Drug coverage is limited to prescription products approved by the Food and Drug Administration as evidenced by a New Drug Application (NDA), Abbreviated New Drug Application (ANDA), or Biologics Licensed Application (BLA) on file. Any legal requirements or group specific benefits for coverage will supersede this (e.g. preventive drugs per the Affordable Care Act).
Drug coverage may also be subject to policy guidelines or exclusions established by Blue Cross and Blue Shield of Alabama. The following guidelines are meant to help members understand the requirements related to their drug coverage. These drugs may require a doctor’s request for preapproval or prior authorization.
Please note: Some employer groups may have specific drug coverage requirements for their employees that are not included in the criteria below.
*Coverage Benefit - (P) Pharmacy Benefit, (M) Medical Benefit, (B) Both
Search by Drug Name
|Product Name||Guideline||*Coverage Benefit||Implementation Date||Change Date|
|ABSTRAL®||Prior authorization for medical necessity is required. Patients must have trial and failure of generic product. The limits are 4 tablets per day.||P||04/01/11||10/01/15|
|ACCOLATE®||The limits are 2 tablets per day.||P||02/01/05|
|ACETAMINOPHEN WITH CODEINE||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.||P||03/23/04|
|ACIPHEX®||Aciphex may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole, omeprazole, pantoprazole, or rabeprazole. The limits are 1 tablet per day for the 20mg tablets and 1 capsule per day for the 5mg and 10mg sprinkle.||P||02/18/02||04/01/14|
|ACTEMRA®||Step Therapy and Quantity Limits apply when self-administered. Predetermination for medical necessity is available when physician-administered.||B||01/01/14||01/01/16|
|ACTICLATE®||Acticlate maybe subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline.||P||10/01/14||01/01/15|
|ACTIQ®||Prior authorization for medical necessity is required. Patients must have trial and failure of generic product. The limits are 4 lozenges per day.||P||06/23/03||10/01/15|
|ACTONEL®||The limits are 1 tablet per day for Actonel 5mg and 30mg, 1 tablet per week for Actonel 35mg, and 1 tablet per 30 days for Actonel 150mg.||P||01/01/00||07/01/13|
|ACTOPLUS MET XR®||The limits are 2 tablets per day for Actoplus Met XR 15/1000mg and 1 tablet per day for Actoplus Met XT 30/1000mg.||P||01/01/11|
|ACTOPLUS MET®||The limits are 3 tablets per day.||P||08/06/08|
|ACTOS®||The limits are 1 tablet per day.||P||07/01/10||04/01/12|
|ADAPALENE||Prior authorization for medical necessity may be required.||P||04/01/01|
|ADCETRIS®||Predetermination for medical necessity is available||M||01/01/15|
|ADCIRCA®||Prior authorization for medical necessity is required.||P||04/01/15|
|ADDERALL XR®||The limits are 2 tablets per day.||P||11/13/02||04/01/11|