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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
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.
AVALIDE® 01/01/11 Avalide may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB.
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 a generic ACE inhibitor or generic ARB.
AVASTIN® 01/01/15 Predetermination for medical necessity is available
AVEED™ 01/01/15 Predetermination for medical necessity is available
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 AND generic immediate release minocycline.
AVINZA® 05/15/09 The limits are 1 capsule per day.
AVITA® 04/01/01 Prior authorization for medical necessity may be required.

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