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|
|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 2 capsules per day.||P||01/01/12|
|XARELTO||The limits are 1 starter pack per 30 days; 1 tablet per day for the 10mg and 20mg tablets; 2 tablets per day for the 15mg tablets.||P||04/01/18|
|XARELTO®||The limits are 2 tablets per day for the 2.5 mg, 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|
|XARTEMIS XR||The limits are 4 tablets per day.||P||07/01/14|
|XELJANZ XR®||Prior authorization for medical necessity is required. The limits are 1 tablet per day.||P||01/01/13||01/01/18|
|XELJANZ®||Prior authorization for medical necessity is required. The limits are 2 tablets per day.||P||01/01/13||01/01/18|
|XELODA||Prior authorization for medical necessity is required.||P||04/01/18|
|XELPROS||The limits for 0.005% are 2.5 ml every 30 days.||P||01/01/19|
|XENICAL||Prior authorization for medical necessity is required. The limits are 3 capsules per day.||P||07/01/19|
|XEOMIN®||Prior authorization for medical necessity is required.||M||01/01/15||04/01/16|
|XERMELO||Prior Authorization for medical necessity is required. The limits are 3 tablets per day.||P||07/01/17|
|XHANCE||The limits are 2 bottles per 30 days.||P||04/01/18|
|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|