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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
PANTOPRAZOLE 07/01/10 The limits are 1 tablet per day.
PATANASE® 08/06/08 The limits are 1 box per 30 days.
PEGASYS® 06/01/06 Prior authorization for medical necessity is required.
PEG-INTRON® 06/01/06 Prior authorization for medical necessity is required. Use of the preferred peginterferon, Pegasys, may be required.
PERCOCET® 09/01/04 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.
PERCODAN® 03/29/04 The limits are 12 tablets per day.
PHRENILLIN FORTE 04/01/13 The limits are 6 capsules per day.
PICATO 04/01/13 The limits are 3 tubes per 90 days of the 0.015% gel and 2 tubes per 90 days of the 0.05% gel.
POMALYST® 04/01/13 Prior authorization for medical necessity is required. The limits are 21 capsules per 28 days.
PRADAXA® 04/01/11 The limits are 2 capsules per day.
PRANDIMET™ 08/06/08 The limits are 5 tablets per day.
PRANDIN 04/01/12 The limits are 120 tablets per 30 days.
PRAVACHOL® 01/01/11 Pravachol may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
PRECOSE 04/01/12 The limits are 90 tablets per 30 days.
PREVACID® 01/01/00 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.

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