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Draft Self-Administered Drug Policies

Draft self-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 for these provider-administered drugs is required when administered in a provider’s office or home health setting; however, this 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.

How to Submit Comments 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:

Birmingham Service Center 
Attn: Pharmacy Department
P.O. Box 10527
Birmingham, AL 35202
 

Fax: 205-220-9576

Draft Policies

Policy # Policy Title Print View
PH-1242 Efgartigimod Prior Authorization with Quantity Limit Program Summary
PH-91000 Androgens and Anabolic Steroids Prior Authorization with Quantity Limit Program Summary
PH-91002 Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-91008 Hereditary Angiodema Prior Authorization with Quantity Limit Program Summary
PH-91012 Immune Globulins Prior Authorization Program Summary
PH-91029 Atypical Antipsychotics Step Therapy with Quantity Limit Program Summary
PH-91030 Bonjesta, Diclegis Prior Authorization with Quantity Limit Program Summary
PH-91036 Constipation Agents Prior Authorization with Quantity Limit Program Summary
PH-91039 Endari (L-glutamine) Prior Authorization Program Summary
PH-91044 Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker (Corlanor) Prior Authorization with Quantity Limit Program Summary
PH-91094 Elmiron® (pentosan polysulfate sodium) Prior Authorization Program Summary
PH-91119 Interleukin-4 (IL-4) Inhibitor Prior Authorization with Quantity Limit Program Summary
PH-91131 Acute Migraine Agents Prior Authorization with Quantity Limit Program Summary
PH-91133 Isturisa (osilodrostt) Prior Authorization with Quantity Limit Program Summary
PH-91139 DPP-4 Inhibitors and Combinations Step Therapy with Quantity Limit Program Summary
PH-91157 Cholestasis Pruritus Prior Authorization Program Summary
PH-91165 Imcivree Prior Authorization with Quantity Limit Program Summary
PH-91170 Interleukin-13 (IL-13) Antagonist Prior Authorization with Quantity Limit Program Summary
PH-91173 Bempedoic Acid Prior Authorization with Quantity Limit Program Summary
PH-91174 Cibinqo (abrocitinib) Prior Authorization with Quantity Limit Program Summary
PH-91180 Camzyos (mavacamten) Prior Authorization with Quantity Limit Program Summary
PH-91196 Furoscix (furosemide) Prior Authorization with Quantity Limit Program Summary
PH-91200 CMV (cytomegalovirus) Quantity Limit Program Summary
PH-91221 Dry Eye Disease Prior Authorization with Quantity Limit Program Summary
PH-91222 Eohilia Prior Authorization with Quantity Limit Program Summary
PH-91240 Crenessity Prior Authorization with Quantity Limit Program Summary
PH-91244 Brensocatib Prior Authorization with Quantity Limit Program Summary
PH-91245 Ctexli Prior Authorization with Quantity Limit Program Summary