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
PH-1131 Acute Migraine Agents Prior Authorization with Quantity Limit Program Summary
PH-1132 Bempedoic Acid Prior Authorization with Quantity Limit Program Summary
PH-1133 Isturisa Prior Authorization with Quantity Limit Program Summary
PH-1134 Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-91030 Bonjesta, Diclegis Prior Authorization with Quantity Limit Program Summary
PH-91050 Insulin Combination Agents (Soliqua, Xultophy) Step Therapy and Quantity Limit Program Summary
PH-91068 Proton Pump Inhibitors (PPIs) Step Therapy and Quantity Limit Program Summary
PH-91088 Copay Waiver for Breast Cancer Primary Prevention Agent ACA Copay Waiver Program Summary – Individual Marketplace, Commercial
PH-91091 Lucemyra Prior Authorization with Quantity Limit Program Summary
PH-91099 Sucralfate Suspension Prior Authorization with Quantity Limit Program Summary
PH-91120 Hepatitis C Direct Acting Antivirals Prior Authorization with Quantity Limit- Through Preferred Agent(s)
PH-91124 Interstitial Lung Disease Prior Authorization with Quantity Limit Program Summary
PH-991007 GLP-1 (glucagon-like peptide-1) Agonists Step Therapy and Quantity Limit Program Summary
PH-991024 Oral Anticoagulant - Bevyxxa (betrixaban), Eliquis (apixaban), Pradaxa (dabigatran), Savaysa (edoxaban), Xarelto (rivaroxaban) Quantity Limit Program Summary
PH-991025 Antiemetic Agents Quantity Limit Program Summary
PH-991026 Anti-Influenza Agents Quantity Limit Program Summary
PH-991027 Angiotensin II Receptor Antagonists (ARBs), Renin Inhibitors, and Combinations Step Therapy Program Summary
PH-991036 Constipation Agents Prior Authorization with Quantity Limit Program Summary
PH-991039 Endari Prior Authorization Program Summary
PH-991066 Proprotein Convertase Subtilisin/Kexin type 9(PCSK9) Inhibitors Prior Authorization with Quantity Limit Program Summary - Through Preferred agent(s)
PH-991072 Statin Step Therapy Program Summary
PH-991082 XermeloTM (telotristat) Prior Authorization with Quantity Limit Program Summary
PH-991094 Elmiron® (pentosan polysulfate sodium) Prior Authorization Program Summary
PH-991104 Neurotrophic Keratitis Prior Authorization with Quantity Limit Program Summary
PH-991105 Weight Loss Agents Prior Authorization with Quantity Limit Program Summary
PH-991110 Alinia Quantity Limit Program Summary
PH-991112 Ocaliva® (obeticholic acid) Prior Authorization with Quantity Limit Criteria
PH-9991000 Androgens and Anabolic Steroids Prior Authorization with Quantity Limit Through Generic Topical Androgen Program Summary
PH-9991017 Opioids ER Prior Authorization and Quantity Limit Criteria
PH-9991041 Gattex (teduglutide) Prior Authorization Program Summary
PH-9991069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
PH-9991107 ATTR Amyloidosis Prior Authorization with Quantity Limit Program Summary
PH-99991002 Biologic Immunomodulators Prior Authorization with Quantity Limit with Preferred Products Program Summary