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
ANADROL®-50 07/20/09 Prior authorization for medical necessity is required.
ANDRODERM® 07/20/09 The limits are 1 patch per day.
ANDROGEL® 06/15/04 The limits are two cartons (60 packets) of 2.5 gram or 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 grams), 30 1.25 gm packets, or 60 2.5 gm packets per 30 days.
ANDROID® 04/01/12 Prior authorization for medical necessity is required.
ANDROXY® 04/01/12 Prior authorization for medical necessity is required.
ANORO ELLIPTA 04/01/14 The limits are 60 doses per 30 days.
ANZEMET® 02/01/05 The limits are 7 tablet per 30 days.
APLENZIN® 08/06/08 The limits are 1 tablet per day.
APTIVUS 07/01/12 The limits are 4 capsules or 13 mL per day.
ARCALYST 12/18/08 Prior authorization for medical necessity is required. Patients must be at least 12 years of age. The limits are one 220 mg vial per week.
ARCAPTA® 01/01/12 The limits are 30 capsules per 30 days.
ARIXTRA® 07/01/10 The limits are 30 syringes per 90 days.
ASMANEX® 01/26/06 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.
ASTELIN 07/01/13 The limits are 60 mL per 30 days.
ASTEPRO 07/01/13 The limits are 60 mL per 30 days.

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