Certain medications may require predefined criteria before being approved for coverage. Other drugs may have daily or monthly limits recommended by the Food and Drug Administration, the drugs manufacturer, and/or  peer-reviewed medical literature. These instances may require a doctors request for preapproval or prior authorization.

 

The following guidelines, developed by Blue Cross and Blue Shield of Alabama's Pharmacy and Therapeutics Committee, are meant to help members understand the requirements related to their pharmacy coverage. Healthcare providers should use their best medical judgment in providing the care they feel is most appropriate for their patients.

 

Please note: Some employer groups may have specific drug coverage requirements for their employees that are not included in the criteria below.

 

For more information please review Physician Administered Drug Policies.

Search by Drug Name

Product Name Implementation Date Change Date Guideline
ABSTRAL® Prior authorization for medical necessity is required. The limits are 4 tablets per day.
ACCOLATE® The limits are 2 tablets per day.
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.
ACIPHEX® 04/01/14 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.
ACTEMRA® 07/01/15 Actemra subcutaneous injection may be subject to step therapy requirements. Patients must have trial and failure of 2 preferred products. Preferred products are Humira, Enbrel, Stelara, and Simponi. The limits are 4 syringes per 28 daysa.
ACTICLATE® 01/01/15 Acticlate maybe subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline.
ACTIQ® Prior authorization for medical necessity is required. The limits are 4 lozenges per day.
ACTONEL® 07/01/13 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.
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.
ACTOPLUS MET® The limits are 3 tablets per day.
ACTOS® 04/01/12 The limits are 1 tablet per day.
ADAPALENE Prior authorization for medical necessity may be required.
ADCIRCA® Prior authorization for medical necessity is required.
ADDERALL XR® 04/01/11 The limits are 2 tablets per day.
ADEMPAS® Prior authorization for medical necessity is required.

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