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
XALATAN® 06/04/02 The limits are 1-2.5mL box per 30 days or 1-7.5mL box per 90 days.
XALKORI® 01/01/12 Prior authorization for medical necessity is required. The limits are 60 capsules per 30 days.
XARELTO® 01/01/12 The limits are 35 tablets per 90 days for the 10mg tablets, which allows for a single course of therapy, 30 tablets per 30 days for 20mg tablets, 60 tablets per 30 days for the 15 mg tablets, and 1 starter pack (51 tablets) per 30 days.
XARTERMIS XR 07/01/14 The limits are 4 tablets per day.
XELJANZ® 01/01/13 Xeljanz may be subject to step therapy requirements. Patients must have trial and failure of Humira AND Enbrel. The limits are 2 tablets per day.
XELODA® 01/01/12 Prior authorization for medical necessity is required.
XIGDUO® 01/01/15 The limits are 1 tablet per day for Xigdio 5/500 mg and 10/500 mg and 2 tablets per day for Xigduo 5/1000 mg.
XODOL® 05/15/09 The limits are 12 tablets per day for Xodol 5/300mg and 6 tablets per day for Xodol 7.5/300mg and 10/300mg.
XOLOX™ 04/01/11 The limits are 8 tablets per day.
XOPENEX HFA 04/01/12 The limits are 2 inhalers per 30 days.
XTANDI® 11/15/12 Prior authorization for medical necessity is required. The limits are 4 capsules per day.
XYREM® 07/01/07 Prior authorization for medical necessity is required. The limits are 9g (18 mL) per day. Patients must be at least 18 years of age.
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