Standard Clinical Review List
October 5, 2023P&T Committee Changes
October 5, 2023Medications may have a high risk of side effects or an adverse event when taken above the recommended FDA amount. To promote safe and appropriate use of such medications, BeneCard PBF has limits for how much medication can be obtained within a specific time period. If a member requires quantities above the recommended amounts, a clinical review is required to obtain an override of the limitation in writing from the patient’s physician, explaining the medical justifications for doses above the recommended FDA guidelines. The safety of each member is extremely important, and quantity management is an integral part of every program to ensure safe and appropriate use of these products.
| Drug Name | Generic Drug Name | Generic Product Identifier | Quantity | Day Supply |
|---|---|---|---|---|
| ABILIFY | Aripiprazole Oral Solution 1 MG/ML | 59250015002020 | 750 | 30 |
| ABILIFY 10 MG | Aripiprazole 10 MG | 59250015000320 | 30 | 30 |
| ABILIFY 15 MG | Aripiprazole 15 MG | 59250015000330 | 30 | 30 |
| ABILIFY 20 MG | Aripiprazole 20 MG | 59250015000340 | 30 | 30 |
| ABILIFY 2 MG | Aripiprazole 2 MG | 59250015000305 | 60 | 30 |
| ABILIFY 30 MG | Aripiprazole 30 MG | 59250015000350 | 30 | 30 |
| ABILIFY 5 MG | Aripiprazole 5 MG | 59250015000310 | 30 | 30 |
| ABILIFY ASIMTUFII 720 | Aripiprazole IM ER Susp Prefilled Syringe 720 MG/2.4ML | 5925001500E455 | 2.4 | 56 |
| ABILIFY ASIMTUFII 960 | Aripiprazole IM ER Susp Prefilled Syringe 960 MG/3.2ML | 5925001500E465 | 3.2 | 56 |
| ABILIFY MYCITE 2 MG | Aripiprazole Tab 2 MG with Sensor | 5925001503B706 | 60 | 30 |
| ABILIFY MYCITE 5 MG | Aripiprazole Tab 5 MG with Sensor | 5925001503B711 | 30 | 30 |
| ABILIFY MYCITE 10 MG | Aripiprazole Tab 10 MG with Sensor | 5925001503B721 | 30 | 30 |
| ABILIFY MYCITE 15 MG | Aripiprazole Tab 15 MG with Sensor | 5925001503B731 | 30 | 30 |
| ABILIFY MYCITE 20 MG | Aripiprazole Tab 20 MG with Sensor | 5925001503B741 | 30 | 30 |
| ABILIFY MYCITE 30 MG | Aripiprazole Tab 30 MG with Sensor | 5925001503B751 | 30 | 30 |
| ABILIFY MYCITE STARTER KIT 2 MG | Aripiprazole Tab 2 MG with sensor, strips & pod Starter Pak | 5925001503B705 | 30 | 180 |
| ABILIFY MYCITE STARTER KIT 5 MG | Aripiprazole Tab 5 MG with sensor, strips & pod Starter Pak | 5925001503B720 | 30 | 180 |
| ABILIFY MYCITE STARTER KIT 15 MG | Aripiprazole Tab 15 MG with sensor, strips & pod Starter Pak | 5925001503B730 | 30 | 180 |
| ABILIFY MYCITE STARTER KIT 20 MG | Aripiprazole Tab 20 MG with sensor, strips & pod Starter Pak | 5925001503B740 | 30 | 180 |
| ABILIFY MYCITE STARTER KIT 30 MG | Aripiprazole Tab 30 MG with sensor, strips & pod Starter Pak | 5925001503B750 | 30 | 180 |
| ABSORICA LD 8 MG | Isotretinoin Micronized Cap 8 MG | 90050013100110 | 210 | 30 |
| ABSORICA LD 16 MG | Isotretinoin Micronized Cap 16 MG | 90050013100115 | 210 | 30 |
| ABSORICA LD 24 MG | Isotretinoin Micronized Cap 24 MG | 90050013100125 | 180 | 30 |
| ABSORICA LD 32 MG | Isotretinoin Micronized Cap 32 MG | 90050013100135 | 120 | 30 |
| ACCOLATE | Zafirlukast Tab 10 MG | 44505080000310 | 60 | 30 |