Formulary drugs requiring prior authorization (pa) for medical necessity

Formulary Drugs Requiring Prior Authorization (PA) for Medical
Necessity
PLEASE NOTE: HOME SELF-ADMINISTERED INJECTABLES (HSIs) REQUIRE PRIOR
AUTHORIZATION
**Drugs listed in bold with dual asterisks will have prior authorization requirements lifted
for the first 90 days of eligibility when requested in advance by the group.
Diagnosis
Exceed Before Prior
Authorization (PA) Required
for Benefit Coverage
PA required. Duration of therapy limit: 2 months PA required if no history of insulin, sulfonylureas, or metformin therapy. Actoplus met**
PA required if no history of other diabetic medication. Ambien CR**
PA required if no history of zolpidem (Ambien) use. Aptivus**
PA required if no history of other antiretroviral therapy. Aromasin**
PA required if male or if female 45 years of age and younger, and if no history of Arimidex Avandamet**
PA required if no history of other diabetic medication. Avandia**
PA required if no history of any diabetic medication. Avapro**, Avalide**
PA required if no history of ACE drug therapy fluoxetine, paroxetine, sertraline, clonazepam, alprazolam Comtan**
Concurrent drug therapy of levodopa/carbidopa required Diovan**, Diovan HCT**
PA required if no history of ACE drug therapy Elidel**
PA required: Quantity limit 1 tube per 30 days if approved Enablex**
PA required if no history of oxybutynin use Epivir HBV**
Exforge**
ACE inhibitor or valsartan (prior therapy with ACE inhibitor Femara**
45 years of age and younger, and if no history of Arimidex use Fexofenadine**
PA required if no history of nasal steroid or nasal antihistamine Flomax**
PA required if no history of doxazosin, prazosin, or terazosin Gleevec**
(CML), CD117 positive Gastrointestinal stromal tumor (GIST), Acute lymphoblastic leukemia Ph+ (ALL), Myelodysplastic syndrome (MDS) or Myeloproliferative diseases (MPD,) Aggressive systemic mastocytosis (ASM), Hypereosinophilic syndrome (HES), Chronic eosinophilic leukemia (CEL), Dermatofibrosarcoma (DFSP) Iressa**
Metastatic Non-Small Cell Lung PA required Cancer Isentress**
PA required if no history of other antiretroviral therapy. Janumet**
Januvia**
PA required if no history of metformin, a TZD, or sulfonylurea. Letairis**
Levemir penfill**
PA required if no history of any anti-diabetic medication. Levitra**
PA required: If approved quantity limited to 6 per 30 days Nexavar**
carcinoma, and non-resectable hepatocellular carcinoma Oxytrol**
PA required if no history of oxybutynin use Parcopa**
Prezista**
PA required if no history of other antiretroviral therapy. Luteal phase defect as part of PA required Provigil**
tablets per day (100mg), 2 tablets per day (200mg) Revlimid**
Transfusion-dependent anemia PA required. Quantity limit: 2 due to myelodysplastic Selzentry**
Sensipar**
Sprycel**
Sutent**
Tarceva**
Tasigna**
Tasmar**
Thalomid**
Tykerb**
Tyzeka**
PA required. Quantity limit: 1 tablet per day. Vytorin**
PA required: If approved quantity limited to 3 tablets per day Zolinza**
*Non-FDA approved indication Medications listed above require member’s physician to obtain Prior Authorization (PA) for medical necessity from Blue Shield Pharmacy Services at 800-535-9481. Applies to al HMO/POS and PPO groups, unless otherwise stated. (HMO/POS groups also require PA for coverage of non-formulary drugs if formulary alternatives failed). Last updated: January 29, 2009. **Drugs listed in bold with dual asterisks will have prior authorization requirements lifted
for the first 90 days of eligibility when requested in advance by the group.

Source: https://mailman.stanford.edu/pipermail/som_postdocs/attachments/20111111/693fced9/attachment-0011.pdf