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Quality Management Drug Program ConnectiCare has a Quality Management Drug Program to limit certain medication quantities to established amounts. The goal of this program is to ensure compliance with FDA and manufacturer dosing recommendations and/or avoid abuse and misuse. For the following drugs, reimbursement through the pharmacy benefit will be limited to the quantities below unless Pharmacy Services has received a medical necessity request from the prescribing physician and ConnectiCare has authorized the exception. To submit request for additional quantities please use Prior Authorization form. Form can be printed at ConnectiCare.com or obtained by calling ConnectiCare at 800-251-7722. Please note: The quantities below are the limits set up for dispensing by pharmacies to members for selfadministration following a doctor's prescription. One time administration of these drugs by doctors or other providers will not be impacted by these limits, nor should one-time administration quantities exceed these amounts. No selfadministered medication (Zofran, Epogen, Neupogen, oral chemotherpay medications, etc.), even those not on this list, may be dispensed for self-administration by ConnectiCare providers and billed through the medical benefit, they must be dispensed through a participating pharmacy. Drug Quantity Limit Comments Aciphex 2 tabs/ day Acular 2 bottles /month Actiq 24 lozenges/ month Actos 1/day Advair 1 diskus/ month 60 blisters/ diskus, maximum dose is twice daily Alocril 2 bottles/ month Alrex 2 bottles/ month Ambien 30 tabs/ month Amerge tablets 9 tablets/ month Antibiotics >90 days of use Antibiotics are monitored to avoid unnecessary long term use. Antidepressants 1/day Prozac, Paxil/CR, Celexa, Zoloft, Lexapro, Prozac Weekly QL 4/ month Antihistamines 1 / day Zyrtec, Allegra, Clarinex, (Allegra 30mg or 60mg 2/day) Anzemet tablets 2 tablets/ month For Chemotherapy use, other uses should be PA’d Aranesp 4 vials/ month Arixtra 10 syringes/ month (CCI use only: Set up as 10/90DS) Avandia 2/day Axert 9 tablets/ month Bextra 1/day 10mg 1/day , 20mg 1/day no males Celebrex 2 / day Cholesterol / Statins 1 tab/ day Lipitor, Pravachol, Zocor, Lescol, Crestor Cipro XR 3 tabs / treatment Crolom 2 bottles/ month Diflucan 150 mg tablet 2 tablets/ month Elidel 100g/ month This limit applied after step therapy authorization Emend 1 three pack / cycle 1 tab= 125mg, 2 tabs = 80mg Enbrel 2 Trays( 8 syringes)/mo Twice weekly administration Epogen / Procrit 12 vials/ month Note: Multidose vials are 4/month (10K, 20k, 40K units) Epipen 2 syringes / month The boxes of 2 are limited to 1 box ( 2 syringes) Fragmin 14 syringes/ month (CCI use only: Set up as 14/90DS) Flovent 2 inhalers, diskus, rotodisks/ month Frova 9 tablets / month Humira 2 syringes/ month Updated 5/2003 Quality Management Drug Program ConnectiCare has a Quality Management Drug Program to limit certain medication quantities to established amounts.
Approximate Word count = 1126
Approximate Pages = 4.5
(250 words per page double spaced)
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