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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
BUPHENYL 07/01/13 Prior authorization for medical necessity is required.
BUTALBITAL COMPOUND 04/01/13 The limits are 6 tablets per day.
BUTALBITAL/ACETAMINOPHEN 04/01/13 The limits are 6 tablets per day.
BUTRANS" 04/01/11 The limits are 4 transdermal systems per 30 days.
BYDUREON® 04/01/12 Bydureon may be subject to step therapy requirements. Patients must have trial and failure of one or more of the following antidiabetic agents: metformin, sulfonylurea, combinations of metformin or sulfonylureas, or basal insulin (Lantus or Levemir). The limits are 4 vials per 30 days.
BYETTA® 07/01/05 Byetta may be subject to step therapy requirements. Patients must have trial and failure of one or more of the following antidiabetic agents: metformin, sulfonylurea, combinations of metformin or sulfonylureas, or basal insulin (Lantus or Levemir). The limits are 1 pen per 30 days.
CADUET® 01/01/00 Only 1 statin covered per month.
CAPITAL® AND CODEINE 04/01/11 The limits are 2700mL per 30 days.
CAPRELSA® 01/01/12 Prior authorization for medical necessity is required. The limits are 2 tablets per day for the 100mg tablets and 1 tablet per day for the 300mg tablets.
CAVERJECT® 07/01/10 Prior authorization for medical necessity may be required. Patients must be at least 18 years of age.
CAYSTON® 04/01/12 Prior authorization for medical necessity may be required. Must not be used concurrently with inhaled tobramycin or Bethkis.
CELEBREX® 01/01/00 The limits are 2 capsules per day, except Celebrex 400mg which has a limit of 1 capsule per day.
CESAMET 04/01/12 The limits are 42 capsules per 30 days.
CHANTIX® 08/01/06 Coverage provided for up to a 24-week (168 days) supply per calendar year.
CIALIS® 01/01/04 Prior authorization for medical necessity may be required. The limits for Cialis 10mg and 20mg tablets are 8 tablets per 30 days. The limits for Cialis 2.5mg and 5mg tablets are 30 tablets per 30 days. Patients must be at least 18 years of age.

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