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||Guideline|
|KADIAN®||The limits are 2 capsules per day.|
|KALETRA||The limits are 10 tablets per day for 100 mg/25 mg, 4 tablets per day for 200 mg/50 mg, and 11 mL per day for 80 mg/20 mg per mL oral solution.|
|KALYDECO®||Prior authorization for medical necessity is required. The limits are 2 tablets or 2 packets per day.|
|KAZANO||The limits are 2 tablets per day.|
|KHEDEZLA®||The limits are 30 tablets per 30 days.|
|KINERET®||Kineret may be subject to step therapy requirements. Patients must have trial and failure of two preferred products. Preferred products are Humira, Enbrel, Stelara and Simponi. The limits are 1 syringe per day.|
|KITABIS®||Prior authorization for medical necessity is required. Must not be used concurrently with Cayston or Bethkis.|
|KOMBIGLYZE® XR||The limits are 1 tablet per day, except Kombiglyze XR 2.5-1000mg which has a limit of 2 tablets per day.|
|KORLYM®||Prior authorization for medical necessity is required. The limits are 2 tablets per day.|
|KYNAMRO||Prior authorization for medical necessity is required.|
|KYTRIL®||The limits are 14 tablets per 30 days.|