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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
FABIOR 07/01/13 Prior authorization for medical necessity may be required.
FARXIGA® 04/01/14 The limits are 1 tablet per day.
FARYDAK® 07/01/15 The limits are 6 capsules per 21 days.
FENTANYL CITRATE LOZENGE 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.
FENTANYL TD® 03/03/15 The limits are 15 patches per 30 days.
FENTORA® 09/01/06 Prior authorization for medical necessity is required. Patients must have trial and failure of generic product. The limits are 4 tablets per day.
FETZIMA® 01/01/14 The limits are 1 capsule per day or 1 titration pack per 180 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 when self-administered or physician-administered.
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.
FLEBOGAMMA® Prior authorization for medical necessity is required.

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