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
IBRANCE® Prior authorization for medical necessity is required. Limits are 21 capsules per 28 days.
IBUDONE™ The limits are 5 tablets per day.
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.
ILARIS® 10/01/12 Prior authorization for medical necessity is required. Patients must be at least 4 years of age. The limits are one 180 mg vial every 8 weeks.
IMBRUVICA® Prior authorization for medical necessity is required. The limits are 4 capsules per day.
IMITREX® 07/01/15 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.
INCIVEK™ Prior authorization for medical necessity is required.
INCRELEX® Prior authorization for medical necessity is required.
INCRUSE ELLIPTA® The limits are 30 blisters per month.
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.
INTELENCE 10/01/12 The limits are 2 tablets per day, except 25 mg tablets with a limit of 4 tablets per day.
INTERMEZZO® 07/01/13 The limits are 1 tablet per day.
INVIRASE The limits are 10 capsules or 4 tablets per day.
INVOKAMET® The limits are 2 tablets per day.
INVOKANA The limits are 1 tablet per day.

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