DRAFT Self-Administered Drug Policies

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.

Final and draft policies are published on this site. Draft policies are available for provider comment for 45 days from the posting date on the document. We encourage practicing physicians to provide input.

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

Please use the Search function above to locate specific drug policy information.

Pharmacy Policies Disclaimer

Pharmacy drug 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.

 

How to Submit Comments on Draft Policies

Complete our policy feedback form online or send comments and supporting documentation to us by mail or fax:

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

Fax: 205-733-6471

 

Policy # Policy Title Print View
MP-991015
MP-9991067
PH-1142 Enspryng (satralizumab-mwge) Prior Authorization with Quantity Limit Program Summary
PH-91022 Afrezza Prior Authorization with Quantity Limit Program Summary
PH-91023 Ampyra Prior Authorization with Quantity Limit Program Summary
PH-91028 Atopic Dermatitis (Elidel, Eucrisa, Protopic tacrolimus ointment) Step Therapy Program Summary
PH-91057 Multiple Sclerosis Agents Step Therapy with Quantity Limit Program Summary
PH-91085 Insulin Prior Authorization Program Summary
PH-91090 Amantadine Extended Release Prior Authorization with Quantity Limit Program Summary
PH-91096 Hyperhidrosis Prior Authorization with Quantity Limit Program Summary
PH-91097 Pseudobulbar Affect (PBA) Prior Authorization with Quantity Limit Program Summary
PH-91118 Hypoactive Sexual Desire Disorder (HSDD) Prior Authorization with Quantity Limit Program Summary
PH-91121 Baclofen Prior Authorization with Quantity Limit Program Summary
PH-91122 Wakix Prior Authorization with Quantity Limit
PH-91135 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-91139 DPP-4 Inhabitors and Combinations Step Therapy and Quantity Limit Program Summary
PH-991008 Hereditary Angioedema Prior Authorization with Quantity Limit Program Summary
PH-991020 Topical Doxepin Prior Authorization with Quantity Limit Program Summary
PH-991032 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Prior authorization with Quantity Limit Program Summary
PH-991050 insulin Combination Agents (Soliqua, Xultophy) Step Therapy and Quantity Limit Program Summary
PH-991056 Metformin ER Step Therapy with Quantity Limit Program Summary
PH-991064 Oral Tetracycline Derivatives Step Therapy Program Summary
PH-991073 Strensiq Prior Authorization Program Summary
PH-991076 Transmucosal Immediate Release Fentanyl Prior Authorization (Through Generic) and Quantity Limit Program Summary
PH-991077 Topiramate ER Prior Authorization with Quantity Limit Program Summary
PH-991078 Triptan Step Therapy and Quantity Limit Program Summary
PH-991083 Oxybate Prior Authorization with Quantity Limit Program Summary
PH-991087 Coverage Exception Program Summary
PH-991088 Copay Waiver for Breast Cancer Primary Prevention Agent ACA Copay Waiver Program Summary - Individual Marketplace, Commercial
PH-991091 Lucemyra Prior Authorization with Quantity Limit Program Summary
PH-991103 Amifampridine Prior Authorization with Quantity Limit Program Summary
PH-991106 Arikayce Prior authorization with Quantity Limit Program Summary
PH-991115 Interleukin-5 (IL-5) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-991119 Interleukin-4 (IL-4) Inhibitor Prior authorization with Quantity Limit
PH-991124 Interstitial Lung Disease (ILD) Prior Authorization with Quantity Limit Program Summary
PH-991130 Risdiplam Prior Authorization with Wuantity Limit Program Summary
PH-9991007 GLP-1 (glucagon-like-peptide-1) Agonists Step Therapy and Quantity Limit Program Summary
PH-9991014 Methotrexate Injectable Step Therapy Program Summary
PH-9991018 Opioid Immediate Release Duration Limit and Quantity Limit Program Summary
PH-9991047 Inhaled Antibiotics Duplicate Therapy Prior Authorization Program Summary
PH-9991080 Urea Cycle Disorders Prior Authorization Program Summary
PH-9991110 Alinia Quantity Limit Program Summary
PH-99991012 Subcutaneous Immune Globulins Prior Authorization Program Summary
PH-99991017 Opiods ER Prior Authorization and Quantity Limit Program Summary
PH-99991024 Oral Anticoagulant - Bevyxxa (betrixaban), Eliquis (apixaban), Pradaxa (dabigatran), Savaysa (edoxaban), Xarelto (rivaroxaban) Quantity Limit Program Summary
PH-99991107 ATTR Amyloidosis Prior Authorization with Quantity Limit Program Summary
PH-999991069 Self-Administered Oncology Agents Prior authorization with Quantity Limit Program Summary
PH-9999991003 Buprenorphine and Buprenorphine/Naloxone for Opioid Dependence Prior Authorization, Quantity Limit and Concomitant Use of Opioid Products Program Summary