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Product Name Implementation Date Guideline
ATACAND HCT® 01/01/11 Atacand HCT 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).
ATACAND® 01/01/11 Atacand 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).
ATELVIA™ 04/01/11 The limits are 4 tablets per 30 days.
ATRALIN® 04/01/01 Prior authorization for medical necessity may be required.
ATRIPLA 07/01/12 The limits are 1 tablet per day.
ATROVENT HFA 04/01/12 The limits are 2 inhalers per 30 days.
ATROVENT NASAL INHALER 07/01/13 The limits are 60 mL per 30 days for 21 mcg/spray and 45 mL per 30 days for 42 mcg/spray.
AUBAGIO® 01/01/13 Aubagio may be subject to step therapy. Patients must have trial and failure of two of the four preferred products: Betaseron, Copaxone, Rebif, or Tecfidera. The limits are 1 tablet per day.
AVALIDE® 01/01/11 Avalide 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).
AVANDAMET® 08/06/08 The limits are 2 tablets per day.
AVANDARYL® 07/01/10 The limits are 1 tablet per day.
AVANDIA® 07/01/10 Avandia 2mg and 4mg has a limit of 2 tablets per day. Avandia 8mg has a limit of 1 tablet per day.
AVAPRO® 01/01/11 Avapro 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).
AVIDOXY™ DK 04/01/13 Avidoxy DK may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline.
AVINZA® 05/15/09 The limits are 1 capsule per day.

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