Draft Self-Administered Drug Policies

Draft self-administered drug policies are listed below. If there are no policies listed, it means there are currently no policies in draft status.

Drug policies are based on:

  • Information in FDA-approved package inserts (and black box warnings, alerts or other information disseminated by the FDA, as applicable);
  • Research of current medical and pharmacy literature; and/or,
  • Review of common medical practices in the treatment and diagnosis of disease.

Note: Coverage is subject to member's specific benefits. Group-specific policies will supersede these policies, when applicable. Always verify member eligibility and benefits.

Pharmacy drug policies provide a guide to coverage. Pharmacy policies are not intended to dictate to providers how to practice medicine. Providers should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

Comment on Draft Drug Policies

Participating providers are invited to submit for consideration scientific, evidence-based information, professional consensus opinions, and other information supported by medical literature relevant to our draft policies.

We accept comments for 45 days from the posting date listed on the draft policy.

Make sure your voice is heard by providing feedback directly to us:

Blue Cross and Blue Shield of Alabama
Attn: Pharmacy Department
P.O. Box 995
Birmingham, AL 35298-0001

Fax: 205-220-9576

Draft Policies

Policy # Policy Title Print View
PH-1166 Lupus Prior Authorization with Quantity Limit Program Summary
PH-91000 Androgens and Anabolic Steroids Prior Authorization with Quantity Limit Through Generic Program Summary
PH-91002 Biologic Immunomodulators Prior Authorization with Quantity Limit with Preferred Products Program Summary
PH-91008 Hereditary Angiodema Prior Authorization with Quantity Limit Program Summary
PH-91009 Peg-interferon Prior Authorization Program Summary
PH-91015 Constipation Agents Prior Authorization Through Preferred with Quantity Limit Program Summary
PH-91017 Opioids ER Prior Authorization and Quantity Limit Program Summary
PH-91018 Opioids Immediate Release (IR) Duration Limit and Quantity Limit Program Summary
PH-91019 Otezla (apremilast) Prior Authorization with Quantity Limit Program Summary
PH-91027 Angiotensin II Receptor Antagonists (ARBs), Renin Inhibitors, and Combinations Step Therapy Program Summary
PH-91033 Calcitonin Gene-Related Peptide (CGRP) Prior Authorization with Quantity Limit Program Summary
PH-91042 Glucose Test Strips and Meters Step Therapy Program Summary
PH-91043 Growth Hormone Prior Authorization Program Summary
PH-91045 Homozygous Familial Hypercholesterolemia Agents (HoFH) Prior Authorization with Quantity Limit Program Summary
PH-91049 Insomnia Agents Step Therapy and Quantity Limit Program Summary
PH-91051 Interleukin (IL)-1 Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91053 Keveyis Prior Authorization with Quantity Limit Program Summary
PH-91055 Lyrica CR (pregabalin ER) Prior Authorization with Quantity Limit Program Summary
PH-91057 Multiple Sclerosis Agents Step Therapy with Quantity Limit Program Summary
PH-91060 Northera (droxidopa) Prior Authorization with Quantity Limit Program Summary
PH-91062 Riluzole Prior Authorization with Quantity Limit Program Summary
PH-91063 Oral Pulmonary Hypertension Agents Prior Authorization with Quantity Limit Program Summary
PH-91065 Parathyroid Hormone Analog for Osteoporosis Prior Authorization through Preferred with Quantity Limit Program Summary
PH-91066 Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) Inhibitors Prior Authorization with Quantity Limit Program Summary-Through Preferred agent(s)
PH-91069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Summary
PH-91071 Selective Serotonin Inverse Agonist (SSIA) Prior Authorization with Quantity Limit Program Summary
PH-91074 Substrate Reduction Therapy Prior Authorization with Quantity Limit Program Summary
PH-91075 Thrombopoietin Receptor Agonists Prior Authorization with Quantity Limit Program Summary
PH-91077 Topiramate ER Prior Authorization with Quantity Limit Program Summary
PH-91078 Triptan Step Therapy and Quantity Limit Program Summary
PH-91089 Erectile Dysfunction -Phosphodiesterase Type 5 Inhibitors, Topical Prostaglandin Quantity Limit Program Summary
PH-91092 Jynarque (tolvaptan) Prior Authorization with Quantity Limit Program Summary
PH-91095 Galafold (migalastat) Prior Authorization with Quantity Limit Program Summary
PH-91098 Samsca (tolvaptan) Prior Authorization And Quantity Limit Program Summary
PH-91100 Cannabidiol Prior Authorization Program Summary
PH-91101 Antidepressant Agents Step Therapy and Quantity Limit Program Summary
PH-91105 Weight Loss Agents Prior Authorization with Quantity Limit Program Summary
PH-91114 Cablivi (caplacizumab-yhdp) Quantity Limit Program Summary
PH-91121 Baclofen Prior Authorization with Quantity Limit Program Summary
PH-91124 Interstitial Lung Disease (ILD) Prior Authorization with Quantity Limit Program Summary
PH-91127 Oxbryta (voxelotor) Prior Authorization with Quantity Limit Program Summary
PH-91128 Peanut Allergy Prior Authorization with Quantity Limit Program Summary
PH-91131 Acute Migraine Agents Prior authorization with Quantity Limit Program Summary
PH-91134 Ophthalmic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-91135 Sodium-glucose Co-transporter 2 (SGLT-2) Inhibitors and Combinations Step Therapy and Quantity Limit Program Summary
PH-91137 Atypical Antipsychotics Short Acting Step Therapy and Quantity Limit Program Summary
PH-91140 Fintepla (fenfluramine) Prior Authorization with Quantity Limit Program Summary
PH-91146 Zokinvy Prior Authorization with Quantity Limit Program Summary
PH-91147 Zeposia (oxanimod) Prior Authorization with Quantity Limit Program Summary
PH-91150 Continuous Glucose Monitor (CGM) Step Therapy with Quantity Limit Program Summary
PH-91151 Iron Chelation Prior Authorization with Quantity Limit Program Summary
PH-91156 Atypical Antipsychotics – Extended Maintenance Agents Step Therapy and Quantity Limit Program Summary
PH-91159 Long Acting Insulin Prior Authorization Program Summary
PH-91168 Hetlioz (tasimelteon) Prior Authorization with Quantity Limit Program Summary
PH-91169 Voxzogo (vosoritide) Prior Authorization with Quantity Limit Program Summary