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Draft Self-Administered Drug Policies

Draft self-administered drug policies are listed below. If there are no policies listed, it means there are currently no policies in draft status.

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.

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

Pharmacy drug policies provide a guide to coverage. Pharmacy policies are not intended to dictate to providers how to practice medicine. Providers should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

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 Policies

Policy # Policy Title Print View
PH-1248 Harliku Prior Authorization with Quantity Limit Program Summary
PH-1251 Atopic Dermatitis (Elidel [pimecrolimus], Eucrisa, tacrolimus) Step Therapy Program Summary
PH-91000 Androgens and Anabolic Steroids Prior Authorization with Quantity Limit Program Summary
PH-91002 Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-910021 Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-910022 Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-91004 Compounded Medications Prior Authorization Program Summary
PH-91005 Contraceptive Prior Authorization Program Summary
PH-91007 GLP-1 (glucagon-like peptide-1) Agonists Prior Authorization with Quantity Limit Program Summary
PH-91008 Hereditary Angiodema Prior Authorization with Quantity Limit Program Summary
PH-91013 Mandatory Generic/Member Pays the Difference Exception Prior Authorization Program Summary
PH-91019 Otezla (apremilast) Prior Authorization with Quantity Limit Program Summary
PH-91020 Topical Doxepin Prior Authorization with Quantity Limit Program Summary
PH-91024 Oral Anticoagulant - Eliquis (apixaban), Pradaxa (dabigatran), Savaysa (edoxaban), Xarelto (rivaroxaban) Quantity Limit Program Summary
PH-91031 Carbaglu (carglumic acid) Prior Authorization Program Summary
PH-91033 Calcitonin Gene-Related Peptide (CGRP) Prior Authorization with Quantity Limit Program Summary
PH-91034 Topical Antifungals, itraconazole, terbinafine Prior Authorization with Quantity Limit Program Summary
PH-91036 Constipation Agents Prior Authorization with Quantity Limit Program Summary
PH-91037 Topical Actinic Keratosis, Basal Cell Carcinoma, Genital Warts Agents Prior Authorization with Quantity Limit Program Summary
PH-91038 Emflaza (deflazacort) Prior Authorization with Quantity Limit Program Summary
PH-91040 Gabapentin ER (extended-release) [Horizant, Gralise] Step Therapy and Quantity Limit Program Summary
PH-91043 Growth Hormone Prior Authorization Program Summary
PH-91046 Corticotropin Prior Authorization Program Summary
PH-91054 Korlym (mifepristone) Prior Authorization with Quantity Limit Program Summary
PH-91058 Myalept (metreleptin) Prior Authorization Program Summary
PH-91063 Pulmonary Hypertension Agents Prior Authorization with Quantity Limit Program Summary
PH-91064 Oral Tetracycline Derivatives Step Therapy Program Summary
PH-91065 Parathyroid Hormone Analog for Osteoporosis Prior Authorization with Quantity Limit Program Summary
PH-91066 Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91067 Phenylketonuria Prior Authorization Program Summary
PH-91069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
PH-91073 Strensiq Prior Authorization Program Summary
PH-91075 Thrombopoietin Receptor Agonists and Tavalisse Prior Authorization with Quantity Limit Program Summary
PH-91078 Triptan Step Therapy and Quantity Limit Program Summary
PH-91080 Urea Cycle Disorders Prior Authorization Program Summary
PH-91083 Oxybate Prior Authorization with Quantity Limit Program Summary
PH-91087 Coverage Exception Program Summary
PH-91088 Copay Waiver for Breast Cancer Primary Prevention Agent ACA Copay Waiver Program Summary – Individual Marketplace, Commercial
PH-91101 Antidepressant Agents Step Therapy and Quantity Limit Program Summary
PH-91105 Weight Loss Agents Prior Authorization with Quantity Limit Program Summary
PH-91113 Procysbi (cysteamine bitartrate) Prior Authorization Program Summary
PH-91115 Interleukin-5 (IL-5) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91119 Interleukin-4 (IL-4) Inhibitor Prior Authorization with Quantity Limit Program Summary
PH-91120 Hepatitis C Direct Acting Antivirals Prior Authorization with Quantity Limit Program Summary
PH-91129 Copay Waiver for Human Immunodeficiency Virus (HIV) Infection: Pre-exposure Prophylaxis (PrEP) ACA Prevention Copay Waiver Program Summary – Individual Marketplace, Commercial
PH-91131 Acute Migraine Agents Prior Authorization with Quantity Limit Program Summary
PH-91133 Isturisa (osilodrostt) Prior Authorization with Quantity Limit Program Summary
PH-91138 Dojolvi Prior Authorization Program Summary
PH-91139 DPP-4 Inhibitors and Combinations Step Therapy with Quantity Limit Program Summary
PH-91142 Enspryng (satralizumab-mwge) Prior Authorization with Quantity Limit Program Summary
PH-91144 Sucraid (sacrosidase) Prior Authorization with Quantity Limit Program Summary
PH-91147 Zeposia (oxanimod) Prior Authorization with Quantity Limit Program Summary
PH-91149 Topical NSAID (Non-Steroidal Anti-Inflammatory Drug) Prior Authorization with Quantity Limit Program Summary
PH-91150 Continuous Glucose Monitor (CGM) Step Therapy with Quantity Limit Program Summary
PH-91153 Ivermectin Prior Authorization Program Summary
PH-91154 Empaveli (pegcetacoplan) Prior Authorization with Quantity Limit Program Summary
PH-91160 Rapid to Intermediate Acting Insulin Prior Authorization Program Summary
PH-91165 Imcivree Prior Authorization with Quantity Limit Program Summary
PH-91169 Voxzogo (vosoritide) Prior Authorization with Quantity Limit Program Summary
PH-91176 Recorlev (levoketoconazole) Prior Authorization with Quantity Limit Program Summary
PH-91178 Topical Psoriasis Quantity Limit
PH-91181 Elagolix/Relugolix Prior Authorization with Quantity Limit Program Summary
PH-91184 Topical Estrogen Quantity Limit Program Summary
PH-91185 Vtama (tapinarof) Prior Authorization Program Summary
PH-91186 Copay Waiver for Statin ACA Prevention Copay Waiver Program Summary – Individual Marketplace, Commercial
PH-91187 ACA Prevention Copay Waiver Contraceptives Program Summary – Individual Marketplace, Commercial
PH-91188 Hyftor (sirolimus) Prior Authorization with Quantity Limit Program Summary
PH-91191 Oral Inhalers Prior Authorization with Quantity Limit Program Summary
PH-91192 Pain Medications (Combination Products) Quantity Limit Program Summary
PH-91194 Zoryve (roflumilast) Prior Authorization Program Summary
PH-91199 Antiretroviral Quantity Limit Program Summary
PH-91201 Winlevi (clascoterone) Step Therapy Program Summary
PH-91209 Qualaquin Quantity Limit Program Summary
PH-91211 Step Therapy Supplement Step Therapy Program Summary
PH-91213 Vasomotor Symptoms Prior Authorization with Quantity Limit Program Summary
PH-91217 Xdemvy Step Therapy with Quantity Limit Program Summary
PH-91218 Fabhalta (iptacopan) Prior Authorization with Quantity Limit Program Summary
PH-91219 Filsuvez (birch triterpenes) Prior Authorization Program Summary
PH-91220 Xphozah (tenapanor) Prior Authorization with Quantity Limit Program Summary
PH-91224 Zelsuvmi (berdazimer) Prior Authorization with Quantity Limit Program Summary
PH-91226 Spevigo (spesolimab-sbzo) Prior Authorization with Quantity Limit Program Summary
PH-91227 Voydeya (danicopan) Prior Authorization with Quantity Limit Program Summary
PH-91228 Weight Management Prior Authorization with Quantity Limit Program Summary
PH-91229 Zilbrysq (zilucoplan) Prior Authorization with Quantity Limit Program Summary
PH-91235 Yorvipath Prior Authorization with Quantity Limit Program Summary
PH-91237 Niemann-Pick Disease Type C Agents Prior Authorization with Quantity Limit Program Summary
PH-91240 Crenessity Prior Authorization with Quantity Limit Program Summary
PH-91244 Brensocatib Prior Authorization with Quantity Limit Program Summary
PH-91249 Sohonos (palovarotene) Prior Authorization with Quantity Limit Program Summary
PH-91250 Topiramate ER Prior Authorization with Quantity Limit Program Summary
PH-991236 Interleukin-31 (IL-31) Inhibitor Prior Authorization with Quantity Limit Program Summary