Go directly to: Content

NOTICE: You are using a browser without adequate or enabled CSS (style sheet) support. This site will appear plain but remain fully useable. To see this site as it is intended, you need to upgrade to a standards-compliant browser, such as the latest version of Internet Explorer or Netscape.

Drug Coverage Guidelines

The purpose of Blue Cross and Blue Shield of Alabama's pharmacy policy is to provide a guide to coverage. Pharmacy policy is not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

Product Name Implementation Date Change Date Guideline
ABSTRAL® 04/01/11   Prior authorization for medical necessity is required. The limits are 4 tablets per day.
ACCOLATE® 02/01/05   The limits are 2 tablets per day.
ACCUPRIL® 01/01/11   Accupril may be subject to step therapy requirements.
ACCURETIC® 01/01/11   Accuretic may be subject to step therapy requirements.
ACEON® 01/01/11   Aceon may be subject to step therapy requirements.
ACETAMINOPHEN WITH CODEINE 03/23/04   The limits are 13 tablets per day for acetaminophen with codeine 300mg/15mg, 12 tablets per day for acetaminophen with codeine 300mg/30mg, and 6 tablets per day for acetaminophen with codeine 300mg/60mg.
ACIPHEX® 02/18/02 08/06/08 Aciphex may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole or omeprazole. The limits are 1 tablet per day.
ACTIQ® 06/23/03   Prior authorization for medical necessity is required. The limits are 4 lozenges per day. Patients must be at least 16 years of age.
ACTONEL® 01/01/00 05/23/08 The limits are 1 tablet per day for Actonel 5mg and 30mg, 1 tablet per week for Actonel 35mg, 2 tablets per 30 days for Actonel 75mg, and 1 tablet per 30 days for Actonel 150mg.
ACTOPLUS MET XR® 01/01/11   The limits are 2 tablets per day for Actoplus Met XR 15/1000mg and 1 tablet per day for Actoplus Met XT 30/1000mg.
ACTOPLUS MET® 08/06/08   The limits are 3 tablets per day.
ACTOS® 07/01/10   The limits are 1 tablet per day, except Actos 15mg which has a limit of 3 tablets per day.
ADAPALENE 04/01/01   Prior authorization for medical necessity may be required.
ADDERALL XR® 11/13/02 04/01/11 The limits are 2 tablets per day.
ADVAIR® 08/06/08   Advair Diskus has a limit of 2 blisters per day. Advair HFA has a limit of 1 inhaler per 30 days.
ADVICOR® 01/01/11   Advicor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
AEROBID® 08/06/08 04/01/11 The limits are 3 boxes per 30 days.
AFINITOR® 07/20/09 07/01/11 Prior authorization for medical necessity is required. The limits are 1 tablet per day.
ALLEGRA D® 12/03/01   The limits are 2 tablets per day for Allegra D 12HR and 1 tablet per day for Allegra D 24HR.
ALLEGRA® 02/25/02 11/12/08 The limits are 2 tablets per day, except for the 180 mg tablet, which has a limit of 1 tablet per day. Allegra oral suspension has a limit of 10mL per day.
ALSUMA" 04/01/11 07/01/11 The limits are 12 doses per 30 days.
ALTACE® 01/01/11   Altace may be subject to step therapy requirements.
ALTOPREV® 01/01/11   Altoprev may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
ALVESCO® 08/06/08 04/01/11 The limits are 1 box per 30 days for 80mcg strength and 2 boxes per 30 days for 160mcg strength.
AMBIEN CR® 10/01/05 07/01/11 The limits are 1 tablet per day.
AMBIEN® 02/25/02 07/01/11 The limits are 1 tablet per day.
AMERGE® 11/01/05 07/01/11 The limits are 18 tablets per 30 days.
AMITIZA® 09/01/06 10/01/11 Prior authorization for medical necessity is required.
AMPYRA" 06/01/10   Prior authorization for medical necessity is required. The limits are 2 tablets per day.
AMRIX® 08/06/08   Prior authorization for medical necessity is required. The limits are 1 capsule per day.
AMTURNIDE" 04/01/11   Amturnide 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/HCT, Exforge/HCT, Micardis/HCT).
ANADROL®-50 07/20/09   Prior authorization for medical necessity is required.
ANDRODERM® 07/20/09   The limits are 3 patches per day for Androderm 2.5mg and 1 patch per day for Androderm 5mg. Not covered for females or patients less than 15 years of age.
ANDROGEL® 06/15/04 01/01/12 The limits are one carton (75 grams) of 2.5 gram unit-dose packets and up to two cartons (300 grams) of 5 gram unit-dose packets per 30 days. The Androgel Pump has a limit of 4 pumps (300 grams) per 30 days. Androgel 1.62% has a limit of 2 bottles (150 gr
ANZEMET® 02/01/05 02/13/08 The limits are 1 tablet per day.
APLENZIN® 08/06/08   The limits are 1 tablet per day.
ARCALYST 12/18/08 07/01/11 Prior authorization for medical necessity is required. Patients must be at least 12 years of age.
ARCAPTA® 01/01/12   The limits are 30 capsules per 30 days.
ARIXTRA® 07/01/10   The limits are 1 syringe per day.
ASMANEX® 01/26/06 04/22/08 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.
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/HCT, 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/HCT, 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.
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/HCT, Exforge/HCT, Micardis/HCT).
AVANDAMET® 08/06/08   The limits are 2 tablets per day, except Avandamet 2/500mg which has a limit of 4 tablets per day.
AVANDARYL® 07/01/10   The limits are 1 tablet per day, except Avandaryl 4-1mg and 4-2mg which have a limit of 2 tablets per day.
AVANDIA® 07/01/10   Avandia 2mg has a limit of 4 tablets per day. Avandia 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/HCT, Exforge/HCT, Micardis/HCT).
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 preferred products: Betaseron, Copaxone, or Rebif.
AXERT® 11/01/05 07/01/11 The limits are 12 tablets per 30 days.
AXIRON® 07/01/11   The limits are 180mL (2 bottles) per 30 days. Not covered for females or patients less than 18 years of age.
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/HCT, 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/HCT, 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/HCT, Exforge/HCT, Micardis/HCT).
BONIVA® 06/01/05 02/13/08 The limits are 1 tablet per day for Boniva 2.5mg and 1 tablet per 30 days for Boniva 150mg.
BUTRANS" 04/01/11   The limits are 4 transdermal systems per 30 days.
BYETTA® 07/01/05 04/01/11 Byetta may be subject to step therapy requirements. Patients have trial and failure of one or more prerequisite oral antidiabetic agents from the following classes: metformin, sulfonylureas, or combinations of metformin or sulfonylureas. The limits are 1
CADUET® 01/01/00   Only 1 statin covered per month.
CAPITAL® AND CODEINE 04/01/11   The limits are 2700mL per 30 days.
CAPOTEN® 01/01/11   Capoten may be subject to step therapy requirements.
CAPOZIDE® 01/01/11   Capozide may be subject to step therapy requirements.
CAPRELSA® 01/01/12   Prior authorization for medical necessity is required. The limits are 2 tablets per day for the 100mg tablets and 1 tablet per day for the 300mg tablets.
CAVERJECT® 07/01/10   Prior authorization for medical necessity may be required. Patients must be at least 18 years of age.
CELEBREX® 01/01/00 07/01/11 The limits are 2 capsules per day, except Celebrex 400mg which has a limit of 1 capsule per day.
CHANTIX® 08/01/06 01/01/07 The limits are 2 tablets per day and up to a 180-day supply per calendar year. Not covered for patients less than 18 years of age.
CIALIS® 01/01/04 02/08/10 Prior authorization for medical necessity may be required. The limits for Cialis 10mg and 20mg tablets are 8 tablets per 30 days. The limits for Cialis 2.5mg and 5mg tablets are 30 tablets per 30 days. Patients must be at least 18 years of age.
CIMZIA® 06/23/09 07/01/11 Cimzia may be subject to step therapy requirements. Patients must have trial and failure of a first-line DMARD AND Humira. The limits are 6 doses per 30 days for the first month then 2 doses per month thereafter.
CLARINEX D® 04/18/06   The limits are 2 tablets per day for Clarinex D 12 HR and 1 tablet per day for Clarinex D 24 HR.
CLARINEX® 01/16/02   The limits are 1 tablet or 10mL of syrup per day.
COCET PLUS® 01/01/11   The limits are 6 tablets per day.
COMBUNOX® 05/01/05   The limits are 28 tablets per 30 days.
COMPOUNDS 01/01/00   Prior authorization for medical necessity may be required.
CONCERTA® 11/01/02 04/01/11 The limits are 2 tablets per day.
CONZIP® 01/01/12   The limits are 30 capsules per 30 days.
COZAAR® 01/01/11   Cozaar 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/HCT, Exforge/HCT, Micardis/HCT).
CRESTOR® 01/01/11   Crestor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
CYMBALTA® 09/01/04   The limits are 2 capsules per day, except Cymbalta 60mg with a limit of 1 capsule per day.
DAYTRANA® 06/12/06 04/01/11 The limits are 1 patch per day.
DEMEROL® 05/15/09   The limits are 4 tablets or 60mL per day.
DEXILANT" 07/01/10   Dexilant may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole or omeprazole. The limits are 1 tablet per day.
DIFFERIN® 04/01/01   Prior authorization for medical necessity may be required.
DILAUDID® 05/15/09   The limits are 4 tablets or 40mL per day.
DIOVAN HCT® 01/01/11   Diovan HCT may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB.
DIOVAN® 01/01/11   Diovan may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB.
DOLOPHINE® 05/15/09   The limits are 6 tablets per day.
DORYX® 11/14/07 11/12/08 Doryx may be subject to step therapy requirements. Patients must have trial and failure of generic doxycycline. The limits are 2 tablets per day, except for Doryx 150mg which has a limit of 1 tablet per day. Patients must be at least 8 years of age, unles
DUETACT® 07/01/10   The limits are 1 tablet per day.
DULERA® 01/01/11   The limits are 1 inhaler per 30 days.
DURAGESIC® 09/01/04 04/01/11 The limits are 15 patches per 30 days.
EDARBI" 04/01/11   Edarbi 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/HCT, Exforge/HCT, Micardis/HCT).
EDEX® 07/01/10   Prior authorization for medical necessity may be required. Patients must be at least 18 years of age.
EDLUAR" 07/06/09   Prior authorization for medical necessity is required. The limits are 1 tablet per day. Patients must be at least 18 years of age.
EFFEXOR XR® 07/01/05 02/13/08 The limits are 1 capsule per day, except Effexor XR 75mg which has a limit of 3 capsules per day.
EMBEDA" 09/09/09   The limits are 2 capsules per day.
EMEND® 11/12/08   The limits are 1 capsule per 30 days for Emend 40mg, 8 capsules per 30 days for Emend 80mg, 4 capsules per 30 days for Emend 125mg, and 4 packs (12 capsules) per 30 days for Emend 125mg/80mg packs.
ENBREL® 05/17/99 07/01/11 Enbrel may be subject to step therapy requirements. Patients must have trial and failure of a first-line DMARD AND Humira. The limits are 8 doses of Enbrel 25mg or 4 doses of Enbrel 50mg per 30 days.
ENDOCET® 01/01/00   The limits for are 12 tablets per day for Endocet 5-325mg , 8 tablets per day for 7.5-325mg and 7.5-500mg, and 6 tablets per day for 10-325mg and 10-650mg.
EPIDUO® 01/01/11   Prior authorization for medical necessity may be required.
ETH-OXYDOSE" 06/18/07   The limits are 9mL per day.
EXALGO® 04/14/10   The limits are 1 tablet per day.
EXFORGE HCT® 01/01/11   Exforge HCT may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB.
EXFORGE® 01/01/11   Exforge may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB.
EXTAVIA® 01/01/12   Extavia may be subject to step therapy. Patients must have trial and failure of one of the preferred products: Betaseron, Copaxone, or Rebif.
FENTANYL CITRATE LOLLIPOP 06/23/03   Prior authorization for medical necessity is required. The limits are 4 lozenges per day. Patients must be at least 16 years of age.
FENTORA® 09/01/06   Prior authorization for medical necessity is required. The limits are 4 tablets per day. Patients must be at least 18 years of age.
FEXMID® 08/06/08   Prior authorization for medical necessity is required. The limits are 3 tablets per day.
FLECTOR® PATCH 08/06/08   Prior authorization for medical necessity is required. The limits are 2 patches per day. Patients must be at least 18 years of age.
FLONASE® 04/01/04   The limits are 1 box per 30 days.
FLOVENT DISKUS® 04/01/05 04/01/11 The limits are 2 blisters per day for Flovent 50mcg and 100mcg. The limits are 8 blisters per day for Flovent 250mcg.
FLOVENT HFA® 04/01/05 04/22/08 The limits are 2 boxes per 30 days.
FLUNISOLIDE NASAL SPRAY 01/01/12   The limits are 3 bottles (75mL) per 30 days.
FOCALIN® XR 07/01/05 01/01/12 The limits are 2 capsules per day except for Focalin XR 25mg, 30mg, 35mg, and 40mg which have a limit of 1 capsule per day.
FORADIL® AEROLIZER® 08/06/08   The limits are 2 blisters per day.
FORTAMET® 05/15/09   The limits are 5 tablets per day for Fortamet 500mg and 2 tablets per day for Fortamet 1000mg.
FORTEO® 08/06/08 07/01/11 Prior authorization for medical necessity is required.
FORTESTA 07/01/11   The limits are 120 grams (2 bottles) per 30 days. Not covered for females or patients less than 18 years of age.
FOSAMAX PLUS D® 04/25/05   The limits are 4 tablets per 30 days.
FOSAMAX® 01/01/00 11/17/08 The limits are 1 tablet per day for Fosamax 5mg, 10mg, and 40mg tablets. The limits are 4 tablets per 30 days for Fosamax 35 mg and 70 mg tablets. Fosamax solution has a limit of 4 bottles (300mL) per 30 days.
FRAGMIN® 07/01/10   The limits are 1 syringe per day or 10 vials per 30 days.
FROVA® 11/01/05 07/01/11 The limits are 18 tablets per 30 days.
GAMUNEX-C® 01/01/12   Prior authorization for medical necessity is required.
GENOTROPIN® 10/01/11   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
GILENYA" 01/01/11 04/01/11 Prior authorization for medical necessity is required. The limits are 1 capsule per day.
GLEEVEC® 05/01/01 07/01/11 Prior authorization for medical necessity is required. The limits are 3 tablets per day for 100mg or 2 tablets per day for 400mg.
GLUCOPHAGE XR® 03/01/04   The limits are 4 tablets per day for Glucophage XR 500mg and 2 tablets per day for Glucophage XR 750mg.
GLUCOPHAGE® 03/01/04   The limits are 5 tablets per day for Glucophage 500mg, 3 tablets per day for Glucophage 850mg, and 2 tablets per day for Glucophage 1000mg.
GLUCOVANCE® 08/06/08   The limits are 4 tablets per day, except Glucovance 1.25/250mg which has a limit of 3 tablets per day.
GLUMETZA® 05/15/09   The limits are 4 tablets per day for Glumetza 500mg and 2 tablets per day for Glumetza 1000mg.
GRALISE® 01/01/12   The limits are 30 capsules per 30 days for 300mg tablets, 90 tablets per 30 days for 600mg tablets, and 1 starter pack per 30 days.
HEXALEN® 01/01/12   Prior authorization for medical necessity is required.
HIZENTRA" 04/14/10   Prior authorization for medical necessity is required.
HORIZANT® 01/01/12   The limits are 30 tablets per 30 days.
HUMATROPE® 10/01/11   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
HUMIRA® 01/17/03 07/01/10 Humira may be subject to step therapy requirements. Patients must have trial and failure of a first-line DMARD. The limits are 2 doses per 30 days, except for Crohn's disease with the limit of 6 doses per 30 days for the first month and plaque psoriasis
HYCAMTIN® 01/01/12   Prior authorization for medical necessity is required.
HYCET" 05/15/09   The limits are 120mL per day.
HYZAAR® 01/01/11   Hyzaar 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/HCT, Exforge/HCT, Micardis/HCT).
IBUDONE" 05/15/09   The limits are 5 tablets per day.
ILARIS® 08/10/09 07/01/11 Prior authorization for medical necessity is required. Patients must be at least 4 years of age.
IMITREX® 11/01/05 07/01/11 The limits are 18 tablets, 12 nasal spray units, 10 vials, or 6 kits per 30 days.
INCIVEK" 10/01/11   Prior authorization for medical necessity is required.
INCRELEX® 01/01/06   Prior authorization for medical necessity is required.
INNOHEP® 07/01/10   The limits are 1 vial per day.
IPRIVASK® 01/01/11   The limits are 20 vials per 30 days.
JANUMET® 05/01/07   The limits are 2 tablets per day.
JANUVIA® 11/01/06   The limits are 1 tablet per day.
KADIAN® 05/15/09   The limits are 2 capsules per day.
KINERET® 07/17/02 07/01/11 Kineret may be subject to step therapy requirements. Patients must have trial and failure of a first-line DMARD AND Humira.The limits are 1 syringe per day.
KOMBIGLYZE" XR 04/01/11   The limits are 1 tablet per day, except Kombiglyze XR 2.5-1000mg which has a limit of 2 tablets per day.
KYTRIL® 12/03/01   The limits are 2 tablets per day.
LANSOPRAZOLE 01/01/00   The limits are 1 capsule or solutab per day.
LAZANDA® 01/01/12   Prior authorization for medical necessity is required. The limits are 1 bottle per day. Patients must be at least 18 years of age.
LESCOL XL® 01/01/11   Lescol XL may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
LESCOL® 01/01/11   Lescol may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
LEVITRA® 09/01/03   Prior authorization for medical necessity may be required. The limits are 8 tablets per 30 days. Patients must be at least 18 years of age.
LEXXEL® 01/01/11   Lexxel may be subject to step therapy requirements.
LIPITOR® 01/01/11   Lipitor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
LIVALO® 01/01/11   Livalo may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
LORCET® 09/01/03   The limits are 8 tablets for the Lorcet - HD tablets and 6 tablets for the Lorcet Plus and Lorcet 10/650 tablets per day. Patients should not take more than a total of 4 grams of acetaminophen per day (3 grams per day if you have liver disease).
LORTAB® 09/01/03   The limits are 8 tablets for the 2.5 mg and 5 mg hydrocodone tablets and 6 tablets for the 7.5 mg and 10 mg tablets per day. The limits for Lortab elixir are 90mL per day. Patients should not take more than a total of 4 grams of acetaminophen per day (3
LOVENOX® 02/01/05   The limits are 2 syringes per day.
LUMIGAN® 06/04/02   The limits are 1-2.5mL box per 30 days or 1-5mL box per 60 days.
LUNESTA® 01/01/05 07/01/11 The limits are 1 tablet per day.
LYRICA® 10/01/05 08/06/08 The limits are 3 capsules per day, except for Lyrica 225mg and 300mg which have a limit of 2 capsules per day. Not covered for patients less than 18 years of age.
LYSODREN® 01/01/12   Prior authorization for medical necessity is required.
MAGNACET" 09/01/04   The limits are 10 tablets per day for Magnacet 2.5/400mg and 5/400mg. The limits are 8 tablets per day for Magnacet 7.5/400mg and 6 tablets per day for Magnacet 10/400mg.
MARGESIC® 09/01/03   The limits are 8 capsules per day.
MATULANE® 01/01/12   Prior authorization for medical necessity is required.
MAVIK® 01/01/11   Mavik may be subject to step therapy requirements.
MAXALT® 11/01/05 07/01/11 The limits are 24 tablets per 30 days.
MAXIDONE" 09/01/03   The limits are 5 tablets per day.
MEPERITAB® 05/15/09   The limits are 4 tablets per day.
METADATE CD® 01/01/05 04/01/11 The limits are 2 capsules per day, except Metadate CD 60mg which has a limit of 1 capsule per day.
METAGLIP" 08/06/08   The limits are 4 tablets per day, except Metaglip 2.5/250mg which has a limit of 3 tablets per day.
METHADONE 05/15/09   The limits are 6 tablets per day for methadone tablets, 30mL per day for methadone oral solution, and 6mL per day for methadone Intensol" oral concentrate.
MEVACOR® 01/01/11   Mevacor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
MICARDIS HCT® 01/01/11   Micardis HCT may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB.
MICARDIS® 01/01/11   Micardis may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB.
MONOPRIL HCT® 01/01/11   Monopril HCT may be subject to step therapy requirements.
MONOPRIL® 01/01/11   Monopril may be subject to step therapy requirements.
MORPHINE IR 05/15/09   The limits are 6 tablets per day for morphine IR tablets, 30mL per day for morphine IR oral solution, and 10mL per day for morphine oral concentrate.
MS CONTIN® 05/15/09   The limits are 3 tablets per day.
MUSE® 07/01/10   Prior authorization for medical necessity may be required. Patients must be at least 18 years of age.
NANDROLONE 07/20/09   Prior authorization for medical necessity is required.
NASACORT AQ® 04/01/04   The limits are 1 box per 30 days.
NASAREL® 08/06/08 04/01/11 The limits are 3 boxes per 30 days.
NASONEX® 02/22/05   The limits are 1 box  17 g per 30 days.
NEXAVAR® 01/01/06   Prior authorization for medical necessity is required. The limits are 4 tablets per day.
NEXIUM® 01/01/00 07/01/10 Nexium may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole or omeprazole. The limits are 1 tablet per day.
NORCO® 09/01/03   The limits are 12 for the 5 mg tablets and 6 for the 7.5 and 10 mg tablets per day. Patients should not take more than a total of 4 grams of acetaminophen per day (3 grams per day if you have liver disease).
NORDITROPIN® 10/01/11   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
NUCYNTA" 07/06/09   The limits are 12 tablets per day for Nucynta 50mg, 8 tablets per day for Nucynta 75mg, and 6 tablets per day for Nucynta 100mg. Patients must be at least 18 years of age.
NUCYNTA" ER 01/01/12   The limits are 60 tablets per 30 days.
NUTROPIN AQ® 10/01/11   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
NUTROPIN® 10/01/11   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
NUVIGIL® 05/06/09   Prior authorization for medical necessity is required. The limits are 1 tablet per day. Patients must be at least 17 years of age.
OFORTA" 12/22/09   Prior authorization for medical necessity is required.
OMEPRAZOLE 01/01/00   The limits are 1 capsule per day.
OMEPRAZOLE-SODIUM BICARBONATE 07/01/10   Omeprazole-sodium bicarbonate may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole or omeprazole. The limits are 1 tablet per day.
OMNARIS" 08/06/08   The limits are 1 box per 30 days.
OMNITROPE® 10/01/11   Prior authorization for medical necessity is required.
ONGLYZA" 08/27/09   The limits are 1 tablet per day.
ONSOLIS" 09/18/09   Prior authorization for medical necessity is required. The limits are 4 tablets per day. Patients must be at least 18 years of age.
OPANA ER® 02/15/07   The limits are 2 tablets per day.
OPANA® 02/15/07 02/13/08 The limits are 12 tablets per day.
ORAMORPH® SR 05/15/09   The limits are 3 tablets per day.
ORENCIA® 12/10/11   Orencia subcutaneous injection may be subject to step therapy requirements. Patients must have trial and failure of a first-line DMARD AND Humira. The limits are 4 syringes per month.
OXANDRIN® 07/20/09   Prior authorization for medical necessity is required.
OXYCONTIN® 01/01/00 05/17/11 The limits are 3 tablets per day, except Oxycontin 80mg which has a limit of 4 tablets per day.
OXYFAST® 06/18/07   The limits are 9mL per day.
OXYIR® 06/18/07   The limits are 12 capsules per day.
PANLOR® DC 06/15/04   The limits are 10 capsules per day.
PANLOR® SS 06/15/04   The limits are 5 capsules per day.
PANTOPRAZOLE 07/01/10 04/01/11 The limits are 1 tablet per day.
PATANASE® 08/06/08   The limits are 1 box per 30 days.
PEGASYS® 06/01/06 01/01/11 Prior authorization for medical necessity is required.
PEG-INTRON® 06/01/06 01/01/11 Prior authorization for medical necessity is required. Use of the preferred peginterferon, Pegasys, may be required.
PERCOCET® 09/01/04   The limits are 12 tablets for the 2.5 mg and 5 mg oxycodone tablets, 8 tablets for the 7.5 mg tablets, and 6 tablets for the 10 mg tablets per day.
PERCODAN® 03/29/04   The limits are 12 tablets per day.
PRADAXA® 04/01/11   The limits are 2 capsules per day.
PRANDIMET" 08/06/08   The limits are 5 tablets per day.
PRAVACHOL® 01/01/11   Pravachol may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
PREVACID® 01/01/00 07/01/10 Prevacid may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole or omeprazole. The limits are 1 capsule, solutab, or packet per day.
PRILOSEC® 01/01/00 07/01/10 Prilosec may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole or omeprazole. The limits are 1 capsule or packet per day, except Prilosec 2.5mg packets for oral suspension which have a limit of 2 packet
PRIMALEV" 05/15/09   The limits are 12 tablets per day for Primalev 2.5/300mg and 5/300mg. The limits are 8 tablets per day for Primalev 7.5/300mg and 6 tablets per day for 10/300mg tablets.
PRINIVIL® 01/01/11   Prinivil may be subject to step therapy requirements.
PRINZIDE® 01/01/11   Prinzide may be subject to step therapy requirements.
PRISTIQ® 05/01/08   The limits are 1 tablet per day. Not covered for patients less than 18 years of age.
PROMACTA® 05/15/09 10/01/11 Prior authorization for medical necessity is required. The limits are 1 tablet per day, except Promacta 25mg which has a limit of 3 tablets per day.
PROTONIX® 01/01/00 07/01/10 Protonix may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole or omeprazole. The limits are 1 tablet or packet per day.
PROVIGIL® 09/01/03 07/01/11 Prior authorization for medical necessity is required. The limits are 1 tablet per day. Patients must be at least 17 years of age.
PULMICORT® 02/01/05 02/13/08 The limits are 2 boxes per 30 days for Pulmicort Flexhaler. The limits are 2 respules per day, except for 1mg respules which have a limit of 1 respule per day.
QUALAQUIN® 05/01/07 01/01/12 The limits are 42 capsules per 90 days, which allows for a single 7-day course of therapy.
QVAR® 08/06/08 04/01/11 The limits are 1 boxes per 30 days for 40mcg strength and 3 boxes per 30 days for 80mcg strength.
RELENZA® 12/03/01   The limits are 20 blisters (1 carton) per 30 days.
RELISTOR" 08/06/08 10/01/11 Prior authorization for medical necessity is required.
RELPAX® 11/01/05 07/01/11 The limits are 12 tablets per 30 days.
RENOVA® 04/01/01   Prior authorization for medical necessity may be required.
REPREXAIN® 05/15/09   The limits are 5 tablets per day for a maximum 14-day supply.
RETIN-A® 04/01/01   Prior authorization for medical necessity may be required.
RHINOCORT AQ® 09/25/02 02/13/08 The limits are 2 boxes  18 g per 30 days.
RIOMET® 04/01/11   The limits are 25mL per day.
RITALIN LA® 07/01/05 04/01/11 The limits are 2 capsules per day.
ROXANOL" 05/15/09   The limits are 10mL per day.
ROXICET" 09/01/04 05/15/09 The limits are 12 tablets per day for 5/325mg tablets, 8 caplets per day for 5/500mg caplets, and 60mL per day for 5/325mg per 5mL oral solution.
ROXICODONE® 06/18/07 03/09/09 The limits are 12 tablets/capsules per day for 5mg and 6 tablets per day for all other strengths.
ROZEREM® 09/01/05 07/01/11 The limits are 1 tablet per day.
RYBIX" ODT 04/01/11   The limits are 8 tablets per day.
RYZOLT" 08/10/09   The limits are 1 tablet per day. Patients must be at least 16 years of age.
SAIZEN® 10/01/11   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
SANCUSO® 11/12/08 01/01/12 Sancuso may be subject to step therapy requirements. Patients must have trial and failure of generic ondansetron or granisetron.
SEREVENT® DISKUS® 08/06/08   The limits are 2 blisters per day.
SEROSTIM® 10/01/11   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
SILENOR 07/01/11   The limits are 1 tablet per day.
SIMCOR® 01/01/11   Simcor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
SIMPONI" 05/06/09 07/01/11 Simponi may be subject to step therapy requirements. Patients must have trial and failure of a first-line DMARD AND Humira. The limits are 1 syringe per month.
SINGULAIR® 01/01/00   The limits are 1 tablet or packet per day.
SKELID® 12/03/01   The limits are 2 tablets per day.
SOLODYN® 05/01/06   Solodyn may be subject to step therapy requirements. Patients must have a trial and failure of generic minocycline. The limits are 1 tablet per day. Patients must be at least 12 years of age.
SOMA® 250MG 05/01/08   Prior authorization for medical necessity is required. The limits are 4 tablets per day.
SONATA® 01/01/05 07/01/11 The limits are 1 capsule per day.
SPIRIVA® 06/07/04   The limits are 1 capsule per day.
SPRIX" 04/01/11   The limits are 5 bottles per 30 days.
SPRYCEL® 07/01/06 07/01/11 Prior authorization for medical necessity is required. The limits are 1 tablets per day, except for Sprycel 20mg which has a limit of 2 tablets per day.
STADOL NS® 09/01/03 06/03/08 The limits are 4 boxes - 10 mL per 30 days. Not covered for patients less than 18 years of age.
STAGESIC" 09/01/03   The limits are 8 capsules per day.
STANOZOLOL 07/20/09   Prior authorization for medical necessity is required.
STAXYN" 01/01/11   Prior authorization for medical necessity may be required. The limits are 8 tablets per 30 days. Patients must be at least 18 years of age.
STRATTERA® 01/15/03 04/01/11 The limits are 2 capsules per day, except Strattera 80mg and 100mg which is 1 capsule per day.
SUBOXONE® 08/06/08 01/01/11 Prior authorization for medical necessity is required. The limits are 4 tablets or films per day. Patients must be at least 16 years of age.
SUBUTEX® 08/06/08   Prior authorization for medical necessity is required. The limits for Subutex 2mg are 4 tablets per day and 8 tablets per 30 days. The limits for Subutex 8mg are 2 tablets per day and 4 tablets per 30 days. Patients must be at least 16 years of age.
SUMAVEL" DOSEPRO" 11/09/09 07/01/11 The limits are 12 prefilled delivery systems per 30 days.
SUTENT® 02/10/06   Prior authorization for medical necessity may be required. The limits are 1 tablet per day.
SYMBICORT® 08/01/07   The limits are 1 box per 30 days.
SYNAGIS® 10/01/11   The limits are 6 doses per year.
TAMIFLU® 02/01/05 04/22/08 The limits are 20 capsules per 30 days for Tamiflu 30mg, 10 capsules per 30 days for Tamiflu 35mg and 75mg, and 75 mL per 30 days for Tamiflu 300mg/25mL oral suspension.
TARCEVA® 03/14/07 07/01/11 Prior authorization for medical necessity is required. The limits are 1 tablet per day, except 25mg tablets with a limit of 2 tablets per day.
TARGRETIN® 01/01/12   Prior authorization for medical necessity is required.
TARKA® 01/01/11   Tarka may be subject to step therapy requirements.
TASIGNA® 04/01/11   Prior authorization for medical necessity is required. The limits are 4 capsules per day.
TAZAROTENE 04/01/01   Prior authorization for medical necessity may be required.
TAZORAC® 04/01/01   Prior authorization for medical necessity may be required.
TEKAMLO® 01/01/11   Tekamlo 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/HCT, Exforge/HCT, Micardis/HCT).
TEKTURNA HCT® 01/01/11   Tekturna 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/HCT, Exforge/HCT, Micardis/HCT).
TEKTURNA® 01/01/11   Tekturna 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/HCT, Exforge/HCT, Micardis/HCT).
TEMODAR® 01/01/12   Prior authorization for medical necessity is required.
TESTIM® 06/15/04   The limits are 10 grams per day. Not covered for females or patients less than 18 years of age.
TEVETEN HCT® 01/01/11   Teveten 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/HCT, Exforge/HCT, Micardis/HCT).
TEVETEN® 01/01/11   Teveten 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/HCT, Exforge/HCT, Micardis/HCT).
TEV-TROPIN® 10/01/11   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
TRADJENTA® 01/01/12   The limits are 30 tablets per 30 days.
TRAVATAN® 06/04/02   The limits are 1-2.5mL box per 30 days or 1-5mL box per 60 days.
TRETINOIN 04/01/01   Prior authorization for medical necessity may be required.
TRETIN-X 04/01/01   Prior authorization for medical necessity may be required.
TREXIMET" 04/22/08 07/01/11 The limits are 18 tablets per 30 days.
TRIBENZOR® 01/01/11   Tribenzor 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/HCT, Exforge/HCT, Micardis/HCT).
TUSSICAPS® 05/15/09   The limits are 2 capsules per day and 20 capsules per month. Not covered for patients less than 12 years of age.
TUSSIONEX® PENNKINETIC® 08/06/08 05/15/09 The limits are 10mL per day and 120mL per 30 days. Not covered for patients less than 12 years of age.
TWYNSTA® 01/01/11   Twynsta 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/HCT, Exforge/HCT, Micardis/HCT).
TYKERB® 11/01/07   Prior authorization for medical necessity is required. The limits are 5 tablets per day.
TYLENOL® 09/01/03   If a combination drug contains Tylenol, the daily dose of the acetaminophen component should not exceed 4 grams. Excessive doses may cause liver toxicity.
TYLENOL® WITH CODEINE 03/23/04   The limits are 12 tablets per day for Tylenol with Codeine 300mg/30mg and 6 tablets per day for Tylenol with Codeine 300mg/60mg.
TYLOX® 04/01/04   The limits are 8 capsules per day.
TYVASO" 09/09/09   Prior authorization for medical necessity is required.
ULORIC® 07/20/09 07/01/11 Uloric may be subject to step therapy requirements. Patients must have a trial and failure of allopurinol 300mg.
ULTRACET® 04/01/07   The limits are 8 tablets per day. Not covered for patients less than 18 years of age.
ULTRAM ER® 02/15/06   The limits are 1 tablet per day. Not covered for patients less than 18 years of age.
ULTRAM® 09/04/02   The limits are 8 tablets per day. Not covered for patients less than 16 years of age.
UNIRETIC® 01/01/11   Uniretic may be subject to step therapy requirements.
UNIVASC® 01/01/11   Univasc may be subject to step therapy requirements.
VALTURNA® 01/01/11   Valturna 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/HCT, Exforge/HCT, Micardis/HCT).
VASERETIC® 01/01/11   Vaseretic may be subject to step therapy requirements.
VASOTEC® 01/01/11   Vasotec may be subject to step therapy requirements.
VELTIN® 01/01/11   Prior authorization for medical necessity may be required.
VENLAFAXINE EXTENDED-RELEASE 11/12/08   The limits are 1 tablet per day.
VENTAVIS® 02/01/07   Prior authorization for medical necessity is required.
VERAMYST® 07/01/07   The limits are 1 box per 30 days.
VIAGRA® 07/01/98 10/18/02 Prior authorization for medical necessity may be required. The limits are 8 tablets per 30 days. Patients must be at least 18 years of age.
VICODIN® 09/01/03   The limits are 8 Vicodin (5 mg hydrocodone) tablets, 6 Vicodin HP tablets, or 5 Vicodin ES tablets per day. Patients should not take more than a total of 4 grams of acetaminophen per day (3 grams per day if you have liver disease).
VICOPROFEN® 09/24/03 05/15/09 The limits are 5 tablets per day for a maximum 14-day supply.
VICTOZA® 02/15/10 04/01/11 Victoza may be subject to step therapy requirements. Patients have trial and failure of one or more prerequisite oral antidiabetic agents from the following classes: metformin, sulfonylureas, or combinations of metformin or sulfonylureas. The limits are 3
VICTRELIS" 10/01/11   Prior authorization for medical necessity is required.
VOTRIENT" 11/13/09   Prior authorization for medical necessity is required. The limits are 4 tablets per day.
VYTORIN® 01/01/11   Vytorin may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
VYVANSE® 07/01/07 04/01/11 The limits are 1 capsule per day.
WELLBUTRIN SR® 08/06/08   The limits are 2 tablets per day.
WELLBUTRIN XL" 07/15/04 02/13/08 The limits are 3 tablets per day for Wellbutrin XL 150mg and 1 tablet per day for Wellbutrin XL 300mg.
WELLBUTRIN® 08/06/08   The limits for Wellbutrin 75mg are 6 tablets per day. The limits for Wellbutrin 100mg are 4 tablets per day.
XALATAN® 06/04/02   The limits are 1-2.5mL box per 30 days or 1-7.5mL box per 90 days.
XALKORI® 01/01/12   Prior authorization for medical necessity is required. The limits are 60 capsules per 30 days.
XARELTO® 01/01/12   The limits are 35 tablets per 90 days for the 10mg tablets, which allows for a single course of therapy.
XELODA® 01/01/12   Prior authorization for medical necessity is required.
XODOL® 05/15/09   The limits are 12 tablets per day for Xodol 5/300mg and 6 tablets per day for Xodol 7.5/300mg and 10/300mg.
XOLOX" 04/01/11   The limits are 8 tablets per day.
XYREM® 07/01/07   Prior authorization for medical necessity is required. The limits are 9g (18 mL) per day. Patients must be at least 16 years of age.
XYZAL® 08/06/08   The limits are 1 tablet or 10mL per day.
ZAMICET" 05/15/09   The limits are 90mL per day.
ZANAFLEX CAPSULES" 11/12/08   Prior authorization for medical necessity may be required. The limits are 6 capsules per day.
ZEGERID® 08/01/06   Zegerid may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole or omeprazole. The limits are 1 capsule or packet per day.
ZELBORAF® 01/01/12   Prior authorization for medical necessity is required. The limits are 8 tablets per day.
ZESTORETIC® 01/01/11   Zestoretic may be subject to step therapy requirements.
ZESTRIL® 01/01/11   Zestril may be subject to step therapy requirements.
ZIANA® 07/01/07   Prior authorization for medical necessity may be required.
ZOCOR® 01/01/11   Zocor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
ZOFRAN® 02/01/05 02/13/08 The limits are 6 tablets per day for Zofran 4mg, 3 tablets per day for Zofran 8mg, and 1 tablet per day for Zofran 24mg.
ZOLINZA® 01/01/12   Prior authorization for medical necessity is required. The limits are 4 capsules per day.
ZOLPIMIST" 05/15/09   Prior authorization for medical necessity is required. The limits are 1 container per month. Patients must be at least 18 years of age.
ZOLVIT" 04/01/11   The limits are 67.5mL per day.
ZOMIG® 11/01/05 07/01/11 The limits are 12 tablets or 12 nasal spray units per 30 days.
ZORPTIVE® 10/01/11   Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
ZUPLENZ® 01/01/11   The limits are 6 films per day for Zuplenz 4mg and 3 films per day for Zuplenz 8mg.
ZYBAN® 08/06/08   The limits are 2 tablets per day.
ZYDONE® 09/01/03   The limits are 8 tablets per day for Zydone 5/400mg and 6 tablets per day for Zydone 7.5/400mg and 10/400mg.
ZYFLO CR® 02/01/05 04/16/08 The limits are 4 tablets per day.
ZYRTEC D® 01/01/00   The limits are 2 tablets per day.
ZYRTEC® 01/01/00   The limits are 1 tablet per day.
ZYTIGA® 01/01/12   Prior authorization for medical necessity is required. The limits are 4 tablets per day.