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
SAIZEN® Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
SAIZEN® CLICK-EASY Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
SANCUSO® 01/01/12 Sancuso may be subject to step therapy requirements. Patients must have trial and failure of generic ondansetron or granisetron.
SAVAYSA® The limits are 30 tablets per month.
SELZENTRY The limits are 2 tablets per day for 150 mg and 4 tablets per day for 300 mg strengths.
SEREVENT® DISKUS® The limits are 2 blisters per day.
SEROSTIM® Prior authorization for medical necessity is required. Use of the preferred growth hormone, Omnitrope, may be required.
SIGNIFOR® Prior authorization for medical necessity is required.
SILENOR 07/01/13 The limits are 1 tablet per day.
SIMCOR® Simcor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
SIMPONI® 07/01/15 Simponi may be subject to step therapy requirements. The limits are 1 syringe per 28 days.
SINGULAIR® The limits are 1 tablet or packet per day.
SOLODYN® 01/01/15 Solodyn may be subject to step therapy requirements. Patients must have a trial and failure of generic immediate release doxycycline AND generic immediate release minocycline.
SONATA® 07/01/13 The limits are 1 capsule per day.
SPIRIVA® 01/01/15 The limits are 1 capsule per day for Spiriva Handihaler and 1 inhaler per 30 days for Spiriva Respimat.

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