**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. |