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Product Name Implementation Date Guideline
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.
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 Predetermination for medical necessity is available.
EDARBI® 04/01/11 Edarbi may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB.
EDARBYCLOR® 07/01/12 Edarbyclor may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB.
EDEX® 07/01/10 Prior authorization for medical necessity may be required. Patients must be at least 18 years of age.
EDLUAR® 07/06/09 The limits are 1 tablet per day.
EDURANT 07/01/12 The limits are 1 tablet per day.
EFFEXOR XR® 07/01/05 The limits are 1 capsule per day, except Effexor XR 75mg which has a limit of 3 capsules per day.
ELIQUIS 07/01/13 The limits are 2 tablets per day for Eliquis 2.5mg and 4 tablets per day for Eliqus 5 mg.
EMBEDA® 09/09/09 The limits are 2 capsules per day.

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