Category Filter
- Advanced Imaging
- Behavioral Health
- Chronic Condition Management
- Genetic Testing
- Hemophilia Drugs
- Medical Oncology Regimen Program
- Medical Policies
- Pre-Service Review (Precertification/Predetermination)
- Provider-Administered Drug Policies
- Radiation Therapy
- Self-Administered Drug Policies
- Transgender Services
Asset Publisher
Xanthine Oxidase Inhibitor Quantity Limit Program Summary
Policy Number: PH-1081
This step therapy applies to Blue Partner, Commercial, and Health Insurance Marketplace formularies.
POLICY REVIEW CYCLE
FDA APPROVED INDICATIONS AND DOSAGE
See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm
POLICY AGENT SUMMARY QUANTITY LIMIT
CLIENT SUMMARY – QUANTITY LIMITS
QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL
This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment. The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy 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. Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.
Commercial _ PS _ Xanthine_Oxidase_Inhibitor_QL _ProgSum_ 04-01-2024
|