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
ARCAPTA® The limits are 30 capsules per 30 days.
ARIXTRA® The limits are 30 syringes per 90 days.
ARNUITY ELLIPTA® The limits are 30 blisters per month.
ASMANEX HFA® The limits are 1 inhaler per month.
ASMANEX® 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 The limits are 60 mL per 30 days.
ASTEPRO The limits are 60 mL per 30 days.
ATACAND HCT® Atacand HCT 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).
ATACAND® Atacand 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).
ATELVIA® The limits are 4 tablets per 30 days.
ATRALIN® Prior authorization for medical necessity may be required.
ATRIPLA The limits are 1 tablet per day.
ATROVENT HFA The limits are 2 inhalers per 30 days.
ATROVENT NASAL INHALER The limits are 60 mL per 30 days for 21 mcg/spray and 45 mL per 30 days for 42 mcg/spray.
AUBAGIO® Aubagio may be subject to step therapy. Patients must have trial and failure of one of the five preferred products: Betaseron, Copaxone, Plegridy, Rebif, or Tecfidera. The limits are 1 tablet per day.

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