||The limits are 1 tablet per day.
||The limits are 1 box per 30 days.
||Prior authorization for medical necessity is required.
||Prior authorization for medical necessity is required. Use of the preferred peginterferon, Pegasys, may be required.
||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.
||The limits are 12 tablets per day.
||The limits are 6 capsules per day.
||The limits are 3 tubes per 90 days of the 0.015% gel and 2 tubes per 90 days of the 0.05% gel.
||The limits are 2 syringes or pens per 30 days and 1 starter kit per 180 days.
||Prior authorization for medical necessity is required. The limits are 21 capsules per 28 days.
||The limits are 2 capsules per day.
||Pravachol may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
||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.
||The limits are 30 tablets per month.
||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.