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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
EPIDUO® 01/01/11 Prior authorization for medical necessity may be required.
EPIVIR 07/01/12 The limits are 2 tablets for Epivir 150 mg, 1 tablet for Epivir 300 mg or 960 ml/month for Epivir solution.
EPZICOM 07/01/12 The limits are 1 tablet per day.
ERIVEDGE® 07/01/12 Prior authorization for medical necessity is required. The limits are 1 capsule per day.
ESBRIET® 10/20/14 Prior authorization for medical necessity is required. The limits are 9 capsules per day.
ESGIC 04/01/13 The limits are 6 tablets or capsules per day.
ESGIC PLUS 04/01/13 The limits are 6 tablets or capsules per day.
ESOMEPRAZOLE STRONTIUM 01/01/14 Esomeprazole strontium may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole, omeprazole, pantoprazole, or rabeprazole. The limits are 1 capsule per day.
EVOTAZ® 04/01/15 The limits are 1 tablet per day.
EVZIO® 02/01/15 The limits are 1 package (2 auto-injections) per 365 days.
EXALGO® 04/14/10 The limits are 1 tablet per day.
EXFORGE HCT® 01/01/11 Exforge HCT may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB.
EXFORGE® 01/01/11 Exforge may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB.
EXTAVIA® 01/01/12 Extavia may be subject to step therapy. Patients must have trial and failure of one of the five preferred products: Betaseron, Copaxone, Plegridy, Rebif, or Tecfidera. The limits are 15 vial/syringe units per 30 days.
FABIOR 07/01/13 Prior authorization for medical necessity may be required.

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