✓=Newy drugs formular www.ibx.com
In an effort to continue our commitment to provide you with comprehensive prescription drug coverage, a formulary feature is included in your prescription drug benefit. A formulary is a list of selected FDA-approved prescription medications reviewed by the FutureScripts® Pharmacy and Therapeutics Committee. These prescription medications have been selected for their reported medical effectiveness, safety, and value, while providing you with the highest level of coverage under your prescription program.
The following information serves as a guide when reviewing the list of formulary drugs on the following pages:
• Bolded drug = Formulary generic available at lowest copay. • Non-bolded drug = Formulary brand available at middle copay. • Drug in parenthesis ( ) = Non-formulary brand drug available at the highest copay. It is displayed next to the equivalent formulary generic
drug that is available at the lowest copay. For example: amoxicillin is the formulary generic drug available at the lowest copay. (Amoxil) is the non-formulary brand available at the highest copay. In most cases when brand drugs have a generic equivalent, the generic version is formulary and the brand version is non-formulary.
• Covered generic drugs not listed are formulary and are available at the lowest copay. • Covered brand drugs not listed are non-formulary and are available at the highest copay. PA = Prior authorization must be requested by the physician. Q = Quantity level limits apply. ✓ = New formulary drug.
The above information is highlighted in a key box on every other page of the formulary list.
Our pharmacy benefits manager, FutureScripts, continuously monitors effectiveness and safety of drugs and drug prescribing patterns. Several procedures support safe prescribing patterns for our prescription drug programs, such as:
• coverage for medications not on the formulary.
These procedures are designed to optimize your prescription drug benefit by promoting appropriate utilization. These procedures are based on U.S. Food and Drug Administration (FDA) guidelines, and the criteria are endorsed by the FutureScripts Pharmacy and Therapeutics Committee.
A detailed description of the procedures that support safe prescribing is included at the end of the formulary list. Please note: Because prescription drug programs vary by group, the inclusion of a drug in this formulary does not imply coverage. This formulary was current at the time of printing and is subject to change. Please call 1-888-678-7012 if you have any questions about your prescription drug benefit. Please discuss any questions or concerns about your drug therapy with your physician or pharmacist. Select Drug Program formulary information can also be obtained on the Independence Blue Cross website: www.ibx.com
This is a listing of formulary medications to be considered for your patient, a Select Drug Program participant. Please refer to this formulary guide in order to choose a medication. Because prescription drug programs vary by group, the inclusion of a drug in this formulary does not imply coverage. This formulary was current at the time of printing and is subject to change.
Please understand that this formulary is not intended as a substitute for your independent professional judgment. Rather, it is offered as a tool to help plan members recognize formulary drugs. We hope that you will refer to the formulary as a guide to prescribing formulary drugs. 1. ANTIBIOTICS & OTHER DRUGS USED doxycycline FOR INFECTION doxycycline monohydrate acyclovir erythromycin delayed release ( Eryc, Ery-Tab) amantadine erythromycin ethylsuccinate ( EES, EryPed) amoxicillin erythromycin stearate amoxicillin /clavulanate erythromycin susp w/sulfa (Pediazole ) amoxicillin /clavulanate extended-release ethambutol famciclovir ampicillin fluconazole azithromycin cefaclor cefaclor ganciclovir cefadroxil cefdinir griseofulvin microsize susp (Grifulvin V susp ) cefditoren cefuroxime cephalexin chloroquine phosphate hydroxychloroquine ciprofloxacin ER tabs (Cipro XR ) isoniazid ciprofloxacin tabs (Cipro ) itraconazole clarithromycin ketoconazole clarithromycin SR (Biaxin XL ) clindamycin clotrimazole mebendazole mefloquine methenamine hippurate metronidazole demeclocycline minocycline dicloxacillin minocycline didanosine Type of covered drug*
• Bolded drug is a formulary generic.
• Non-bolded drug is a formulary brand.
• Drug in parenthesis ( ) is a non-formulary brand drug. It is displayed to help you identify the equivalent Highest copay
formulary generic drug that is available at the lowest copay.
• Covered generic drugs not listed are formulary.
• Covered brand drugs not listed are non-formulary. PA = Prior authorization must be requested by the physician. Q = Quantity level limits apply.
✓ = New formulary drug. * Unless specifically excluded from your contract. 1. ANTIBIOTICS & OTHER DRUGS USED FOR INFECTION (cont.) cyclophosphamide cyclosporine mycophenolate nitrofurantoin macrocrystals etoposide nystatin ofloxacin flutamide penicillin phenazopyridine hydroxyurea leucovorin pyrazinamide megestrol ribavirin mercaptopurine rifampin methotrexate rimantadine prednisone stavudine sulfamethoxazole/tmp tacrolimus sulfisoxazole tamoxifen terbinafine thioguanine tetracycline tinidazole 3. PAIN, NERVOUS SYSTEM & PSYCH valacyclovir acetaminophen/butalbital Q acetaminophen/codeine acetazolamide alprazolam amantadine amitriptyline amoxapine amphetamine aspartate/amphetamine sulfate/ zidovudine dextroamphetamine (Adderall ) 2. CANCER & ORGAN TRANSPLANT DRUGS amphetamine aspartate/amphetamine sulfate/ dextroamphetamine ER (Adderall XR ) anastrazole aspirin with codeine azathioprine benztropine bicalutamide bromocriptine mesylate 3. PAIN, NERVOUS SYSTEM & PSYCH (cont.) ergotamine/tartrate/caffeine ethosuximide etodolac bupropion fenoprofen bupropion Q, PA fentanyl citrate OTFC (Actiq) bupropion Q fentanyl transdermal buspirone fluoxetine Q butalbital/apap/caffeine fluphenazine Q butalbital/aspirin/caffeine flurbiprofen carbamazepine fluvoxamine carbamazepine gabapentin carbidopa/levodopa galantamine carbidopa/levodopa galantamine carbidopa/levodopa haloperidol Q hydrocodone/acetaminophen chlorpromazine Q hydrocodone/acetaminophen choline magnesium trisalicylate Q hydrocodone/acetaminophen citalopram Q hydrocodone/ibuprofen clomipramine Q hydromorphone clonazepam ibuprofen /oxycodone clozapine imipramine indomethacin isometheptene/dichloralphenazone/apap ketoprofen ketorolac desipramine lamotrigine dexmethylphenidate levetiracetam diazepam diazepam rectal gel (Diastat ) carbonate diazepam rectal gel (Diastat AcuDial ) lithium carbonate SR ( Eskalith CR, Lithobid) diclofenac potassium lorazepam diclofenac loxapine diflunisal divalproex maprotiline divalproex sodium ER (Depakote ER ) divalproex sprinkle cap (Depakote Sprinkle Caps ) meclofenamate Type of covered drug*
• Bolded drug is a formulary generic.
• Non-bolded drug is a formulary brand.
• Drug in parenthesis ( ) is a non-formulary brand drug. It is displayed to help you identify the equivalent Highest copay
formulary generic drug that is available at the lowest copay.
• Covered generic drugs not listed are formulary.
• Covered brand drugs not listed are non-formulary. PA = Prior authorization must be requested by the physician. Q = Quantity level limits apply.
✓ = New formulary drug. * Unless specifically excluded from your contract. 3. PAIN, NERVOUS SYSTEM & PSYCH (cont.) sertraline sulindac Q meperidine Q, PA sumatriptan methadone Q temazepam methamphetamine thioridazine methylphenidate thiothixene migergot tolmetin topiramate mirtazapine topiramate sprinkle cap (Topamax Sprinkle Capsules ) mirtazapine rapid dissolve tabs (Remeron SolTab ) tramadol morphine sulfate , extended release (MS Contin ) PA tramadol Q morphine tranycypromine morphine sulfate supp (RMS ) trazodone nabumetone Q, PA Treximet trifluoperazine naproxen trihexyphenidyl naproxen valproic naproxen sodium SA (Naprelan ) venlafaxine Q, PA naratriptan venlafaxine Q zaleplon nefazodone Q zolpidem tartrate nortriptyline oxaprozin 4. HEART, BLOOD PRESSURE & CHOLESTEROL oxazepam oxcarbazepine acebutolol Q oxycodone amiloride oxycodone /apap ( Roxicet, Percocet, Tylox) amiloride Q oxycodone /aspirin aminocaproic oxycodone CR 12 hour tabs (OxyContin ) amiodarone Q, ✓ oxymorphone amlodipine paroxetine amlodipine /benazepril paroxetine HCl ext-release (Paxil CR ) anagrelide perphenazine atenolol phenobarbital atenolol /chlorthalidone phenytoin phenytoin benazepril piroxicam benazepril pramipexole primidone propoxyphene HCl/apap betaxolol Q propoxyphene napsylate/apap bisoprolol/HCTZ pyridostigmine bumetanide risperidone captopril rivastigmine captopril ropinirole carvedilol salsalate chlorothiazide selegiline chlorthalidone 4. HEART, BLOOD PRESSURE & CHOLESTEROL (cont.) hydrochlorothiazide indapamide isosorbide dinitrate cholestyramine isosorbide dinitrate ER cilostazol isosorbide mononitrate clonidine isosorbide mononitrate ER (Imdur ) clonidine isradipine colestipol labetalol lisinopril lisinopril /HCTZ (Prinzide ) PA losartan diltiazem PA losartan-HCTZ diltiazem extended release ( Cardizem CD, Dilacor XR) lovastatin diltiazem ER 24 hour (Tiazac ) diltiazem methyldopa diltiazem SR (Cardizem SR ) metolazone metoprolol tartrate metoprolol succinate dipyridamole mexiletine disopyramide minoxidil disopyramide CR 150mg (Norpace CR ) moexipril/HCTZ doxazosin mesylate enalapril nadolol-bendroflume thiazide enalapril /HCTZ (Vaseretic ) eplerenone nifedipine felodipine fenofibrate nisoldipine fenofibric flecainide nitroglycerin fosinopril nitroglycerin furosemide nitroglycerin gemfibrozil pentoxifylline guanabenz perindopril guanfacine hydralazine Type of covered drug*
• Bolded drug is a formulary generic.
• Non-bolded drug is a formulary brand.
• Drug in parenthesis ( ) is a non-formulary brand drug. It is displayed to help you identify the equivalent Highest copay
formulary generic drug that is available at the lowest copay.
• Covered generic drugs not listed are formulary.
• Covered brand drugs not listed are non-formulary. PA = Prior authorization must be requested by the physician. Q = Quantity level limits apply.
✓ = New formulary drug. * Unless specifically excluded from your contract. 4. HEART, BLOOD PRESSURE & CHOLESTEROL (cont.) betamethasone/clotrimazole calcipotriene ciclopirox cream, susp (Loprox ) pindolol ciclopirox pravastatin ciclopirox solution prazosin clindamycin procainamide clindamycin-benzoyl peroxide gel (BenzaClin ) clindamycin phosphate propafenone clobetasol propranolol propranolol desoximetasone quinapril diflorasone diacetate quinapril/HCTZ econazole quinapril gluconate quinidine gluconate ER quinidine erythromycin ramipril erythromycin solution simvastatin erythromycin fluocinolone acetonide cream, soln (Synalar ) spironolactone fluocinonide gel, oint, cream ( Lidex, Lidex E) spironolactone terazosin fluorouracil solution ticlopidine fluticasone propionate gentamicin topical cream, oint torsemide HC acetate/lidocaine HCl (Senatec HC ) trandolapril hydrocortisone 2.5% (Hytone ) trandolapril-verapamil extended-release hydrocortisone butyrate 0.1% (Locoid ) triamterene/HCTZ hydrocortisone valerate 0.2% (Westcort ) imiquimod isotretinoin ketoconazole ketoconazole verapamil lidocaine warfarin MEDICATIONS malathion mometasone adapalene metronidazole alclometasone dipropionate cream (Aclovate ) metronidazole amcinonide mupirocin anthralin nystatin nystatin /triamcinolone bencort lotion kit (Vanoxide-HC ) benzoyl peroxide gel (Brevoxyl gel ) peroxide /erythromycin permethrin peroxide podofilox betamethasone dipropionate prednicarbate ointment betamethasone dipropionate augmented prilocaine/lidocaine prutect topical emulsion (Biafine ) betamethasone valerate selenium 5. SKIN MEDICATIONS (cont.) sulfadiazine sodium sulfacetamide lotion (Klaron ) sulfacetamide/sulfur sulfacetamide sulfacetamide sodium /urea lotion (Carmol scalp lotion ) calcitriol capsules tretinoin triamcinolone desmopressin dexamethasone fludrocortisone 6. EAR, NOSE & THROAT MEDICATIONS acetic acid HC (Acetasol HC ) glimepiride glipizide benzocaine/antipyrine glipizide chlorhexidine gluconate glyburide flunisolide glyburide micronized fluticasone propionate nasal susp (Flonase ) ipratropium hydrocortisone neomycin/polymyxin/hydrocortisone ofloxacin triamcinolone levothyroxine 7. DIABETES, THYROID, STEROIDS & OTHER liothyronine MISCELLANEOUS HORMONES metformin metformin acarbose metformin /glyburide methimazole methylprednisolone Type of covered drug*
• Bolded drug is a formulary generic.
• Non-bolded drug is a formulary brand.
• Drug in parenthesis ( ) is a non-formulary brand drug. It is displayed to help you identify the equivalent Highest copay
formulary generic drug that is available at the lowest copay.
• Covered generic drugs not listed are formulary.
• Covered brand drugs not listed are non-formulary. PA = Prior authorization must be requested by the physician. Q = Quantity level limits apply.
✓ = New formulary drug. * Unless specifically excluded from your contract. 7. DIABETES, THYROID, STEROIDS & OTHER omeprazole MISCELLANEOUS HORMONES (cont.) PA omeprazole-sodium bicarbonate ondansetron pancrelipase nateglinide PA pantoprazole PEG 3350 & electrolytes (Nulytely ) phenobarb/hyoscyamine/atrop/scop prochlorperazine oxandrolone promethazine ranitidine sucralfate sulfasalazine prednisolone sodium phosphate ( Pediapred, Orapred) trimethobenzamide prednisolone ursodiol prednisone propylthiouracil 9. BIOTECHNOLOGY tolbutamide enoxaparin 8. STOMACH, ULCER & BOWEL MEDS balsalazide 10. BONES, JOINTS & MUSCLES chlordiazepoxide/clidinium Q alendronate cimetidine allopurinol dicyclomine azathioprine diphenoxylate HCl/atropine baclofen dronabinol calcitonin-salmon (rDNA origin) nasal spray famotidine carisoprodol famotidine suspension chlorzoxazone choline magnesium trisalicylate granisetron colchicine hydrocortisone cyclobenzaprine hydrocortisone /pramoxine kit (Analpram E Kit ) dexamethasone hydrocortisone retention enema (Colocort ) diazepam hyoscyamine diclofenac potassium diclofenac lactulose diflunisal PA lansoprazole mesalamine rectal susp (Rowasa ) etodolac metoclopramide misoprostol fenoprofen flurbiprofen nizatidine 10. BONES, JOINTS & MUSCLES (cont.) 11. FEMALE, HORMONE REPLACEMENT & BIRTH CONTROL hydrocortisone hydroxychloroquine ibuprofen indomethacin clindamycin indomethacin ketoprofen ketoprofen SR (Oruvail ) desogestrel/ethinyl estradiol ketorolac esterified estrogens/methyltestosterone leflunomide meclofenamate estradiol PA meloxicam estradiol transdermal metaxalone methocarbamol methotrexate estropipate methylprednisolone estradiol/drospirenone nabumetone naproxen fluconazole naproxen naproxen sodium SA (Naprelan ) oxaprozin piroxicam levonorgestrel/ethinyl estradiol prednisolone sodium phosphate ( Pediapred, Orapred) prednisolone prednisone medroxyprogesterone probenecid salsalate sulfasalazine sulfinpyrazone sulindac metronidazole vaginal gel (Metrogel ) tizanidine norethindrone tolmetin norethindrone norethindrone acetate /ethinyl estradiol / ferrous fumarate (Estrostep FE ) norethindrone /ethinyl estradiol Type of covered drug*
• Bolded drug is a formulary generic.
• Non-bolded drug is a formulary brand.
• Drug in parenthesis ( ) is a non-formulary brand drug. It is displayed to help you identify the equivalent Highest copay
formulary generic drug that is available at the lowest copay.
• Covered generic drugs not listed are formulary.
• Covered brand drugs not listed are non-formulary. PA = Prior authorization must be requested by the physician. Q = Quantity level limits apply.
✓ = New formulary drug. * Unless specifically excluded from your contract. 11. FEMALE, HORMONE REPLACEMENT & BIRTH CONTROL (cont.) homatropine ketorolac opth soln (Acular/Acular LS ) levobunolol norethindrone /ethinyl estradiol , Fe norethindrone /mestranol norgestimate/ethinyl estradiol methazolamide norgestrel/ethinyl estradiol neomycin/polymyxin B/dexamethasone ofloxacin nystatin pilocarpine polymyxin B/neo/bacitracin polymyxin B/neo/gramicidin prednisolone prednisolone sodium phosphate (Inflamase Forte ) prednisolone/sodium sulfacetamide terconazole sulfacetamide tri-lo-sprintec timolol ophth (Timoptic ) 12. EYE MEDICATIONS tobramycin tobramycin-dexamethasone acetazolamide trifluridine acetazolamide trimethoprim sulfate/polymyxin B (Polytrim ) tropicamide atropine azelastine HCL drops (Optivar ) bacitracin 13. ALLERGY, COUGH, COLD & LUNG MEDS bacitracin/polymyxin B ophth oint (Polysporin ) acetylcysteine betaxolol albuterol albuterol brimonidine tartrate carbachol aminophylline carteolol ciprofloxacin azelastine nasal spray (Astelin Nasal Spray ) cromolyn cyclopentolate benzonatate dexamethasone brompheniramine/phenylephrine diclofenac budesonide dipivefrin chlorpheniramine/phenylephrine dorzolamide HCl 2% (Trusopt ) chlorpheniramine/phenylephrine dorzolamide-timolol methscopolamine chewable tabs, syrup (Extendryl ) erythromycin chlorpheniramine/phenylephrine fluorometholone methscopolamine extended release (Hista-Vent DA ) gentamicin 13. ALLERGY, COUGH, COLD & LUNG MEDS (cont.) phenylephrine HCl/COD/prometh cromolyn inhalation soln (Intal soln ) cyproheptadine phenylephrinecarbinoxamine w/hydrocodone dexamethasone liquid (Max HC ) phenylephrine/cpm/hydrocodone epinephrine pen injector (AdrenaClick ) phenylephrine/hydrocodone/BPM phenylephrine/hydrocodone/CP prednisolone sodium phosphate ( Pediapred, Orapred) prednisolone fexofenadine prednisone fexofenadine-PSE promethazine promethazine /codeine flunisolide promethazine /dextromethorphan promethazine /phenylephrine/codeine guaifenesin/codeine guaifenesin/codeine /pseudopephedrine pseudoephedrine/brompheniramine/ guaifenesin/hydrocodone hydrocodone liquid (Brovex HC ) guaifenesin/phenylephrine/hydrocodone pseudoephedrine/chlorpheniramine pseudoephedrine/cpm/codeine guaifenesin/pseudoephedrine/codeine pseudoephedrine/guaifenesin extended release hydrocodone-chlorpheniramine hydrocodone/homatropine hydrocortisone hydroxyzine hydroxyzine ipratropium-albuterol ipratropium inhalation soln (Atrovent soln ) terbutaline sulfate tabs (Brethine ) levalbuterol inhalation solution theophylline extended release ( Theochron, Uniphyl) metaproterenol tabs, syrup, inh soln methylprednisolone Type of covered drug*
• Bolded drug is a formulary generic.
• Non-bolded drug is a formulary brand.
• Drug in parenthesis ( ) is a non-formulary brand drug. It is displayed to help you identify the equivalent Highest copay
formulary generic drug that is available at the lowest copay.
• Covered generic drugs not listed are formulary.
• Covered brand drugs not listed are non-formulary. PA = Prior authorization must be requested by the physician. Q = Quantity level limits apply.
✓ = New formulary drug. * Unless specifically excluded from your contract. 13. ALLERGY, COUGH, COLD & LUNG MEDS (cont.) 15. VITAMINS & ELECTROLYTES ergocalciferol fluoride 14. URINARY & PROSTATE MEDS iron, carbonyl 15mg (Icar ) bethanechol Multigen doxazosin mesylate Multigen multivitamin with fluoride drops, tabs finasteride
(Tri-Vi-Flor, Poly-Vi-Flor with and without iron )
flavoxate potassium bicarbonate/potassium citrate methenamine/methylene blue/benzoic acid/ effervescent (K-Lyte ) salicylic acid/atropine (Prosed EC tab ) potassium chloride methenamine/phenylsalicylate/atropine/ hyoscyamine /benzoic acid/methylene blue (Urised ) sodium fluoride drops (Luride drops ) 16. DIAGNOSTICS & MISCELLANEOUS AGENTS oxybutynin oxybutynin phenazopyridine peroxide potassium Q, PA buprenorphine tamsulosin terazosin etidronate disodium midodrine Q, PA Viagra pilocarpine Q, PA Suboxone Q, PA Suboxone Sublingual Film PROCEDURES THAT SUPPORT SAFE PRESCRIBING
Independence Blue Cross utilizes an independent pharmacy benefits management (PBM) company, FutureScripts, to manage the administration of its commercial prescription drug programs. As our PBM, FutureScripts is responsible for providing a network of participating pharmacies, administering pharmacy benefits, and providing customer service to our members and providers. Prior authorization Prior authorization is a requirement that your physician obtain approval from your health plan for coverage of, or payment for, your medication. Independence Blue Cross requires prior authorization of certain covered drugs to ensure that the drug prescribed is medically necessary and appropriate and is being prescribed according to FDA guidelines. The approval criteria were developed and endorsed by the FutureScripts Pharmacy and Therapeutics Committee, which is an established group of medical directors and practicing area physicians and pharmacists.
Using these approved criteria, clinical pharmacists evaluate requests for these drugs based on clinical data, information submitted by the member’s prescribing physician, and the member’s available prescription drug therapy history. Their review includes a determination that there are no drug interactions or contraindications, that dosing and length of therapy are appropriate, and that other drug therapies, if necessary, were utilized. Without prior authorization, the member's prescription will not be covered at the retail or mail-order pharmacy (see “96-Hour Temporary Supply Program” on page 17). The prior authorization process may take up to two working days once complete information from the prescribing physician has been received. Incomplete information will result in a delayed decision.
Prior authorization approvals for some drugs may be limited to 6 to 12 months. If the prior authorization for a drug is limited to a certain time frame, an expiration date will be given at the time the approval is made. If the physician wants a member to continue the drug therapy after the expiration date, a new prior authorization request will need to be submitted and approved in order for coverage to continue.
Currently, the drugs listed below are a part of the prior authorization program. Prior authorization applies to all formulations of these specific drugs, including, but not limited to, tablet, capsule, and oral suspension.
* All diabetic test strips require prior authorization except the following: Autodisc®, Breeze® 2, Contour®, FreeStyle Lite®, and Precision XTRA®. Age and gender limits The FDA has established specific procedures that govern prescription prescribing practices. These rules are designed to prevent potential harm to patients and to ensure that the medication is being prescribed according to FDA guidelines. For example, some drugs are approved by the FDA only for individuals age 14 and older, such as ciprofloxacin, or prescribed only for females, such as prenatal vitamins. The pharmacist’s computer provides up-to-date information about FDA rules. If the member’s prescription falls outside of the FDA guidelines, it will not be covered until prior authorization is obtained. The prescribing physician may request preapproval of restricted medications when medically necessary. The approval criteria for this review were developed and endorsed by the FutureScripts Pharmacy and Therapeutics Committee, which is an established group of medical directors and practicing area physicians and pharmacists. The member should contact the prescribing physician to request that he or she initiate the preapproval process. To determine if a covered prescription drug prescribed for you has an age or gender limit, call FutureScripts at 1-888-678-7012. Quantity level limits Quantity level limits are designed to allow a sufficient supply of medication based upon FDA-approved maximum daily doses and length of therapy of a particular drug. We have several different types of quantity level limits that are explained in detail below. Rolling 30-day period This quantity limit is based on dosing guidelines over a rolling 30-day period. Examples of quantity level limits per rolling 30-day period are: Emend® (four 125mg capsules + eight 80mg capsules or four trifold packs [one 125mg capsule + two 80mg capsules]); Boniva® (two 150mg tablets); Avonex® (one kit, four injections); Betaseron® (15 vials); Copaxone® (32 vials); Fosamax Plus DTM (five tablets); and Rebif®(12 injections); Amerge® (nine 2.5mg tablets), Imitrex® (36 50mg tablets), Maxalt® (12 10mg tablets), Migranal® (eight 4mg nasal spray units), Stadol NS® (four 10mg units), and Zomig® (nine 5mg tablets); Sonata® (14 capsules) and Ambien® (14 tablets); OxyContin® (90 units), Percocet® (180 units), and Percodan® (180 units).
For example, if a member went to the pharmacy on October 1, 2010, for one of these medications, the computer system would have looked back 30 days to September 1, 2010, to see how much medication was dispensed. The purpose of these limits is to make certain that these drugs are being used appropriately and to guard against overuse or stockpiling. Refill too soon
With this quantity level limit, if a member used less than 75 percent of the total day supply dispensed, the claim will be rejected at the pharmacy. This will ensure that the medication is being taken in accordance with the prescribed dose and frequency of administration. Therapeutic drug class
This quantity level limit applies to some classes of drugs, such as narcotics (i.e., short-acting and long-acting). If a member uses more than one drug within the same class, he or she may be unsafely duplicating medications and would be affected by the total quantity limits for a therapeutic drug class. Members will be able to obtain only a 30-day total supply of any combination of drugs in the same therapeutic drug class each month.
If a physician requires that a member needs a medication therapy that exceeds any of the quantity level limits described above, the physician must request a quantity limit override. The member is required to contact the prescribing physician to initiate a preapproval request for an override.
Some drugs may have a time period for quantity limit exceptions of 6 to 12 months. If the exception for a drug is limited to a certain time frame, an expiration date will be given at the time the approval is made. If the physician wants a member to continue the drug therapy that exceeds a quantity limit after the expiration date, a new request for a quantity limit exception will need to be submitted and approved in order for coverage to continue.
To determine if a covered prescription drug prescribed for you has a quantity level limit, call FutureScripts at 1-888-678-7012. 96-Hour Temporary Supply Program The 96-Hour Temporary Supply Program applies to the following covered medications:
• most medications that require prior authorization;
• medications that are subject to age limits (preapproval required for ages outside of recommended ranges);
• migraine medications with quantity level limits, such as Amerge®, Imitrex®, Maxalt®, Migranal® , Stadol NS®, and Zomig® (preapproval of
quantity override required for amounts over the quantity level limits).
Under the 96-Hour Temporary Supply Program, if a member's doctor writes a prescription for a drug that requires prior authorization, has an age limit, or exceeds the quantity level limit for a medication, and prior authorization/preapproval has not been obtained by the doctor, the following steps will occur:
1. The participating retail pharmacy will be instructed to release a 96-hour supply of the drug to the member with no out-of-pocket cost-sharing
2. By the next business day, our PBM will contact the member's doctor to request that he or she submit the necessary documentation of medical
necessity or medical appropriateness for review.
3. Once the completed medical documentation is received by our PBM, the review will be completed, and the medication will be approved
4. If approved, the remainder of the prescription order will be filled, and the appropriate prescription drug out-of-pocket cost-sharing will be applied.*
5. If denied, notification will be sent to the doctor and the member. Obtaining a 96-hour temporary supply does not guarantee that the prior authorization/preapproval request will be approved. Some medications are not eligible for the 96-Hour Temporary Supply Program due to packaging or other limitations such as Retin-A® (tube), Enbrel® (two-week injection kit), medroxyprogesterone acetate (monthly injectable), and erectile dysfunction drugs. Additionally, certain drugs to treat hemophilia (antihemophilic factors) are not usually purchased at the pharmacy and must be special-ordered; therefore, they are not eligible for the 96-hour temporary supply. The process for requesting a prior authorization/preapproval or override is as follows: • The physician prescribing the medication completes a prior authorization form or writes a letter of medical necessity and submits it to our PBM
by fax at 215-241-3073 or 1-888-671-5285. A member's physician may request the form by calling 1-888-678-7012. Members may request the form through Customer Service on behalf of their physician, but it must be completed and submitted by the doctor.
* Members with an integrated drug benefit (e.g., CMM and Major Medical) will pay the discounted cost of the 96-hour supply as well as the remainder of the prescription order (if
approved) at the time of purchase, and the medical claim for reimbursement will be processed through standard procedures.
• The PBM will review the prior authorization request or letter of medical necessity. If a clinical pharmacist cannot approve the request based on
established criteria, a medical director will review the document.
• A decision is made regarding the request.
• If approved, the prescribing physician will be notified of approval via fax or telephone, and the claims system will be coded with the approval.
• The member may call the Customer Service phone number on his or her ID card to determine if the prescription is approved.
• If denied, the prescribing physician will be notified via letter, fax, or telephone.
• The member is also notified of all denied requests via letter.
• The appeals process will be detailed on the denial letters sent to the members and physicians. Coverage for medications not on the formulary (specific to Select Drug Program members only) Providers may request formulary coverage of a covered non-formulary medication when all formulary alternatives have been exhausted or there are contraindications to using the formulary alternatives. The provider should complete the covered non-formulary appeal form, providing detail to support use of the covered non-formulary medication, and should fax the request to 215-241-3073 or 1-888-671-5285. If the non-formulary request is approved, the drug will be paid at the appropriate formulary benefit level. If the request is denied, the member and provider will receive a denial letter with the appropriate appeals language. Whether or not an appeal is filed, the member may always obtain benefits for the covered non-formulary drug at the appropriate non-formulary benefit level. Out-of-pocket expenses for non-formulary drugs are higher than for formulary drugs. Appealing a decision If a request for prior authorization/preapproval or override results in a denial, the member, or physician on the member's behalf, may file an appeal. Both the member and his or her provider will receive written notification of a denial, which will include the appropriate telephone number and address to direct an appeal. In all cases, the physician needs to be involved in the appeals process to provide the required medical information for the basis of the appeal.
amantadine 3, 4
Ambien 6, 16
Amerge 6, 15, 16, 17
acetazolamide 4, 12
amoxicillin/clavulanate extended-release 3
Anaprox DS 6, 11
Ansaid 5, 10
benzoyl peroxide 8, 14
Autodisc 9, 15
Avonex 10, 16
azathioprine 4, 10
betaxolol 6, 12
Azulfidine 10, 11
Bactroban 8, 9
Byetta 9, 15
Cafergot 5, 6
choline magnesium trisalicylate 5, 10
Cardura 7, 14
Cipro 3, 9
ciprofloxacin 3, 12
Cataflam 5, 10
Cleocin 3, 8, 11
clindamycin 3, 8, 11
Clinoril 6, 11
danazol 4, 9
Danocrine 4, 9
Daypro 6, 11
Decadron 9, 10, 13
Deltasone 4, 10, 11, 13
Copaxone 10, 16
Cortef 9, 11, 13
dexamethasone 9, 10, 12, 13
Crestor 7, 15
doxazosin mesylate 7, 14
diazepam 5, 10
diclofenac potassium 5, 10
diclofenac sodium 5, 10, 12
Diflucan 3, 11
diflunisal 5, 10
Emend 10, 16
Enbrel 15, 17
Dolobid 5, 10
Feldene 6, 11
erythromycin 3, 8, 12
fenoprofen calcium 5, 10
esterified estrogens/methyltestosterone 11
Floxin 4, 9
fluconazole 3, 11
etodolac 5, 10
flunisolide 9, 13
Extendryl 12, 13
flurbiprofen 5, 10
fluticasone propionate 8, 9
FreeStyle Lite Test Strips 9FreeStyle Meter 9
Humatrope 9, 15
Humira 10, 15
Gleevec 4, 15
hydrocortisone 8, 9, 10, 11, 13
hydroxychloroquine 3, 11
hyoscyamine 10, 14
Hytrin 8, 14
ibuprofen 5, 11
Imitrex 6, 15, 16, 17
Imuran 4, 10
Indocin 5, 11
ketoprofen 5, 11
Indocin SR 5, 11
indomethacin 5, 11
ketorolac 5, 11, 12
ipratropium 9, 13
ipratropium-albuterol 13ipratropium inhalation soln 13
Maxalt 5, 15, 16, 17
meclofenamate 5, 11
Lodine XL 5, 10
Medrol 9, 11, 13
medroxyprogesterone acetate 11, 17
methotrexate 4, 11
methylprednisolone 9, 11, 13
multivitamin with fluoride drops, tabs 14
Muse 14, 15
metronidazole 3, 8, 11
Mycostatin 4, 8
nabumetone 6, 11
Nalfon 5, 10
Naprelan 6, 11
Migranal 16, 17
Naprosyn 6, 11
naproxen 6, 11
naproxen sodium 6, 11
naproxen sodium SA 6, 11
Nasacort AQ 9, 13
Nasarel 9, 13
Nasonex 9, 13
Mobic 11, 15
Neurontin 5, 6
nystatin 4, 8, 12
Nexium 10, 15
ofloxacin 4, 9, 12
Orapred 10, 11, 13
Norditropin 10, 15
norethindrone 11, 12
norethindrone/ethinyl estradiol 11, 12
Oruvail 5, 11
oxaprozin 6, 11
OxyContin 6, 16
piroxicam 6, 11
Plaquenil 3, 11
Pediapred 10, 11, 13
Percocet 6, 16
Percodan 6, 16
prednisolone sodium phosphate 10, 11, 12, 13
prednisolone syrup 10, 11, 13
prednisone 4, 10, 11, 13
phenazopyridine 4, 14
prednisone tabs 10, 11, 13
Phenergan 10, 13
Prelone 10, 11, 13
Prevacid 10, 15
pilocarpine 12, 14
Prograf 4 promethazine 10, 13
Relafen 6, 11
Protonix 10, 15
Proventil 12, 13
Retin-A 9, 17
pseudoephedrine/guaifenesin extended release 13
Pyridium 4, 14
Sonata 6, 16
Stadol NS 16, 17
salsalate 6, 11
Suboxone 14, 15
Suboxone Sublingual Film 14, 15
Subutex 14, 15
sulfacetamide 9, 12
sulfasalazine 10, 11
Symlin 10, 15
Symmetrel 3, 4
Singulair 13, 15
tolmetin 6, 11
Toradol oral 5, 11
terazosin 8, 14
trandolapril-verapamil extended-release 8
Treximet 6, 16
Tribenzor 8, 16
timolol 8, 12
Tri-Vi-Flor, Poly-Vi-Flor with and without iron 14
Ultram ER 6, 16
Voltaren 5, 10, 12
Voltaren XR 5, 10
Valium 5, 10
Valturna 8, 16
Viagra 14, 16
Videx 3, 4
Zegerid 10, 16
Zetia 8 Ziac 6 Ziagen 4 zidovudine 4 Zipsor 16 Zithromax 3 Zmax 16 Zocor 8 Zoderm 8 Zofran 10 Zolinza 16 Zoloft 6 zolpidem tartrate 6 Zomig 16, 17 Zorbtive 16 Zovirax 3, 9 Zovirax oint 9 Zyloprim 10 Zyprexa 6 Zyvox 16 Prescription Drug Program provider payment information A pharmacy benefits management (PBM) company administers our prescription drug benefits and is responsible for providing a network of participating pharmacies and processing pharmacy claims. The PBM also negotiates price discounts with pharmaceutical manufacturers and provides drug utilization and quality reviews. Price discounts may include rebates from a drug manufacturer based on the volume purchased. Independence Blue Cross anticipates that it will pass on a high percentage of the expected rebates it receives from its PBM through reductions in the overall cost of pharmacy benefits. Under most benefits plans, prescription drugs are subject to a member copayment.
Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company,
and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.
Produced by Independence Blue Cross Business Services Center
Meals in Costa Rica Breakfast. Rice and beans are a staple diet for Costa Ricans, and this is true even at breakfast. Most mornings will begin with gallo pinto , or rice and beans cooked together with onions, garlic, and other spices. This will often be accompanied by eggs, toast, fruit and coffee, juice or tea. Lunch: Whatever we have for lunch, it will almost certainly be accompanied by ri
Ancient Trails A classic trek: Peru’s 28-mile Inca Trailtakes hikers to the ancient city ofMachu Picchu. The high-altitude routecrosses three passes, each at elevationsover 12,000 feet. (elevation 11,207 feet) several daysbefore the hike to allow for acclimatiza-tion both to the altitude and the culture. Flying up from sea level, most of usdeveloped pounding headaches andmild nausea within a f