Bcn quantity limits_jan 2007_112906.xls

Blue Care Network - January 2007
DOSE OPTIMIZATION PROGRAM
Antidepressants
Cymbalta (Nonformulary)*
Emsam (Nonformulary)
Paxil CR (Nonformulary)*
Pexeva (Nonformulary)*
Prozac Weekly (Nonformulary)*
Wellbutrin XL (Nonformulary)*
Antidiabetics
Actoplus Met (Nonformulary)*
Avandamet (Nonformulary)*
Byetta (Nonformulary)*
Duetact (Nonformulary)*
Antihypertensives
Atacand (Nonformulary)*
Avalide (Nonformulary)*
Avapro (Nonformulary)*
Diovan HCT (Nonformulary)*
Mavik (Nonformulary)
Micardis, HCT (Nonformulary)*
Lipotropics
Advicor (Nonformulary)*
Altoprev (Nonformulary)*
Caduet (Nonformulary)*
Crestor*
Lescol, XL (Nonformulary)*
Lipitor (Nonformulary)*
Vytorin (Nonformulary)*
Oxytrol (Nonformulary)
This does not apply to BCN Advantage members.
*Prior Authorization or Step Therapy may also be required.
Please refer to BCN's Quality Interchange Program available on the web at
www.bcbsm.com/providers/physicians/physicians_rx_bcn.shtml
90-Day at Retail program is now available. Commercial members may receive a 90-day supply of most maintenance medications at their
local pharmacy for only 2 copays (provided they have received a minimum 28-day supply prior to filling the 90-day).
Blue Care Network - January 2007
Quantity Restrictions
Anti-Infectives
Limit per Rx
Testosterone Replacement
Cipro XR (Nonformulary)*
Proquin XR (Nonformulary)*
Androgel Gel Pkt (Nonformulary)
Androgel Pump (Nonformulary)
Erectile Dysfunction Drugs
Xifaxan (Nonformulary)
Anti-Emetic Products
Limit per Rx
Edex (Nonformulary)*
Anzemet 100mg (Nonformulary)
Levitra (Nonformulary)*
Gastrointestinal
Amitiza (Nonformulary)*
Lotronex (Nonformulary)*
Zegerid (Nonformulary)*
Antifungals
Zelnorm (Nonformulary)*
Long-Acting Narcotics
Avinza (Nonformulary)
Anti-Migraine Products
Limit per Rx
Amerge (Nonformulary)
Fentora (Nonformulary)
Axert (Nonformulary)
Opana ER (Nonformulary)
Celebrex (Nonformulary)*
Frova (Nonformulary)
Osteoporosis
Boniva 150mg (Nonformulary)
Relpax (Nonformulary)
Daytrana (Nonformulary)
Antivirals
Humira (Nonformulary)*
Halflytely (Nonformulary)
Kineret (Nonformulary)*
Lyrica (Nonformulary)*
Neulasta (Nonformulary)
Estrogens/Combinations
Revlimid (Nonformulary)*
Pulmonary
Climara Pro (Nonformulary)
Combipatch (Nonformulary)
Smoking Cessation Products
Limit per 360 days
Chantix (Nonformulary)*
(Nonformulary)*
Femring (Nonformulary)
Menostar (Nonformulary)
Weight Reduction Products
Limit per Lifetime
Nuvaring (Nonformulary)
Meridia (Nonformulary)*
Seasonique (Nonformulary)
Tenuate (g)*
Xenical (Nonformulary)*
This does not apply to BCN Advantage members.
*Prior Authorization or Step Therapy may also be required.
Please refer to BCN's Quality Interchange Program available on the web at www.bcbsm.com/providers/physicians/physicians_rx_bcn.shtml

Source: http://www.mednetone.com/downloads/2007_Quantity_limits.pdf