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|
|H.P. ACTHAR GEL®||04/01/12||Prior authorization for medical necessity is required.|
|HEXALEN®||01/01/12||Prior authorization for medical necessity is required.|
|HIZENTRA™||04/14/10||Prior authorization for medical necessity is required.|
|HORIZANT®||01/01/12||The limits are 60 tablets per 30 days. Horizant may be subject to step therapy requirements, if the member's benefit includes the Enhanced step therapy package. Patients must have history of trial and failure of generic gabapentin.|
|HUMATROPE®||10/01/11||Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.|
|HUMIRA®||01/17/03||Humira may be subject to step therapy requirements. Patients must have trial and failure of a first-line DMARD. The limits are 2 doses per 28 days. One starter kit for Crohn's disease or Psoriasis will be covered per 180 days.|
|HYCAMTIN®||01/01/12||Prior authorization for medical necessity is required.|
|HYCET™||05/15/09||The limits are 120mL per day.|
|HYDROCODONE/ACETAMINOPHEN||10/01/12||The limits are 12 tablets per day for 2.5mg-325mg tablets.|
|HYZAAR®||01/01/11||Hyzaar 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).|