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State Health Plan Specialty Medication Quantity Limit Program

 

As of February 22, 2012, the specialty medications Arava®, Cimzia®, Enbrel®, Humira®, Kineret®, Orencia® (subcutaneous), Simponi® and Stelara® will have quantity limits under the State Health Plan’s pharmacy benefit. In addition, the benefit will help ensure that the clinical indication for use meets the State Health Plan’s conditions for coverage.

Maintenance prescriptions for these medications can be filled up to the quantities indicated in the chart. These quantities are based on FDA-approved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe and effective.  If greater amounts are required, a coverage review must be completed.

Specialty Medication

Covered Amount

Arava

20 mg per day (30 tablets)

Cimzia

Maintenance dose – 400 mg (2 syringes)    per month

Enbrel

200 mg per month

Humira

Two units/doses per month

Kineret

31 syringes per month

Orencia (subcutaneous)

4 syringes per month

Simponi

1 unit per month

Stelara

5 vials or syringes per 365 days

Program information is located on the pharmacy prior authorization policy Web page at www.shpnc.org.

If greater amounts are required, providers may call Medco toll-free at 1-800-417-1764, from 8:00 a.m. to 9:00 p.m., Eastern Time, Monday through Friday, or log in to www.medco.com/coverage to request a review. Members will be responsible for the full cost of the prescription if the provider does not receive approval during the coverage review.

These specialty medications are available through Accredo Health Group, Inc., Medco’s Specialty Pharmacy. You or your patient may contact Accredo at 1-877-988-0059 or visit www.shpnc.org for more information.