DRAFT Self-Administered Drug Policies

Drug policies are based on:

  • information in FDA-approved package inserts (and black box warnings, alerts or other information disseminated by the FDA, as applicable);
  • research of current medical and pharmacy literature; and/or,
  • review of common medical practices in the treatment and diagnosis of disease.

Final and draft policies are published on this site. Draft policies are available for provider comment for 45 days from the posting date on the document. We encourage practicing physicians to provide input.

Note: Coverage is subject to member's specific benefits. Group-specific policies will supersede these policies, when applicable. Always verify member eligibilty and benefits.

Please use the Search function above to locate specific drug policy information.

Pharmacy Policies Disclaimer

Pharmacy drug policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.


Policy # Policy Title Print View
PH-81002 Biologic Immunomodulators Prior Authorization with Quantity Limit with Preferred Products Program Summary
PH-991009 PePeg-interferon Prior Authorization Program Summary
PH-991012 Immune Globulins Prior Authorization Program Summary
PH-991107 hATTR Amyloidosis Neuropathy Prior Authorization with Quantity Limit Program Summary