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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 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.

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:

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

Fax: 205-220-9576

Draft Provider-Administered Drug Policies

Policy # Policy Title Print View
PH-90003 Corticotropin-ACTH: Acthar® Gel (repository corticotropin injection) Cortrophin® Gel (repository corticotropin injection)
PH-90018 Berinert® (C1 Esterase Inhibitor, Human)
PH-90059 SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, Gammagard Liquid ERC®, Gamunex®-C, Gammaked®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify®
PH-90061 Hyaluronic Acid Derivatives: Durolane®, Euflexxa™, Gel-One®, GelSyn-3™, GenVisc 850®, Hyalgan™, Hymovis®, Monovisc®, Orthovisc™, Synojoynt, Supartz/Supartz FX™, Synvisc™, Synvisc-One™, Triluron™, TriVisc™, VISCO-3™
PH-90071 Immune Globulins (immunoglobulin): Alyglo™; Bivigam®; Flebogamma®; Gamunex-C®; Gammagard® Liquid; Gammagard® S/D; Gammagard Liquid ERC®; Gammaked™; Gammaplex®; Octagam®; Privigen®; Panzyga®, Yimmugo®
PH-90080 Leuprolide Suspension: Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Lutrate Depot®; Camcevi™, Leuprolide Acetate Depot(Precertification not required)
PH-90098 Denosumab: Prolia®; Jubbonti®; Ospomyv™; Stoboclo®; Denosumab-dssb; Conexxence®; Denosumab-bnht; Xgeva®; Wyost®; Xbryk™; Osenvelt®; Bomyntra®
PH-90109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-90117 Ustekinumab: Stelara®; Wezlana™; Selarsdi™; Pyzchiva®; Otulfi™; Imuldosa®; Yesintek™; Steqeyma®; Starjemza™; Ustekinumab-aekn§; Ustekinumab-ttwe§; Ustekinumab- aauz§; Ustekinumab-stba§; Ustekinumab§
PH-90120 Synagis® (palivizumab)
PH-90137 Bortezomib Velcade®; Boruzu®; Bortezomib
PH-90167 Kalbitor® (ecallantide)
PH-90168 Cinryze® (C1 Esterase Inhibitor, Human)
PH-90169 Firazyr® (icatibant)
PH-90207 Ruconest® (C1 Esterase Inhibitor [recombinant])
PH-90234 Long-Acting Granulocyte Colony Stimulating Factors (LA-gCSF): Neulasta®; Fulphila®; Udenyca®; Ziextenzo®; Nyvepria™; Fylnetra®; Stimufend®; Rolvedon®; Ryzneuta®; Pegfilgrastim-fpgk§
PH-90284 Exondys 51™ (eteplirsen)
PH-90307 Haegarda® (C1 Esterase Inhibitor Subcutaneous [Human])
PH-90310 Tremfya® (guselkumab)
PH-90312 Injectafer® (ferric carboxymaltose injection)
PH-90392 Takhzyro™ (lanadelumab-flyo)
PH-90421 Gamifant™ (emapalumab-lzsg)
PH-90481 Spravato® (esketamine)
PH-90503 Reblozyl® (luspatercept-aamt)
PH-90512 Scenesse® (afamelanotide)
PH-90514 Givlaari (givosiran)
PH-90520 Vyondys 53™ (golodirsen)
PH-90524 Monoferric™ (ferric derisomaltose)
PH-90525 Tepezza® (teprotumumab-trbw)
PH-90549 Uplizna™ (inebilizumab-cdon)
PH-90562 Viltepso™ (viltolarsen)
PH-90579 Oxlumo® (lumasiran)
PH-90591 Evkeeza™ (evinacumab-dgnb)
PH-90593 Amondys 45™  (casimersen)
PH-90652 Leqvio® (inclisiran)
PH-90660 Enjaymo™ (sutimlimab-jome)
PH-90670 Amvuttra (vutrisiran)
PH-90694 Leqembi™ (lecanemab-irmb)
PH-90712 Vyvgart® Hytrulo (efgartigimod alfa-fcab and hyaluronidase-qvfc)
PH-90713 Elevidys® (delandistrogene moxeparvovec-rokl)
PH-90762 Piasky ™ (crovalimab-akkz)
PH-90763 Kisunla™ (donanemab-azbt)
PH-90781 Ryoncil® (remestemcel-L-rknd)
PH-97044 Casgevy™ (exagamglogene autotemcel)
VP-0795 Penpulimab-KCQX (penpulimab-kcqx)
VP-0803 Lynozyfic™ (linvoseltamab-gcpt)
VP-90004 Adcetris® (brentuximab vedotin)
VP-90038 Erbitux® (cetuximab)
VP-90136 Vectibix® (panitumumab) (Intravenous)
VP-90225 Blincyto® (blinatumomab)
VP-90266 Darzalex™ (daratumumab)
VP-90267 Portrazza™ (necitumumab)
VP-90559 Monjuvi® (tafasitamab-cxix)
VP-90607 Rybrevant® (amivantamab-vmjw)
VP-90724 Elrexfio™ (elranatamab-bcmm)
VP-90778 Ziihera® (zanidatamab-hrii)
VP-90785 Datroway® (datopotamab deruxtecan-dlnk) (Intravenous)