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 established by Blue Cross and Blue Shield of Alabama. Drug coverage policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their 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.

Drug Coverage Guidelines

Search by Drug Name

Product Name Guideline Coverage Benefit* Implementation Date Change Date
ABILIFY Abilify may be subject to step therapy requirements. Patients must have trial and failure of a generic atypical antipsychotic. The limits are 1 tablet per day for the 2mg, 5mg, 10mg, 15mg, 20mg, 30mg tablets. The limits are 900mls per 30 days for the oral solution. The limits are 3 vials per day for the 9.75mg/1.3mL injection. P 07/01/16
ABILIFY DISCMELT Abilify Discmelt may be subject to step therapy requirements. Patients must have trial and failure of a generic atypical antipsychotic. The limits are 2 tablets per day for the 10 mg and 15 mg tablets. P 07/01/16
ABILIFY MAINTENA Abilify Maintena may be subject to step therapy requirements. Patients must have trial and failure of a generic atypical antipsychotic. The limits are 1 syringe per 28 day for the 300 mg and 400 mg injection. P 07/01/16
ABRAXANE® Prior authorization for medical necessity is required. M 05/01/16
ABSTRAL® Prior authorization for medical necessity is required. Patients must have trial and failure of generic product. The limits are 4 tablets per day. P 04/01/11 10/01/15
ACCOLATE® The limits are 2 tablets per day. P 02/01/05
ACCU-CHEK Accu-chek glucose test strips and meters are not included in our formularies and are non-covered. P 09/01/16
ACETAMINOPHEN WITH CODEINE The limits are 12 tablets per day for acetaminophen with codeine 300mg/15mg and 300mg/30mg, and 6 tablets per day for acetaminophen with codeine 300mg/60mg. P 03/23/04 01/01/18
Acetaminophen/Caffeine/Dihydrocodeine The limits are 10 tablets for 325 mg/30 mg/16 mg tablet; 5 tablets per 712.8mg/60mg/32mg tablets per day. P 04/01/18
Acetaminophen/codeine The limit is 90mLs per day of the 120 mg/12 mg/5 mL suspension; s 12 tablets of the 300 mg/15 mg tablet, 300mg/30mg tablets; 6 tablets of the 300mg/60mg tablets per day. P 04/01/18
ACIPHEX® Aciphex may be subject to step therapy requirements. Patients must have trial and failure of generic lansoprazole, omeprazole, pantoprazole, or rabeprazole. The limits are 1 tablet per day for the 20mg tablets and 1 capsule per day for the 5mg and 10mg sprinkle. P 02/18/02 04/01/14
ACTEMRA® Prior authorization for medical necessity is required. Actemra has a limit of 4 syringes per 28 days. B 01/01/14 01/01/18
ACTICLATE® Acticlate maybe subject to step therapy requirements. Patients must have trial and failure of generic immediate release doxycycline AND generic immediate release minocycline. P 10/01/14 01/01/15
ACTIQ® Prior authorization for medical necessity is required. Patients must have trial and failure of generic product. The limits are 4 lozenges per day. P 06/23/03 10/01/15
ACTONEL® The limits are 1 tablet per day for Actonel 5mg and 30mg, 4 tablets per 28 days for 35mg, and 1 tablet per month for 150mg. P 01/01/00 01/01/18