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 Prior Authorizations & Drugs with Special Limitations 


Prior Authorization

Your prescription drug program provides coverage for some drugs only if they are prescribed for certain uses and amounts, so those drugs require prior authorization for coverage. Prior Authorization is handled by the Rational Drug Therapy Program (RDT). If your medication must be authorized, your pharmacist or physician can initiate the review process for you. The prior authorization process is typically resolved over the phone; if done by letter it can take up to two (2) business days. If your medication is not approved for plan coverage, you will have to pay the full cost of the drug.

PEIA will cover, and your pharmacist can dispense, up to a five (5) day supply of a medication requiring prior authorization for the applicable copayment. This policy applies when your doctor is either unavailable or temporarily unable to complete the prior authorization process promptly. Prior authorizations may be approved retroactively for up to thirty (30) days to allow time for the physician to work with and provide documentation to RDT. If the prior authorization is ultimately approved, your pharmacist will be able to dispense the remainder of the approved amount with no further copayment for that month’s supply if you have already paid the full copayment.

The medications listed below require prior authorization:

  • adalimumab (Humira®)*
  • ambrisentan (Letairis®)*
  • amphetamines (Adderall XR®, Vyvanse®)
  • anakinra (Kineret®)*
  • armodafinil (Nuvigil®)
  • atomoxetine (Strattera®)
  • becaplermin (Regranex®)
  • bimatoprost (Lumigan®)
  • bosentan (Tracleer®)*
  • botulinum toxin Type A (Botox®)*
  • Brand-name medically necessary prescriptions. If the medication your doctor prescribes is a multi-source drug (more than one manufacturer markets the drug) and there is an FDA‐approved or “A‐B‐rated” generic on the market, then PEIA will pay only for the generic version, unless your physician provides medical justification for 90 coverage of the brand-name drug. If prior authorization is granted, these drugs will be covered as non-preferred brand-name drugs.
  • certolizumab (Cimzia®)
  • ciclopirox (Penlac®)
  • corticotropin (Acthar®)*
  • enfuvirtide (Fuzeon®)*
  • erythroid stimulants (Epogen®, Procrit®, Aranesp®)*
  • etanercept (Enbrel®)*
  • etravirine (Intelence®)
  • exenatide (Byetta®)
  • fentanyl (Actiq®, Duragesic®, and Fentora®)
  • fluconazole (Diflucan®)
  • golimumab (Simponi®)
  • growth hormones*
  • itraconazole (Sporanox®)
  • latanoprost (Xalatan®)
  • legend oral contraceptives for dependents (covered for treatment of medical conditions only)
  • leuprolide (Lupron®, Lupron Depot®)*
  • maraviroc (Selzentry®)
  • modafinil (Provigil®)
  • botulinum toxin Type B (Myobloc®)*
  • oxycodone hydrochloride (Oxycontin®)
  • quetiapine (Seroquel®)
  • raltegravir (Insentress®)
  • rilonacept (Arcalyst®)
  • sacrosidasesacrosildase (Sucraid®)
  • sildenafil (Revatio®)
  • stimulants (Concerta®, Focalin XR®)
  • tazarotene (Tazorac®)
  • terbinafine (Lamisil®)
  • teriparatide (Forteo®)*
  • travoprost (Travatan/Z®)
  • tretinoin cream (e.g. Retin-A) for individuals 27 years of age or older
  • topiramate (Topamax®)
  • vacation supplies of medication for foreign travel (allow 7 days for processing)
  • voriconazole (VFEND®)
  • zonisamide (Zonegran®)
*These drugs must be purchased through the Common Specialty Medications Program. See information later in this section.

This list is subject to change during the plan year if circumstances arise which require adjustment. Changes will be communicated to members through the PEIA News. The changes will be included in PEIA’s Plan Document, which is filed with the Secretary of State’s office, and will be incorporated into the next edition of the Summary Plan Description.

Step Therapy

Step Therapy promotes appropriate utilization of first-line drugs and/or therapeutic categories. Step Therapy requires that participants receive one or more first-line drug(s), as defined by program criteria before prescriptions are covered for second-line drugs in defined cases where a step approach to drug therapy is clinically justified.

To promote use of cost-effective first-line therapy, PEIA uses step therapy in the following therapeutic classes:

  • Alzheimer’s Disease (Aricept®, Razadyme/ER®, Exelon®, Exelon Patch®, Cognex®)
  • Analgesics (Ultram/ER®, Ultracet®, Ryzolt®)
  • Angiotensin-Converting Enzyme (ACE) Inhibitors (Accuretic®, Accupril®, Aceon®, Altace®, Capoten®, Capozide®, Lexxel®, Lotesin/HCT®, Lotrel®, Mavik®, Monopril/HCT®, Prinivil®, Prinizide®, Tarka®, Uniretic®, Univasc®, Vasotec®, Vaseretic®)
  • Angiotensin II Receptor Antagonists (Atacand/HCT®, Teveten/HCT®, Avapro®, Cozaar®, Benicar/HCT®, Micardis/HCT®, Diovan/HCT®, Avalide®, Hyzaar®, Az0r®, Exforge®)
  • Anti-depressants (Cymbalta®, Effexor/XR®, Symbyax®, Wellbutrin XL®, Pristiq®, Aplenzin®, venlafaxine ER, Savella®)
  • Antihistamines (Zyrtec®, Allegra®, Clarinex®; Clarinex® Reditabs®)
  • Anti-hypertensives (Covera HS®, Verelan PM®, Norvasc®, Cardene SR®, Sular®, DynaCirc CR®, Tekturna®)
  • Benign Prostatic Hypertrophy (Avodart®, Proscar®)
  • Beta Blockers (Sectral®, Tenormin®, Kerlone®, Zebeta®, Coreg®, Trandate®, Lopressor®, Toprol XL®, Corgard®, Levatol®, Visken®, Inderal®, Inderal® LA , InnoPran XL®, Blocadren®, Tenoretic®, Ziac®, Lopressor® HCT , Corzide®, Inderide®, Timolide®, Coreg CR®, Bystolic®)
  • Bisphosphonates (Fosamax®, Fosamax Plus D™, Actonel®, Actonel® with Calcium, Boniva®)
  • Cholesterol-lowering medications (Advicor®, Altoprev®, Caduet®, Crestor®, Lescol®, Lipitor®, Pravachol®, Vytorin®, Zetia®, Simcor®)
  • Fenofibrates (Tricor®, Lofibra®, Antara®, Triglid®, Lipoten®, Fenoglide®, Trilipix®)
  • Leukotriene Inhibitors (e.g., Accolate®, Singulair®, Zyflo®, Zyflo CR®)
  • Lyrica®
  • Mirapex®
  • Nasal Steroids (Rhinocort Aqua™, Flonase®, Beconase AQ®, Nasacort AQ®, Nasarel®, Nasonex®, Veramyst®,Omnaris®)
  • Non-Steroidal Anti-inflammatory Drugs (brand-name NSAID e.g., Celebrex®, Arthrotec®, Mobic®)
  • Overactive Bladder: (Ditropan®, Ditropan XL®, Oxytrol®, Detrol®, Detrol LA®, Sanctura®, Toviaz®, Vesicare®, Enablex®, Sanctura XR®)
  • Proton Pump Inhibitors (e.g., Prilosec®, Prevacid®, Nexium®, Aciphex®, Protonix®, Zegerid®, Kapidex®)
  • Requip/XL®
  • Sedative Hypnotics (Ambien®, Ambien CR™, Sonata®, Lunesta™, Rozerem™)
  • Selective Serotonin Reuptake Inhibitors (e.g., Celexa®, Lexapro®, Luvox®, Paxil®, Paxil CR®, Prozac®, Prozac Weekly®, Zoloft®, Sarafem®, Pexeva®, Luvox CR®)
  • Strattera®
  • Thiazolidinedione (TZD) (Actos®, Avandia®, Actoplus®, Avandamet®, Duelact®, Avandaryl®)
  • Topical Steroids -- various
  • Xopenex®
This list is subject to change during the plan year, if circumstances arise which require adjustment. Changes will be communicated to members through the PEIA News. The changes will be included in PEIA’s Plan Document, which is filed with the Secretary of State’s office, and will be incorporated into the next edition of the Summary Plan Description.

Quantity Limits

Under the PEIA PPB Plan Prescription Drug Program, certain drugs have preset coverage limitations (quantity limits). Quantity limits ensure that the quantity of units supplied in each prescription remains consistent with clinical dosing guidelines and PEIA’s benefit design. Quantity limits encourage safe, effective and economic use of drugs and ensure that members receive quality care. Select medications from the quantity limit list are provided below. If you are taking one of the medications listed below and you need to get more of the medication than the plan allows, ask your pharmacist or doctor to call RDT to discuss your refill options.

  • Antipsychotic Drugs (Abilify® 30 units, Geodon® 60 units, Risperdal® 60 units, Seroquel® varies, Zyprexa® 30 units, and Zyprexa Zydis® 30 units)
  • Antiemetics:

Aloxi® is limited to 1 capsule/vial per prescription
Anzemet® is limited to 1 tablet per prescription
Cesamet® is limited to 30 capsules per prescription
Emend® 40 mg is limited to 1 capsule per prescription
Emend® 80 mg is limited to 2 capsules per prescription
Emend® 115 mg vial is limited to 1 vial per prescription
Emend® 125 mg is limited to 1 capsule per prescription
Emend® Bi-fold Pack is limited to 1 package per prescription
Emend® Tri-fold Pack is limited to 1 package per prescription
Kytril® is limited to 2 tablets/1 bottle per prescription
Sancuso® is limited to 1 patch per prescription
Zofran® 24 mg is limited to 1 tablet per prescription
Zofran® 4mg and 8 mg are limited to 12 tablets per prescription
Zofran® ODT 4mg and 8 mg are limited to 12 tablets per prescription
Zofran® Solution is limited to 3 bottles per prescription

  • Actiq® and Fentora®. Coverage is limited to 90 lozenges per 30 days
  • Cholesterol Lowering Medications. (Advicor® varies, Caduet® 30 units, Vytorin® 30 units, Altoprev® 30 units, Crestor® 30 units, Lescol® varies, Lipitor® 30 units, lovastatin varies, mevacor 30 units, Pravachol® 30 units, pravastatin sodium 30 units, Simcor® 30 units, simvastatin 30 units, and Zocor® 30 units)
  • Diflucan® 150 mg. Coverage is limited to 2 tablets per prescription
  • Enbrel®. Coverage is limited to 4 syringes or 8 vials per prescription
  • Humira®. Coverage is limited to 2 syringes/pens per prescription
  • Invega®. Coverage limit varies.
  • Migraine medications. Coverage is limited to quantities listed below:

 Generic Name

 Brand 
Name

 Quantity Limit Per Dispensing

 Total Quantity Level Limit within a 28-Day Period

 Almotriptan tablets 6.25 mg

 Axert®

 6 tablets

 18 tablets
 Almotriptan tablets 12.5 mg  Axert®   12 tablets  24 tablets
 Dihydrergotamine nasal spray, 4 mg/ml vial  MIgranal®  1 kit  1 kit = 8 unit dose sprays
 Eletriptan tablets 20 mg, 40 mg  Relpax®  6 tablets  18 tablets
 Frovatriptan tablets 2.5 mg  Frova®  9 tablets  27 tablets
 Naratriptan tablets 1 mg,
2.5 mg		  Amerge®  9 tablets   18 tablets
 Rizatriptan tablets 5 mg, 10 mg, orally disintegrating tablets  Maxalt-MLT®   12 tablets   24 tablets
 Rizatriptan tablets 5 mg, 10 mg  Maxalt® - Merck  12 tablets  24 tablets
 Sumatriptan injection syringes, 4 mg/0.5 ml and 6 mg/0.5 ml  Imitrex® Statdose System®  1 kit   8 kits = 16 injections
 Sumatriptan injection vials, 4 mg/0.5 ml  Generics  2 vials  16 vials
 Sumatriptan injection vials, 6 mg/0.5 ml  Imitrex®, generics  2 vials  16 vials
 Sumatriptan nasal spray 20 mg  Imitrex®, generics  1 box  3 boxes = 18 unit dose spray devices
 Sumatriptan nasal spray 5 mg  Imitrex®,  generics  1 box  6 boxes = 36 unit dose spray devices
 Sumatriptan tablets 25 mg, 50 mg, 100 mg  Imitrex®,  generics  9 tablets  18 tablets
 Sumatriptan (85 mg) and naproxen sodium (500 mg) tablets TreximetTM   9 tablets  18 tablets
 Zolmitriptan nasal spray 5 mg Zomig®  1 box  3 boxes = 18 unit dose spray devices
 Zolmatriptan tablets 2.5 mg,
5 mg orally disintegrating tablets		  Zomig-ZMT®  6 tablets  18 tablets
 Zolmatriptan tablets 2.5 mg,
5 mg		  Zomig®  6 tablets  18 tablets


  • New drugs approved by the FDA that have not yet been reviewed by Express Scripts’ Pharmacy and Therapeutics Committee will have a non-preferred status. PEIA reserves the right to exclude a drug or technology from coverage until it has been proven effective.
  • Nuvigil®. Coverage is limited to 60 units per 30-day supply
  • Other Antidepressants (Budeprion SR® 60 units, Budeprion XL® 30 units, Bupropion HCL SR® 60 units, Wellbutrin SR® 60 units and Wellbutrin XL® 30 units, Aplenzin® 30 units)
  • Oxycontin®. Coverage is limited to 90 tablets per prescription
  • Provigil®. Coverage is limited to 60 units per 30-day supply
  • Sedative Hypnotics (Ambien®, Ambien CR™, Doral®, estazolam, flurazepam, Lunesta™, Restoril®, Rozerem™, Sonata®, temazepam, triazolam). Coverage is limited to 15 units per 30 days.
  • Selective Serotonin Reuptake Inhibitors (Celexa® 30 units, citalopram HBR 30 units, fluoxetine HCL varies, fluvoxamine maleate varies, Lexapro® 30 units, Luvox CR varies, ®,paroxetine HCL® varies, Paxil® varies, Paxil CR® 60 units, Pexeva® varies, Prozac Weekly® 5 units, Sarafem® 30 units, Selfemra ™ varies, sertraline HCL® varies, and Zoloft® varies)
  • Seroquel XR®. Coverage limit varies.
  • Serotonin‐Norepinephrine Reuptake Inhibitors (Cymbalta® varies, Effexor® varies, Effexor XR® varies, Pristiq® 30 units, Savella® varies, venlafaxine ER® varies)
  • Toradol. Coverage is limited to one course of treatment (5 days) per 90-day period.
  • Tamiflu® and Relenza®. Coverage is limited to one course of treatment within 180 days. Additional quantities require prior authorization from RDT.
  • Vasodilator Antihypertensives (Cardura XL® 30 unit, Doxazosin Mesylate® varies, and Terazosin HCL® varies)
†These drugs must be purchased through the Common Specialty Medications Program.

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