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
RAVICTI 07/01/13 Prior authorization for medical necessity is required.
REBIF® 10/01/12 The limits are 3 syringes per week or 1 titration kit per 28 days.
RELENZA® 12/03/01 The limits are 20 blisters (1 carton) per 30 days.
RELISTOR™ 08/06/08 Prior authorization for medical necessity is required.
RELPAX® 11/01/05 The limits are 12 tablets per 30 days.
RENOVA® 04/01/01 Prior authorization for medical necessity may be required.
REPREXAIN® 05/15/09 The limits are 5 tablets per day.
RESCRIPTOR 07/01/12 The limits are 3 tablets per day for 100 mg tablets and 6 tablets per day for 200 mg tablets.
RETIN-A® 04/01/01 Prior authorization for medical necessity may be required.
RETROVIR 07/01/12 The limits are 6 capsules, 2 tablets, or 64 mL per day.
REVLIMID® 01/01/13 Prior authorization for medical necessity is required. The limits are 1 capsule per day, except for 15 mg and 25 mg strengths which have a limit of 21 capsules per 28 days.
REYATAZ 07/01/12 The limits are 1 capsule per day, except 200 mg which has a limit of 2 capsules per day.
RHINOCORT AQ® 09/25/02 The limits are 2 boxes – 18 g per 30 days.
RIOMET® 04/01/11 The limits are 25mL per day.
RITALIN LA® 07/01/05 The limits are 2 capsules per day.

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