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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
RAVICTI 07/01/13 Prior authorization for medical necessity is required.
REBIF® 10/01/12 The limits are 3 syringes per week or 1 titration kit per 28 days.
RELENZA® 12/03/01 The limits are 20 blisters (1 carton) per 30 days.
RELISTOR" 08/06/08 Prior authorization for medical necessity is required.
RELPAX® 11/01/05 The limits are 12 tablets per 30 days.
RENOVA® 04/01/01 Prior authorization for medical necessity may be required.
REPREXAIN® 05/15/09 The limits are 5 tablets per day.
RESCRIPTOR 07/01/12 The limits are 3 tablets per day for 100 mg tablets and 6 tablets per day for 200 mg tablets.
RETIN-A® 04/01/01 Prior authorization for medical necessity may be required.
RETROVIR 07/01/12 The limits are 6 capsules, 2 tablets, or 64 mL per day.
REVLIMID® 01/01/13 Prior authorization for medical necessity is required. The limits are 1 capsule per day, except for 15 mg and 25 mg strengths which have a limit of 21 capsules per 28 days.
REYATAZ 07/01/12 The limits are 1 capsule per day, except 200 mg which has a limit of 2 capsules per day.
RHINOCORT AQ® 09/25/02 The limits are 2 boxes  18 g per 30 days.
RIOMET® 04/01/11 The limits are 25mL per day.
RITALIN LA® 07/01/05 The limits are 2 capsules per day.

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