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. |