Microsoft word - wbp dqm drug list for members 07 31 09 _2_.doc
To help make the use of prescription drugs safer and more affordable, our plan is now using a Drug Quantity Management program. That is, for certain medications, you can receive an amount to last you a certain number of days. This gives you the right amount to take the daily dose considered safe and effective, according to the recommendations of the U.S. Food and Drug Administration (FDA). Based on the FDA’s guidelines and other medical information, our plan developed this program together with Express Scripts, the company chosen to manage our prescription drug benefit. The following limits are based on a 34-day supply, but our benefit may provide a different supply. For instance, you may be able to get a 90-day supply of your medication through mail order service. Your doctor could also request a prior authorization. If this request is approved, a prior authorization would let you receive more than the recommended quantity. Drug Quantity Limits for Concordia Health Plans Prescription Drug Benefit Name of Prescription Drug Maximum Quantity
Advair Diskus 100/50, 250/50, and 500/50 with device
68 tablets/orally disintegrating tablets
Aloxi injection 0.25 mg/5 ml and 0.075 mg/1.5 ml
List is subject to change; Updated 7/31/09
Name of Prescription Drug Maximum Quantity
Atrovent nasal spray 0.03% (30 grams), generic
Atrovent nasal spray 0.06% (15 grams), generic
Avandamet 1 mg/500 mg, 2/500, 4/500, 2/1000, 4/1000
Avandaryl 4mg/1mg, 4mg/2mg, 4mg/4mg, 8mg/2mg, 8mg/4mg
2 inhalers 14 or 15 vials with prefilled diluent
syringe (depending on product packaging)
Brovana Inhalation Solution (30 vial carton)
Chorionic gonadotropin 10000 units, generic
Claritin 10 mg/Claritin Reditabs 10 mg, Claritin 5 mg chewable
Depo-Provera Contraceptive Injection 150 mg/mL
List is subject to change; Updated 7/31/09
Name of Prescription Drug Maximum Quantity
Emend Trifold Pack (one 125 mg and two 80 mg capsules)
Foradil Aerolizer & 12 capsules in blisters
Foradil Aerolizer & 60 capsules in blisters
Fosamax Plus D 70 mg/2800 IU, 70mg/5600 IU
Imitrex 4mg injection (syringes/cartridges)
List is subject to change; Updated 7/31/09
Name of Prescription Drug Maximum Quantity
Lioresal Inthrathecal Refill Kit 1 ampule 10 mg/20 ml
2 ampules 10 mg/5 ml 1 ampule 40 mg/20 ml Lunesta 1mg, 2mg, 3mg
Monistat 3 combination pack 200 mg & equivalent
Monistat 3 suppositories 200 mg & equivalent
Monistat 7 combination pack & equivalent
Monistat 7 suppositories 100 mg & equivalent
Monistat Dual Pak (1200 mg vaginal insert, 9 gram 2% cream)
Monistat Dual-Pak (three 200 mg vaginal supp, 15 gram 2% cream)
PEG Intron Pens/Kit (containing 1 vial each) 50 mcg, 80 mcg, 120
List is subject to change; Updated 7/31/09
Name of Prescription Drug Maximum Quantity
Pegasys 180 mcg Convenience Pack ( 4 vials)
Pegasys 180 mcg Convenience Pack (4 prefilled syringes)
Pulmicort Respules 0.25 mg/2 mL and 0.5 mg/2 mL
Rebetron Combination, Rebetron 1200, 1000, and 600 Therapy Pak
Relenza 5 mg/blister with inhalation device
Rhinocort Aqua 32 mcg (120 inhalations) 8.4ml bottle
Sandostatin LAR Depot 10 mg/5 ml and 30 mg/5 ml
Spiriva Handihaler 6 capsules (1 blister card) with inhaler device
Spiriva Handihaler 30 capsules (5 blister cards) with inhaler device
Spiriva Handihaler 90 capsules (6 blister cards) with inhaler device
List is subject to change; Updated 7/31/09
Name of Prescription Drug Maximum Quantity
Zithromax for oral suspension 100 mg/5 mL, 15 ml bottle
Zithromax for oral suspension 200 mg/5 mL, 15 and 22.5 ml bottle
Zithromax for oral suspension 200 mg/5 mL, 30 ml bottle
List is subject to change; Updated 7/31/09
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TRENDS in Cognitive Sciences Vol.5 No.7 July 2001 Graded representations in behavioral dissociations Yuko Munakata Why do people sometimes seem to know things when they are tested in one a weak representation, but fail another task way, while seeming unaware of this information when tested in a different designed to measure the same knowledge because it way? Such task-dependent behavi