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.
Question | Answer |
---|---|
Form Name | Prime Therapeutics Pa Form |
Form Length | 6 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min 30 sec |
Other names | editable prime therapeutics prior authorization form, prime therapeutics pa form pdf, prime therapeutics prior authorization forms, prime therapeutics prior auth form |
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
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
of pocket cost share when using an
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 |
|
|
|
|
|
Dificid
40 tabs / 180 days
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
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
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.