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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
SAIZEN® 10/01/11 Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
SAIZEN® CLICK-EASY 01/01/13 Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
SANCUSO® 11/12/08 Sancuso may be subject to step therapy requirements. Patients must have trial and failure of generic ondansetron or granisetron.
SELZENTRY 07/01/12 The limits are 2 tablets per day for 150 mg and 4 tablets per day for 300 mg strengths.
SEREVENT® DISKUS® 08/06/08 The limits are 2 blisters per day.
SEROSTIM® 10/01/11 Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
SIGNIFOR® 07/01/13 Prior authorization for medical necessity is required.
SILENOR 07/01/11 The limits are 1 tablet per day.
SIMCOR® 01/01/11 Simcor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
SIMPONI" 05/06/09 Simponi may be subject to step therapy requirements. Patients must have trial and failure of Humira AND Enbrel. The limits are 1 syringe per 28 days.
SINGULAIR® 01/01/00 The limits are 1 tablet or packet per day.
SOLODYN® 05/01/06 Solodyn may be subject to step therapy requirements. Patients must have a trial and failure of generic immediate release minocycline.
SONATA® 01/01/05 The limits are 1 capsule per day.
SPIRIVA® 06/07/04 The limits are 1 capsule per day.
SPRIX" 04/01/11 The limits are 5 bottles per 30 days.

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