DRAFT Self-Administered Drug Policies

Drug policies are based on:

  • information in FDA-approved package inserts (and black box warnings, alerts or other information disseminated by the FDA, as applicable);
  • research of current medical and pharmacy literature; and/or,
  • review of common medical practices in the treatment and diagnosis of disease.

Final and draft policies are published on this site. Draft policies are available for provider comment for 45 days from the posting date on the document. We encourage practicing physicians to provide input.

Note: Coverage is subject to member's specific benefits. Group-specific policies will supersede these policies, when applicable. Always verify member eligibilty and benefits.

Pharmacy Policies Disclaimer

The purpose of Blue Cross and Blue Shield's  pharmacy 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.

 

Policy # Policy Title Print View
PH-1093 Orilissa
PH-1094 Elmiron® (pentosan polysulfate sodium) Prior Authorization Criteria
PH-1095 Galafold (migalastat) Prior Authorization with Quantity Limit
PH-1096 Hyperhidrosis Prior Authorization with Quantity Limit Program Summary
PH-1097 Pseudobulbar Affect (PBA) Prior Authorization with Quantity Limits Criteria
PH-1098 Samsca® (tolvaptan) Prior Authorization And Quantity Limit Criteria
PH-1099 Sucralfate Suspension Prior Authorization with Quantity Limit Criteria
PH-1100 Cannabidiol Prior Authorization Criteria
PH-1102 Nocturia Prior Authorization with Quantity Limit Criteria
PH-91000 Androgens and Anabolic Steroids Prior Authorization with Quantity Limit Through Generic Topical Androgen Criteria
PH-91017 Opioids ER Prior Authorization and Quantity Limit Criteria
PH-91018 Opioids IR Quantity Limit Criteria
PH-91021 Hypoactive Sexual Desire Disorder (HSDD) Prior Authorization with Quantity Limit Program Summary
PH-91023 Ampyra (dalfampridine) Prior Authorization with Quantity Limit Criteria
PH-91024 Oral Anticoagulant - Bevyxxa® (betrixaban), Eliquis® (apixaban), Pradaxa® (dabigatran), SavaysaTM (edoxaban), Xarelto® (rivaroxaban) Quantity Limit Criteria
PH-91031 Carbaglu (carglumic acid) Prior Authorization Criteria
PH-91032 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Prior Authorization with Quantity Limit Criteria
PH-91033 CGRP Prior Authorization with Quantity Limit Criteria
PH-91038 Emflaza (deflazacort) Prior Authorization with Quantity Limit Criteria
PH-91043 Growth Hormone Prior Authorization Criteria
PH-91047 Inhaled Antibiotics Duplicate Therapy Prior Authorization Criteria
PH-91051 Interleukin-4 (IL-4) Inhibitor Prior Authorization with Quantity Limit Criteria
PH-91052 Idiopathic Pulmonary Fibrosis Prior Authorization with Quantity Limit Criteria
PH-91054 Korlym (mifepristone) Prior Authorization with Quantity Limit Criteria
PH-91056 Metformin ER Step Therapy Criteria
PH-91058 Myalept (metreleptin) Prior Authorization Criteria
PH-91059 Natpara (parathyroid hormone) Prior Authorization with Quantity Limit Criteria
PH-91063 Oral Pulmonary Hypertension Agents Prior Authorization with Quantity Limit Criteria
PH-91065 Parathyroid Hormone Analog for Osteoporosis Prior Authorization through Preferred with Quantity Limit Criteria
PH-91067 Phenylketonuria Prior Authorization Criteria
PH-91069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Criteria
PH-91070 Signifor (pasireotide) Prior Authorization with Quantity Limit Criteria
PH-91073 Strensiq (asfotase alfa) Prior Authorization Criteria
PH-91079 URAT1 Inhibitor Prior Authorization with Quantity Limit Criteria
PH-91080 Urea Cycle Disorders Prior Authorization Criteria
PH-91081 Xanthine Oxidase Inhibitor Step Therapy with Quantity Limit Criteria
PH-91085 Insulin Prior Authorization Criteria
PH-91087 Coverage Exception Criteria