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 |
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MP-9991067 |
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PH-1142 |
Enspryng (satralizumab-mwge) Prior Authorization with Quantity Limit Program Summary |
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PH-91022 |
Afrezza Prior Authorization with Quantity Limit Program Summary |
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PH-91023 |
Ampyra Prior Authorization with Quantity Limit Program Summary |
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PH-91028 |
Atopic Dermatitis (Elidel, Eucrisa, Protopic tacrolimus ointment) Step Therapy Program Summary |
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PH-91057 |
Multiple Sclerosis Agents Step Therapy with Quantity Limit Program Summary |
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PH-91085 |
Insulin Prior Authorization Program Summary |
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PH-91090 |
Amantadine Extended Release Prior Authorization with Quantity Limit Program Summary |
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PH-91096 |
Hyperhidrosis Prior Authorization with Quantity Limit Program Summary |
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PH-91097 |
Pseudobulbar Affect (PBA) Prior Authorization with Quantity Limit Program Summary |
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PH-91118 |
Hypoactive Sexual Desire Disorder (HSDD) Prior Authorization with Quantity Limit Program Summary |
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PH-91121 |
Baclofen Prior Authorization with Quantity Limit Program Summary |
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PH-91122 |
Wakix Prior Authorization with Quantity Limit |
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PH-91135 |
SGLT-2 Inhibitors and Combinations Step Therapy and Quantity Limit Program Summary |
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PH-91137 |
Atypical Antipsychotics, Short Acting Step Therapy and Quantity Limit Program Summary |
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PH-91139 |
DPP-4 Inhabitors and Combinations Step Therapy and Quantity Limit Program Summary |
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PH-991008 |
Hereditary Angioedema Prior Authorization with Quantity Limit Program Summary |
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PH-991020 |
Topical Doxepin Prior Authorization with Quantity Limit Program Summary |
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PH-991032 |
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Prior authorization with Quantity Limit Program Summary |
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PH-991050 |
insulin Combination Agents (Soliqua, Xultophy) Step Therapy and Quantity Limit Program Summary |
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PH-991056 |
Metformin ER Step Therapy with Quantity Limit Program Summary |
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PH-991064 |
Oral Tetracycline Derivatives Step Therapy Program Summary |
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PH-991073 |
Strensiq Prior Authorization Program Summary |
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PH-991076 |
Transmucosal Immediate Release Fentanyl Prior Authorization (Through Generic) and Quantity Limit Program Summary |
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PH-991077 |
Topiramate ER Prior Authorization with Quantity Limit Program Summary |
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PH-991078 |
Triptan Step Therapy and Quantity Limit Program Summary |
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PH-991083 |
Oxybate Prior Authorization with Quantity Limit Program Summary |
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PH-991087 |
Coverage Exception Program Summary |
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PH-991088 |
Copay Waiver for Breast Cancer Primary Prevention Agent ACA Copay Waiver Program Summary - Individual Marketplace, Commercial |
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PH-991091 |
Lucemyra Prior Authorization with Quantity Limit Program Summary |
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PH-991103 |
Amifampridine Prior Authorization with Quantity Limit Program Summary |
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PH-991106 |
Arikayce Prior authorization with Quantity Limit Program Summary |
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PH-991115 |
Interleukin-5 (IL-5) Inhibitors Prior Authorization with Quantity Limit Program Summary |
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PH-991119 |
Interleukin-4 (IL-4) Inhibitor Prior authorization with Quantity Limit |
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PH-991124 |
Interstitial Lung Disease (ILD) Prior Authorization with Quantity Limit Program Summary |
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PH-991130 |
Risdiplam Prior Authorization with Wuantity Limit Program Summary |
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PH-9991007 |
GLP-1 (glucagon-like-peptide-1) Agonists Step Therapy and Quantity Limit Program Summary |
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PH-9991014 |
Methotrexate Injectable Step Therapy Program Summary |
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PH-9991018 |
Opioid Immediate Release Duration Limit and Quantity Limit Program Summary |
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PH-9991047 |
Inhaled Antibiotics Duplicate Therapy Prior Authorization Program Summary |
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PH-9991080 |
Urea Cycle Disorders Prior Authorization Program Summary |
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PH-9991110 |
Alinia Quantity Limit Program Summary |
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PH-99991012 |
Subcutaneous Immune Globulins Prior Authorization Program Summary |
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PH-99991017 |
Opiods ER Prior Authorization and Quantity Limit Program Summary |
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PH-99991024 |
Oral Anticoagulant - Bevyxxa (betrixaban), Eliquis (apixaban), Pradaxa (dabigatran), Savaysa (edoxaban), Xarelto (rivaroxaban) Quantity Limit Program Summary |
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PH-99991107 |
ATTR Amyloidosis Prior Authorization with Quantity Limit Program Summary |
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PH-999991069 |
Self-Administered Oncology Agents Prior authorization with Quantity Limit Program Summary |
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PH-9999991003 |
Buprenorphine and Buprenorphine/Naloxone for Opioid Dependence Prior Authorization, Quantity Limit and Concomitant Use of Opioid Products Program Summary |
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