In an effort to promote the appropriate use of certain drugs and to help better manage the cost of expensive drugs, the ConnectiCare Pharmacy & Therapeutics Committee has developed a list of prescription drugs that require prior authorization. Prior authorization requests must be faxed to ConnectiCare’s Pharmacy Services department at 860-674-2851 or toll free 800-249-1367 by the prescribing physician’s office. POS members receiving out-of-network care are responsible for initiating this process. When submitting a request for Prior Authorization please use a Prior Authorization form which can be printed at ConnectiCare.com or obtained by calling ConnectiCare at 800-251-7722. If the prescribed drug is approved, the prescription will be filled as usual at a participating pharmacy or administered by a provider (where appropriate).
Chantix (PA not required for initial 30 day supply)
Aciphex (Use Prilosec OTC-Tier 1)
Clarinex / D (Use loratadine OTC first-Tier 1)
Contraceptives (if excluded by group)
Allegra / Allegra D (Use loratadine OTC first-Tier 1)
*Crestor (Use simva-, prava-, lovastatin first)
Altoprev (Use simva-, prava-, lovastatin first)
*Cymbalta (Use generic SSRI’s first)
*Detrol / LA (Use oxybutynin IR/XL first)
*Effexor XR (Use generic SSRI’s first)
Aranesp (PA required for pharmacy claims only)
*Enablex (Use oxybutynin IR/XL first)
*Beconase AQ (Use generic flonase first)
fexofenadine (Use loratadine OTC-Tier 1)
*Cardura XL (Use generic doxazosin first)
Fosamax plus D 5600 (Use fosamax plus D 2800)
Note: Self administeredmedications (i.e. interferons), even those not on this list, may not be dispensed for self administration and billed through the medical benefit by a provider, they must be dispensed through a participating pharmacy. (*) prior authorization is not required within the first 90 days of membership with ConnectiCare. (M) physician administered drug, usually billed under the medical benefit Rev. 12/2007
In an effort to promote the appropriate use of certain drugs and to help better manage the cost of expensive drugs, the ConnectiCare Pharmacy & Therapeutics Committee has developed a list of prescription drugs that require prior authorization. Prior authorization requests must be faxed to ConnectiCare’s Pharmacy Services department at 860-674-2851 or toll free 800-249-1367 by the prescribing physician’s office. POS members receiving out-of-network care are responsible for initiating this process. When submitting a request for Prior Authorization please use a Prior Authorization form which can be printed at ConnectiCare.com or obtained by calling ConnectiCare at 800-251-7722. If the prescribed drug is approved, the prescription will be filled as usual at a participating pharmacy or administered by a provider (where appropriate).
MMirena (levonorgestrel-releasing IUD)
Myrac (Use generics first)
*Nasacort AQ (Use fluticasone, Nasonex,or Veramyst first)
*Nasarel (Use fluticasone,Nasonex,Veramyst first)
Neulasta (PA required for pharmacy claims only)
Injectable Drugs- All (excluding insulin)
Klonopin Wafers (Use clonazepam tablets)
*Omacor (note name change to “Lovaza”)
*Omnaris (Use fluticasone, Nasonex, or Veramyst first)
*Lescol/XL (Use simva-, prava-, lovastatin first)
*Lipitor (Use simva-, prava-, lovastatin first)
*Oxytrol (Use generic oxybutynin IR/XL first)
Prevacid (Use Prilosec OTC-Tier 1)
Minocin Combo Pack (Use generics first)
Note: Self administeredmedications (i.e. interferons), even those not on this list, may not be dispensed for self administration and billed through the medical benefit by a provider, they must be dispensed through a participating pharmacy. (*) prior authorization is not required within the first 90 days of membership with ConnectiCare. (M) physician administered drug, usually billed under the medical benefit Rev. 12/2007
In an effort to promote the appropriate use of certain drugs and to help better manage the cost of expensive drugs, the ConnectiCare Pharmacy & Therapeutics Committee has developed a list of prescription drugs that require prior authorization. Prior authorization requests must be faxed to ConnectiCare’s Pharmacy Services department at 860-674-2851 or toll free 800-249-1367 by the prescribing physician’s office. POS members receiving out-of-network care are responsible for initiating this process. When submitting a request for Prior Authorization please use a Prior Authorization form which can be printed at ConnectiCare.com or obtained by calling ConnectiCare at 800-251-7722. If the prescribed drug is approved, the prescription will be filled as usual at a participating pharmacy or administered by a provider (where appropriate).
MSynvisc (hyaluronate sodium)
*Prozac Weekly (Use generics first)
Travel Medication: including Malarone,
*Rhinocort Aqua (Use fluticasone, Nasonex, Veramyst first)
*Vesicare (Use oxybutynin IR/XL first)
*Sanctura (Use oxybutynin IR/XL first)
MVivaglobulin (SQ Immuneglobulin)
Singulair (Use loratadine OTC first for allergic rhinitis)
*Vytorin (Use simva-, prava-, lovastatin first)
Weight Loss Medication (if covered by your plan);
Meridia, Xenical, Ionamin, Tenuate, etc
Xanax XR (use generic alprazolam)
Steroids, Anabolic (i.e Nandrolone)
Xyzal (Use OTC loratadine first-Tier 1)
Zegerid (PA for age > 15 y/o) (Use Prilosec OTC)
Note: Self administeredmedications (i.e. interferons), even those not on this list, may not be dispensed for self administration and billed through the medical benefit by a provider, they must be dispensed through a participating pharmacy. (*) prior authorization is not required within the first 90 days of membership with ConnectiCare. (M) physician administered drug, usually billed under the medical benefit Rev. 12/2007
In an effort to promote the appropriate use of certain drugs and to help better manage the cost of expensive drugs, the ConnectiCare Pharmacy & Therapeutics Committee has developed a list of prescription drugs that require prior authorization. Prior authorization requests must be faxed to ConnectiCare’s Pharmacy Services department at 860-674-2851 or toll free 800-249-1367 by the prescribing physician’s office. POS members receiving out-of-network care are responsible for initiating this process. When submitting a request for Prior Authorization please use a Prior Authorization form which can be printed at ConnectiCare.com or obtained by calling ConnectiCare at 800-251-7722. If the prescribed drug is approved, the prescription will be filled as usual at a participating pharmacy or administered by a provider (where appropriate).
MZevelin Zolinza Zyban Zyrtec / Zyrtec D (Use OTC)
Note: Self administeredmedications (i.e. interferons), even those not on this list, may not be dispensed for self administration and billed through the medical benefit by a provider, they must be dispensed through a participating pharmacy. (*) prior authorization is not required within the first 90 days of membership with ConnectiCare. (M) physician administered drug, usually billed under the medical benefit Rev. 12/2007
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