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
VELTIN® 01/01/11 Prior authorization for medical necessity may be required.
VENLAFAXINE EXTENDED-RELEASE 11/12/08 The limits are 1 tablet per day.
VENTOLIN HFA 04/01/12 The limits are 2 inhalers per 30 days.
VERAMYST® 07/01/07 The limits are 1 box per 30 days.
VIAGRA® 07/01/98 Prior authorization for medical necessity may be required. The limits are 8 tablets per 30 days. Patients must be at least 18 years of age.
VIBRAMYCIN® 04/01/13 Vibramycin capsules, suspension and syrup may be subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline.
VICODIN® 09/01/03 The limits are 8 Vicodin (5 mg hydrocodone) tablets, 6 Vicodin HP tablets, or 5 Vicodin ES 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).
VICOPROFEN® 09/24/03 The limits are 5 tablets.
VICTOZA® 02/15/10 Victoza may be subject to step therapy requirements. Patients must have trial and failure of one or more of the following antidiabetic agents: metformin, sulfonylurea, combinations of metformin or sulfonylureas, or basal insulin (Lantus or Levemir). The limits are 3 pens (9mL) per 30 days.
VICTRELIS™ 10/01/11 Prior authorization for medical necessity is required.
VIRACEPT 07/01/12 The limits are 9 capsules per day for 250 mg and 4 tablets per day for 625 mg strengths.
VIRAMUNE 07/01/12 The limits are 2 tablets or 40 mL per day.
VIRAMUNE XR 07/01/12 The limits are 1 tablet per day for 400 mg tablets and 3 tablets per day for 100 mg tablets.
VIREAD 07/01/12 The limits are 1 tablet or 8 g per day.
VOGELXO 10/01/14 Vogelxo may be subject to step therapy requirements. Patients must have trial and failure of Androderm or Androgel. The limits are 2 packets per day or 4 pumps (300 gm) per 30 days for the pump.

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