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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-91000 Androgens and Anabolic Steroids Prior Authorization with Quantity Limit Program Summary
PH-91002 Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-910022 Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-91003 Buprenorphine and Buprenorphine/Naloxone for Opioid Dependence Prior Authorization, Quantity Limit and Concomitant Use of Opioid Products 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-91014 Methotrexate Injectable Step Therapy Program Summary
PH-91017 Opioids ER Prior Authorization and Quantity Limit Program Summary
PH-91022 Afrezza Prior Authorization with Quantity Limit Program Summary
PH-91023 Ampyra (dalfampridine) Prior Authorization with Quantity Limit Program Summary
PH-91032 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) 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-91040 Gabapentin ER (extended-release) [Horizant, Gralise] Step Therapy and Quantity Limit Program Summary
PH-91043 Growth Hormone Prior Authorization Program Summary
PH-91047 Inhaled Antibiotics Duplicate Therapy Prior Authorization with Quantity Limit Program Summary
PH-91050 Insulin Combination Agents (Soliqua, Xultophy) Step Therapy and Quantity Limit Program Summary
PH-91051 Interleukin (IL)-1 Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91054 Korlym (mifepristone) Prior Authorization with Quantity Limit Program Summary
PH-91056 Metformin ER Step Therapy Program Summary
PH-91057 Multiple Sclerosis Agents Step Therapy with Quantity Limit 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-91068 Proton Pump Inhibitors (PPIs) Step Therapy with Quantity Limit Program Summary
PH-91069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
PH-91074 Substrate Reduction Therapy Prior Authorization with Quantity Limit Program Summary
PH-91076 Transmucosal Immediate Release Fentanyl (TIRF) Prior Authorization with Quantity Limit Program Summary
PH-91080 Urea Cycle Disorders Prior Authorization Program Summary
PH-91081 Xanthine Oxidase Inhibitor Quantity Limit Program Summary
PH-91083 Oxybate Prior Authorization with Quantity Limit Program Summary
PH-91090 Amantadine Extended Release Prior Authorization with Quantity Limit Program Summary
PH-91092 Jynarque Prior Authorization with Quantity Limit Program Summary
PH-91096 Hyperhidrosis Prior Authorization with Quantity Limit Program Summary
PH-91097 Pseudobulbar Affect (PBA) Prior Authorization with Quantity Limit Program Summary
PH-91098 Samsca (tolvaptan) Prior Authorization with Quantity Limit Program Summary
PH-91101 Antidepressant Agents Step Therapy and Quantity Limit Program Summary
PH-91103 Amifampridine Prior Authorization with Quantity Limit Program Summary
PH-91105 Weight Loss Agents Prior Authorization with Quantity Limit Program Summary
PH-91106 Arikayce Prior Authorization with Quantity Limit Program Summary
PH-91107 ATTR (transthyretin amyloid) Amyloidosis Prior Authorization with Quantity Limit Program Summary
PH-91115 Interleukin-5 (IL-5) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91117 Opioids Immediate Release (IR) Quantity Limit Program Summary
PH-91118 Hypoactive Sexual Desire Disorder (HSDD) Prior Authorization with Quantity Limit Program Summary
PH-91119 Interleukin-4 (IL-4) Inhibitor Prior Authorization with Quantity Limit Program Summary
PH-91121 Baclofen Prior Authorization with Quantity Limit Program Summary
PH-91122 Wakix (pitolisant) Prior Authorization with Quantity Limit Program Summary
PH-91124 Interstitial Lung Disease (ILD) 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-91130 Risdiplam Prior Authorization with Quantity Limit Program Summary
PH-91134 Ophthalmic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-91135 Sodium-glucose Co-transporter (SGLT-2) Inhibitors and Combinations Step Therapy and Quantity Limit Program Summary
PH-91139 DPP-4 Inhibitors and Combinations Step Therapy with Quantity Limit Program Summary
PH-91143 Sunosi (solriamfetol) Prior Authorization with Quantity Limit Program Summary
PH-91145 Xhance Prior Authorization with Quantity Limit Program Summary
PH-91147 Zeposia (oxanimod) Prior Authorization with Quantity Limit Program Summary
PH-91150 Continuous Glucose Monitor (CGM) Step Therapy with Quantity Limit Program Summary
PH-91152 Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91155 Insulin Pumps Quantity Limit Program Summary
PH-91156 Atypical Antipsychotics – Extended Maintenance Agents Step Therapy and Quantity Limit Program Summary
PH-91158 Kerendia (finerenone) Prior Authorization with Quantity Limit Program Summary
PH-91159 Long Acting Insulin Prior Authorization Program Summary
PH-91160 Rapid to Intermediate Acting Insulin Prior Authorization Program Summary
PH-91162 Opzelura (ruxolitinib) Prior Authorization with Quantity Limit Program Summary
PH-91171 Xolair (omalizumab) Prior Authorization Program Summary
PH-91172 Antidepressant Agents Step Therapy with Quantity Limit Program Summary
PH-91174 Cibinqo (abrocitinib) Prior Authorization with Quantity Limit Program Summary
PH-91179 Attention Deficit [Hyperactivity] Disorder (ADHD/ADD) Agents Quantity Limit Program Summary
PH-91189 Nasal Antiepileptics Quantity Limit Program Summary
PH-91190 Nasal Inhalers Quantity Limit Program Summary
PH-91191 Oral Inhalers Quantity Limit Program Summary
PH-91192 Pain Medications (Combination Products) Quantity Limit Program Summary
PH-91194 Zoryve (roflumilast) Prior Authorization Program Summary
PH-91197 Tezspire (tezepelumab-ekko) Prior Authorization with Quantity Limit Program Summary
PH-91206 Rezurock (belumosudil) Prior Authorization with Quantity Limit Program Summary
PH-91208 Daybue (trofinetide) Prior Authorization with Quantity Limit Program Summary
PH-91215 Resmetirom Prior Authorization with Quantity Limit Program Summary
PH-91216 Rivfloza (nedosiran) Prior Authorization with Quantity Limit Program Summary
PH-91217 Xdemvy Step Therapy with Quantity Limit Program Summary