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All A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Product Name Implementation Date Guideline
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 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 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 The limits are 1 tablet per day.
ADAPALENE 04/01/01 Prior authorization for medical necessity may be required.
ADDERALL XR® 11/13/02 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).

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