The Pharmaceutical Utilization Management (UM) Programs help ensure access to medically necessary and appropriate, cost-effective drug therapy. Horizon Blue Cross Blue Shield of New Jersey uses the following Pharmaceutical Utilization Management Programs.

Please click on each title to see a short description of the program.

• Medical Necessity Determination
  • Drug Dispensing Limitations
  • Drug Utilization Review (DUR)
  • Prior Authorization (PA)
  • Maintenance Drug List
• Specialty Pharmaceutical Management

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Medical Necessity Determination
All medications are subject to Medical Necessity review. We focus our reviews on those drugs that have a high potential for inappropriate use; high-cost medications; those that have narrowly defined, FDA-approved indications; and medications that have a significant interaction risk if taken with other agents. Medical Necessity criteria and guidelines are established and approved by our Pharmacy and Therapeutics (P&T) Committee and Quality Improvement Committee, both consisting of practicing physicians and pharmacists. These external oversight committees assure that our Medical Necessity criteria and guidelines reflect community prescribing standards for the appropriate medication prescribed for members.

Drug Dispensing Limitations, Drug Utilization Review (DUR), and Prior Authorization (PA) are the three programs that make up Medical Necessity determination.

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Drug Dispensing Limitations
Certain prescription medications have specific dispensing limitations for quantity, age, gender, and maximum dose. To arrive at these quantity or safety limits, Horizon BCBSNJ follows recommendations by the federal Food and Drug Administration (FDA), coupled with our analysis of prescription dispensing trends and standard clinical guidelines. These dispensing limitations are drug specific and designed to provide a safe and effective amount of medication to the member.

The following medications are subject to dispensing limitations. (The list is subject to change and will be periodically updated.)

DISPENSING LIMITS DRUG LIST

Limits will apply to drugs listed below, as well as the generic equivalents.

Drug Name

Accolate

Aciphex

Actimmune injection

Actiq

Actonel

Actonel with CA

Adderall XR

Advair Diskus

Advair HFA

Aerobid

Aerobid M

Afinitor

Alinia

Allegra Suspension

Allegra

Allegra-D

Allegra ODT

Alora

Alvesco

Ambien

Ambien CR

Amerge

Amitiza

Amrix

Androderm

Androgel

Anzemet

Apokyn

Aranesp and Aranesp Albumin Free

Aricept

Arixtra

Asmanex twisthaler

Astelin and Astepro (based on new formulation of 200 metered sprays in 30ml)

Atrovent

Atrovent solution

Avelox ABC

Avelox tablets

Avinza

Avonex injection

Axert

Azilect

Azmacort

Beconase AQ

Betaseron injection

Biaxin

Biaxin XL

Boniva

Bravelle vials

Brovana

Butorphanol tartrate

Byetta inj pen

Bystolic

Caduet

Catapres-TTS

Celebrex

Cesamet

Cetrotide kit

Chantix

Cimizia

Cipro XR

Clarinex

Clarinex syrup

Clarinex-D 12 hour

Clarinex-D 24 hour

Climara

Climara Pro

Clomid / Serophene

Cognex

Combipatch

Combivent

Concerta

Copaxone kit

Copegus tablets

Cromolyn Sodium

Darvocet

Daytrana

Delatestryl 1ml syringe(testosterone enanthate (in oil))

Delatestryl 5ml vial(testosterone enanthate (in oil))

Depo Provera

Depo-testosterone 10ml vial (testosterone cypionate (in oil))

Depo-testosterone 1ml vial (testosterone cypionate (in oil))

Detrol

Detrol LA

Dilaudid (including generic hydromorphone)

Ditropan (including generic oxybutynin)

Ditropan XL

Divigel

Dostinex

Duragesic

Elestrin

Eligard injection

Emend

Emend therapy pack

Emsam

Enablex

Enbrel injection and SureClick Injection

Enbrel injection

Epipen

Epipen-JR

Epogen injection

Esclim

Estraderm

Estring

Estrogel

Evamist

Exelon

Exelon syrup

Exelon patch

Exubera Kit

Exubera Combination Pack 12

Exubera Combination Pack 15

Exubera Chamber and Release Unit

Factive

Femring

Fentora

Fexmid

Fioricet

Fioricet w/Codeine

Fiorinal capsule

Fiorinal w/Codeine

Flector

Flexeril

Flonase

Flovent/Flovent HFA

Flovent Diskus

Flovent Rotadisk

Flunisolide nasal

Focalin XR

Follistim AQ injection

Foradil

Forteo injection

Fosamax

Fosamax oral solution

Fosamax Plus D

Fragmin

Frova

Fuzeon injection kit

Ganirelix Acetate

Gleevec tablets

Gonal-F injection

Helidac

Humira injection and Humira Pen Injection

Humira injection Crohn's Disease Starter Package

Humira injection Psoriasis Starter Package

Imitrex

Infergen injection

Innohep

Intal inhaler

Intal solution

Ipratropium Bromide solution

Iressa tablets

Isentress

Istalol

Januvia

Kadian

Kapidex

Ketek

Ketorolac

Kineret injection

Kytril

Lamisil tablet

Lamisil granules packet

Lariam

Letairis

Leukine

Levaquin

Levaquin LEVA-PAK

Liquadd

Lorcet

Lorcet-HD

Lortab

Lortab Elixir

Lovenox

Lumigan

Lunesta

Lupron 2 week

Lupron Depot

Lupron Depot-ped

Luveris

Magnacet

Maxair Autohaler

Maxalt/Maxalt MLT

Maxaquin

Menopur

Menostar

Mepron

Meridia

Metadate CD

Metadate ER

Methylin ER

Migranal

Mobic

MS Contin

MSIR solution

MSIR tablets

Namenda

Nasacort AQ

Nasarel

Nasonex

Neulasta injection

Neumega injection

Neupogen injection

Neupro

Nexavar

Nexium

Novarel vials

Noxafil Oral Suspension

Nuvaring

Nuvigil

Omnaris

Opana

Opana ER

Optivar

Oramorph SR

Ortho Evra

Ovidrel vials

Oxycodone Immediate Release

Oxycodone oral solution

Oxycontin

Oxydose

Oxyfast

Oxytrol

Patanol

Patanase

Pegasys injection

Peg-intron injection

Percocet

Perforomist

Plenaxis

Pravigard PAC

Pregnyl vials

Prevacid

Prevpac

Priftin

Prilosec

Procrit injection

Promacta

Protonix

Provigil

Prozac weekly

Pulmicort respules

Pulmicort Turbuhaler

Pulmicort Flexhaler

Pulmozyme solution

Pylera

Qvar

Ranexa

Raptiva kit

Razadyne/Reminyl

Razadyne ER

Razadyne oral solution

Rebetol capsules

Rebetol solution

Rebetron kit

Rebif injection

Rebif titration pack

Regranex

Relenza

Relpax

Repronex vials

Revatio

Revlimid

Rhinocort AQ

Ribasphere/Ribatab

Ribasphere/Ribavirin

Ribatab

Ribavirin

Ritalin LA

Ritalin SR

Rozerem

Sanctura

Sanctura XR

Sancuso

Sandostatin

Sandostatin LAR

Selzentry

Serevent

Serevent Diskus

Serostim injection

Simponi

Singulair

Skelaxin

Soma

Soma compound

Soma compound w/Codeine

Somatuline Depot

Somavert

Sonata

Spiriva

Sprycel

Stadol NS

Strattera

Striant

Suboxone

Subutex

Supprelin LA

Sutent

Symbicort

Symlin

Symlin Pen

Tamiflu

Tarceva

Tasigna

Tekturna

Tekturna HCT

Temodar capsules

Tequin tablets

Tequin teq-paq

Tequin

Testim

Thalomid capsules

Tilade

Tobi nebulizer (vials)

Toradol

Toviaz ER

Tracleer tablets

Transderm-scop

Travatan / Travatan Z

Trelstar depot

Trelstar la injection

Treximet

Tylenol w/codeine elixir

Tylenol w/codeine tablets

Tyzeka

Ultracet

Ultram

Ultram ER

Urispas (including generic flavoxate)

Vantas

Veramyst

Vesicare

Viadur implant

Vicodin

Vivelle

Vivelle-DOT

Vyvanse

Xalatan

Xeloda tablets

Xeloda tablets

Xenazine

Xenical

Xyrem oral soln

Xyzal

Zaditor

Zavesca

Zegerid (Omeprazole powder)

Zemplar

Zithromax

Zmax

Zofran

Zofran/Zofran ODT

Zofran oral solution

Zomig/Zomig ZMT

Zoladex implant

Zolinza

Zorbtive

Zyflo/Zyflo CR

AGE LIMITS DRUG LIST

Limits will apply to drugs listed below, as well as the generic equivalents.

Alinia

Benzodiazepines (including estazolam, quazepam, temazepam, triazolam)

Benzodiazepine (flurazepam)

Elidel

Exjade

Femara

Growth Hormones (including Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Tev-tropin)

Growth Hormones (including Serostim and Zorbtive)

Hypnotics (including Ambien, Lunesta, Sonata, and Rozerem)

Infertility Medications (including Clomid, Gonal F, Follistim, Bravelle, Ovidrel, Novarel, Pregnyl, Profasi HP, Chorionic Gonadotropin (generic and brands), Luveris, Repronex, Menopur)

Ketek

Lupron (leuprolide acetate)

Mecasermin rinfabate (including Increlex and Iplex)

Phenergan (promethazine)

Protopic

Rapitiva

Relenza

Tamoxifen

Tindamax

Tussionex and Tussionex Pennkinetic Extended

Vanos

Viagra/Levitra/Cialis

Xifaxan

Zyflo

Zyrtec syrup

GENDER LIMITS DRUG LIST

Limits will apply to drugs listed below, as well as the generic equivalents.

Androderm

Androgel

Arimidex

Caverject

Cialis

Delatestryl

Depo-testosterone

Edex

Estrogen (oral contraceptives, estrogen combinations)

Femara

Levitra

Lotronex

Muse

Striant

Tamoxifen

Testim

Testoderm

Testopel

Testosterone Cypionate (all dosage forms available)

Testosterone Enanthate

Viagra

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Drug Utilization Review (DUR)
Since a member can be seen by different doctors and obtain medication through a variety of pharmacies, DUR edits help prevent potential drug interactions. Our online claims processing computer system allows immediate review and verification of eligibility, prescription drug coverage, drug-to-drug interactions, and restrictions. We provide written reports to all of the member's treating physicians to fully inform them of the activities of other prescribers.

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Prior Authorization (PA)
PA ensures appropriate utilization of certain drugs, promotes treatment or step-therapy protocols, actively manages drugs with serious side effects, and positively influences the process of managing drug costs.

Medications that have medical utility for only a select group of patients require PA before coverage is approved. Specific guidelines, developed and approved by practicing physicians and pharmacists from Horizon BCBSNJ's P&T Committee, have to be met for certain drugs to be approved and covered under your prescription drug benefits. The P&T Committee establishes PA criteria after evaluating medical literature, physician opinion, and FDA-approved labeling information. If the PA is approved, you can obtain the drug. Your copayment is determined by your prescription drug benefit. If you do not meet the PA requirements, you may still purchase the drug, but the cost will not be reimbursed by your health plan.

The following medications are subject to PA criteria. (The list is subject to change and will be periodically updated.)

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Maintenance Drug List
Certain prescription medications are classified as maintenance drugs. A maintenance drug is prescribed for chronic conditions and should be taken on a regular or long-term basis.

The following list includes 20 of the most common maintenance drugs in each drug category. This list is subject to change and will be updated periodically.

Maintenance Drug List
Limits will apply to drugs listed below, as well as the generic equivalents
Drug Category	Drug Name
ANTINEOPLASTICS	TAMOXIFEN CITRATE
	NOLVADEX
CARDIOVASCULAR	LIPITOR
	TOPROL XL
	NORVASC
	ZOCOR
	HYDROCHLOROTHIAZIDE
	ATENOLOL
	FUROSEMIDE
	DIOVAN HCT
	PLAVIX
	ENALAPRIL MALEATE
	ALTACE
	METOPROLOL TARTRATE
	LISINOPRIL
	LOTREL
	DIOVAN
	PRAVACHOL
	ZETIA
	WARFARIN SODIUM
	TRIAMTERENE W/HCTZ
	COZAAR
CNS	ALPRAZOLAM
	ZOLOFT
	WELLBUTRIN XL
	PAXIL CR
	FLUOXETINE HCL
	CLONAZEPAM
	NEURONTIN
	CLONAZEPAM
	LORAZEPAM
	PAROXETINE HCL
	RISPERDAL
	AMITRIPTYLINE HCl
	ZYPREXA
	TRAZODONE HCL
	DILANTIN
	TOPAMAX
	DIAZEPAM
	SEROQUEL
	LAMICTAL
DIABETES/ENDOCRINE	SYNTHROID
	LEVOXYL
	METFORMIN HCL
	PREDNISONE
	FOSAMAX
	AVANDIA
	METHYLPREDNISOLONE
	ACTOS
	LANTUS
	GLIPIZIDE ER
	AMARYL
	LEVOTHYROXINE SODIUM
	ACTONEL
	AVANDAMET
	GLYBURIDE
	METFORMIN HCL ER
	GLUCOPHAGE XR
	HUMULIN N
	GLUCOTROL XL
	GLUCOVANCE
EAR/NOSE/THROAT	FLONASE
	NASONEX
	RHINOCORT AQUA
	NASACORT AQ
	NASAREL
	BECONASE AQ
	FLUNISOLIDE
	RHINOCORT
GASTROENTEROLOGY	ASACOL
	HYOSCYAMINE SULFATE
	PROCHLORPERAZINE MALEATE
	BELLADONNA W/PHENOBARBITAL
	SUCRALFATE
	PENTASA
	CARAFATE
	PAMINE FORTE
	PROMETHAZINE HCL
MISCELLANEOUS	AZATHIOPRINE
	NEORAL
	CELLCEPT
	PROGRAF
	PROGESTERONE
	CYCLOSPORINE
	SANDIMMUNE
	IMURAN
	AZASAN
	ESTRIOL
	MYFORTIC
	CLONIDINE HCL
	KETOPROFEN
	PAPAVERINE HCL
	GENGRAF
OB-GYN	PREMARIN
	MEDROXYPROGESTERONE ACETATE
	PREMPRO
	CLIMARA
	ESTRADIOL
	PROMETRIUM
	VAGIFEM
	NORETHINDRONE ACETATE
	CENESTIN
	ORTHO TRI-CYCLEN LO
	YASMIN 28
	FEMHRT
	LO/OVRAL-28
	VIVELLE-DOT
	ORTHO TRI-CYCLEN
	LOESTRIN FE
	ACTIVELLA
	PREMPHASE
	OVCON-35
	ALESSE-28
OPHTHALMOLOGY	ALPHAGAN P
	COSOPT
	TIMOLOL MALEATE
	TIMOPTIC-XE
	TRUSOPT
	AZOPT
	BETIMOL
	ACETAZOLAMIDE
	PILOCARPINE HCL
	BETOPTIC S
	DIAMOX SEQUELS
	LEVOBUNOLOL HCL
	BETAGAN
	TIMOPTIC
	ALPHAGAN
	BRIMONIDINE TARTRATE
	ISOPTO CARBACHOL
	ISTALOL
	DIPIVEFRIN HCL
	PHOSPHOLINE IODIDE
PAIN MANAGEMENT/MUSCULOSKELETAL	CELEBREX
	MOBIC
	NAPROXEN
	IBUPROFEN
	ALLOPURINOL
	NABUMETONE
	NAPROXEN SODIUM
	INDOMETHACIN
	DICLOFENAC SODIUM
	ARTHROTEC 75
	COLCHICINE
	ETODOLAC
	TIZANIDINE HCL
	ENBREL
	BACLOFEN
	KETOROLAC TROMETHAMINE
	OXAPROZIN
	ARAVA
	RELAFEN
	PIROXICAM
RESPIRATORY	ALBUTEROL
	ADVAIR DISKUS
	ZYRTEC
	SINGULAIR
	COMBIVENT
	ALBUTEROL SULFATE
	FLOVENT
	PROVENTIL HFA
	HYDROXYZINE HCL
	SPIRIVA
	XOPENEX
	PULMICORT
	SEREVENT DISKUS
	PROMETHAZINE HCL
	THEOPHYLLINE ANHYDROUS
	HYDROXYZINE PAMOATE
	MAXAIR AUTOHALER
UROLOGICAL	FLOMAX
	DETROL LA
	DITROPAN XL
	PROSCAR
	UROXATRAL
	AVODART
	OXYBUTYNIN CHLORIDE
	OXYTROL
	DETROL
	URISPAS
VITAMINS/ELECTROLYTES	RENAGEL

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Specialty Pharmaceuticals Program

Members who use specialty pharmaceuticals have unique needs relating to the management of their diseases and the therapies associated with them. Horizon Blue Cross Blue Shield of New Jersey has a program to address these needs.

Specialty Pharmaceuticals

Specialty pharmaceuticals is a class of prescription drugs that are typically produced through biotechnology (sometimes known as biologicals) and require special patient monitoring and handling. Specialty pharmaceuticals also require unique education prior to use.

Specialty Pharmaceutical List

To assist members who are taking a specialty pharmaceutical, Horizon BCBSNJ has contracted with pharmacies that specialize in these therapies. In addition to a high level of service, drug-/disease-specific education and support, these pharmacies provide:

• Personal attention from a pharmacist-led team to provide condition-specific education, medication administration instruction and advice to help manage therapy.
• Claims assistance to help determine individual coverage and file the necessary paperwork.
• Easy access to pharmacists and other health experts 24 hours a day, seven days a week.
• Informative condition-specific materials.
• Easy ordering with a dedicated toll-free number.
• Convenient delivery to the location of choice (e.g., member's home, physician's office, vacation spot, etc.).
• Helpful follow-up care calls to remind members when it's time to refill a prescription, to check on therapy progress and answer any questions members may have.

Horizon BCBSNJ members who use certain specialty pharmaceuticals and want to minimize their cost-sharing by using in-network pharmacies, are required to obtain the prescription drugs from a participating specialty pharmacy listed below.

Please note:

• Other prescription drugs not on the Specialty Pharmaceutical List should still be obtained through participating retail or mail-service pharmacies under your prescription drug plan to obtain in-network benefits.
• Specialty pharmaceuticals may be subject to medical necessity review.
• The list of specialty pharmaceutical drugs may be subject to change and may be updated periodically.

If you are undergoing treatment for infertility, please click here.

If you are a physician and would like more information about our Specialty Pharmaceutical Program for office-based medications, please click here.

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