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900301_oebb_rx_restrictions doc _ 10 01 2010 final_x

OEBB PRESCRIPTION MEDICATIONS
REQUIRING AUTHORIZATION

Medications subject to: prior authorizations, step therapy and quantity restrictions
EFFECTIVE October 1, 2010

This list of medications requiring authorizations may change periodically. For prior effective dates, to submit a request for authorization, or to determine if your medication currently requires authorization, please contact ODS Pharmacy Customer Service. SPECIALTY MEDICATIONS
All specialty medications require prior authorization before they can be dispensed. The list below does not include applicable specialty medications. To determine if the medication you are taking is a specialty medication, please refer to the ODS Specialty Listing available through your myODS account at www.odscompanies.com/oebb/members/ , or by calling ODS Pharmacy Customer Service. IMMUNIZATIONS AND VACCINES
Your pharmacy benefit includes coverage of select immunization and vaccine products. These products are not listed in this document and some restrictions may apply. To determine if the immunization or vaccine you will be receiving is covered under your pharmacy benefit or if there are any limitations, please refer to the ODS Rx Customary Vaccine Listing available under your myODS account or by calling ODS Pharmacy Customer Service. ODS PHARMACY CUSTOMER SERVICE
BRAND NAME
CHEMICAL NAME
MEDICATION CLASS
EDIT TYPE
Prior prescription for at least a 30 day supply of Prior prescription for generic proton pump inhibitor. Max quantity is 62 per 31 days or 180 Prior prescription for metformin or a sulfonylurea Prior prescription for metformin or a sulfonylurea BRAND NAME
CHEMICAL NAME
MEDICATION CLASS
EDIT TYPE
Max quantity is 5mg, 10mg, 15mg - 62 per 31 DEXTROAMPHETAMINE / (ADD), ATTENTION DEFECIT days or 180 per 90 days; 20mg, 25mg, 30mg - Max quantity is 10 per 31 days or 30 per 90 days Prior prescription for angiotensin converting Prior prescription for angiotensin converting Prior prescription for metformin or a sulfonylurea Prior prescription for metformin or a sulfonylurea Prior prescription for metformin or a sulfonylurea Prior prescription for angiotensin converting Max quantity is 30mg, 45mg, 60mg, 75mg - 31 per 31 days or 90 per 90 days; 90mg, 120mg - Prior prescription for Extavia or Copaxone Max quantity is 6 per 31 days or 18 per 90 days Prior prescription for angiotensin converting Prior prescription for Extavia or Copaxone Prior prescription for metformin, a sulfonylurea or a thiazolidinedione. Max quantity is 1 pen per 31 Prior prescription for generic beta blocker. Max quantity is 31 per 31 days or 90 per 90 days Max quantity is 31 per 31 days or 90 per 90 days Prior prescription of 2 Non-Steroidal Anti- Inflammatory Agents for patients under 60 years of age. Max quantity is 62 per 31 days or 180 Prior prescription for Allegra or Allegra D. Max quantity is 93 per 31 days or 270 per 90 BRAND NAME
CHEMICAL NAME
MEDICATION CLASS
EDIT TYPE
Prior prescription for Galantamin HBR, Exelon, Prior prescription for angiotensin converting Max quantity is 31 per 31 days or 90 per 90 days Prior prescription for at least a 30 day supply of venlafaxine, citalopram, fluoxetine, paroxetine, and/or sertraline Prior prescription for omeprazole. Max quantity Max quantity is 200 test strips per 31 days or Prior prescription for angiotensin converting Prior prescription for metformin or a sulfonylurea Prior prescription for topical anti-inflammatory Prior prescription for Estring, Femring, and/or Prior prescription for clindamycin phosphate Prior prescription for angiotensin converting Max quantity is 93 per 31 days or 270 per 90 DEXMETHYLPHENIDATE (ADD), ATTENTION DEFECIT Max quantity is 62 per 31 days or 180 per 90 DEXMETHYLPHENIDATE (ADD), ATTENTION DEFECIT Max quantity is 31 per 31 days or 90 per 90 days Prior prescription for at least a 30 day supply of Prior prescription for alendronate, Boniva, and/or Actonel. Max quantity is 1 pen per 31 day Max quantity is 10 per 31 days or 30 per 90 days BRAND NAME
CHEMICAL NAME
MEDICATION CLASS
EDIT TYPE
Max quantity is 1 kit per 31 days or 3 kits per 90 Prior prescription for at least a 30 day supply of risperidone. Max quantity is 62 per 31 days or Prior prescription for angiotensin converting Max quantity is 9 tablets per 31 days or 27 per 90 days; nasal spray - 6ml (1 box) per 31 days or 18ml (3 boxes) per 90 days; injections - 4 packages per 31 day supply or 12 packages per 90 days Prior prescription for clozapine, risperidone, Seroquel, or Seroquel XR. Max quantity is 3mg & 9mg - 31 per 31 days or 90 per 90 days; 6mg Prior prescription for metformin or a sulfonylurea Max quantity 31 per 31 days or 90 per 90 days Max quantity is 20mg & 40mg - 62 per 31 days or 180 per 90 days; 80mg - 31 per 31 days or 90 Prior prescription for NPH insulin. Max quantity Prior prescription for at least a 30 day supply of citalopram, fluoxetine, paroxetine and/or sertraline Max quantity is 31 per 31 days or 90 per 90 days Prior prescription for hydrocortisone butyrate Prior prescription for hydrocortisone butyrate Max quantity is 62 per 31 days or 180 per 90 Max quantity is 10 per 31 days or 30 per 90 days Prior prescription for angiotensin converting Prior prescription for omeprazole. Max quantity BRAND NAME
CHEMICAL NAME
MEDICATION CLASS
EDIT TYPE
Max quantity is 31 per 31 days or 90 per 90 days Max quantity is 124 per 31 days or 360 per 90 Max quantity is 60 vials per 31 days or 180 vials Prior prescription for Estring, Femring, and/or Prior prescription for omeprazole. Max quantity is 15mg - 31 per 31 days or 90 per 90 days; 30mg - 62 per 31 days or 180 per 90 days Max quantity is 10mg - 31 per 31 days or 90 per Prior prescription for at least a 30 day supply of venlafaxine, citalopram, fluoxetine, paroxetine, and/or sertraline Max quantity is 31 per 31 days or 90 per 90 Prior prescription for topical anti-inflammatory Max quantity is 62 per 31 days or 180 per 90 Max quantity is 4mg, 8mg, 12mg - 62 per 31 days or 180 per 90 days; 8mg (ER), 16mg, 24mg - 31 per 31 days or 90 per 90 days Prior prescription for Extavia or Copaxone Max quantity is 6 per 31 days or 18 per 90 days Max quantity is 60 single use vials per 30 days Max quantity is 62 tablets per 31 days or 180 tablets per 90 days; 8 bottles (240ml) every 6 Prior prescription for at least a 30 day supply of Prior prescription for at least a 30 day supply of risperidone. Max quantity is 93 per 31 days or Prior prescription for at least a 30 day supply of risperidone. Max quantity is 31 per 31 days or Max quantity is 2 boxes per 31 days or 6 boxes Max quantity is 10mg, 18mg, 25mg - 62 per 31 days or 180 per 90 days; 40mg, 60mg, 80mg, BRAND NAME
CHEMICAL NAME
MEDICATION CLASS
EDIT TYPE
Clinical criteria. Max quantity is 62 per 31 days Max quantity is 93 tablets per 31 days or 270 per Prior prescription for angiotensin converting Clinical criteria. Max quantity is 2 per 31 days or Prior prescription for angiotensin converting Max quantity is 9 tablets per 31 days or 27 per Prior prescription for Extavia or Copaxone Max quantity is 186 per 31 days or 540 per 90 Prior prescription for angiotensin converting Prior prescription for at least a 30 day supply of a generic non-steroidal anti-inflammatory drug (NSAID). Max quantity is 31 per 31 days or 90 per 90 days Max quantity is 30 per 30 days or 90 per 90 days Prior prescription for at least a 30 day supply of citalopram, fluoxetine, paroxetine and/or sertraline. Step therapy applicable to both brand and generic budeprion XL Max quantity is 200mg – 92 per 31 days or 270 per 90 days; 550mg – 62 per 31 days or 180 per 90 days Max quantity is 31 per 31 days or 90 per 90 Max quantity is 62 per 31 days or 180 per 90 Max quantity is 6 per 31 days or 18 per 90 days Prior prescription for at least a 30 day supply of risperidone. Max quantity is 31 per 31 days or

Source: https://www.bluecc.edu/sites/bluecc.edu/files/File/hr/insurance/2010-11%20OEBB%20Medications%20Requiring%20Authorization.pdf

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