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Product Name | Implementation Date | Guideline |
---|---|---|
IBRANCE® | 02/20/15 | Prior authorization for medical necessity is required. Limits are 21 capsules per 28 days. |
IBUDONE™ | 05/15/09 | The limits are 5 tablets per day. |
ICLUSIG™ | 04/01/13 | Prior authorization for medical necessity is required. The limits are 2 tablets per day of the 15 mg tablets and 1 tablet per day of the 45 mg tablets. |
ILARIS® | 08/10/09 | Prior authorization for medical necessity is required. Patients must be at least 4 years of age. The limits are two 180 mg vial every 28 days.. |
IMBRUVICA® | 01/01/14 | Prior authorization for medical necessity is required. The limits are 4 capsules per day. |
IMITREX® | 11/01/05 | Imitrex may be subject to step therapy requirements. Patients must have trial and failure of a generic triptan (naratriptan,sumatriptan,rizatriptan). The limits are 18 tablets, 12 nasal spray units, 10 vials, or 6 kits per 30 days. |
INCIVEK™ | 10/01/11 | Prior authorization for medical necessity is required. |
INCRELEX® | 01/01/06 | Prior authorization for medical necessity is required. |
INCRUSE ELLIPTA® | 04/01/15 | The limits are 30 blisters per month. |
INFLECTRA | 04/05/16 | Inflectra is non-covered until a drug policy is in place, at which time prior authorization will be required. |
INLYTA® | 07/01/12 | Prior authorization for medical necessity is required. The limits are 6 tablets per day of the 1 mg tablets and 4 tablets per day of the 5 mg tablets. |
INTELENCE | 07/01/12 | The limits are 2 tablets per day, except 25 mg tablets with a limit of 4 tablets per day. |
INTERMEZZO® | 07/01/12 | The limits are 1 tablet per day. |
INVIRASE | 07/01/12 | The limits are 10 capsules or 4 tablets per day. |
INVOKAMET® | The limits are 2 tablets per day. |
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