New Pharmacy Prior Authorization Changes for July 2011
There will be pharmacy prior authorization programs implemented for Xyrem® (sodium oxybate) on July 1 and Sedative Hypnotic agents on July 15.
Xyrem® (sodium oxybate) is a prescription medicine used for the treatment of narcolepsy to reduce too much daytime sleepiness and reduce cataplexy (weak or paralyzed muscles) attacks. Due to the safety concerns and known abuse potential for this medication, the Plan will require a prior authorization for all users to ensure the appropriate patients are receiving the medication at the recommended dose.
Currently, the Plan has a quantity limit on Sedative Hypnotic agents which limits them to a 15 days supply every 30 days unless approval is obtained for larger quantities.
Due to the recent release of generics in this category, mainly generic Ambien® and Ambien® CR, the Plan will now also require in addition to the quantity limit, that all members requesting a brand hypnotic, regardless of the quantity, have tried and failed or been intolerant to one generic hypnotic in the past. The step therapy requirement will become effective July 15, 2011. This requirement for trial of a generic first will apply to current and new users of brand sedative hypnotic agents.
The brand name medications affected by this step therapy program include Rozerem®, Sonata®, Ambien®, Ambien® CR, Lunesta®, Edluar™, Zolpimist™ and Silenor®.
The available generics include zolpidem, zolpidem ER, and zaleplon. Generic hypnotics will still be subject to quantity limits.
You or your provider can request a coverage review by calling Medco toll-free at 800-417-1764, 8 a.m. to 9 p.m., Eastern Time, Monday through Friday. If the review is approved, you will pay the appropriate copay for the prescription. If approval is not obtained after July 15, 2011, you will be responsible for the entire cost of the prescription.
You may call Medco Member Services at 800-336-5933 for more information.