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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
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.
DIOVAN HCT® 01/01/11 Diovan HCT may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB.
DIOVAN® 01/01/11 Diovan may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB.
DOLGIC PLUS 04/01/13 The limits are 5 tablets per day.
DOLOPHINE 01/01/13 The limits are 3 tablets per day.
DORYX® 11/14/07 Doryx may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline.
DOXYCYCLINE 04/01/13 Doxycycline may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline.
DUETACT® 07/01/10 The limits are 1 tablet per day.
DULERA® 01/01/11 The limits are 1 inhaler per 30 days.
DURAGESIC® 09/01/04 The limits are 15 patches per 30 days.
DURLAZA™ 09/04/15 Durlaza is not included in our formularies and is non-covered.
DYMISTA® 10/01/12 The limits are 1 bottle (23 grams) per 30 days.
DYNACIN® 04/01/13 Dynacin may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline.
DYSPORT® 01/01/15 Prior authorization for medical necessity is required.

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