Self-administered medications, must be

[Pages:22]MANDATORY DRUG LIMITATIONS PROGRAM

ConnectiCare has a Quality Management Drug Program to limit certain medication quantities to established amounts. The goal of this program is to ensure compliance with U.S. Food and Drug Administration and manufacturer dosing recommendations and/or avoid abuse and misuse. For the following drugs, reimbursement will be limited to the quantities below unless ConnectiCare has received a medical necessity request from the prescribing physician and has authorized the additional quantity.

To submit request for additional quantities, please complete a pre-authorization form. Pre-authorization forms can be obtained from .

Providers please note: The quantities below are the limits set up for prescriptions dispensed by pharmacies to members for self administration. Self-administered medications, 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.

To find a drug, click this Search button and enter the name of the drug in the pop-up task pane.

Effective February 2021

DRUG CLASS OPIOIDS

Drug

LONG & SHORT ACTING OPIOID PRODUCTS (ALL) *See formulary

Quantity Limit

Comments

200 mg Morphine

Refer to policies: Long

Equivalent Dose per Acting Opioids, Short

day

Acting Opioids

MISCELLANEOUS ANTI-INFECTIVES Albenza tablets Alinia tablets Alinia suspension Aemcolo Arikayce Baxdela Solosec Tindazole (Tindamax) Xenleta Zyvox (linezolid)

ADRENAL HORMONES

DIABETIC SUPPLIES AND EQUIPMENT

Acthar Gel

Dexcom G4 and G5 Platinum Sensor

120 tabs/month 6 tabs/month 60ml 12 tablets/month 235.2mL/28 days 28 tablets/Rx 1 packet/30 days 12 tabs 10 tablets/Rx 28 tabs, or 150 cc (1 bottle) every 60 days 1 vial/fill 1 box = 4 Sensors = 28 days

Dexcom G4 Platinum Transmitter Dexcom G5 Transmitter

2 per year

4 per year = 1 per 90 day period

The information in this document does not apply to ConnectiCare VIP Medicare Plan members.

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MANDATORY DRUG LIMITATIONS PROGRAM

DRUG CLASS

Drug Dexcom G4 Platinum Receiver

Quantity Limit 1 per year

Comments

Dexcom G5 Mobile Receiver

1 per year

Dexcom G6 Receiver

1 per year

Dexcom G6 Transmitter Kit Dexcom G6 Sensor Freestyle Libre Reader

4 per year = 1 per 90 day period

1 box = 3 Sensors = 30 days

1 reader per 365 days

Freestyle Libre Sensor Glucagon vials

3 sensors per 23 days; 9 sensors per 69 days mail order

4 units/month

Glucolet Lancing Devices (Diabetic) 1 unit

GVOKE

2 syringes/claim

Baqsimi

2 nasal devices/claim

MULTIPLE SCLEROSIS

Bafiertam

120 capsules/month

Copaxone 20mg/ml syringe

3 syringes

NARCOTIC ANALGESICS

Glatopa 20 mg/ml syringe Abstral SL

3 syringes 120 tabs/month

Apadaz Belbuca Butorphanol Nasal spray Butrans Fentanyl lozenges (Actiq) Fentora Hydromorphone ER (Exalgo) Lazanda Oxycodone/Ibuprofen Oxycontin

168 tabs/14 days 60 films/month 2 bottles (5ml) 4 patches/month 120 lozenges/month 120 buccal tabs/mon 60 caps/month 15 bottles/month 30 tabs/month 5/day or 150/month

Subsys

120 doses

Zohydro ER

90 tabs/month

OPIOID WITHDRAWAL

Lucemyra 0.18mg tabs

224 tabs/365 days

Narcan

4 units/23 days

The information in this document does not apply to ConnectiCare VIP Medicare Plan members.

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MANDATORY DRUG LIMITATIONS PROGRAM

DRUG CLASS

Drug

Quantity Limit

Comments

SYMPATHOMIMETICS

EpiPen/Epinephrine auto injector

2 syringes/month

MISCELLANEOUS HORMONES

Androderm

60 patches/month

Androgel 1.62%

2 bottles/month

Androgel 1%

60 packets (4 bottles)/month

Android

Androxy

Jatenzo 158mg capsules Jatenzo 237mg capsules Jatenzo 198mg capsules

60 tabs/month

60 tabs/month

60 caps/month 60 caps/month 120 caps/month

Methyltestosterone (Testred)

2 tablets/month

Pregnyl Striant

3 vials 60 tabs/month

MISCELLANEOUS GI AGENTS

Testim Vogelxo Mytesi

60 packets/month 300gm/month 60 tabs/month

Akynzeo

4 capsules/23 days

Alosetron (Lotronex) Amitiza

60 tabs/month 60 tabs/month

Anzemet

2 tabs/month

Bonjesta

60 tabs/month

Cimzia

400mg/month (1 kit) 1 kit = 2 syringes

Diclegis

120 tabs/month

Emend Granisetron

2 Tri-packs/ month or Note: Tri-pack = 125mg x

6 caps of 40 mg &

1 and 80mg x 2

80mg/claim

6 tabs/month

Linzess

30 caps/month

Motegrity

30 tabs/month

Ondansetron 24mg

1 tablet per fill

Renagel

270 tabs/month

Sancuso

2 patches/month

Trulance

30 per month

Varubi The information in this document does not apply to ConnectiCare VIP Medicare Plan members.

4 tabs/28 days

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MANDATORY DRUG LIMITATIONS PROGRAM

DRUG CLASS ANTIFUNGAL AGENTS

ANTIHISTAMINES NON-INSULIN HYPOGLYCEMIC AGENTS

Drug Zuplenz Cresemba Oravig Tolsura V-Fend (voriconazole suspension) V-Fend (voriconazole tabs) Clarinex/D (desloratadine/D) Actoplus Met XR

Quantity Limit 12 strips/month 60 tabs/month 14 tabs per fill 120 caps/month 75ml 42 tabs/month 30 tabs/month 60 tabs/month

Comments

Adlyxin Avandia Bydureon Byetta 5mcg Byetta 10mcg Farxiga Glyxambi Invokamet Invokana Jardiance Metformin oral solution Ozempic 0.25mg or 0.5mg Ozempic 1mg Pioglitazone (Actos) Pioglitazone/metformin (Actoplus Met) Qtern 5/5 mg & 10/5 mg tablets Riomet oral solution Rybelsus Segluromet Soliqua Steglatro Steglujan

2 pens per month 60 tabs/month 4 pens/month 1.2 ml/month 2.4 ml/month 30 tabs/month 30 tabs/month 30 tabs/month 30 tabs/month 30 tabs/month 765 ml/30 days 1.5mL/ 28 days 3mL/28 days 30 tabs/month 90 tabs/month

30 tabs/month 765 ml/30 days 30 tabs/month 30 tabs/month 5 pens per 25 days 30 tabs/month 30 tabs/month

The information in this document does not apply to ConnectiCare VIP Medicare Plan members.

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MANDATORY DRUG LIMITATIONS PROGRAM

DRUG CLASS

LIPID-CHOLESTEROL LOWERING AGENTS

INTERLEUKINS OTHER RHEUMATOLOGICALS

Drug Symlin Synjardy/XR Trijardy XR Trulicity Victoza

Xigduo Xultophy Ezetimibe (Zetia)

Juxtapid Livalo Nexletol Nexlizet Praluent Repatha 140mg Repatha 420mg Kineret Enbrel 50mg

Quantity Limit 4 pens per month 30 tabs/month 30 tabs/month 4 pens per moth 3 pens (9ml) per month 30 tabs/month 5 pens per month 30 tabs/month

Comments

30 caps/month 30 tabs/month 30 tabs/month 30 tablets/30 days 2 pens/month 2 pens/month 1 pen/month 30 syringes/month 4 syringes/month

Enbrel 25mg

8 syringes/month

Humira

2 syringes/mon

Olumiant

30 tabs/month

Simponi

1 syringe/month

Xeljanz

60 tabs/month

MIGRAINE AND CLUSTER HEADACHE THERAPY

Aimovig Ajovy

2 syringes/month 1 syringe/month

Almotriptan (Axert)

9 tabs/month

Alsuma

Cambia

Dihydroergotamine nasal spray (Migranal)

1 package/mon

9 packets/month

1 package (8 doses)/month

The information in this document does not apply to ConnectiCare VIP Medicare Plan members.

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MANDATORY DRUG LIMITATIONS PROGRAM

DRUG CLASS

Drug Eletriptan Emgality Frovatriptan (Frova) Naratriptan (Amerge) Nurtec ODT Onzetra Xsail

Relpax Reyvow 50mg tablets Reyvow 100mg tablets Rizatriptan (Maxalt) Sumatriptan injectable (Imitrex) Sumatriptan nasal spray (Imitrex) Sumatriptan tablets (Imitrex) Tosymra

Quantity Limit

Comments

9 tabs/month

1 syringe/month

9 tabs/month

9 tabs/month

15 tabs/month

16 units/month (8 doses per nostril)

9 tabs/month

8 tabs/28 days 16 tabs/28 days

9 tabs/month

2 kits (4 doses)/month

1 pkg (6 doses)/mon

18 tabs/month

6 units/month

Treximet

9 tabs/month

Ubrelvy 50mg tablet Ubrelvy 100mg tablet

Zolmitriptan tablets (Zomig)

16 tabs/month 16 tabs/monthR

9 tabs/month

ANTINEOPLASTIC AND IMMUNOSUPPRESANT AGENTS

Zolmitriptan Nasal Spray (Zomig) Ayvakit

1 package (6 doses/mon)

30 tabs/month

Besponsa

7 vials/21 days

Bosulif

Braftovi 50mg capsule Braftovi 75mg capsule

Calquence

30 tabs/month

120 caps/month 180 caps/month

60 capsules/month

Caprelsa

30 tabs/month

Copiktra

60 capsules/month

Daurismo 25mg tablets Daurismo 100 mg tablets

Erivedge

60 tabs/month 30 tabs/month

30 tabs/month

Erleada

120 tabs/month

Gavreto The information in this document does not apply to ConnectiCare VIP Medicare Plan members.

120 capsules/month

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MANDATORY DRUG LIMITATIONS PROGRAM

DRUG CLASS

Drug Gilotrif Ibrance Idhifa Imbruvica Inlyta Inrebic Inqovi Jakafi Mekinist Mektovi 15mg tablet Nerlynx Odomzo Onureg 200 mg tablets Onureg 300 mg tablets Pemazyre Piqray Qinlock 50mg tablet Retevmo 40 mg capsules Retevmo 80 mg capsules Rozlytrek 100 mg capsules Rozlytrek 200 mg capsules Sandostatin LAR Signifor LAR vials Stivarga Sutent Tabrecta Tafinlar Talzenna 0.25mg capsules Talzenna 1mg capsules Tarceva 25mg Tarceva 100mg/150mg Thalomid Tibsovo

Quantity Limit

Comments

30 tabs/month

21 caps/month

30 tabs/month

120 tabs/month

60 tabs/month

120 caps/month

5 tabs/28 days

60 tabs/month

30 tabs/month 180 tabs/month 180 tabs/month

30 caps/month

14 tablets per 28 days 14 tablets per 28 days

14 tablets/21 days

28 tabs/28 days

90 tabs/month

60 capsules/30 days 120 capsules/30 days 180 capsules/30 days 90 capsules/30 days 1 kit per month 1 vial per fill 84 tabs/month 28 tablets per fill 112 tablets/28 days 120 tabs/month 90 caps/month 30 caps/month 60 tabs/month 30 tabs/month 30 tabs/month 60 tabs/month

The information in this document does not apply to ConnectiCare VIP Medicare Plan members.

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MANDATORY DRUG LIMITATIONS PROGRAM

DRUG CLASS

Drug Tukysa Tykerb Unituxin Vitrakvi 25mg capsules Vitrakvi 100mg capsules Vitrakvi 20mg/ml solution Vizimpro Xalkori Xospata Xtandi Yonsa Zejula Zelboraf Zytiga

Quantity Limit 120 tabs/month 180 tabs/month 12 vials/28 days 180 caps/month 60 caps/month 300 ml/month 30 tabs/month 60 tabs/month 90 tabs/month 120 caps/month 120 tabs/month 90 per month 240 tabs/month 120 tabs (250mg)/month

Comments

ANTIPARKINSONISM AGENTS

Apokyn Inbrija

60 tabs (500mg)/month 60 ml/month

300 capsules/month

4 cartons of 5--3ml syringes

Nuplazid 10mg tablet Nuplazid 17 mg tablet Nuplazid 34 mg capsule

Ongentys 25mg capsules Ongentys 50mg capsules

Ropinirole 5mg (Requip)

30 tablets/month 60 tablets/month 30 capsules/month

30 capsules/month 30 capsules/month

120 tabs/month

ANTIPSORIATIC/ANTISEBORRHEIC AGENTS

Ropinirole 3mg (Requip) Ropinirole 4mg (Requip) Calcipotriene cream (Dovonex)

Calcipotriene Foam (Sorilux)

90 tabs/month 180 tabs/month 120 gm/month

120 gm per fill

Enstilar Foam Skyrizi Stelara syringes

Stelara vials

400 gm per fill

2 syringes/3 months

1 syringe every *3* months

3 vials for loading dose

The information in this document does not apply to ConnectiCare VIP Medicare Plan members.

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