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: See Palmetto LCD L37863 and article A56419.
• Orencia-SQ/self-administered: See Palmetto article A53066. 
• Riabni: For dates of service on or after October 1, 2021, see LCD L35026 and article A56380. For dates of service prior to October 1, 2021, see PH-0109 below.
• Testopel: See Palmetto article A53793 for gender reassignment services for gender dysphoria. For all other indications, for dates of service on or after May 11, 2022, see Palmetto article A58828. For dates of service prior to May 11, 2022, see 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:

For billing and coding information for luteinizing hormone-releasing hormone (LHRH) analogs, refer to LCD L39387 and article A59160 for the following drugs:

For erythropoiesis stimulating agents (ESAs), refer to LCD L39237/Article A58982.

For dates of service on or after August 21, 2022: For billing and coding information for hyaluronic acid injections for knee osteoarthritis, see LCD L39260 and article A59030 for the below drugs. For dates of service prior to, August 21, 2022, see PH-0061 below.

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.