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Draft Provider-Administered Drug Policies (Excluding Oncology)

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

The drugs below require that a member’s medical condition meets the policy requirements prior to being given (precertification) unless otherwise specified. Providers must submit a request for pre-service review in order to be approved. If the provider does not receive approval for precertification, the plan will pay no benefits.

Currently, precertification is required for these provider-administered drugs when administered in a provider’s office or home health setting; precertification does not apply to inpatient hospital claims at this time.

Precertification for the drugs listed below is also required in the outpatient facility setting. Exceptions to this include: Luxturna, Kymriah and Yescarta, which require a precertification for any place of treatment.

Members can request a copy of a full drug policy, by calling the Customer Service number on their ID card.

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-90002 Tocilizumab: Actemra®; Tofidence™; Tyenne®
PH-90003 Corticotropin-ACTH: Acthar® Gel (repository corticotropin injection) Cortrophin® Gel (repository corticotropin injection)
PH-90017 Benlysta® (belimumab)
PH-90036 Fosaprepitant: Emend®; Fosaprepitant Ψ; Focinvez Ψ
PH-90052 Alpha-1-Proteinase Inhibitors: Aralast NP®; Glassia®; Prolastin®-C; Zemaira®
PH-90080 Leuprolide Suspension: Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Camcevi™, Lutrate Depot™, Leuprolide Acetate Depot Ψ(Precertification not required)
PH-90098 Denosumab: Prolia®; Jubbonti®; Xgeva®; Wyost®
PH-90105 Elelyso™ (taliglucerase alfa)
PH-90109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-90111 Sandostatin® LAR (octreotide suspension) (Precertification not required)
PH-90114 Soliris® (eculizumab)
PH-90131 Trelstar® (triptorelin) (Precertification not required)
PH-90141 VPRIV® (velaglucerase alfa)
PH-90146 Xolair® (omalizumab)
PH-90151 Zoladex® (goserelin acetate) (Precertification not required)
PH-90202 Entyvio® (vedolizumab)
PH-90234 Long-Acting Granulocyte Colony Stimulating Factors (LA-gCSF): Neulasta®; Fulphila®; Udenyca®; Ziextenzo®; Nyvepria™; Fylnetra®; Stimufend®; Rolvedon®; Ryzneuta®
PH-90235 Colony Stimulating Factors: Filgrastim (Neupogen®); Filgrastim-aafi (Nivestym™); Filgrastim-sndz (Zarxio®); Filgrastim-ayow (Releuko®); Tbo-Filgrastim (Granix®)
PH-90237 Leukine® (sargramostim)
PH-90242 Aranesp® (darbepoetin alfa)
PH-90243 Epoetin alfa: Epogen®; Procrit®; Retacrit™
PH-90244 Mircera® (methoxy polyethylene glycol-epoetin beta) (Precertification not required)
PH-90284 Exondys 51™ (eteplirsen)
PH-90312 Injectafer® (ferric carboxymaltose injection)
PH-90347 Fasenra® (benralizumab)
PH-90427 Ultomiris® (ravulizumab-cwvz)
PH-90503 Reblozyl® (luspatercept-aamt)
PH-90520 Vyondys 53™ (golodirsen)
PH-90524 Monoferric™ (ferric derisomaltose)
PH-90562 Viltepso™ (viltolarsen)
PH-90591 Evkeeza™ (evinacumab-dgnb)
PH-90593 Amondys 45™  (casimersen)
PH-90614 Saphnelo™ (anifrolumab-fnia)
PH-90652 Leqvio® (inclisiran)
PH-90660 Enjaymo™ (sutimlimab-jome)
PH-90672 Zynteglo® (betibeglogene autotemcel)
PH-90674 Spevigo® (spesolimab)
PH-90708 Elfabrio® (pegunigalsidase alfa-iwxj)
PH-90721 Izervay™ (avacincaptad pegol)
PH-90751 Lenmeldy™ (atidarsagene autotemcel)
PH-91154 Empaveli (pegcetacoplan) Prior Authorization with Quantity Limit Program Summary
PH-91166 Lupus Prior Authorization with Quantity Limit Program Summary
PH-91175 Pyrukynd (mitapivat) Prior Authorization with Quantity Limit Program Summary
VP-90522 Enhertu® (fam-trastuzumab deruxtecan-nxki)