TRS-ActiveCare
Prior Authorization, Quantity Limit and Step Therapy List
Certain prescription drugs are subject to step therapy requirements, prior authorization
requirements and quantity limits. These programs are in place to ensure appropriate use of
these medications.
Prior Authorization
Your doctor needs to get prior authorization for the drugs listed below before your prescription
benefit plan administered by Caremark will cover them.
Anti-Obesity Medications
Adipex-P
Bontril PDM
Diethylpropion
Qsymia
Xenical
Belviq
Bontril SR
Phendimetrazine ER/SR
Regimex (benzphetamine)
Contrave
Benzphetamine
Didrex
Phentermine
Suprenza
Attention Deficit Hyperactivity Disorder (ADHD) and Narcolepsy Medications
(Prior Authorization Required for 19 Years and Older)
Adderall
Adderall XR
Concerta
Daytrana
Desoxyn
Dexedrine
Focalin Products
LiQuadd/ProCentra
Metadate Products
Methylin Products
Quillivant XR Susp
Ritalin Products
Strattera
Vyvanse
Dextroamphetamine Products
Evekeo
GLP-1 Agonists
Bydureon
Tanzeum
Byetta
Trulicity
Victoza
Narcolepsy Medications
Nuvigil
Provigil
Xyrem
Oral/Intranasal Fentanyl Medications
Abstral
Actiq
Lazanda
Onsolis
Testosterone Topical/Buccal Medications
Androderm
Axiron
Striant
Fentora
Subsys
Fortesta
Topical Acne Medications
(Prior Authorization Required for 35 Years and Older)
Atralin
Fabior
Tazorac
Veltin
Avita
Retin-A
Tretinoin
Ziana
Differin
Retin-A Micro
Tretin-X
Log in to www.caremark.com to check coverage and copay information for a specific drug. Discuss this information with your
doctor or health care provider. This information is not a substitute for medical advice or treatment. Talk to your doctor or health care
provider about this information and any health-related questions you have. Caremark assumes no liability whatsoever for the
information provided or for any diagnosis or treatment made as a result of this information. This document contains references to
brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with
Caremark. This list is subject to change. There may be additional plan restrictions. Please consult your plan for further information.
106-T31719a 071614
Quantity Limits
The drugs listed below have limits based on U.S. Food and Drug Administration (FDA)approved prescribing information, approved medical guidelines and/or the average utilization
quantity for the drugs. The limits listed below affect only the amount of medication that the
prescription benefit plan pays for, not whether you can get a greater quantity. The final decision
about the amount of medication you receive remains between you and your doctor.
Note: Some of the quantity limits have a prior authorization available if you exceed the drug’s
limit. Those drugs with a prior authorization available are noted in chart below. If your doctor has
determined that a greater amount is appropriate, your doctor should call Caremark toll-free at 1800-294-5979 to request prior authorization for a larger quantity. The prior authorization line is
for your doctor’s use only.
Antiemetic Medications
Quantity Limit With Post Limit Prior Authorization
Aloxi
1 vial (5 mL) per 15 days
Anzemet Tablets
3 tabs per 15 days
Cesamet
18 per 30 days
Emend 115 mg injection
1 vial per 15 days
Emend 125 mg
1 cap per 15 days
Emend 150 mg injection
1 vial per 15 days
Emend 40 mg
3 caps per 180 days
Emend 80 mg
2 caps per 15 days
Emend Bi-Pak
1 bi-pak per 15 days
Emend Tri-Pak
1 tri-pak per 15 days
Granisol (Granisetron) Oral Solution
30 mL per 15 days
Kytril (Granisetron) 1 mg tab
6 per 15 days
Kytril (Granisetron) injection
1 mL per 15 days
Marinol (dronabinol)
60 per 30 days
Sancuso
1 patch per 15 days
Zofran (Ondansetron) 24 mg tab
1 per 15 days
Zofran (Ondansetron) 2 mg/mL injection
10 mL per 15 days
Zofran (Ondansetron) 4 and 8 mg ODT
12 per 15 days
Zofran (Ondansetron) 4 and 8 mg tabs
12 per 15 days
Zofran (Ondansetron) oral solution
100ml per 15 days
Zuplenz 4 and 8 mg films
12 per 15 days
Antiemetic Medications
Anzemet Injection
5 mL per15 days
Antimigraine Medications
Quantity Limit With Post Limit Prior Authorization
Alsuma (sumatriptan) injection
12 per 30 days
Amerge (naratriptan)
12 per 30 days
Axert
12 per 30 days
Frova
18 per 30 days
Log in to www.caremark.com to check coverage and copay information for a specific drug. Discuss this information with your
doctor or health care provider. This information is not a substitute for medical advice or treatment. Talk to your doctor or health care
provider about this information and any health-related questions you have. Caremark assumes no liability whatsoever for the
information provided or for any diagnosis or treatment made as a result of this information. This document contains references to
brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with
Caremark. This list is subject to change. There may be additional plan restrictions. Please consult your plan for further information.
106-T31719a 071614
Imitrex (sumatriptan) 20 mg nasal spray
Imitrex (sumatriptan) 5 mg nasal spray
Imitrex (sumatriptan) injection
Imitrex (sumatriptan) tabs
Maxalt/Maxalt MLT (rizatriptan) tabs
Relpax
Sumavel
Treximet
Zomig (zolmitriptan) nasal spray
Zomig/Zomig ZMT (zolmitriptan) tabs
12 per 30 days
24 per 30 days
12 per 30 days
12 per 30 days
18 per 30 days
12 per 30 days
12 per 30 days
9 per 30 days
12 per 30 days
12 per 30 days
Antimigraine Medications
Migranal NS
8 mL per 30 days
Erectile Dysfunction Medications
Caverject
Cialis 10 mg/20 mg
Edex
Levitra
Muse
Staxyn
Stendra
Viagra
8 per 30 days
8 per 30 days
8 per 30 days
8 per 30 days
8 per 30 days
8 per 30 days
8 per 30 days
8 per 30 days
Erectile Dysfunction Medications
Quantity Limit With Post Limit Prior Authorization
Cialis 2.5 mg/5 mg
8 per 30 days
Influenza Medications
Quantity Limit With Post Limit Prior Authorization
Relenza
40 caps per 180 days
Tamiflu 45 mg and 75 mg caps
14 per 180 days
Tamiflu 30 mg caps
28 per 180 days
Tamiflu oral suspension
180 mL per 180 days
Pain/Stadol Medications
Quantity Limit With Post Limit Prior Authorization
Stadol NS
5mL per 30 days
Sedative/Hypnotic Medications
Doral
Estazolam
Flurazepam
Halcion
Restoril
15 per 30 days
15 per 30 days
15 per 30 days
10 per 30 days
15 per 30 days
Sedative/Hypnotic Medications
Quantity Limit With Post Limit Prior Authorization
Ambien (zolpidem)
15 per 30 days
Ambien CR (zolpidem)
15 per 30 days
Lunesta (eszopiclone)
15 per 30 days
Log in to www.caremark.com to check coverage and copay information for a specific drug. Discuss this information with your
doctor or health care provider. This information is not a substitute for medical advice or treatment. Talk to your doctor or health care
provider about this information and any health-related questions you have. Caremark assumes no liability whatsoever for the
information provided or for any diagnosis or treatment made as a result of this information. This document contains references to
brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with
Caremark. This list is subject to change. There may be additional plan restrictions. Please consult your plan for further information.
106-T31719a 071614
Sonata (zaleplon)
15 per 30 days
Toradol/Sprix Medications
Sprix
Toradol
5 bottles per 30 days
20 tabs per 30 days
Step Therapy
You are required to try a specific drug before your prescription benefit plan will cover one of the
drugs listed below. Your doctor may call Caremark to request prior authorization for these
drugs.
Atypical Antipsychotics
Abilify
Invega
Seroquel (Brand Only)
Fanapt
Latuda
Seroquel XR
Minocycline ER Brand Only
Solodyn
Ximoni
Geodon (Brand Only)
Saphris
Generic Step Therapy
Step 1: You may have to try one
Drug Class
Condition Treated**
or two* of these generic medications
first:
Step 2: Before you can try one of
these brand drugs:
These preferred select brand
drugs do not require use of a
generic first:
Log in to www.caremark.com to check coverage and copay information for a specific drug. Discuss this information with your
doctor or health care provider. This information is not a substitute for medical advice or treatment. Talk to your doctor or health care
provider about this information and any health-related questions you have. Caremark assumes no liability whatsoever for the
information provided or for any diagnosis or treatment made as a result of this information. This document contains references to
brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with
Caremark. This list is subject to change. There may be additional plan restrictions. Please consult your plan for further information.
106-T31719a 071614
ACE Inhibitors/Angiotensin II
Receptor Antagonists (ARBs)/
Direct Renin Inhibitors/
Combinations
High Blood Pressure
amlodipine-benazepril
Tekturna/Tekturna HCT
Benicar/Benicar HCT
Preferred select brand not
available in class
benazepril/benazepril HCTZ
candesartan/candesartan HCTZ
captopril/captopril HCTZ
enalapril/enalapril HCTZ
eprosartan
fosinopril/fosinopril HCTZ
irbesartan/irbesartan HCTZ
lisinopril/lisinopril HCTZ
losartan/losartan HCTZ
moexipril/moexipril HCTZ
quinapril/quinapril HCTZ
*Please note. A member’s Plan determines whether one or
two generics must be tried first.
ramipril
telmisartan/telmisartan HCTZ
trandolapril
trandolapril-verapamil ext-rel
valsartan/valsartan HCTZ
Acne/Topical
benzoyl peroxide
Acanya
Skin
clindamycin solution
Azelex
clindamycin-benzoyl peroxide
erythromycin solution
erythromycin-benzoyl peroxide
sodium sulfacetamide
sulfacetamide-sulfur
Benign Prostatic Hyperplasia-Alpha blockers
alfuzosin ext-rel
Cardura XL
Preferred select brand not
Prostate
doxazosin
Rapaflo
available in class
tamulosin
terazosin
Log in to www.caremark.com to check coverage and copay information for a specific drug. Discuss this information with your
doctor or health care provider. This information is not a substitute for medical advice or treatment. Talk to your doctor or health care
provider about this information and any health-related questions you have. Caremark assumes no liability whatsoever for the
information provided or for any diagnosis or treatment made as a result of this information. This document contains references to
brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with
Caremark. This list is subject to change. There may be additional plan restrictions. Please consult your plan for further information.
106-T31719a 071614
Benign Prostatic Hyperplasia5 Alpha Reductase Inhibitors/Combinations
finasteride
Avodart
available in class
Prostate
Bisphosphonates/Combinations
alendronate
Atelvia
Osteoporosis
ibandronate
Binosto
risedronate 150 mg
Fosamax Plus D
COX-2 Inhibitors/Nonsteroidal
Anti-Inflammatory (NSAIDs)/
Combinations
celecoxib
Cambia
diclofenac sodium/misoprostol
Nalfon
Pain and Inflammation
diclofenac sodium
Voltaren Gel
diclofenac sodium solution
Zipsor
ibuprofen
Zorvolex
*Please note. A member’s Plan determines whether one or
two generics must be tried first.
Preferred select brand not
Preferred select brand not
available in class
Preferred select brand not
available in class
meloxicam
naproxen
(additional generic NSAIDs
available)
Fibrates
gemfibrozil
Fenoglide
Preferred select brand not
High Triglycerides
fenofibrate
Triglide
available in class
amlodipine-atorvastatin
Crestor (excluding 40 mg)
atorvastatin
Simcor
Preferred select brand not
available in class
fluvastatin
Vytorin
fenofibric acid
HMG-CoA Reductase Inhibitors
(HMGs or Statins)/Combinations
High Cholesterol
lovastatin
niacin ext-rel
pravastatin
simvastatin
Ophthalmic/Prostaglandins
latanoprost
Travatan Z
Glaucoma
travoprost
Zioptan
Preferred select brand not
available in class
Log in to www.caremark.com to check coverage and copay information for a specific drug. Discuss this information with your
doctor or health care provider. This information is not a substitute for medical advice or treatment. Talk to your doctor or health care
provider about this information and any health-related questions you have. Caremark assumes no liability whatsoever for the
information provided or for any diagnosis or treatment made as a result of this information. This document contains references to
brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with
Caremark. This list is subject to change. There may be additional plan restrictions. Please consult your plan for further information.
106-T31719a 071614
Proton Pump Inhibitors (PPIs)
lansoprazole
Dexilant
Stomach Acid
omeprazole
Nexium
omeprazole-sodium bicarbonate
capsule
Prilosec Packets
*Please note. A member’s Plan determines whether one or
two generics must be tried first.
pantoprazole
Preferred select brand not
available in class
Zegerid Powder for Oral Susp
rabeprazole
Selective Serotonin Agonists/
Combinations
Migraine
naratriptan
Alsuma
rizatriptan
Axert
sumatriptan
Frova
zolmitriptan
Relpax
Preferred select brand not
available in class
Sumavel Dosepro
Treximet
Serotonin Norepinephrine
Reuptake Inhibitors (SNRIs)
Depression
duloxetine
Fetzima
venlafaxine/venlafaxine ext-rel
Khedelza
Preferred select brand not
available in class
Pristiq
Selective Serotonin Reuptake
Inhibitors (SSRIs)
Depression
citalopram
Brintellix
escitalopram
Pexeva
fluoxetine
Viibryd
Preferred select brand not
available in class
fluvoxamine/fluvoxamine ext-rel
paroxetine/paroxetine ext-rel
sertraline
Sleeping Agents
eszopiclone
Edluar
Insomnia/Sleep Problems
zaleplon
Silenor
zolpidem/zolpidem ext-rel
Zolpimist
Preferred select brand not
available in class
zolpidem ext-rel
Log in to www.caremark.com to check coverage and copay information for a specific drug. Discuss this information with your
doctor or health care provider. This information is not a substitute for medical advice or treatment. Talk to your doctor or health care
provider about this information and any health-related questions you have. Caremark assumes no liability whatsoever for the
information provided or for any diagnosis or treatment made as a result of this information. This document contains references to
brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with
Caremark. This list is subject to change. There may be additional plan restrictions. Please consult your plan for further information.
106-T31719a 071614
Urinary Antispasmodics
oxybutynin/oxybutynin ext-rel
Enablex
Overactive Bladder/Incontinence
tolterodine/tolterodine ext-rel
Gelnique
trospium/trospium ext-rel
Myrbetriq
*Please note. A member’s Plan determines whether one or
two generics must be tried first.
Preferred select brand not
available in class
Vesicare
Log in to www.caremark.com to check coverage and copay information for a specific drug. Discuss this information with your
doctor or health care provider. This information is not a substitute for medical advice or treatment. Talk to your doctor or health care
provider about this information and any health-related questions you have. Caremark assumes no liability whatsoever for the
information provided or for any diagnosis or treatment made as a result of this information. This document contains references to
brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with
Caremark. This list is subject to change. There may be additional plan restrictions. Please consult your plan for further information.
106-T31719a 071614