Pharmacy Programs

1. Prior Authorization
2. Age Restriction
3. Step-Therapy
4. Half-Tablet

Prior Authorization

To promote the most appropriate utilization, selected high-risk or high-cost drugs require prior authorization to be eligible for coverage. The prior authorization criteria are approved by the Community Health Plan Pharmacy and Therapeutics Committee.

Current drugs that require prior authorization for all members are:

Afinitor Amitiza Aranesp Arixtra Banzel Enbrel Epogen Exjade Fentanyl Transdermal Gleevec Humira Hycamtin Increlex Kuvan Leukine Lovenox Neupogen

Nexavar Noxafil Omnitrope Pegasys Procrit Promacta Relistor Revatio Selzentry Sporanox Sprycel Sutent Tarceva Tev-Tropin Tykerb Xenazine Zolinza

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Age Restriction

Age restrictions apply to a few drugs. These drugs are covered without prior authorization for specific age ranges, but otherwise require prior authorization.

Budesonide inhalation suspension – covered for members younger than 7 years old.
Retin A, Retin A Micro, tretinoin – covered for members younger than 30 years old.

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Step-Therapy

• Step-therapy is a program that requires one or more “first line” drugs must be tried before the requested drug will be covered.
• The first line drugs have been determined by the Community Health Plan Pharmacy and Therapeutic Committee to be effective in treating the same medical condition as the requested drug.
• If the doctor thinks the requested drug is medically necessary, the doctor must request an exception by contacting 1-888-256-6132. If the request is approved, the drug will then be covered.
  

  Current drugs that require step-therapy for all members are:

  Actonel Actonel with Calcium Actos Advair Cozaar Crestor Diovan Effexor XR Elidel Flomax

  Fosamax Oral Solution Fosamax Plus D Letairis Protopic Singulair Strattera Symbicort Tracleer TriCor Valtrex

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Half-Tablet

The following drugs are on the Community Health Plan half-tablet program. One tablet splitter is covered at $0.00 copay for members using this program. The half-tablet program is a voluntary program. Members and providers can decline the half-tablet program by having the provider call Express Scripts, Inc at 1-888-256-6132.

Drug	Strength Required	Comments
Abilify (aripiprazole)	5 mg 10 mg 15 mg	Use ½ of 10 mg Use ½ of 20 mg Use ½ of 30 mg
citalopram	10 mg 20 mg	Use ½ of 20 mg Use ½ of 40 mg
Crestor (rosuvastatin)	5 mg 10 mg 20 mg	Use ½ of 10 mg Use ½ of 20 mg Use ½ of 40 mg
lisinopril	2.5 mg 5 mg 10 mg 20 mg	Use ½ of 5 mg Use ½ of 10 mg Use ½ of 20 mg Use ½ of 40 mg
nefazodone	50 mg 100 mg	Use ½ of 100 mg Use ½ of 200 mg
paroxetine	10 mg 20 mg	Use ½ of 20 mg Use ½ of 40 mg
risperidone	0.25 mg 0.5 mg 1 mg 2 mg	Use ½ of 0.5 mg Use ½ of 1 mg Use ½ of 2 mg Use ½ of 4 mg
Seroquel (quetiapine)	25 mg 50 mg 100 mg 200 mg	Use ½ of 50 mg Use ½ of 100 mg Use ½ of 200 mg Use ½ of 400 mg
sertraline	25 mg 50 mg	Use ½ of 50 mg Use ½ of 100 mg
simvastatin	5 mg 10 mg 20 mg 40 mg	Use ½ of 10 mg Use ½ of 20 mg Use ½ of 40 mg Use ½ of 80 mg
Valtrex (valacyclovir)	500 mg	Use ½ of 1000 mg
venlafaxine	25 mg 37.5 mg 50 mg	Use ½ of 50 mg Use ½ of 75 mg Use ½ of 100 mg
Zyprexa (olanzapine)	2.5 mg 5 mg 7.5 mg 10 mg	Use ½ of 5 mg Use ½ of 10 mg Use ½ of 15 mg Use ½ of 20 mg

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