**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. |