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Draft Provider-Administered Drug Policies (Excluding Oncology)

Draft provider-administered drug policies are listed below. If there are no policies listed, it means there are currently no policies in draft status.

The drugs below require that a member’s medical condition meets the policy requirements prior to being given (precertification) unless otherwise specified. 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 is required for these provider-administered drugs when administered in a provider’s office or home health setting; precertification does not apply to inpatient hospital claims at this time.

Precertification for the drugs listed below is also required in the outpatient facility setting. Exceptions to this include: Luxturna, Kymriah and Yescarta, which require a precertification for any place of treatment.

Members can request a copy of a full drug policy, by calling the Customer Service number on their ID card.

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-90006 Aldurazyme® (laronidase)
PH-90034 Elaprase® (idursulfase)
PH-90042 Fabrazyme® (agalsidase beta)
PH-90059 SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify®
PH-90071 Immune Globulins (immunoglobulin): Alyglo™; Bivigam®; Flebogamma®; Gamunex-C®; Gammagard® Liquid; Gammagard® S/D; Gammaked™; Gammaplex®; Octagam®; Privigen®; Panzyga®
PH-90079 Lumizyme® (alglucosidase alfa)
PH-90084 Naglazyme® (galsulfase)
PH-90089 Nplate® (romiplostim)
PH-90109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-90145 Xiaflex® (collagenase)
PH-90146 Xolair® (omalizumab)
PH-90183 Levoleucovorin: Fusilev®; Khapzory™
PH-90190 Vimizim (elosulfase alfa)
PH-90229 Cosentyx® (secukinumab)
PH-90234 Colony Stimulating Factors – Pegfilgrastim: Neulasta®; Fulphila™; Udenyca®; Ziextenzo™; Nyvepria™; Fylnetra®, Stimufend®
PH-90238 Botox® (onabotulinumtoxinA)
PH-90239 Dysport® (abobotulinumtoxinA)
PH-90240 Myobloc® (rimabotulinumtoxinB)
PH-90241 Xeomin® (incobotulinumtoxinA) (Precertification not required)
PH-90277 Kanuma™ (sebelipase alfa)
PH-90299 Brineura (cerliponase alfa)
PH-90346 Mepsevii® (vestronidase alfa-vjbk)
PH-90594 Nulibry™ (fosdenopterin)
PH-90615 Nexviazyme™ (avalglucosidase alfa-ngpt)
PH-90649 Vyvgart™ (efgartigimod alfa-fcab)
PH-90673 Xenpozyme™ (olipudase alfa)
PH-90677 Skysona® (elivaldogene autotemcel)
PH-90696 Lamzede® (velmanase alfa-tycv)
PH-90708 Elfabrio® (pegunigalsidase alfa-iwxj)
PH-90709 Vyjuvek™ (beremagene geperpavec-svdt)
PH-90712 Vyvgart® Hytrulo (efgartigimod alfa-fcab and hyaluronidase-qvfc)
PH-90714 Rystiggo® (rozanolixizumab-noli)
PH-90731 Pombiliti™ (cipaglucosidase alfa-atga)
PH-990712 Vyvgart® Hytrulo (efgartigimod alfa-fcab and hyaluronidase-qvfc)