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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-90002 Actemra® (tocilizumab)
PH-90017 Benlysta® (belimumab)
PH-90018 Berinert® (C1 Esterase Inhibitor, Human)
PH-90026 Aflibercept: Eylea®; Eylea® HD
PH-90027 Cerezyme® (imiglucerase)
PH-90028 Cimzia® (certolizumab pegol)
PH-90059 SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify®
PH-90061 Hyaluronic Acid Derivatives: Durolane®, Euflexxa™, Gel-One®, GelSyn-3™, GenVisc 850®, Hyalgan™, Hymovis®, Monovisc®, Orthovisc™, Synojoynt, Supartz/Supartz FX™, Synvisc™, Synvisc-One™, Triluron™, TriVisc™, VISCO-3™
PH-90078 Ranibizumab: Lucentis®; Byooviz™; Cimerli™
PH-90098 Denosumab: Prolia®; Xgeva®
PH-90104 Infliximab: Remicade®; Inflectra™; Renflexis™; Avsola™, Infliximab*
PH-90105 Elelyso™ (taliglucerase alfa)
PH-90109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-90117 Stelara® (ustekinumab)
PH-90133 Natalizumab: (Tysabri®; Tyruko®)
PH-90141 VPRIV® (velaglucerase alfa)
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-90177 Ilaris® (canakinumab)
PH-90181 Visudyne® (verteporfin)
PH-90202 Entyvio® (vedolizumab)
PH-90207 Ruconest® (C1 Esterase Inhibitor [recombinant])
PH-90223 Lemtrada® (alemtuzumab)
PH-90238 Botox® (onabotulinumtoxinA)
PH-90239 Dysport® (abobotulinumtoxinA)
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-90260 Nucala® (mepolizumab)
PH-90273 Cinqair® (reslizumab)
PH-90282 Testopel® (testosterone pellets)
PH-90298 Ocrevus™ (ocrelizumab)
PH-90307 Haegarda® (C1 Esterase Inhibitor Subcutaneous [Human])
PH-90347 Fasenra® (benralizumab)
PH-90379 Onpattro® (patisiran lipid complex)
PH-90392 Takhzyro™ (lanadelumab-flyo)
PH-90427 Ultomiris® (ravulizumab-cwvz)
PH-90497 Beovu® (brolucizumab-dbll)
PH-90503 Reblozyl® (luspatercept-aamt)
PH-90525 Tepezza® (teprotumumab-trbw)
PH-90549 Uplizna™ (inebilizumab-cdon)
PH-90610 Aduhelm™ (aducanumab-avwa)
PH-90614 Saphnelo™ (anifrolumab-fnia)
PH-90634 Susvimo™ (ranibizumab)
PH-90635 Dextenza® (dexamethasone insert)
PH-90649 Vyvgart™ (efgartigimod alfa-fcab)
PH-90659 Vabysmo™ (faricimab-svoa)
PH-90660 Enjaymo™ (sutimlimab-jome)
PH-90670 Amvuttra (vutrisiran)
PH-90674 Spevigo® (spesolimab)
PH-90687 Tzield™ (teplizumab-mzwv)
PH-90693 Briumvi™ (ublituximab-xiiy)
PH-90697 Syfovre™ (pegcetacoplan)
PH-90712 Vyvgart® Hytrulo (efgartigimod alfa-fcab and hyaluronidase-qvfc)
PH-90727 Veopoz® (pozelimab-bbfg)
PH-91154 Empaveli (pegcetacoplan) Prior Authorization with Quantity Limit Program Summary