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|
|NASACORT AQ®||04/01/04||The limits are 1 box per 30 days.|
|NASAREL®||08/06/08||The limits are 3 boxes per 30 days.|
|NASONEX®||02/22/05||The limits are 1 box – 17 g per 30 days.|
|NESINA||04/01/13||The limits are 1 tablet per day.|
|NEVIRAPINE||07/01/12||The limits are 40 mL per day.|
|NEXAVAR®||01/01/06||Prior authorization for medical necessity is required. The limits are 4 tablets per day.|
|NEXIUM®||01/01/00||Nexium may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole, omeprazole, pantoprazole, or rabeprazole. The limits are 1 capsule or packet for oral suspension per day.|
|NICAZELDOXY® KIT||01/01/14||Nicazeldoxy may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline.|
|NORCO®||09/01/03||The limits are 12 for the 5 mg tablets and 6 for the 7.5 and 10 mg tablets per day. Patients should not take more than a total of 4 grams of acetaminophen per day (3 grams per day if you have liver disease).|
|NORDITROPIN®||10/01/11||Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.|
|NORVIR||07/01/12||The limits are 12 tablets or capsules or 16 mL per day.|
|NUCYNTA®||07/06/09||The limits are 12 tablets per day.|
|NUCYNTA® ER||01/01/12||The limits are 60 tablets per 30 days.|
|NUTRIDOX® KIT||04/01/13||Nutridox may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline.|
|NUTROPIN AQ NUSPIN®||01/01/13||Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.|