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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
GAMASTAN™ S/D Prior authorization for medical necessity is required.
GAMMAGARD® LIQUID 10/01/14 Prior authorization for medical necessity is required when self-administered or physician-administered.
GAMMAGARD® S/D 01/01/15 Prior authorization for medical necessity is required when self-administered or physician-administered.
GAMMAKED™ 10/01/14 Prior authorization for medical necessity is required when self-administered or physician-administered.
GAMMAPLEX® LIQUID Prior authorization for medical necessity is required.
GAMUNEX®-C 01/01/12 Prior authorization for medical necessity is required when self-administered or physician-administered.
GATTEX® 07/01/13 Prior authorization for medical necessity is required.
GAZYVA™ 01/01/15 Prior authorization for medical necessity is required.
GEL-ONE® 05/01/15 Gel-One is not covered per medical policy. Refer to preferred products Synvisc or Synvisc-One.
GENOTROPIN® 10/01/11 Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
GENVISC 850® 04/01/16 Genvisc 850 is not covered per medical policy. Refer to preferred products Synvisc or Synvisc-One.
GENVOYA 11/10/15 The limits are 30 tablets per 30 days.
GILENYA® 01/01/11 Gilenya may be subject to step therapy. Patients must have trial and failure of one of the five preferred products: Betaseron, Copaxone, Plegridy, 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.

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