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||Change Date||Guideline|
|FABIOR||Prior authorization for medical necessity may be required.|
|FARXIGA®||The limits are 1 tablet per day.|
|FARYDAK®||The limits are 6 capsules per 21 days.|
|FENTANYL CITRATE LOLLIPOP||Prior authorization for medical necessity is required. The limits are 4 lozenges per day. Patients must be at least 16 years of age.|
|FENTANYL TD®||The limits are 15 patches per 30 days.|
|FENTORA®||Prior authorization for medical necessity is required. The limits are 4 tablets per day.|
|FETZIMA®||The limits are 1 capsule per day or 1 titration pack per 28 days.|
|FIORICET||The limits are 6 tablets per day.|
|FIORICET WITH CODEINE||The limits are 6 tablets per day.|
|FIORINAL||The limits are 6 capsules per day.|
|FIORINAL WITH CODEINE||The limits are 6 capsules per day.|
|FIRAZYR®||Prior authorization for medical necessity is required. The limits are 3 syringes per prescription.|
|FIRST-LANSOPRAZOLE||04/01/14||FIRST-Lansoprazole may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole, omeprazole, pantoprazole, or rabeprazole. The limits are 10 mL per day.|
|FIRST-OMEPRAZOLE||04/01/14||FIRST-Omeprazole may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole, omeprazole, pantoprazole, or rabeprazole. The limits are 20 mL per day.|
|FIRST-TESTOSTERONE||The limits are 60 grams per 30 days.|