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-1182 Penicillamine Step Therapy Program Summary
PH-1183 Radicava (edaravone) Prior Authorization with Quantity Limit Program Summary
PH-91000 Androgens and Anabolic Steroids Prior Authorization with Quantity Limit Through Generic Program Summary
PH-91002 Biologic Immunomodulators Prior Authorization with Quantity Limit 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-91009 Peg-interferon Prior Authorization Program Summary
PH-91012 Immune Globulins Prior Authorization Program Summary
PH-91013 Mandatory Generic/Member Pays the Difference Exception Prior Authorization Program Summary
PH-91018 Opioids Immediate Release (IR) Duration Limit and Quantity Limit 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-91025 Antiemetic Step Therapy with Quantity Limit Program Summary
PH-91026 Anti-Influenza Agents Quantity Limit Program Summary
PH-91027 Angiotensin II Receptor Antagonists (ARBs), Renin Inhibitors, and Combinations Step Therapy Program Summary
PH-91028 Atopic Dermatitis (Elidel [pimecrolimus], Eucrisa, Protopic [tacrolimus]) Step Therapy Program Summary
PH-91029 Atypical Antipsychotics Step Therapy with Quantity Limit Program Summary
PH-91030 Bonjesta, Diclegis Prior Authorization with Quantity Limit Program Summary
PH-91031 Carbaglu (carglumic acid) Prior Authorization Program Summary
PH-91032 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Prior Authorization with Quantity Limit Program Summary
PH-91033 Calcitonin Gene-Related Peptide (CGRP) Prior Authorization with Quantity Limit Program Summary
PH-91034 Antifungal Agents - ciclopirox, efinaconazole, tavaborole 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-91039 Endari (L-glutamine) Prior Authorization Program Summary
PH-91041 Gattex (teduglutide) Prior Authorization Program Summary
PH-91043 Growth Hormone Prior Authorization Program Summary
PH-91044 Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker (Corlanor) Prior Authorization with Quantity Limit Program Summary
PH-91046 Corticotropin Prior Authorization 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-91057 Multiple Sclerosis Agents Step Therapy with Quantity Limit Program Summary
PH-91058 Myalept (metreleptin) Prior Authorization Program Summary
PH-91059 Natpara (parathyroid hormone) Prior Authorization with Quantity Limit Program Summary
PH-91063 Oral 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-91067 Phenylketonuria Prior Authorization Program Summary
PH-91068 Proton Pump Inhibitors (PPIs) Step Therapy and Quantity Limit Program Summary
PH-91069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
PH-91070 Signifor (pasireotide) Prior Authorization with Quantity Limit Program Summary
PH-91072 Statin Step Therapy Program Summary
PH-91073 Strensiq Prior Authorization Program Summary
PH-91080 Urea Cycle Disorders Prior Authorization Program Summary
PH-91082 Xermelo (telotristat) Prior Authorization with Quantity Limit Program Summary
PH-91086 Quantity Limit Summary
PH-910861 Quantity Limit Summary Part 2
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-91094 Elmiron® (pentosan polysulfate sodium) Prior Authorization Program Summary
PH-91098 Samsca (tolvaptan) Prior Authorization with Quantity Limit Program Summary
PH-91099 Sucralfate Suspension Prior Authorization with Quantity Limit Program Summary
PH-91101 Antidepressant Agents Step Therapy and Quantity Limit Program Summary
PH-91102 Nocturia Prior Authorization with Quantity Limit Program Summary
PH-91104 Neurotrophic Keratitis Prior Authorization with Quantity Limit Program Summary
PH-91105 Weight Loss Agents Prior Authorization with Quantity Limit Program Summary
PH-91108 Eysuvis (loteprednol etabonate) Prior Authorization with Quantity Limit Program Summary
PH-91110 Alinia Quantity Limit Program Summary
PH-91112 Ocaliva (obeticholic acid) 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-91117 Opioids Immediate Release (IR) 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-91121 Baclofen Prior Authorization with Quantity Limit Program Summary
PH-91124 Interstitial Lung Disease (ILD) Prior Authorization with Quantity Limit Program Summary
PH-91127 Oxbryta (voxelotor) 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-91133 Isturisa (osilodrostt) Prior Authorization with Quantity Limit Program Summary
PH-91134 Ophthalmic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-91138 Dojolvi Prior Authorization Program Summary
PH-91139 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors and Combinations Step Therapy with Quantity Limit Program Summary
PH-91140 Fintepla (fenfluramine) Prior Authorization with Quantity Limit Program Summary
PH-91141 Rho Kinase Inhibitor Step Therapy and 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-91148 Verquvo 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-91151 Iron Chelation Prior Authorization with Quantity Limit Program Summary
PH-91153 Ivermectin Prior Authorization Program Summary
PH-91157 Cholestasis Pruritus Prior Authorization Program Summary
PH-91158 Kerendia (finerenone) Prior Authorization with Quantity Limit Program Summary
PH-91162 Opzelura (ruxolitinib) Prior Authorization with Quantity Limit Program Summary
PH-91163 Tavneos (avacopan) Prior Authorization with Quantity Limit Program Summary
PH-91164 Tyrvaya (varenicline) Prior Authorization with Quantity Limit Program Summary
PH-91165 Imcivree Prior Authorization with Quantity Limit Program Summary
PH-91169 Voxzogo (vosoritide) Prior Authorization with Quantity Limit Program Summary
PH-91170 Interleukin-13 (IL-13) Antagonist 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-91173 Bempedoic Acid Prior Authorization with Quantity Limit Program Summary
PH-91174 Cibinqo (abrocitinib) Prior Authorization with Quantity Limit Program Summary
PH-91177 Tarpeyo Prior Authorization with Quantity Limit Program Summary
PH-91178 Topical Psoriasis Quantity Limit
PH-91179 Attention Deficit [Hyperactivity] Disorder (ADHD/ADD) Agents Quantity Limit Program Summary
PH-91180 Camzyos (mavacamten) Prior Authorization with Quantity Limit Program Summary
PH-91181 Elagolix/Relugolix Prior Authorization with Quantity Limit Program Summary
PH-91182 Penicillamine Step Therapy Program Summary
PH-91183 Radicava (edaravone) Prior Authorization with Quantity Limit Program Summary
PH-91184 Topical Estrogen Quantity Limit Program Summary
PH-91185 Vtama (tapinarof) Prior Authorization Program Summary
PH-91201 Winlevi (clascoterone) Step Therapy Program Summary