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.

Please use the Search function above to locate specific drug policy information.

Pharmacy Policies Disclaimer

Pharmacy drug policies are 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.

 

How to Submit Comments on Draft Policies

Complete our policy feedback form online or send comments and supporting documentation to us by mail or fax:

Blue Cross and Blue Shield of Alabama
Attn: Pharmacy Department
P.O. Box 995
Birmingham, AL 35298-0001

Fax: 205-733-6471

 

Policy # Policy Title Print View
MP-91004 Compounded Medications Prior Authorization Program Summary
PH-1108 Interleukin (IL)-1 Inhibitors Prior Authorization with Quantity Limit
PH-1109 Interleukin-5 (IL-5) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-1110 Alinia Quantity Limit Program Summary
PH-1111 Tafamidis Prior Authorization with Quantity Limit Program Summary
PH-1112 Riluzole Prior Authorization with Quantity Limit Program Summary
PH-1113 Procysbi (cysteamine bitartrate) Prior Authorization Program Summary
PH-1201 Interleukin (IL)-1 Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-81002 Biologic Immunomodulators Prior Authorization with Quantity Limit with Preferred Products Program Summary
PH-90199 Sucralfate Suspension Prior Authorization with Quantity Limit Program Summary
PH-91000 Androgens and Anabolic Steroids Prior Authorization with Quantity Limit Through Generic Topical Androgen Program Summary
PH-91009 Hepatitis C Antivirals Prior Authorization - Through Preferred Agent(s) Program Summary
PH-91012 Immune Globulins Prior Authorization Program Summary
PH-91014 Methotrexate Injectable Step Therapy Program Summary
PH-91027 Angiotensin II Receptor Antagonists (ARBs), Renin Inhibitors, and Combinations Step Therapy Program Summary
PH-91032 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Prior Authorization with Quantity Limit Program Summary
PH-91036 Constipation Agents Prior Authorization Program Summary
PH-91039 Endari Prior Authorization Program Summary
PH-91044 Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker (Corlanor) Prior Authorization with Quantity Limit Program Summary
PH-91045 Homozygous Familial Hypercholesterolemia Agents (HoFH) Prior Authorization with Quantity Limit Program Summary
PH-91051 Interleukin-4 (IL-4) Inhibitor Prior Authorization with Quantity Limit Program Summary
PH-91053 Keveyis Prior Authorization with Quantity Limit Program Summary
PH-91072 Statin Step Therapy Program Summary
PH-91078 Acute Migraine 5HT Step Therapy and Quantity Limit Program Summary
PH-91080 Urea Cycle Disorders Prior Authorization Program Summary
PH-91082 XermeloTM (telotristat) Prior Authorization with Quantity Limit Program Summary
PH-91089 Erectile Dysfunction -Phosphodiesterase Type 5 Inhibitors, Topical Prostaglandin Quantity Limit Program Summary
PH-91094 Elmiron® (pentosan polysulfate sodium) Prior Authorization Program Summary
PH-91103 Amifampridine 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-91107 hATTR Amyloidosis Neuropathy Prior Authorization with Quantity Limit Program Summary
PH-991002 Biologic Immunomodulators Prior Authorization with Quantity Limit with Preferred Products Program Summary
PH-991009 PePeg-interferon Prior Authorization Program Summary
PH-991012 Immune Globulins Prior Authorization Program Summary
PH-991019 Otezla (apremilast) Prior Authorization with Quantity Limit Program Summary
PH-991033 CGRP Prior Authorization with Quantity Limit Program Summary
PH-991041 Gattex (teduglutide) Prior Authorization Program Summary
PH-991049 Insomnia Agents Step Therapy and Quantity Limit Program Summary
PH-991069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
PH-991075 Thrombopoietin Receptor Agonists Prior Authorization with Quantity Limit Program Summary
PH-991107 hATTR Amyloidosis Neuropathy Prior Authorization with Quantity Limit Program Summary
PH-9991008