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
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).
DIOVAN® 01/01/11 Diovan may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB.
DOLGIC PLUS 04/01/13 The limits are 5 tablets per day.
DOLOPHINE 01/01/13 The limits are 3 tablets per day.
DORYX® 11/14/07 Doryx may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline.
DOXYCYCLINE 04/01/13 Doxycycline may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline.
DUETACT® 07/01/10 The limits are 1 tablet per day.
DULERA® 01/01/11 The limits are 1 inhaler per 30 days.
DURAGESIC® 09/01/04 The limits are 15 patches per 30 days.
DYMISTA® 10/01/12 The limits are 1 bottle (23 grams) per 30 days.
DYNACIN® 04/01/13 Dynacin may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline.
EDARBI™ 04/01/11 Edarbi 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).
EDARBYCLOR™ 07/01/12 Edarbyclor 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).
EDEX® 07/01/10 Prior authorization for medical necessity may be required. Patients must be at least 18 years of age.
EDLUAR™ 07/06/09 The limits are 1 tablet per day.

Affordable Care Act

Healthcare Reform Questions? Learn More

HealthQuotient®

What's your HQ Score? Get Started Now!