Asset Publisher

Draft Provider-Administered Drug Policies 

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 Provider-Administered Drug Policies

Policy # Policy Title Print View
PH-90002 Tocilizumab: Actemra®; Tofidence™; Tyenne®
PH-90003 Corticotropin-ACTH: Acthar® Gel (repository corticotropin injection) Cortrophin® Gel (repository corticotropin injection)
PH-90008 Palonosetron: Aloxi®; Palonosetron Ψ
PH-90017 Benlysta® (belimumab)
PH-90018 Berinert® (C1 Esterase Inhibitor, Human)
PH-90026 Aflibercept: Eylea®; Eylea® HD; Opuviz™; Yesafili™; Ahzantive™
PH-90052 Alpha-1-Proteinase Inhibitors: Aralast NP®; Glassia®; Prolastin®-C; Zemaira®
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-90091 Orencia® (abatacept)
PH-90109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-90111 Sandostatin® LAR (octreotide suspension) (Precertification not required)
PH-90114 Eculizumab: Soliris®; Bkemv™
PH-90117 Ustekinumab: Stelara®; Wezlana™; Selarsdi™; Pyzchiva®
PH-90131 Trelstar® (triptorelin) (Precertification not required)
PH-90146 Xolair® (omalizumab)
PH-90151 Zoladex® (goserelin acetate) (Precertification not required)
PH-90167 Kalbitor® (ecallantide)
PH-90168 Cinryze® (C1 Esterase Inhibitor, Human)
PH-90169 Firazyr® (icatibant)
PH-90177 Ilaris® (canakinumab)
PH-90207 Ruconest® (C1 Esterase Inhibitor [recombinant])
PH-90229 Cosentyx® (secukinumab)
PH-90234 Long-Acting Granulocyte Colony Stimulating Factors (LA-gCSF): Neulasta®; Fulphila®; Udenyca®; Ziextenzo®; Nyvepria™; Fylnetra®; Stimufend®; Rolvedon®; Ryzneuta®
PH-90235 Short-Acting Granulocyte Colony Stimulating Factors (SA-gCSF): Filgrastim (Neupogen®); Filgrastim-aafi (Nivestym™); Filgrastim-sndz (Zarxio®); Filgrastim-ayow (Releuko®); Tbo-Filgrastim (Granix®); Filgrastim-txid (Nypozi™)
PH-90237 Leukine® (sargramostim)
PH-90291 Spinraza™ (nusinersen)
PH-90307 Haegarda® (C1 Esterase Inhibitor Subcutaneous [Human])
PH-90358 Ilumya™ (tildrakizumab-asmn)
PH-90392 Takhzyro™ (lanadelumab-flyo)
PH-90468 Zolgensma® (onasemnogene abeparvovec-xioi)
PH-90481 Spravato (esketamine)
PH-90503 Reblozyl® (luspatercept-aamt)
PH-90591 Evkeeza™ (evinacumab-dgnb)
PH-90614 Saphnelo™ (anifrolumab-fnia)
PH-90652 Leqvio® (inclisiran)
PH-90671 Skyrizi® (risankizumab-rzaa)
PH-90672 Zynteglo® (betibeglogene autotemcel)
PH-90674 Spevigo® (spesolimab)
PH-90751 Lenmeldy™ (atidarsagene autotemcel)
PH-90762 Piasky ™ (crovalimab-akkz)
PH-90763 Kisunla™ (donanemab-azbt)
VP-90004 Adcetris® (brentuximab vedotin)
VP-90008 Palonosetron: Aloxi®; Posfrea™ Ψ
VP-90038 Erbitux® (cetuximab) (Intravenous)
VP-90710 Epkinly™ (epcoritamab-bysp)