Draft Provider-Administered Drug Policies

The drugs below require that a member’s medical condition meets the policy requirements prior to being given (precertification). Providers must submit a request for pre-service review in order to be approved. If the provider does not receive approval for precertification, the plan will pay no benefits. Currently, precertification for these provider-administered drugs is required when administered in a provider’s office or home health setting; however, this precertification does not apply to inpatient hospital claims at this time. Precertification for the drugs listed below will be required in the outpatient facility setting beginning April 1, 2019. Exceptions to this exist at this time: Luxturna, Kymriah and Yescarta require a precertification for any place of treatment. To request a copy of a full drug policy, members can contact Customer Service by calling the number on their ID card.

Please use the Search function above to locate specific drug policy information.

 

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-90002 Actemra (tocilizumab)
PH-90006 Aldurazyme (laronidase)
PH-90018 Berinert (C1 Esterase Inhibitor, Human)
PH-90026 Eylea (aflibercept)
PH-90028 Cimzia (certolizumab pegol)
PH-90034 Elaprase (idursulfase)
PH-90059 Immune Globulins SC (Hizentra, Gammagard Liquid, Gamunex-C, Gammaked, Hyqvia, Cuvitri, Cutaquig, Xembify)
PH-90061 Hyaluronic Acid Derivatives
PH-90071 Immune Globulins (Asceniv, Bivigam, Carimune NF, Flebogamma, Gamunex-C, Gammagard Liquid, Gammagard S/D, Gamaked, Gammaplex, Octagam, Privigen, Panzyga)
PH-90078 Lucentis (ranibizumab)
PH-90079 Lumizyme (alglucosidase alfa)
PH-90081 Macugen (pegaptanib)
PH-90084 Naglazyme (galsulfase)
PH-90109 Rituximab: Rituxan, Truxima, Ruxience
PH-90114 Soliris (eculizumab)
PH-90133 Tysabri (natalizumab)
PH-90146 Xolair (omalizumab)
PH-90158 Krystexxa (pegloticase)
PH-90167 Kalbitor (ecallantide)
PH-90168 Cinryze (C1 Esterase Inhibitor Human)
PH-90169 Firazyr (icatibant)
PH-90176 Simponi ARIA (golimumab)
PH-90190 Vimizim (elosulfase alfa)
PH-90202 Entyvio (vedolizumab)
PH-90207 Ruconest (C1 Esterase Inhibitor [recombinant])
PH-90223 Lemtrada (alemtuzumab)
PH-90234 Colony Stimulating Factors – Pegfilgrastim: Neulasta®; Fulphila™; Udenyca®; Ziextenzo™; Nyvepria™
PH-90241 Xeomin® (incobotulinumtoxinA)
PH-90260 Nucala (mepolizumab)
PH-90273 Cinqair (reslizumab)
PH-90291 Spinraza (nusinersen)
PH-90298 Ocrevus (ocrelizumab)
PH-90299 Brineura (cerliponase alfa)
PH-90307 Haegarda (C1 Esterase Inhibitor Subcutaneous [Human])
PH-90346 Mepsevii (vestronidase alfa-vjbk)
PH-90347 Fasenra (benralizumab)
PH-90350 Luxturna (voretigene neparvovec-rzyl)
PH-90363 Akynzeo (fosnetupitant/palonosetron)
PH-90379 Onpattro (patisiran lipid complex)
PH-90392 Takhzyro (lanadelumab-flyo)
PH-90427 Ultomiris (ravulizumab-cwvz)
PH-90468 Zolgensma (onasemnogene abeparvovec-xioi)
PH-90481 Spravato (esketamine)
PH-90497 Beovu (brolucizumab-dbll)
PH-90503 Reblozyl (luspatercept-aamt)
PH-90514 Givlaari (givosiran)
PH-90525 Tepezza (teprotumumab-trbw)