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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
COCET® 04/01/13 The limits are 6 tablets per day.
CODEINE 01/01/13 The limits are 180 tablets per 30 days.
COMBIVENT 04/01/12 The limits are 2 inhalers per 30 days.
COMBIVENT RESPIMAT 07/01/12 The limits are 2 inhalers per 30 days.
COMBIVIR 07/01/12 The limits are 2 tablets per day.
COMBUNOX® 05/01/05 The limits are 120 tablets per 30 days.
COMETRIQ® 04/01/13 Prior authorization for medical necessity is required. The limits are 1 kit/28 days.
COMPLERA 07/01/12 The limits are 1 tablet per day.
COMPOUNDS 01/01/00 Prior authorization for medical necessity may be required.
CONCERTA® 11/01/02 The limits are 2 tablets per day.
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.
CORLANOR® 10/01/15 Prior Authorization for medical necessity may be required. Quantity limits are 2 tablets per day.
COSENTYX® 04/01/15 Cosentyx may be subject to step therapy requirements. Patients must have trial and failure of 2 preferred products. Preferred products are Humira, Enbrel, Stelara, and Simponi. Quantity limits apply based on package size.
COTELLIC 11/25/15 Prior authorization for medical necessity is required. The limits are 63 tablets per 30 days.

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