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The formulary list was last updated on 09/01/07, please be advised the information listed may not reflect the most current data and may be updated at any time without notice.
Please call HNE Member Services at (413) 787-4000 or
(800) 310-2835 for assistance.
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Prior Authorizations
The following medications require HNE's prior approval. For more information, please contact our Member Services Department at 1-800-310-2835 or 787-4004, or visit our Web site @ hne.com for the appropriate form. Only FDA maintenance indicator drugs are allowed through mail order.
shaded Rx rows= Maintenance Medications
|
Brand
Drug Name
|
Generic
Drug Name
|
Indication
|
Tier
|
| Actiq |
fentanyl |
breakthrough cancer pain |
3
|
| Ambien CR |
zolpidem |
insomnia |
3
|
| Antagon |
ganirelix |
infertility |
2
|
| Aranesp |
darbepoetin alfa |
anemia |
3
|
| Bravelle |
urofollitropin |
infertility |
3
|
| Celebrex |
celecoxib |
Arthritis Medication |
2
|
| Cetrotide |
cetrorelix |
infertility |
2
|
| Differin |
adaplene |
acne |
3
|
| Enbrel |
etanercept |
Rheumatoid Arthritis, psoriasis |
2
|
| Epogen |
erythropoetin |
anemia |
2
|
| Exubera |
human insulin inhaled |
diabetes |
3
|
fentanyl lozenge
(eq=actiq) |
fentanyl OTIF |
breakthrough cancer pain |
1
|
| Fentora |
|
Breakthrough Cancer Pain |
3
|
| Fertinex |
urofollitropin |
infertility |
3
|
| Follistim |
follitropin beta |
infertility |
3
|
| Follistim/Anatagon Kit |
follitropin beta/ganirelix |
infertility |
2
|
| Ganirelix |
ganirelix |
infertility |
2
|
| Genotropin |
somatropin |
grwth hormone |
3
|
| Gleevec |
imatinib |
cancer-CML/GIST |
3
|
| Gonal-F |
follitropin alfa |
infertility |
2
|
| Humatrope |
somatropin |
grwth hormone |
3
|
| Humira |
adalimumab |
Rheumatoid Arthritis |
2
|
| Increlex |
mecasermin |
growth hormone |
3
|
| Kineret |
anakinra |
Rheumatoid Arthritis |
3
|
| Leukine |
sargramostim |
neutropenia |
3
|
| Lunesta |
eszopiclone |
insomnia |
3
|
| Luveris |
lutropin alfa |
infertility |
3
|
meloxicam
(eq-Mobic) |
meloxicam |
Arthritis Medication |
1
|
| Menopur |
menotropin |
infertility |
3
|
| Meridia |
sibutramin |
Weight Loss |
3
|
| Metrodin |
urofollitropin |
infertility |
2
|
| Mobic |
meloxicam |
Arthritis Medication |
3
|
| Nexavar |
sorafenib tosylate |
Renal Cell Cancer |
3
|
| Norditropin |
somatropin |
grwth hormone |
3
|
| Noxafil |
|
Antifungal |
3
|
| Nutropin |
somatropin |
grwth hormone |
3
|
| Pergonal |
menotropins |
infertility |
2
|
| Procrit |
erythropoietin |
anemia |
2
|
| Protropin |
somatrem |
grwth hormone |
3
|
| Provigil |
modafinil |
Narcolepsy |
3
|
| Raptiva |
efalizumab |
psoriasis |
3
|
| Repronex |
menotropins |
infertility |
2
|
| Retin-A . |
tretinoin |
acne |
3
|
| Retin-A Micro |
tretinoin |
derm |
3
|
| Revatio |
sildenafil |
pulmonary hypertension |
2
|
| Revlimid |
lenalidomide |
Cancer |
3
|
| Rozerem |
ramelteon |
insomnia |
3
|
| Saizen |
somatropin |
grwth hormone |
3
|
| Serostim |
somatropin |
AIDS wasting |
3
|
| Singulair |
montelukast |
asthma |
2
|
| Sprycel |
dasatinib |
leukemia |
3
|
| Sutent |
sunitinib malate |
Renal cell cancer and GIST |
3
|
| Tazorac |
tazarotene |
Acne, psoriasis |
3
|
| Tev-Tropin |
somatropin |
grwth hormone |
2
|
| Tracleer |
bosentan |
Primary Pulmonary Hypertension |
3
|
trentinoin
(eq=Retin-A) . |
tretinoin |
acne |
1
|
| Tykerb |
Lapatinib |
Breast Cancer |
3
|
| Vfend |
voriconazole |
fungal infection |
3
|
| Xenical |
orlistat |
Weight Loss |
3
|
| Zolinza |
Vorinostat |
cutaneous t-cell lymphoma |
3
|
| Zorbtive |
somatropin |
short bowel syndrome |
3
|
| Zyvox |
linezolid |
infection |
3
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Medical Drugs requiring prior approval
|
Brand
Drug Name
|
Generic
Drug Name
|
Indication
|
| Amevive |
alefacept |
psoriasis |
| Botox |
botulinum toxin A |
Variuos |
| Elaprase |
|
Hunter's Syndrome |
| Cerezyme |
imiglucerase |
enzyme disorder |
| Fabrazyme |
agalsidase beta |
enzyme disorder |
| Flolan |
epoprostenol |
pulmonary hypertension |
| Myobloc |
botulinum toxin B |
Variuos |
| Orencia |
abatacep/maltose |
rheumatoid arthritis, psoriatic arthritis, Crohn's disease |
| Remicade |
infliximab |
rheumatoid arthritis, psoriatic arthritis, Crohn's disease |
| Remodulin |
treprostinol |
Primary Pulmonary Hypertension |
| Rituxan |
rituximab |
Rhematoid Arthritis, Cancer |
| Tysabri |
natalizumab |
Multiple Sclerosis |
| Vivitrol |
|
Alcohol Dependence |
| Xolair |
omalizumab |
allergic asthma |
Only FDA maintenance indicator drugs are allowed through mail order
** See quantity limitation list
Note: This list is subject to change.
Generally a maintenance drug can be described as a medication that is used for the treatment of a chronic condition (i.e.: diabetes, asthma, arthritis and heart disease) taken to stabilize the illness or symptoms of the illness AND that has been classified by FDB (industry standard classifier) as a maintenance medication.
Only maintenance medications will be available through mail order. Health New England excludes the following medications from mail order. Narcotic/Opiate, quantity limitation, prior authorization and injectable medications.
When to use the mail service prescription drug benefit (*if you have the mailorder benefit):
- You have verified that your medication is a true maintenance medication: all medications are classified as “Maintenance" according to their approved FDA indications for use.
- You have obtained at least 2 refills at Retail and have not had an adverse reaction.
- To take advantage of lower co-payments for your generic and formulary maintenance medications.
Note: The co-payments for non-formulary medications will not change.
- To plan ahead when you are going on an extended vacation.
How to use the mail service prescription drug benefit:
- We recommend obtaining 2 prescriptions one to be used for a preliminary 30-day supply to be filled by your local in network retail pharmacy. The second prescription will be for up to a 90- day supply plus refills for up to one year.
- Complete the mailorder member profile and submit following directions on the form.
- For faster service you can order refills on line as indicated on invoice received from mailorder (this only applies to prescriptions with refills and does not apply to any initial orders)
Note: This list is subject to change.
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