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
CRESTOR® 01/01/11 Crestor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
CRIXIVAN 07/01/12 The limits are 9 capsules per day for 200 mg, and 6 capsules per day for 400 mg strengths.
CYCLOSET 04/01/12 The limits are 180 tablets per 30 days.
CYMBALTA® 09/01/04 The limits are 2 capsules per day, except Cymbalta 60mg with a limit of 1 capsule per day.
DANAZOL 04/01/12 Prior authorization for medical necessity is required.
DAYTRANA® 06/12/06 The limits are 1 patch per day.
DEMEROL 01/01/13 The limits are 8 tablets per day for 50 mg and 100 mg tablets. Demerol 50 mg/5 mL solution has a limit of 80 mL/day.
DESVENLAFAXINE SR 24HR 07/01/13 The limits are 1 tablet per day.
DEXILANT™ 07/01/10 Dexilant may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole, omeprazole, pantoprazole, or rabeprazole. The limits are 1 tablet per day.
DIABENESE 04/01/12 The limits are 60 tablets per 30 days for 100mg and 90 tablets per 30 days for 250mg.
DIABETA 04/01/12 The limits are 30 tablets per 30 days for 1.25mg and 2.5mg tablets, and 120 tablets per 30 days for 5mg tablets.
DIDANOSINE 07/01/12 The limits are 1 capsule per day.
DIFFERIN® 04/01/01 Prior authorization for medical necessity may be required.
DILAUDID 01/01/13 The limits are 6 tablets per day or 48 mL/day for the Dilaudid 1 mg/mL solution.
DIOVAN HCT® 01/01/11 Diovan 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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