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|
|IBRANCE®||Prior authorization for medical necessity is required. Limits are 21 capsules per 28 days.||P||02/20/15|
|IBUDONE™||The limits are 5 tablets per day.||P||05/15/09|
|ICLUSIG™||Prior authorization for medical necessity is required. The limits are 2 tablets per day of the 15 mg tablets and 1 tablet per day of the 45 mg tablets.||P||04/01/13|
|IDELVION||Prior authorization for medical necessity and dispensing may be required.||P||07/01/19|
|IDHIFA||Prior authorization for medical necessity is required. The limits are 1 tablet per day.||P||09/01/17|
|ILARIS®||Prior authorization for medical necessity is required. Patients must be at least 4 years of age. The limits are two 180 mg vial every 28 days..||P||08/10/09||10/01/15|
|ILUMYA||Prior Authorization for medical necessity is required.||M||03/20/18||11/01/18|
|IMBRUVICA®||Prior authorization for medical necessity is required. The limits are 1 capsule per day of the 70mg; 4 capsules per day of the 140mg and 1 per day of the tablets.||P||01/01/14||10/01/18|
|IMIQUIMOD CREAM||Prior Authorization is required for medical necessity. The limits will vary based on the disease being treated.||P||10/01/16|
|IMITREX®||Imitrex may be subject to step therapy requirements. Patients must have trial and failure of a generic triptan (naratriptan,sumatriptan,rizatriptan). The limits are 12 doses of the injection, or 5mL of the vials , 12 units of nasal spray, or 18 tablets per 30 days.||P||11/01/05||07/01/15|
|IMVEXXY||The limits are 18 inserts (4mcg/starter pack) per 180 days; 8 inserts (4mcg/maintenance pack) per 28 days; 18 inserts (10mcg/starter pack) per 180 days; 8 inserts (10mcg/maintenance pack) per 28 days.||P||04/01/19|
|INCRUSE ELLIPTA®||The limits are 30 blisters per month.||P||04/01/15|
|INFLECTRA||Prior authorization for medical necessity is required.||M||04/05/16||01/01/17|
|INGENOL GEL||Prior Authorization is required for medical necessity. The limits are 3 tubes for up to 90 days for the 0.015% gel or 2 tubes for up to 90 days of the 0.05% gel.||P||10/01/16|
|INLYTA®||Prior authorization for medical necessity is required. The limits are 6 tablets per day of the 1 mg tablets and 4 tablets per day of the 5 mg tablets.||P||07/01/12|