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
AVITA® 04/01/01 Prior authorization for medical necessity may be required.
AVONEX® 01/01/12 Avonex may be subject to step therapy. Patients must have trial and failure of two of the four preferred products: Betaseron, Copaxone, Rebif, or Tecfidera. The limits are one 30mg vial, syringe, or pen per week.
AXERT® 11/01/05 The limits are 12 tablets per 30 days.
AXIRON® 07/01/11 The limits are 180mL (2 bottles) per 30 days.
AZOR® 01/01/11 Azor 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).
BECONASE AQ® 11/13/01 The limits are 2 bottles per 30 days.
BENICAR HCT® 01/01/11 Benicar 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).
BENICAR® 01/01/11 Benicar 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).
BETASERON® 10/01/12 The limits are 14 vial/syringe units per 28 days and 1 kit (14 prefilled syringes) per 28 days.
BETHKIS® 01/01/14 Prior authorization for medical necessity may be required. Must not be used concurrently with inhaled tobramycin or Cayston.
BINOSTO™ 01/01/13 The limits are 4 tablets per 28 days.
BIO-T-GEL® 10/01/12 The limits are 2 packets per day.
BONIVA® 06/01/05 The limits are 1 tablet per 30 days for Boniva 150mg.
BOSULIF® 11/15/12 Prior authorization for medical necessity is required. The limits are 1 tablet per day.
BREO ELLIPTA® 01/01/14 The limits are 2 blisters per day.

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