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Epinephrine – Enhanced Formulary
Restricted Product(s)
Quantity limits apply to all epinephrine
- Epinephrine (Amneal/Avkare brand)
- Epipen (brand name)
- Epipen Jr (brand name)
- neffy (epinephrine nasal spray)Symjepi (epinephrine injection)
Unrestricted/ Suggested Alternative(s)
- Auvi-Q (epinephrine autoinjector)
- Epinephrine (generic Epipen)
- Epinephrine (Mylan) (generic Epipen Jr)
FDA Approved Use
- EpiPen, EpiPen Jr, neffy, and Symjepi contain epinephrine, a non-selective alpha and beta-adrenergic receptor agonist, indicated in the emergency treatment of allergic reactions (Type I) including anaphylaxis
Criteria for Approval of Restricted Product(s)
- The patient has a documented physical or cognitive impairment which places them at high risk of inappropriate administration with generic Epinephrine (Epipen/Epipen Jr) or Auvi-Q.
Duration of Approval: 365 days (1 year)
Quantity Limitations
Quantity limitations apply to brand and associated generic products.
| Medication | Quantity per Day (unless specified) |
|---|---|
| Auvi-Q (epinephrine 0.1 mg/0.1 mL, 0.15 mg/0.15 mL, 0.3 mg/0.3 mL auto-injector) 4 | 4 pens per 30 days |
| Epipen (epinephrine 0.3 mg/0.3 mL auto-injector) | 4 pens per 30 days |
| Epipen Jr. (epinephrine 0.15 mg/0.3 mL auto-injector) | 4 pens per 30 days |
| Epinephrine (Amneal/Avkare brand; epinephrine 0.3 mg/0.3 mL auto-injector) | 4 pens per 30 days |
| neffy (epinephrine 2 mg/0.1 mL nasal spray) | 4 devices per 30 days |
| Symjepi (epinephrine 0.15 mg/0.3 mL, 0.3 mg/0.3 mL prefilled syringe) | 4 syringes per 30 days |
Quantity Limit Exception Criteria
- The quantity (dose) requested is for documented titration purposes at the initiation of therapy (authorization for a 90 day titration period); AND
- The prescribed dose cannot be achieved using a lesser quantity of a higher strength; AND
- The quantity (dose) requested does not exceed the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert; OR
- If the quantity (dose) requested exceeds the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert, then the prescriber must submit documentation in support of therapy with a higher dose for the intended diagnosis (submitted documentation may include medical records OR fax form which reflects medical record documentation that shows the length of time the requested dose has been used, and what other medications and doses have been tried and failed).
Duration of Approval: 365 days (1 year)
References
All information referenced is from FDA package insert unless otherwise noted below.
Policy Implementation/Update Information
Criteria and treatment protocols are reviewed annually by the Blue Cross NC P&T Committee, regardless of change. This policy is reviewed in Q4 annually.
October 2024: Criteria change: Added quantity limits to Auvi-Q, Epipen, Epipen Jr., and Symjepi.
August 2024: Criteria update: Added neffy to the policy. Added quantity limit section to policy.
April 2024: Criteria change: Added restriction to Symjepi.
January 2024: Criteria change: Removed restriction from Auvi-Q. Removed Epinephrine (authorized generic Adrenaclick) from policy (obsolete product).
September 2022: Criteria Update: Formatting changes.
Dec 2020: Criteria Update: Addition of Epinephrine autoinjector (authorized generic Adrenaclick) to policy.
Jul 2019: Criteria Change: Allowance for low dose Auvi-Q explicitly added. Branded products restricted and Symjepi added as a nonrestricted product. Removed UM from Essential and Net Results
Feb 2017: Original utilization management criteria issued.
Disclosures:
BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross NC is an independent licensee of the Blue Cross and Blue Shield Association. All other marks are the property of their respective owners.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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