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Product Name Implementation Date Guideline
EMEND® 11/12/08 The limits are 4 capsules per 30 days for Emend 80mg, 2 capsules per 30 days for Emend 125mg, and 2 packs (6 capsules) per 30 days for Emend 125mg/80mg packs.
EMTRIVA 07/01/12 The limits are 1 capsule or 24 mL per day.
ENBREL® 05/17/99 Enbrel may be subject to step therapy requirements. Patients must have trial and failure of a first-line DMARD. The limits are 8 doses of Enbrel 25mg or 4 doses of Enbrel 50mg per 28 days.
ENDOCET® 01/01/00
ENTRESTO® 07/08/15 Prior authorization for medical necessity may be required. The quantity limits are 2 tablets per day.
ENTYVIO® 01/01/15 Predetermination for medical necessity is available.
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.
ERBITUX® 01/01/15 Predetermination for medical necessity is available.
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.

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