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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
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 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 one of the five preferred products: Betaseron, Copaxone, Plegridy, Rebif, or Tecfidera. The limits are 1 tablet per day.

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