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-0239 Dysport® (abobotulinumtoxinA)
PH-90002 Actemra® (tocilizumab)
PH-90034 Elaprase® (idursulfase)
PH-90078 Ranibizumab: Lucentis®; Byooviz™
PH-90080 Leuprolide Suspension: Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Camcevi™(Precertification not required)
PH-90098 Denosumab: Prolia®; Xgeva®
PH-90105 Elelyso™ (taliglucerase alfa)
PH-90109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-90111 Sandostatin® LAR (octreotide suspension) (Precertification not required)
PH-90117 Stelara® (ustekinumab)
PH-90120 Synagis® (palivizumab)
PH-90131 Trelstar® (triptorelin) (Precertification not required)
PH-90135 Vantas® (histrelin acetate) (Precertification not required)
PH-90141 VPRIV® (velaglucerase alfa)
PH-90151 Zoladex® (goserelin acetate) (Precertification not required)
PH-90183 Levoleucovorin: Fusilev®; Khapzory™
PH-90202 Entyvio® (vedolizumab)
PH-90234 Colony Stimulating Factors – Pegfilgrastim: Neulasta®; Fulphila™; Udenyca®; Ziextenzo™; Nyvepria™
PH-90235 Colony Stimulating Factors: Filgrastim (Neupogen®); Filgrastim-aafi (Nivestym™); Filgrastim-sndz (Zarxio®); Filgrastim-ayow (Releuko®); Tbo-Filgrastim (Granix®)
PH-90237 Leukine® (sargramostim)
PH-90238 Botox® (onabotulinumtoxinA)
PH-90240 Myobloc® (rimabotulinumtoxinB)
PH-90241 Xeomin® (incobotulinumtoxinA) (Precertification not required)
PH-90242 Aranesp® (darbepoetin alfa)
PH-90243 Epoetin alfa: Epogen®; Procrit®; Retacrit™
PH-90244 Mircera® (methoxy polyethylene glycol-epoetin beta) (Precertification not required)
PH-90362 Crysvita® (burosumab-twza)
PH-90497 Beovu® (brolucizumab-dbll)
PH-90503 Reblozyl® (luspatercept-aamt)
PH-90527 Vyepti® (eptinezumab-jjmr)
PH-90591 Evkeeza™ (evinacumab-dgnb)
PH-90614 Saphnelo™ (anifrolumab-fnia)