Horizon Blue Cross Blue Shield of New Jersey - Health Insurance: Medical, Dental, Pharmacy and Life

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Rx Utilization Management Programs

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
Administrative Policy Manual

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 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 are the three programs that make up Medical Necessity determination.

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 are 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	Strength	Dispensing Limit
Accolate	10 mg and 20 mg	180 tablets every 90 days
Aciphex	All strengths	90 tablets/capsules every 90 days Limit also includes all Proton Pump Inhibitors (Nexium, Prevacid, Prilosec, Protonix, Kapidex)
Actimmune injection	2 mmu/0.5	36 vials every 84 days
Actiq	All strengths	120 units every 30 days Limit also includes Fentora and Onsolis
Actonel	35 mg tablets	13 tablets every 90 days
Actonel	30 mg	60 tablets every 365 days
Actonel	5 mg	90 tablets every 90 days
Actonel	75 mg	6 tablets every 84 days
Actonel	150 mg	3 tablets every 84 days
Actonel with CA		84 tablets (3 dispensing packs) every 84 days
Actoplus Met	15 mg/500 mg, 15 mg/850 mg	270 tablets every 90 days
Actoplus Met XR	15 mg/1000 mg	180 tablets every 90 days
Actoplus Met XR	30 mg/1000 mg	90 tablets every 90 days
Actos	15 mg, 30 mg, 45 mg	90 tablets every 90 days
Acuvail	0.45% ophth solution	30 vials of 0.4 ml (12 ml) per 1 year
Adcirca	20 mg	180 tablets every 90 days
Adderall XR	5 mg, 10 mg, 15 mg	30 tablets every 30 days
Adderall XR	20 mg, 25 mg, 30 mg	60 tablets every 30 days
Advair Diskus	All strengths	180 units (3 packs of 60 blisters or 6 packs of 28 blisters) every 90 days
Advair HFA	All strengths	36 grams ( 3 inhalers of 12 grams) every 90 days
Aerobid	All strengths	63 gm (9 inhalers of 7gm) every 90 days
Aerobid M	All strengths	63 gm (9 inhalers of 7gm) every 90 days
Afinitor	5 mg and 10 mg	90 tablets every 90 days
Aggrenox	200 mg	180 capsules every 90 days
Agrylin (including generic anagrelide hydrochloride)	0.5 mg	360 capsules every 90 days
Agrylin (including generic anagrelide hydrochloride)	1 mg	900 capsules every 90 days
Alinia	100 mg / 5 ml suspension	60 ml (1 bottle of 60 ml) every 30 days
Alinia	500 mg tablet	6 tablets every 30 days
Allerga Suspension	30 mg/ 5 mL	900 ml every 90 days
Allegra	60 mg	180 capsules every 90 days
Allegra	180 mg	90 tablets every 90 days
Allegra	30 mg	180 tablets every 90 days
Allegra�D	120/60	180 tablets every 90 days
Allegra-D	180/240	90 tablets every 90 days
Allegra ODT	30 mg	360 tablets every 90 days
Alora	0.025 mg, 0.05 mg, 0.075 mg, 0.1 mg	26 patches every 90 days
Alvesco	80 mcg and 160 mcg	42 grams(6 inhalers of 6.1 grams each) every 90 days
Amaryl/Glimepiride	1 mg	720 tablets every 90 days
Amaryl/Glimepiride	2 mg	360 tablets every 90 days
Amaryl/Glimepiride	3 mg	180 tablets every 90 days
Ambien	All strengths	90 tablets every 90 days Limit also includes Ambien CR, Lunesta, and Sonata
Ambien CR	All strengths	90 tablets every 90 days Limit also includes Ambien, Lunesta, and Sonata
Amerge	All strengths and dosage forms	54 tablets/ml/units every 90 days Limit also includes all oral and nasal spray formulations of TRIPTANs (Axert, Frova, Imitrex, Maxalt, Maxalt MLT, Relpax, Treximet, Zomig, Zomig ZMT)
Amitiza	8 mcg and 24 mcg	180 capsules every 90 days
Amrix	15 mg and 30 mg	90 capsules every 90 days
Androderm	All strengths	90 patches every 90 days
Androgel	All strengths	900 gm every 90 days
Anzemet	50 mg	20 tablets per prescription
Anzemet	100 mg	10 tablets per prescription
Apokyn	30 mg / 3 ml	180 ml every 90 days
Aranesp and Aranesp Albumin Free	All strengths except 500 mcg	6 injections (6 ml) every 84 days
Aranesp and Aranesp Albumin Free	500 mcg	4 injections (4 ml) every 84 days
Aricept	All strengths	90 tablets every 90 days
Arixtra	All strengths	90 injections every 90 days
Asmanex twisthaler	110 mcg	3 inhalers of 0.135 gm / inhaler every 90 days
Asmanex twisthaler	220 mcg	3 inhalers of 0.24 gm / inhaler every 90 days
Astelin and Astepro (based on new formulation of 200 metered sprays in 30ml)	All strengths	120 ml (4 bottles of 30 ml) every 90 days
Atrovent	18 mcg	90 gm (6 inhalers of 15 gm) every 90 days
Atrovent solution	0.02% solution for inhalation	900 ml (6 boxes of 60 units of 2.5 ml) every 90 days
Avandamet	2 mg/500 mg	90 tablets every 90 days
Avandamet	2 mg/1000 mg, 4 mg/500 mg, 4 mg/1000 mg	180 tablets every 90 days
Avandaryl	4 mg/2 mg	180 tablets every 90 days
Avandaryl	4 mg/4 mg, 8 mg/2 mg, 8 mg/4 mg	90 tablets every 90 days
Avandia	2 mg, 4 mg, and 8 mg	90 tablets every 90 days
Avelox ABC	400 mg	15 tablets per prescription
Avelox tablets	400 mg	15 tablets per prescription
Avinza	All strengths	30 capsules every 30 days
Avonex injection	30 mcg	12 injections every 84 days
Axert	All strengths and dosage forms	54 tablets/ml/units every 90 days Limit also includes all oral and nasal spray formulations of TRIPTANs (Amerge, Frova, Imitrex, Maxalt, Maxalt MLT, Relpax, Treximet, Zomig, Zomig ZMT)
Azilect	0.5 mg and 1 mg	90 tablets every 90 days
Azmacort	All strengths	120 gm (6 inhalers of 20 gm) every 90 days
Beconase AQ	All strengths	100 gm (4 bottles of 25 gm) every 90 days
Betaseron injection	0.3 mg	45 injections every 90 days
Biaxin	250 mg	28 tablets per prescription
Biaxin	500 mg	28 tablets per prescription
Biaxin XL	500 mg	28 tablets per prescription
Boniva	150 mg	3 tablets every 84 days
Boniva	2.5 mg	90 tablets every 90 days
Bravelle vials	75 IU	4,500 IU equivalent every 30 days
Brovana	15 mcg/2 ml	360 ml (180 units of 2 ml) every 90 days
Butorphanol tartrate	10 mg/ml nasal spray	36 ml (12 bottles of 3 ml) every 90 days
Byetta inj pen	5 mcg	3 pens of 1.2 ml (6 ml) every 90 days
Byetta inj pen	10 mcg / 0.04 ml	3 pens of 2.4 ml (9 ml) every 90 days
Bystolic	2.5 mg, 5 mg, 10 mg	360 tablets every 90 days
Caduet	All strengths	90 tablets every 90 days
Catapres-TTS	TTS-1	13 patches every 90 days
Catapres-TTS	TTS-2	13 patches every 90 days
Catapres-TTS	TTS-3	13 patches every 90 days
Celebrex	50 mg	180 capsules every 90 days
Celebrex	400 mg	90 capsules every 90 days
Celebrex	100 mg	180 capsules every 90 days
Celebrex	200 mg	180 capsules every 90 days
Cesamet	1 mg	20 capsules every 30 days
Cetrotide kit	3 mg	1 kit every 30 days
Cetrotide kit	0.25 mg	5 injections every 30 days
Chantix	All Strengths	56 tablets every 28 days
Chlorpropamide	100 mg	720 tablets every 90 days
Chlorpropamide	200 mg	270 tablets every 90 days
Cimzia	200 mg/ml syringe	6 injections every 84 days
Cipro XR	500 mg, 1000 mg	15 tablets per prescription
Clarinex	5 mg (includes Reditab)	90 tablets every 90 days
Clarinex syrup	0.5 mg/ml	900 ml every 90 days
Clarinex-D 12 hour	2.5-120 mg	180 tablets every 90 days
Clarinex-D 24 hour	5-240 mg	90 tablets every 90 days
Climara	0.025 mg, 0.0375 mg, 0.05 mg, 0.06 mg, 0.075 mg, 0.1 mg	13 patches every 90 days
Climara Pro	4.40 mg/1.39 mg	13 patches every 90 days
Clomid / Serophene	50 mg	10 tablets every 30 days (30 tablets every 365 days)
Cognex	All strengths	360 capsules every 90 days
Combipatch	0.05 mg / 0.14 mg and 0.05 mg / 0.25 mg	26 patches every 90 days
Combivent	All strengths	90 gm (6 inhalers of 15 gm) every 90 days
Concerta	18 mg, 27 mg, 54 mg	30 tablets every 30 days
Concerta	36 mg	60 tablets every 30 days
Copaxone kit	20 mg/ml	3 kits / 90 injections every 90 days
Copegus tablets	200 mg	588 tablets every 84 days Limit also includes Rebetol and Ribasphere
Cromolyn Sodium	20 mg / 2 ml solution for inhalation	720ml (3 boxes of 120 vials of 2 ml) every 90 days
Darvocet	All strengths	540 tablets every 90 days
Daytrana	All strengths	90 patches every 90 days
Delatestryl 1ml syringe(testosterone enanthate (in oil))	200 mg/ml	10 ml (10 syringes) every 90 days
Delatestryl 5ml vial(testosterone enanthate (in oil))	200 mg/ml	10 ml (2 vials) every 90 days
Depo Provera	150 mg/ml	1 injection every 90 days
Depo-testosterone 10ml vial (testosterone cypionate (in oil))	200 mg/ml	10 ml (1 vial) every 90 days
Depo-testosterone 10ml vial (testosterone cypionate (in oil))	100 mg/ml	40 ml (4 vials) every 90 days
Depo-testosterone 1ml vial (testosterone cypionate (in oil))	200 mg/ml	10 ml (10 vials) every 90 days
Detrol	1 mg and 2 mg	180 tablets every 90 days
Detrol LA	2 mg and 4 mg	90 capsules every 90 days
Diabeta/Micronase/Glyburide	1.25 mg, 2.5 mg	720 tablets every 90 days
Diabeta/Micronase/Glyburide	5 mg	360 tablets every 90 days
Dilaudid (including generic hydromorphone)	1 mg/1 mL oral solution	1200 ml every 30 days
Dilaudid (including generic hydromorphone)	2 mg, 4 mg, and 8 mg	180 tablets every 30 days
Ditropan (including generic oxybutynin)	5 mg	360 tablets every 90 days
Ditropan (including generic oxybutynin)	5 mg syrup (5 mg/5 mL)	1800 ml every 90 days
Ditropan XL	10 mg and 15 mg	180 tablets every 90 days
Ditropan XL	5 mg	90 tablets every 90 days
Divigel	0.25 mg, 0.5 mg, 1 mg	90 packets every 90 days
Dostinex	0.5 mg tablets	52 tablets every 90 days
Duetact	30 mg/2 mg, 30 mg/4 mg	90 tablets every 90 days
Duragesic	All strengths	15 patches every 30 days
Effient	5 mg and 10 mg	90 tablets every 90 days
Elestrin	0.06% gel	144 grams (1 pump) every 90 days
Eligard injection	30 mg	1 injection per prescription / 3 prescriptions every 365 days
Eligard injection	7.5 mg	1 injection per prescription / 12 prescriptions every 365 days
Eligard injection	22.5 mg	1 injection per prescription / 4 prescriptions every 365 days
Eligard injection	45 mg	1 injection per prescription / 2 prescriptions every 365 days
Embeda	All strengths	60 capsules every 30 days
Emend	125 mg	2 capsules per prescription
Emend	80 mg	4 capsules per prescription
Emend	40 mg	4 capsules per prescription
Emend therapy pack	80 mg / 125 mg	6 capsules or 2 packs per prescription
Emsam	6 mg/24 hour, 9 mg/24 hour, and 12 mg/24 hours	90 patches every 90 days
Enablex	7.5 mg and 15 mg	90 tablets every 90 days
Enbrel injection and SureClick Injection	50 mg	12 injections every 84 days
Enbrel injection	25 mg	24 injections every 84 days
Epipen	0.3 mg syr	2 pens of 0.3 ml per prescription
Epipen-JR	0.15 mg syr	2 pens of 0.3 ml per prescription
Epogen injection	All except 40,000 unit vial	36 injections every 84 days
Epogen injection	40,000 unit vial	18 injections every 84 days
Esclim	0.025 mg, 0.0375 mg, 0.05 mg, 0.075 mg, 0.1 mg	26 patches every 90 days
Estraderm	0.05 mg, 0.1 mg	26 patches every 90 days
Estring		1 ring every 90 days
Estrogel	0.06%	558 gm (6 pumps of 93 gm) every 365 days (1 year)
Evamist	1.53 mg/spray	49 ml (6 pumps) every 90 days
Exelon	All strengths	180 capsules every 90 days
Exelon syrup	2 mg/ml	540 ml every 90 days
Exelon patch	4.6 mg/24 hours, 9.5 mg/24 hours	90 patches every 90 days
Extavia	0.3 mg	45 injections every 90 days
Exubera Kit		1 kit per prescription / 1 prescription every 365 days
Exubera Combination Pack 12		540 units (3 boxes) every 90 days
Exubera Combination Pack 15		810 units (3 boxes) every 90 days
Exubera Chamber and Release Unit		1 fill per prescription / 1 prescription every 365 days
Factive	320 mg	15 tablets every prescription
Femring		1 ring every 90 days
Fentora	All Strengths	120 tablets every 30 days Limit also include Actiq and Onsolis
Fexmid	7.5 mg	270 tablets every 90 days
Fioricet	325/40/40	540 tablets every 90 days
Fioricet w/Codeine	30/325/40/50	540 capsules every 90 days
Fiorinal capsule	325/40/50	540 capsules every 90 days
Fiorinal w/Codeine	30/325/40/50	540 capsules every 90 days
Flector	1.3% Patches	180 patches every 90 days
Flexeril	All strengths	270 tablets every 90 days
Flonase	All strengths	48 gm (3 bottles of 16 gm) every 90 days
Flovent/Flovent HFA	All strengths	78 gm (6 inhalers of 13 gm [220 mcg/inh]) every 90 days
Flovent Diskus	All strengths	720 units (12 boxes of 60 doses [250 mcg/inh]) every 90 days
Flovent Rotadisk	All strengths	720 units (12 boxes of 60 doses [250 mcg/inh]) every 90 days
Flunisolide nasal	0.03%	200ml (8 bottles of 25ml) every 90 days
Focalin XR	All strengths	30 tablets every 30 days
Follistim AQ injection	All strengths	4,500 IU equivalent every 30 days
Foradil	All strengths	180 units (3 boxes of 60 unit doses) every 90 days
Fortamet	500 mg	360 tablets every 90 days
Fortamet	1000 mg	180 tablets every 90 days
Forteo injection	750 mg / 3 ml	9 ml or 3 injection pens every 84 days
Fosamax	35 mg, 70 mg tablets	13 tablets every 90 days
Fosamax	40 mg	90 tablets every 90 days for 6 months out of 1 year
Fosamax	5 mg and 10 mg	90 tablets every 90 days
Fosamax oral solution	70 mg/75 mL	975 mL every 90 days
Fosamax Plus D		12 tablets every 84 days
Fragmin	All strengths	90 injections every 90 days
Frova	All strengths and dosage forms	54 tablets/ml/units every 90 days Limit also includes all oral and nasal spray formulations of TRIPTANs (Amerge, Axert, Imitrex, Maxalt, Maxalt MLT, Relpax, Treximet, Zomig, Zomig ZMT)
Fuzeon injection kit		3 kits or 180 injections every 90 days
Ganirelix Acetate	250 mcg/0.5 ml	5 injections every 30 days
Gelnique	10% gel sachets/packets	90 packets every 90 days
Gleevec tablets	100 mg	270 tablets every 90 days
Gleevec tablets	400 mg	180 tablets every 90 days
Glimepiride/Amaryl	1 mg	720 tablets every 90 days
Glimepiride/Amaryl	2 mg	360 tablets every 90 days
Glimepiride/Amaryl	3 mg	180 tablets every 90 days
Glucophage/Metformin	500 mg	450 tablets every 90 days
Glucophage/Metformin	850 mg	270 tablets every 90 days
Glucophage/Metformin	1000 mg	180 tablets every 90 days
Glucophage XR/Metformin XR	500 mg	360 tablets every 90 days
Glucophage XR/Metformin XR	750 mg	180 tablets every 90 days
Glucotrol/Glipizide	5 mg	720 tablets every 90 days
Glucotrol/Glipizide	10 mg	360 tablets every 90 days
Glucotrol XL/Glipizide XL	2.5 mg	720 tablets every 90 days
Glucotrol XL/Glipizide XL	5 mg	360 tablets every 90 days
Glucotrol XL/Glipizide XL	10 mg	180 tablets every 90 days
Glumetza	500 mg	360 tablets every 90 days
Glumetza	1000 mg	180 tablets every 90 days
Glyburide/Diabeta/Micronase	1.25 mg, 2.5 mg	720 tablets every 90 days
Glyburide/Diabeta/Micronase	5 mg	360 tablets every 90 days
Glynase Prestabs	1.5 mg, 3 mg	360 tablets every 90 days
Glynase Prestabs	4.5 mg, 6 mg	180 tablets every 90 days
Gonal-F injection	All strengths	4,500 IU equivalent every 30 days
Helidac		1 kit every 30 days
Humira injection and Humira Pen Injection	40 mg / 0.8 ml	6 injections every 84 days
Humira injection and Humira Pen Injection	20 mg / 0.4 ml	6 injections every 84 days
Humira injection Crohn's Disease Starter Package	40 mg / 0.8 ml	6 injections (1 package) per lifetime
Humira Injection Psoriasis Starter Package	40 mg/0.8 ml	4 injections (1 package) per lifetime
Imitrex	All strengths and dosage forms except injections	54 tablets/ml/units every 90 days Limit also includes all oral and nasal spray formulations of TRIPTANs (Amerge, Axert, Frova, Maxalt, Maxalt MLT, Relpax, Treximet, Zomig, Zomig ZMT)
Imitrex	6MG/0.5ML INJECTION	24 mL (48 injections) every 90 days
Infergen injection	15 mcg	36 injections (18 ml) every 84 days
Infergen injection	9 mcg	36 injections (11 ml) every 84 days
Innohep	All strengths	10 injections per prescription
Intal inhaler	0.8 mg	63 gm (4 inhalers of 15 gm or 7 inhalers of 7 gm) every 90 days
Intal solution	20 mg / 2 ml solution for inhalation	720 units (3 boxes of 120 vials [2 ml/vial]) every 90 days
Intuniv	1 mg, 2, mg, 3 mg, 4 mg	90 tablets every 90 days
Ipratropium Bromide solution	0.02% solution for inhalation	900 ml (6 boxes of 60 units of 2.5 ml) every 90 days
Iressa tablets	250 mg	90 tablets every 90 days
Isentress	400 mg	180 tablets every 90 days
Istalol	0.50%	30 ml (6 bottles of 5 ml) every 365 days (1 year)
Januvia	All strengths	90 tablets every 90 days
Kadian	All strengths	120 capsules every 30 days
Kapidex	All strengths	90 tablets/capsules every 90 days Limit also includes all Proton Pump Inhibitors (Nexium, Prevacid, Prilosec, Protonix, Aciphex)
Ketek	400 mg	20 tablets per prescription
Ketorolac	10 mg tablets	20 tablets per prescription
Kineret injection		84 injections every 84 days
Kytril	1 mg tablet	20 tablets per prescription
Kytril	2 mgl10 ml solution	30 ml per prescription
Lamisil tablet	250 mg	90 tablets every 365 days
Lamisil granules packet	125 mg and 187.5 mg	42 packets every 365 days
Lariam	250 mg	15 tablets every 90 days
Letairis	5 mg and 10 mg	90 tablets every 90 days
Leukine	250 mcg powder	42 vials every 84 days
Leukine	500 mcg ml vial	42 ml (42 vials) every 84 days
Levaquin	250 mg and 500 mg	15 tablets per prescription
Levaquin	750 mg	15 tablets per prescription
Levaquin LEVA-PAK	750 mg	15 tablets per prescription
Lorcet	All strengths	450 tablets every 90 days Limit also includes Lortab and Vicodin
Lorcet-HD	All strenghts	450 units every 90 days Limit also includes Lortab and Vicodin
Lortab	All strengths	450 units every 90 days Limit also includes Lorcet and Vicodin
Lortab Elixir	2.5/167	8100 ml every 90 days
Lovaza	1 gram	360 capsules every 90 days
Lovenox	All strengths	90 injections every 90 days
Lumigan	0.03%	10 ml (4 bottles of 2.5 ml or 2 bottles of 5 ml) every 90 days
Lunesta	All strengths	90 tablets every 90 days Limit also includes Ambien, Ambien CR, and Sonata
Lupron 2 week	5 mg	6 vials every 84 days
Lupron Depot	3.75 mg	1 injection per prescription / 12 prescriptions every 365 days
Lupron Depot	30 mg	1 injection per prescription / 3 prescriptions every 365 days
Lupron Depot	22.5 mg	1 injection per prescription / 4 prescriptions every 365 days
Lupron Depot	7.5 mg	1 injection per prescription / 12 prescriptions every 365 days
Lupron Depot	11.25 mg	1 injection per prescription / 4 prescriptions every 365 days
Lupron Depot-ped	11.25 mg	1 injection per prescription /13 prescriptions every 365 days
Lupron Depot-ped	15 mg	1 injection per prescription / 13 prescriptions every 365 days
Lupron Depot-ped	7.5 mg	1 injection per prescription / 13 prescriptions every 365 days
Luveris	75 units	60 vials (4500 units) every 30 days
Magnacet	all strenghts	240 tablets every 30 days
Maxair Autohaler	All strengths	84 gm (3 inhalers of 14 gm) every 90 days
Maxalt/Maxalt MLT	All strengths and dosage forms	54 tablets/ml/units every 90 days Limit also includes all oral and nasal spray formulations of TRIPTANs (Amerge, Axert, Frova, Imitrex, Relpax, Treximet, Zomig, Zomig ZMT)
Maxaquin	400 mg	15 tablets every prescription
Menopur	75 units	60 vials (4500 units) every 30 days
Menostar	14 mcg/day patch	13 patches every 90 days
Mepron	750 mg/5 mL	900 mL every 90 days
Meridia	All strengths	90 capsules every 90 days
Metadate CD	10 mg	30 capsules every 30 days
Metadate CD	20 mg and 30 mg	60 capsules every 30 days
Metadate ER	10 mg and 20 mg	90 tablets every 30 days Limits also includes Methylin ER and Ritalin SR
Metformin/Glucophage	500 mg	450 tablets every 90 days
Metformin/Glucophage	850 mg	270 tablets every 90 days
Metformin/Glucophage	1000 mg	180 tablets every 90 days
Metformin XR/Glucophage XR	500 mg	360 tablets every 90 days
Metformin XR/Glucophage XR	750 mg	180 tablets every 90 days
Methylin ER	10 mg and 20 mg	90 tablets every 30 days Limits also includes Metadate ER and Ritalin SR
Micronase/Glyburide/Diabeta	1.25 mg, 2.5 mg	720 tablets every 90 days
Micronase/Glyburide/Diabeta	5 mg	360 tablets every 90 days
Migranal	4 mg/ml	24 ml (4 kits) every 90 days
Mobic	7.5 mg	180 tablets every 90 days
Mobic	15 mg	90 tablets every 90 days
Mobic	7.5 mg/5 mL	900 ml every 90 days
MS Contin	All strengths	120 capsules every 30 days Limit also includes Oramorph SR
MSIR solution	20 mg/ml	270 ml every 30 days
MSIR solution	20 mg / 5 ml	500 ml every 30 days
MSIR solution	10 mg/5ml	500 ml every 30 days
MSIR tablets	All strengths	180 tablets every 30 days
Namenda	10 mg tablet	180 tablets every 90 days
Namenda	5 mg tablet	180 tablets every 90 days
Namenda	5-10 mg TITRATION PK	1 packet (49 tablets) every 365 days
Nasacort AQ	All strengths	51 gm (3 bottles of 17 gm) every 90 days
Nasarel	0.03%	200ml (8 bottles of 25ml) every 90 days
Nasonex	All strengths	51 gm (3 bottles of 17 gm) every 90 days
Neulasta injection	6 mg	6 injections every 84 days
Neumega injection	5 mg	63 injections every 90 days
Neupogen injection	All strengths	42 injections every 90 days
Neupro	All strenghts	90 patches every 90 days
Nexavar	200 mg	360 tablets every 90 days
Nexium	All strengths	90 tablets/capsules every 90 days Limit also includes all Proton Pump Inhibitors (Aciphex, Prevacid, Prilosec, Protonix, Kapidex)
Novarel vials		2 vials every 30 days
Noxafil Oral Suspension	40 mg/ml	1800 ml every 90 days
Nucynta	50 mg and 100 mg	540 tablets every 90 days
Nucynta	75 mg	720 tablets every 90 days
Nuvaring		3 rings every 84 days
Nuvigil	150 mg and 250 mg	90 tablets every 90 days
Nuvigil	50 mg kit	180 tablets every 90 days
Omnaris	50 mcg/actuation - 12.5 grams/bottle	39 grams (3 bottles of 12.5 grams each) per 90 days
Onglyza	2.5 mg and 5 mg	90 tablets every 90 days
Onsolis	All strengths	120 tablets every 30 days Limit also include Actiq and Fentora
Opana	All strengths	120 tablets every 30 days
Opana ER	All strengths	120 tablets every 30 days
Optivar	0.05%	18 ml (3 bottles of 6 ml) every 90 days
Oramorph SR	All strengths	120 capsules every 30 days Limit also includes MS Contin
Ortho Evra		10 patches every 90 days
Ovidrel vials		2 vials every 30 days
Oxycodone Immediate Release	All Strengths	180 tablets/capsules every 30 days
Oxycodone oral solution	5 mg/5 mL	600 ml every 30 days
Oxycontin	All strengths	120 tablets every 30 days
Oxydose	20 mg/ml	30 ml every 30 days Limit also includes Oxyfast solution
Oxyfast	20 mg/ml	30 ml every 30 days Limit also includes Oxydose solution
Oxytrol		26 patches every 90 days
Patanase	0.60%	93 g (3 bottles of 30.5g each) every 90 days
Patanol	0.10%	15 ml (3 bottles of 5 ml or 6 bottles of 2.5 ml) every 90 days
Pegasys injection	180 mcg	12 injections every 84 days
Peg-intron injection	All strengths	12 injections every 84 days
Percocet	All strengths	240 tablets every 30 days
Perforomist	20 mcg / 2 ml	360 ml every 90 days
Persantine (including generic dipyridamole)	25 mg and 75 mg	360 tablets every 90 days
Persantine (including generic dipyridamole)	50 mg	720 tablets every 90 days
Plavix (including generic clopidogrel)	75 mg and 300 mg	90 tablets every 90 days
Plenaxis	100 mg vial	3 vials every 84 days
Pletal (including generic cilostazol)	50 mg	270 tablets every 90 days
Pletal (including generic cilostazol)	100 mg	180 tablets every 90 days
Pravigard PAC	All strengths	90 tablets every 90 days
Pregnyl vials	All strengths	2 vials every 30 days
Prevacid	All strengths	90 tablets/capsules every 90 days Limit also includes all Proton Pump Inhibitors (Aciphex, Nexium, Prilosec, Protonix, Kapidex)
Prevpac		14 packs (1 pack contains 8 tablets) every 30 days
Priftin	150 mg tablets	104 tablets every 90 days
Prilosec	All strengths	90 tablets/capsules every 90 days Limit also includes all Proton Pump Inhibitors (Aciphex, Nexium, Prevacid, Protonix, Kapidex) except generic Prilosec (omeprazole) 20 mg
Procentra	5mg/5ml	1419 ml (3 bottles of 473ml each) per 90 days
Procrit injection	All except 40,000 unit vial	36 injections every 84 days
Procrit injection	40,000 unit vial	18 injections every 84 days
Promacta	25 mg and 50 mg	30 tablets every 30 days
Protonix	All strengths	90 tablets/capsules/packets every 90 days Limit also includes all Proton Pump Inhibitors (Aciphex, Nexium, Prevacid, Prilosec, Kapidex)
Provigil	100 mg, 200 mg	180 tablets every 90 days
Prozac weekly		13 capsules every 90 days
Pulmicort respules	All strengths except 1 mg/2 mL	360 ml (6 boxes of 30 vials [2 ml per vial]) every 90 days
Pulmicort respules	1 mg/2 mL	180 ml (3 boxes of 30 vials [2 ml per vial]) every 90 days
Pulmicort Turbuhaler	200 mcg	6 units/ inhalers every 90 days
Pulmicort Flexhaler	90 mcg and 100 mcg	6 units/ inhalers every 90 days
Pulmozyme solution	1 mg/ml	450 ml or 180 amps every 90 days
Pylera	125-125 mg	120 capsules every 30 days
Qvar	All strengths	64 gm (8 inhalers of 8 gm) every 90 days
Ranexa	500 mg	180 tablets every 90 days
Ranexa	1000 mg	180 tablets every 90 days
Rapaflo	4 mg and 8 mg	90 capsules every 90 days
Raptiva kit	125 mg	12 injections every 84 days
Razadyne/Reminyl	All strengths	180 tablets every 90 days
Razadyne ER	8 mg, 16 mg and 24 mg	90 capsules every 90 days
Razadyne oral solution	4mg/mL	540 mL every 90 days
Rebetol capsules	200 mg	588 capsules every 84 days Limit also includes Copegus, Ribasphere
Rebetol solution	40 mg/ml	2940 ml every 84 days
Rebetron kit	All strengths	6 kits every 90 days
Rebif injection	22 mcg/.5 & 44 mcg/.5	36 injections every 84 days
Rebif titration pack	Titration Pack	1 pack per prescription / 1 prescription per 365 days
Regranex	0.01% gel	30 gm every 365 days
Relenza	5 mg	20 blisters (1 package) every 365 days
Relpax	All strengths and dosage forms	54 tablets/ml/units every 90 days Limit also includes all oral and nasal spray formulations of TRIPTANs (Amerge, Axert, Frova, Imitrex, Maxalt, Maxalt MLT, Treximet, Zomig, Zomig ZMT)
Repronex vials	75 IU	60 vials every 30 days
Revatio	20 mg	270 tablets every 90 days
Revlimid	5 mg and 10 mg	90 capsuless every 90 days
Revlimid	15 mg and 25 mg	63 capsules every 84 days
Rhinocort AQ	All strengths	54 gm (6 inhalers of 9 gm) every 90 days
Ribasphere/Ribatab	600 mg	168 tablets every 84 days
Ribasphere/Ribatab	400 mg	252 tablets every 84 days
Ribasphere/Ribavirin	200 mg	588 capsules/tablets every 84 days Limit also includes Copegus, Rebetol
Ribatab	400 mg & 600 mg	168 tablets every 84 days
Ribavirin	500 mg	168 tablets every 84 days
Riomet	500 mg/ 5 ml	720 mL every 90 days
Ritalin LA	10 mg, 20 mg, 40 mg	30 tablets every 30 days
Ritalin LA	30 mg	60 tablets every 30 days
Ritalin SR	20 mg	90 tablets every 30 days Limit also includes Metadate ER and Methylin ER
Rozerem	8 mg	90 tablets every 90 days
Sabril	500 mg	540 tablets every 90 days
Sanctura	20 mg	180 tablets every 90 days
Sanctura XR	60 mg	90 tablets every 90 days
Sancuso Patch	34.3mg of granisetron delivering 3.1mg per 24 hours	6 patches per prescription
Sandostatin	50 mcg/mL	2700 mL every 90 days
Sandostatin	100 mcg/mL	1350 mL every 90 days
Sandostatin	500 mcg/mL	270 mL every 90 days
Sandostatin	200 mcg/mL	720 mL every 90 days
Sandostatin	1000 mcg/mL	180 mL every 90 days
Sandostatin LAR	10 mg, 20 mg, 30 mg	3 kits every 84 days
Selzentry	150 mg	180 tablets every 90 days
Selzentry	300 mg	360 tablets every 90 days
Serevent	MDI inhaler	39 gm (3 inhalers of 13 gm) every 90 days
Serevent Diskus	All strengths	180 units (3 boxes of 60 blister packs) every 90 days
Serostim injection	All strengths	84 injections every 84 days
Simponi	50 mg	3 injections every 90 days
Singulair	All strengths (includes chewable)	90 tablets every 90 days
Skelaxin	All strengths	360 tablets every 90 days
Soma	350 mg and 250 mg	360 tablets every 90 days
Soma compound	325/200	720 tablets every 90 days
Soma compound w/Codeine	325/200/16	720 tablets every 90 days
Somatuline Depot	60 mg, 90 mg, and 120 mg	3 syringes every 84 days
Somavert	All strengths except 15 mg	90 vials every 90 days
Somavert	15 mg	180 vials every 90 days
Sonata	All strengths	90 capsules every 90 days Limit also includes Ambien, Ambien CR, and Lunesta
Spiriva	18 mcg Handihaler	90 capsules every 90 days
Sprycel	All strengths	180 tablets every 90 days
Stadol NS	10mg/ml nasal spray 2.5ml	36 ml (12 bottles of 3 ml) every 90 days
Strattera	10 mg, 18 mg, and 25 mg	180 capsules every 90 days
Strattera	40 mg, 60 mg, 80 mg, and 100 mg	90 capsules every 90 days
Striant	30 mg	180 units every 90 days
Suboxone	All strengths	360 tablets every 90 days
Subutex	All strengths	360 tablets every 90 days
Supprelin LA	50 mg kit	1 kit every 365 days
Symbicort	All strenghts	33 grams (3 inhalers) every 90 days
Sutent	12.5 mg, 25 mg, and 50 mg	56 capsules every 84 days
Symlin	0.6 mg/ml vial	12 vials of 5ml (60 ml) every 90 days
Symlin Pen	60 - pen injector	18 ml (12 pens) every 90 days
Symlin Pen	120 - pen injector	33 ml (12 pens) every 90 days
Tamiflu	75 mg	84 capsules every 365 days
Tamiflu	12 mg/ml	550 ml every 365 days
Tamiflu	30 mg	40 capsules every 365 days
Tamflu	45 mg	20 capsules every 365 days
Tarceva	25 mg	270 tablets every 90 days
Tarceva	100 mg	90 tablets every 90 days
Tarceva	150 mg	90 tablets every 90 days
Tasigna	200 mg	360 capsules every 90 days
Tekturna	150 mg and 300 mg	90 tablets every 90 days
Tekturna HCT	150 mg/12.5 mg, 150 mg/25 mg, 300 mg/12.5 mg	90 tablets every 90 days
Temodar capsules	250 mg	30 capsules every 90 days
Temodar capsules	180 mg, 140 mg, 100 mg, 20 mg & 5 mg	60 capsules every 90 days
Tequin tablets	400 mg	15 tablets per prescription
Tequin teq-paq	400 mg	15 tablets per prescription
Tequin	200 mg	15 tablets every prescription
Testim	All strengths	900 grams every 90 days
Thalomid capsules	50 mg	84 capsules every 84 days
Thalomid capsules	100 mg	252 capsules every 84 days
Thalomid capsules	150 mg and 200 mg	336 capsules every 84 days
Ticlid (including generic ticlopidine)	250 mg	180 tablets every 90 days
Tilade	All strengths	119 gm (7 inhalers of 17 gm) every 90 days
Tobi nebulizer (vials)	300 mg / 5 ml	280 ml or 56 vials every 50 days
Tolazamide	250 mg	360 tablets every 90 days
Tolbutamide	all strenghts	540 tablets every 90 days
Toradol	10 mg tabletS	20 tablets per prescription
Toviaz ER	4 mg and 8 mg	90 tablets every 90 days
Tracleer tablets	125 mg & 62.5 mg	180 tablets every 90 days
Transderm-scop		30 patches every 90 days
Travatan / Travatan Z	0.00%	10 ml (4 bottles of 2.5 ml) every 90 days
Trelstar depot	3.75 mg	1 injection per prescription / 12 injections every 365 days
Trelstar la injection	11.25 mg	1 injection per prescription / 4 injections every 365 days
Treximet	85 mg-500 mg	54 tablets/ml/units every 90 days Limit also includes all oral and nasal spray formulations of TRIPTANs (Amerge, Axert, Frova, Imitrex, Maxalt, Maxalt MLT, Relpax, Zomig, Zomig ZMT)
Tylenol w/codeine elixir	120/12	1500 ml every 90 days
Tylenol w/codeine tablets	All strengths	1170 tablets every 90 days
Tyzeka	600 mg	90 tablets every 90 days
Ultracet	325 mg/37.5 mg	720 tablets every 90 days
Ultram	50 mg	720 tablets every 90 days
Ultram ER	100 mg, 200 mg, and 300 mg	90 tablets every 90 days
Urispas (including generic flavoxate)	100 mg	360 tablets every 90 days
Vantas	50 mg kit	1 implant every 365 days
Veramyst	27.5 mcg Nasal Spray	30 grams (3 bottles) every 90 days
Vesicare	5 mg and 10 mg	90 tablets every 90 days
Viadur implant		1 box every 365 days
Vicodin	All tablet strengths	450 tablets every 90 days Limit also includes Lorcet, Lortab
Vivelle	0.025 mg, 0.0375 mg, 0.05 mg, 0.075 mg, 0.1 mg	26 patches every 90 days
Vivelle-DOT	0.025 mg, 0.0375 mg, 0.05 mg, 0.075 mg, 0.1 mg	26 patches every 90 days
Votrient	200 mg and 400 mg	180 tablets every 90 days
Vyvanse	20 mg, 30 mg, 40 mg, 50 mg, 60 mg and 70 mg	30 capsules every 30 days
Xalatan	0.01%	10 ml (4 bottles of 2.5 ml) every 90 days
Xeloda tablets	150 mg	240 tablets every 90 days
Xeloda tablets	500 mg	480 tablets every 90 days
Xenazine	12.5 mg and 25 mg	360 tablets every 90 days
Xenical	120 mg	270 capsules every 90 days
Xyrem oral soln	500 mg/ml	1620 ml (9 bottles) every 90 days
Xyzal	5 mg	90 tablets every 90 days
Zaditor	0.03%	15 ml (3 bottles of 5 ml or 2 bottles of 7.5 ml) every 90 days
Zavesca	100 mg	270 capsules every 90 days
Zegerid (Omeprazole powder)	20 mg and 40 mg packets	90 packets (3 box of 30 packets) every 90 days
Zemplar	1 OR 2 mcg	90 capsules every 90 days
Zemplar	4 mcg	36 capsules every 84 days
Zithromax	1 gm packet	2 packets per prescription
Zithromax	250 mg	12 tabs every 30 days
Zithromax	600 mg	24 tablets every 84 days
Zithromax	500 mg	6 tablets every 30 days
Zmax	2 gm powder	2 packets per prescription
Zofran	24 mg	10 tablets per prescription
Zofran/Zofran ODT	4 mg	42 tablets per precription
Zofran/Zofran ODT	8 mg	30 tablets per prescription
Zofran oral solution	4 mg / 5 ml	210 ml per prescription
Zomig/Zomig ZMT	All strengths and dosage forms	54 tablets/ml/units every 90 days Limit also includes all oral and nasal spray formulations of TRIPTANs (Amerge, Axert, Frova, Imitrex, Maxalt, Maxalt MLT, Relpax, Treximet)
Zoladex implant	3.6 mg	1 implant per prescription / 12 prescriptions every 365 days
Zoladex implant	10.8 mg	1 implant per prescription / 4 prescriptions every 365 days
Zolinza	100 mg	360 capsules every 90 days
Zorbtive	8.8 mg	84 vials every 84 days
Zyflo/Zyflo CR	600 mg	360 tablets every 90 days

Drug Dispensing Limitations

Dispensing Limit Exception Request (2995)

AGE LIMITS DRUG LIST
Limits will apply to drugs listed below, as well as the generic equivalents.
Drug Name	Strength	Dispensing Limit
Alinia	100mg/5ml suspension	Covered for members 1 year and above
Alinia	500mg tablet	Covered for members 12 years and above
Amphetamines	All strengths anf formulations	Covered for members 3 years and above
Benzodiazepines (including estazolam, quazepam, temazepam, triazolam)	All strengths	Covered for members 18 years and above
Benzodiazepine (flurazepam)	All strengths	Covered for members 15 years and above
Elidel	1%	Covered for members 2 years and above
Exjade	All strengths	Covered for members 2 years and above
Femara	2.5 mg	Covered for females, Covered for males 18 years and below
Growth Hormones (including Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Tev-tropin)	All strengths	Covered for members less than 18 years old
Growth Hormones (including Serostim and Zorbtive)	All strengths	Covered for members 18 years and above
Hypnotics (including Ambien, Lunesta, Sonata, and Rozerem)	All strengths	Covered for members 18 years and above
Infertility Medications (including Clomid, Gonal F, Follistim, Bravelle, Ovidrel, Novarel, Pregnyl, Profasi HP, Chorionic Gonadotropin (generic and brands), Luveris, Repronex, Menopur, Ganirelix, Cetrotide)	All strengths	Cover for members less than or equal to 45 years old
Intuniv	1 mg, 2 mg, 3 mg, and 4 mg	Covered for members 6 years and above
Ketek	400mg	Covered for members 18 years and above
Lovaza	1 gram	Covered for members 18 years and above
Lupron (leuprolide acetate)	5 mg/mL SQ injections	Cover for members less than or equal to 45 years old
Mecasermin rinfabate (including Increlex and Iplex)	All strengths	Covered for members less than 18 years old
Methylphenidate	All strengths and formulations	Covered for members 6 years and above
Nucynta	All strengths	Covered for members 18 years and above
Phenergan (promethazine)	All strengths	Covered for members 2 years and above
Protopic	All strengths	Covered for members 2 years and above
Raptiva	All strenghts	Covered for members 18 years and above
Relenza	Aer Diskhale	Covered for members 5 years and above
Tamoxifen	All strengths	Covered for females, Covered for males 18 years and below
Tindamax	All strengths	Covered for members 3 years and above
Tussionex and Tussionex Pennkinetic Extended	All strenghts	Covered for members 6 years and above
Vanos	All strengths	Covered for members 12 years and above
Viagra/Levitra/Cialis	All strengths	Covered for members 18 years and above
Xifaxan	200mg	Covered for members 12 years and above
Zyflo	All strengths	Covered for members 12 years and above
Strattera	All strengths	Covered for members 6 years and above
Vectical	All strengths	Covered for members 18 years and above
Zyrtec syrup	5 mg / 5 ml	Covered for members 2 years and less

GENDER LIMITS DRUG LIST
Limits will apply to drugs listed below, as well as the generic equivalents.
Drug Name	Strength	Dispensing Limit
Androderm	All strengths	Men Only
Androgel	All strengths	Men Only
Arimidex	All strengths	Women only
Caverject	All strengths	Men Only
Cialis	All strengths	Men Only
Delatestryl	All strenghts	Men Only
Depo-testosterone	All strengths	Men Only
Edex	All strengths	Men Only
Estrogen (oral contraceptives, estrogen combinations)	All strengths	Women only
Femara	2.5 mg	Covered for females, Covered for males 18 years and below
Levitra	All strengths	Men Only
Lotronex	All strengths	Women Only
Muse	All strengths	Men Only
Striant	All strengths	Men Only
Tamoxifen	All strengths	Covered for females, Covered for males 18 years and below
Testim	All strengths	Men Only
Testoderm	All strengths	Men Only
Testopel	All strengths	Men Only
Testosterone Cypionate (all dosage forms available)	All strengths	Men Only
Testosterone Enanthate	All strengths	Men Only
Viagra	All strengths	Men Only

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 the member's treating physicians to fully inform them of the activities of other prescribers.

Prior Authorization (PA)
Prior Authorization 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 physicians and pharmacists, have to be met for certain drugs to be approved and covered under your prescription drug benefits. The Horizon BCBSNJ internal committee establishes PA criteria after evaluating medical literature, physician opinion, and FDA-approved labeling information. If the PA is approved, your patient can obtain the drug. The patient's copayment is determined by their prescription drug benefit. If the patient does not meet the PA requirements, the patient may still purchase the drug, but the cost will not be reimbursed by the health plan.

The following medications are subject to PA criteria. (The list is subject to change and will be periodically updated.) Medical Necessity Guidelines are available by clicking on the following underlined drugs.

Drug Name

AMPHETAMINE SALT COMBO

CHORIONIC GONADOTROPIN

DEXTROAMPHETAMINE SULFATE

DEXTROSTAT

DIDREX

DIETHYLPROPION HCL ER

PHENDIMETRAZINE TARTRATE

Prior Authorization List

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

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

Maintenance Drug List

Administrative Policy Manual

Medical Necessity Determination Policy For Prescription Drugs
This policy sets forth the procedure Horizon BCBSNJ uses in making a medical necessity determination for prescription drugs or categories of prescription drugs. Drug Dispensing Limitations, Drug Utilization Reviews (DURs), and Prior Authorization are the three programs that make up the Medical Necessity Determination drug list. All medications are subject to Medical Necessity review. Horizon BCBSNJ focuses reviews on drugs that have a high potential for inappropriate use, are expensive, have narrowly defined FDA-approved indications, and have a significant interaction risk if taken with other agents. The Medical Necessity Determination process can be initiated in three ways: point of service, prior to point of service, and after drug is dispensed.

Medical Necessity Determination Policy For Prescription Drugs

Pharmaceutical Prior Authorization Policy
This policy sets forth the procedure for the Pharmaceutical Prior Authorization process. Prior Authorization 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. The Pharmaceutical Prior Authorization process can be initiated in three ways: point of service, prior to point of service, and after drug is dispensed.

Pharmaceutical Prior Authorization Policy

Prescription Drug Formulary Exceptions Approval Policy
The purpose of this policy is to describe the process of obtaining coverage of a non-preferred drug at the preferred level of coverage -if the member has prescription drug benefits with a Drug Formulary based tier structure. The preferred drug list is a list of prescription medications that contains preferred generics and preferred brand-name medications. This preferred drug list is created, reviewed, and continually updated by an independent group of physicians and pharmacist who sit on the Horizon BCBSNJ Pharmacy and Therapeutic Committee.

Prescription Drug Formulary Exceptions Approval Policy

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