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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
ANADROL®-50 07/20/09 Prior authorization for medical necessity is required.
ANDRODERM® 07/20/09 The limits are 1 patch per day.
ANDROGEL® 06/15/04 The limits are two cartons (60 packets) of 2.5 gram or 5 gram unit-dose packets per 30 days. The Androgel Pump has a limit of 4 pumps (300 grams) per 30 days. Androgel 1.62% has a limit of 2 bottles (150 grams), 30 1.25 gm packets, or 60 2.5 gm packets per 30 days.
ANDROID® 04/01/12 Prior authorization for medical necessity is required.
ANDROXY® 04/01/12 Prior authorization for medical necessity is required.
ANORO ELLIPTA 04/01/14 The limits are 60 doses per 30 days.
ANZEMET® 02/01/05 The limits are 7 tablet per 30 days.
APLENZIN® 08/06/08 The limits are 1 tablet per day.
APTIVUS 07/01/12 The limits are 4 capsules or 13 mL per day.
ARCALYST 12/18/08 Prior authorization for medical necessity is required. Patients must be at least 12 years of age. The limits are one 220 mg vial per week.
ARCAPTA® 01/01/12 The limits are 30 capsules per 30 days.
ARIXTRA® 07/01/10 The limits are 30 syringes per 90 days.
ASMANEX® 01/26/06 The limits for Asmanex Twisthaler 110mcg are 30 inhalation units per 30 days and for Asmanex Twisthaler 220mcg are 120 inhalation units per 30 days.
ASTELIN 07/01/13 The limits are 60 mL per 30 days.
ASTEPRO 07/01/13 The limits are 60 mL per 30 days.

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