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
AVALIDE® Avalide 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).
AVANDAMET® The limits are 2 tablets per day.
AVANDARYL® The limits are 1 tablet per day.
AVANDIA® Avandia 2mg and 4mg has a limit of 2 tablets per day. Avandia 8mg has a limit of 1 tablet per day.
AVAPRO® Avapro 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).
AVIDOXY® DK Avidoxy DK may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline.
AVINZA® The limits are 1 capsule per day.
AVITA® Prior authorization for medical necessity may be required.
AVONEX® Avonex 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 one 30mg vial, syringe, or pen per week or 1 kit per 28 days.
AXERT® Axert may be subject to step therapy requirements. Patients must have trial and failure of generic triptan (naratriptan, sumatriptan, rizatriptan). The limits are 12 tablets per 30 days.
AXIRON® The limits are 180mL (2 bottles) per 30 days.
AZOR® 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® The limits are 2 bottles per 30 days.
BELSOMRA® The limits are 1 tablet per day.
BENICAR HCT® 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).

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