||Prior authorization for medical necessity may be required.
||The limits are 1 tablet per day.
||The limits are 2 inhalers per 30 days.
||The limits are 1 box per 30 days.
||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 capsules, suspension and syrup may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline.
||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).
||The limits are 5 tablets.
||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.
||Prior authorization for medical necessity is required.
||The limits are 9 capsules per day for 250 mg and 4 tablets per day for 625 mg strengths.
||The limits are 2 tablets or 40 mL per day.
||The limits are 1 tablet per day for 400 mg tablets and 3 tablets per day for 100 mg tablets.
||The limits are 1 tablet or 8 g per day.
||Vogelxo may be subject to step therapy requirements. Patients must have trial and failure of Androderm or Androgel. The limits are 2 packets per day or 4 pumps (300 gm) per 30 days for the pump.