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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
AVITA® 04/01/01 Prior authorization for medical necessity may be required.
AVONEX® 01/01/12 Avonex 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 one 30mg vial, syringe, or pen per week.
AXERT® 11/01/05 The limits are 12 tablets per 30 days.
AXIRON® 07/01/11 The limits are 180mL (2 bottles) per 30 days.
AZOR® 01/01/11 Azor 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).
BECONASE AQ® 11/13/01 The limits are 2 bottles per 30 days.
BENICAR HCT® 01/01/11 Benicar 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).
BENICAR® 01/01/11 Benicar 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).
BETASERON® 10/01/12 The limits are 14 vial/syringe units per 28 days and 1 kit (14 prefilled syringes) per 28 days.
BETHKIS® 01/01/14 Prior authorization for medical necessity may be required. Must not be used concurrently with inhaled tobramycin or Cayston.
BINOSTO" 01/01/13 The limits are 4 tablets per 28 days.
BIO-T-GEL® 10/01/12 The limits are 2 packets per day.
BONIVA® 06/01/05 The limits are 1 tablet per 30 days for Boniva 150mg.
BOSULIF® 11/15/12 Prior authorization for medical necessity is required. The limits are 1 tablet per day.
BREO ELLIPTA® 01/01/14 The limits are 2 blisters per day.

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