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. |
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 |
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 |
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. |