Microsoft word - gp49484.doc

2009 ASO CVSCaremark
Principal Life
Prior Authorization and
Des Moines, IA 50392-0002 Insurance Company Dispensing Limitation List
The following drugs have a Dispensing Limitation (quantity limit per 30 days unless otherwise specified)
Prescription Drug
Quantity Limits
Comments
Limitation applies to drugs either singularly or in combination Limitation applies to drugs either singularly or in combination Limitation applies to drugs either singularly or in combination Limitation applies to drugs either singularly or in combination Limitation applies to drugs either singularly or in combination Limitation applies to drugs either singularly or in combination Limitation applies to drugs either singularly or in combination Limitation applies to drugs either singularly or in combination Limitation applies to drugs either singularly or in combination Limitation applies to drugs either singularly or in combination Limitation applies to drugs either singularly or in combination Prescription Drug
Quantity Limits
Comments
Prior Authorization Drugs
Acne Agents for individuals 31 years of age and older
Actinic Kerasotes (Solaraze)
Antihyperglycemic (Symlin, Byetta) for individuals 18 years of age and older
Benign Prostatic Hypertrophy (Avodart, Proscar, finasteride)
Blood Modifiers (Aranesp, Epogen, Leukine, Neulasta, Neupogen, Procrit) – Specialty Rx Benefit
Crohne’s Disease (Cimzia) – Speciality Rx Benefit
Erectile Dysfunction (Viagra, Cialis, Levitra) for males through the age of 49 years
Growth Hormones - Specialty Rx Benefit
Hepatitis C (Infergen, Intron A, Pegasys, Peg-Intron, Redipen, Rebetron, Roferon-A) - Specialty Rx Benefit
Irritable Bowel Syndrome (Lotronex, Zelnorm)
IVIG Medications – Specialty Rx Benefit
Lupron, Lupron Depot Ped, leuprolide acetate - for diagnosis other than infertility - Specialty Rx Benefit
Miscellaneous (Actimmune, Alferon N, Botox, Forteo, Myobloc, Prialt, Progesterone in Oil, Synagis, Viadur,
Xolair) – Specialty Rx Benefit
Multiple Sclerosis (Avonex, Betaseron, Copaxone, Novantrone, Rebif, Tysabri, mitoxantrone) – Specialty Rx Benefit
Metabolic Modifier-(Kuvan)-Specialty Rx Benefit
Narcolepsy (Provigil)
Narcotic Analgesics (Actiq, fentanyl citrate, Fentora)
Oncology (Arimidex, Aromasin, Femara, Gleevac, Iressa, Nexavar, Revlimid, Sprycel, Sutent, Tarceva, Temordar,
Tykerb, Xeloda, Zolinza)
Oncology (Rituxan, Tasigna, Trelstar) – Specialty Rx Benefit
Osteo-Arthritis (Euflexxa, Hyalgan, Orthovisc, Supartz, Synvisc) – Specialty Rx Benefit
Other (Anabolic Steroids (oral only), Progesterone, Micronized (Crinone and Prochieve), Testosterone (Androgel)
Psoriasis (Amevive, Raptiva) – Specialty Rx Benefit
Pulmonary Arterial Hypertension (Revatio all Genders, Viagra Females only)
Rheumatoid Arthritis (Arava, leflunomide)
Rheumatology (Enbrel, Humira, Kineret, Orencia, Remicade) – Specialty Rx Benefit
Secondary Hyperparathyroidism and Hypercalcemia (Sensipar)
Transplant/Anti-Rejection (Cellcept, Myfortic)
Additional drugs may be added to the prior authorization or quantity limit list throughout the year. Your specific benefit
design may not cover certain drugs, even though they appear on this list.
This document is a summary reference and may not necessarily reflect all coverage and exclusions of the plan benefit
system. Please contact your account team for any questions.
Prior Authorization Process
For the medications on this form that indicate a prior authorization is required, please follow the process below.
1. Bring your prescription to a pharmacist.
2. If not approved, the pharmacist will receive a prompt stating that the physician must contact or call 888-413-2723 for
3. The pharmacist should advise the member to have their physician call the number given above. 4. This means that either your doctor will have to call the number or FAX a letter of medical necessity to CVSCaremark.
Physician prior authorization number 888-413-2723 Physician prior authorization FAX number 888-836-0730 5. CVSCaremark will evaluate the information received based on our internally developed clinical criteria. The decision will be an approval, denial, or review for more information. Approval
After a claim is approved, an override is applied so that the claim will process electronically at the pharmacy and a letter
will be sent to the member and the physician indicating the approval and the time period it is valid for.
Denial
If the medication is denied, then a letter is sent to both the physician and the member. The denial letter will outline
directions on how to appeal the decision.
Missing Information
If more information is required, the physician’s office will be contacted. Once the physician’s office provides
CVSCaremark with the required information then a review will be completed within 24 – 48 hours.

Source: https://www.wvwc.edu/offices/hr/pdf/caremark/GP49484.pdf