Osuhealthplan.org

Dose Optimization for Cholesterol Lowering Medications and
Quantity Level Limits for Proton Pump Inhibitors

In a continuing effort to promote quality, affordable, cost-effective health care, the pharmacy benefit plan for
OSU has adopted prescription quantity and/or dosing limits for certain medications. Drug quantity limits and
dosing limits (dose optimizations) are based on guidelines for most approved medical conditions. Effective
April 1, 2011, there will be medications within two therapeutic classes that will be added to the pharmacy benefit
under the quantity level limit and dose optimization programs. These two therapeutic classes of medications are
utilized to treat high cholesterol and gastroesophageal reflux disease (GERD).
What is dose optimization?
When clinically appropriate, dose optimization typically involves changing from twice-daily dosing to a once-daily
dosing schedule. For example, a 10mg dose taken twice per day would be changed to a 20mg dose taken only
once per day.
For a few specific drugs, it is common practice for doctors to initially prescribe a lower strength of medication
and then gradually move to higher strengths over a period of time. In these cases, the goal of dose optimization
is to help ensure that as higher dosages are prescribed, the member takes a single dose at the higher strength.
If a member submits a prescription that exceeds the dosing limits set by the dose optimization program, the
pharmacy’s computer will receive an electronic message that the prescription claim is being rejected due to
Drug Utilization Review (DUR). The pharmacist may contact the doctor to determine if a different dose
consistent with dose optimization guidelines is appropriate. If so, the drug is prescribed and filled at the new
dosage. Or if there are medical reasons for the drug dosing schedule as originally prescribed, the doctor can
request prior authorization review.
The cholesterol lowering medications, limited to one dose per day, and subject to the dose optimization program are:
Crestor
Pravastatin
Simvastatin
Pravachol

What are medication quantity limits?
Taking too much medication or using it too often isn’t safe and may even drive up members’ health care costs.
Quantity limits regulate the amount of medication covered by the plan for a certain length of time. Most plans
cover a 30-day retail pharmacy supply or up to a 90-day supply using home delivery. Quantity limits follow U.S.
Food and Drug Administration (FDA) guidelines, as well as manufacturer recommendations.
If members refill prescriptions too soon or their doctors prescribe an amount higher than recommended
guidelines, our pharmacy system will reject the claim. When this happens, the pharmacist receives an electronic
“Invalid/Excessive Quantity” message. If the physician believes the situation requires an exception, he or she
may request prior authorization review. To avoid disrupting treatment, members will be covered for the approved
amount while review takes place.
The medications to treat gastroesophageal reflux disorder which are subject to the quantity level limits and
limited to 30 tablets/capsules per 30 days (retail) and 90 tablets/capsules per 90 days (home delivery) are:
Aciphex
Prevacid
Pantoprazole
Lansoprazole
Dexilant
Protonix
Omeprazole

Source: http://www.osuhealthplan.org/pdf/providers/QLL%20and%20Dose%20Optimization_2011.pdf