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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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