Microsoft word - cci pa list-12-07.doc

In an effort to promote the appropriate use of certain drugs and to help better manage the cost of expensive drugs, the ConnectiCare Pharmacy & Therapeutics Committee has developed a list of prescription drugs that require prior authorization. Prior authorization requests must be faxed to ConnectiCare’s Pharmacy Services department at 860-674-2851 or toll free 800-249-1367 by the prescribing physician’s office. POS members receiving out-of-network care are responsible for initiating this process. When submitting a request for Prior Authorization please use a Prior Authorization form which can be printed at ConnectiCare.com or obtained by calling ConnectiCare at 800-251-7722. If the prescribed drug is approved, the prescription will be filled as usual at a participating pharmacy or administered by a provider (where appropriate). Chantix (PA not required for initial 30 day supply) Aciphex (Use Prilosec OTC-Tier 1) Clarinex / D (Use loratadine OTC first-Tier 1) Contraceptives (if excluded by group) Allegra / Allegra D (Use loratadine OTC first-Tier 1) *Crestor (Use simva-, prava-, lovastatin first) Altoprev (Use simva-, prava-, lovastatin first) *Cymbalta (Use generic SSRI’s first) *Detrol / LA (Use oxybutynin IR/XL first) *Effexor XR (Use generic SSRI’s first) Aranesp (PA required for pharmacy claims only) *Enablex (Use oxybutynin IR/XL first) *Beconase AQ (Use generic flonase first) fexofenadine (Use loratadine OTC-Tier 1) *Cardura XL (Use generic doxazosin first) Fosamax plus D 5600 (Use fosamax plus D 2800) Note: Self administered medications (i.e. interferons), even those not on this list, may not be dispensed for self administration and
billed through the medical benefit by a provider, they must be dispensed through a participating pharmacy. (*) prior authorization is not
required within the first 90 days of membership with ConnectiCare.
(M) physician administered drug, usually billed under the medical benefit
Rev. 12/2007
In an effort to promote the appropriate use of certain drugs and to help better manage the cost of expensive drugs, the ConnectiCare Pharmacy & Therapeutics Committee has developed a list of prescription drugs that require prior authorization. Prior authorization requests must be faxed to ConnectiCare’s Pharmacy Services department at 860-674-2851 or toll free 800-249-1367 by the prescribing physician’s office. POS members receiving out-of-network care are responsible for initiating this process. When submitting a request for Prior Authorization please use a Prior Authorization form which can be printed at ConnectiCare.com or obtained by calling ConnectiCare at 800-251-7722. If the prescribed drug is approved, the prescription will be filled as usual at a participating pharmacy or administered by a provider (where appropriate). MMirena (levonorgestrel-releasing IUD) Myrac (Use generics first) *Nasacort AQ (Use fluticasone, Nasonex,or Veramyst first) *Nasarel (Use fluticasone,Nasonex,Veramyst first) Neulasta (PA required for pharmacy claims only) Injectable Drugs- All (excluding insulin) Klonopin Wafers (Use clonazepam tablets) *Omacor (note name change to “Lovaza”) *Omnaris (Use fluticasone, Nasonex, or Veramyst first) *Lescol/XL (Use simva-, prava-, lovastatin first) *Lipitor (Use simva-, prava-, lovastatin first) *Oxytrol (Use generic oxybutynin IR/XL first) Prevacid (Use Prilosec OTC-Tier 1) Minocin Combo Pack (Use generics first) Note: Self administered medications (i.e. interferons), even those not on this list, may not be dispensed for self administration and
billed through the medical benefit by a provider, they must be dispensed through a participating pharmacy. (*) prior authorization is not
required within the first 90 days of membership with ConnectiCare.
(M) physician administered drug, usually billed under the medical benefit
Rev. 12/2007
In an effort to promote the appropriate use of certain drugs and to help better manage the cost of expensive drugs, the ConnectiCare Pharmacy & Therapeutics Committee has developed a list of prescription drugs that require prior authorization. Prior authorization requests must be faxed to ConnectiCare’s Pharmacy Services department at 860-674-2851 or toll free 800-249-1367 by the prescribing physician’s office. POS members receiving out-of-network care are responsible for initiating this process. When submitting a request for Prior Authorization please use a Prior Authorization form which can be printed at ConnectiCare.com or obtained by calling ConnectiCare at 800-251-7722. If the prescribed drug is approved, the prescription will be filled as usual at a participating pharmacy or administered by a provider (where appropriate). MSynvisc (hyaluronate sodium) *Prozac Weekly (Use generics first) Travel Medication: including Malarone, *Rhinocort Aqua (Use fluticasone, Nasonex, Veramyst first) *Vesicare (Use oxybutynin IR/XL first) *Sanctura (Use oxybutynin IR/XL first) MVivaglobulin (SQ Immuneglobulin) Singulair (Use loratadine OTC first for allergic rhinitis) *Vytorin (Use simva-, prava-, lovastatin first) Weight Loss Medication (if covered by your plan); Meridia, Xenical, Ionamin, Tenuate, etc Xanax XR (use generic alprazolam) Steroids, Anabolic (i.e Nandrolone) Xyzal (Use OTC loratadine first-Tier 1) Zegerid (PA for age > 15 y/o) (Use Prilosec OTC) Note: Self administered medications (i.e. interferons), even those not on this list, may not be dispensed for self administration and
billed through the medical benefit by a provider, they must be dispensed through a participating pharmacy. (*) prior authorization is not
required within the first 90 days of membership with ConnectiCare.
(M) physician administered drug, usually billed under the medical benefit
Rev. 12/2007
In an effort to promote the appropriate use of certain drugs and to help better manage the cost of expensive drugs, the ConnectiCare Pharmacy & Therapeutics Committee has developed a list of prescription drugs that require prior authorization. Prior authorization requests must be faxed to ConnectiCare’s Pharmacy Services department at 860-674-2851 or toll free 800-249-1367 by the prescribing physician’s office. POS members receiving out-of-network care are responsible for initiating this process. When submitting a request for Prior Authorization please use a Prior Authorization form which can be printed at ConnectiCare.com or obtained by calling ConnectiCare at 800-251-7722. If the prescribed drug is approved, the prescription will be filled as usual at a participating pharmacy or administered by a provider (where appropriate). MZevelin
Zolinza
Zyban
Zyrtec / Zyrtec D (Use OTC)
Note: Self administered medications (i.e. interferons), even those not on this list, may not be dispensed for self administration and
billed through the medical benefit by a provider, they must be dispensed through a participating pharmacy. (*) prior authorization is not
required within the first 90 days of membership with ConnectiCare.
(M) physician administered drug, usually billed under the medical benefit
Rev. 12/2007

Source: http://www.cbia.com/ieb/ag/medical/zpdf/CtCare/CtCarePriorAuthorDrugList.pdf