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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
ADDERALL XR® 11/13/02 The limits are 2 tablets per day.
ADDYI 01/01/16 Prior authorization for medical necessity is required. The limits are 1 tablet per day.
ADEMPAS® 04/01/15 Prior authorization for medical necessity is required.
ADOXA® 04/01/13 Adoxa may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline.
ADVAIR® 08/06/08 Advair Diskus has a limit of 2 blisters per day. Advair HFA has a limit of 1 inhaler per 30 days.
ADVICOR® 01/01/11 Advicor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
AEROSPAN® 04/01/14 The limits are 2 canisters per month.
AFINITOR® 07/20/09 Prior authorization for medical necessity is required. The limits are 1 tablet per day.
AFINITOR® DISPERZ 07/01/13 Prior authorization for medical necessity is required. The limits are 2 tablets per day, except the 3 mg tablets which have a limit of 3 tablets per day.
AFREZZA® 01/22/15 Prior authorization for medical necessity is required. The limits are 2,520 cartridges per 30 days for the 4 unit pack, 1,530 cartridges per 30 days for the 30 x 4 unit mix pack, and 1,890 cartridges per 30 days for the 60 x 4 unit mix pack.
AKYNZEO® 01/01/15 The limits are 2 capsules per 30 days.
ALECENSA® 04/01/16 Prior authorization for medical necessity is required. The quantity limits are 8 capsules per day.
ALENDRONATE 07/01/13 The limits are 1 tablet per day for 40mg tablets and 300mls per 28 days for the oral solution.
ALIMTA® 05/01/16 Prior authorization for medical necessity is required.
ALODOX® 04/01/13 Alodox may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline.

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