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Rx Utilization Management Changes Effective April 1

Release Date: January 14, 2013

We want to inform you about the following new pharmacy utilization management requirements that will be effective April 1, 2013. 

Provigil and Nuvigil 

A quantity limit will apply for Provigil and Nuvigil for ALL members, in addition to the current prior review requirement for these sleep-disorder medications. Provigil will be limited to two tablets per day, and Nuvigil to one tablet per day.

Attention-Deficit Hyperactivity Disorder Medications

A quantity limit will apply for all NEW users for the following attention-deficit hyperactivity disorder medications.  Please refer to the pharmacy utilization criteria for the specific quantity limit for each medication listed below: 

  • Adderall / Adderall XR
  • Concerta
  • Daytrana
  • DextroStat
  • Dexedrine
  • Desoxyn
  • Focalin / Focalin XR
  • Intuniv
  • Kapvay
  • Metadate CD / Metadate ER
  • Methylin / ER
  • Procentra
  • Ritalin / Ritalin LA / Ritalin SR
  • Strattera
  • Vyvanse

Doxycycline and Minocycline for Acne or Rosacea

ALL users of any brand-name forms of Doxcycline and Minocycline will be required to first try an oral generic and a prescription topical acne product before the brand-name drug will be approved for treatment for acne or rosacea.

Angiotensin II Receptor Blockers (ARBs)

NEW users of the following ARBs will be required to first try a preferred ARB before the following nonpreferred ARBs can be considered for coverage:  

  • Exforge / Exforge HCT
  • Micardis/ Micardis HCT
  • Tribenzor
  • Twynsta

Diabetic Test Strips Program

We will be introducing a new prior review program for diabetic test strips in April, which will require the use of Bayer and Lifescan test strips for NEW users.  In October 2013, this program will apply to ALL members.  We will work with you and our members to ensure that appropriate communication is given regarding this new program, and we will help our members prepare for this change.  More information regarding this program will be available in the next few months.

The detailed review criteria for these pharmacy utilization management programs are available via the Provider portal on the “Prior Review” page.

These changes will be effective April 1, 2013, and will apply to all commercial members who have their pharmacy benefits with us.  These changes will not apply to State Health Plan, Federal Employee Program, Medicare Part D members, or for any ASO employer groups that carve out their pharmacy benefits to another pharmacy benefits manager. 

If you have questions, please contact the Provider Blue LineSM at 1.800.214.4844.