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Product Name Implementation Date Guideline
AVALIDE® 01/01/11 Avalide 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).
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 the following: 1) generic ACE inhibitor or generic ARB, AND 2) preferred brand ARB (Diovan, Exforge/HCT, Micardis/HCT).
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.
AVONEX® 01/01/12 Avonex 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 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.
BELSOMRA® 04/01/15 The limits are 1 tablet per day.
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).

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