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
FABIOR 07/01/13 Prior authorization for medical necessity may be required.
FARXIGA® 04/01/14 The limits are 1 tablet per day.
FENTANYL CITRATE LOLLIPOP 06/23/03 Prior authorization for medical necessity is required. The limits are 4 lozenges per day. Patients must be at least 16 years of age.
FENTORA® 09/01/06 Prior authorization for medical necessity is required. The limits are 4 tablets per day.
FETZIMA® 01/01/14 The limits are 1 capsule per day or 1 titration pack per 28 days.
FIORICET 04/01/13 The limits are 6 tablets per day.
FIORICET WITH CODEINE 04/01/13 The limits are 6 tablets per day.
FIORINAL 04/01/13 The limits are 6 capsules per day.
FIORINAL WITH CODEINE 04/01/13 The limits are 6 capsules per day.
FIRAZYR® 04/01/12 Prior authorization for medical necessity is required. The limits are 3 syringes per prescription.
FIRST-LANSOPRAZOLE 07/01/12 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 07/01/12 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 04/01/12 The limits are 60 grams per 30 days.
FIRST-TESTOSTERONE MC 04/01/12 The limits are 60 grams per 30 days.
FLECTOR® PATCH 08/06/08 Prior authorization for medical necessity is required. The limits are 2 patches per day. Patients must be at least 18 years of age.

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