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Department of Pharmaceutical Programs
arrow Medication Requiring Prior Authorization (PA)
arrow Medications subject to Quantity Restrictions

For Commercial Groups Only
2004

Medication Type of Authorization Authorization Expires: Updated
Amevive (alefacept) Prior authorization required. Documentation of severe plaque psoriasis; failure or contraindication to first line therapies, >10% of body surface area or hands, feet, neck, face, genitalia affected. 12 weeks 12-30-2003
Arixtra (fondaparinux) Quantity restriction:2.5mg syringe - #10/30daysRequires documentation of Medical Necessity for quantity greater than 10 syringes in a 30 day period 1 year 2-27-02
Avonex (interferon beta 1a)
Betaseron (interferon beta 1b)
Copaxone (glatiramer)
Rebif (interferon beta 1a)		 All require high dollar override at pharmacy for prescriptions >$500No PA required 2 years 01-01-98
Bextra (valdecoxib)
Celebrex (celecoxib)
Vioxx (rofecoxib)		 Requires diagnosis of OA- (715) or RA- (714) and patients must meet two of the following criteria: Documented hx of peptic ulcer; Previous hx of NSAID induced gastropathy; Current use of a PPI, H2A, Cytotec; Additional risk factors; >Age 65; Corticosteroid therapy; Coumadin (warfarin) use; <65; Must have tried and failed tx with 2 non-specific NSAIDS, i.e.: nabumetone, etodolac. 2 years 03-25-02
Eligard (leuprolide) Requires confirmation of diagnosis. 1 year 10-22-02
Enbrel (etanercept)
Kineret (anakinra)
Humira (adalimumab)		 Requires diagnosis of RA-(714) JRA-(714.31-714.33) or Psoriatic-(696.0). Must have tried and failed one or more DMARD treatments: MTX, Plaquenil, Gold Compounds, other.
Continued coverage requires submission of:
1. Physician global assessment or equivalent assessment of symptom improvement,
2. Baseline and post-treatment CRP or ESR lab 		Initial 3 months
Then 1 year		 2-28-02
Gleevec (imatinab)

CML, GI stromal tumors. Please submit diagnosis, CML phase, failure of Interferon.
Subsequent approval requires submission of CBC

 Initial approval for 6 months, subsequent approval for 1 year 11-01-2001
Gylquin (hydroquinone) Confirmation of non-cosmetic Diagnosis. 1 year 10-22-02
Growth Hormone  Coverage plan specific.  Requires prior authorization. 1 year Contact ODS Pharmacy Customer Service: 503-243-3960
FAX: 503-948-5556		  
Infertility treatment Plan specific 1 year Contact Pharmacy Customer Service for plan specific coverage info
503-243-3960		  
Inspra (eplerenone) Requires confirmation of diagnosis. 2 years 12/31/2003
Anti-fungal:
Lamisil (terbinafine)
Sporanox (itraconazole)		 No PA required, subject to quantity limits.
Lamisil 250mg tab, #56 within 6 months
Sporanox 100mg tab, #84 within 6 months
Oral soln has no restrictions.
Documentation of Medical Necessity for quantity greater than established quantity limits.		 1 year  
Mesnex (mesna) Quantity restriction 400mg – 10/30 days. Documentation of Medical Necessity for quantity greater than 10 tablets in a 30-day period. 1 year 10-22-02
Oxandrin (oxandrolone) Requires confirmation of diagnosis. 1 year 10-22-02
Medications for weight loss:
Meridia (sibutramine)
Xenical (orlistat)		 Plan specific, most plans specifically exclude.
Covered under medical benefit. Contact medical Customer Service for plan specific coverage 		1 year  
Oral influenza meds
Relenza (zanamivir)
Tamiflu (oseltamivir)		 Members are eligible for tx of acute illness or prophylaxis against influenza when the following criteria are met:
Failed tx with Amantadine or rimantadine; Pt has moderate to severe respiratory disease; Pt has significant cardio disease; Pt has diabetes; Pt has renal dysfunction or hemoglobinopathies; Pt is immunocompromised or immunodeficient		 Approval is limited to 7 doses for acute illness and 42 doses for prophylaxis per 6 months 12-05-00
Copegus (ribavirin)
PegIntron/Rebetrol (peginterferon alfa 2b/ribavirin)
Pegasys (peginterferon alfa 2a)
Hepsera (adefovir)		 Requires documentation of medical necessity.
Please provide genotype, Biopsy, HCRNA, History of previous treatment		 Initial approval 3 months 09-01-02
Retin A (tretinoin)
Renova (tretinoin)		 Covered for members less than or equal to 26 yrs old.
Members >26 yrs old require covered diagnosis.
Not covered for cosmetic use. 		Authorization for 1 year 01-01-98
Raptiva (efalizumab) Prior authorization required. Documentation of severe plaque psoriasis; failure or contraindication to first line therapies, >10% of body surface area or hands, feet, neck, face, genitalia affected. Authorization for 1 year 6-1-2004
Triptan Class:
Amerge (naratriptan)		 Quantity Restriction
1mg-18tabs/30 days
2.5mg-9/30 days		 Quantity restrictions are overridden without documentation when requested by a neurologist. Contact ODS Pharmacy Services
FAX 503-948-5556		 02-13-02
Axert (almotriptan) 6.25mg-6/30 days
12.5mg-6/30 days		 Quantity restrictions are overridden without documentation when requested by a neurologist. Contact ODS Pharmacy Services
FAX 503-948-5556		 02-13-02
Frova (frovatriptan) 2.5mg-9/30 days Quantity restrictions are overridden without documentation when requested by a neurologist. Contact ODS Pharmacy Services
FAX 503-948-5556		 02-13-02
Imitrex (sumatriptan) 25mg-36/30days;
50mg-18/30days;
100mg-9/30days;
Injection-6/30days;
Nasal Spray 0.5mg 4 boxes/30days;
Nasal Spray 20mg- 2 boxes/30days		 Quantity restrictions are overridden without documentation when requested by a neurologist. Contact ODS Pharmacy Services
FAX 503-948-5556		 02-13-02
Maxalt (rizatriptan) 5mg-12/30days
10mg-6/30days		 Quantity restrictions are overridden without documentation when requested by a neurologist. Contact ODS Pharmacy Services
FAX 503-948-5556		 02-13-02
Relpax (eletriptan) 20mg-12/30 days
40mg-12/30 days		 Quantity restrictions are overridden without documentation when requested by a neurologist. Contact ODS Pharmacy Services
FAX 503-948-5556		 12-30-2003
Zomig (zolmitriptan) 2.5mg-12/30days
5mg-6/30days		 Quantity restrictions are overridden without documentation when requested by a neurologist. Contact ODS Pharmacy Services
FAX 503-948-5556		 02-13-02
Osteoporosis treatments
(oral, once weekly)
Actonel (risedronate)
Fosamax (alendronate)		 Quantity Limits apply, No Prior authorization required
Actonel 35mg- 4/30 days
Fosamax 35mg-4/30 days
Fosamax 70mg-4/30 days		 Documentation of Medical Necessity for quantity greater than 4 tablets per 30-day period. 06-17-02
Remicade (infliximab)  Not covered in outpatient pharmacy benefit, covered under medical. Prior Authorization Required Contact Medical Intake:
503-243-4496
FAX: 503-243-5105		  
Remodulin (treprostinil) All strengths – 10 vials/30 day supply. Documentation of Medical Necessity for quantity greater than 10 vials in a 30-day period. 6-17-02
Zithromax 500mg (azithromycin) #9/30 days Documentation of Medical Necessity for quantity greater than 9 tablets in a 30-day period. 8-20-02
Forteo (teriparatide) Self injectable drug for severe osteoporosis.  Must have failed a trial of oral agents. 18 months approval only 01-06-2003
Vfend (voriconazole) Covered for treatment of severe fungal infections. Documentation of medical necessity required for coverage. 6 months 03-28-2003
Proton Pump Inhibitors
(PERS ONLY)
Aciphex (rabeprozole)
Nexium (esomeprazole)
Protonix (pantoprazole)
Prevacid (lansoprazole)		 PERS ONLY- Requires trial and failure of OTC Prilosec. Subject to quantity limits,
QD dosing does not require prior authorization. 
BID approved for erosive esophagitis and short-term treatment for healing and symptomatic relief of active duodenal ulcer.		 1 Year 03-28-2003
(PERS ONLY)
Allegra (fexofenadine)
Clarinex (desloratadine)
Zyrtec (cetirizine)  		Oral Non-Sedating Antihistamines require trial and failure of Claritin 2 years 05-16-2003
Fuzeon (enfuvirtide) Confirmation of diagnosis;  Viral load; phenotype/genotype & number of mutations. 6 months – lab results required upon renewal 05-19-2003
Iressa (gefitinib) Confirmation of diagnosis.   05-23-2003
Somavert (pegvisomant) Confirmation of diagnosis and trial and failure of somatropin required for coverage. 1 year 12-31-2003
Xolair (omalizumab) Requires referral of Allergist/Pulmonologist, verification of diagnosis, prior treatment failure, current treatment regimen. 3 month initial approval followed by 1 year authorization 06-23-2003

Updated 08/04/2004