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Prior Authorizations and Drugs with Special Limitations

Prior Authorization
Your prescription drug program provides coverage for some drugs only if they are prescribed for certain uses and amounts, so those drugs require prior authorization for coverage. Prior Authorization is handled by the Rational Drug Therapy Program (RDT). If your medication must be authorized, your pharmacist or physician can initiate the review process for you. The prior authorization process is typically resolved over the phone; if done by letter it can take up to two business days. If your medication is not approved for plan coverage, you will have to pay the full cost of the drug.
PEIA will cover, and your pharmacist can dispense, up to a five-day supply of a medication requiring prior authorization for the applicable copayment. This policy applies when your doctor is either unavailable or temporarily unable to complete the prior authorization process promptly. Prior authorizations may be approved retroactively for up to 30 days to allow time for the physician to work with and provide documentation to RDT. If the prior authorization is ultimately approved, your pharmacist will be able to dispense the remainder of the approved amount with no further copayment for that month’s supply if you have already paid the full copayment. All prior authorization requests must be reviewed annually.
The medications listed below require prior authorization:

1.      amphetamines (Adderall XR®, Vyvanse®)
2.      Anabolic Steroids (Anadrol, Oxandrin)
3.      apixaban (Eliquis®)
4.      armodafinil (Nuvigil®)
5.      atomoxetine (Strattera®)
6.      becaplermin (Regranex®)
7.      buprenorphine (Subutex®)
8.      buprenorphine/naloxone (Suboxone®, Bunavail™, Zubsolv®)
9.      Butrans Patch
10.  chenodiol (Chenodal™)*
11.  cinacalcet (Sensipar®)
12.  Compounded Medications
13.  cyclosporine ophthalmic emulsion (Restasis®)
14.  dabigatran etexilate (Pradaxa®)
15.  dextromethorphan/quinidine (Nuedexta™)
16.  diclofenac sodium gel (Solaraze®)
17.  edoxaban tosylate (Savaysa™)
18.  enfuvirtide (Fuzeon®)*
19.  Entresto
20.  fentanyl oral and topical (Abstral®, Actiq®, Duragesic®, Fentora®, Lazanda®,Onsolis® and Subsys™)
21.  linezolid (Zyvox®)
22.  modafinil (Provigil®)
23.  Oral Acne medications (Absorica, Clavaris)
24.  oxycodone hydrochloride (Oxycontin®)
25.  rivaroxaban (Xarelto®)
26.  roflumilast (Daliresp®)
27.  sacrosidase (Sucraid®)
28.  Specialty medications *
29.  stimulants (Concerta®, Focalin XR®, methylphenidate)
30.  tazarotene (Tazorac®)
31.  testosterone products  (oral, topical, injectable products)
32.  tolvaptan (Samsca®)
33.  Topical Antifungals (Jublia, Kerydin)
34.  tretinoin cream (e.g. Retin-A) for individuals 35 years of age or older
35.  vacation supplies of medication for foreign travel (allow 7 days for processing)
36.  vorapaxar (Zontivity®)

*These drugs must be purchased through the Common Specialty Medications Program. See information later in this section.
This list is subject to change during the plan year if circumstances arise which require adjustment. Changes will be communicated to members in writing. The changes will be included in PEIA’s Plan Document, which is filed with the Secretary of State’s office, and will be incorporated into the next edition of the Summary Plan Description.
 
Drugs with Special Limitations
Step Therapy
Step Therapy promotes appropriate utilization of first-line drugs and/or therapeutic categories. Step Therapy requires that participants receive one or more first-line drug(s), as defined by program criteria before prescriptions are covered for second-line drugs in defined cases where a step approach to drug therapy is clinically justified. To promote use of cost-effective, first-line therapy, PEIA uses step therapy in the following therapeutic classes:
1.      AerospanAlvesco
2.      Angiotensin II Receptor Antagonists (Benicar, Benicar HCT, Tekturna, Tekturna HCT, Edarbi, Edarbychlor, Teveten)
3.      Anti-depressants (Pristiq®, Aplenzin®, Khedezla®, Fetzima™, Irenka)
4.      Apidra
5.      Benign Prostatic Hypertrophy (Cardura/XL®, Rapaflo®)
6.      Bisphosphonates (Fosamax Plus D™,. Binosto®)
7.      Cholesterol-lowering medications ( Altoprev®,, Crestor®,  Vytorin®, Livalo™, Liptruzet™)
8.      Dipeptidyl peptidase-4 (DPP-4) Inhibitors (Onglyza®, Kombiglyze™ XR, Juvisync®, Nesina®, Kazano®, Oseni®)
9.      Febuxostat (Uloric®)
10.  Fenofibrates (Triglide®, Lipofen®, Fenoglide®)
11.  Glucagon Peptide 1 Receptor Antagonist (GLP-1): Bydureon, Byetta
12.  Humalog
13.  Humulin
14.  Incruse ELLIPTA
15.  Long-acting Opioids (Avinza™, Embeda™, Exalgo™, Kadian®, MS Contin®, Opana® ER, Oramorph SR™, Nucynta® ER, Zohydro ER)
16.  Lyrica®, Gralise®, Horizant®, Neurontin®
17.  Migraines (Sumavel Dosepro™, Alsuma,  Relpax®, Treximet®)
18.  Nasal Steroids ( Beconase AQ®, Nasonex®,Veramyst®,Omnaris®, Dymista®, Qnasl®, Zetonna®)
19.  non-OneTouch blood glucose test strips
20.  Non-Steroidal Anti-inflammatory Drugs (brand-name NSAID e.g., Cambia®, Flector®, Pennsaid®, Nalfon, Tivorbex, Voltaren Gel®, Zipsor, Zorvolex)
21.  Novolin Reli On
22.  Ophthalmic prostaglandins (Lumigan®, Travatan/Z®, Zioptan®)
23.  Overactive Bladder: (Oxytrol, Toviaz®, Vesicare®, Enablex®, Gelnique®, Myrbetriq®)
24.  Proton Pump Inhibitors (e.g., Dexilant®,  Prilosec/Protonix/Zegerid Powder packets,  compounding kits for PPI suspension formulations)
25.  Sedative Hypnotics (Belsomra,, Rozerem™, Edluar™, Zolpimist™, Silenor®, Intermezzo®)
26.  Selective Serotonin Reuptake Inhibitors (e.g., Pexeva, Viibyrd®, Brintellix®, Brisdelle®)
27.  Sodium Glucose Co-Transporter – 2 Inhibitors (Invokana™, Invokamet™,)
28.  Symbicort
29.  Tetracyclines (e.g., Adoxa®, Doryx®, Oracea®, Solodyn®, Oraxyl®, Vibramycin®)
30.  Topical Acne products, kits and cleansers,
31.  Topical immunomodulators (Elidel®, Protopic®)
32.  Tudorza
33.  Xopenex HFA
This list is subject to change during the plan year, if circumstances arise which require adjustment. Changes will be communicated to members in writing. The changes will be included in PEIA’s Plan Document, which is filed with the Secretary of State’s office, and will be incorporated into the next edition of the Summary Plan Description.
Quantity Limits (QLL)
Under the PEIA PPB Plan Prescription Drug Program, certain drugs have preset coverage limitations (quantity limits). Quantity limits ensure that the quantity of units supplied in each prescription remains consistent with clinical dosing guidelines and PEIA’s benefit design. Quantity limits encourage safe, effective and economic use of drugs and ensure that members receive quality care. If you are taking one of the medications listed below and you need to get more of the medication than the plan allows, ask your pharmacist or doctor to call RDT to discuss your refill options.
1.         Antipsychotic Drugs (Abilify® 30 units, Abilify Discmelt® 60 units, FanaptTM 60 units, Geodon® 60 units, Invega® varies, Risperdal® 60 units, Saphris® 60 units, Seroquel/XR® varies, Zyprexa® 30 units, and Zyprexa Zydis® 30 units, Latuda® 30 units)
2.         Antiemetics:
·         Aloxi® is limited to 1 capsule/vial per 15 days.
·         Anzemet® is limited to 3 tablets per 15 days
·         Akynzeo is limited to 1 capsule per 15 days
·         Cesamet® is limited to 18 capsules per 30 days.
·         Emend® 40 mg is limited to 3 capsule per 6 months.
·         Emend® 80 mg is limited to 2 capsules per 15 days.
·         Emend® 115 mg and 150 mg vial are limited to 1 vial per 15 days.
·         Emend® 125 mg is limited to 1 capsule per 15 days.
·         Emend® Bi-fold Pack is limited to 1 package per 15 days.
·         Emend® Tri-fold Pack is limited to 1 package per 15 days.
·         Kytril® is limited to 6 tablets/1 bottle per 15 days.
·         Sancuso® is limited to 1 patch per 15 days.
·         Zofran® 24 mg is limited to 1 tablet per 15 days.
·         Zofran® 4mg and 8 mg are limited to 12 tablets per 15 days.
·         Zofran® ODT 4mg and 8 mg are limited to 12 tablets per 15 days.
·         Zofran® Solution is limited to 100 ml per 15 days.
·         Zuplenz® is limited to 12 films per 15 days.
 
3.      Abstral®, Actiq®, OnsolisTM, Fentora®, Subsys® Coverage is limited to 90 units per 30 days; Lazanda®. Coverage is limited to 23 units per 30 days.
4.      Buprenorphine/naltrexone containing products (Bunavail, Suboxone®, Subutex® and Zubsolv®) is limited to 24mg in initial 60-day period then 16mg.
5.      Cholesterol Lowering Medications. (Advicor® varies, Caduet® 30 units, Vytorin® 30 units, Altoprev® 30 units, Crestor® 30 units, Lescol® varies, Lipitor® 30 units, Liptruzet® 30 units, lovastatin varies, Mevacor® 30 units, Pravachol® 30 units, pravastatin sodium 30 units, Simcor® 30 units, simvastatin 30 units, Zocor® 30 units and Livalo® 30 units)
6.      Enbrel®. Coverage is limited to 4 syringes or 8 vials per 28 days.
7.      Estrogen patches: Alora®, Estraderm®, Minivelle®, Vivelle/Dot® limit is 8 patches/28 days. Climara/Pro and Menostar® limit is 4 patches per 28 days.
8.      Humira®. Coverage is limited to 2 syringes/pens per 28 days.
9.      Long-acting Opioids (Avinza® 60 units, Kadian® 90 units, MS Contin® 120 units, Opana® ER 90 units, Oramorph® 120 units, Oxycontin® 90 units, Exalgo® 60 units, Embeda® 90 units, Nucynta® ER 60 units)
10.  Lidocaine/Lidocaine topical products is limited to I tube/pack every 25 days
11.  Migraine medications. Coverage is limited to quantities listed below:
Generic name
Brand name
Quantity Level Limit for 28-Day Period
Almotriptan tablets 6.25 mg
Axert®
12 tablets
Almotriptan tablets 12.5 mg
Axert®
12 tablets
Diclofenac potassium, 50 mg powder packet
Cambia™
9 packets
Dihydroergotamine nasal spray vials, 4 mg/mL vial
Migranal®
1 kits = 8 unit dose sprayers
Eletriptan 20 mg, 40 mg
Relpax®
12 tablets
Frovatriptan tablets 2.5 mg
Frova®
18 tablets
Naratriptan tablets 1 mg, 2.5 mg
Amerge®
12 tablets
Rizatriptan tablets 5 mg, 10 mg
Maxalt®
18 tablets
Rizatriptan tablets 5 mg, 10 mg, orally disintegrating tablets
Maxalt-MLT®
18 tablets
Sumatriptan injection pre-filled auto-injectors, 6 mg/0.5 ml
Alsuma®
6 kits (12 syringes)
Sumatriptan injection syringes, 4 mg/0.5 ml and 6 mg/0.5 ml
Imitrex® Statdose System®
6 kits = 12 injections
Sumatriptan injection vials, 4 mg/0.5 ml
Generics
18 vials
Sumatriptan injection vials, 6 mg/0.5 ml
Imitrex®, generics
12 vials
Sumatriptan nasal spray 20 mg
Imitrex®, generics
2 boxes = 12 unit dose spray devices
Sumatriptan nasal spray 5 mg
Imitrex®, generics
4 boxes = 24 unit dose spray devices
Sumatriptan needle-free injection vial 6 mg/0.5 mL
Sumavel™ DosePro™
3 boxes = 18 needle-free devices
Sumatriptan tablets 25 mg, 50 mg, 100 mg
Imitrex®, generics
12 tablets
Sumatriptan (85 mg) and naproxen sodium (500 mg) tablets
TreximetTM
9 tablets
Zolmitriptan nasal spray 5 mg
Zomig®
2 boxes = 12 unit dose spray devices
Zolmitriptan tablets 2.5 mg and 5 mg, orally disintegrating
Zomig-ZMT®
12 tablets
Zolmitriptan tablets 2.5 mg, 5 mg
Zomig®
12 tablets
12.  Multiple Sclerosis: Avonex® 4 units per 30 days, Betaseron®/Extavia 14 or 15 units per 30 days, Copaxone® 1 kit per 30 days, Rebif® 1 pkg/12 syringes per 30 days.
13.  Nuvigil®. Coverage limit varies.
14.  Opioid pain medications have a quantity limit (QL) for all medications in the opioid class.  Additional quantities require Prior Authorization. 
15.  Other Antidepressants (Budeprion SR® 60 units, Budeprion XL® 30 units, Bupropion HCL SR® 60 units, Forfivo® XL 30 units, Wellbutrin SR® 60 units, and Wellbutrin XL® 30 units, Aplenzin® 30 units)
16.  Provigil®. Coverage limit varies.
17.  Sedative Hypnotics (Ambien®, Ambien CR™, Doral®, estazolam, flurazepam, Intermezzo®, Lunesta™, Restoril®, Rozerem™, Sonata®, Edluar™, Silenor®, temazepam, triazolam). Coverage is limited to 15 units per 30 days. Zolpimist™ – coverage is limited to 1 bottle.
18.  Selective Serotonin Reuptake Inhibitors (Celexa® 30 units, citalopram HBR 30 units, fluoxetine HCL varies, fluvoxamine maleate varies, Lexapro® 30 units, Luvox CR® varies, paroxetine HCL® varies, Paxil® varies, Paxil CR® 60 units, Pexeva® varies, Prozac Weekly® 5 units, Sarafem® 30 units, Selfemra™ varies, sertraline HCL® varies, Viibyrd® 30 units, and Zoloft® varies)
19.  Serotonin and Norepinephrine Reuptake Inhibitors (Cymbalta® varies, Effexor® varies, Effexor XR® varies, Pristiq® 30 units, Savella® varies, venlafaxine ER® Varies, Viibryd® 1 pack)
20.  Sprix. Coverage is limited to 5 days of therapy per prescription.
21.  Tamiflu® and Relenza®. Coverage is limited to one course of treatment every 90 days. Additional quantities require prior authorization from RDT.
22.  Toradol. Coverage is limited to 20 tablets per prescription.



Maintenance Medications

You may receive up to a 90-day supply of ONLY maintenance medications.  View the list of Maintenance Medications  by clicking the above link.

 

Common Specialty Medications


All specialty medications require Precertification. The process begins with a call to HealthSmart Specialty Drug Program at 1-888-440-7342. HealthSmart will review the drug for medical necessity, and if approved, will coordinate the purchase through an approved source. Many specialty medications have manufacturer programs which will financially assist patients in the purchase of the medication. PEIA requires that if a financial assistance program is available, you must participate in the program. Specialty drugs have the following key characteristics:

  • Need frequent dosage adjustments
  • Cause more severe side effects than traditional drugs
  • Need special storage, handling and/or administration
  • Have a narrow therapeutic range
  • Require periodic laboratory or diagnostic testing
After you have met your prescription drug deductible, the copayment on these medications will be $50 for any Common Specialty Medications on the WV Preferred Drug List and $100 for any Common Specialty Medications not on the WV Preferred Drug List. Only your actual out-of-pocket payments will count toward your drug deductable and annual out-of-pocket maximum. Amounts discounted off the price by the manufacturer or seller of the specialty medication do not count. These drugs are not available in 90- day supplies. If you are prescribed one of these common specialty medications, call HealthSmart at 1-888-440-7342.
View the list of Common Specialty Medications by clicking the above link.