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.

Search by Drug Name

Product Name Implementation Date Guideline
AEROSPAN® 04/01/14 The limits are 2 canisters per month.
AFINITOR® 07/20/09 Prior authorization for medical necessity is required. The limits are 1 tablet per day.
AFINITOR® DISPERZ 07/01/13 Prior authorization for medical necessity is required. The limits are 2 tablets per day, except the 3 mg tablets which have a limit of 3 tablets per day.
ALENDRONATE 07/01/13 The limits are 1 tablet per day for 40mg tablets and 300mls per 28 days for the oral solution.
ALODOX™ 04/01/13 Alodox may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline.
ALSUMA™ 04/01/11 The limits are 12 doses per 30 days.
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 The limits are 1 box per 30 days for 80mcg strength and 2 boxes per 30 days for 160mcg strength.
AMARYL 04/01/12 The limits are 30 tablets per 30 days, except 4mg tablets which have a limit of 60 tablets per 30 days.
AMBIEN CR® 10/01/05 The limits are 1 tablet per day.
AMBIEN® 02/25/02 The limits are 1 tablet per day.
AMERGE® 11/01/05 The limits are 18 tablets per 30 days.
AMITIZA® 09/01/06 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.
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, Exforge/HCT, Micardis/HCT).

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