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Health Net Pharmaceutical Services (HNPS) at (800) 977-8226 PHARMACEUTICAL PRIOR AUTHORIZATION REQUIREMENTS Practitioners may Fax completed Prior Authorization Form to Health Net Pharmaceutical Services (HNPS) at (800) 977-8226. The following medications/classes require Prior Authorization. CONNECTICUT PLANS THIS LIST IS NOT APPLICABLE TO MEDICARE PART D PLANS DRUGS THAT REQUIRE PRIOR AUTHORIZATION FOR VARIOUS PRESCRIPTION RIDERS GENERIC NAME / DRUG CLASS BRAND NAME EXAMPLES Angiotensin II Receptor Blockers (ARBs), & ATACAND, ATACAND HCT, AVAPRO, AVALIDE, AZOR, BENICAR, BENICAR HCT, Renin Inhibitors COZAAR, DIOVAN, DIOVAN HCT, EXFORGE, HYZAAR, MICARDIS, MICARDIS HCT, TEKTURNA, TEKTURNA HCT, TEVETEN, TEVETEN HCT 2, 6 2, 6 Antidepressants CYMBALTA, EFFEXOR XR, LEXAPRO, PRISTIQ [Effective April 1, 2009] Compounded Prescriptions N/A 1 Fertility Agents BRAVELLE, CETROTIDE, GANIRELIX, HCG, FOLLISTIM AQ, FERTINEX, GONAL-F, LUPRON, LUVERIS, MENOPUR, NOVAREL, OVIDREL, PREGNYL, PROCHIEVE, PROFASI, REPRONEX, etc. 1, 5 Growth Hormone (somatropin) HUMATROPE, NUTROPIN, NUTROPIN AQ, 1, 5 (somatropin) ACCRETROPIN, GENOTROPIN, NORDITROPIN, OMNITROPE, SAIZEN, SEROSTIM, TEV-TROPIN 1, 5, 6 (IGF) INCRELEX, IPLEX 1, 5 Drug Utilization Review (DUR) exceptions See: Drug Utilization Review (DUR) & Quantity Limits (QL) Low-Sedating Antihistamines ALLEGRA, ALLEGRA-D, CLARINEX, CLARINEX-D, XYZAL 2, 6 desloratadine, fexofenadine Nicotine Addiction CHANTIX, IVERSINE, NICOTROL, ZYBAN 1 bupropion, nicotine, mecamylamine, varenicline Nutritional Supplements MSUD, PHENYL-FREE, XP-ANALOG, XPHEN, NEOCATE, etc. 1 Onychomycosis Agents LAMISIL, PENLAC, SPORANOX 1 (Not covered for cosmetic treatment): ciclopirox, itraconazole, terbinafine Proton Pump Inhibitors: KAPIDEX, NEXIUM, PRILOSEC, PROTONIX, ZEGERID 2, 6 dexlansoprazole, esomeprazole, pantoprazole, rabeprazole gamma interferon ACTIMMUNE 1, 5 fentanyl lozenge ACTIQ 1 risedronate ACTONEL, ACTONEL w/Calcium 2, 6 zolpidem CR AMBIEN CR 2, 6 2, 6 cyclobenzaprine SR 24 hr AMRIX [Effective April 1, 2009] apomorphine APOKYN 2 rilonacept ARCALYST 1 interferon beta-1a AVONEX 1, 3, 5 entecavir BARACLUDE 2 interferon beta-1b BETASERON 1, 3, 5 ibandronate BONIVA 2, 6 exenatide BYETTA 1, 6 acamprosate CAMPRAL 2 celecoxib CELEBREX 2, 6 glatiramer acetate COPAXONE 1, 3, 5 ribavirin COPEGUS, REBETOL1 rosuvastatin CRESTOR (5mg dose only) 2, 6 2, 6 doxycycline hyclate DR DORYX [Effective April 1, 2009] fentanyl patch DURAGESIC 2, 6 etanercept ENBREL 1, 5 inhaled insulin EXUBERA 1 1. Prior Authorization Required For All Members 2. Prior Authorization Required For 3-Tier Rx plans 3. Prior Authorization NOT required for members for initial dose if administered in physician office and billed by Physician 4. Prior Authorization NOT required for members if administered in physician office and billed by Physician 5. Availability may be limited through the Specialty Injectable Pharmacy (SIP) Network 6. Indicates a Step Therapy Prior Authorization drug Revised 2-15-2009 - CONNECTICUT Page 1 of 3 PHARMACEUTICAL PRIOR AUTHORIZATION REQUIREMENTS Practitioners may Fax completed Prior Authorization Form to Health Net Pharmaceutical Services (HNPS) at (800) 977-8226. The following medications/classes require Prior Authorization. GENERIC NAME / DRUG CLASS (CON’T) BRAND NAME EXAMPLES (CON’T) fentanyl buccal tablet FENTORA 1 teriparatide FORTEO 1 alendronate FOSAMAX, FOSAMAX PLUS D 2, 6 imatinib GLEEVEC 2_ adefovir HEPSERA 2 adalinumab HUMIRA 1, 5 interferon alfacon-1 INFERGEN 1, 3, 5 interferon alfa-2b INTRON A 1, 3, 5 gefitinib IRESSA 2_ 2, 6 levetiracetam SR 24 hr KEPPRA XR [Effective April 1, 2009] anakinra KINERET 1, 5 fluvastatin LESCOL, LESCOL XL2, 6 atorvastatin LIPITOR 2, 6 omega-3-acid ethyl esters LOVAZA 1 leuprolide LUPRON 1, 5 leuprolide LUPRON DEPOT 3.75, 11.25mg, LUPRON DEPOT-PED 7.5, 11.25, 15mg 1, 3, 5 leuprolide LUPRON DEPOT 7.5, 22.5, 30mg 1, 4 pregabalin LYRICA 2, 6 sorafenib tosylate NEXAVAR 1 2, 6 doxycycline delayed release caps ORACEA [Effective April 1, 2009] oxycodone SR 12 hr OXYCONTIN 2, 6 peginterferon alfa-2a PEGASYS 1, 5 peginterferon alfa-2b PEG-INTRON 1, 5 2 eltrombopag olamine PROMACTA [Effective April 1, 2009] modafinil PROVIGIL 2 efalizumab RAPTIVA 1, 5 interferon beta-1a REBIF 1, 3, 5 2 methylnaltrexone bromide RELISTOR [Effective April 1, 2009] sildenafil REVATIO 1 lenalidomide REVLIMID 1 interferon alfa-2a ROFERON A 1, 3, 5 octreotide SANDOSTATIN 1, 5 montelukast SINGULAIR 2, 6 2, 6 minocycline SR 24-hr SOLODYN [Effective April 1, 2009] pegvisomant SOMAVERT 1, 5 dasatinib SPRYCEL 2_ 1 ustekinumab STELARA [Effective April 1, 2009] sunitinib SUTENT 2_ pramlintide SYMLIN 1 erlotinib TARCEVA 2 nilotinib TASIGNA 2_ thalidomide THALOMID 2 2, 6 sumatriptan-naproxen TREXIMET [Effective April 1, 2009] lapatinib TYKERB 1 telbivudine TYZEKA 2 iloprost VENTAVIS 2 2, 6 miconazole,zinc oxide, petrolatum VUSION [Effective April 1, 2009] ezetimibe-simvastatin VYTORIN (10-10mg dose only) 2, 6 sodium oxybate XYREM 1 vorinostat ZOLINZA 2_ 1. Prior Authorization Required For All Members 2. Prior Authorization Required For 3-Tier Rx plans 3. Prior Authorization NOT required for members for initial dose if administered in physician office and billed by Physician 4. Prior Authorization NOT required for members if administered in physician office and billed by Physician 5. Availability may be limited through the Specialty Injectable Pharmacy (SIP) Network 6. Indicates a Step Therapy Prior Authorization drug Revised 2-15-2009 - CONNECTICUT Page 2 of 3 PHARMACEUTICAL PRIOR AUTHORIZATION REQUIREMENTS Practitioners may Fax completed Prior Authorization Form to Health Net Pharmaceutical Services (HNPS) at (800) 977-8226. The following medications/classes require Prior Authorization. DRUGS/ PRODUCTS THAT REQUIRE PRIOR AUTHORIZATION FOR ALL MEDICAL PLANS GENERIC NAME / DRUG CLASS BRAND-NAME EXAMPLES Alpha-1 Proteinase ARALAST, ARALAST NP, PROLASTIN, ZEMAIRA 1, 5 Inhibitors Botulinum Toxins BOTOX, MYOBLOC 1, 5 Glucometers & Test strips Non-Preferred Glucometers and Test Strips 1, 6 (Non-Preferred only) (The preferred brands by Abbott Diabetes Care & Roche Diagnostics that do not require a Prior Authorization are: ACCU-CHEK® Active, Advantage, Aviva, and Compact; FreeStyle® Flash®, Freedom®, and Lite; and Precision XtraTM) Hemophilia Blood Factors ADVATE, ALPHANATE, ALPHANINE SD, BENEFIX, BEBULIN VH, FEIBA VH, GENARC, HELIXATE FS, HEMOFIL M, HUMATE-P, KOATE-DVI, KOGENATE FS, MONARC-M, MONOCLATE-P, MONONINE, NOVOSEVEN, PROFILNINE SD, PROPLEX T, RECOMBINATE, REFACTO, XYNTHA 1, 5 Hyaluronic Acid EUFLEXXA, HYALGAN, ORTHOVISC, SUPARTZ, SYNVISC, SYNVISC-ONE 1, 5 Derivatives Immune Globulin IV CARIMUNE, FLEBOGAMMA, GAMMAGARD S/D, GAMUNEX, IVEEGAM, OCTAGAM, PANGLOBULIN, (IVIG), or SC POLYGAM S/D, PRIVIGEN, VIVAGLOBIN 1, 5 1 tocilizumab ACTEMRA [Effective June 1, 2009] corticotropin gel ACTHAR HP 1 darbepoetin alfa ARANESP 1 nelarabine ARRANON 1, 5 ibandronate BONIVA IV 1, 5 laronidase ALDURAZYME 1, 5 pemetrexed ALIMTA 1, 5 alefacept AMEVIVE 1, 5 bevacizumab AVASTIN 1 alglucerase CEREDASE 1, 5 imiglucerase CEREZYME 1, 5 certolizumab CIMZIA 1, 5 1 C1 inhibitor CINRYZE [Effective June 1, 2009] anidulafungin ERAXIS 1, 5 cetuximab ERBITUX 1, 5 agalsidase beta FABRAZYME 1, 5 epoprostenol FLOLAN 1 alglucosidase alfa MYOZYME 1, 5 1 romiplostim NPLATE [Effective June 1, 2009] 1 motavizumab NUMAX [Effective June 1, 2009] abatacept ORENCIA 1 abarelix PLENAXIS 1, 5 infliximab REMICADE 1, 5 treprostinil REMODULIN 1 octreotide SANDOSTATIN LAR 1, 5 eculizumab SOLIRIS 1 lanreotide SOMATULINE DEPOT 1 palivizumab SYNAGIS 1, 5 temsirolimus TORISEL 1 natalizumab TYSABRI 1, 5 bortezomib VELCADE 1, 5 omalizumab XOLAIR 1, 5 goserelin ZOLADEX 1, 4 HEALTH NET RESERVES THE RIGHT TO REQUIRE PRIOR AUTHORIZATION FOR ORAL AND TOPICAL DRUGS EXCEPT WHERE MANDATED BY LAW. 1. Prior Authorization Required For All Members 2. Prior Authorization Required For 3-Tier Rx plans 3. Prior Authorization NOT required for members for initial dose if administered in physician office and billed by Physician 4. Prior Authorization NOT required for members if administered in physician office and billed by Physician 5. Availability may be limited through the Specialty Injectable Pharmacy (SIP) Network 6. Indicates a Step Therapy Prior Authorization drug Revised 2-15-2009 - CONNECTICUT Page 3 of 3 .
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