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Draft Provider-Administered Drug Policies 

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 Provider-Administered Drug Policies

Policy # Policy Title Print View
PH-90002 Tocilizumab: Actemra®; Tofidence™; Tyenne®; Avtozma®; Tocilizumab-anoh§
PH-90028 Cimzia® (certolizumab pegol)
PH-90091 Orencia® (abatacept)
PH-90104 Infliximab: Remicade®; Inflectra™; Renflexis™; Avsola™, Infliximab*
PH-90117 Ustekinumab: Stelara®; Wezlana™; Selarsdi™; Pyzchiva®; Otulfi™; Imuldosa®; Yesintek™; Steqeyma®; Ustekinumab-aekn§
PH-90137 Velcade (bortezomib)
PH-90176 Simponi ARIA® (golimumab)
PH-90202 Entyvio® (vedolizumab)
PH-90229 Cosentyx® (secukinumab)
PH-90298 Ocrevus™ (ocrelizumab)
PH-90310 Tremfya® (guselkumab)
PH-90358 Ilumya™ (tildrakizumab-asmn)
PH-90421 Gamifant™ (emapalumab-lzsg)
PH-90481 Spravato® (esketamine)
PH-90514 Givlaari (givosiran)
PH-90579 Oxlumo® (lumasiran)
PH-90598 Abecma® (idecabtagene vicleucel)
PH-90634 Susvimo™ (ranibizumab)
PH-90649 Vyvgart™ (efgartigimod alfa-fcab)
PH-90659 Vabysmo™ (faricimab-svoa)
PH-90671 Skyrizi® (risankizumab-rzaa)
PH-90674 Spevigo® (spesolimab)
PH-90688 Hemgenix® (etranacogene dezaparvovec-drlb)
PH-90694 Leqembi™ (lecanemab-irmb)
PH-90712 Vyvgart® Hytrulo (efgartigimod alfa-fcab and hyaluronidase-qvfc)
PH-90713 Elevidys® (delandistrogene moxeparvovec-rokl)
PH-90714 Rystiggo® (rozanolixizumab-noli)
PH-90721 Izervay™ (avacincaptad pegol)
PH-90751 Lenmeldy™ (atidarsagene autotemcel)
VP-0612 Rylaze® (asparaginase Erwinia chrysanthemi (recombinant)-rywn)
VP-0785 Datroway® (datopotamab deruxtecan-dlnk)
VP-90001 Paclitaxel Albumin-Bound: Abraxane®; Paclitaxel Albumin-Bound Ψ
VP-90007 Pemetrexed: Alimta®; Pemfexy™; Pemrydi RTU®; Pemetrexed Ψ
VP-90014 Bevacizumab: Avastin®; Mvasi®; Zirabev®; Alymsys®; Vegzelma®; Avzivi®
VP-90057 Trastuzumab: Herceptin®; Ogivri®; Kanjinti®; Trazimera™; Herzuma®; Ontruzant®
VP-90074 Cabazitaxel: Jevtana®; Cabazitaxel§
VP-90100 Provenge® (sipuleucel-T)
VP-90148 Yervoy™ (ipilimumab) (Intravenous)
VP-90200 Sylvant® (siltuximab) (Intravenous)
VP-90522 Enhertu® (fam-trastuzumab deruxtecan-nxki)
VP-90766 Lymphir™ (denileukin diftitox-cxdl)