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
simvastatin (Zocor®), pravastatin (Pravachol®), lovastatin (Mevacor®)
simvastatin (Zocor®), pravastatin (Pravachol®), lovastatin (Mevacor®),
bupropion SR (Wellbutrin SR®), bupropion XL 300mg (Wellbutrin XL®),
fluoxetine (Prozac®), fluvoxamine maleate, mirtazapine (Remeron®),
paroxetine (Paxil®), sertraline (Zoloft®)
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®

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
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
ciclopirox (solution)
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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