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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
CONZIP® 01/01/12 The limits are 30 capsules per 30 days.
COPAXONE® 10/01/12 The limits are 1 carton of 30 syringes per 30 days.
COZAAR® 01/01/11 Cozaar 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).
CRESTOR® 01/01/11 Crestor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
CRIXIVAN 07/01/12 The limits are 3 capsules per day for 100 mg, 9 capsules per day for 200 mg, and 6 capsules per day for 400 mg strengths.
CYMBALTA® 09/01/04 The limits are 2 capsules per day, except Cymbalta 60mg with a limit of 1 capsule per day.
DANAZOL 04/01/12 Prior authorization for medical necessity is required.
DAYTRANA® 06/12/06 The limits are 1 patch per day.
DEMEROL 01/01/13 The limits are 8 tablets per day for 50 mg and 100 mg tablets. Demerol 50 mg/5 mL solution has a limit of 80 mL/day.
DESVENLAFAXINE SR 24HR 07/01/13 The limits are 1 tablet per day.
DEXILANT™ 07/01/10 Dexilant may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole, omeprazole, pantoprazole, or rabeprazole. The limits are 1 tablet per day.
DIABENESE 04/01/12 The limits are 60 tablets per 30 days for 100mg and 90 tablets per 30 days for 250mg.
DIDANOSINE 07/01/12 The limits are 1 capsule per day.
DIFFERIN® 04/01/01 Prior authorization for medical necessity may be required.
DILAUDID 01/01/13 The limits are 6 tablets per day or 48 mL/day for the Dilaudid 1 mg/mL solution.

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