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|
|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.|
|EDURANT||07/01/12||The limits are 1 tablet per day.|
|EFFEXOR XR®||07/01/05||The limits are 1 capsule per day, except Effexor XR 75mg which has a limit of 3 capsules per day.|
|ELIQUIS||07/01/13||The limits are 2 tablets per day.|
|EMBEDA™||09/09/09||The limits are 2 capsules per day.|
|EMEND®||11/12/08||The limits are 4 capsules per 30 days for Emend 80mg, 2 capsules per 30 days for Emend 125mg, and 2 packs (6 capsules) per 30 days for Emend 125mg/80mg packs.|
|EMTRIVA||07/01/12||The limits are 1 capsule or 24 mL per day.|
|ENBREL®||05/17/99||Enbrel may be subject to step therapy requirements. Patients must have trial and failure of a first-line DMARD. The limits are 8 doses of Enbrel 25mg or 4 doses of Enbrel 50mg per 28 days.|
|ENDOCET®||01/01/00||The limits for are 12 tablets per day for Endocet 5-325mg , 8 tablets per day for 7.5-325mg and 7.5-500mg, and 6 tablets per day for 10-325mg and 10-650mg.|
|EPIDUO®||01/01/11||Prior authorization for medical necessity may be required.|
|EPIVIR||07/01/12||The limits are 1 tablet or 32 mL per day.|
|EPZICOM||07/01/12||The limits are 1 tablet per day.|