Drug coverage is limited to prescription products approved by the Food and Drug Administration as evidenced by a New Drug Application (NDA), Abbreviated New Drug Application (ANDA), or Biologics Licensed Application (BLA) on file. Any legal requirements or group specific benefits for coverage will supersede this (e.g. preventive drugs per the Affordable Care Act).
Drug coverage may also be subject to policy guidelines or exclusions established by Blue Cross and Blue Shield of Alabama. The following guidelines are meant to help members understand the requirements related to their drug coverage. These drugs may require a doctor’s request for preapproval or prior authorization.
Please note: Some employer groups may have specific drug coverage requirements for their employees that are not included in the criteria below.
*Coverage Benefit - (P) Pharmacy Benefit, (M) Medical Benefit, (B) Both
Search by Drug Name
|Product Name||Guideline||*Coverage Benefit||Implementation Date||Change Date|
|IBRANCE®||Prior authorization for medical necessity is required. Limits are 21 capsules per 28 days.||P||02/20/15|
|IBUDONE™||The limits are 5 tablets per day.||P||05/15/09|
|ICLUSIG™||Prior authorization for medical necessity is required. The limits are 2 tablets per day of the 15 mg tablets and 1 tablet per day of the 45 mg tablets.||P||04/01/13|
|ILARIS®||Prior authorization for medical necessity is required. Patients must be at least 4 years of age. The limits are two 180 mg vial every 28 days..||P||08/10/09||10/01/15|
|IMBRUVICA®||Prior authorization for medical necessity is required. The limits are 4 capsules per day.||P||01/01/14|
|IMITREX®||Imitrex may be subject to step therapy requirements. Patients must have trial and failure of a generic triptan (naratriptan,sumatriptan,rizatriptan). The limits are 18 tablets, 12 nasal spray units, 10 vials, or 6 kits per 30 days.||P||11/01/05||07/01/15|
|INCIVEK™||Prior authorization for medical necessity is required.||P||10/01/11|
|INCRELEX®||Prior authorization for medical necessity is required.||P||01/01/06|
|INCRUSE ELLIPTA®||The limits are 30 blisters per month.||P||04/01/15|
|INLYTA®||Prior authorization for medical necessity is required. The limits are 6 tablets per day of the 1 mg tablets and 4 tablets per day of the 5 mg tablets.||P||07/01/12|
|INTELENCE||The limits are 2 tablets per day, except 25 mg tablets with a limit of 4 tablets per day.||P||07/01/12||10/01/12|
|INTERMEZZO®||The limits are 1 tablet per day.||P||07/01/12||07/01/13|
|INVIRASE||The limits are 10 capsules or 4 tablets per day.||P||07/01/12|
|INVOKAMET®||The limits are 2 tablets per day.||P|
|INVOKANA||The limits are 1 tablet per day.||P||04/01/14|