Prescription Prior Authorization
Prior authorization helps ensure that covered medications provide the best safety and value. It is needed
when a medication has only been proven to benefit a limited number of people or if unusually large doses
These medications require prior authorization Possible alternatives because alternatives may offer a better value Cholesterol simvastatin (Zocor®), pravastatin (Pravachol®), lovastatin (Mevacor®) simvastatin (Zocor®), pravastatin (Pravachol®), lovastatin (Mevacor®), Crestor® Depression bupropion SR (Wellbutrin SR®), bupropion XL 300mg (Wellbutrin XL®), fluoxetine (Prozac®), fluvoxamine maleate, mirtazapine (Remeron®), paroxetine (Paxil®), sertraline (Zoloft®) Diabetes ACTOplus Met™, Actos®, Avandamet®, Avandaryl™, Bydureon™, metformin (Glucophage®), glimepiride (Amaryl®), glipizide (Glucotrol®),
Byetta®, Duetact™, Janumet®, Janumet® XR, Januvia™,
glyburide (Diabeta®), insulin
Jentadueto™, Juvisync™, Kombiglyze™ XR, Onglyza™, pioglitazone, piotglitazone-metformin, Tradjenta™, Victoza® High Blood Pressure benazepril/HCT (Lotensin/HCT®), captopril/HCT (Capoten/Captozide®)
Benicar®, Benicar HCT®, Micardis®, Micardis HCT®
enalapril /HCT(Vasotec/Vaseretic®), fosinopril/HCT (Monopril/HCT®), lisinopril/HCT (Zestril/Zestoretic®, Prinivil/Prinzide®), losartan/HCT (Cozaar/Hyzaar®), moexipril/HCT (Univasc/Uniretic®), quinapril/HCT (Accupril/Accuretic®), trandolapril (Mavik®)
Amturnide™, Atacand®, Atacand-HCT®, Azor®, Diovan®, Diovan benazepril/HCT (Lotensin/HCT®), captopril/HCT(Capoten/Captozide®)
HCT®, Edarbi™, Exforge®, Exforge HCT®, Tekamlo™, Tekturna®, enalapril/HCT (Vasotec/Vaseretic®), fosinopril/HCT (Monopril/HCT®),
Tekturna HCT®, Teveten®, Teveten HCT®, Tribenzor™, Twynsta®, lisinopril/HCT (Zestril/Zestoretic®, Prinivil/Prinzide®), losartan/HCT
(Cozaar/Hyzaar®), moexipril/HCT (Univasc/Uniretic®), quinapril/HCT (Accupril/Accuretic®), trandolapril (Mavik®), Benicar®, Benicar HCT®, Micardis®, Micardis HCT® Mental Health clozapine (Clozaril®), olanzapine (Zyprexa®), risperidone (Risperdal®),
Abilify®, Fanapt®, Geodon®, Invega®, Latuda®, Saphris®,
quetiapine (Seroquel®), Seroquel XR® ziprasidone Migraines sumatriptan (Imitrex®)
Maxalt®, Maxalt-MLT®, Relpax®Alsuma™, Axert®, Frova®, Sumavel™ DosePro™, Treximet™, Zomig
sumatriptan (Imitrex®), Maxalt®, Maxalt-MLT®, Relpax® Multiple Sclerosis Nasal Steroids flunisolide (Nasalide®), fluticasone (Flonase®), triamcinolone
Beconase AQ®, Dymista™, Nasonex®, Omnaris®, Qnasl™,
acetonide (Nasacort® AQ)
Rhinocort Aqua®, Veramyst®, Zetonna™ Pain and Inflammation
Generic non-steroidal anti-inflammatory medications (NSAIDs) such
as: diclofenac (Voltaren®), etodolac (Lodine®), flurbiprofen (Ansaid®), ibuprofen (Motrin®), indomethacin (Indocin®), ketoprofen (Orudis®), nabumetone (Relafen®), naproxen (Naprosyn®), oxaprozin (Daypro®), piroxicam (Feldene®), salsalate (Disalcid®), sulindac (Clinoril®), tolmetin (Tolectin®) Stomach Acid omeprazole (Prilosec®)
Dexilant™, Kapidex™, lansoprazole Aciphex®, Nexium®, Prevacid®, Vimovo™ omeprazole (Prilosec®), Dexilant™, Kapidex™
Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association
Effective 09/12 NOTE: Our medication Prior Authorization List is subject to change. If the requested medication is authorized, there maybe limits to the amount of medication that is eligible for coverage. Please call our Customer Service Department if you have any questions.
Medications that need Prior Authorization The Bottom Line – Safety is our top priority and our prior authorization program helps you and your doctors choose quality medications that provide the most value. Some alternatives might also help you save money. These medications require prior authorization Maximum quantity per month if prescribed above the maximum quantity unless otherwise specified
Ambien CR™ (zolpidem tartrate er)
Imitrex® (sumatriptan succinate) tablet
Imitrex® (sumatriptan succinate) injection
10 discs (2 treatment courses) per 6 months
40 capsules (2 treatment courses) per 6 months
20 capsules (2 treatment courses) per 6 months
These medications require prior authorization to determine if they can be covered for your medical condition terbinafine vandetanib itraconazole ciclopirox (solution) modafinil
NOTE: In addition to the above medications, there are limits to the amount of medication eligible for coverage for all prescriptions. These limits are based on your prescription benefit along with information from the FDA and scientific literature about maximum, safe, effective dosages.
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