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Drug Coverage Guidelines

The purpose of Blue Cross and Blue Shield of Alabama's pharmacy policy is to provide a guide to coverage. Pharmacy policy is not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

Product Name Implementation Date Change Date Guideline
ABSTRAL® 04/01/11   Prior authorization for medical necessity is required. The limits are 4 tablets per day.
ACCOLATE® 02/01/05   The limits are 2 tablets per day.
ACETAMINOPHEN WITH CODEINE 03/23/04   The limits are 13 tablets per day for acetaminophen with codeine 300mg/15mg, 12 tablets per day for acetaminophen with codeine 300mg/30mg, and 6 tablets per day for acetaminophen with codeine 300mg/60mg.
ACIPHEX® 02/18/02 04/01/14 Aciphex may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole, omeprazole, pantoprazole, or rabeprazole. The limits are 1 tablet per day for the 20mg tablets and 1 capsule per day for the 5mg and 10mg sprinkle.
ACTEMRA® 01/01/14   Actemra subcutaneous injection may be subject to step therapy requirements. Patients must have trial and failure of Humira AND Enbrel. The limits are 4 syringes per 28 days.
ACTIQ® 06/23/03   Prior authorization for medical necessity is required. The limits are 4 lozenges per day.
ACTONEL® 01/01/00 07/01/13 The limits are 1 tablet per day for Actonel 5mg and 30mg, 1 tablet per week for Actonel 35mg, and 1 tablet per 30 days for Actonel 150mg.
ACTOPLUS MET XR® 01/01/11   The limits are 2 tablets per day for Actoplus Met XR 15/1000mg and 1 tablet per day for Actoplus Met XT 30/1000mg.
ACTOPLUS MET® 08/06/08   The limits are 3 tablets per day.
ACTOS® 07/01/10 04/01/12 The limits are 1 tablet per day.
ADAPALENE 04/01/01   Prior authorization for medical necessity may be required.
ADDERALL XR® 11/13/02 04/01/11 The limits are 2 tablets per day.
ADOXA® 04/01/13   Adoxa may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline.
ADVAIR® 08/06/08   Advair Diskus has a limit of 2 blisters per day. Advair HFA has a limit of 1 inhaler per 30 days.
ADVICOR® 01/01/11   Advicor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
AEROSPAN® 04/01/14   The limits are 2 canisters per month.
AFINITOR® 07/20/09 07/01/11 Prior authorization for medical necessity is required. The limits are 1 tablet per day.
AFINITOR® DISPERZ 07/01/13   Prior authorization for medical necessity is required. The limits are 2 tablets per day, except the 3 mg tablets which have a limit of 3 tablets per day.
ALENDRONATE 07/01/13 01/01/14 The limits are 1 tablet per day for 40mg tablets and 300mls per 28 days for the oral solution.
ALODOX™ 04/01/13   Alodox may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline.
ALSUMA™ 04/01/11 01/01/12 The limits are 12 doses per 30 days.
ALTOPREV® 01/01/11   Altoprev may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
ALVESCO® 08/06/08 04/01/11 The limits are 1 box per 30 days for 80mcg strength and 2 boxes per 30 days for 160mcg strength.
AMARYL 04/01/12   The limits are 30 tablets per 30 days, except 4mg tablets which have a limit of 60 tablets per 30 days.
AMBIEN CR® 10/01/05 07/01/13 The limits are 1 tablet per day.
AMBIEN® 02/25/02 07/01/13 The limits are 1 tablet per day.
AMERGE® 11/01/05 01/01/12 The limits are 18 tablets per 30 days.
AMITIZA® 09/01/06 10/01/11 Prior authorization for medical necessity is required.
AMPYRA™ 06/01/10   Prior authorization for medical necessity is required. The limits are 2 tablets per day.
AMTURNIDE™ 04/01/11 04/01/13 Amturnide may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
ANADROL®-50 07/20/09   Prior authorization for medical necessity is required.
ANDRODERM® 07/20/09 04/01/14 The limits are 1 patch per day.
ANDROGEL® 06/15/04 01/01/13 The limits are two cartons (60 packets) of 2.5 gram or 5 gram unit-dose packets per 30 days. The Androgel Pump has a limit of 4 pumps (300 grams) per 30 days. Androgel 1.62% has a limit of 2 bottles (150 grams), 30 1.25 gm packets, or 60 2.5 gm packets per 30 days.
ANDROID® 04/01/12   Prior authorization for medical necessity is required.
ANDROXY® 04/01/12   Prior authorization for medical necessity is required.
ANORO ELLIPTA 04/01/14   The limits are 60 doses per 30 days.
ANZEMET® 02/01/05 04/01/12 The limits are 7 tablet per 30 days.
APLENZIN® 08/06/08   The limits are 1 tablet per day.
APTIVUS 07/01/12   The limits are 4 capsules or 13 mL per day.
ARCALYST 12/18/08 10/01/12 Prior authorization for medical necessity is required. Patients must be at least 12 years of age. The limits are one 220 mg vial per week.
ARCAPTA® 01/01/12   The limits are 30 capsules per 30 days.
ARIXTRA® 07/01/10 04/01/12 The limits are 30 syringes per 90 days.
ASMANEX® 01/26/06 04/22/08 The limits for Asmanex Twisthaler 110mcg are 30 inhalation units per 30 days and for Asmanex Twisthaler 220mcg are 120 inhalation units per 30 days.
ASTELIN 07/01/13   The limits are 60 mL per 30 days.
ASTEPRO 07/01/13   The limits are 60 mL per 30 days.
ATACAND HCT® 01/01/11 04/01/13 Atacand HCT may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
ATACAND® 01/01/11 04/01/13 Atacand may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
ATELVIA™ 04/01/11 07/01/13 The limits are 4 tablets per 30 days.
ATRALIN® 04/01/01   Prior authorization for medical necessity may be required.
ATRIPLA 07/01/12   The limits are 1 tablet per day.
ATROVENT HFA 04/01/12   The limits are 2 inhalers per 30 days.
ATROVENT NASAL INHALER 07/01/13   The limits are 60 mL per 30 days for 21 mcg/spray and 45 mL per 30 days for 42 mcg/spray.
AUBAGIO® 01/01/13 01/01/14 Aubagio may be subject to step therapy. Patients must have trial and failure of two of the four preferred products: Betaseron, Copaxone, Rebif, or Tecfidera. The limits are 1 tablet per day.
AVALIDE® 01/01/11 04/01/13 Avalide may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
AVANDAMET® 08/06/08 04/01/12 The limits are 2 tablets per day.
AVANDARYL® 07/01/10 04/01/12 The limits are 1 tablet per day.
AVANDIA® 07/01/10 04/01/12 Avandia 2mg and 4mg has a limit of 2 tablets per day. Avandia 8mg has a limit of 1 tablet per day.
AVAPRO® 01/01/11 04/01/13 Avapro may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
AVIDOXY™ DK 04/01/13   Avidoxy DK may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline.
AVINZA® 05/15/09   The limits are 1 capsule per day.
AVITA® 04/01/01   Prior authorization for medical necessity may be required.
AVONEX® 01/01/12 01/01/14 Avonex may be subject to step therapy. Patients must have trial and failure of two of the four preferred products: Betaseron, Copaxone, Rebif, or Tecfidera. The limits are one 30mg vial, syringe, or pen per week.
AXERT® 11/01/05 01/01/12 The limits are 12 tablets per 30 days.
AXIRON® 07/01/11 04/01/12 The limits are 180mL (2 bottles) per 30 days.
AZOR® 01/01/11 04/01/13 Azor may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
BECONASE AQ® 11/13/01   The limits are 2 bottles per 30 days.
BENICAR HCT® 01/01/11 04/01/13 Benicar HCT may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
BENICAR® 01/01/11 04/01/13 Benicar may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
BETASERON® 10/01/12 01/01/14 The limits are 14 vial/syringe units per 28 days and 1 kit (14 prefilled syringes) per 28 days.
BETHKIS® 01/01/14   Prior authorization for medical necessity may be required. Must not be used concurrently with inhaled tobramycin or Cayston.
BINOSTO™ 01/01/13 07/01/13 The limits are 4 tablets per 28 days.
BIO-T-GEL® 10/01/12   The limits are 2 packets per day.
BONIVA® 06/01/05 07/01/13 The limits are 1 tablet per 30 days for Boniva 150mg.
BOSULIF® 11/15/12   Prior authorization for medical necessity is required. The limits are 1 tablet per day.
BREO ELLIPTA® 01/01/14   The limits are 2 blisters per day.
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 04/01/12 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 04/01/13 Prior authorization for medical necessity may be required. Must not be used concurrently with inhaled tobramycin or Bethkis.
CELEBREX® 01/01/00 01/01/12 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 04/01/12 Coverage provided for up to a 24-week (168 days) supply per calendar year.
CIALIS® 01/01/04 02/08/10 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.
CIMZIA® 06/23/09 01/01/14 Cimzia may be subject to step therapy requirements. Patients must have trial and failure of Humira AND Enbrel. The limits are two 200 mg vials or syringes per 28 days. One starter kit (containing 6 syringes) is available per 180 days.
COCET PLUS® 01/01/11   The limits are 6 tablets per day.
COCET® 04/01/13   The limits are 6 tablets per day.
CODEINE 01/01/13   The limits are 180 tablets per 30 days.
COMBIVENT 04/01/12   The limits are 2 inhalers per 30 days.
COMBIVENT RESPIMAT 07/01/12   The limits are 2 inhalers per 30 days.
COMBIVIR 07/01/12   The limits are 2 tablets per day.
COMBUNOX® 05/01/05 04/01/12 The limits are 120 tablets per 30 days.
COMETRIQ™ 04/01/13   Prior authorization for medical necessity is required. The limits are 1 kit/28 days.
COMPLERA 07/01/12   The limits are 1 tablet per day.
COMPOUNDS 01/01/00   Prior authorization for medical necessity may be required.
CONCERTA® 11/01/02 04/01/11 The limits are 2 tablets per day.
CONZIP® 01/01/12   The limits are 30 capsules per 30 days.
COPAXONE® 10/01/12   The limits are 1 carton of 30 syringes per 30 days.
COZAAR® 01/01/11 04/01/13 Cozaar may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
CRESTOR® 01/01/11   Crestor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
CRIXIVAN 07/01/12   The limits are 9 capsules per day for 200 mg, and 6 capsules per day for 400 mg strengths.
CYCLOSET 04/01/12   The limits are 180 tablets per 30 days.
CYMBALTA® 09/01/04   The limits are 2 capsules per day, except Cymbalta 60mg with a limit of 1 capsule per day.
DANAZOL 04/01/12   Prior authorization for medical necessity is required.
DAYTRANA® 06/12/06 04/01/11 The limits are 1 patch per day.
DEMEROL 01/01/13   The limits are 8 tablets per day for 50 mg and 100 mg tablets. Demerol 50 mg/5 mL solution has a limit of 80 mL/day.
DESVENLAFAXINE SR 24HR 07/01/13   The limits are 1 tablet per day.
DEXILANT™ 07/01/10 04/01/14 Dexilant may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole, omeprazole, pantoprazole, or rabeprazole. The limits are 1 tablet per day.
DIABENESE 04/01/12   The limits are 60 tablets per 30 days for 100mg and 90 tablets per 30 days for 250mg.
DIABETA 04/01/12   The limits are 30 tablets per 30 days for 1.25mg and 2.5mg tablets, and 120 tablets per 30 days for 5mg tablets.
DIDANOSINE 07/01/12   The limits are 1 capsule per day.
DIFFERIN® 04/01/01   Prior authorization for medical necessity may be required.
DILAUDID 01/01/13   The limits are 6 tablets per day or 48 mL/day for the Dilaudid 1 mg/mL solution.
DIOVAN HCT® 01/01/11 04/01/13 Diovan HCT may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
DIOVAN® 01/01/11   Diovan may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB.
DOLGIC PLUS 04/01/13   The limits are 5 tablets per day.
DOLOPHINE 01/01/13   The limits are 3 tablets per day.
DORYX® 11/14/07 04/01/13 Doryx may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline.
DOXYCYCLINE 04/01/13   Doxycycline may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline.
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 04/01/11 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 minocycline.
EDARBI™ 04/01/11 04/01/13 Edarbi may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
EDARBYCLOR™ 07/01/12 04/01/13 Edarbyclor may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
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 07/01/13 The limits are 1 tablet per day.
EDURANT 07/01/12   The limits are 1 tablet per day.
EFFEXOR XR® 07/01/05 02/13/08 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.
EMBEDA™ 09/09/09   The limits are 2 capsules per day.
EMEND® 11/12/08 04/01/12 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 01/01/14 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   The limits for are 12 tablets per day for Endocet 5-325mg , 8 tablets per day for 7.5-325mg and 7.5-500mg, and 6 tablets per day for 10-325mg and 10-650mg.
EPIDUO® 01/01/11   Prior authorization for medical necessity may be required.
EPIVIR 07/01/12   The limits are 1 tablet or 32 mL per day.
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.
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 04/01/14 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.
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 01/01/14 Extavia may be subject to step therapy. Patients must have trial and failure of two of the four preferred products: Betaseron, Copaxone, 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.
FARXIGA® 04/01/14   The limits are 1 tablet per day.
FENTANYL CITRATE LOLLIPOP 06/23/03   Prior authorization for medical necessity is required. The limits are 4 lozenges per day. Patients must be at least 16 years of age.
FENTORA® 09/01/06   Prior authorization for medical necessity is required. The limits are 4 tablets per day.
FETZIMA® 01/01/14   The limits are 1 capsule per day or 1 titration pack per 28 days.
FIORICET 04/01/13   The limits are 6 tablets per day.
FIORICET WITH CODEINE 04/01/13   The limits are 6 tablets per day.
FIORINAL 04/01/13   The limits are 6 capsules per day.
FIORINAL WITH CODEINE 04/01/13   The limits are 6 capsules per day.
FIRAZYR® 04/01/12   Prior authorization for medical necessity is required. The limits are 3 syringes per prescription.
FIRST-LANSOPRAZOLE 07/01/12 04/01/14 FIRST-Lansoprazole may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole, omeprazole, pantoprazole, or rabeprazole. The limits are 10 mL per day.
FIRST-OMEPRAZOLE 07/01/12 04/01/14 FIRST-Omeprazole may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole, omeprazole, pantoprazole, or rabeprazole. The limits are 20 mL per day.
FIRST-TESTOSTERONE 04/01/12   The limits are 60 grams per 30 days.
FIRST-TESTOSTERONE MC 04/01/12   The limits are 60 grams per 30 days.
FLECTOR® PATCH 08/06/08   Prior authorization for medical necessity is required. The limits are 2 patches per day. Patients must be at least 18 years of age.
FLONASE® 04/01/04   The limits are 1 box per 30 days.
FLOVENT DISKUS® 04/01/05 04/01/11 The limits are 2 blisters per day for Flovent 50mcg and 100mcg. The limits are 8 blisters per day for Flovent 250mcg.
FLOVENT HFA® 04/01/05 04/01/12 The limits are 1 inhaler per 30 days for 44mcg and 110mcg, and 2 inhalers per 30 days for 220mcg.
FLUNISOLIDE NASAL SPRAY 01/01/12   The limits are 3 bottles (75mL) per 30 days.
FOCALIN® XR 07/01/05 01/01/12 The limits are 2 capsules per day except for Focalin XR 25mg, 30mg, 35mg, and 40mg which have a limit of 1 capsule per day.
FORADIL® AEROLIZER® 08/06/08   The limits are 2 blisters per day.
FORFIVO XL 07/01/12   The limits are 1 tablet per day.
FORTAMET® 05/15/09 04/01/12 The limits are 3tablets per day for Fortamet 500mg and 2 tablets per day for Fortamet 1000mg.
FORTEO® 08/06/08 07/01/11 Prior authorization for medical necessity is required.
FORTESTA 07/01/11 04/01/12 The limits are 120 grams (2 bottles) per 30 days.
FOSAMAX PLUS D® 04/25/05 07/01/13 The limits are 4 tablets per 30 days.
FOSAMAX® 01/01/00 01/01/14 The limits are 1 tablet per day for Fosamax 5mg, 10mg, and 40mg tablets. The limits are 4 tablets per 30 days for Fosamax 35 mg and 70 mg tablets.
FRAGMIN® 07/01/10 07/01/13 The limits are 30 syringe per 90 days.
FROVA® 11/01/05 01/01/12 The limits are 18 tablets per 30 days.
FUZEON 07/01/12   The limits are 2 vials per day.
GAMUNEX-C® 01/01/12   Prior authorization for medical necessity is required.
GATTEX® 07/01/13   Prior authorization for medical necessity is required.
GENOTROPIN® 10/01/11   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
GILENYA™ 01/01/11 01/01/14 Gilenya may be subject to step therapy. Patients must have trial and failure of two of the four preferred products: Betaseron, Copaxone, Rebif or Tecfidera. The limits are 1 tablet per day.
GILOTRIF® 01/01/14   Prior authorization for medical necessity is required. The limits are 1 tablets per day.
GLEEVEC® 05/01/01 07/01/11 Prior authorization for medical necessity is required. The limits are 3 tablets per day for 100mg or 2 tablets per day for 400mg.
GLUCOPHAGE XR® 03/01/04   The limits are 4 tablets per day for Glucophage XR 500mg and 2 tablets per day for Glucophage XR 750mg.
GLUCOPHAGE® 03/01/04 04/01/12 The limits are 3 tablets per day for Glucophage 500mg, 3 tablets per day for Glucophage 850mg, and 2 tablets per day for Glucophage 1000mg.
GLUCOTROL 04/01/12   The limits are 30 tablets per 30 days for 5mg, and 120 tablets per 30 days for 10mg.
GLUCOTROL XL 04/01/12   The limits are 30 tablets per 30 days for 2.5mg and 5mg, and 60 tablets per 30 days for 10mg.
GLUCOVANCE® 08/06/08 04/01/12 The limits are 4 tablets per day, except Glucovance 1.25/250mg which has a limit of 2 tablets per day.
GLUMETZA® 05/15/09 04/01/12 The limits are 3 tablets per day for Glumetza 500mg and 2 tablets per day for Glumetza 1000mg.
GLYNASE PRESTAB 04/01/12   The limits are 30 tablets per 30 days for 1.5mg and 3mg, and 60 tablets per 30 days for 4.5mg and 6mg.
GLYSET 04/01/12   The limits are 90 tablets per 30 days.
GRALISE® 01/01/12 07/01/13 The limits are 30 capsules per 30 days for 300mg tablets, 90 tablets per 30 days for 600mg tablets, and 1 starter pack per 30 days.
GRANISOL 04/01/12   The limits are 60 mL (2 bottles) per 30 days.
H.P. ACTHAR GEL® 04/01/12   Prior authorization for medical necessity is required.
HEXALEN® 01/01/12   Prior authorization for medical necessity is required.
HIZENTRA™ 04/14/10   Prior authorization for medical necessity is required.
HORIZANT® 01/01/12 07/01/13 The limits are 60 tablets per 30 days.
HUMATROPE® 10/01/11   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
HUMIRA® 01/17/03 10/01/12 Humira may be subject to step therapy requirements. Patients must have trial and failure of a first-line DMARD. The limits are 2 doses per 28 days. One starter kit for Crohn's disease or Psoriasis will be covered per 180 days.
HYCAMTIN® 01/01/12   Prior authorization for medical necessity is required.
HYCET™ 05/15/09   The limits are 120mL per day.
HYDROCODONE/ACETAMINOPHEN 10/01/12   The limits are 12 tablets per day for 2.5mg-325mg tablets.
HYZAAR® 01/01/11 04/01/13 Hyzaar may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
IBUDONE™ 05/15/09   The limits are 5 tablets per day.
ICLUSIG™ 04/01/13   Prior authorization for medical necessity is required. The limits are 2 tablets per day of the 15 mg tablets and 1 tablet per day of the 45 mg tablets.
ILARIS® 08/10/09 10/01/12 Prior authorization for medical necessity is required. Patients must be at least 4 years of age. The limits are one 180 mg vial every 8 weeks.
IMBRUVICA® 01/01/14   Prior authorization for medical necessity is required. The limits are 4 capsules per day.
IMITREX® 11/01/05 01/01/12 The limits are 18 tablets, 12 nasal spray units, 10 vials, or 6 kits per 30 days.
INCIVEK™ 10/01/11   Prior authorization for medical necessity is required.
INCRELEX® 01/01/06   Prior authorization for medical necessity is required.
INLYTA® 07/01/12   Prior authorization for medical necessity is required. The limits are 6 tablets per day of the 1 mg tablets and 4 tablets per day of the 5 mg tablets.
INTELENCE 07/01/12 10/01/12 The limits are 2 tablets per day, except 25 mg tablets with a limit of 4 tablets per day.
INTERMEZZO™ 07/01/12 07/01/13 The limits are 1 tablet per day.
INVIRASE 07/01/12   The limits are 10 capsules or 4 tablets per day.
INVOKANA 04/01/14   The limits are 1 tablet per day.
ISENTRESS 07/01/12   The limits are 6 tablets per day for 25 mg, 4 tablets per day for 100 mg, and 2 tablets per day for 400 mg strengths.
JAKAFI™ 04/01/12   Prior authorization for medical necessity is required. The limits are 2 tablets per day.
JANUMET® 05/01/07   The limits are 2 tablets per day.
JANUMET® XR 07/01/12   The limits are 1 tablet per day, except 50 mg/1000 mg tablets which have a limit of 2 tablets per day.
JANUVIA® 11/01/06   The limits are 1 tablet per day.
JENTADUETO™ 07/01/12   The limits are 2 tablets per day.
JUVISYNC 04/01/12   The limits are 30 tablets per 30 days.
JUXTAPID 07/01/13   Prior authorization for medical necessity is required.
KADIAN® 05/15/09   The limits are 2 capsules per day.
KALETRA 07/01/12   The limits are 2 tablets per day for 100 mg/25 mg, 4 tablets per day for 200 mg/50 mg, and 11 mL per day for 80 mg/20 mg per mL oral solution.
KALYDECO™ 07/01/12   Prior authorization for medical necessity is required. The limits are 2 tablets per day.
KAZANO 04/01/13   The limits are 2 tablets per day.
KHEDEZLA® 01/01/14   The limits are 30 tablets per 30 days.
KINERET® 07/17/02 01/01/14 Kineret may be subject to step therapy requirements. Patients must have trial and failure of Humira AND Enbrel. The limits are 1 syringe per day.
KOMBIGLYZE™ XR 04/01/11   The limits are 1 tablet per day, except Kombiglyze XR 2.5-1000mg which has a limit of 2 tablets per day.
KORLYM™ 10/01/12   Prior authorization for medical necessity is required. The limits are 2 tablets per day.
KYNAMRO 07/01/13   Prior authorization for medical necessity is required.
KYTRIL® 12/03/01 04/01/12 The limits are 14 tablets per 30 days.
LANSOPRAZOLE 01/01/00   The limits are 1 capsule or solutab per day.
LAZANDA® 01/01/12   Prior authorization for medical necessity is required. The limits are 1 bottle per day.
LESCOL XL® 01/01/11   Lescol XL may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
LESCOL® 01/01/11   Lescol may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
LEVITRA® 09/01/03   Prior authorization for medical necessity may be required. The limits are 8 tablets per 30 days. Patients must be at least 18 years of age.
LEVORPHANOL 01/01/13   The limits are 4 tablets per day.
LEXIVA 07/01/12   The limits are 4 tablets per 60 mL per day.
LEXXEL® 01/01/11   Lexxel may be subject to step therapy requirements.
LINZESS™ 04/01/13   Prior authorization for medical necessity is required.
LIPITOR® 01/01/11   Lipitor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
LIPTRUZET® 07/01/13   Liptruzet may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
LIVALO® 01/01/11   Livalo may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
LORCET® 09/01/03 04/01/13 The limits are 6 tablets per day.
LORTAB® 09/01/03   The limits are 8 tablets for the 2.5 mg and 5 mg hydrocodone tablets and 6 tablets for the 7.5 mg and 10 mg tablets per day. The limits for Lortab elixir are 90mL per day. Patients should not take more than a total of 4 grams of acetaminophen per day (3 grams per day if have liver disease).
LOVENOX® 02/01/05 04/01/12 The limits are 30 syringes or 10 vials per 90 days.
LUMIGAN® 06/04/02   The limits are 1-2.5mL box per 30 days or 1-5mL box per 60 days.
LUNESTA® 01/01/05 07/01/13 The limits are 1 tablet per day.
LYRICA® 10/01/05 01/01/13 The limits are 3 capsules per day, except for Lyrica 225mg and 300mg which have a limit of 2 capsules per day. Lyrica solution has a limit of 30 mL per day.
LYSODREN® 01/01/12   Prior authorization for medical necessity is required.
MAGNACET™ 09/01/04 04/01/13 The limits are 10 tablets per day for Magnacet 5/400mg. The limits are 8 tablets per day for Magnacet 7.5/400mg and 6 tablets per day for Magnacet 10/400mg.
MATULANE® 01/01/12   Prior authorization for medical necessity is required.
MAXAIR 04/01/12   The limits are 1 inhaler per 30 days.
MAXALT® 11/01/05 04/01/12 The limits are 18 tablets per 30 days.
MAXIDONE™ 09/01/03   The limits are 5 tablets per day.
MEKINIST® 01/01/14   Prior authorization for medical necessity is required. The limits are 3 tablets per day for 0.5 mg strength and 1 tablet per for all other strengths.
METADATE CD® 01/01/05 04/01/11 The limits are 2 capsules per day, except Metadate CD 60mg which has a limit of 1 capsule per day.
METAGLIP™ 08/06/08 04/01/12 The limits are 4 tablets per day, except Metaglip 2.5/250mg which has a limit of 8 tablets per day.
METHADONE 01/01/13   The limits for the 5 mg/5 mL solution is 30 mL per day and the 10 mg/5 mL solution is 15 mL per day.
METHADOSE 01/01/13   The limits are 3 tablets per day or 3 mL of the 10 mg/mL concentrated solution per day.
METHITEST® 04/01/12   Prior authorization for medical necessity is required.
MEVACOR® 01/01/11   Mevacor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
MICARDIS HCT® 01/01/11   Micardis HCT may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB.
MICARDIS® 01/01/11   Micardis may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB.
MINOCIN® 04/01/13   Minocin may be subject to step therapy requirements. Patients must have a trial and failure of generic immediate release minocycline.
MINOCIN® KIT 04/01/13   Minocin may be subject to step therapy requirements. Patients must have a trial and failure of generic immediate release minocycline.
MONODOX® 04/01/13   Monodox may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline.
MORGIDOX® KIT 04/01/13   Morgidox may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline.
MORPHINE 01/01/13   The limits are 6 tablets per day, 90 mL/day for the 10 mg/5 mL solution, 45 mL/day for the 20 mg/5 mL solution, or 9 mL/day for the 20 mg/mL concentrated solution.
MS CONTIN® 05/15/09   The limits are 3 tablets per day.
MUSE® 07/01/10   Prior authorization for medical necessity may be required. Patients must be at least 18 years of age.
NASACORT AQ® 04/01/04   The limits are 1 box per 30 days.
NASAREL® 08/06/08 04/01/11 The limits are 3 boxes per 30 days.
NASONEX® 02/22/05   The limits are 1 box – 17 g per 30 days.
NESINA 04/01/13   The limits are 1 tablet per day.
NEVIRAPINE 07/01/12   The limits are 40 mL per day.
NEXAVAR® 01/01/06   Prior authorization for medical necessity is required. The limits are 4 tablets per day.
NEXIUM® 01/01/00 04/01/14 Nexium 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 or packet for oral suspension per day.
NICAZELDOXY® KIT 01/01/14   Nicazeldoxy may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline.
NORCO® 09/01/03   The limits are 12 for the 5 mg tablets and 6 for the 7.5 and 10 mg tablets per day. Patients should not take more than a total of 4 grams of acetaminophen per day (3 grams per day if you have liver disease).
NORDITROPIN® 10/01/11   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
NORVIR 07/01/12   The limits are 12 tablets or capsules or 16 mL per day.
NUCYNTA™ 07/06/09 04/01/12 The limits are 12 tablets per day.
NUCYNTA™ ER 01/01/12   The limits are 60 tablets per 30 days.
NUTRIDOX™ KIT 04/01/13   Nutridox may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline.
NUTROPIN AQ NUSPIN® 01/01/13   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
NUTROPIN AQ® 10/01/11   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
NUTROPIN® 10/01/11   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
NUVIGIL® 05/06/09   Prior authorization for medical necessity is required. The limits are 1 tablet per day. Patients must be at least 17 years of age.
OCUDOX® KIT 04/01/13   Ocudox may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline.
OFORTA™ 12/22/09   Prior authorization for medical necessity is required.
OMEPRAZOLE 01/01/00   The limits are 1 capsule per day.
OMEPRAZOLE-SODIUM BICARBONATE 07/01/10 04/01/14 Omeprazole-sodium bicarbonate may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole, omeprazole, pantoprazole, or rabeprazole. The limits are 1 tablet per day.
OMNARIS™ 08/06/08   The limits are 1 box per 30 days.
OMNITROPE® 10/01/11   Prior authorization for medical necessity is required.
ONGLYZA™ 08/27/09   The limits are 1 tablet per day.
ONSOLIS™ 09/18/09   Prior authorization for medical necessity is required. The limits are 4 tablets per day.
OPANA ER® 02/15/07   The limits are 2 tablets per day.
OPANA® 01/01/13   The limits are 6 tablets per day.
ORACEA® 04/01/13   Oracea may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline.
ORAMORPH® SR 05/15/09   The limits are 3 tablets per day.
ORAXYL® 04/01/13   Oraxyl may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline.
ORBIVAN 04/01/13   The limits are 6 capsules per day.
ORBIVAN CF 04/01/13   The limits are 6 tablets per day.
ORENCIA® 12/10/11 01/01/14 Orencia subcutaneous injection may be subject to step therapy requirements. Patients must have trial and failure of Humira AND Enbrel. The limits are 4 syringes per 28 days.
OSENI 04/01/13   The limits are 1 tablet per day.
OXANDRIN® 07/20/09   Prior authorization for medical necessity is required.
OXECTA® 01/01/13   The limits are 6 tablets per day.
OXYCODONE 01/01/13   The limits are 6 capsules or tablets per day.
OXYCONTIN® 01/01/00 05/17/11 The limits are 3 tablets per day, except Oxycontin 80mg which has a limit of 4 tablets per day.
OXYMORPHONE SR 10/01/12   The limits are 2 tablets per day.
PANTOPRAZOLE 07/01/10 04/01/11 The limits are 1 tablet per day.
PATANASE® 08/06/08   The limits are 1 box per 30 days.
PEGASYS® 06/01/06 01/01/11 Prior authorization for medical necessity is required.
PEG-INTRON® 06/01/06 01/01/11 Prior authorization for medical necessity is required. Use of the preferred peginterferon, Pegasys, may be required.
PERCOCET® 09/01/04   The limits are 12 tablets for the 2.5 mg and 5 mg oxycodone tablets, 8 tablets for the 7.5 mg tablets, and 6 tablets for the 10 mg tablets per day.
PERCODAN® 03/29/04   The limits are 12 tablets per day.
PHRENILLIN FORTE 04/01/13   The limits are 6 capsules per day.
PICATO 04/01/13   The limits are 3 tubes per 90 days of the 0.015% gel and 2 tubes per 90 days of the 0.05% gel.
POMALYST® 04/01/13   Prior authorization for medical necessity is required. The limits are 21 capsules per 28 days.
PRADAXA® 04/01/11   The limits are 2 capsules per day.
PRANDIMET™ 08/06/08 04/01/13 The limits are 5 tablets per day.
PRANDIN 04/01/12   The limits are 120 tablets per 30 days.
PRAVACHOL® 01/01/11   Pravachol may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
PRECOSE 04/01/12   The limits are 90 tablets per 30 days.
PREVACID® 01/01/00 04/01/14 Prevacid 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, solutab, or packet per day.
PREZISTA 07/01/12 04/01/14 The limits are 2 tablets per day, except for the 75 mg and 800 mg tablets which have a limit of 1 tablet per day. Prezista solution has a limit of 400 mL per 30 days.
PRILOSEC® 01/01/00 04/01/14 Prilosec 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 or packet per day, except Prilosec 2.5mg packets for oral suspension which have a limit of 2 packets per day.
PRIMLEV™ 05/15/09 10/01/12 The limits are 12 tablets per day for Primalev 5/300mg. The limits are 8 tablets per day for Primalev 7.5/300mg and 6 tablets per day for 10/300mg tablets.
PRISTIQ® 05/01/08   The limits are 1 tablet per day. Not covered for patients less than 18 years of age.
PROAIR 04/01/12   The limits are 2 inhalers per 30 days.
PROMACTA® 05/15/09 10/01/11 Prior authorization for medical necessity is required. The limits are 1 tablet per day, except Promacta 25mg which has a limit of 3 tablets per day.
PROTONIX® 01/01/00 04/01/14 Protonix may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole, omeprazole, pantoprazole, or rabeprazole. The limits are 1 tablet or packet per day.
PROVENTIL HFA 04/01/12   The limits are 2 inhalers per 30 days.
PROVIGIL® 09/01/03 07/01/11 Prior authorization for medical necessity is required. The limits are 1 tablet per day. Patients must be at least 17 years of age.
PULMICORT® 02/01/05 04/01/12 The limits are 2 inhalers per 30 days for Pulmicort Flexhaler 180mcg and 1 inhaler per 30 days for 90mcg.
QNASL 07/01/12   The limits are 1 bottle per 30 days.
QUALAQUIN® 05/01/07 01/01/12 The limits are 42 capsules per 90 days, which allows for a single 7-day course of therapy.
QUILLIVANT XR 04/01/13   The limits are 360 mL per 30 days.
QVAR® 08/06/08 04/01/11 The limits are 1 boxes per 30 days for 40mcg strength and 3 boxes per 30 days for 80mcg 7.3 grams and 2 boxes per 30 days for 80mcg 8.7 grams.
RAVICTI 07/01/13   Prior authorization for medical necessity is required.
REBIF® 10/01/12   The limits are 3 syringes per week or 1 titration kit per 28 days.
RELENZA® 12/03/01   The limits are 20 blisters (1 carton) per 30 days.
RELISTOR™ 08/06/08 10/01/11 Prior authorization for medical necessity is required.
RELPAX® 11/01/05 01/01/12 The limits are 12 tablets per 30 days.
RENOVA® 04/01/01   Prior authorization for medical necessity may be required.
REPREXAIN® 05/15/09 04/01/12 The limits are 5 tablets per day.
RESCRIPTOR 07/01/12   The limits are 3 tablets per day for 100 mg tablets and 6 tablets per day for 200 mg tablets.
RETIN-A® 04/01/01   Prior authorization for medical necessity may be required.
RETROVIR 07/01/12   The limits are 6 capsules, 2 tablets, or 64 mL per day.
REVLIMID® 01/01/13   Prior authorization for medical necessity is required. The limits are 1 capsule per day, except for 15 mg and 25 mg strengths which have a limit of 21 capsules per 28 days.
REYATAZ 07/01/12   The limits are 1 capsule per day, except 200 mg which has a limit of 2 capsules per day.
RHINOCORT AQ® 09/25/02 02/13/08 The limits are 2 boxes – 18 g per 30 days.
RIOMET® 04/01/11   The limits are 25mL per day.
RITALIN LA® 07/01/05 04/01/11 The limits are 2 capsules per day.
ROXICET™ 09/01/04 05/15/09 The limits are 12 tablets per day for 5/325mg tablets, 8 tablets per day for 5/500mg tablets, and 60mL per day for 5/325mg per 5mL oral solution.
ROXICODONE 01/01/13   The limits are 6 tablets or 180 mL/day.
ROXICODONE INTENSOL 01/01/13   The limits are 9 mL/day of the 20 mg/mL concentrated solution.
ROZEREM® 09/01/05 07/01/13 The limits are 1 tablet per day.
RYBIX™ ODT 04/01/11   The limits are 8 tablets per day.
RYZOLT™ 08/10/09 04/01/12 The limits are 1 tablet per day.
SAIZEN® 10/01/11   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
SAIZEN® CLICK-EASY 01/01/13   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
SANCUSO® 11/12/08 01/01/12 Sancuso may be subject to step therapy requirements. Patients must have trial and failure of generic ondansetron or granisetron.
SELZENTRY 07/01/12   The limits are 2 tablets per day for 150 mg and 4 tablets per day for 300 mg strengths.
SEREVENT® DISKUS® 08/06/08   The limits are 2 blisters per day.
SEROSTIM® 10/01/11   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
SIGNIFOR® 07/01/13   Prior authorization for medical necessity is required.
SILENOR 07/01/11 07/01/13 The limits are 1 tablet per day.
SIMCOR® 01/01/11   Simcor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
SIMPONI™ 05/06/09 01/01/14 Simponi may be subject to step therapy requirements. Patients must have trial and failure of Humira AND Enbrel. The limits are 1 syringe per 28 days.
SINGULAIR® 01/01/00   The limits are 1 tablet or packet per day.
SOLODYN® 05/01/06 04/01/13 Solodyn may be subject to step therapy requirements. Patients must have a trial and failure of generic immediate release minocycline.
SONATA® 01/01/05 07/01/13 The limits are 1 capsule per day.
SPIRIVA® 06/07/04   The limits are 1 capsule per day.
SPRIX™ 04/01/11   The limits are 5 bottles per 30 days.
SPRYCEL® 07/01/06 07/01/11 Prior authorization for medical necessity is required. The limits are 1 tablets per day, except for Sprycel 20mg which has a limit of 2 tablets per day.
STAGESIC™ 09/01/03   The limits are 8 capsules per day.
STARLIX 04/01/12   The limits are 90 tablets per 30 days.
STAXYN™ 01/01/11   Prior authorization for medical necessity may be required. The limits are 8 tablets per 30 days. Patients must be at least 18 years of age.
STENDRA® 07/01/13   Prior authorization for medical necessity may be required. The limits are 8 tablets per 30 days. Patients must be at least 18 years of age.
STIVARGA® 11/15/12   Prior authorization for medical necessity may be required. The limits are 4 tablets per day.
STRATTERA® 01/15/03 04/01/11 The limits are 2 capsules per day, except Strattera 80mg and 100mg which is 1 capsule per day.
STRIANT 04/01/12   The limits are 60 buccal systems per 30 days.
STRIBILD 01/01/13   The limits are 1 tablet per day.
SUBOXONE® 08/06/08 04/01/14 Prior authorization for medical necessity is required. The limits are 3 tablets per day. The 2 mg films have a limit of 3 films per day. The 4 mg film has a limit of 1 film per day. The 8 mg and 12 mg films have a limit of 2 films per day. Patients must be at least 18 years of age.
SUBSYS™ 07/01/12 04/01/14 Prior authorization for medical necessity is required. The limits are 8 sprays per day for 1200 mcg and 1600 mcg strengths and 4 sprays per day for all other strengths.
SUBUTEX® 08/06/08 04/01/14 Prior authorization for medical necessity is required. The limits are 15 tablets per 90 days. Patients must be at least 18 years of age.
SUMAVEL™ DOSEPRO™ 11/09/09 01/01/12 The limits are 12 prefilled delivery systems per 30 days.
SUSTIVA 07/01/12   The limits are 3 capsules per day for 50 mg, 2 capsules per day for 200 mg, and 1 tablet per day for 600 mg strengths.
SUTENT® 02/10/06   Prior authorization for medical necessity is required. The limits are 1 tablet per day.
SYLATRON® 01/01/13   Prior authorization for medical necessity is required.
SYMBICORT® 08/01/07   The limits are 1 box per 30 days.
SYNAGIS® 10/01/11   The limits are 6 doses per year.
TAFINLAR® 01/01/14   Prior authorization for medical necessity is required. The limits are 4 capsules per day.
TALACEN 04/01/12   The limits are 180 tablets per 30 days.
TAMIFLU® 02/01/05 07/01/13 The limits are 20 capsules per 30 days for Tamiflu 30mg, 10 capsules per 30 days for Tamiflu 35mg and 75mg, and 180 mL per 30 days for Tamiflu 6mg/mL oral suspension.
TARCEVA® 03/14/07 07/01/11 Prior authorization for medical necessity is required. The limits are 1 tablet per day, except 25mg tablets with a limit of 2 tablets per day.
TARGRETIN® 01/01/12   Prior authorization for medical necessity is required.
TASIGNA® 04/01/11   Prior authorization for medical necessity is required. The limits are 4 capsules per day.
TAZAROTENE 04/01/01   Prior authorization for medical necessity may be required.
TAZORAC® 04/01/01   Prior authorization for medical necessity may be required.
TECFIDERA™ 05/01/13 01/01/14 The limits are 2 capsules per day and 1 starter kit per 30 days.
TEKAMLO® 01/01/11 04/01/13 Tekamlo may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
TEKTURNA HCT® 01/01/11 04/01/13 Tekturna HCT may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
TEKTURNA® 01/01/11 04/01/13 Tekturna may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
TEMODAR® 01/01/12   Prior authorization for medical necessity is required.
TESTIM® 06/15/04 04/01/12 The limits are 10 grams per day.
TESTRED® 04/01/12   Prior authorization for medical necessity is required.
TEVETEN HCT® 01/01/11 04/01/13 Teveten HCT may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
TEVETEN® 01/01/11 04/01/13 Teveten may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
TEV-TROPIN® 10/01/11   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
THALOMID® 01/01/13   Prior authorization for medical necessity is required. The limits are 1 capsule per day for the 50 mg and 100 mg strengths, and 2 capsules per day for the 150 mg and 200 mg strengths.
TIVICAY® 01/01/14   The limits are 2 tablets per day.
TOBI® 04/01/12 04/01/13 Prior authorization for medical necessity may be required. Must not be used concurrently with Cayston or Bethkis.
TOBI® Podhaler 07/01/13   Prior authorization for medical necessity may be required. Must not be used concurrently with Cayston or Bethkis.
TOLAZAMIDE 04/01/12   The limits are 30 tablets per 30 days for 250mg, and 60 tablets per 30 days for 500mg.
TOLBUTAMIDE 04/01/12   The limits are 180 tablets per 30 days.
TRADJENTA® 01/01/12   The limits are 30 tablets per 30 days.
TRAVATAN Z® 06/04/02 01/01/13 The limits are 1-2.5mL box per 30 days or 1-5mL box per 60 days.
TRETINOIN 04/01/01   Prior authorization for medical necessity may be required.
TRETIN-X 04/01/01   Prior authorization for medical necessity may be required.
TREXIMET™ 04/22/08 01/01/12 The limits are 18 tablets per 30 days.
TREZIX 04/01/13   The limits are 10 capsules per day.
TRIBENZOR® 01/01/11 04/01/13 Tribenzor may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
TRIZIVIR 07/01/12   The limits are 2 tablets per day.
TRUVADA 07/01/12   The limits are 1 tablet per day.
TUDORZA® PRESSAIR 01/01/13   The limits are 1 canister per 30 days.
TUSSICAPS® 05/15/09   The limits are 2 capsules per day and 20 capsules per month. Not covered for patients less than 12 years of age.
TUSSIONEX® PENNKINETIC® 08/06/08 05/15/09 The limits are 10mL per day and 120mL per 30 days. Not covered for patients less than 12 years of age.
TWYNSTA® 01/01/11 04/01/13 Twynsta may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
TYKERB® 11/01/07   Prior authorization for medical necessity is required. The limits are 5 tablets per day.
TYLENOL® 09/01/03   If a combination drug contains Tylenol, the daily dose of the acetaminophen component should not exceed 4 grams. Excessive doses may cause liver toxicity.
TYLENOL® WITH CODEINE 03/23/04 04/01/12 The limits are 12 tablets per day for Tylenol with Codeine 300mg/30mg and 300mg/15mg and 6 tablets per day for Tylenol with Codeine 300mg/60mg.
TYLOX® 04/01/04   The limits are 8 capsules per day.
ULORIC® 07/20/09 07/01/11 Uloric may be subject to step therapy requirements. Patients must have a trial and failure of allopurinol 300mg.
ULTRACET® 04/01/07 04/01/12 The limits are 8 tablets per day.
ULTRAM ER® 02/15/06 04/01/12 The limits are 1 tablet per day.
ULTRAM® 09/04/02 04/01/12 The limits are 8 tablets per day.
VALTURNA® 01/01/11 04/01/13 Valturna may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
VELTIN® 01/01/11   Prior authorization for medical necessity may be required.
VENLAFAXINE EXTENDED-RELEASE 11/12/08   The limits are 1 tablet per day.
VENTOLIN HFA 04/01/12   The limits are 2 inhalers per 30 days.
VERAMYST® 07/01/07   The limits are 1 box per 30 days.
VIAGRA® 07/01/98 10/18/02 Prior authorization for medical necessity may be required. The limits are 8 tablets per 30 days. Patients must be at least 18 years of age.
VIBRAMYCIN® 04/01/13   Vibramycin capsules, suspension and syrup may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline.
VICODIN® 09/01/03   The limits are 8 Vicodin (5 mg hydrocodone) tablets, 6 Vicodin HP tablets, or 5 Vicodin ES tablets per day. Patients should not take more than a total of 4 grams of acetaminophen per day (3 grams per day if you have liver disease).
VICOPROFEN® 09/24/03 04/01/12 The limits are 5 tablets.
VICTOZA® 02/15/10 04/01/11 Victoza 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 3 pens (9mL) per 30 days.
VICTRELIS™ 10/01/11   Prior authorization for medical necessity is required.
VIRACEPT 07/01/12   The limits are 9 capsules per day for 250 mg and 4 tablets per day for 625 mg strengths.
VIRAMUNE 07/01/12   The limits are 2 tablets or 40 mL per day.
VIRAMUNE XR 07/01/12 07/01/13 The limits are 1 tablet per day for 400 mg tablets and 3 tablets per day for 100 mg tablets.
VIREAD 07/01/12   The limits are 1 tablet or 8 g per day.
VOTRIENT™ 11/13/09   Prior authorization for medical necessity is required. The limits are 4 tablets per day.
VYTORIN® 01/01/11   Vytorin may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
VYVANSE® 07/01/07 04/01/11 The limits are 1 capsule per day.
WELLBUTRIN SR® 08/06/08   The limits are 2 tablets per day.
WELLBUTRIN XL™ 07/15/04 02/13/08 The limits are 3 tablets per day for Wellbutrin XL 150mg and 1 tablet per day for Wellbutrin XL 300mg.
WELLBUTRIN® 08/06/08   The limits for Wellbutrin 75mg are 6 tablets per day. The limits for Wellbutrin 100mg are 4 tablets per day.
XALATAN® 06/04/02   The limits are 1-2.5mL box per 30 days or 1-7.5mL box per 90 days.
XALKORI® 01/01/12   Prior authorization for medical necessity is required. The limits are 60 capsules per 30 days.
XARELTO® 01/01/12 11/21/12 The limits are 35 tablets per 90 days for the 10mg tablets, which allows for a single course of therapy, 30 tablets per 30 days for 20mg tablets, and 60 tablets per 30 days for the 15 mg tablets.
XELJANZ® 01/01/13 01/01/14 Xeljanz may be subject to step therapy requirements. Patients must have trial and failure of Humira AND Enbrel. The limits are 2 tablets per day.
XELODA® 01/01/12   Prior authorization for medical necessity is required.
XODOL® 05/15/09   The limits are 12 tablets per day for Xodol 5/300mg and 6 tablets per day for Xodol 7.5/300mg and 10/300mg.
XOLOX™ 04/01/11   The limits are 8 tablets per day.
XOPENEX HFA 04/01/12   The limits are 2 inhalers per 30 days.
XTANDI® 11/15/12   Prior authorization for medical necessity is required. The limits are 4 capsules per day.
XYREM® 07/01/07 04/01/14 Prior authorization for medical necessity is required. The limits are 9g (18 mL) per day. Patients must be at least 18 years of age.
ZAMICET™ 05/15/09   The limits are 90mL per day.
ZECUITY 07/01/13   The limits are 12 transdermal systems per 30 days.
ZEGERID® 08/01/06 04/01/14 Zegerid 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 or packet per day.
ZELBORAF® 01/01/12   Prior authorization for medical necessity is required. The limits are 8 tablets per day.
ZERIT 07/01/12   The limits are 2 capsules or 80 mL per day.
ZETONNA 07/01/12   The limits are 1 bottle per 30 days.
ZIAGEN 07/01/12   The limits are 2 tablets or 32 mL per day.
ZIANA® 07/01/07   Prior authorization for medical necessity may be required.
ZIOPTAN 07/01/12   The limits are 1 single-use container per day.
ZOCOR® 01/01/11   Zocor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
ZOFRAN® 02/01/05 04/01/12 The limits are 21 tablets per 30 days for Zofran 4mg and 8mg, and 1 tablet per 30 days for Zofran 24mg.
ZOFRAN® ODT 02/01/05   The limits are 21 tablets per 30 days.
ZOHYDRO ER 04/01/14   The limits are 2 capsules per day.
ZOLINZA® 01/01/12   Prior authorization for medical necessity is required. The limits are 4 capsules per day.
ZOLPIMIST™ 05/15/09 07/01/13 The limits are 1 container per month.
ZOLVIT™ 04/01/11   The limits are 67.5mL per day.
ZOMIG® 11/01/05 01/01/12 The limits are 12 tablets or 12 nasal spray units per 30 days.
ZORPTIVE® 10/01/11   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
ZUBSOLV® 01/01/14   Prior authorization for medical necessity is required. The limits are 3 tablets per day. Patients must be at least 18 years of age.
ZUPLENZ® 01/01/11 04/01/12 The limits are 20 films (2 boxes of 10) per 30 days for Zuplenz 4mg and 8mg.
ZYBAN® 08/06/08   The limits are 2 tablets per day.
ZYDONE® 09/01/03   The limits are 8 tablets per day for Zydone 5/400mg and 6 tablets per day for Zydone 7.5/400mg and 10/400mg.
ZYFLO CR® 02/01/05 04/16/08 The limits are 4 tablets per day.
ZYTIGA® 01/01/12   Prior authorization for medical necessity is required. The limits are 4 tablets per day.