University Of Michigan Benefits Office

Exclusions, Limitations, Prior Authorizations (PA), Dose Optimization, Step Therapy, and Self-Administered Injectable Medications

Updated September 23, 2008

Chart of Drugs with Coverage Requirements and Limitations
Plan Exclusions
Refill too Soon
Plan Limitations (QL)
Prior Authorization Drugs (PA)
Dose Optimization Program
Step Therapy

Plan Exclusions

Certain drugs and supplies are excluded from the plan. The list includes the items listed below. These exclusions apply to both the retail and mail service program.

• Topical acne medications for individuals age 40 and older

• Anorexiants, CNS stimulants (such as Adipex-P, phenteramine, Bontril, Didex, Ionamin)

• Blood products

• Cosmetic products, or any drug used for cosmetic purposes (such as Rogaine, Renova, Propecia, Avage, Botox)

• Experimental, investigational or unproven drugs, or one that is being used for a treatment that has not been approved by the FDA

• Injectable medications, except those listed in this book as covered

• New drugs and medicines that have not been reviewed by the plan

• Over-the-counter (OTC) medications and any prescription medication that contains the same active ingredient(s) as an existing over-the-counter medication. Examples include Lac-Hydrin, Mentax, Zaditor, MiraLAX, Lovaza, and benzoyl peroxide products. More examples (PDF)

• Medical foods, examples include Limbrel, Deplin, FolTx, Metanx, Folbee Plus Cz, Diatx Zn, Cerefolin, and Vanchol

• Vitamins, other than prenatal vitamins and injectable B-12, D and K

• Therapeutic devices, appliances or medical equipment, support garments, or ostomy supplies. Your medical plan benefits may cover certain medical equipment and supplies and/or injectables administered by your health care provider. Questions about items covered or excluded by your medical plan should be directed to your medical plan.

Refill too Soon
Prescriptions cannot be refilled before 75% use (26 days for a 34-day supply or 68 days for a 90-day supply). Drugs subject to quantity limits can be refilled no earlier than 25 days for a one-month supply or 75 days for a three-month supply.

Plan Limitations (QL)
Some drugs are subject to quantity limits (QL) on the amount of the medication that you can receive (number of days’ supply, quantity limits, frequency of refills, etc.). See the chart below for the current retail and mail-order pharmacy limits. If your prescription exceeds the quantity limits listed and your condition meets the treatment guidelines, your physician may contact SXC to discuss additional supplies by calling 866-715-0874 (TTY 866-261-0791).

• Fertility agents (oral and injectable medications) are covered up to a lifetime family maximum of $5,000. In addition, prior authorization (PA) is required for participants age 45 and older.

• One month extra refill of your prescriptions for vacations or travel overseas can be requested by contacting SXC at 866-715-0874 (TTY 866-261-0791).

Prior Authorization Drugs (PA)
Certain drugs require prior authorization from the plan. If your doctor prescribes any medication listed with a “PA” requirement, your doctor must contact SXC by calling 866-715-0874 (TTY 866-261-0791) to receive prior authorization before you fill your prescription. In some cases you may be required to submit a letter from your doctor verifying the medical necessity of the prescribed drug. Drugs that require prior authorization from the plan are listed below. The list is subject to change.

After the initial approval, prior authorization may be required again periodically.

For more information about the Prior Authorization process, see PA Appeals Process.

Dose optimization program
The University of Michigan maintains within its Prescription Drug Plan a dose optimization or dose consolidation program for selected medications. The purpose of the program is to change multiple dose medications to a single daily dose where appropriate. The program applies when all of these criteria are met:

• The patient is taking an established medication for a chronic condition

• The medication is available in multiple strengths

• There is an opportunity for a member to change from multiple units per day dosing to a once daily dose of the same medication

• The physician supports the drug interchange as clinically appropriate for the patient

• Significant pharmacy cost savings can be achieved by the Prescription Drug Plan

SXC will notify a retail and/or mail-order pharmacist when there appears to be an opportunity for dose optimization. The pharmacist may contact the prescribing physician for approval of the dosage conversion.

Step therapy
The University will select a number of specific drug classifications where drugs must be prescribed in a progression. Selected drug classes are reviewed and based on medical evidence and cost. Physicians must verify the patient’s failure with a step drug progression or provide medical documentation that the patient should be dispensed a drug out of sequence.

Exclusions, Limitations Quantity Limits (QL)*, Prior Authorizations (PA), Dose Optimization, Step Therapy, and Self- Administered Injectable Medications

The list is subject to change.

*All Quantity Limit (QL) maximums are based on approved FDA dosing maximums.

Updated September 23, 2008

Drug Class/Drug Name	Special Conditions for Coverage
Sterile Water	Covered only for Self-administered injection. Irrigation water NOT covered.
ADD/Narcolepsy	All stimulants have maximum daily dosing limitations based on the FDA approved upper limit
Concerta	Prior Authorization age 18 and over; Dose Opt. on 18mg & 27mg tablets (for higher doses use 36mg & 54mg tabs)
Daytrana	Prior Authorization is required. (FDA approved only for ages 6-12)
Amphetamine salts (Adderall, Adderall XR), Desoxyn, Dexedrine, Dextrostat, Focalin, Focalin XR, methylphenidate (Metadate CD, Metadate ER, Methylin, Ritalin, Ritalin SR, Ritalin LA), Vyvanse	Prior Authorization required if age 18 and older
Allergic Emergency Kits/Insect Sting Kits
Epi-Pen, Epi- Pen Jr, Twinject	Self-administered injectable covered. 1 co-pay per every 2 pens.
Alzheimer’s
Aricept 5mg	Dose Optimization (for 10mg dose use 10mg tab)
Anabolic Steroids
Anadrol-50, Nandrolone, Oxandrin, Winstrol	Prior Authorization Required
Anemia Treatments
Aranesp, Epogen, Procrit	Self-administered injectable covered with approved Prior Authorization; Supply Maximum - 34 Days Supply per fill (90 day fills not allowed)
Antianginal
Ranexa	Prior Authorization Required
Anticholinergics
Atrovent Inhaler, Combivent Inhaler	QL Maximum - 2 per month or 6 per 90 days
Ipratropium (Atrovent UD Neb), Ipratropium and Albuterol (DuoNeb)	QL Maximum - 4 pkgs per month or 12 per 90 days
Spiriva	QL Maximum - 1 pkg per month or 3 per 90 days
Anticonvulsants
Lyrica	Dose Optimization on 25mg, 50mg, 75mg, 100mg, 150mg = Max. 4 caps/day. Use higher strength capsules;
gabapentin (Neurontin)	QL Maximum 3600mg/day
Antidepressant
citalopram (Celexa), paroxetine (Paxil)	Dose Optimization on 10mg, 20mg (for higher doses use the 20mg & 40mg tablets)
Effexor XR	Dose Optimization on 37.5mg, 75mg (for 150mg XR doses use the 150mg XR capsule)
Emsam	Prior Authorization is required
Fluoxetine	Dose Optimization on 10mg, 40mg (for 40mg and higher doses use multiples of 20mg caps)
Lexapro	Dose Optimization on 5mg, 10mg (for higher doses use the 10mg & 20mg tablets)
mirtazapine and SolTabs (Remeron)	Dose Optimization on 15mg (for higher doses use 30mg or 45mg tabs)
Paxil CR	Dose Optimization on 12.5mg
Prozac	Dose Optimization on 10mg
Zoloft	Dose Optimization on 25mg, 50mg
Anti-Emetics
Anzemet 100mg/5ml or 12.5mg/0.625 inj.	Self-administered injectable covered; QL Maximum - 5ml per month or 15ml per 90 days
Anzemet 50mg & 100mg Tablets	QL Maximum - 5 tabs per month or 15 per 90 days
Cesamet	QL Maximum of 6mg per day, and one course per fill. Step Therapy: previously treated with ondansetron (Zofran), granisetron (Kytril), dolasetron (Anzemet), or aprepitant (Emend).
dronabinol (Marinol) 2.5mg, 5mg, & 10mg Capsules	QL Maximum - 60 capsules. Not a maintenance medication.
granisetron (Kytril) 1 mg Tablet	QL Maximum - 12 tabs per month/ 36 per 90 days
granisetron (Kytril) Injection 1mg/ml	Self-administered injectable covered; QL Maximum -1ml per month or 3ml per 90 days
granisetron (Kytril) Injection 0.1mg/ml	Self-administered injectable covered; QL Maximum - 4ml per month or 12ml per 90 days
granisetron (Kytril) Oral Solution	QL Maximum - 60ml per month or 180ml per 90 days
Antifungal
fluconazole (Diflucan) 150mg	QL Maximum - 4 tabs per month or 12 per 90 days
terbinafine (Lamisil)	QL Maximum - 12 weeks per year
itraconazole (Sporanox)	Oral form covered with approved Prior Authorization
Antihistamine
fexofenadine (generic for Allegra)	QL Maximum - 30mg & 60mg tablets = 2 per day; 180mg tablet = 1 tablet per day. Brand Allegra products are Not Covered.
Clarinex, Xyzal	Not Covered
Diphenhydramine HCL	Self-administered injectable covered
Zyrtec 1mg/ml Syrup	Not Covered
Zyrtec tablets and chewables	Not Covered
Antihistamine/Decongestant
Allegra-D 12 Hour, Zyrtec-D 12 Hour	Not Covered
Allegra-D 24 Hour, Clarinex-D	Not Covered
Anti-Infective
ciprofloxacin sustained release (Cipro XR)	QL Maximum - 500mg XR = 3; 1000mg XR = 14 (Based on FDA approved dosing)
colistimethate (Coly-Mycin M)	Self-administered injectable covered
Xifaxan	QL Maximum - 9 tablets, PA required for larger supplies.
Antipsychotic
Zyprexa (includes Zydis)	Dose Optimization on 2.5mg, 5mg
Arthritis Agent
Enbrel, Humira, Kineret	Self-administered injectable covered with approved Prior Authorization; Supply Maximum - 34 Days Supply per fill (90 day fills not allowed)
Leflunomide (Arava)	Prior Authorization Required
methotrexate 25mg/ml	Self-administered injectable covered
Asthma
Accolate & Zyflo	Step Therapy - Prior claim for inhaled corticosteroid or combination product AND one short acting beta-agonist; OR prior claim for Accolate or Zyflo
Singulair	Step Therapy age>5 - Prior claim for inhaled corticosteroid or combination product AND one short acting beta-agonist; OR prior claim for a nasal steroid, Intal or Singulair.
Xolair	Self-administered injectable covered with approved Prior Authorization; Supply Maximum - 34 Days Supply per fill (90 day fills not allowed)
Bladder Irrigation Solutions
Gentamicin	Injection Covered only as a compounded medication for bladder irrigation solution
Bone Loss Prevention
Calcitonin Injection (i.e., Miacalcin)	Self-administered injectable covered
Forteo	Self-administered injectable covered, Supply Maximum - 34 Days Supply per fill (90 day fills not allowed)
Cancer
Proleukin	Self-administered injectable covered
Cholesterol-Reducing Medication	Step Therapy for New Starts requires 'generics first' except Lipitor 80mg
Altoprev	QL = 1 tablet per day.
Crestor	Dose Optimization on 5mg,10mg, 20mg, 40mg. Voluntary Pill-Splitting Incentive Program 10mg 20mg, 40mg = 50% copay reduction.
Lipitor, pravastatin (Pravachol)	Dose Optimization on 10mg, 20mg, 40mg. Voluntary Pill-Splitting Incentive Program 20mg, 40mg & 80mg = 50% copay reduction.
Lovastatin (Mevacor)	Voluntary Pill-Splitting Incentive Program 20mg, 40mg = 50% copay reduction.
simvastatin (Zocor)	Dose Optimization on 5mg 10mg, 20mg, 40mg. Voluntary Pill-Splitting Incentive Program 10mg 20mg, 40mg & 80mg = 50% copay reduction.
Vytorin	QL = 1 tablet per day.
Constipation, chronic idiopathic
Amitiza	Prior Authorization Required
Contraceptive
medroxyprogesterone acetate (Depo-Provera)	Self-administered injectable covered
Diabetic Medication
Actos	Dose Optimization on 15mg tablet (for 30mg dose use 30mg tablets)
Avapro	Dose Optimization on 75mg, 150mg tablets (for higher dose use the 150mg or 300mg tablets)
Byetta	Self-administered injectable covered only for diabetics also using an oral hypoglycemic agent.
Glucagon, insulin, Symlin	Self-administered injectable covered
Januvia	Dose Optimization on 25mg, 50mg tablets (for higher dose use 50mg or 100mg tablets). Maximum dose is 100mg per day.
Diabetic Ulcer
Regranex	Prior Authorization required
Eczema
Elidel/Protopic	PA required; Step Therapy: Over age 2, Previously treated with at least 2 trials of a topical steroid.
Erectile Dysfunction
Caverject, Edex	Self-administered injectable covered. PA required for under age 35. QL Maximum - 6 units per month or 18 units per 90 days, 72 per year
Cialis, Levitra, Muse, Viagra	PA required for under age 35. QL Maximum - 6 units per month or 18 units per 90 days, 72 per year
Gastrointestinal	Step Therapy for New Starts requires trial of generic omeprazole before brand products.
Aciphex, Nexium, Prevacid, Protonix	PA required for dosing above 1 per day.
Omeprazole (Prilosec)	Brand Prilosec not covered. Dose Optimization on 10mg. For higher dosing use 20 mg or multiples of 20mg.
Growth Hormones
Examples: Genotropin, Geref, Humatrope, Increlex, Iplex, Norditropin, Nordiflex Pen, Nutropin, Nutropin AQ, Nutropin Depot, Omnitrope, Saizen, Serostim, Tev-Tropin, Zorbtive	Self-administered injectable covered with approved PA; Supply Maximum - 34 Days Supply per fill (90 day fills not allowed)
Heparin & Low Molecular Weight Heparins
Arixtra, Fragmin, Innohep, Lovenox	Self-administered injectable covered; Supply Maximum - 34 Days Supply per fill (90 day fills not allowed)
Hepatitis C
Rebetron	Self-administered injectable covered
HIV-1 Replication
Fuzeon	Self-administered injectable covered with approved PA; Supply Maximum - 34 Days Supply per fill (90 day fills not allowed).
Hormonal Diagnostics
Factrel	Self-administered injectable covered
Hormone Replacement
Estrogen in Oil, Progesterone in Oil, Testosterone in Oil	Self-administered injectable covered only in oil form
Hypertension
Benicar	Dose Optimization on 20mg
Diovan HCT	Dose Optimization on 80mg/12.5mg
Amlodipine (Norvasc)	Dose Optimization on 2.5mg, 5mg
Tekturna	Dose Optimization on 150mg tablets (for 300mg dose, use 300mg tablets). Maximum dose is 300mg per day.
Immune Globulin
Vivaglobin	Self-administered injectable, prior authorization is required. Supply Maximum – 34 days supply per fill (90 day fills not allowed).
Irritable Bowel Syndrome (IBS)
Lotronex	Prior Authorization required
Infertility Agents
Examples: Gonal-F, Fertinex, Bravelle, Follistim, Antagon, Cetrotide, Repronex, Menopur, Profasi, Pregnyl, Noverel, chorionic gonadotropin-hCG, Ovidrel	Self-administered injectable. Prior Authorization is only required if you are age 45 or older. A combined lifetime family maximum benefit of $5,000 applies to all regardless of age
Influenza Treatment and Prevention
Relenza	QL Maximum – 20 capsules every 180 days
Tamiflu	QL Maximum - 60mg/5ml oral liquid = 75ml every 180 days; 45mg & 75mg capsules = 10 caps every 180 days; 30mg capsules = 20 caps every 180 days
Interferons
Actimmune, Alferon N, Infergen, Intron A, Peg-Intron, Roferon A	Self-administered injectable covered
Malaria
Qualaquin	Minimum daily dose of 2 per day and maximum days supply of 14 days per year. This product is only FDA approved for treatment of malaria.
Mast Cell Stabilizers
cromolyn sodium Neb Solution (Intal Neb)	QL Maximum - 1 pkg per month or 3 per 90 days
Intal MDI	QL Maximum - 1 per month or 3 per 90 days
Migraine
Amerge 1mg & 2.5mg, Frova 2.5mg	QL Maximum - 9 per month or 27 per 90 days
Axert 6.25 & 12.5mg	QL Maximum - 12 per month or 36 per 90 days
D.H.E. – 45	Self-administered injectable covered
Imitrex Injection	Self-administered injectable covered. QL Maximum - Kits (2 injections) = 4 per month or 12 per 90 days; vials = 8 per month or 24 per 90 days
Imitrex NS 5 & 20mg, Maxalt & Maxalt MLT 5mg & 10mg	QL Maximum - 12 per month or 36 per 90 days
Imitrex Tablets	QL Maximum – 25 & 50mg tabs = 18 per month or 54 per 90 days; 100mg tablets = 9 per month or27 per 90 days
Migranal NS 4ml pkg	QL Maximum - 4ml per month or 12ml per 90 days
Relpax 20 & 40mg	QL Maximum - 6 per month or 18 per 90 days
Treximet	QL Maximum – 9 per month or 27 per 90 days
Zomig NS (6/box)	QL Maximum - 6 per month or 18 per 90 days
Zomig Tablets & ZMT	QL Maximum - 2.5mg = 12 per month or 36 per 90 days; 5mg = 6 per month or 18 per 90 days
Multi-Class
Desmopressin (i.e., DDAVP)	Self-administered injectable covered
Multiple Sclerosis Treatment
Avonex, Betaseron, Copaxone, Rebif	Self-administered injectable covered; Supply maximum – 34 Days Supply per fill (90 day fills not allowed)
Myeloid Stimulants
Leukine, Neulasta, Neupogen	Self-administered injectable covered; Supply Maximum - 34 Days Supply per fill (90 day fills not allowed)
Prokine	Self-administered injectable covered with approved PA; Supply Maximum - 34 Days Supply per fill (90 day fills not allowed)
Narcolepsy/SWSD/EDS with Sleep Apnea
Provigil	Prior Authorization required; Dose opt on 100mg; Max allowed dosing 400mg/day
Nasal Spray
Astelin Nasal 30ml, Beconase AQ, flunisolide 0.025% (Nasalide), flunisolide 0.025% (Nasarel), fluticasone (Flonase), Nasacort AQ, Nasonex, Omnaris, Patanase, Rhinocort Aqua, Veramyst	QL Maximum - 1 per month or 3 per 90 days
Osteoporosis
Actonel 35mg & 75mg, alendronate 35mg & 75mg (Fosamax) and just below that, add Actonel 150mg in front of Boniva 150mg	QL Maximum - 4 tabs per month or 12 tabs per 90 days
Boniva 150mg	QL Maximum - 1 tab per month or 3 tabs per 90 days
Pain Medication
butorphanol (Stadol)	Self-administered injectable covered
butorphanol NS (Stadol NS)	QL Maximum - 1 bottle
Celebrex	PA, Step Therapy: Under age 60; Not currently taking anticoagulants; Not currently taking oral corticosteroids; Not taking clopidogrel (Plavix); Previously treated with at least 2 trials of a generic NSAID
fentanyl (Actiq & Fentora)	PA, QL Maximum - 4 units per day
ketorolac tabs (Toradol)	QL Maximum - 20 tablets
Parkinson’s
Apokyn	Self-administered injectable covered
Selegiline	Dose Optimization on 5mg capsule “use tablets”
Psoriasis
Raptiva	Self-administered injectable covered with approved PA; Supply Maximum - 34 Days Supply per fill (90 day fills not allowed)
Taclonex	Prior Authorization is required. QL Maximum of 28 days supply per calendar year.
Platelet Proliferation Stimulants
Neumega	Self-administered injectable covered; Supply Maximum - 34 Days Supply per fill (90 day fills not allowed)
Precocious Puberty
Supprelin subcutaneous	Self-administered injectable covered
Prostatic Cancer
Leuprolide subcutaneous (Lupron)	Lupron Depot IM is NOT covered. Only self-administered SQ injectable is covered. Contact your medical plan for Lupron Depot coverage information.
Pulmonary Arterial Hypertension (PAH)
Revatio, Ventavis	Prior Authorization is required.
Respiratory Agents
albuterol (AccuNeb UD Neb), Xopenex UD Neb 0.31mg, 0.63mg, 1.25mg/3ml	QL Maximum - 4 pkgs per month or 14 per 90 days
Advair Diskus, Advair HFA, Flovent HFA, Foradil, Perforomist, Pulmicort Turbohaler, Pulmicort Respules 1mg/2ml, Servent Diskus, Symbicort	QL Maximum – 1 pkg per month or 3 pkgs per 90 days
Aerobid, Aerobid M, Pulmicort Respules 0.25mg/2ml or 0.5mg/2ml, Xopenex UD Neb1.25mg/0.5ml	QL Maximum - 3 pkgs per month or 9 pkgs per 90 days
Albuterol MDI Inhaler, Alupent MDI Inhaler, Asmanex, Azmacort, Brovana, Maxair, Proventil HFA, Pulmicort Flexhaler, ProAir HFA (Tier 1 copay), Qvar, Ventolin HFA, Xopenex HFA	QL Maximum - 2 pkgs per month or 6 pkgs per 90 days
Albuterol Nebulizer Solution	QL Maximum - 0.5% 20ml = 3 pkgs per month or 9 per 90 days; 0.83% soln = 4 pkgs per month or 12 per 90 days
metaproterenol (Alupent Nebulizer Solution)	QL Maximum - 0.4% & 0.6% soln: 4 pkgs/month or 12pkgs per 90 days
Flovent Diskus	QL Maximum - 100mcg & 250mcg = 2 per month or 6 per 90 days; 50mcg = 1 per month or 3 per 90 days
Sedative/Hypnotics
Ambien CR 6.25 & 12.5mg	QL Maximum - 1 per day
Doral 7.5 & 15mg	QL Maximum - 15mg per day
estazolam (ProSom) 1mg & 2mg	QL Maximum - 2mg per day
flurazepam (Dalmane) 15 & 30mg	QL Maximum - 30mg per day
Lunesta 1mg, 2mg, 3mg	Dose Optimization on 1mg and 2mg. QL Maximum - if < 65 years = 3mg per day; if 65 years = 2mg per day
temazepam (Restoril) 15mg & 30mg	QL Maximum - 30mg per day
triazolam (Halcion) 0.125 & 0.25mg	QL Maximum - 0.25mg per day
zaleplon 5mg and 10mg (Sonata)	QL Maximum - 20mg per day
zolpidem (Ambien) 5mg & 10mg	QL Maximum - 10mg per day
Smoking Cessation Products
Chantix	QL Maximum 90 days supply every calendar year. PA for 2nd 12 week course of therapy.
Nicotrol Inhaler, Nicotrol NS, Zyban	QL Maximum 90 days supply every calendar year.
Somatostatic Agent
octreotide acetate (Sandostatin), Sandostatin LAR, Somavert, Somatuline	Self-administered injectable covered; Supply Maximum - 34 Days Supply per fill (90 day fills not allowed)
Steroid
Acthar HP	Self-administered injectable covered
Topical Acne Agents
Differin, Tazorac	Prior Authorization required for age 40 and over
Vitamin
Vitamin B-12, Vitamin D, Vitamin K	Self-administered injectable covered
Weight Loss Medications
Meridia, Xenical	PA required. 180 days lifetime maximum