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-1114 |
Sunosi Prior Authorization with Quantity Limit Program Summary |
|
PH-1114 |
Cablivi Quantity Limit Program Summary |
|
PH-1116 |
Acute Migraine 5HT Step Therapy and Quantity Limit Program Summary |
|
PH-1118 |
Hypoactive Sexual Desire Disorder (HSDD) Prior Authorization with Quantity Limit Program Summary |
|
PH-1119 |
Interleukin-4 (IL-4) Inhibitor Prior Authorization with Quantity Limit Program Summary |
|
PH-91005 |
|
|
PH-91007 |
GLP-1 (glucagon-like peptide-1) Agonists Step Therapy and Quantity Limit Program Summary |
|
PH-91013 |
Mandatory Generic/Member Pays the Difference Exception Prior Authorization Program Summary |
|
PH-91015 |
Constipation Agents Prior Authorization with Quantity Limit Program Summary |
|
PH-91017 |
Opioids ER Prior Authorization and Quantity Limit Program Summary |
|
PH-91018 |
Opioid Immediate Release Duration Limit and Quantity Limit Program Summary |
|
PH-91020 |
Topical Doxepin Prior Authorization with Quantity Limit Program Summary |
|
PH-91024 |
Oral Anticoagulant - Bevyxxa, (betrixaban), Eliquis (apixaban), Pradaxa (dabigatran), Savaysa (edoxaban), Xarelto (rivaroxaban) Quantity Limit Program Summary |
|
PH-91025 |
Antiemetic Agents Quantity Limit Program Summary |
|
PH-91026 |
Anti-Influenza Agents Quantity Limit Program Summary |
|
PH-91031 |
Carbaglu (carglumic acid) Prior Authorization Program Summary |
|
PH-91034 |
Antifungal Agents - ciclopirox, efinaconazole, tavaborole Prior Authorization with Quantity Limit Program Summary |
|
PH-91037 |
Topical Diclofenac Gel, Fluorouracil Cream, Imiquimod Cream, and Ingenol Gel Prior Authorization with Quantity Limit and Quantity Limit Program Summary |
|
PH-91046 |
H.P. Acthar Gel (repository corticotropin) Prior Authorization Program Summary |
|
PH-91054 |
Korlym (mifepristone) Prior Authorization with Quantity Limit Program Summary |
|
PH-91058 |
Myalept (metreleptin) Prior Authorization Program Summary |
|
PH-91059 |
Parathyroid Hormone Analog for Osteoporosis Prior Authorization through Preferred with Quantity Limit Program Summary |
|
PH-91064 |
Oral Tetracycline Derivatives Step Therapy Program Summary |
|
PH-91065 |
Parathyroid Hormone Analog for Osteoporosis Prior Authorization through Preferred with Quantity Limit Program Summary |
|
PH-91067 |
Phenylketonuria Prior Authorization Program Summary |
|
PH-91070 |
|
|
PH-91073 |
Strensiq (asfotase alfa) Prior Authorization Program Summary |
|
PH-91087 |
Coverage Exception Program Summary |
|
PH-91093 |
Orilissa 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-91110 |
Alinia Quantity Limit Program Summary |
|
PH-91111 |
Tafamidis Prior Authorization with Quantity Limit Program Summary |
|
PH-91112 |
Riluzole Prior Authorization with Quantity Limit Program Summary |
|
PH-991000 |
Androgens and Anabolic Steroids Prior Authorization with Quantity Limit Through Generic Topical Androgen Program Summary |
|
PH-991009 |
PePeg-interferon Prior Authorization Program Summary |
|
PH-991012 |
Immune Globulins Prior Authorization Program Summary |
|
PH-991017 |
Opioids IR Quantity Limit Program Summary |
|
PH-991038 |
Emflaza (deflazacort) Prior Authorization with Quantity Limit Program Summary |
|
PH-991043 |
Growth Hormone Prior authoriztion |
|
PH-991059 |
Natpara (parathyroid hormone) Prior Authorization with Quantity Limit Program Summary |
|
PH-991063 |
Oral Pulmonary Hupertension Agents Prior Authorization wiht Quantity Limit Program Summary |
|
PH-991080 |
Urea Cycle Disorders Prior Authorization Program Summary |
|
PH-991107 |
hATTR Amyloidosis Neuropathy Prior Authorization with Quantity Limit Program Summary |
|
PH-9991002 |
Biologic Immunomodulators Prior Authorization with Quantity Limit with Preferred Products Program Summary |
|
PH-9991009 |
Hepatitis C Direct Acting Antivirals Prior Authorization - Through Preferred Agent(s) Program Summary |
|
PH-9991075 |
Thrombopoietin receptor agonists Prior Authorization with Quantity Limit Program Summary |
|