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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
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 for the 4 unit pack and 1,890 cartridges for the 4 unit and 8 unit mix cartridges pack.
AKYNZEO® 01/01/15 The limits are 2 capsules per 30 days.
ALENDRONATE 07/01/13 The limits are 1 tablet per day for 40mg tablets and 300mls per 28 days for the oral solution.
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.
ALSUMA® 04/01/11 Alsuma may be subject to step therapy. Patients must have trial and failure of generic triptan (naratriptan, sumatriptan,rizatriptan). The limits are 12 doses per 30 days.
ALTOPREV® 01/01/11 Altoprev may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
ALVESCO® 08/06/08 The limits are 1 box per 30 days for 80mcg strength and 2 boxes per 30 days for 160mcg strength.
AMBIEN CR® 10/01/05 The limits are 1 tablet per day.
AMBIEN® 02/25/02 The limits are 1 tablet per day.

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