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|
|PANTOPRAZOLE||04/01/11||The limits are 1 tablet per day.|
|PATANASE®||The limits are 1 box per 30 days.|
|PEG-INTRON®||01/01/11||Prior authorization for medical necessity is required. Use of the preferred peginterferon, Pegasys, may be required.|
|PEGASYS®||01/01/11||Prior authorization for medical necessity is required.|
|PERCOCET®||The limits are 12 tablets for the 2.5 mg and 5 mg oxycodone tablets, 8 tablets for the 7.5 mg tablets, and 6 tablets for the 10 mg tablets per day.|
|PERCODAN®||The limits are 12 tablets per day.|
|PHRENILLIN FORTE||The limits are 6 capsules per day.|
|PICATO||The limits are 3 tubes per 90 days of the 0.015% gel and 2 tubes per 90 days of the 0.05% gel.|
|PLEGRIDY®||The limits are 2 syringes or pens per 30 days and 1 starter kit per 180 days.|
|POMALYST®||Prior authorization for medical necessity is required. The limits are 21 capsules per 28 days.|
|PRADAXA®||The limits are 2 capsules per day.|
|PRAVACHOL®||Pravachol may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).|
|PREVACID®||04/01/14||Prevacid 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, solutab, or packet per day.|
|PREZCOBIX®||The limits are 30 tablets per month.|
|PREZISTA||10/01/14||The limits are 10 tablets per day for the 75 mg, 6 tablets per day for the 150 mg, 2 tablets for the 600 mg, and 1 tablet per day for the 800 mg. Prezista solution has a limit of 400 mL per 30 days.|