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
PH-1093 Elagolix Prior Authorization with Quantity Limit Program Summary
PH-1135 SGLT-2 Inhibitors and Combinations Step Therapy and Quantity Limit Program Summary
PH-1136 Atypical Antipsychotics, Long Acting Step Therapy and Quantity Limit Program Summary
PH-1137 Atypical Antipsychotics, Short Acting Step Therapy and Quantity Limit Program Summary
PH-1138 Dojolvi Prior Authorization Program Summary
PH-1139 DPP-4 Inhibitors and Combinations Step Therapy and Quantity Limit Program Summary
PH-1140 Fintepla (fenfluramine) Prior Authorization with Quantiy Limit Program Summary
PH-1141 Rho Kinase Inhibitor Step Therapy and Quantity Limit program Summary
PH-91062 Riluzole Prior Authorization with Quantity Limit Program Summary
PH-91083 Sodium Oxybate Prior Authorization with Qunatity Limit Program Summary
PH-91113 Procysbi (cysteamine bitartrate) Prior Authorization Program Summary
PH-91117 Opioids IR 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-91133 Isturisa Prior Authorization with Quantity Limit Program Summary
PH-991005 Contraceptive Prior Authorization Program Summary
PH-991013 Mandatory Generic/Member Pays the Difference Exception Prior Authorization
PH-991014 Methotrexate Injectable Step Therapy Program Summary
PH-991018 Opioid Immediate Release Duration Limit and Quantity Limit Program Summary
PH-991031 Carbaglu (carglumic acid) Prior Authoriaztion Program Summary
PH-991034 Antifungal Agents - ciclopirox, efinaconazole, tavaborle Prior authoriaztion with Quantity Limit Program Summary
PH-991037 Topical Diclofenac Gel, Fluorouracil Cream, Imiquimod Cream, and Ingenol Gel Prior Authorization with Quantity Limit
PH-991046 Corticotropin (repository corticotropin) Prior Authorization Program Summary
PH-991047 Inhaled Antibiotics Duplicate Therapy Prior Authorization Program Summary
PH-991051 Interleukin (IL)-1 Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-991054 Korlym (mifepristone) Prior Authorization with Quantity Limit Program Summary
PH-991058 Myalept (metreleptin) Prior Authorization Program Summary
PH-991065 Parathyroid Hormone Analog for Osteoporosis Prior Authorization through Preferred with Quantity Limit Program Summary
PH-991067 Phenylketonuria Prior Authorization Program Summary
PH-991070 Signifor Prior Authorization with Quantity Limit Program Summary
PH-991098 Samsca (tolvaptan) Prior Authorization and Quantity Limit Program Summary
PH-991100 Cannabidiol Prior Authorization Program Summary
PH-991120 Hepatitis C Direct Acting antivirals Prior authorization with Quantity Limit - through Preferred Agent(s) Program Summary
PH-9991019 Otezla (apremilast) Prior Authorization with Quantity Limit
PH-9991024 Oral Anticoagulant - Bevyxxa (betrixaban), Eliquis (apixaban), Pradaxa (dabigatran), Savaysa (edoxaban), Xarelto (rivaroxaban) Quanitity Limit Program Summary
PH-9991025 Antiemetic Step Therapy with Quantity Limit and Quantity Limit Program Summary
PH-9991038 Emflaza (deflazacort) Prior Authorization with Quantity Limit Program Summary
PH-9991043 Growth Hormone Prior Authorization Program Summary
PH-9991059 Natpara (parathyroid hormone) Prior Authorization with Quantity Limit Program Summary
PH-99991069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
PH-999991002 Biologic Immunomodulators prior Authorization with Quantity Limit with Preferred Products Program Summary