plans, inclusion of a drug and related items on the drug list
(formulary) is not a guarantee of coverage. Please refer to your prescription drug benefit description of
coverage, limitations and exclusions.
PRX0301_0413
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