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
MAGNACET™ 09/01/04 The limits are 10 tablets per day for Magnacet 5/400mg. The limits are 8 tablets per day for Magnacet 7.5/400mg and 6 tablets per day for Magnacet 10/400mg.
MATULANE® 01/01/12 Prior authorization for medical necessity is required.
MAXAIR 04/01/12 The limits are 1 inhaler per 30 days.
MAXALT® 11/01/05 The limits are 18 tablets per 30 days.
MAXIDONE™ 09/01/03 The limits are 5 tablets per day.
MEKINIST® 01/01/14 Prior authorization for medical necessity is required. The limits are 3 tablets per day for 0.5 mg strength and 1 tablet per for all other strengths.
METADATE CD® 01/01/05 The limits are 2 capsules per day, except Metadate CD 60mg which has a limit of 1 capsule per day.
METAGLIP™ 08/06/08 The limits are 4 tablets per day, except Metaglip 2.5/250mg which has a limit of 8 tablets per day.
METHADONE 01/01/13 The limits for the 5 mg/5 mL solution is 30 mL per day and the 10 mg/5 mL solution is 15 mL per day.
METHADOSE 01/01/13 The limits are 3 tablets per day or 3 mL of the 10 mg/mL concentrated solution per day.
METHITEST® 04/01/12 Prior authorization for medical necessity is required.
MEVACOR® 01/01/11 Mevacor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
MICARDIS HCT® 01/01/11 Micardis HCT may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB.
MICARDIS® 01/01/11 Micardis may be subject to step therapy requirements. Patients must have trial and failure of a generic ACE Inhibitor or generic ARB.
MINOCIN® 04/01/13 Minocin may be subject to step therapy requirements. Patients must have a trial and failure of generic immediate release minocycline.

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