Member Policies - Medical Policies - Alabama

Current Provider-Administered Drug Policies (Excluding Oncology)

• Botulinum Toxin: See Palmetto Local Coverage Determination (LCD) L33458 and article A56646.
• Eylea: See Palmetto article A53387. 
• Firazyr: See Palmetto article A53066. 
• H.P. Acthar: See Palmetto article A53066. 
• Haegarda: See Palmetto article A53066. 
• Lemtrada: See Palmetto article A55310. 
• Luxturna: For dates of service May 16, 2019, and after see Palmetto LCD L37863 and article A56419. For prior dates of service, see policy number PH-111.
• Orencia-SQ/self-administered: See Palmetto article A53066. 
• Orencia-IV/provider-administered: See policy number PH-0091 below.
• Sublocade: For dates of service July 1, 2019, and after, see policy number PH-0463 below. For dates of service July 1, 2018-June 30, 2019, see policy number PH-109. For dates of service prior to July 1, 2018, it is noncovered.
• Testopel: See Palmetto article A53793 for gender reassignment services for gender dysphoria. For all other indications, see policy number PH-0282 below.
• White Colony Stimulating Factors: See Palmetto LCD L37176. 

For billing and coding information for Infliximab, refer to LCD L35677 and article A56432 for the following drugs:

For billing and coding information for Rituximab, refer to LCD L35026 and article A56380 for the following drugs:

Note: Coverage is subject to member's specific benefits. Group-specific policies will supersede these policies when applicable. Please refer to member's benefit plan.

The purpose of provider-administered drug policies is to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.