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|
|WELLBUTRIN SR®||The limits are 2 tablets per day.|
|WELLBUTRIN XL®||02/13/08||The limits are 3 tablets per day for Wellbutrin XL 150mg and 1 tablet per day for Wellbutrin XL 300mg.|
|WELLBUTRIN®||The limits for Wellbutrin 75mg are 6 tablets per day. The limits for Wellbutrin 100mg are 4 tablets per day.|