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 Guideline
ADOXA® Adoxa may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline.
ADVAIR® Advair Diskus has a limit of 2 blisters per day. Advair HFA has a limit of 1 inhaler per 30 days.
ADVICOR® Advicor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
AEROSPAN® The limits are 2 canisters per month.
AFINITOR® Prior authorization for medical necessity is required. The limits are 1 tablet per day.
AFINITOR® DISPERZ 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.
AFREZZA® Prior authorization for medical necessity is required. The limits are 2,520 cartridges for the 4 unit pack and 1,890 cartridges for the 4 unit and 8 unit mix cartridges pack.
AKYNZEO® The limits are 2 capsules per 30 days.
ALENDRONATE The limits are 1 tablet per day for 40mg tablets and 300mls per 28 days for the oral solution.
ALODOX® Alodox may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline.
ALSUMA® Alsuma may be subject to step therapy. Patients must have trial and failure of generic triptan (naratriptan, sumatriptan,rizatriptan). The limits are 12 doses per 30 days.
ALTOPREV® Altoprev may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
ALVESCO® The limits are 1 box per 30 days for 80mcg strength and 2 boxes per 30 days for 160mcg strength.
AMBIEN CR® The limits are 1 tablet per day.
AMBIEN® The limits are 1 tablet per day.

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