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|
|ZAMICET®||The limits are 90mL per day.|
|ZECUITY||Zecuity may be subject to step therapy requirements. Patients must have trial and failure of a generic triptan (naratriptan, sumatriptan, rizatriptan). The limits are 12 transdermal systems per 30 days.|
|ZEGERID®||Zegerid may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole, omeprazole, pantoprazole, or rabeprazole. The limits are 1 capsule or packet per day.|
|ZELBORAF®||Prior authorization for medical necessity is required. The limits are 8 tablets per day.|
|ZERIT||The limits are 2 capsules or 80 mL per day.|
|ZETONNA||The limits are 1 bottle per 30 days.|
|ZIAGEN||The limits are 2 tablets or 32 mL per day.|
|ZIANA®||Prior authorization for medical necessity may be required.|
|ZIOPTAN||The limits are 1 single-use container per day.|
|ZOCOR®||Zocor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).|
|ZOFRAN®||The limits are 21 tablets per 30 days for Zofran 4mg and 8mg, and 1 tablet per 30 days for Zofran 24mg.|
|ZOFRAN® ODT||The limits are 21 tablets per 30 days.|
|ZOHYDRO ER||The limits are 2 capsules per day.|
|ZOLINZA®||Prior authorization for medical necessity is required. The limits are 4 capsules per day.|
|ZOLPIMIST®||The limits are 1 container per month.|