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Drug coverage is limited to prescription products approved by the Food and Drug Administration as evidenced by a New Drug Application (NDA), Abbreviated New Drug Application (ANDA), or Biologics Licensed Application (BLA) on file. Any legal requirements or group specific benefits for coverage will supersede this (e.g. preventive drugs per the Affordable Care Act). Drug coverage may also be subject to policy guidelines established by Blue Cross and Blue Shield of Alabama. Drug coverage policies are 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.

*Coverage Benefit - (P) Pharmacy Benefit, (M) Medical Benefit, (B) Both

Product Name | Guideline | Coverage Benefit* | Implementation Date | Change Date |
---|---|---|---|---|

ABSTRAL® | Prior authorization for medical necessity is required. Patients must have trial and failure of generic product. The limits are 4 tablets per day. | P | 04/01/11 | 10/01/15 |

ACCOLATE® | The limits are 2 tablets per day. | P | 02/01/05 | |

ACETAMINOPHEN WITH CODEINE | 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. | P | 03/23/04 | |

ACIPHEX® | 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. | P | 02/18/02 | 04/01/14 |

ACTEMRA® | Step Therapy and Quantity Limits apply when self-administered. Predetermination for medical necessity is available when physician-administered. | B | 01/01/14 | 01/01/16 |

ACTICLATE® | Acticlate maybe subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline. | P | 10/01/14 | 01/01/15 |

ACTIQ® | Prior authorization for medical necessity is required. Patients must have trial and failure of generic product. The limits are 4 lozenges per day. | P | 06/23/03 | 10/01/15 |

ACTONEL® | 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. | P | 01/01/00 | 07/01/13 |

ACTOPLUS MET XR® | The limits are 2 tablets per day for Actoplus Met XR 15/1000mg and 1 tablet per day for Actoplus Met XT 30/1000mg. | P | 01/01/11 | |

ACTOPLUS MET® | The limits are 3 tablets per day. | P | 08/06/08 | |

ACTOS® | The limits are 1 tablet per day. | P | 07/01/10 | 04/01/12 |

ADAPALENE | Prior authorization for medical necessity may be required. | P | 04/01/01 | |

ADCETRIS® | Predetermination for medical necessity is available | M | 01/01/15 | |

ADCIRCA® | Prior authorization for medical necessity is required. | P | 04/01/15 | |

ADDERALL XR® | The limits are 2 tablets per day. | P | 11/13/02 | 04/01/11 |

ADDYI | Prior authorization for medical necessity is required. The limits are 1 tablet per day. | P | 01/01/16 | |

ADEMPAS® | Prior authorization for medical necessity is required. | P | 04/01/15 | |

ADOXA® | Adoxa may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline. | P | 04/01/13 | 01/01/15 |

ADVAIR® | Advair Diskus has a limit of 2 blisters per day. Advair HFA has a limit of 1 inhaler per 30 days. | P | 08/06/08 | |

ADVICOR® | Advicor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin). | P | 01/01/11 | |

AEROSPAN® | The limits are 2 canisters per month. | P | 04/01/14 | |

AFINITOR® | Prior authorization for medical necessity is required. The limits are 1 tablet per day. | P | 07/20/09 | 07/01/11 |

AFINITOR® DISPERZ | 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. | P | 07/01/13 | |

AFREZZA® | Prior authorization for medical necessity is required. The limits are 2,520 cartridges per 30 days for the 4 unit pack, 1,530 cartridges per 30 days for the 30 x 4 unit mix pack, and 1,890 cartridges per 30 days for the 60 x 4 unit mix pack. | P | 01/22/15 | 06/28/15 |

AKYNZEO® | The limits are 2 capsules per 30 days. | P | 01/01/15 | |

ALENDRONATE | The limits are 1 tablet per day for 40mg tablets and 300mls per 28 days for the oral solution. | P | 07/01/13 | 01/01/14 |

ALODOX® | Alodox may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline. | P | 04/01/13 | 01/01/15 |

ALOXI® | Predetermination for medical necessity is available | M | 01/01/15 | |

ALSUMA® | Alsuma may be subject to step therapy. Patients must have trial and failure of generic triptan (naratriptan, sumatriptan,rizatriptan). The limits are 12 doses per 30 days. | P | 04/01/11 | 07/01/15 |

ALTOPREV® | Altoprev may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin). | P | 01/01/11 | |

ALVESCO® | The limits are 1 box per 30 days for 80mcg strength and 2 boxes per 30 days for 160mcg strength. | P | 08/06/08 | 04/01/11 |

AMBIEN CR® | The limits are 1 tablet per day. | P | 10/01/05 | 07/01/13 |

AMBIEN® | The limits are 1 tablet per day. | P | 02/25/02 | 07/01/13 |

AMERGE® | Amerge may be subject to step therapy. Patients must have trial and failure of a generic triptan (naratriptan, sumatriptan, rizatriptan). The limits are 18 tablets per 30 days. | P | 11/01/05 | 07/01/15 |

AMITIZA® | Prior authorization for medical necessity is required. | P | 09/01/06 | 10/01/11 |

AMPYRA® | Prior authorization for medical necessity is required. The limits are 2 tablets per day. | P | 06/01/10 | |

AMTURNIDE® | Amturnide may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB. | P | 04/01/11 | 10/01/15 |

ANADROL®-50 | Prior authorization for medical necessity is required. | P | 07/20/09 | |

ANDRODERM® | The limits are 1 patch per day. | P | 07/20/09 | 04/01/14 |

ANDROGEL® | 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. | P | 06/15/04 | 01/01/13 |

ANDROID® | Prior authorization for medical necessity is required. | P | 04/01/12 | |

ANDROXY® | Prior authorization for medical necessity is required. | P | 04/01/12 | |

ANORO ELLIPTA | The limits are 60 doses per 30 days. | P | 04/01/14 | |

ANZEMET® | The limits are 7 tablet per 30 days. | P | 02/01/05 | 04/01/12 |

APIDRA® | Apidra may be subject to prior authorization. Patients must have trial and failure of Novolog. | P | 01/01/15 | |

APLENZIN® | The limits are 1 tablet per day. | P | 08/06/08 | |

APTENSIO XR® | The limits are 1 tablet per day. | P | 07/01/15 | |

APTIVUS | The limits are 4 capsules or 13 mL per day. | P | 07/01/12 | |

ARCALYST | Prior authorization for medical necessity is required. Patients must be at least 12 years of age. The limits are four 220 mg vial per 28 days. | P | 12/18/08 | 10/01/15 |

ARCAPTA® | The limits are 30 capsules per 30 days. | P | 01/01/12 | |

ARIXTRA® | The limits are 30 syringes per 90 days. | P | 07/01/10 | 04/01/12 |

ARNUITY ELLIPTA® | The limits are 30 blisters per month. | P | 04/01/15 | |

ARZERRA® | Predetermination for medical necessity is available | M | 01/01/15 | |

ASMANEX HFA® | The limits are 1 inhaler per month. | P | 04/01/15 | |

ASMANEX® | 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. | P | 01/26/06 | 04/22/08 |

ASTELIN | The limits are 60 mL per 30 days. | P | 07/01/13 | |

ASTEPRO | The limits are 60 mL per 30 days. | P | 07/01/13 | |

ATACAND HCT® | Atacand HCT may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB. | P | 01/01/11 | 10/01/15 |

ATACAND® | Atacand may be subject to step therapy requirements. Patients must have trial and failure a generic ACE inhibitor or generic ARB. | P | 01/01/11 | 10/01/15 |

ATELVIA® | The limits are 4 tablets per 30 days. | P | 04/01/11 | 07/01/13 |

ATRALIN® | Prior authorization for medical necessity may be required. | P | 04/01/01 | |

ATRIPLA | The limits are 1 tablet per day. | P | 07/01/12 | |

ATROVENT HFA | The limits are 2 inhalers per 30 days. | P | 04/01/12 | |

ATROVENT NASAL INHALER | The limits are 60 mL per 30 days for 21 mcg/spray and 45 mL per 30 days for 42 mcg/spray. | P | 07/01/13 | |

AUBAGIO® | Aubagio 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 1 tablet per day. | P | 01/01/13 | 01/01/15 |

AVALIDE® | Avalide may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB. | P | 01/01/11 | 10/01/15 |

AVANDAMET® | The limits are 2 tablets per day. | P | 08/06/08 | 04/01/12 |

AVANDARYL® | The limits are 1 tablet per day. | P | 07/01/10 | 04/01/12 |

AVANDIA® | Avandia 2mg and 4mg has a limit of 2 tablets per day. Avandia 8mg has a limit of 1 tablet per day. | P | 07/01/10 | 04/01/12 |

AVAPRO® | Avapro may be subject to step therapy requirements. Patients must have trial and failure of both of a generic ACE inhibitor or generic ARB. | P | 01/01/11 | 10/01/15 |

AVASTIN® | Predetermination for medical necessity is available | M | 01/01/15 | |

AVEED™ | Predetermination for medical necessity is available | M | 01/01/15 | |

AVIDOXY® DK | Avidoxy DK may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline. | P | 04/01/13 | 01/01/15 |

AVINZA® | The limits are 1 capsule per day. | P | 05/15/09 | |

AVITA® | Prior authorization for medical necessity may be required. | P | 04/01/01 | |

AVONEX® | Avonex 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 one 30mg vial, syringe, or pen per week or 1 kit per 28 days. | P | 01/01/12 | 01/01/15 |

AXERT® | Axert may be subject to step therapy requirements. Patients must have trial and failure of generic triptan (naratriptan, sumatriptan, rizatriptan). The limits are 12 tablets per 30 days. | P | 11/01/05 | 07/01/15 |

AXIRON® | The limits are 180mL (2 bottles) per 30 days. | P | 07/01/11 | 04/01/12 |

AZOR® | Azor may be subject to step therapy requirements. Patients must have a trial and failure of a generic ACE inhibitor or generic ARB. | P | 01/01/11 | 10/01/15 |

BECONASE AQ® | The limits are 2 bottles per 30 days. | P | 11/13/01 | |

BELSOMRA® | The limits are 1 tablet per day. | P | 04/01/15 | |

BENICAR HCT® | Benicar HCT may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB. | P | 01/01/11 | 10/01/15 |

BENICAR® | Benicar may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB. | P | 01/01/11 | 10/01/15 |

BENLYSTA® | Predetermination for medical necessity is available. | M | 01/01/15 | 01/01/16 |

BERINERT® | Prior authorization for medical necessity is required when self-administered. Predetermination for medical necessity is available when physician-administered. | B | 01/01/15 | 01/01/16 |

BETASERON® | The limits are 14 vial/syringe units per 28 days and 1 kit (14 prefilled syringes) per 28 days. | P | 10/01/12 | 01/01/14 |

BETHKIS® | Prior authorization for medical necessity may be required. Must not be used concurrently with inhaled tobramycin or Cayston. | P | 01/01/14 | |

BINOSTO® | The limits are 4 tablets per 28 days. | P | 01/01/13 | 07/01/13 |

BIO-T-GEL® | The limits are 2 packets per day. | P | 10/01/12 | |

BIVIGAM™ | Predetermination for medical necessity is available. | M | 01/01/15 | |

BONIVA® | The limits are 1 tablet per 30 days for Boniva 150mg. | P | 06/01/05 | 07/01/13 |

BOSULIF® | Prior authorization for medical necessity is required. The limits are 1 tablet per day. | P | 11/15/12 | |

BOTOX® | Predetermination for medical necessity is available. | M | 01/01/15 | |

BREO ELLIPTA® | The limits are 1 inhaler per month. | P | 01/01/14 | 10/01/15 |

BUNAVIL® | Prior authorization for medical necessity is required. The limits are 2 films per day. | P | 01/01/15 | |

BUPHENYL® | Prior authorization for medical necessity is required. | P | 07/01/13 | |

BUTALBITAL COMPOUND | The limits are 6 tablets per day. | P | 04/01/13 | |

BUTALBITAL/ACETAMINOPHEN | The limits are 6 tablets per day. | P | 04/01/13 | |

BUTRANS® | The limits are 4 transdermal systems per 30 days. | P | 04/01/11 | |

BYDUREON® | 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 or pens per 28 days. | P | 04/01/12 | 10/01/14 |

BYETTA® | 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. | P | 07/01/05 | 04/01/12 |

CADUET® | Only 1 statin covered per month. | P | 01/01/00 | |

CAPITAL® AND CODEINE | The limits are 2700mL per 30 days. | P | 04/01/11 | |

CAPRELSA® | 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. | P | 01/01/12 | |

CARIMUNE® NF | Predetermination for medical necessity is available. | M | 01/01/15 | |

CAVERJECT® | Prior authorization for medical necessity may be required. Patients must be at least 18 years of age. | P | 07/01/10 | |

CAYSTON® | Prior authorization for medical necessity may be required. Must not be used concurrently with inhaled tobramycin or Bethkis. | P | 04/01/12 | 04/01/13 |

CELEBREX® | The limits are 2 capsules per day, except Celebrex 400mg which has a limit of 1 capsule per day. | P | 01/01/00 | 01/01/12 |

CESAMET | The limits are 42 capsules per 30 days. | P | 04/01/12 | |

CHANTIX® | Coverage provided for up to a 24-week (168 days) supply per calendar year. | P | 08/01/06 | 04/01/12 |

CIALIS® | 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. | P | 01/01/04 | 02/08/10 |

CIMZIA® | Step Therapy and Quantity Limits apply when self-administered. Predetermination for medical necessity is available when physician-administered. | B | 06/23/09 | 01/01/16 |

CINRYZE® | Prior authorization for medical necessity is required when self-administered. Predetermination for medical necessity is available when physician-administered. | B | 01/01/15 | 01/01/16 |

COCET PLUS® | The limits are 6 tablets per day. | P | 01/01/11 | |

COCET® | The limits are 6 tablets per day. | P | 04/01/13 | |

CODEINE | The limits are 180 tablets per 30 days. | P | 01/01/13 | |

COMBIVENT | The limits are 2 inhalers per 30 days. | P | 04/01/12 | |

COMBIVENT RESPIMAT | The limits are 2 inhalers per 30 days. | P | 07/01/12 | |

COMBIVIR | The limits are 2 tablets per day. | P | 07/01/12 | |

COMBUNOX® | The limits are 120 tablets per 30 days. | P | 05/01/05 | 04/01/12 |

COMETRIQ® | Prior authorization for medical necessity is required. The limits are 1 kit/28 days. | P | 04/01/13 | |

COMPLERA | The limits are 1 tablet per day. | P | 07/01/12 | |

COMPOUNDS | Prior authorization for medical necessity may be required. | B | 01/01/00 | 01/01/16 |

CONCERTA® | The limits are 2 tablets per day. | P | 11/01/02 | 04/01/11 |

CONZIP® | The limits are 30 capsules per 30 days. | P | 01/01/12 | |

COPAXONE® | The limits are 1 carton of 30 syringes per 30 days. | P | 10/01/12 | |

CORLANOR® | Prior Authorization for medical necessity may be required. Quantity limits are 2 tablets per day. | P | 10/01/15 | |

COSENTYX® | Cosentyx may be subject to step therapy requirements. Patients must have trial and failure of 2 preferred products. Preferred products are Humira, Enbrel, Stelara, and Simponi. Quantity limits apply based on package size. | P | 04/01/15 | |

COTELLIC | Prior authorization for medical necessity is required. The limits are 63 tablets per 30 days. | P | 11/25/15 | 01/01/16 |

COZAAR® | Cozaar may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB. | P | 01/01/11 | 10/01/15 |

CRESTOR® | Crestor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin). | P | 01/01/11 | |

CRIXIVAN | The limits are 9 capsules per day for 200 mg, and 6 capsules per day for 400 mg strengths. | P | 07/01/12 | 10/01/15 |

CYMBALTA® | The limits are 2 capsules per day, except Cymbalta 60mg with a limit of 1 capsule per day. | P | 09/01/04 | |

DAKLINZA® | Prior authorization for medical necessity is required. Quantity limits may apply based on strength. | P | 08/14/15 | |

DANAZOL | Prior authorization for medical necessity is required. | P | 04/01/12 | |

DAYTRANA® | The limits are 1 patch per day. | P | 06/12/06 | 04/01/11 |

DEMEROL | 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. | P | 01/01/13 | |

DERMACINRX AZENASE PAK | The limits are 1 pak per 30 days. | P | 11/19/15 | 01/01/16 |

DERMAPAK PAK PLUS | Prior authorization for medical necessity is required. | p | 10/06/15 | 01/01/16 |

DESVENLAFAXINE SR 24HR | The limits are 1 tablet per day. | P | 07/01/13 | |

DEXILANT® | 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. | P | 07/01/10 | 04/01/14 |

DIABENESE | The limits are 60 tablets per 30 days for 100mg and 90 tablets per 30 days for 250mg. | P | 04/01/12 | |

DIDANOSINE | The limits are 1 capsule per day. | P | 07/01/12 | |

DIFFERIN® | Prior authorization for medical necessity may be required. | P | 04/01/01 | |

DILAUDID | The limits are 6 tablets per day or 48 mL/day for the Dilaudid 1 mg/mL solution. | P | 01/01/13 | |

DIOVAN HCT® | Diovan HCT may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB. | P | 01/01/11 | 10/01/15 |

DIOVAN® | Diovan may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB. | P | 01/01/11 | |

DOLGIC PLUS | The limits are 5 tablets per day. | P | 04/01/13 | |

DOLOPHINE | The limits are 3 tablets per day. | P | 01/01/13 | |

DORYX® | Doryx may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline. | P | 11/14/07 | 01/01/15 |

DOXYCYCLINE | Doxycycline may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline. | P | 04/01/13 | 01/01/15 |

DUETACT® | The limits are 1 tablet per day. | P | 07/01/10 | |

DULERA® | The limits are 1 inhaler per 30 days. | P | 01/01/11 | |

DURAGESIC® | The limits are 15 patches per 30 days. | P | 09/01/04 | 04/01/11 |

DYMISTA® | The limits are 1 bottle (23 grams) per 30 days. | P | 10/01/12 | |

DYNACIN® | Dynacin may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline. | P | 04/01/13 | 01/01/15 |

DYSPORT® | Predetermination for medical necessity is available. | M | 01/01/15 | |

EDARBI® | Edarbi may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB. | P | 04/01/11 | 10/01/15 |

EDARBYCLOR® | Edarbyclor may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB. | P | 07/01/12 | 10/01/15 |

EDEX® | Prior authorization for medical necessity may be required. Patients must be at least 18 years of age. | P | 07/01/10 | |

EDLUAR® | The limits are 1 tablet per day. | P | 07/06/09 | 07/01/13 |

EDURANT | The limits are 1 tablet per day. | P | 07/01/12 | |

EFFEXOR XR® | The limits are 1 capsule per day, except Effexor XR 75mg which has a limit of 3 capsules per day. | P | 07/01/05 | 02/13/08 |

ELIQUIS | The limits are 2 tablets per day for Eliquis 2.5mg and 4 tablets per day for Eliqus 5 mg. | P | 07/01/13 | 10/01/14 |

EMBEDA® | The limits are 2 capsules per day. | P | 09/09/09 | |

EMEND® | 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. | P | 11/12/08 | 04/01/12 |

EMTRIVA | The limits are 1 capsule or 24 mL per day. | P | 07/01/12 | |

ENBREL® | 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. | P | 05/17/99 | 01/01/14 |

ENDOCET® | P | 01/01/00 | ||

ENTRESTO® | Prior authorization for medical necessity may be required. The quantity limits are 2 tablets per day. | P | 07/08/15 | |

ENTYVIO® | Predetermination for medical necessity is available. | M | 01/01/15 | |

EPIDUO® | Prior authorization for medical necessity may be required. | P | 01/01/11 | |

EPIVIR | The limits are 2 tablets for Epivir 150 mg, 1 tablet for Epivir 300 mg or 960 ml/month for Epivir solution. | P | 07/01/12 | 04/01/15 |

EPZICOM | The limits are 1 tablet per day. | P | 07/01/12 | |

ERBITUX® | Predetermination for medical necessity is available. | M | 01/01/15 | |

ERIVEDGE® | Prior authorization for medical necessity is required. The limits are 1 capsule per day. | P | 07/01/12 | |

ESBRIET® | Prior authorization for medical necessity is required. The limits are 9 capsules per day. | P | 10/20/14 | |

ESGIC | The limits are 6 tablets or capsules per day. | P | 04/01/13 | |

ESGIC PLUS | The limits are 6 tablets or capsules per day. | P | 04/01/13 | |

ESOMEPRAZOLE STRONTIUM | 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. | P | 01/01/14 | 04/01/14 |

EUFLEXXA® | Predetermination for medical necessity is available. | M | 01/01/15 | |

EVOTAZ® | The limits are 1 tablet per day. | P | 04/01/15 | |

EVZIO® | The limits are 1 package (2 auto-injections) per 365 days. | P | 02/01/15 | |

EXALGO® | The limits are 1 tablet per day. | P | 04/14/10 | |

EXFORGE HCT® | Exforge HCT may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB. | P | 01/01/11 | |

EXFORGE® | Exforge may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB. | P | 01/01/11 | |

EXTAVIA® | 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. | P | 01/01/12 | 01/01/15 |

EYLEA® | Predetermination for medical necessity is available. | M | 01/01/15 | |

FABIOR | Prior authorization for medical necessity may be required. | P | 07/01/13 | |

FARXIGA® | The limits are 1 tablet per day. | P | 04/01/14 | |

FARYDAK® | The limits are 6 capsules per 21 days. | P | 07/01/15 | |

FENTANYL CITRATE LOZENGE | Prior authorization for medical necessity is required. The limits are 4 lozenges per day. Patients must be at least 16 years of age. | P | 06/23/03 | |

FENTANYL TD® | The limits are 15 patches per 30 days. | P | 03/03/15 | |

FENTORA® | Prior authorization for medical necessity is required. Patients must have trial and failure of generic product. The limits are 4 tablets per day. | P | 09/01/06 | |

FETZIMA® | The limits are 1 capsule per day or 1 titration pack per 28 days. | P | 01/01/14 | |

FIORICET | The limits are 6 tablets per day. | P | 04/01/13 | |

FIORICET WITH CODEINE | The limits are 6 tablets per day. | P | 04/01/13 | |

FIORINAL | The limits are 6 capsules per day. | P | 04/01/13 | |

FIORINAL WITH CODEINE | The limits are 6 capsules per day. | P | 04/01/13 | |

FIRAZYR® | Prior authorization for medical necessity is required when self-administered. Predetermination for medical necessity is available when physician-administered. | B | 04/01/12 | 01/01/16 |

FIRST-LANSOPRAZOLE | 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. | P | 07/01/12 | 04/01/14 |

FIRST-OMEPRAZOLE | 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. | P | 07/01/12 | 04/01/14 |

FIRST-TESTOSTERONE | The limits are 60 grams per 30 days. | P | 04/01/12 | |

FIRST-TESTOSTERONE MC | The limits are 60 grams per 30 days. | P | 04/01/12 | |

FLEBOGAMMA® | Predetermination for medical necessity is available. | M | 01/01/16 | |

FLECTOR® PATCH | Prior authorization for medical necessity is required. The limits are 2 patches per day. Patients must be at least 18 years of age. | P | 08/06/08 | |

FLONASE® | The limits are 1 box per 30 days. | P | 04/01/04 | |

FLOVENT DISKUS® | The limits are 2 blisters per day for Flovent 50mcg and 100mcg. The limits are 8 blisters per day for Flovent 250mcg. | P | 04/01/05 | 04/01/11 |

FLOVENT HFA® | The limits are 1 inhaler per 30 days for 44mcg and 110mcg, and 2 inhalers per 30 days for 220mcg. | P | 04/01/05 | 04/01/12 |

FLUNISOLIDE NASAL SPRAY | The limits are 3 bottles (75mL) per 30 days. | P | 01/01/12 | |

FOCALIN® XR | 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. | P | 07/01/05 | 01/01/12 |

FORADIL® AEROLIZER® | The limits are 2 blisters per day. | P | 08/06/08 | |

FORFIVO XL | The limits are 1 tablet per day. | P | 07/01/12 | |

FORTEO® | Prior authorization for medical necessity is required. | P | 08/06/08 | 07/01/11 |

FORTESTA | The limits are 120 grams (2 bottles) per 30 days. | P | 07/01/11 | 04/01/12 |

FOSAMAX PLUS D® | The limits are 4 tablets per 30 days. | P | 04/25/05 | 07/01/13 |

FOSAMAX® | 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. | P | 01/01/00 | 01/01/14 |

FRAGMIN® | The limits are 30 syringes or 10 vials per 90 days. | P | 07/01/10 | 07/01/14 |

FROVA® | Frova may be subject to step therapy requirements. Patients must have trial and failure of a generic triptan (naratriptan,sumatriptan,rizatriptan). The limits are 18 tablets per 30 days. | P | 11/01/05 | 07/01/15 |

FUZEON | The limits are 2 vials per day. | P | 07/01/12 | |

GAMASTAN™ S/D | Predetermination for medical necessity is available. | M | 01/01/16 | |

GAMMAGARD® LIQUID | B | 10/01/14 | 01/01/16 | |

GAMMAGARD® S/D | B | 01/01/15 | 01/01/16 | |

GAMMAKED™ | B | 10/01/14 | 01/01/16 | |

GAMMAPLEX® LIQUID | Predetermination for medical necessity is available. | M | 01/01/16 | |

GAMUNEX®-C | B | 01/01/12 | 01/01/16 | |

GATTEX® | Prior authorization for medical necessity is required. | P | 07/01/13 | |

GAZYVA™ | Predetermination for medical necessity is available. | M | 01/01/15 | |

GENOTROPIN® | Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required. | P | 10/01/11 | |

GENVOYA | The limits are 30 tablets per 30 days. | P | 11/10/15 | 01/01/16 |

GILENYA® | Gilenya 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 1 tablet per day. | P | 01/01/11 | 01/01/15 |

GILOTRIF® | Prior authorization for medical necessity is required. The limits are 1 tablets per day. | P | 01/01/14 | |

GLEEVEC® | Prior authorization for medical necessity is required. The limits are 3 tablets per day for 100mg or 2 tablets per day for 400mg. | P | 05/01/01 | 07/01/11 |

GLYXAMBI® | Prior authorization for medical necessity is required. The limits are 1 tablet per day. | P | 07/01/15 | |

GRALISE® | 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. | P | 01/01/12 | 07/01/13 |

GRANISOL | The limits are 60 mL (2 bottles) per 30 days. | P | 04/01/12 | |

GRANIX® | Predetermination for medical necessity is available when physician-administered. | B | 04/01/15 | 01/01/16 |

H.P. ACTHAR GEL® | B | 04/01/12 | 01/01/16 | |

HARVONI® | Prior authorization for medical necessity is required. | P | 10/14/14 | 01/22/15 |

HERCEPTIN® | Predetermination for medical necessity is available. | M | 01/01/15 | |

HETLIOZ® | Prior authorization for medical necessity is required. | P | 10/01/14 | |

HEXALEN® | Prior authorization for medical necessity is required. | P | 01/01/12 | |

HIZENTRA™ | B | 04/14/10 | 01/01/16 | |

HORIZANT® | The limits are 60 tablets per 30 days. | P | 01/01/12 | 07/01/13 |

HUMALOG® | Humalog may be subject to prior authorization. Patients must have trial and failure of Novolog. | P | 01/01/15 | |

HUMATROPE® | Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required. | P | 10/01/11 | |

HUMIRA® | 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. | P | 01/17/03 | 10/01/12 |

HUMULIN® | Humulin may be subject to prior authorization. Patients must have trial and failure of Novolin. | P | 01/01/15 | |

HYCAMTIN® | Prior authorization for medical necessity is required. | P | 01/01/12 | |

HYCET™ | The limits are 120mL per day. | P | 05/15/09 | |

HYDROCODONE/ACETAMINOPHEN | The limits are 12 tablets per day for 2.5mg-325mg tablets. | P | 10/01/12 | |

HYQVIA | B | 01/01/16 | ||

HYSINGLA ER® | The limits are 30 tablets per month. | P | 04/01/15 | |

HYZAAR® | Hyzaar may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB. | P | 01/01/11 | 10/01/15 |

IBRANCE® | Prior authorization for medical necessity is required. Limits are 21 capsules per 28 days. | P | 02/20/15 | |

IBUDONE™ | The limits are 5 tablets per day. | P | 05/15/09 | |

ICLUSIG™ | 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. | P | 04/01/13 | |

ILARIS® | Prior authorization for medical necessity is required. Patients must be at least 4 years of age. The limits are two 180 mg vial every 28 days.. | P | 08/10/09 | 10/01/15 |

IMBRUVICA® | Prior authorization for medical necessity is required. The limits are 4 capsules per day. | P | 01/01/14 | |

IMITREX® | Imitrex may be subject to step therapy requirements. Patients must have trial and failure of a generic triptan (naratriptan,sumatriptan,rizatriptan). The limits are 18 tablets, 12 nasal spray units, 10 vials, or 6 kits per 30 days. | P | 11/01/05 | 07/01/15 |

INCIVEK™ | Prior authorization for medical necessity is required. | P | 10/01/11 | |

INCRELEX® | Prior authorization for medical necessity is required. | P | 01/01/06 | |

INCRUSE ELLIPTA® | The limits are 30 blisters per month. | P | 04/01/15 | |

INLYTA® | 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. | P | 07/01/12 | |

INTELENCE | The limits are 2 tablets per day, except 25 mg tablets with a limit of 4 tablets per day. | P | 07/01/12 | 10/01/12 |

INTERMEZZO® | The limits are 1 tablet per day. | P | 07/01/12 | 07/01/13 |

INVIRASE | The limits are 10 capsules or 4 tablets per day. | P | 07/01/12 | |

INVOKAMET® | The limits are 2 tablets per day. | P | ||

INVOKANA | The limits are 1 tablet per day. | P | 04/01/14 | |

IRENKA® | The limits are 3 capsules per day. | P | 10/01/15 | |

IRESSA® | The limits are 1 tablet per day. | P | 10/01/15 | |

ISENTRESS | The limits are 6 tablets per day for 25 mg, 4 tablets per day for 100 mg, 2 tablets per day for 400 mg strengths, and 2 packets for the 100mg powder packet. | P | 07/01/12 | 10/01/14 |

JAKAFI™ | Prior authorization for medical necessity is required. The limits are 2 tablets per day. | P | 04/01/12 | |

JANUMET® | The limits are 2 tablets per day. | P | 05/01/07 | |

JANUMET® XR | The limits are 1 tablet per day, except 50 mg/1000 mg tablets which have a limit of 2 tablets per day. | P | 07/01/12 | |

JANUVIA® | The limits are 1 tablet per day. | P | 11/01/06 | |

JARDIANCE® | The limits are 1 tablet per day. | P | 10/01/14 | |

JENTADUETO® | The limits are 2 tablets per day. | P | 07/01/12 | |

JUVISYNC | The limits are 30 tablets per 30 days, except for the 50-10 mg and 50-20 mg strengths with a limit of 60 tablets per 30 days. | P | 04/01/12 | 07/01/14 |

JUXTAPID | Prior authorization for medical necessity is required. The limits are 1 capsule per day. | P | 07/01/13 | |

KADCYLA® | Predetermination for medical necessity is available. | M | 01/01/15 | |

KADIAN® | The limits are 2 capsules per day. | P | 05/15/09 | |

KALBITOR® | B | 01/01/15 | 01/01/16 | |

KALETRA | The limits are 6 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. | P | 07/01/12 | 10/01/15 |

KALYDECO® | Prior authorization for medical necessity is required. The limits are 2 tablets or 2 packets per day. | P | 07/01/12 | 07/01/15 |

KAZANO | The limits are 2 tablets per day. | P | 04/01/13 | |

KEYTRUDA® | Predetermination for medical necessity is available. | M | 01/01/15 | |

KHEDEZLA® | The limits are 30 tablets per 30 days. | P | 01/01/14 | |

KINERET® | Kineret may be subject to step therapy requirements. Patients must have trial and failure of two preferred products. Preferred products are Humira, Enbrel, Stelara and Simponi. The limits are 1 syringe per day. | P | 07/17/02 | 07/01/15 |

KITABIS® | Prior authorization for medical necessity is required. Must not be used concurrently with Cayston or Bethkis. | P | 04/01/15 | |

KOMBIGLYZE® XR | The limits are 1 tablet per day, except Kombiglyze XR 2.5-1000mg which has a limit of 2 tablets per day. | P | 04/01/15 | |

KORLYM® | Prior authorization for medical necessity is required. The limits are 4 tablets per day. | P | 10/30/15 | 01/01/16 |

KRYSTEXXA® | Predetermination for medical necessity is available. | M | 01/01/15 | |

KYNAMRO | Prior authorization for medical necessity is required. | P | 07/01/13 | |

KYPROLIS® | Predetermination for medical necessity is available. | M | 01/01/15 | |

KYTRIL® | The limits are 14 tablets per 30 days. | P | 12/03/01 | 04/01/12 |

LANSOPRAZOLE | The limits are 1 capsule or solutab per day. | P | 01/01/00 | |

LAZANDA® | Prior authorization for medical necessity is required. Patients must have trial and failure of generic product. The limits are 1 bottle per day. | P | 01/01/12 | 10/01/15 |

LEMTRADA® | Predetermination for medical necessity is available. | M | 01/01/15 | |

LENVIMA® | Prior authorization for medical necessity is required. Quantity limits are in place and vary based on strength. | P | 04/01/15 | |

LESCOL XL® | Lescol XL may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin). | P | 01/01/11 | |

LESCOL® | Lescol may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin). | P | 01/01/11 | |

LETAIRIS® | Prior authorization for medical necessity is required. | P | 04/01/15 | |

LEUKINE® | Predetermination for medical necessity is available when physician-administered. | B | 04/01/15 | 01/01/16 |

LEVITRA® | 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. | P | 09/01/03 | |

LEVORPHANOL | The limits are 4 tablets per day. | P | 01/01/13 | |

LEXIVA | The limits are 4 tablets per 60 mL per day. | P | 07/01/12 | |

LEXXEL® | Lexxel may be subject to step therapy requirements. | P | 01/01/11 | |

LINZESS® | Prior authorization for medical necessity is required. | P | 04/01/13 | |

LIPITOR® | Lipitor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin). | P | 01/01/11 | |

LIPTRUZET® | Liptruzet may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin). | P | 07/01/13 | |

LIVALO® | Livalo may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin). | P | 01/01/11 | |

LONSURF | Prior Authorization for medical necessity is required. The limits are 40 tablets per 28 days for the 6.14 mg/15mg strenght and 80 tablets per 28 days for the 20-8.19 tablet. | P | 10/06/15 | 01/01/16 |

LORCET® | The limits are 6 tablets per day. | P | 09/01/03 | 04/01/13 |

LORTAB® | 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). | P | 09/01/03 | |

LOVENOX® | The limits are 30 syringes or 10 vials per 90 days. | P | 02/01/05 | 04/01/12 |

LUCENTIS® | Predetermination for medical necessity is available. | M | 01/01/15 | |

LUMIGAN® | The limits are 1-2.5mL box per 30 days or 1-5mL box per 60 days. | P | 06/04/02 | |

LUNESTA® | The limits are 1 tablet per day. | P | 01/01/05 | 07/01/13 |

LYNPARZA® | Prior authorization for medical necessity is required. The limits are 16 capsules per day. | P | 04/01/15 | |

LYRICA® | 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. | P | 10/01/05 | 01/01/13 |

LYSODREN® | Prior authorization for medical necessity is required. | P | 01/01/12 | |

MACUGEN® | Predetermination for medical necessity is available. | M | 01/01/15 | |

MAGNACET® | 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. | P | 09/01/04 | 04/01/13 |

MAKENA® | Predetermination for medical necessity is available. | M | 01/01/15 | |

MATULANE® | Prior authorization for medical necessity is required. | P | 01/01/12 | |

MAXAIR | The limits are 1 inhaler per 30 days. | P | 04/01/12 | |

MAXALT® | Maxalt may be subject to step therapy requirements. Patients must have trial and failure of a generic triptan (naratriptan, sumatriptan, rizatriptan). The limits are 18 tablets per 30 days. | P | 11/01/05 | 07/01/15 |

MAXIDONE® | The limits are 5 tablets per day. | P | 09/01/03 | |

MEKINIST® | 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. | P | 01/01/14 | |

METADATE CD® | The limits are 2 capsules per day, except Metadate CD 60mg which has a limit of 1 capsule per day. | P | 01/01/05 | 04/01/11 |

METHADONE | 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. | P | 01/01/13 | |

METHADOSE | The limits are 3 tablets per day or 3 mL of the 10 mg/mL concentrated solution per day. | P | 01/01/13 | |

METHITEST® | Prior authorization for medical necessity is required. | P | 04/01/12 | |

MEVACOR® | Mevacor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin). | P | 01/01/11 | |

MICARDIS HCT® | Micardis HCT may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB. | P | 01/01/11 | |

MICARDIS® | Micardis may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB. | P | 01/01/11 | |

MINOCIN® | Minocin may be subject to step therapy requirements. Patients must have a trial and failure of generic immediate release doxycycline AND generic immediate release minocycline. | P | 04/01/13 | 01/01/15 |

MINOCIN® KIT | Minocin may be subject to step therapy requirements. Patients must have a trial and failure of generic immediate release doxycycline AND generic immediate release minocycline. | P | 04/01/13 | 01/01/15 |

MONODOX® | Monodox may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline. | P | 04/01/13 | 01/01/15 |

MORGIDOX® KIT | Morgidox may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline. | P | 04/01/13 | 01/01/15 |

MORPHINE | 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. | P | 01/01/13 | |

MOVANTIK® | Prior authorization for medical necessity may be required. | P | 07/01/15 | |

MS CONTIN® | The limits are 3 tablets per day. | P | 05/15/09 | |

MUSE® | Prior authorization for medical necessity may be required. Patients must be at least 18 years of age. | P | 07/01/10 | |

MYALEPT® | Prior authorization for medical necessity is required. | P | 10/01/14 | |

MYOBLOC® | Predetermination for medical necessity is available. | M | 01/01/15 | |

NASACORT AQ® | The limits are 1 box per 30 days. | P | 04/01/04 | |

NASAREL® | The limits are 3 boxes per 30 days. | P | 08/06/08 | 04/01/11 |

NASONEX® | The limits are 1 box – 17 g per 30 days. | P | 02/22/05 | |

NATESTO® | May be subject to step therapy requirements. Patients must have trial and failure of Androderm or Androgel. The limits are 180 pumps per 30 days. | P | 07/01/15 | |

NATPARA® | Prior Authorization for medical necessity is required. The limits are 14 packages of 2 cartridges per 28 days. | P | 10/01/15 | |

NESINA | The limits are 1 tablet per day. | P | 04/01/13 | |

NEULASTA® | Predetermination for medical necessity is available when physician-administered. | B | 04/01/15 | 01/01/16 |

NEUPOGEN® | Predetermination for medical necessity is available when physician-administered. | B | 04/01/15 | 01/01/16 |

NEVIRAPINE | The limits are 40 mL per day. | P | 07/01/12 | |

NEXAVAR® | Prior authorization for medical necessity is required. The limits are 4 tablets per day. | P | 01/01/06 | |

NEXIUM® | 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. | P | 01/01/00 | 04/01/14 |

NICAZELDOXY® KIT | Nicazeldoxy may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline. | P | 01/01/14 | 01/01/15 |

NORCO® | 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). | P | 09/01/03 | |

NORDITROPIN® | Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required. | P | 10/01/11 | |

NORTHERA® | Prior authorization for medical necessity is required. The limits are 15 capsules per day for the 100mg capsule and 6 capsules per day for the 100 and 200 mg capsules. | P | 07/01/15 | |

NORVIR | The limits are 12 tablets or capsules or 16 mL per day. | P | 07/01/12 | |

NPLATE® | Predetermination for medical necessity is available. | M | 01/01/15 | |

NUCYNTA® | The limits are 12 tablets per day. | P | 07/06/09 | 04/01/12 |

NUCYNTA® ER | The limits are 2 tablets per day. | P | 01/01/12 | 01/01/16 |

NUTRIDOX® KIT | Nutridox may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline. | P | 04/01/13 | 01/01/15 |

NUTROPIN AQ NUSPIN® | P | 01/01/13 | ||

NUTROPIN AQ® | P | 10/01/11 | ||

NUTROPIN® | P | 10/01/11 | ||

NUVIGIL® | Prior authorization for medical necessity is required. The limits are 1 tablet per day. Patients must be at least 17 years of age. | P | 05/06/09 | |

OCTAGAM® | Predetermination for medical necessity is available. | M | 01/01/15 | 01/01/16 |

OCUDOX® KIT | Ocudox may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline. | P | 04/01/13 | 01/01/15 |

ODOMZO | Prior authorization for medical necessity is required. The limits are 1 capsule daily. | P | 10/08/15 | 01/01/16 |

OFEV® | Prior authorization for medical necessity is required. The limits are 2 tablets per day. | P | 10/20/14 | |

OMEPRAZOLE | The limits are 1 capsule per day. | P | 01/01/00 | |

OMEPRAZOLE-SODIUM BICARBONATE | 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. | P | 07/01/10 | 04/01/14 |

OMNARIS® | The limits are 1 box per 30 days. | P | 08/06/08 | |

OMNITROPE® | Prior authorization for medical necessity is required. | P | 10/01/11 | |

ONGLYZA® | The limits are 1 tablet per day. | P | 08/27/09 | |

ONSOLIS™ | Prior authorization for medical necessity is required. The limits are 4 tablets per day. | P | 09/18/09 | |

OPANA ER® | The limits are 2 tablets per day. | P | 02/15/07 | |

OPANA® | The limits are 6 tablets per day. | P | 01/01/13 | |

OPDIVO® | Predetermination for medical necessity is available. | M | 01/01/15 | |

OPSUMIT® | Prior authorization for medical necessity is required. | P | 04/01/15 | |

ORACEA® | Oracea may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline. | P | 04/01/13 | 01/01/15 |

ORAMORPH® SR | The limits are 3 tablets per day. | P | 05/15/09 | |

ORAXYL® | Oraxyl may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline. | P | 04/01/13 | 01/01/15 |

ORBIVAN | The limits are 6 capsules per day. | P | 04/01/13 | |

ORBIVAN CF | The limits are 6 tablets per day. | P | 04/01/13 | |

ORENCIA® | Step Therapy and Quantity Limits apply when self-administered. Predetermination for medical necessity is available when physician-administered. | B | 12/10/11 | 01/01/16 |

ORENITRAM® | Prior authorization for medical necessity is required. | P | 04/01/15 | |

ORKAMBI® | Prior authorization for medical necessity is required. Quantity limits are 4 tablets per day. | P | 10/30/15 | |

OSENI | The limits are 1 tablet per day. | P | ||

OTEZLA® | Otezla may be subject to step therapy requirements. Patients must have trial and failure of 2 preferred products. Preferred products are Humira, Enbrel, Stelara, and Simponi. The limits are 60 tablets per 30 day or 1 starter kit/180 days. | P | 10/01/14 | 07/01/15 |

OTREXUP® | Otrexup may be subject to step therapy requirements. Patients must have trial and failure of a generic injectable methotrexate. | P | 07/01/15 | |

OXANDRIN® | Prior authorization for medical necessity is required. | P | 07/20/09 | |

OXAYDO | The limits are 6 tablets daily. | P | 09/21/15 | 10/06/15 |

OXECTA® | The limits are 6 tablets per day. | P | 01/01/13 | |

OXYCODONE | The limits are 6 capsules or tablets per day. | P | 01/01/13 | |

OXYCONTIN® | The limits are 3 tablets per day, except Oxycontin 80mg which has a limit of 4 tablets per day. | P | 01/01/00 | 05/17/11 |

OXYMORPHONE SR | The limits are 2 tablets per day. | P | 10/01/12 | |

PANTOPRAZOLE | The limits are 1 tablet per day. | P | 07/01/10 | 04/01/11 |

PATANASE® | The limits are 1 box per 30 days. | P | 08/06/08 | |

PEGASYS® | Prior authorization for medical necessity is required. | P | 06/01/06 | 01/01/11 |

PEG-INTRON® | Prior authorization for medical necessity is required. Use of the preferred peginterferon, Pegasys, may be required. | P | 06/01/06 | 01/01/11 |

PERCOCET® | 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. | P | 09/01/04 | |

PERCODAN® | The limits are 12 tablets per day. | P | 03/29/04 | |

PERJETA® | Predetermination for medical necessity is available. | M | 01/01/15 | |

PHRENILLIN FORTE | The limits are 6 capsules per day. | P | 04/01/13 | |

PICATO | The limits are 3 tubes per 90 days of the 0.015% gel and 2 tubes per 90 days of the 0.05% gel. | P | 04/01/13 | |

PLEGRIDY® | The limits are 2 syringes or pens per 30 days and 1 starter kit per 180 days. | P | 01/01/15 | |

POMALYST® | Prior authorization for medical necessity is required. The limits are 21 capsules per 28 days. | P | 04/01/13 | |

PRADAXA® | The limits are 2 capsules per day. | P | 04/01/11 | |

PRALUENT® | Prior authorization for medical necessity is required. The limits are 2 syringes per 28 days. | P | 07/24/15 | |

PRAVACHOL® | Pravachol may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin). | P | 01/01/11 | |

PREVACID® | 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. | P | 01/01/00 | 04/01/14 |

PREZCOBIX® | The limits are 30 tablets per month. | P | 04/01/15 | |

PREZISTA | The limits are 10 tablets per day for the 75 mg, 6 tablets per day for the 150 mg, 2 tablets for the 600 mg, and 1 tablet per day for the 800 mg. Prezista solution has a limit of 400 mL per 30 days. | P | 07/01/12 | 10/01/14 |

PRILOSEC® | 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. | P | 01/01/00 | 04/01/14 |

PRIMLEV® | 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. | P | 05/15/09 | 10/01/12 |

PRISTIQ® | The limits are 1 tablet per day. Not covered for patients less than 18 years of age. | P | 05/01/08 | |

PRIVIGEN™ | Predetermination for medical necessity is available. | M | 01/01/15 | 01/01/16 |

PROAIR RESPICLICK® | The limits are 2 inhalers per 30 days. | P | 07/01/15 | |

PROAIR+A187 | The limits are 2 inhalers per 30 days. | P | 04/01/12 | |

PROMACTA® | 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. | P | 05/15/09 | 10/01/11 |

PROTONIX® | 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. | P | 01/01/00 | 04/01/14 |

PROVENGE® | Predetermination for medical necessity is available. | M | 01/01/15 | |

PROVENTIL HFA | The limits are 2 inhalers per 30 days. | P | 04/01/12 | |

PROVIGIL® | Prior authorization for medical necessity is required. The limits are 1 tablet per day. Patients must be at least 17 years of age. | P | 09/01/03 | 07/01/11 |

PULMICORT® | The limits are 2 inhalers per 30 days for Pulmicort Flexhaler 180mcg and 1 inhaler per 30 days for 90mcg. | P | 02/01/05 | 04/01/12 |

QNASL CHILDREN® | The limits are 1 inhaler per month. | P | 04/01/15 | |

QNASL® | The limits are 1 bottle per 30 days. | P | 07/01/12 | |

QUALAQUIN® | The limits are 42 capsules per 90 days, which allows for a single 7-day course of therapy. | P | 05/01/07 | 01/01/12 |

QUILLIVANT XR | The limits are 360 mL per 30 days. | P | 04/01/13 | |

QVAR® | 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. | P | 08/06/08 | 04/01/11 |

RASUVO® | Rasuvo may be subject to step therapy. Patients must have trial and failure of a generic injectable methotrexate. | P | 07/01/15 | |

RAVICTI | Prior authorization for medical necessity is required. | P | 07/01/13 | |

REBIF® | The limits are 3 syringes per week or 1 titration kit per 28 days. | P | 10/01/12 | |

RELENZA® | The limits are 20 blisters (1 carton) per 30 days. | P | 12/03/01 | |

RELISTOR® | Prior authorization for medical necessity is required. | P | 08/06/08 | 10/01/11 |

RELPAX® | Relpax may be subject to step therapy. Patients must have trial and failure of a generic triptan (naratriptan, sumatriptan, rizatriptan). The limits are 12 tablets per 30 days. | P | 11/01/05 | 07/01/15 |

REMICADE® | Predetermination for medical necessity is available. | M | 01/01/15 | |

RENOVA® | Prior authorization for medical necessity may be required. | P | 04/01/01 | |

REPATHA® | Prior authorization for medical necessity may be required. The quantity limits are 3 syringes per 30 days. | P | 08/26/15 | 01/01/16 |

REPREXAIN® | The limits are 5 tablets per day. | P | 05/15/09 | 04/01/12 |

RESCRIPTOR | The limits are 12 tablets per day for 100 mg tablets and 6 tablets per day for 200 mg tablets. | P | 07/01/12 | 10/01/14 |

RETIN-A® | Prior authorization for medical necessity may be required. | P | 04/01/01 | |

RETROVIR | The limits are 6 capsules, 2 tablets, or 64 mL per day. | P | 07/01/12 | |

REVATIO® | Prior authorization for medical necessity is required. | P | 04/01/15 | |

REVLIMID® | 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. | P | 01/01/13 | |

REYATAZ® | The limits are 1 capsule per day, except 200 mg which has a limit of 2 capsules per day or 150 powder packets per month. | P | 07/01/12 | 04/01/15 |

RHINOCORT AQ® | The limits are 2 boxes – 18 g per 30 days. | P | 09/25/02 | 02/13/08 |

RITALIN LA® | The limits are 2 capsules per day. | P | 07/01/05 | 04/01/11 |

RITUXAN | Predetermination for medical necessity is available. | M | 01/01/15 | |

ROXICET® | 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. | P | 09/01/04 | 05/15/09 |

ROXICODONE | The limits are 6 tablets or 180 mL/day. | P | 01/01/13 | |

ROXICODONE INTENSOL | The limits are 9 mL/day of the 20 mg/mL concentrated solution. | P | 01/01/13 | |

ROZEREM® | The limits are 1 tablet per day. | P | 09/01/05 | 07/01/13 |

RUCONEST® | B | 01/01/15 | 01/01/16 | |

RYBIX™ ODT | The limits are 8 tablets per day. | P | 04/01/11 | |

RYZOLT® | The limits are 1 tablet per day. | P | 08/10/09 | 04/01/12 |

SAIZEN® | P | 10/01/11 | ||

SAIZEN® CLICK-EASY | P | 01/01/13 | ||

SANCUSO® | Sancuso may be subject to step therapy requirements. Patients must have trial and failure of generic ondansetron or granisetron. The quantity limits are 1 patch per month. | P | 11/12/08 | 10/01/15 |

SAVAYSA® | The limits are 30 tablets per month. | P | 04/01/15 | |

SEEBRI NEOHALER | The limits are 60 capsules per 30 days. | P | 11/19/15 | 01/01/16 |

SELZENTRY | The limits are 2 tablets per day for 150 mg and 2 tablets per day for 300 mg strengths. | P | 07/01/12 | 10/01/15 |

SEREVENT® DISKUS® | The limits are 2 blisters per day. | P | 08/06/08 | |

SEROSTIM® | P | 10/01/11 | ||

SIGNIFOR® | Prior authorization for medical necessity is required. Quantity limits are 2ml/day. | P | 07/01/13 | 01/01/16 |

SILENOR | The limits are 1 tablet per day. | P | 07/01/11 | 07/01/13 |

SIMCOR® | Simcor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin). | P | 01/01/11 | |

SIMPONI ARIA | Predetermination for medical necessity is available. | M | 01/01/15 | 01/01/16 |

SIMPONI® | Step Therapy and Quantity Limits apply when self-administered. | P | 05/06/09 | 01/01/16 |

SINGULAIR® | The limits are 1 tablet or packet per day. | P | 01/01/00 | |

SOLARAZE | Prior authorization for medical necessity is required. Limited to one 100 gram tube per 30 days. | P | 01/01/16 | |

SOLODYN® | Solodyn may be subject to step therapy requirements. Patients must have a trial and failure of generic immediate release doxycycline AND generic immediate release minocycline. | P | 05/01/06 | 01/01/15 |

SONATA® | The limits are 1 capsule per day. | P | 01/01/05 | 07/01/13 |

SOVALDI | Prior authorization for medical necessity is required. Quantity limits may apply based on strength. | P | 01/01/16 | |

SPIRIVA® | The limits are 1 capsule per day for Spiriva Handihaler and 1 inhaler per 30 days for Spiriva Respimat. | P | 06/07/04 | 01/01/15 |

SPRIX® | The limits are 5 bottles per 30 days. | P | 04/01/11 | |

SPRYCEL® | 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. | P | 07/01/06 | 07/01/11 |

STAGESIC® | The limits are 8 capsules per day. | P | 09/01/03 | |

STAXYN® | 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. | P | 01/01/11 | |

STELARA® | B | 10/01/14 | 01/01/16 | |

STENDRA® | 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. | P | 07/01/13 | |

STIOLTO® RESPIMAT | The limits are 1 inhaler per day. | P | 10/01/15 | |

STIVARGA® | Prior authorization for medical necessity may be required. The limits are 4 tablets per day. | P | 11/15/12 | |

STRATTERA® | The limits are 2 capsules per day, except Strattera 80mg and 100mg which is 1 capsule per day. | P | 01/15/03 | 04/01/11 |

STRIANT | The limits are 60 buccal systems per 30 days. | P | 04/01/12 | |

STRIBILD | The limits are 1 tablet per day. | P | 01/01/13 | |

STRIVERDI® | The limits are 1 canister per 30 days. | P | 10/01/14 | |

SUBOXONE® | 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 16 years of age. | P | 08/06/08 | 04/01/14 |

SUBSYS® | Prior authorization for medical necessity is required. Patients must have trial and failure and generic product. The limits are 8 sprays per day for 1200 mcg and 1600 mcg strengths and 4 sprays per day for all other strengths. | P | 07/01/12 | 10/01/15 |

SUBUTEX® | Prior authorization for medical necessity is required. The limits are 15 tablets per 90 days. Patients must be at least 18 years of age. | P | 08/06/08 | 04/01/14 |

SUMAVEL® DOSEPRO® | Sumavel may be subject to step therapy requirements. Patients must have trial and failure of a generic triptan (naratriptan, sumatriptan, rizatriptan). The limits are 12 prefilled delivery systems per 30 days. | P | 11/09/09 | 07/01/15 |

SUSTIVA | 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. | P | 07/01/12 | |

SUTENT® | Prior authorization for medical necessity is required. The limits are 1 tablet per day. | P | 02/10/06 | |

SYLATRON® | Prior authorization for medical necessity is required. | P | 01/01/13 | |

SYMBICORT® | The limits are 1 box per 30 days. | P | 08/01/07 | |

SYNAGIS® | Predetermination for medical necessity is available. | M | 01/01/15 | |

SYNJARDY | The limits are 60 tablets per 30 days. | P | 09/17/15 | 01/01/16 |

SYNVISC® | Predetermination for medical necessity is available. | M | 01/01/15 | |

SYNVISC-ONE® | Predetermination for medical necessity is available. | M | 01/01/15 | |

TAFINLAR® | Prior authorization for medical necessity is required. The limits are 4 capsules per day. | P | 01/01/14 | |

TAGRISSO | Prior authorization for medical necessity is required. Limits are 30 tablets per 30 days. | P | 11/25/15 | 01/01/16 |

TALACEN | The limits are 180 tablets per 30 days. | P | 04/01/12 | |

TAMIFLU® | 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. | P | 02/01/05 | 07/01/13 |

TANZEUM® | Tanzeum 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 28 days. | P | 10/01/14 | |

TARCEVA® | 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. | P | 03/14/07 | 07/01/11 |

TARGADOX® | Targadox may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND immediate release minocycline. | P | 06/21/15 | |

TARGRETIN® | Prior authorization for medical necessity is required. | P | 01/01/12 | |

TASIGNA® | Prior authorization for medical necessity is required. The limits are 4 capsules per day. | P | 04/01/11 | |

TAZAROTENE | Prior authorization for medical necessity may be required. | P | 04/01/01 | |

TAZORAC® | Prior authorization for medical necessity may be required. | P | 04/01/01 | |

TECFIDERA® | The limits are 2 capsules per day and 1 starter kit per 30 days. | P | 05/01/13 | 01/01/14 |

TECHNIVIE® | Prior authorization for medical necessity may be required. Quantity limits may apply. | P | 08/14/15 | |

TEKAMLO® | Tekamlo may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB. | P | 01/01/11 | 10/01/15 |

TEKTURNA HCT® | Tekturna HCT may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB. | P | 01/01/11 | 10/01/15 |

TEKTURNA® | Tekturna may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB. | P | 01/01/11 | 10/01/15 |

TEMODAR® | Prior authorization for medical necessity is required. | P | 01/01/12 | |

TESOPEL® | Predetermination for medical necessity is available. | M | 01/01/15 | |

TESTIM® | The limits are 10 grams per day. | P | 06/15/04 | 04/01/12 |

TESTOSTERONE GEL | Testosterone gel may be subject to step therapy requirements. Patients must have trial and failure of Androderm or Androgel. The limits are 300 gm per 30 days or 2 pump bottles per 30 days. | P | 10/01/14 | 08/31/14 |

TESTRED® | Prior authorization for medical necessity is required. | P | 04/01/12 | |

TEVETEN HCT® | Teveten HCT may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB. | P | 01/01/11 | 10/01/15 |

TEVETEN® | Teveten may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB. | P | 01/01/11 | 10/01/15 |

TEV-TROPIN® | P | 10/01/11 | ||

THALOMID® | 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. | P | 01/01/13 | |

TIVICAY® | The limits are 2 tablets per day. | P | 01/01/14 | |

TOBI® | Prior authorization for medical necessity may be required. Must not be used concurrently with Cayston or Bethkis. | P | 04/01/12 | 04/01/13 |

TOBI® Podhaler | Prior authorization for medical necessity may be required. Must not be used concurrently with Cayston or Bethkis. | P | 07/01/13 | |

TRACLEER® | Prior authorization for medical necessity is required. | P | 04/01/15 | |

TRADJENTA® | The limits are 30 tablets per 30 days. | P | 01/01/12 | |

TRAVATAN Z® | The limits are 1-2.5mL box per 30 days or 1-5mL box per 60 days. | P | 06/04/02 | 01/01/13 |

TRETINOIN | Prior authorization for medical necessity may be required. | P | 04/01/01 | |

TRETIN-X | Prior authorization for medical necessity may be required. | P | 04/01/01 | |

TREXIMET® | Treximet may be subject to step therapy requirements. Patients must have trial and failure of a generic triptan (naratriptan, sumatriptan, rizatriptan). The limits are 18 tablets per 30 days. | P | 04/22/08 | 07/01/15 |

TREZIX® | The limits are 10 capsules per day. | P | 04/01/13 | |

TRIBENZOR® | Tribenzor may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB. | P | 01/01/11 | 10/01/15 |

TRIUMEQ® | The limits are 1 tablet per day. | P | 01/01/15 | |

TRIZIVIR | The limits are 2 tablets per day. | P | 07/01/12 | |

TRULICITY® | Trulicity 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 pens per 30 days. | P | 01/01/15 | |

TRUVADA | The limits are 1 tablet per day. | P | 07/01/12 | |

TUDORZA® PRESSAIR | The limits are 1 canister per 30 days. | P | 01/01/13 | |

TUSSICAPS® | The limits are 2 capsules per day and 20 capsules per month. Not covered for patients less than 12 years of age. | P | 05/15/09 | |

TUSSIONEX® PENNKINETIC® | The limits are 10mL per day and 120mL per 30 days. Not covered for patients less than 12 years of age. | P | 08/06/08 | 05/15/09 |

TUZISTRA XR | The limits are 240ml per 30 days. | P | 10/01/15 | |

TWYNSTA® | Twynsta may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB. | P | 01/01/11 | 10/01/15 |

TYBOST® | The limits are 1 tablet per day. | P | 01/01/15 | |

TYKERB® | Prior authorization for medical necessity is required. The limits are 5 tablets per day. | P | 11/01/07 | |

TYLENOL® | If a combination drug contains Tylenol, the daily dose of the acetaminophen component should not exceed 4 grams. Excessive doses may cause liver toxicity. | P | 09/01/03 | |

TYLENOL® WITH CODEINE | 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. | P | 03/23/04 | 04/01/12 |

TYLOX® | The limits are 8 capsules per day. | P | 04/01/04 | |

TYSABRI® | Predetermination for medical necessity is available. | P | 01/01/15 | |

TYVASO® | Prior authorization for medical necessity is required. The limits are 1 starter kit/180 days, 1 package of 28 ampules /28 days, or 7 packages of 4 ampules/28 days. | P | 07/01/15 | |

ULORIC® | Uloric may be subject to step therapy requirements. Patients must have a trial and failure of allopurinol 300mg. | P | 07/20/09 | 07/01/11 |

ULTRACET® | The limits are 8 tablets per day. | P | 04/01/07 | 04/01/12 |

ULTRAM ER® | The limits are 1 tablet per day. | P | 02/15/06 | 04/01/12 |

ULTRAM® | The limits are 8 tablets per day. | P | 09/04/02 | 04/01/12 |

UTIBRON NEOHALER | The limits are 60 capsules per 30 days | P | 11/19/15 | 01/01/16 |

VARUBI | The limits are 4 tablets per 30 days. | P | 11/03/15 | 01/01/16 |

VECTIBIX® | Predetermination for medical necessity is available. | M | 01/01/15 | |

VELTIN® | Prior authorization for medical necessity may be required. | P | 01/01/11 | |

VENLAFAXINE EXTENDED-RELEASE | The limits are 1 tablet per day. | P | 11/12/08 | |

VENTAVIS® | Prior authorization for medical necessity is required. The limits are 9 packages of 30 ampules/30 days. | P | 07/01/15 | |

VENTOLIN HFA | The limits are 2 inhalers per 30 days. | P | 04/01/12 | |

VERAMYST® | The limits are 1 box per 30 days. | P | 07/01/07 | |

VIAGRA® | P | 07/01/98 | 10/18/02 | |

VIBRAMYCIN® | Vibramycin capsules, suspension and syrup may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline. | P | 04/01/13 | 01/01/15 |

VICODIN® | 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). | P | 09/01/03 | |

VICOPROFEN® | The limits are 5 tablets. | P | 09/24/03 | 04/01/12 |

VICTOZA® | 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. | P | 02/15/10 | 04/01/11 |

VICTRELIS® | Prior authorization for medical necessity is required. | P | 10/01/11 | |

VIEKIRA® | Prior authorization for medical necessity is required. | P | 01/22/15 | |

VIRACEPT | The limits are 9 capsules per day for 250 mg and 4 tablets per day for 625 mg strengths. | P | 07/01/12 | |

VIRAMUNE | The limits are 2 tablets or 40 mL per day. | P | 07/01/12 | |

VIRAMUNE XR | The limits are 1 tablet per day for 400 mg tablets and 3 tablets per day for 100 mg tablets. | P | 07/01/12 | 07/01/13 |

VIREAD® | The limits are 1 tablet or 8 g per day. | P | 07/01/12 | |

VISUDYNE® | Predetermination for medical necessity is available. | M | 01/01/15 | |

VITEKTA® | The limits are 30 tablets per month. | P | 04/01/15 | |

VIVITROL® | Predetermination for medical necessity is available. | M | 01/01/15 | |

VOGELXO | Vogelxo may be subject to step therapy requirements. Patients must have trial and failure of Androderm or Androgel. The limits are 2 packets per day or 4 pumps (300 gm) per 30 days for the pump. | P | 10/01/14 | |

VOTRIENT™ | Prior authorization for medical necessity is required. The limits are 4 tablets per day. | P | 11/13/09 | |

VYTORIN® | Vytorin may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin). | P | 01/01/11 | |

VYVANSE® | The limits are 1 capsule per day. | P | 07/01/07 | 04/01/11 |

WELLBUTRIN SR® | The limits are 2 tablets per day. | P | 08/06/08 | |

WELLBUTRIN XL® | The limits are 3 tablets per day for Wellbutrin XL 150mg and 1 tablet per day for Wellbutrin XL 300mg. | P | 07/15/04 | 02/13/08 |

WELLBUTRIN® | The limits for Wellbutrin 75mg are 6 tablets per day. The limits for Wellbutrin 100mg are 4 tablets per day. | P | 08/06/08 | |

XALATAN® | The limits are 1-2.5mL box per 30 days or 1-7.5mL box per 90 days. | P | 06/04/02 | |

XALKORI® | Prior authorization for medical necessity is required. The limits are 60 capsules per 30 days. | P | 01/01/12 | |

XARELTO® | 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, 60 tablets per 30 days for the 15 mg tablets, and 1 starter pack (51 tablets) per 30 days. | P | 01/01/12 | 01/01/15 |

XARTERMIS XR | The limits are 4 tablets per day. | P | 07/01/14 | |

XELJANZ® | Xeljanz may be subject to step therapy requirements. Patients must have trial and failure of 2 preferred products. Preferred products are Humira, Enbrel, Stelara, and Simponi. The limits are 2 tablets per day. | P | 01/01/13 | 07/01/15 |

XELODA® | Prior authorization for medical necessity is required. | P | 01/01/12 | |

XEOMIN® | Predetermination for medical necessity is available. | M | 01/01/15 | |

XIAFLEX® | Predetermination for medical necessity is available. | M | 01/01/15 | |

XIGDUO® | The limits are 1 tablet per day for Xigdio 5/500 mg and 10/500 mg and 2 tablets per day for Xigduo 5/1000 mg. | P | 01/01/15 | |

XODOL® | The limits are 12 tablets per day for Xodol 5/300mg and 6 tablets per day for Xodol 7.5/300mg and 10/300mg. | P | 05/15/09 | |

XOLAIR® | Predetermination for medical necessity is available. | M | 01/01/15 | |

XOLOX® | The limits are 8 tablets per day. | P | 04/01/11 | |

XOPENEX HFA | The limits are 2 inhalers per 30 days. | P | 04/01/12 | |

XTANDI® | Prior authorization for medical necessity is required. The limits are 4 capsules per day. | P | 11/15/12 | |

XYREM® | Prior authorization for medical necessity is required. The limits are 9g (18 mL) per day. Patients must be at least 18 years of age. | P | 07/01/07 | 04/01/14 |

YERVOY® | Predetermination for medical necessity is available. | M | 01/01/15 | |

ZALTRAP® | Predetermination for medical necessity is available. | M | 01/01/15 | |

ZAMICET® | The limits are 90mL per day. | P | 05/15/09 | |

ZARXIO® | Predetermination for medical necessity is available when physician-administered. | M | 01/01/16 | |

ZECUITY | Zecuity may be subject to step therapy requirements. Patients must have trial and failure of a generic triptan (naratriptan, sumatriptan, rizatriptan). The limits are 12 transdermal systems per 30 days. | P | 07/01/13 | 07/01/15 |

ZEGERID® | 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. | P | 08/01/06 | 04/01/14 |

ZELBORAF® | Prior authorization for medical necessity is required. The limits are 8 tablets per day. | P | 01/01/12 | |

ZERIT | The limits are 2 capsules or 80 mL per day. | P | 07/01/12 | |

ZETONNA | The limits are 1 bottle per 30 days. | P | 07/01/12 | |

ZIAGEN | The limits are 2 tablets or 32 mL per day. | P | 07/01/12 | |

ZIANA® | Prior authorization for medical necessity may be required. | P | 07/01/07 | |

ZIOPTAN | The limits are 1 single-use container per day. | P | 07/01/12 | |

ZOCOR® | Zocor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin). | P | 01/01/11 | |

ZOFRAN® | The limits are 21 tablets per 30 days for Zofran 4mg and 8mg, and 1 tablet per 30 days for Zofran 24mg. | P | 02/01/05 | 04/01/12 |

ZOFRAN® ODT | The limits are 21 tablets per 30 days. | P | 02/01/05 | |

ZOHYDRO ER | The limits are 2 capsules per day. | P | 04/01/14 | |

ZOLINZA® | Prior authorization for medical necessity is required. The limits are 4 capsules per day. | P | 01/01/12 | |

ZOLPIMIST® | The limits are 1 container per month. | P | 05/15/09 | 07/01/13 |

ZOLVIT® | The limits are 67.5mL per day. | P | 04/01/11 | |

ZOMACTON® | Prior authorization for medical necessity is required. | P | 05/20/15 | |

ZOMIG® | Zomig may be subject to step therapy requirements Patients must have trial and failure of a generic triptan (naratriptan, sumatriptan, rizatriptan). The limits are 12 tablets or 12 nasal spray units per 30 days. | P | 11/01/05 | 07/01/15 |

ZORPTIVE® | P | 10/01/11 | ||

ZUBSOLV® | Zubsolv is subject to quantity limits. | P | 09/17/15 | 01/01/16 |

ZUPLENZ® | The limits are 20 films (2 boxes of 10) per 30 days for Zuplenz 4mg and 8mg. | P | 01/01/11 | 04/01/12 |

ZYBAN® | The limits are 2 tablets per day. | P | 08/06/08 | |

ZYDELIG™ | Prior authorization for medical necessity is required. The limits are 2 tablets per day. | P | 10/01/14 | |

ZYDONE® | The limits are 8 tablets per day for Zydone 5/400mg and 6 tablets per day for Zydone 7.5/400mg and 10/400mg. | P | 09/01/03 | |

ZYFLO ® | The limits are 4 tablets per day. | P | 01/09/15 | |

ZYFLO CR® | The limits are 4 tablets per day. | P | 02/01/05 | 04/16/08 |

ZYKADIA | Prior authorization for medical necessity is required. The limits are 5 tablets per day. | P | 07/01/14 | |

ZYTIGA® | Prior authorization for medical necessity is required. The limits are 4 tablets per day. | P | 01/01/12 |