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|
|DAKLINZA®||Prior authorization for medical necessity is required. Quantity limits may apply based on strength.||P||08/14/15|
|DAURISMO||Prior authorization for medical necessity is required. The limits are 60 tablets per 30 days for 25mg; 30 tablets per 30 days for 100mg.||P||04/01/19|
|DAYTRANA®||The limits are 1 patch per day.||P||06/12/06||04/01/11|
|DEMEROL||The limits are 8 tablets per day for 50 mg and 100 mg tablets. Demerol 50 mg/5 mL solution has a limit of 80 mL/day.||P||01/01/13|
|DESCOVY||The limits are 1 tablet per day.||P||07/01/16|
|Desoxyn||The limits are 5 tablets per day for the 5mg tablets.||P||04/01/18|
|Desvenlafaxine||The limits are 1 tablet per day.||P||04/01/18|
|Desvenlafaxine fumarate||The limits are 1 tablet per day.||P||04/01/18|
|DESVENLAFAXINE SR 24HR||The limits are 1 tablet per day.||P||07/01/13|
|DEXEDRINE||The limits are 4 capsules per day except for Dexedrine 5 mg which has a limit of 3 capsules per day.||P||10/01/16|
|DEXILANT®||Dexilant 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.||P||07/01/10||04/01/14|
|dextroamphetamine||The limits are 3 tablets per day for the 5mg tablets; 6 tablets per day for the 10mg tablets.||P||04/01/18|
|DICLEGIS||Diclegis is not included in our formularies and is non-covered.||P||07/01/17|
|DICLOFENAC GEL 3%||Prior Authorization for medical necessity is required. The limits are one 100 gram tube per month for up to 90 days.||P||10/01/16||04/01/18|
|DIDANOSINE||The limits are 1 capsule per day.||P||07/01/12|