Product Name |
Implementation Date |
Guideline |
MAGNACET"
| 09/01/04 |
The limits are 10 tablets per day for Magnacet 5/400mg. The limits are 8 tablets per day for Magnacet 7.5/400mg and 6 tablets per day for Magnacet 10/400mg. |
MATULANE®
| 01/01/12 |
Prior authorization for medical necessity is required. |
MAXAIR
| 04/01/12 |
The limits are 1 inhaler per 30 days. |
MAXALT®
| 11/01/05 |
The limits are 18 tablets per 30 days. |
MAXIDONE"
| 09/01/03 |
The limits are 5 tablets per day. |
MEKINIST®
| 01/01/14 |
Prior authorization for medical necessity is required. The limits are 3 tablets per day for 0.5 mg strength and 1 tablet per for all other strengths. |
METADATE CD®
| 01/01/05 |
The limits are 2 capsules per day, except Metadate CD 60mg which has a limit of 1 capsule per day. |
METAGLIP"
| 08/06/08 |
The limits are 4 tablets per day, except Metaglip 2.5/250mg which has a limit of 8 tablets per day. |
METHADONE
| 01/01/13 |
The limits for the 5 mg/5 mL solution is 30 mL per day and the 10 mg/5 mL solution is 15 mL per day. |
METHADOSE
| 01/01/13 |
The limits are 3 tablets per day or 3 mL of the 10 mg/mL concentrated solution per day. |
METHITEST®
| 04/01/12 |
Prior authorization for medical necessity is required. |
MEVACOR®
| 01/01/11 |
Mevacor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin). |
MICARDIS HCT®
| 01/01/11 |
Micardis HCT may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB. |
MICARDIS®
| 01/01/11 |
Micardis may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB. |
MINOCIN®
| 04/01/13 |
Minocin may be subject to step therapy requirements. Patients must have a trial and failure of generic immediate release minocycline. |