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All A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Product Name Implementation Date Guideline
DAKLINZA® 08/14/15 Prior authorization for medical necessity is required. Quantity limits may apply based on strength.
DANAZOL 04/01/12 Prior authorization for medical necessity is required.
DAYTRANA® 06/12/06 The limits are 1 patch per day.
DEMEROL 01/01/13 The limits are 8 tablets per day for 50 mg and 100 mg tablets. Demerol 50 mg/5 mL solution has a limit of 80 mL/day.
DERMACINRX AZENASE PAK 11/19/15 The limits are 1 pak per 30 days.
DERMAPAK PAK PLUS 10/06/15 Prior authorization for medical necessity is required.
DESVENLAFAXINE SR 24HR 07/01/13 The limits are 1 tablet per day.
DEXILANT® 07/01/10 Dexilant may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole, omeprazole, pantoprazole, or rabeprazole. The limits are 1 tablet per day.
DIABENESE 04/01/12 The limits are 60 tablets per 30 days for 100mg and 90 tablets per 30 days for 250mg.
DIDANOSINE 07/01/12 The limits are 1 capsule per day.
DIFFERIN® 04/01/01 Prior authorization for medical necessity may be required.
DILAUDID 01/01/13 The limits are 6 tablets per day or 48 mL/day for the Dilaudid 1 mg/mL solution.
DIOVAN HCT® 01/01/11 Diovan HCT may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB.
DIOVAN® 01/01/11 Diovan may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB.
DOLGIC PLUS 04/01/13 The limits are 5 tablets per day.

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