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-91006 Flector® Prior Authorization with Quantity Limit Program Summary
PH-91007 GLP-1 (glucagon-like peptide-1) Agonists Step Therapy and Quantity Limit Program Summary
PH-91019 Otezla (apremilast) Prior Authorization with Quantity Limit Program Summary
PH-91029 Atypical Antipsychotics Step Therapy and 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
PH-91062 Riluzole Prior Authorization with Quantity Limit Program Summary
PH-91067 Phenylketonuria Prior Authorization Program Summary
PH-91095 Galafold (migalastat) Prior Authorization with Quantity Limit Program Summary
PH-91109 Imcivree Prior Authorization with Quantity Limit
PH-91114 Cablivi Quantity Limit Program Summary
PH-91128 Peanut allergy Prior Authorization with Quantity Limit
PH-91136 Atypical Antipsychotics - Extended Maintenance Agents Step Therapy and Quantity Limit Program Summary
PH-91140 Fintepla (fenfluramine) Prior Authorization with Quantity Limit Program Summary
PH-991001 Lupus Prior Authorization with Quantity Limit Program Summary
PH-991035 Hetlioz (tasimelteon) Prior Authoriztaion with Quantity Limit Program Summary
PH-991045 Homozygous Familial Hpercholesterolemia Agents (HoFH) Prior Authorization with Quantity Limit Program Summary
PH-991053 Keveyis Prior Authorization with Quantity Limit Program Summary
PH-991055 Lyrica CR® (pregabalin CR) Prior Authorization with Quantity Limit Program Summary
PH-991057 Multiple Sclerosis Agents Step Therapy with Quantity Limit Program Summary
PH-991060 Northera® (droxidopa) Prior Authorization with Quantity Limit Program Summary
PH-991071 Selective Serotonin Inverse Agonist (SSIA) Prior Authorization with Quantity Limit Program Summary
PH-991074 Substrate Reduction Therapy Prior Authorization with Quantity Limit Program Summary
PH-991089 Erectile Dysfunction - Phosphodiesterase Type 5 Inhibitors, Topical Prostaglandin Quantity Limit
PH-991090 Amantadine Extended Release Prior Authorization with Wuantity Limit Program Summary
PH-991092 Jynarque Prior Authorization with Quantity Limit
PH-991101 Antidepressant Agents Step Therapy and Quantity Limit Program Summary
PH-991117 Opioids IR Quantity Limit
PH-991131 Acute Migraine Agents Prior Authorization with Quantity Limit Program Summary
PH-991137 Atypical Antipsychotics Step Therapy and Quantity Limit Program Summary
PH-9991031 Carbaglu (carglumic acid) Prior Authorization Criteria
PH-9991033 CGRP Prior Authorization with Quantity Limit Program Summary
PH-9991037 Topical Actinic Keratosis, Basal Cell Carcinoma, Genital Warts Agents Prior Authorization with Quantity Limit and Quantity Limit Program Summary
PH-9991063 Oral Pulmonary Arterial Hypertension Agents Prior Authorization with Quantity Limit
PH-9991065 Parathyroid Hormone Analog for Osteoporosis Prior Authorization through Preferred with Quantity Limit Program Summary
PH-9991066 Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) Inhibitors Prior Authorization with Quantity Limit-Through Preferred Agent(s)
PH-9991072 Statin Step Therapy Program Summary
PH-9991077 Topiramate ER Prior Authorization with Quantity Limit Program Summary
PH-9991078 Triptan Step Therapy and Quantity Limit Program Summary
PH-9991098 Samsca (tolvaptan) Prior Authorization with Quantity Limit Program Summary
PH-9991100 Cannabidiol Prior Authorization Prgram Summary
PH-9991105 Weight Loss Agents Prior Authorization with Quantity Limit Program Summary
PH-99991018 Opioids Immediate Release Duration Limit and Quantity Limit Program Summary
PH-99991075 Thrombopoietin Receptor Agonists Prior Authorization with Quantity Limit Program Summary
PH-999991000 Androgens and Anabolic Steroids Prior Authorization with Quantity Limit Through Generic Program Summary
PH-999991017 Opioids ER Prior Authorization and Quantity Limit Program Summary
PH-9999991069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
PH-99999991002 Biologic Immunomodulators Prior Authorization with Quantity Limit with Preferred Products Program Summary
PH-99999991003 Buprenorphine and Buprenorphine/Naloxone for Opioid Dependence Prior Authorization, Quantity Limit and Concomitant Use of Opioid Products Program Summary