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University System of Georgia
Prior Authorization, Step Therapy and Quantity Limit List
Prior Authorization (PA)
Your doctor will need to obtain a prior authorization for the drugs listed below, before
your prescription drug plan administered by CVS/caremark will cover them. The prior
authorization process ensures that you are receiving the appropriate drugs for the
treatment of specific conditions and in quantities approved by the U.S. Food and Drug
Administration (FDA).
For prior authorization review, your doctor should call CVS/caremark toll-free at
1-800-294-5979 before you go to the pharmacy. The prior authorization line is for your
doctor’s use only.
Drug Class
Acne
ADHD/Narcolepsy
Anabolic Steroids
Antifungals, Topical
Compounded
Medications*
Products Requiring Prior Authorization (PA)
Differin (adapalene) – PA required only in adults age 30 and older
Tazorac/Fabior (tazarotene)
Topical Retinoids (Atralin, Avita, Retin-A, Retin-A Micro, Tretin-X, tretinoin, Veltin,
Ziana) – PA required only in adults age 30 and older
Amphetamine products (Adderall, Adderall XR, Desoxyn, Dexedrine,
LiQuadd/ProCentra, Vyvanse) – PA required only in adults age 22 and older
Methylphenidate products (Concerta, Daytrana, Focalin Products, Metadate
Products, Methylin Products, Quillivant XR, Ritalin Products) – PA required only in
adults age 22 and older
Strattera (atomoxetine) – PA required only in adults age 22 and older
Anadrol-50, Oxandrin
Ciclopirox Products (Penlac)
Select medications (check with the pharmacy)
*A compounded medication is one that is made by combining, mixing or altering ingredients, in response to a
prescription, to create a customized medication that is not otherwise commercially available.
Narcolepsy – Other
Pain
Testosterone
Products,
Topical & Buccal
Provigil (modafinil), Nuvigil (armodafinil), Xyrem (sodium oxybate)
Oral-Intranasal Fentanyl (Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys)
AndroGel, Androderm, Axiron, Fortesta, Striant, Testim, Testosterone Cream,
Testosterone Ointment, Testosterone Powder
Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. Due to
the large number of available medicines, this list may not be all inclusive and may change without notice. Dispensing limits and/or
prior authorization requirements apply to all brand and generic equivalents unless otherwise indicated. Products distributed and
therapies covered by CVS/caremark may change or expand from time to time. This document contains references to brand-name
prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS/caremark.
Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information.
106-32150a 111014
TDD: 1-800-863-5488
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Specialty Guideline Management – Prior Authorization for Specialty Drugs
Your doctor will need to obtain a prior authorization for specialty drugs, before they will
be covered by your prescription benefit plan. The prior authorization process ensures
that you are receiving the appropriate drugs for the treatment of specific conditions.
For a full list of specialty drugs, please refer to www.CVSCaremarkSpecialtyRx.com.
For specialty drug prior authorization review, your doctor should call CVS Caremark
toll-free at 1-866-814-5506 before you go to the pharmacy. The prior authorization line
is for your doctor’s use only.
Step Therapy
Before your prescription drug plan will cover one of the drugs listed below, you will need
to try one of the covered options available for that drug. Please consult with your doctor
about what covered medications are right for you. Your doctor should call
CVS/caremark toll-free at 1-800-294-5979 to request prior authorization. The prior
authorization line is for your doctor’s use only.
Drug Class
Brand Minocycline Extended-Release
(Acne)
COX-2 Inhibitors (Pain)
Immunosuppressants, Topical
(eczema, psoriasis)
Products Requiring Step Therapy
Solodyn, Ximino
Celebrex (celecoxib)
Elidel (pimecrolimus), Protopic (tacrolimus)
Quantity Limits
The drugs listed on the following pages 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 on the
following pages. If your doctor has determined that a greater amount is appropriate,
your doctor should call CVS/caremark toll-free at 1-800-294-5979 to request prior
authorization for a larger quantity. The prior authorization line is for your doctor’s use
only.
©2014 CVS/caremark. All rights reserved. 106-32150a 111014
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Quantity Limits
Quantity Per
90-day Supply
Prior
Authorization
Available
(To Exceed
Quantity Limit)
12 units (6 mL)
12 tablets
12 tablets
18 tablets
36 units (18 mL)
36 tablets
36 tablets
54 tablets
Yes
Yes
Yes
Yes
12 units (6 mL)
36 units (18 mL)
Yes
12 units (6 mL)
36 units (19 mL)
Yes
12 units (6 mL)
40 units (20 mL)
Yes
24 nasal units
72 nasal units
Yes
12 nasal units
36 nasal units
Yes
12 tablets
18 tablets
36 tablets
54 tablets
Yes
Yes
8 nasal units
24 nasal units
No
12 tablets
12 DosePro units
36 tablets
36 DosePro units
Yes
Yes
9 tablets
36 tablets
Yes
12 systems
12 nasal units
12 tablets
36 systems
36 nasal units
36 tablets
Yes
Yes
Yes
6 units
18 units
No, except
Cialis 5 mg
30 units
90 units
No
Quantity Per
30-day Supply
Anti-Migraine (quantities accumulate across the class)
Alsuma Injection (sumatriptan)
Amerge (naratriptan)
Axert (almotriptan)
Frova (frovatriptan)
Imitrex (sumatriptan) 4 mg Injection
Syringes
Imitrex (sumatriptan) 6 mg Injection
Syringes
Imitrex (sumatriptan) 6 mg Injection
Vials
Imitrex (sumatriptan) 5 mg nasal spray
(NS)
Imitrex (sumatriptan) 20 mg nasal spray
(NS)
Imitrex (sumatriptan) oral
Maxalt, Maxalt MLT (rizatriptan)
Migranal (dihydroergotamine nasal
spray)
Relpax (eletriptan)
Sumavel DosePro (sumatriptan)
Treximet (sumatriptan/naproxen
sodium)
Zecuity Transdermal (sumatriptan)
Zomig nasal spray (zolmitriptan)
Zomig/Zomig ZMT (zolmitriptan)
Erectile Dysfunction (quantities accumulate across the class)
Caverject, Edex, Muse, Cialis (5 mg,
10 mg, 20 mg), Levitra, Staxyn,
Stendra, Viagra
Cialis 2.5 mg
Influenza
Relenza Caps (zanamivir inhalation)
Tamiflu 30 mg Caps (oseltamivir)
Tamiflu 45 mg, 75 mg Caps
(oseltamivir)
Tamiflu 30 mg/5 mL Oral Liquid
(oseltamivir)
©2014 CVS/caremark. All rights reserved. 106-32150a 111014
40 capsules per 90 days
28 capsules per 90 days
Yes
Yes
14 capsules per 90 days
Yes
180 mL per 90 days
Yes
`
Quantity Limits
Prior
Authorization
Available
(To Exceed
Quantity Limit)
Quantity Per
30-day Supply
Quantity Per
90-day Supply
2 bottles
20 tablets
5 bottles
6 bottles
20 tablets
5 bottles
Yes
120 tablets
360 tablets
Yes
120 tablets
360 tablets
Yes
360 - 375 vials
(1,180 -1,125 mL),
varies by package size
No
Pain
butorphanol (Stadol NS)
ketoroloc tabs (Toradol)
ketorolac nasal spray (Sprix)
Opana ER (oxymorphone hydrochloride
extended-release tablets)
Oxycontin (oxycodone hydrochloride
controlled-release tablets
Respiratory – SHORT-ACTING Beta 2 Agonist/Combinations
Albuterol inhalation solution (AccuNeb)
120 - 125 vials
0.63 mg/3 mL and 1.25 mg/3 mL
(360 - 375 mL),
varies by package
size
125
vials
(375 mL)
Albuterol inhalation solution 0.083%
3 (20 mL) containers
Albuterol inhalation solution 0.5%
ProAir HFA inhaler (albuterol)
2 containers, varies
by package size
Proventil HFA inhaler (albuterol)
2 containers, varies
by package size
Ventolin HFA inhaler (albuterol) – 8 gram
6 containers (48 gm)
container (60 inhalations/container)
Ventolin HFA inhaler (albuterol) – 18 gram
2 containers (36 gm)
container (200 inhalations/container)
Xopenex HFA inhaler (levalbuterol) –
8.4 gram container (80 inhalations/
5 containers (42 gm)
container)
Xopenex HFA inhaler (levalbuterol) –
15 gram container (200 inhalations/
2 containers (30 gm)
container)
Xopenex inhalation solution 0.31 mg/3 mL
96 vials (288 mL)
(levalbuterol)
Xopenex inhalation solution 0.63 mg/3 mL
96 vials (288 mL)
(levalbuterol)
Xopenex inhalation solution 1.25 mg/3 mL
96 vials (288 mL)
(levalbuterol)
Xopenex inhalation soln conc 1.25 mg/
90 vials (90 ea)
0.5 mL (levalbuterol)
Respiratory – LONG-ACTING Beta 2 Agonist/Combinations
Advair Diskus (fluticasone/salmeterol)
1 container (60 ea)
Advair HFA (fluticasone/salmeterol)
1 container (12 g)
©2014 CVS/caremark. All rights reserved. 106-32150a 111014
No
No
375 vials (1125 mL)
9 (20 mL) containers
6 containers, varies by
package size
6 containers, varies by
package size
No
No
18 containers (144 gm)
No
6 containers (108 gm)
No
15 containers (126 gm)
No
6 containers (90 gm)
No
288 vials (864 mL)
No
288 vials (864 mL)
No
288 vials (864 mL)
No
270 vials (270 ea)
No
3 containers (180 ea)
No
3 containers (36 g)
No
No
No
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Quantity Limits
Anoro Ellipta (umeclidinium/vilanterol)
Arcapta Neohaler (indacaterol)
Breo Ellipta (fluticasone furoate/vilanterol)
Brovana inhalation solution (aformeterol
tartrate)
Dulera Inhalation Aerosol 100 mcg/5 mcg
and 200 mcg/5 mcg (mometasone/
formoterol)
Foradil Aerolizer (formoterol)
Perforomist inhalation solution (formoterol)
Serevent Diskus (salmeterol)
Striverdi Respimat (olodaterol)
Symbicort inhalation aerosol (budesonide/
formoterol)
Quantity Per
30-day Supply
Quantity Per
90-day Supply
Prior
Authorization
Available
(To Exceed
Quantity Limit)
1 container (60 ea)
3 containers (180 ea)
No
1 container (30 ea)
3 containers (90 ea)
No
1 container (60 ea)
3 containers (180 ea)
No
60 vials (120 mL)
180 vials (360 mL)
No
1 container (13 gm)
3 containers (39 gm)
No
1 container (60ea)
3 containers (180 ea)
No
60 vials (120 mL)
180 vials (360 mL)
No
1 container (60 ea)
3 containers (180 ea)
No
1 container (4 gm)
3 containers (12 gm)
No
1 container (11 gm)
3 containers (31 gm)
No
6 containers (78 gm)
No
6 containers (24 gm)
No
360 units (720 mL)
No
540 vials(1620 mL)
No
375 units (939 mL)
No
90 units +
1 Handihaler device
No
3 containers
No
6 containers
9 containers
No
No
6 containers
No
Respiratory – Mast Cell Stabilizers and Anticholinergics
Atrovent HFA Inhaler (ipratropium
2 containers
bromide)
(26 gm)
Combivent Respimat Inhaler
2 containers (8 gm)
(ipratropium/albuterol)
Cromolyn Inhalation Solution
120 units (240 mL)
(cromolyn)
DuoNeb Inhalation Solution
180 vials (540 mL)
(ipratropium/albuterol)
Ipratropium Inhalation Solution
125 units (313 mL)
(ipratropium bromide)
Spiriva Handihaler (tiotropium)
30 units +
1 Handihaler device
Tudorza Pressair Inhaler (aclidinium
1 container
bromide)
Respiratory – Inhaled Corticosteroids
2 containers
Aerospan (flunisolide)
3 containers
Alvesco inhalation (ciclesoide) 80 mcg
Alvesco inhalation (ciclesonide)
2 containers
160 mcg
©2014 CVS/caremark. All rights reserved. 106-32150a 111014
`
Quantity Limits
Quantity Per
30-day Supply
Asmanex 110 mcg (mometasone
2 containers
furoate)
Asmanex 30 Aer 220 mcg
4 containers
(mometasone furoate)
Asmanex 60 Aer 220 mcg
2 packages
(mometasone furoate)
Asmanex 120 Aer 220 mcg
1 package
(mometasone furoate)
Flovent Diskus 50 mcg mcg/inhalation
2 packages
(fluticasone)
Flovent Diskus 100 mcg/inhalation
4 packages
(fluticasone)
Flovent Diskus 250 mcg/inhalation
4 packages
(fluticasone)
Flovent HFA 44 mcg/inhalation
2 containers
(fluticasone)
Flovent HFA 110 mcg/inhalation
2 containers
(fluticasone)
Flovent HFA 220 mcg/inhalation
2 containers
(fluticasone)
Pulmicort Flexhaler 180 mcg/inhalation
2 containers
(budesonide)
Pulmicort Flexhaler 90 mcg/inhalation
3 containers
(budesonide)
Pulmicort Respules 0.25 mg per
90 respules
respule (budesonide)
Pulmicort Respules 0.5 mg per respule
60 respules
(budesonide)
Pulmicort Respules 1 mg per respule
30 respules
(budesonide)
2 containers
Qvar Inhaler 40 mcg (beclomethasone)
2 containers
Qvar Inhaler 80 mcg (beclomethasone)
Allergy – Intranasal Steroids/Antihistamines
2 containers
Astelin (azelastine)
2 containers
Astepro (azelastine)
2 containers
Beconase AQ (beclomethasone)
1 container
Dymista (azelastine/fluticasone)
1 container
Flonase (fluticasone)
3 containers
Flunisolide (flunisolide)
1 container
Nasacort AQ (triamcinolone)
2 containers
Nasonex (mometasone)
©2014 CVS/caremark. All rights reserved. 106-32150a 111014
Quantity Per
90-day Supply
Prior
Authorization
Available
(To Exceed
Quantity Limit)
6 containers
No
12 containers
No
6 packages
No
3 packages
No
6 packages
No
12 packages
No
12 packages
No
6 containers
No
6 containers
No
6 containers
No
6 containers
No
9 containers
No
270 respules
No
180 respules
No
90 respules
No
6 containers
6 containers
No
No
6 containers
6 containers
6 containers
3 containers
3 containers
9 containers
3 containers
6 containers
No
No
No
No
No
No
No
No
`
Quantity Limits
Omnaris (ciclesonide)
Patanase (olopatadine)
Qnasl (beclomethasone)
Rhinocort Aqua (budesonide)
Veramyst (fluticasone furoate)
Zetonna (ciclesonide)
Quantity Per
30-day Supply
Quantity Per
90-day Supply
Prior
Authorization
Available
(To Exceed
Quantity Limit)
1 container
1 container
1 container
2 containers
1 container
1 container
3 containers
3 containers
3 containers
6 containers
3 containers
3 containers
No
No
No
No
No
No
Log in to www.caremark.com to check coverage and copay** information for a specific
medicine. For additional information, contact a CVS/caremark Customer Care
Representative toll-free at 1-877-362-3922.
**Copay, copayment or coinsurance means the amount a plan member is required to pay for a prescription in accordance with a
Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any,
paid by a Plan.
©2014 CVS/caremark. All rights reserved. 106-32150a 111014