Product Name |
Implementation Date |
Guideline |
CADUET®
| 01/01/00 |
Only 1 statin covered per month. |
CAPITAL® AND CODEINE
| 04/01/11 |
The limits are 2700mL per 30 days. |
CAPRELSA®
| 01/01/12 |
Prior authorization for medical necessity is required. The limits are 2 tablets per day for the 100mg tablets and 1 tablet per day for the 300mg tablets. |
CAVERJECT®
| 07/01/10 |
Prior authorization for medical necessity may be required. Patients must be at least 18 years of age. |
CAYSTON®
| 04/01/12 |
Prior authorization for medical necessity may be required. Must not be used concurrently with inhaled tobramycin or Bethkis. |
CELEBREX®
| 01/01/00 |
The limits are 2 capsules per day, except Celebrex 400mg which has a limit of 1 capsule per day. |
CESAMET
| 04/01/12 |
The limits are 42 capsules per 30 days. |
CHANTIX®
| 08/01/06 |
Coverage provided for up to a 24-week (168 days) supply per calendar year. |
CIALIS®
| 01/01/04 |
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 |
Cimzia may be subject to step therapy requirements. Patients must have trial and failure of 2 preferred products. Preferred products are Humira, Enbrel, Stelara and Simponi. The limits are two 200 mg vials or syringes per 28 days. One starter kit (containing 6 syringes) is available per 180 days. |
COCET PLUS®
| 01/01/11 |
The limits are 6 tablets per day. |
COCET®
| 04/01/13 |
The limits are 6 tablets per day. |
CODEINE
| 01/01/13 |
The limits are 180 tablets per 30 days. |
COMBIVENT
| 04/01/12 |
The limits are 2 inhalers per 30 days. |
COMBIVENT RESPIMAT
| 07/01/12 |
The limits are 2 inhalers per 30 days. |