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 12 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. |
RITALIN LA®
| 07/01/05 |
The limits are 2 capsules per day. |
ROXICET™
| 09/01/04 |
The limits are 12 tablets per day for 5/325mg tablets, 8 tablets per day for 5/500mg tablets, and 60mL per day for 5/325mg per 5mL oral solution. |