**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 |
---|---|---|

ARCALYST | 12/18/08 | Prior authorization for medical necessity is required. Patients must be at least 12 years of age. The limits are four 220 mg vial per 28 days. |

ARCAPTA® | 01/01/12 | The limits are 30 capsules per 30 days. |

ARIXTRA® | 07/01/10 | The limits are 30 syringes per 90 days. |

ARNUITY ELLIPTA® | 04/01/15 | The limits are 30 blisters per month. |

ASMANEX HFA® | 04/01/15 | The limits are 1 inhaler per month. |

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. |

ATACAND HCT® | 01/01/11 | Atacand HCT may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB. |

ATACAND® | 01/01/11 | Atacand may be subject to step therapy requirements. Patients must have trial and failure a generic ACE inhibitor or generic ARB. |

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. |