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
LANSOPRAZOLE 01/01/00 The limits are 1 capsule or solutab per day.
LAZANDA® 01/01/12 Prior authorization for medical necessity is required. The limits are 1 bottle per day.
LESCOL XL® 01/01/11 Lescol XL may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
LESCOL® 01/01/11 Lescol may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
LEVITRA® 09/01/03 Prior authorization for medical necessity may be required. The limits are 8 tablets per 30 days. Patients must be at least 18 years of age.
LEVORPHANOL 01/01/13 The limits are 4 tablets per day.
LEXIVA 07/01/12 The limits are 4 tablets per 60 mL per day.
LEXXEL® 01/01/11 Lexxel may be subject to step therapy requirements.
LINZESS™ 04/01/13 Prior authorization for medical necessity is required.
LIPITOR® 01/01/11 Lipitor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
LIPTRUZET® 07/01/13 Liptruzet may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
LIVALO® 01/01/11 Livalo may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
LORCET® 09/01/03 The limits are 6 tablets per day.
LORTAB® 09/01/03 The limits are 8 tablets for the 2.5 mg and 5 mg hydrocodone tablets and 6 tablets for the 7.5 mg and 10 mg tablets per day. The limits for Lortab elixir are 90mL per day. Patients should not take more than a total of 4 grams of acetaminophen per day (3 grams per day if have liver disease).
LOVENOX® 02/01/05 The limits are 30 syringes or 10 vials per 90 days.

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