Drug coverage is limited to prescription products approved by the Food and Drug Administration as evidenced by a New Drug Application (NDA), Abbreviated New Drug Application (ANDA), or Biologics Licensed Application (BLA) on file. Any legal requirements or group specific benefits for coverage will supersede this (e.g. preventive drugs per the Affordable Care Act).
Drug coverage may also be subject to policy guidelines or exclusions established by Blue Cross and Blue Shield of Alabama. The following guidelines are meant to help members understand the requirements related to their drug coverage. These drugs may require a doctor’s request for preapproval or prior authorization.
Please note: Some employer groups may have specific drug coverage requirements for their employees that are not included in the criteria below.
*Coverage Benefit - (P) Pharmacy Benefit, (M) Medical Benefit, (B) Both
Search by Drug Name
|Product Name||Guideline||*Coverage Benefit||Implementation Date||Change Date|
|DAKLINZA®||Prior authorization for medical necessity is required. Quantity limits may apply based on strength.||P||08/14/15|
|DANAZOL||Prior authorization for medical necessity is required.||P||04/01/12|
|DAYTRANA®||The limits are 1 patch per day.||P||06/12/06||04/01/11|
|DEMEROL||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.||P||01/01/13|
|DERMACINRX AZENASE PAK||The limits are 1 pak per 30 days.||P||11/19/15||01/01/16|
|DERMAPAK PAK PLUS||Prior authorization for medical necessity is required.||p||10/06/15||01/01/16|
|DESVENLAFAXINE SR 24HR||The limits are 1 tablet per day.||P||07/01/13|
|DEXILANT®||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.||P||07/01/10||04/01/14|
|DIABENESE||The limits are 60 tablets per 30 days for 100mg and 90 tablets per 30 days for 250mg.||P||04/01/12|
|DIDANOSINE||The limits are 1 capsule per day.||P||07/01/12|
|DIFFERIN®||Prior authorization for medical necessity may be required.||P||04/01/01|
|DILAUDID||The limits are 6 tablets per day or 48 mL/day for the Dilaudid 1 mg/mL solution.||P||01/01/13|
|DIOVAN HCT®||Diovan HCT may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE inhibitor or generic ARB.||P||01/01/11||10/01/15|
|DIOVAN®||Diovan may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB.||P||01/01/11|
|DOLGIC PLUS||The limits are 5 tablets per day.||P||04/01/13|