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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
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.
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.
ALSUMA" 04/01/11 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.
AMARYL 04/01/12 The limits are 30 tablets per 30 days, except 4mg tablets which have a limit of 60 tablets per 30 days.
AMBIEN CR® 10/01/05 The limits are 1 tablet per day.
AMBIEN® 02/25/02 The limits are 1 tablet per day.
AMERGE® 11/01/05 The limits are 18 tablets per 30 days.
AMITIZA® 09/01/06 Prior authorization for medical necessity is required.
AMPYRA" 06/01/10 Prior authorization for medical necessity is required. The limits are 2 tablets per day.
AMTURNIDE" 04/01/11 Amturnide may be subject to step therapy requirements. Patients must have trial and failure of both of the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).

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