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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
GAMUNEX-C® 01/01/12 Prior authorization for medical necessity is required.
GATTEX® 07/01/13 Prior authorization for medical necessity is required.
GENOTROPIN® 10/01/11 Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
GILENYA" 01/01/11 Gilenya may be subject to step therapy. Patients must have trial and failure of two of the four preferred products: Betaseron, Copaxone, Rebif or Tecfidera. The limits are 1 tablet per day.
GILOTRIF® 01/01/14 Prior authorization for medical necessity is required. The limits are 1 tablets per day.
GLEEVEC® 05/01/01 Prior authorization for medical necessity is required. The limits are 3 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 3 tablets per day for Glucophage 500mg, 3 tablets per day for Glucophage 850mg, and 2 tablets per day for Glucophage 1000mg.
GLUCOTROL 04/01/12 The limits are 30 tablets per 30 days for 5mg, and 120 tablets per 30 days for 10mg.
GLUCOTROL XL 04/01/12 The limits are 30 tablets per 30 days for 2.5mg and 5mg, and 60 tablets per 30 days for 10mg.
GLUCOVANCE® 08/06/08 The limits are 4 tablets per day, except Glucovance 1.25/250mg which has a limit of 2 tablets per day.
GLUMETZA® 05/15/09 The limits are 3 tablets per day for Glumetza 500mg and 2 tablets per day for Glumetza 1000mg.
GLYNASE PRESTAB 04/01/12 The limits are 30 tablets per 30 days for 1.5mg and 3mg, and 60 tablets per 30 days for 4.5mg and 6mg.
GLYSET 04/01/12 The limits are 90 tablets per 30 days.
GRALISE® 01/01/12 The limits are 30 capsules per 30 days for 300mg tablets, 90 tablets per 30 days for 600mg tablets, and 1 starter pack per 30 days.

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