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|
|DANAZOL||Prior authorization for medical necessity is required.|
|DAYTRANA®||The limits are 1 patch per day.|
|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.|
|DESVENLAFAXINE SR 24HR||The limits are 1 tablet per day.|
|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.|
|DIABENESE||The limits are 60 tablets per 30 days for 100mg and 90 tablets per 30 days for 250mg.|
|DIDANOSINE||The limits are 1 capsule per day.|
|DIFFERIN®||Prior authorization for medical necessity may be required.|
|DILAUDID||The limits are 6 tablets per day or 48 mL/day for the Dilaudid 1 mg/mL solution.|
|DIOVAN HCT®||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®||Diovan may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB.|
|DOLGIC PLUS||The limits are 5 tablets per day.|
|DOLOPHINE||The limits are 3 tablets per day.|
|DORYX®||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||Doxycycline may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline.|