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New Specialty Pharmacy Quantity Limit Program for February 22, 2012

As of February 22, 2012, the specialty medications, Arava®, Cimzia®, Enbrel®, Humira®, Kineret®, Orencia® (subcutaneous), Simponi®, and Stelara® used to treat rheumatoid arthritis, psoriasis, Crohn's disease and other conditions, will have quantity limits under the pharmacy benefit in addition to ensuring that the clinical indication for use meets the State Health Plan's conditions for coverage.

Maintenance prescriptions for these medications can be filled up to the quantities indicated in the chart. These quantities are based on FDA-approved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe and effective. If higher quantities are required, a coverage review must be completed.

Specialty Medication Covered Quantity
Arava 20mg per day (30 tablets)
Cimzia Maintenance dose – 400mg (2 syringes) per month
Enbrel 200mg per month
Humira Two units/doses per month
Kineret 31 syringes per month
Orencia (subcutaneous) 4 syringes per month
Simponi 1 unit per month
Stelara 5 vials or syringes per 365 days

If higher quantities are required, providers may call Express Scripts toll-free at 800-417-1764, from 8 a.m. to 9 p.m., Eastern Time, Monday through Friday. Members will be responsible for the full cost of the prescription if the provider does not receive approval during the coverage review.

These specialty medications are available through Accredo Health Group. You may contact Accredo at 877-988-0059 for more information.

You may also call Express Scripts Member Services at 800-336-5933 for additional information.

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