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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-91002 Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-910022 Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-91007 GLP-1 (glucagon-like peptide-1) Agonists Prior Authorization with Quantity Limit Program Summary
PH-91017 Opioids ER Prior Authorization and Quantity Limit Program Summary
PH-91019 Otezla (apremilast) Prior Authorization with Quantity Limit Program Summary
PH-91024 Oral Anticoagulant - Eliquis (apixaban), Pradaxa (dabigatran), Savaysa (edoxaban), Xarelto (rivaroxaban) Quantity Limit Program Summary
PH-91029 Atypical Antipsychotics Step Therapy with Quantity Limit Program Summary
PH-91033 Calcitonin Gene-Related Peptide (CGRP) Prior Authorization with Quantity Limit Program Summary
PH-91040 Gabapentin ER (extended-release) [Horizant, Gralise] Step Therapy and Quantity Limit Program Summary
PH-91042 Glucose Test Strips and Meters Step Therapy Program Summary
PH-91043 Growth Hormone Prior Authorization Program Summary
PH-91046 Corticotropin Prior Authorization Program Summary
PH-91049 Insomnia Agents Quantity Limit Program Summary
PH-91051 Interleukin (IL)-1 Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91055 Lyrica and Savella Step Therapy with Quantity Limit Program Summary
PH-91060 Northera (droxidopa) Prior Authorization with Quantity Limit Program Summary
PH-91063 Pulmonary Hypertension Agents Prior Authorization with Quantity Limit Program Summary
PH-91066 Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program 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 and Tavalisse 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, Quantity Limit Program Summary
PH-91092 Jynarque Prior Authorization with Quantity Limit Program Summary
PH-91095 Galafold (migalastat) Prior Authorization with Quantity Limit Program Summary
PH-91098 Samsca (tolvaptan) Prior Authorization with 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-91107 ATTR (transthyretin amyloid) Amyloidosis Prior Authorization with Quantity Limit Program Summary
PH-91114 Cablivi (caplacizumab-yhdp) Quantity Limit Program Summary
PH-91115 Interleukin-5 (IL-5) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91117 Opioids Immediate Release (IR) Quantity Limit Program Summary
PH-91118 Hypoactive Sexual Desire Disorder (HSDD) Prior Authorization with Quantity Limit Program Summary
PH-91130 Risdiplam Prior Authorization with Quantity Limit Program Summary
PH-91131 Acute Migraine Agents Prior Authorization with Quantity Limit Program Summary
PH-91140 Fintepla (fenfluramine) Prior Authorization with Quantity Limit Program Summary
PH-91142 Enspryng (satralizumab-mwge) 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-91153 Ivermectin Prior Authorization Program Summary
PH-91154 Empaveli (pegcetacoplan) Prior Authorization with Quantity Limit Program Summary
PH-91156 Atypical Antipsychotics – Extended Maintenance Agents Step Therapy and Quantity Limit Program Summary
PH-91163 Tavneos (avacopan) Prior Authorization with Quantity Limit Program Summary
PH-91165 Imcivree Prior Authorization with Quantity Limit Program Summary
PH-91166 Lupus Prior Authorization with Quantity Limit Program Summary
PH-91168 Hetlioz (tasimelteon) Prior Authorization with Quantity Limit Program Summary
PH-91170 Interleukin-13 (IL-13) Antagonist Prior Authorization with Quantity Limit Program Summary
PH-91175 Pyrukynd (mitapivat) Prior Authorization with Quantity Limit Program Summary
PH-91179 Attention Deficit [Hyperactivity] Disorder (ADHD/ADD) Agents Quantity Limit Program Summary
PH-91181 Elagolix/Relugolix Prior Authorization with Quantity Limit Program Summary
PH-91182 Penicillamine Step Therapy Program Summary
PH-91183 Radicava (edaravone) Prior Authorization with Quantity Limit Program Summary
PH-91185 Vtama (tapinarof) Prior Authorization Program Summary
PH-91196 Furoscix (furosemide) Prior Authorization with Quantity Limit Program Summary
PH-91198 Vijoice (alpelisib) Prior Authorization with Quantity Limit Program Summary
PH-91199 Antiretroviral Quantity Limit Program Summary
PH-91202 Filspari (sparsentan) Prior Authorization with Quantity Limit Program Summary
PH-91204 Joenja (leniolisib) Prior Authorization with Quantity Limit Program Summary
PH-91207 Skyclarys (omaveloxolone) Prior Authorization with Quantity Limit Program Summary
PH-91212 Combination NSAID Prior Authorization with Quantity Limit Program Summary
PH-91218 Fabhalta (iptacopan) Prior Authorization with Quantity Limit Program Summary
PH-91220 Xphozah (tenapanor) Prior Authorization with Quantity Limit Program Summary
PH-91225 Anti-COVID19 Quantity Limit Program Summary
PH-91226 Spevigo (spesolimab-sbzo) Prior Authorization with Quantity Limit Program Summary
PH-91227 Voydeya (danicopan) Prior Authorization with Quantity Limit Program Summary
PH-91228 Weight Management Prior Authorization with Quantity Limit Program Summary
PH-91229 Zilbrysq (zilucoplan) Prior Authorization with Quantity Limit Program Summary
PH-91230 Primary Biliary Cholangitis Prior Authorization with Quantity Limit Program Summary
PH-91236 Interleukin-31 (IL-31) Inhibitor Prior Authorization with Quantity Limit Program Summary
PH-91240 Crenessity Prior Authorization with Quantity Limit Program Summary
PH-91241 Tryngolza Prior Authorization with Quantity Limit Program Summary