Microsoft word - wbp dqm drug list for members 07 31 09 _2_.doc

To help make the use of prescription drugs safer and more affordable, our plan is now
using a Drug Quantity Management program. That is, for certain medications, you can
receive an amount to last you a certain number of days. This gives you the right amount
to take the daily dose considered safe and effective, according to the recommendations of
the U.S. Food and Drug Administration (FDA). Based on the FDA’s guidelines and
other medical information, our plan developed this program together with Express
Scripts, the company chosen to manage our prescription drug benefit.
The following limits are based on a 34-day supply, but our benefit may provide a different
supply. For instance, you may be able to get a 90-day supply of your medication through
mail order service. Your doctor could also request a prior authorization. If this request is
approved, a prior authorization would let you receive more than the recommended
quantity.
Drug Quantity Limits
for Concordia Health Plans
Prescription Drug Benefit
Name of Prescription Drug
Maximum Quantity
Advair Diskus 100/50, 250/50, and 500/50 with device 68 tablets/orally disintegrating tablets Aloxi injection 0.25 mg/5 ml and 0.075 mg/1.5 ml List is subject to change; Updated 7/31/09 Name of Prescription Drug
Maximum Quantity
Atrovent nasal spray 0.03% (30 grams), generic Atrovent nasal spray 0.06% (15 grams), generic Avandamet 1 mg/500 mg, 2/500, 4/500, 2/1000, 4/1000 Avandaryl 4mg/1mg, 4mg/2mg, 4mg/4mg, 8mg/2mg, 8mg/4mg 2 inhalers 14 or 15 vials with prefilled diluent syringe (depending on product packaging) Brovana Inhalation Solution (30 vial carton) Chorionic gonadotropin 10000 units, generic Claritin 10 mg/Claritin Reditabs 10 mg, Claritin 5 mg chewable Depo-Provera Contraceptive Injection 150 mg/mL List is subject to change; Updated 7/31/09 Name of Prescription Drug
Maximum Quantity
Emend Trifold Pack (one 125 mg and two 80 mg capsules) Foradil Aerolizer & 12 capsules in blisters Foradil Aerolizer & 60 capsules in blisters Fosamax Plus D 70 mg/2800 IU, 70mg/5600 IU Imitrex 4mg injection (syringes/cartridges) List is subject to change; Updated 7/31/09 Name of Prescription Drug
Maximum Quantity
Lioresal Inthrathecal Refill Kit 1 ampule 10 mg/20 ml 2 ampules 10 mg/5 ml 1 ampule 40 mg/20 ml Lunesta 1mg, 2mg, 3mg Monistat 3 combination pack 200 mg & equivalent Monistat 3 suppositories 200 mg & equivalent Monistat 7 combination pack & equivalent Monistat 7 suppositories 100 mg & equivalent Monistat Dual Pak (1200 mg vaginal insert, 9 gram 2% cream) Monistat Dual-Pak (three 200 mg vaginal supp, 15 gram 2% cream) PEG Intron Pens/Kit (containing 1 vial each) 50 mcg, 80 mcg, 120 List is subject to change; Updated 7/31/09 Name of Prescription Drug
Maximum Quantity
Pegasys 180 mcg Convenience Pack ( 4 vials) Pegasys 180 mcg Convenience Pack (4 prefilled syringes) Pulmicort Respules 0.25 mg/2 mL and 0.5 mg/2 mL Rebetron Combination, Rebetron 1200, 1000, and 600 Therapy Pak Relenza 5 mg/blister with inhalation device Rhinocort Aqua 32 mcg (120 inhalations) 8.4ml bottle Sandostatin LAR Depot 10 mg/5 ml and 30 mg/5 ml Spiriva Handihaler 6 capsules (1 blister card) with inhaler device Spiriva Handihaler 30 capsules (5 blister cards) with inhaler device Spiriva Handihaler 90 capsules (6 blister cards) with inhaler device List is subject to change; Updated 7/31/09 Name of Prescription Drug
Maximum Quantity
Zithromax for oral suspension 100 mg/5 mL, 15 ml bottle Zithromax for oral suspension 200 mg/5 mL, 15 and 22.5 ml bottle Zithromax for oral suspension 200 mg/5 mL, 30 ml bottle List is subject to change; Updated 7/31/09

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