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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
XALATAN® 06/04/02 The limits are 1-2.5mL box per 30 days or 1-7.5mL box per 90 days.
XALKORI® 01/01/12 Prior authorization for medical necessity is required. The limits are 60 capsules per 30 days.
XARELTO® 01/01/12 The limits are 35 tablets per 90 days for the 10mg tablets, which allows for a single course of therapy, 30 tablets per 30 days for 20mg tablets, and 60 tablets per 30 days for the 15 mg tablets.
XELJANZ® 01/01/13 Xeljanz may be subject to step therapy requirements. Patients must have trial and failure of Humira AND Enbrel. The limits are 2 tablets per day.
XELODA® 01/01/12 Prior authorization for medical necessity is required.
XODOL® 05/15/09 The limits are 12 tablets per day for Xodol 5/300mg and 6 tablets per day for Xodol 7.5/300mg and 10/300mg.
XOLOX™ 04/01/11 The limits are 8 tablets per day.
XOPENEX HFA 04/01/12 The limits are 2 inhalers per 30 days.
XTANDI® 11/15/12 Prior authorization for medical necessity is required. The limits are 4 capsules per day.
XYREM® 07/01/07 Prior authorization for medical necessity is required. The limits are 9g (18 mL) per day. Patients must be at least 18 years of age.