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 Humira AND Enbrel. 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. |