Member Policies - Medical Policies - Alabama

Current Provider-Administered Drug Policies (Excluding Oncology)

• Botulinum Toxin: See Palmetto L33458 and 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 L37863 and A56419. For dates of service prior, see PH-111.
• Orencia-SQ/self-administered: See Palmetto article A53066. 
• Orencia-IV/provider-administered: See PH-0091 below.
• Sublocade: For dates of service July 1, 2019, and after, see PH-0463. For dates of service July 1, 2018-June 30, 2019, see 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 PH-0282 below.
• White Colony Stimulating Factors: See Palmetto LCD L37176. 

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

For billing and coding for Rituximab, refer to LCD L35026/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.

Provider-Administered Drug Policies Disclaimer:
The purpose of provider-administered drug policies are 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.