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. |
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. |
INVOKANA
| 04/01/14 |
The limits are 1 tablet per day. |