Prime Therapeutics Prior Authorization Forms Details

Prime Therapeutics Pa Form is a service that provides pharmacy benefits management for individuals and families. This form can help you to get the most out of your prescription drug coverage. By using this form, you can learn about your plan's benefits and how to use them correctly. You can also find out more about the drugs that are covered by your plan. Prime Therapeutics Pa Form is a great resource for anyone who wants to better understand their pharmacy benefits. If you have any questions or need help completing the form, please call Prime Therapeutics at 1-800-282-0515.

The listing includes information regarding the prime therapeutics pa form. There, you'll discover the information regarding the PDF you intend to fill out, which includes the estimated time to complete it along with other data.

QuestionAnswer
Form NamePrime Therapeutics Pa Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other nameseditable prime therapeutics prior authorization form, prime therapeutics pa form pdf, prime therapeutics prior authorization forms, prime therapeutics prior auth form

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Page 1 of 6

Effective January 1, 2012, Blue Cross and Blue Shield of Florida, Inc. (BCBSF) and Health Options, Inc. will expand our Responsible Rx pharmacy program for BlueCare, BlueChoice and BlueOptions. Responsible Rx refers to an umbrella of programs including Prior Authorization, Responsible Step and Responsible Quantity programs. Members with endorsements that support these programs may be affected.

Prior Authorization

Effective January 1, 2012, the medications listed below will require prior authorization for coverage under the member’s pharmacy benefit.

Oral Oncology

Afinitor® (everolimus)

Nexavar® (sorafenib)

Temodar® (emozolomide)

Xeloda® (capecitabine)

Caprelsa® (vandetanib)

Oforta® (fludarabine)

Targretin® (bexarotene)

Zelboraf® (vemurafenib)

Gleevec® (imatinib)

Revlimid® (lenalidomide)

Thalomid (thalidomide)

Zolinza® (vorinostat)

Hexalen® (altretamine)

Sprycel® (dasatinib)

Tretinoin® (oral)

Zytiga® (abiraterone)

Hycamtin® (topotecan)

Sutent® (sunitinib)

Tykerb® (lapatinib)

Sylatron® (peginterferon)

Matulane® (procarbazine)

Tarceva® (erlotinib)

Votrient® (pazopanib)

 

Lysodren® (mitotane)

Tasigna® (nilotinib)

Xalkori® (crizotinib)

 

The intent of the Oral Oncology Agents Prior Authorization (PA) program is to ensure appropriate selection of patients for treatment according to product labeling and/or clinical studies and clinical guidelines. Patients currently prescribed therapy with one of these agents will be able to continue their established therapy. New prescriptions after January 1, 2012 will require review.

Pharmaceutical compendia [National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium, American Hospital Formulary Service (AHFS) Drug Information, DrugDex, and Clinical Pharmacology] may be consulted to evaluate for medically accepted off-label use. Prior Authorization requests for oral oncology agents will be reviewed when patient-specific documentation is provided.

BCBSFL will also be classifying these oral oncology medications as specialty pharmacy medications, effective January 1, 2012. BCBSF’s preferred specialty pharmacy provider is CVS Caremark Specialty Pharmacy. CVS Caremark’s toll free number is 1-866-278-5108. Some members may pay a higher out

of pocket cost share when using an out-of-network pharmacy for specialty medications.

New Drugs to Existing Programs

Orencia subcutaneous® (abatacept)

Orencia subcutaneous will be added to our Immunomodulators PA program.

Prior authorization request forms are available on the provider website at www.bcbsfl.com under For Providers, then Pharmacy, and the Prior Authorization Program Information and Authorization forms link.

Page 2 of 6

Responsible Quantity Expansion

This program ensures coverage of certain prescription drugs that reflect dosing guidelines of drug manufacturers and the U.S. Food and Drug Administration (FDA). The table below lists all additional medications and limits added to the Responsible Quantity Program effective January 1, 2012. This only applies to members in plans that are part of the Responsible Quantity Program. You can find a complete list of prescription drugs modified in the program at www.bcbsfl.com; select For Providers, Pharmacy, and then click the Responsible Quantity Program Information link.

Additions to the Responsible Quantity Program Effective 1/1/12

Responsible Quantity Program limits also apply to generic drugs where applicable

Brand/ Generic Name

Antidepressants

Strength

Dispensing Limit

Per Month

(unless noted)

Aplenzin

 

30 tabs

 

 

 

bupropion

75 mg

60 tabs

 

 

 

bupropion

100 mg

120 tabs

 

 

 

bupropion SR

100 mg, 150 mg, 200 mg

60 tabs

 

 

 

bupropion ER

150 mg, 300 mg

30 tabs

 

 

 

Celexa (citalopram)

tablets

30 tabs

 

 

 

Celexa (citalopram)

oral solution

600 mL

 

 

 

fluvoxamine

25 mg, 50 mg

30 caps

 

 

 

fluvoxamine

100 mg

90 caps

 

 

 

Lexapro

tablets

30 tabs

 

 

 

Lexapro

oral solution

600mL

 

 

 

Luvox CR

 

60 caps

 

 

 

Maprotiline

 

90 tabs

 

 

 

mirtazapine

7.5 mg, 15 mg, 30 mg, 45 mg

30 tabs

 

 

 

Oleptro

150 mg

45 tabs

 

 

 

Oleptro

300 mg

30 tabs

 

 

 

Paxil (paroxetine)

10 mg, 20 mg, 40mg

30 tabs

 

 

 

Paxil (paroxetine)

30 mg

60 tabs

 

 

 

Paxil (paroxetine)

oral suspension

900 mL

 

 

 

Paxil CR (paroxetine ER)

12.5 mg

30 tabs

 

 

 

Paxil CR (paroxetine ER)

25 mg, 37.5 mg

60 tabs

 

 

 

Pexeva (paroxetine)

10 mg, 20 mg, 40 mg

30 tabs

 

 

 

Pexeva (paroxetine)

30 mg

60 tabs

 

 

 

Prozac (fluoxetine)

10 mg

30 caps/tabs

 

 

 

Prozac (fluoxetine)

20 mg

120 caps/tabs

 

 

 

Prozac (fluoxetine)

40mg

60 caps

 

 

 

fluoxetine

60 mg

30 tabs

 

 

 

Prozac (fluoxetine)

oral solution

600 mL

 

 

 

Prozac weekly (fluoxetine)

 

4 caps / 28 days

 

 

 

Page 3 of 6

Additions to the Responsible Quantity Program Effective 1/1/12

Responsible Quantity Program limits also apply to generic drugs where applicable

 

 

Dispensing Limit

Brand/ Generic Name

Strength

Per Month

 

 

(unless noted)

Viibryd

10 mg, 20 mg, 40 mg

30 tabs

 

 

 

Zoloft (sertraline)

25 mg, 50 mg

30 tabs

 

 

 

Zoloft (sertraline)

100 mg

60 tabs

 

 

 

Zoloft (sertraline)

oral concentrate

300 mL

 

 

 

Anti-infectives

 

 

Dificid

40 tabs / 180 days

Anti-inflammatory

Orencia subcutaneous

4 syringes / 28 days

Diabetes

Juvisync

100 mg/10 mg, 100 mg/20 mg, 100 mg/40

30 tabs

(sitagliptin/simvastatin)

mg

 

Hematology

Xarelto

Xarelto

10 mg

35 tabs / 90 days

15 mg and 20 mg

30 tabs

 

 

Oral Oncology

Afinitor

Caprelsa

Caprelsa

Gleevec

Gleevec

Nexavar

Revlimid

Revlimid

Sprycel

Sprycel

Sutent

Sutent

Tarceva

Tarceva

Tasigna

Thalomid

Thalomid

Tykerb

Votrient

Xalkori

Zelboraf Zolinza

 

30 tablets

100 mg

60 tabs

300 mg

30 tabs

100 mg

90 tabs

400 mg

60 tabs

 

120 tabs

5 mg, 10 mg

30 caps

15 mg, 25 mg

21 caps/28 days

20 mg

60 tabs

50 mg, 70 mg, 80 mg, 100 mg, 140 mg

30 tabs

12.5 mg

90 caps

25 mg, 50 mg

60 caps

25 mg

60 tabs

100 mg, 150 mg

30 tabs

 

120 caps

50 mg, 100 mg

30 caps

150 mg, 200 mg

60 caps

 

180 tabs

 

120 tabs

 

60 caps

 

240 tabs

 

120 caps

 

 

Page 4 of 6

Additions to the Responsible Quantity Program Effective 1/1/12

Responsible Quantity Program limits also apply to generic drugs where applicable

 

 

Dispensing Limit

Brand/ Generic Name

Strength

Per Month

 

 

(unless noted)

Zytiga

 

120 tabs

 

 

 

Pain

Conzip

Nucynta ER

Suboxone/Subutex

30tabs

60tabs

15 tabs / 90 days

Vaccines

Influenza

1 / 90 days

For members requiring a larger monthly quantity than the coverage maximum, based on medical necessity, you may submit a prior authorization request by filling out the Quantity Limit Prior Authorization form at www.bcbsfl.com; select For Providers and then Pharmacy.

Responsible Steps Expansion

Drugs included in Responsible Steps Program and qualifying prerequisites beginning

1/1/12

 

New Programs

Prerequisite(s)

Hyalgan, Orthovisc, Supartz*

Euflexxa, Synvisc, Synvisc One

 

 

Juvisync

metformin, sulfonylureas, metformin/TZD

 

 

combination, metformin/sulfonylurea

 

 

combination, sulfonylurea/TZD combination

*this program is part of our Medical Step Therapy program and only applies medical claims for members in new HMO products that support medical step therapy

Authorization request forms are available on the provider website at www.bcbsfl.com under For Providers, then Pharmacy, then the Responsible Steps Program Information and Authorization Forms link.

Pharmacy Coverage Exclusions

Effective JANUARY 1, 2012, BCBSF commercial pharmacy plans will no longer cover the brand name drugs listed in the table below. However, BCBSF will cover many of their generic alternatives. This exclusion only applies to members in plans that allow pharmacy coverage exclusions.

Drugs not covered

 

Covered alternatives

 

 

 

Benzoyl Peroxide Wash 7% & Cream 5.5% Kit

 

benzoyl peroxide (Rx only)

 

 

 

Veltin gel, Ziana gel

 

clindamycin phosphate topical gel 1%, tretinoin

 

 

topical gel 0.025%

 

 

 

Page 5 of 6

Responsible Rx Expansion

QUESTIONS AND ANSWERS

Responsible Quantity

QUESTION: Why are there limits on the quantity that I can get on my prescription?

ANSWER: BlueCross and BlueShield of Florida has established quantity limits or coverage maximums for certain medications based on manufacturers and FDA approved dosing guidelines.

QUESTION: Will there be limits on all of my medicines?

ANSWER: Only medications included in the Responsible Quantity Program have quantity limits.

QUESTION: My doctor said I had to have this many pills. What can I do?

ANSWER: Responsible Quantity does not prevent you from receiving the medicine your doctor has prescribed for you. The program places a coverage maximum on select medicines filled in a 30-day period. If your doctor prescribed a greater quantity of the medicine for you, we will cover the Responsible Quantity maximum quantity for your usual copayment or coinsurance, and you may pay for the remainder of the quantity prescribed by your doctor. However, if your doctor determines you must have a greater quantity than the limit, your doctor can request an authorization from BlueCross and BlueShield of Florida to have a greater limit covered for you.

Page 6 of 6

Responsible Steps

QUESTION: I received a letter that said I would no longer have coverage for my medication unless I have tried a generic first. I do not like to use generics because I have read that they are not as effective as brand drugs.

ANSWER:

Generic drugs are FDA-approved and proven to be safe and effective for treating certain conditions. Please check with your doctor if a generic drug is right for you.

QUESTION: I have asked my doctor about generics and he/she put me on the brand drug that you are no longer covering. What can I do?

ANSWER: Check with your doctor if a generic drug is right for you. If not, authorization forms for drugs in our Responsible Steps program are available on our website. Your doctor will fill out the form and fax it in for review. Forms are available at www.bcbsfl.com under providers, then pharmacy, then Responsible Steps Program Information and Authorization Forms.

QUESTION: I have taken the prerequisite meds in the past, but it has been longer than the time period required in the responsible steps program. Can I still qualify for coverage?

ANSWER: In order for your claim for a responsible steps drug to be covered, you will need to have a claim for a prerequisite drug within the last 90 days.

QUESTION: It says that current users will not be affected by this step. Does this mean that no matter what, I can still get my prescription filled?

ANSWER: No. In order for your claim for your drug to be covered, you will need to have a claim in our system for a prerequisite drug within the last 90 days. In other words, you have to keep refilling your prescription regularly.