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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
APLENZIN® 08/06/08 The limits are 1 tablet per day.
APTENSIO XR® 07/01/15 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 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.
ARZERRA® 01/01/15 Predetermination for medical necessity is available
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.

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