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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
-90734 Omvoh® (mirikizumab-mrkz)
PH-90059 SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify®
PH-90071 Immune Globulins (immunoglobulin): Bivigam; Flebogamma; Gamunex-C; Gammagard Liquid; Gammagard S/D; Gammaked; Gammaplex; Octagam; Privigen; Panzyga
PH-90091 Orencia® (abatacept)
PH-90109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-90117 Ustekinumab: Stelara®; Wezlana™
PH-90145 Xiaflex® (collagenase)
PH-90238 Botox® (onabotulinumtoxinA)
PH-90239 Dysport® (abobotulinumtoxinA)
PH-90240 Myobloc® (rimabotulinumtoxinB)
PH-90241 Xeomin® (incobotulinumtoxinA) (Precertification not required)
PH-90305 Radicava® (edaravone)
PH-90312 Injectafer® (ferric carboxymaltose injection)
PH-90350 Luxturna® (voretigene neparvovec-rzyl)
PH-90355 Trogarzo™ (ibalizumab-uiyk)
PH-90421 Gamifant™ (emapalumab-lzsg)
PH-90512 Scenesse® (afamelanotide)
PH-90513 Adakveo® (crizanlizumab-tmca)
PH-90514 Givlaari (givosiran)
PH-90525 Tepezza® (teprotumumab-trbw)
PH-90527 Vyepti® (eptinezumab-jjmr)
PH-90579 Oxlumo® (lumasiran)
PH-90594 Nulibry™ (fosdenopterin)
PH-90648 Rethymic® (allogeneic processed thymus tissue-agdc)
PH-90649 Vyvgart™ (efgartigimod alfa-fcab)
PH-90659 Vabysmo™ (faricimab-svoa)
PH-90687 Tzield™ (teplizumab-mzwv)
PH-90714 Rystiggo® (rozanolixizumab-noli)
PH-90736 Adzynma® (ADAMTS13, recombinant-krhn)
PH-90743 Lyfgenia® (lovotibeglogene autotemcel)
PH-97044 Casgevy™ (exagamglogene autotemcel)
PH-990712 Vyvgart® Hytrulo (efgartigimod alfa-fcab and hyaluronidase-qvfc)