Drug coverage is limited to prescription products approved by the Food and Drug Administration as evidenced by a New Drug Application (NDA), Abbreviated New Drug Application (ANDA), or Biologics Licensed Application (BLA) on file. Any legal requirements or group specific benefits for coverage will supersede this (e.g. preventive drugs per the Affordable Care Act).
Drug coverage may also be subject to policy guidelines or exclusions established by Blue Cross and Blue Shield of Alabama. The following guidelines are meant to help members understand the requirements related to their drug coverage. These drugs may require a doctor’s request for preapproval or prior authorization.
Please note: Some employer groups may have specific drug coverage requirements for their employees that are not included in the criteria below.
*Coverage Benefit - (P) Pharmacy Benefit, (M) Medical Benefit, (B) Both
Search by Drug Name
|Product Name||Guideline||*Coverage Benefit||Implementation Date||Change Date|
|XALATAN®||The limits are 1-2.5mL box per 30 days or 1-7.5mL box per 90 days.||P||06/04/02|
|XALKORI®||Prior authorization for medical necessity is required. The limits are 60 capsules per 30 days.||P||01/01/12|
|XARELTO®||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.||P||01/01/12||01/01/15|
|XARTERMIS XR||The limits are 4 tablets per day.||P||07/01/14|
|XELJANZ XR®||Xeljanz XR® may be subject to step therapy requirements. Patients must have trial and failure of 2 preferred products. Preferred products are Humira, Enbrel, Stelara, and Simponi. The limits are 1 tablet per day.||P||01/01/13||07/01/16|
|XELJANZ®||Xeljanz may be subject to step therapy requirements. Patients must have trial and failure of 2 preferred products. Preferred products are Humira, Enbrel, Stelara, and Simponi. The limits are 2 tablets per day.||P||01/01/13||07/01/15|
|XELODA®||Prior authorization for medical necessity is required.||P||01/01/12|
|XEOMIN®||Prior authorization for medical necessity is required.||M||01/01/15||04/01/16|
|XIAFLEX®||Prior authorization for medical necessity is required.||M||01/01/15||04/01/16|
|XIGDUO®||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.||P||01/01/15|
|XODOL®||The limits are 12 tablets per day for Xodol 5/300mg and 6 tablets per day for Xodol 7.5/300mg and 10/300mg.||P||05/15/09|
|XOLAIR®||Prior authorization for medical necessity is required.||M||01/01/15||04/01/16|
|XOLOX®||The limits are 8 tablets per day.||P||04/01/11|
|XOPENEX HFA||The limits are 2 inhalers per 30 days.||P||04/01/12|
|XTANDI®||Prior authorization for medical necessity is required. The limits are 4 capsules per day.||P||11/15/12|