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Drug Coverage Guidelines

The purpose of Blue Cross and Blue Shield of Alabama's pharmacy policy is to provide a guide to coverage. Pharmacy policy is not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

Product Name Implementation Date Change Date Guideline
ACCOLATE® 02/01/05   The limits are 2 tablets per day.
ACETAMINOPHEN WITH CODEINE 03/23/04   The limits are 13 tablets per day for acetaminophen with codeine 300mg/15mg, 12 tablets per day for acetaminophen with codeine 300mg/30mg, and 6 tablets per day for acetaminophen with codeine 300mg/60mg.
ACIPHEX® 02/18/02 08/06/08 Prior authorization for medical necessity may be required. The limits are 1 tablet per day.
ACTIQ® 06/23/03   Prior authorization for medical necessity is required. The limits are 4 lozenges per day. Patients must be at least 16 years of age.
ACTONEL® 01/01/00 05/23/08 The limits are 1 tablet per day for Actonel 5mg and 30mg, 1 tablet per week for Actonel 35mg, 2 tablets per 30 days for Actonel 75mg, and 1 tablet per 30 days for Actonel 150mg.
ACTOPLUS MET® 08/06/08   The limits are 3 tablets per day.
ACTOS® 07/01/10   The limits are 1 tablet per day, except Actos 15mg which has a limit of 3 tablets per day.
ADCIRCA™ 08/03/09   Prior authorization for medical necessity is required. The limits are 2 tablets per day.
ADDERALL XR® 11/13/02   The limits are 2 tablets per day. Not covered for patients less than 6 years of age.
ADVAIR® 08/06/08   Advair Diskus has a limit of 2 blisters per day. Advair HFA has a limit of 1 inhaler per 30 days.
ADVICOR® 01/01/00   Only 1 statin covered per month.
AEROBID® 08/06/08   The limits are 2 boxes per 30 days.
AFINITOR® 07/20/09   Prior authorization for medical necessity is required. The limits are 1 tablet per day.
ALLEGRA D® 12/03/01   The limits are 2 tablets per day for Allegra D 12HR and 1 tablet per day for Allegra D 24HR.
ALLEGRA® 02/25/02 11/12/08 The limits are 2 tablets per day, except for the 180 mg tablet, which has a limit of 1 tablet per day. Allegra oral suspension has a limit of 10mL per day.
ALTOPREV® 01/01/00   Only 1 statin covered per month.
ALVESCO® 08/06/08   The limits are 1 box per 30 days.
AMBIEN CR® 10/01/05 05/07/07 The limits are 1 tablet per day. Only 1 insomnia drug is covered per month. Not covered for patients less than 18 years of age.
AMBIEN® 02/25/02   The limits are 1 tablet per day. Only 1 insomnia drug is covered per month. Not covered for patients less than 18 years of age.
AMERGE® 11/01/05 11/01/05 The limits are 9 tablets per 30 days. Only 1 oral triptan is covered per month. Prior authorization is required for patients less than 12 years of age.
AMITIZA® 09/01/06   Prior authorization for medical necessity may be required. The limits are 2 capsules per day. Patients must be at least 18 years of age.
AMPYRA™ 06/01/10   Prior authorization for medical necessity is required. The limits are 2 tablets per day.
AMRIX® 08/06/08   Prior authorization for medical necessity is required. The limits are 1 capsule per day. Patients must be at least 18 years of age.
ANADROL®-50 07/20/09   Prior authorization for medical necessity is required.
ANDRODERM® 07/20/09   The limits are 3 patches per day for Androderm 2.5mg and 1 patch per day for Androderm 5mg. Not covered for females or patients less than 15 years of age.
ANDROGEL® 06/15/04 02/13/08 The limits are one carton (75 grams) of 2.5 gram unit-dose packets and up to two cartons (300 grams) of 5 gram unit-dose packets per 30 days. The Androgel Pump has a limit of 4 pumps (300 grams) per 30 days. Not covered for females or patients less than 18 years of age.
ANZEMET® 02/01/05 02/13/08 The limits are 1 tablet per day.
APLENZIN® 08/06/08   The limits are 1 tablet per day.
ARCALYST 12/18/08   Prior authorization for medical necessity is required. The limits are 2 vials the first week, then 1 vial per week thereafter. Patients must be at least 12 years of age.
ARIXTRA® 07/01/10   The limits are 1 syringe per day.
ASMANEX® 01/26/06 04/22/08 The limits for Asmanex Twisthaler 110mcg are 30 inhalation units per 30 days and for Asmanex Twisthaler 220mcg are 120 inhalation units per 30 days.
AVANDAMET® 08/06/08   The limits are 2 tablets per day, except Avandamet 2/500mg which has a limit of 4 tablets per day.
AVANDARYL® 07/01/10   The limits are 1 tablet per day, except Avandaryl 4-1mg and 4-2mg which have a limit of 2 tablets per day.
AVANDIA® 07/01/10   Avandia 2mg has a limit of 4 tablets per day. Avandia 4mg has a limit of 2 tablets per day. Avandia 8mg has a limit of 1 tablet per day.
AVINZA® 05/15/09   The limits are 1 capsule per day.
AVITA® 04/01/01   Prior authorization for medical necessity may be required.
AXERT® 11/01/05 11/01/05 The limits are 9 tablets per 30 days. Only 1 oral triptan is covered per month. Prior authorization is required for patients less than 12 years of age.
BALACET® 01/01/00   The limits are 6 tablets per day.
BECONASE AQ® 11/13/01   The limits are 2 bottles per 30 days.
BONIVA® 06/01/05 02/13/08 The limits are 1 tablet per day for Boniva 2.5mg and 1 tablet per 30 days for Boniva 150mg.
BYETTA® 07/01/05 09/01/06 Prior authorization for medical necessity may be required. The limits are 1 pen per 30 days. Patients must be at least 18 years of age.
CADUET® 01/01/00   Only 1 statin covered per month.
CELEBREX® 01/01/00 07/01/10 The limits are 2 capsules per day.
CHANTIX® 08/01/06 01/01/07 The limits are 2 tablets per day and up to a 180-day supply per calendar year. Not covered for patients less than 18 years of age.
CIALIS® 01/01/04 02/08/10 Prior authorization for medical necessity may be required. The limits for Cialis 10mg and 20mg tablets are 8 tablets per 30 days. The limits for Cialis 2.5mg and 5mg tablets are 30 tablets per 30 days. Patients must be at least 18 years of age.
CIMZIA® 06/23/09 07/01/10 Prior authorization for medical necessity may be required. The limits are 6 doses per 30 days for the first month then 2 doses per month thereafter.
CLARINEX D® 04/18/06   The limits are 2 tablets per day for Clarinex D 12 HR and 1 tablet per day for Clarinex D 24 HR.
CLARINEX® 01/16/02   The limits are 1 tablet or 10mL of syrup per day.
COMBUNOX® 05/01/05   The limits are 28 tablets per 30 days.
COMPOUNDS 01/01/00   Prior authorization for medical necessity may be required.
CONCERTA® 11/01/02 08/06/08 The limits are 2 tablets per day. Not covered for patients less than 6 years of age.
CRESTOR® 01/01/00   Only 1 statin covered per month.
CYMBALTA® 09/01/04   The limits are 2 capsules per day, except Cymbalta 60mg with a limit of 1 capsule per day.
DARVOCET® 03/29/04   The limits are 6 tablets per day, except for Darvocet-N 50 which has a limit of 12 tablets per day.
DARVON® 05/15/09   The limits are 6 capsules per day.
DARVON-N® 05/15/09   The limits are 6 tablets per day.
DAYTRANA® 06/12/06 08/10/09 The limits are 1 patch per day. Patients must be at least 6 years of age.
DEMEROL® 05/15/09   The limits are 4 tablets or 60mL per day.
DEXILANT™ 07/01/10   Prior authorization for medical necessity may be required. The limits are 1 capsule per day.
DIFFERIN® 04/01/01   Prior authorization for medical necessity may be required.
DILAUDID® 05/15/09   The limits are 4 tablets or 40mL per day.
DOLOPHINE® 05/15/09   The limits are 6 tablets per day.
DORYX® 11/14/07 11/12/08 Prior authorization for medical necessity may be required. The limits are 2 tablets per day, except for Doryx 150mg which has a limit of 1 tablet per day. Patients must be at least 8 years of age, unless diagnosed with anthrax.
DUETACT® 07/01/10   The limits are 1 tablet per day.
DURAGESIC® 09/01/04   The limits are 10 patches per 30 days.
EDLUAR™ 07/06/09   Prior authorization for medical necessity is required. The limits are 1 tablet per day. Patients must be at least 18 years of age.
EFFEXOR XR® 07/01/05 02/13/08 The limits are 1 capsule per day, except Effexor XR 75mg which has a limit of 3 capsules per day.
EMBEDA™ 09/09/09   The limits are 2 capsules per day.
EMEND® 11/12/08   The limits are 1 capsule per 30 days for Emend 40mg, 8 capsules per 30 days for Emend 80mg, 4 capsules per 30 days for Emend 125mg, and 4 packs (12 capsules) per 30 days for Emend 125mg/80mg packs.
ENBREL® 05/17/99 07/01/10 Prior authorization for medical necessity may be required. The limits are 8 doses of Enbrel 25mg or 4 doses of Enbrel 50mg per 30 days.
ENDOCET® 01/01/00   The limits for are 12 tablets per day for Endocet 5-325mg , 8 tablets per day for 7.5-325mg and 7.5-500mg, and 6 tablets per day for 10-325mg and 10-650mg.
ETH-OXYDOSE™ 06/18/07   The limits are 9mL per day.
EXALGO® 04/14/10   The limits are 1 tablet per day.
FENTORA® 09/01/06   Prior authorization for medical necessity is required. The limits are 4 tablets per day. Patients must be at least 18 years of age.
FEXMID® 08/06/08   Prior authorization for medical necessity is required. The limits are 3 tablets per day. Patients must be at least 15 years of age.
FLECTOR® PATCH 08/06/08   Prior authorization for medical necessity is required. The limits are 2 patches per day. Patients must be at least 18 years of age.
FLONASE® 04/01/04   The limits are 1 box per 30 days.
FLOVENT DISKUS® 04/01/05 01/08/10 The limits are 2 blisters per day for Flovent 50mcg and 100mcg. The limits are 4 blisters per day for Flovent 250mcg.
FLOVENT HFA® 04/01/05 04/22/08 The limits are 2 boxes per 30 days.
FOCALIN XR 07/01/05 12/22/09 The limits are 2 capsules per day except for Focalin XR 30mg which has a limit of 1 capsule per day. Not covered for patients less than 6 years of age.
FOCALIN® 01/01/00   Patients must be at least 6 years of age.
FORADIL® AEROLIZER® 08/06/08   The limits are 2 blisters per day.
FORTAMET® 05/15/09   The limits are 5 tablets per day for Fortamet 500mg and 2 tablets per day for Fortamet 1000mg.
FORTEO® 08/06/08   Prior authorization for medical necessity is required. The limits are 1 pen per 30 days.
FOSAMAX PLUS D® 04/25/05   The limits are 4 tablets per 30 days.
FOSAMAX® 01/01/00 11/17/08 The limits are 1 tablet per day for Fosamax 5mg, 10mg, and 40mg tablets. The limits are 4 tablets per 30 days for Fosamax 35 mg and 70 mg tablets. Fosamax solution has a limit of 4 bottles (300mL) per 30 days.
FRAGMIN® 07/01/10   The limits are 1 syringe per day or 10 vials per 30 days.
FROVA® 11/01/05 11/01/05 The limits are 9 tablets per 30 days. Only 1 oral triptan is covered per month. Prior authorization is required for patients less than 12 years of age.
GLEEVEC® 05/01/01 05/15/09 Prior authorization for medical necessity is required. The limits are 6 tablets per day for 100mg or 2 tablets per day for 400mg.
GLUCOPHAGE XR® 03/01/04   The limits are 4 tablets per day for Glucophage XR 500mg and 2 tablets per day for Glucophage XR 750mg.
GLUCOPHAGE® 03/01/04   The limits are 5 tablets per day for Glucophage 500mg, 3 tablets per day for Glucophage 850mg, and 2 tablets per day for Glucophage 1000mg.
GLUCOVANCE® 08/06/08   The limits are 4 tablets per day, except Glucovance 1.25/250mg which has a limit of 3 tablets per day.
GLUMETZA® 05/15/09   The limits are 4 tablets per day for Glumetza 500mg and 2 tablets per day for Glumetza 1000mg.
HIZENTRA™ 04/14/10   Prior authorization for medical necessity is required.
HUMIRA® 01/17/03 07/01/10 Prior authorization for medical necessity may be required. The limits are 2 doses per 30 days, except for Crohn's disease with the limit of 6 doses per 30 days for the first month and plaque psoriasis with a limit of 4 doses per 30 days for the first month.
HYCET™ 05/15/09   The limits are 120mL per day.
IBUDONE™ 05/15/09   The limits are 5 tablets per day.
ILARIS® 08/10/09   Prior authorization for medical necessity is required. The limits are 1 vial (180mg) every 8 weeks. Patients must be at least 4 years of age.
IMITREX® 11/01/05 11/01/05 The limits are 9 tablets, 12 nasal spray units, 10 vials, or 4 kits per 30 days. Only 1 oral triptan is covered per month. Prior authorization is required for patients less than 12 years of age.
INCRELEX® 01/01/06   Prior authorization for medical necessity is required.
INNOHEP® 07/01/10   The limits are 1 vial per day.
JANUMET® 05/01/07   The limits are 2 tablets per day.
JANUVIA® 11/01/06   The limits are 1 tablet per day.
KADIAN® 05/15/09   The limits are 2 capsules per day.
KINERET® 07/17/02 07/01/10 Prior authorization for medical necessity may be required. The limits are 1 syringe per day.
KYTRIL® 12/03/01   The limits are 2 tablets per day.
LESCOL XL® 01/01/00   Only 1 statin covered per month.
LESCOL® 01/01/00   Only 1 statin covered per month.
LEVITRA® 09/01/03   Prior authorization for medical necessity may be required. The limits are 8 tablets per 30 days. Patients must be at least 18 years of age.
LIPITOR® 01/01/00   Only 1 statin covered per month.
LIVALO® 07/01/10   Only 1 statin covered per month.
LORCET® 09/01/03   The limits are 8 tablets for the Lorcet - HD tablets and 6 tablets for the Lorcet Plus and Lorcet 10/650 tablets per day. Patients should not take more than a total of 4 grams of acetaminophen per day (3 grams per day if you have liver disease).
LORTAB® 09/01/03   The limits are 8 tablets for the 2.5 mg and 5 mg hydrocodone tablets and 6 tablets for the 7.5 mg and 10 mg tablets per day. The limits for Lortab elixir are 90mL per day. Patients should not take more than a total of 4 grams of acetaminophen per day (3 grams per day if have liver disease).
LOVENOX® 02/01/05   The limits are 2 syringes per day.
LUMIGAN® 06/04/02   The limits are 1-2.5mL box per 30 days or 1-5mL box per 60 days.
LUNESTA® 01/01/05   The limits are 1 tablet per day. Only 1 insomnia drug is covered per month. Not covered for patients less than 18 years of age.
LYRICA® 10/01/05 08/06/08 The limits are 3 capsules per day, except for Lyrica 225mg and 300mg which have a limit of 2 capsules per day. Not covered for patients less than 18 years of age.
MAGNACET™ 09/01/04   The limits are 10 tablets per day for Magnacet 2.5/400mg and 5/400mg. The limits are 8 tablets per day for Magnacet 7.5/400mg and 6 tablets per day for Magnacet 10/400mg.
MARGESIC® 09/01/03   The limits are 8 capsules per day.
MAXALT® 11/01/05 11/01/05 The limits are 9 tablets per 30 days. Only 1 oral triptan is covered per month. Prior authorization is required for patients less than 12 years of age.
MAXIDONE™ 09/01/03   The limits are 5 tablets per day.
MEPERITAB® 05/15/09   The limits are 4 tablets per day.
METADATE CD® 01/01/05 08/06/08 The limits are 2 capsules per day, except Metadate CD 60mg which has a limit of 1 capsule per day. Not covered for patients less than 6 years of age.
METADATE ER® 01/01/00   Patients must be at least 6 years of age.
METAGLIP™ 08/06/08   The limits are 4 tablets per day, except Metaglip 2.5/250mg which has a limit of 3 tablets per day.
METHADONE 05/15/09   The limits are 6 tablets per day for methadone tablets, 30mL per day for methadone oral solution, and 6mL per day for methadone Intensol™ oral concentrate.
METHYLIN ER® 01/01/00   Patients must be at least 6 years of age.
METHYLIN® 01/01/00   Patients must be at least 6 years of age.
MEVACOR® 01/01/00   Only 1 statin covered per month.
MORPHINE IR 05/15/09   The limits are 6 tablets per day for morphine IR tablets, 30mL per day for morphine IR oral solution, and 10mL per day for morphine oral concentrate.
MS CONTIN® 05/15/09   The limits are 3 tablets per day.
NANDROLONE 07/20/09   Prior authorization for medical necessity is required.
NASACORT AQ® 04/01/04   The limits are 1 box per 30 days.
NASAREL® 08/06/08   The limits are 2 boxes per 30 days.
NASONEX® 02/22/05   The limits are 1 box – 17 g per 30 days.
NEXAVAR® 01/01/06   Prior authorization for medical necessity is required. The limits are 4 tablets per day.
NEXIUM® 01/01/00 07/01/10 Prior authorization for medical necessity may be required. The limits are 1 capsule or packet per day.
NORCO® 09/01/03   The limits are 12 for the 5 mg tablets and 6 for the 7.5 and 10 mg tablets per day. Patients should not take more than a total of 4 grams of acetaminophen per day (3 grams per day if you have liver disease).
NUCYNTA™ 07/06/09   The limits are 12 tablets per day for Nucynta 50mg, 8 tablets per day for Nucynta 75mg, and 6 tablets per day for Nucynta 100mg. Patients must be at least 18 years of age.
NUVIGIL® 05/06/09   Prior authorization for medical necessity is required. The limits are 1 tablet per day. Patients must be at least 17 years of age.
OFORTA™ 12/22/09   Prior authorization for medical necessity is required.
OMNARIS™ 08/06/08   The limits are 1 box per 30 days.
ONGLYZA™ 08/27/09   The limits are 1 tablet per day.
ONSOLIS™ 09/18/09   Prior authorization for medical necessity is required. The limits are 4 tablets per day. Patients must be at least 18 years of age.
OPANA ER® 02/15/07   The limits are 2 tablets per day.
OPANA® 02/15/07 02/13/08 The limits are 12 tablets per day.
ORAMORPH® SR 05/15/09   The limits are 3 tablets per day.
OXANDRIN® 07/20/09   Prior authorization for medical necessity is required.
OXYCONTIN® 01/01/00 01/29/01 The limits are 3 tablets per day.
OXYFAST® 06/18/07   The limits are 9mL per day.
OXYIR® 06/18/07   The limits are 12 capsules per day.
PANLOR® DC 06/15/04   The limits are 10 capsules per day.
PANLOR® SS 06/15/04   The limits are 5 capsules per day.
PATANASE® 08/06/08   The limits are 1 box per 30 days.
PEGASYS® 06/01/06   Prior authorization for medical necessity is required. The limits are 4 vials or 1 kit per 30 days. Patients must be at least 18 years of age.
PEG-INTRON® 06/01/06 03/09/09 Prior authorization for medical necessity is required. The limits are 4 pens or vials per 30 days.
PERCOCET® 09/01/04   The limits are 12 tablets for the 2.5 mg and 5 mg oxycodone tablets, 8 tablets for the 7.5 mg tablets, and 6 tablets for the 10 mg tablets per day.
PERCODAN® 03/29/04   The limits are 12 tablets per day.
PRANDIMET™ 08/06/08   The limits are 5 tablets per day.
PRAVACHOL® 01/01/00   Only 1 statin covered per month.
PREVACID® 01/01/00 07/01/10 Prior authorization for medical necessity may be required for brand Prevacid. Prior authorization is not required for generic lansoprazole. The limits are 1 capsule, tablet, or packet per day.
PRILOSEC® 01/01/00 07/01/10 Prior authorization for medical necessity may be required for brand Prilosec. Prior authorization is not required for generic lansoprazole. Prilosec 20 mg is available OTC. The limits are 1 capsule or packet per 30 days, except Prilosec 2.5mg packets which has a limit of 2 packets per day.
PRIMALEV™ 05/15/09   The limits are 12 tablets per day for Primalev 2.5/300mg and 5/300mg. The limits are 8 tablets per day for Primalev 7.5/300mg and 6 tablets per day for 10/300mg tablets.
PRISTIQ® 05/01/08   The limits are 1 tablet per day. Not covered for patients less than 18 years of age.
PROMACTA® 05/15/09   Prior authorization for medical necessity is required. The limits are 3 tablets per day for Promacta 25mg and 1 tablet per day for Promacta 50mg.
PROTONIX® 01/01/00 07/01/10 Prior authorization for medical necessity may be required for brand Protonix or generic pantoprazole. The limits are 1 tablet or packet per day.
PROVIGIL® 09/01/03 07/20/09 Prior authorization for medical necessity is required. The limits are 2 tablets per day for Provigil 200mg and 1 tablet per day for Provigil 100mg. Patients must be at least 5 years of age.
PULMICORT® 02/01/05 02/13/08 The limits are 2 boxes per 30 days for Pulmicort Flexhaler. The limits are 2 respules per day, except for 1mg respules which have a limit of 1 respule per day.
QUALAQUIN® 05/01/07   Prior authorization for medical necessity is required. Patients must be at least 16 years of age.
QVAR® 08/06/08   The limits are 2 boxes per 30 days.
RELENZA® 12/03/01   The limits are 20 blisters (1 carton) per 30 days.
RELISTOR™ 08/06/08   Prior authorization for medical necessity is required. The limits are 1 vial per day. Patients must be at least 18 years of age.
RELPAX® 11/01/05 11/01/05 The limits are 9 tablets per 30 days. Only 1 oral triptan is covered per month. Prior authorization is required for patients less than 12 years of age.
RENOVA® 04/01/01   Prior authorization for medical necessity may be required.
REPREXAIN® 05/15/09   The limits are 5 tablets per day for a maximum 14-day supply.
RETIN-A® 04/01/01   Prior authorization for medical necessity may be required.
RHINOCORT AQ® 09/25/02 02/13/08 The limits are 2 boxes – 18 g per 30 days.
RITALIN LA® 07/01/05 08/06/08 The limits are 2 capsules per day. Not covered for patients less than 6 years of age.
RITALIN SR® 01/01/00   Patients must be at least 6 years of age.
RITALIN® 01/01/00   Patients must be at least 6 years of age.
ROXANOL™ 05/15/09   The limits are 10mL per day.
ROXICET™ 09/01/04 05/15/09 The limits are 12 tablets per day for 5/325mg tablets, 8 caplets per day for 5/500mg caplets, and 60mL per day for 5/325mg per 5mL oral solution.
ROXICODONE® 06/18/07 03/09/09 The limits are 12 tablets/capsules per day for 5mg and 6 tablets per day for all other strengths.
ROZEREM® 09/01/05   The limits are 1 tablet per day. Only 1 insomnia drug is covered per month. Not covered for patients less than 18 years of age.
RYZOLT™ 08/10/09   The limits are 1 tablet per day. Patients must be at least 16 years of age.
SANCUSO® 11/12/08   Prior authorization for medical necessity may be required. The limits are 4 patches per 30 days. Patients must be at least 18 years of age.
SEREVENT® DISKUS® 08/06/08   The limits are 2 blisters per day.
SIMCOR® 01/01/00   Only 1 statin covered per month.
SIMPONI™ 05/06/09 07/01/10 Prior authorization for medical necessity may be required. The limits are 1 syringe per month.
SINGULAIR® 01/01/00   The limits are 1 tablet or packet per day.
SKELID® 12/03/01   The limits are 2 tablets per day.
SOLODYN® 05/01/06   Prior authorization for medical necessity may be required. The limits are 1 tablet per day. Patients must be at least 12 years of age.
SOMA® 250MG 05/01/08   Prior authorization for medical necessity is required. The limits are 4 tablets per day. Patients must be at least 16 years of age.
SONATA® 01/01/05 02/13/08 The limits are 1 capsule per day for Sonata 5mg and 2 capsules per day for Sonata 10mg. Only 1 insomnia drug is covered per month. Not covered for patients less than 18 years of age.
SPIRIVA® 06/07/04   The limits are 1 capsule per day.
SPRYCEL® 07/01/06 01/18/10 Prior authorization for medical necessity is required. The limits are 4 tablets per day for Sprycel 20mg, 3 tablets per day for Sprycel 50mg, 2 tablets per day for Sprycel 70mg, and 1 tablet per day for Sprycel 100mg.
STADOL NS® 09/01/03 06/03/08 The limits are 4 boxes - 10 mL per 30 days. Not covered for patients less than 18 years of age.
STAGESIC™ 09/01/03   The limits are 8 capsules per day.
STANOZOLOL 07/20/09   Prior authorization for medical necessity is required.
STRATTERA® 01/15/03 08/01/08 The limits are 2 capsules per day, except Strattera 80mg and 100mg which is 1 capsule per day. Not covered for patients less than 6 years of age.
SUBOXONE® 08/06/08   Prior authorization for medical necessity is required. The limits are 4 tablets per day. Patients must be at least 16 years of age.
SUBUTEX® 08/06/08   Prior authorization for medical necessity is required. The limits for Subutex 2mg are 4 tablets per day and 8 tablets per 30 days. The limits for Subutex 8mg are 2 tablets per day and 4 tablets per 30 days. Patients must be at least 16 years of age.
SUMAVEL™ DOSEPRO™ 11/09/09   The limits are 10 prefilled delivery systems per 30 days. Prior authorization is required for patients less than 12 years of age.
SUTENT® 02/10/06   Prior authorization for medical necessity may be required. The limits are 1 tablet per day.
SYMBICORT® 08/01/07   The limits are 1 box per 30 days.
TACLONEX®, TACLONEX SCALP® 05/15/09   Prior authorization for medical necessity is required. The limits are 400g per month. Patients must be at least 18 years of age.
TAMIFLU® 02/01/05 04/22/08 The limits are 20 capsules per 30 days for Tamiflu 30mg, 10 capsules per 30 days for Tamiflu 35mg and 75mg, and 75 mL per 30 days for Tamiflu 300mg/25mL oral suspension.
TARCEVA® 03/14/07   Prior authorization for medical necessity is required. The limits are 1 tablet per day, except 25mg tablets with a limit of 3 tablets per day.
TESTIM® 06/15/04   The limits are 10 grams per day. Not covered for females or patients less than 18 years of age.
TRAVATAN® 06/04/02   The limits are 1-2.5mL box per 30 days or 1-5mL box per 60 days.
TRETINOIN® 04/01/01   Prior authorization for medical necessity may be required.
TREXIMET™ 04/22/08   The limits are 9 tablets per 30 days. Only 1 triptan is covered per month. Prior authorization is required for patients less than 12 years of age.
TUSSICAPS® 05/15/09   The limits are 2 capsules per day and 20 capsules per month. Not covered for patients less than 12 years of age.
TUSSIONEX® PENNKINETIC® 08/06/08 05/15/09 The limits are 10mL per day and 120mL per 30 days. Not covered for patients less than 12 years of age.
TYKERB® 11/01/07   Prior authorization for medical necessity is required. The limits are 5 tablets per day.
TYLENOL® 09/01/03   If a combination drug contains Tylenol, the daily dose of the acetaminophen component should not exceed 4 grams. Excessive doses may cause liver toxicity.
TYLENOL® WITH CODEINE 03/23/04   The limits are 12 tablets per day for Tylenol with Codeine 300mg/30mg and 6 tablets per day for Tylenol with Codeine 300mg/60mg.
TYLOX® 04/01/04   The limits are 8 capsules per day.
TYVASO™ 09/09/09   Prior authorization for medical necessity is required.
ULORIC® 07/20/09   Prior authorization for medical necessity is required. The limits are 1 tablet per day.
ULTRACET® 04/01/07   The limits are 8 tablets per day. Not covered for patients less than 18 years of age.
ULTRAM ER® 02/15/06   The limits are 1 tablet per day. Not covered for patients less than 18 years of age.
ULTRAM® 09/04/02   The limits are 8 tablets per day. Not covered for patients less than 16 years of age.
VENLAFAXINE EXTENDED-RELEASE 11/12/08   The limits are 1 tablet per day.
VENTAVIS® 02/01/07   Prior authorization for medical necessity is required.
VERAMYST® 07/01/07   The limits are 1 box per 30 days.
VIAGRA® 07/01/98 10/18/02 Prior authorization for medical necessity may be required. The limits are 8 tablets per 30 days. Patients must be at least 18 years of age.
VICODIN® 09/01/03   The limits are 8 Vicodin (5 mg hydrocodone) tablets, 6 Vicodin HP tablets, or 5 Vicodin ES tablets per day. Patients should not take more than a total of 4 grams of acetaminophen per day (3 grams per day if you have liver disease).
VICOPROFEN® 09/24/03 05/15/09 The limits are 5 tablets per day for a maximum 14-day supply.
VICTOZA® 02/15/10   Prior authorization for medical necessity may be required. The limits are 3 pens (9mL) per 30 days. Patients must be at least 18 years of age.
VIVAGLOBIN® 08/01/06   Prior authorization for medical necessity is required. Patients must be at least 2 years of age.
VOTRIENT™ 11/13/09   Prior authorization for medical necessity is required. The limits are 4 tablets per day.
VYTORIN® 01/01/00   Only 1 statin covered per month.
VYVANSE® 07/01/07 05/15/08 The limits are 1 capsule per day. Not covered for patients less than 6 years of age.
WELLBUTRIN SR® 08/06/08   The limits are 2 tablets per day.
WELLBUTRIN XL™ 07/15/04 02/13/08 The limits are 3 tablets per day for Wellbutrin XL 150mg and 1 tablet per day for Wellbutrin XL 300mg.
WELLBUTRIN® 08/06/08   The limits for Wellbutrin 75mg are 6 tablets per day. The limits for Wellbutrin 100mg are 4 tablets per day.
XALATAN® 06/04/02   The limits are 1-2.5mL box per 30 days or 1-7.5mL box per 90 days.
XODOL® 05/15/09   The limits are 12 tablets per day for Xodol 5/300mg and 6 tablets per day for Xodol 7.5/300mg and 10/300mg.
XOPENEX® 12/27/05   The limits are 30 grams (2 inhalers) per 30 days.
XYREM® 07/01/07   Prior authorization for medical necessity is required. The limits are 9g (18 mL) per day. Patients must be at least 16 years of age.
XYZAL® 08/06/08   The limits are 1 tablet or 10mL per day.
ZAMICET™ 05/15/09   The limits are 90mL per day.
ZANAFLEX CAPSULES™ 11/12/08   Prior authorization for medical necessity may be required. The limits are 6 capsules per day. Patients must be at least 18 years of age.
ZEGERID® 08/01/06   Prior authorization for medical necessity may be required. The limits are 1 capsule or packet per day.
ZIANA® 07/01/07   Prior authorization for medical necessity may be required.
ZOCOR® 01/01/00   Only 1 statin covered per month.
ZOFRAN® 02/01/05 02/13/08 The limits are 6 tablets per day for Zofran 4mg, 3 tablets per day for Zofran 8mg, and 1 tablet per day for Zofran 24mg.
ZOLPIMIST™ 05/15/09   Prior authorization for medical necessity is required. The limits are 1 container per month. Patients must be at least 18 years of age.
ZOMIG® 11/01/05 11/01/05 The limits are 9 tablets or 12 nasal spray units per 30 days. Only 1 oral triptan is covered per month. Prior authorization is required for patients less than 12 years of age.
ZYBAN® 08/06/08   The limits are 2 tablets per day.
ZYDONE® 09/01/03   The limits are 8 tablets per day for Zydone 5/400mg and 6 tablets per day for Zydone 7.5/400mg and 10/400mg.
ZYFLO CR® 02/01/05 04/16/08 The limits are 4 tablets per day.
ZYRTEC D® 01/01/00   The limits are 2 tablets per day.
ZYRTEC® 01/01/00   The limits are 1 tablet per day.