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Product Name Implementation Date Guideline
VALTURNA® 01/01/11 Valturna may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
VELTIN® 01/01/11 Prior authorization for medical necessity may be required.
VENLAFAXINE EXTENDED-RELEASE 11/12/08 The limits are 1 tablet per day.
VENTOLIN HFA 04/01/12 The limits are 2 inhalers per 30 days.
VERAMYST® 07/01/07 The limits are 1 box per 30 days.
VIAGRA® 07/01/98 Prior authorization for medical necessity may be required. The limits are 8 tablets per 30 days. Patients must be at least 18 years of age.
VIBRAMYCIN® 04/01/13 Vibramycin capsules, suspension and syrup may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline.
VICODIN® 09/01/03 The limits are 8 Vicodin (5 mg hydrocodone) tablets, 6 Vicodin HP tablets, or 5 Vicodin ES tablets per day. Patients should not take more than a total of 4 grams of acetaminophen per day (3 grams per day if you have liver disease).
VICOPROFEN® 09/24/03 The limits are 5 tablets.
VICTOZA® 02/15/10 Victoza may be subject to step therapy requirements. Patients must have trial and failure of one or more of the following antidiabetic agents: metformin, sulfonylurea, combinations of metformin or sulfonylureas, or basal insulin (Lantus or Levemir). The limits are 3 pens (9mL) per 30 days.
VICTRELIS" 10/01/11 Prior authorization for medical necessity is required.
VIRACEPT 07/01/12 The limits are 9 capsules per day for 250 mg and 4 tablets per day for 625 mg strengths.
VIRAMUNE 07/01/12 The limits are 2 tablets or 40 mL per day.
VIRAMUNE XR 07/01/12 The limits are 1 tablet per day for 400 mg tablets and 3 tablets per day for 100 mg tablets.
VIREAD 07/01/12 The limits are 1 tablet or 8 g per day.

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