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
MP-991116 Acute Migraine Agents Prior Authorization with Quantity Limit Program Summary
PH-1144 Sucraid Prior Authorization with Quantity Limit Program Summary
PH-1145 Xhance Prior Authorization with Quantity Limit Program Summary
PH-1146 Zokinvy Prior Authorization with Quantity Limit Program Summary
PH-1147 Zeposia Prior Authorization with Quantity Limit Program Summary
PH-1155 Insulin Pump Prior Authorization with Quantity Limit Program Summary
PH-1156 Atypical Antipsychotics – Extended Maintenance Agents Step Therapy and Quantity Limit Program Summary
PH-1157 Cholestasis Pruritus Prior Authorization Program Summary
PH-1158 Kerendia Prior Authorization with Quantity Limit Program Summary
PH-1159 Long Acting Insulin Prior Authorization Program Summary
PH-1160 Rapid to Intermediate Acting Insulin Prior Authorization Program Summary
PH-91005 Contraceptive Prior Authorization Program Summary
PH-91006 Flector® Prior Authorization with Quantity Limit Program Summary
PH-91007 GLP-1 (glucagon-like peptide-1) Agonists Step Therapy and Quantity Limit Program Summary
PH-91013 Mandatory Generic/Member Pays the Difference Exception Prior Authorization Program Summary
PH-91017 Opioids ER Prior Authorization and Quantity Limit Program Summary
PH-91018 Opioid Immediate Release Duration Limit and Quantity Limit Program Summary
PH-91028 Atopic Dermatitis (Elidel [pimecrolimus], Eucrisa, Protopic [tacrolimus]) Step Therapy Program Summary
PH-91029 Atypical Antipsychotics Step Therapy and Quantity Limit Program Summary
PH-91031 Carbaglu (carglumic acid) Prior Authorization Program Summary
PH-91033 Calcitonin Gene-Related Peptide (CGRP) Prior Authorization with Quantity Limit Program Summary
PH-91040 Gabapentin ER (extended-release) [Horizant, Gralise] Step Therapy and Quantity Limit Program Summary
PH-91042 Glucose Test Strips and Meters Step Therapy
PH-91043 Growth Hormone Prior Authorization Program Summary
PH-91058 Myalept (metreleptin) Prior Authorization Program Summary
PH-91059 Natpara (parathyroid hormone) Prior Authorization with Quantity Limit Program Summary
PH-91062 Riluzole Prior Authorization with Quantity Limit Program Summary
PH-91064 Oral Tetracycline Derivatives Step Therapy Program Summary
PH-91065 Parathyroid Hormone Analog for Osteoporosis Prior Authorization through Preferred with Quantity Limit Program Summary
PH-91067 Phenylketonuria Prior Authorization Program Summary
PH-91069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Summary
PH-91070 Signifor Prior Authorization with Quantity Limit Program Summary
PH-91072 Statin Step Therapy Program Summary
PH-91075 Thrombopoietin Receptor Agonists Prior Authorization with Quantity Limit Program Summary
PH-91078 Triptans Step Therapy and Quantity Limit Program Summary
PH-91087 Coverage Exception Program Summary
PH-91088 Copay Waiver for Breast Cancer Primary Prevention Agent ACA Copay Waiver Program Summary – Individual Marketplace, Commercial
PH-91093 Elagolix/Relugolix Prior Authorization with Quantity Limit Program Summary
PH-91095 Galafold (migalastat) Prior Authorization with Quantity Limit Program Summary
PH-91098 Samsca (tolvaptan) Prior Authorization And Quantity Limit Program Summary
PH-91101 Antidepressant Agents Step Therapy and Quantity Limit Program Summary
PH-91105 Weight Loss Agents Prior Authorization with Quantity Limit Program Summary
PH-91109 Imcivree Prior Authorization with Quantity Limit
PH-91113 Procysbi (cysteamine bitartrate) Prior Authorization Program Summary
PH-91114 Cablivi Quantity Limit Program Summary
PH-91115 Interleukin-5 (IL-5) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91117 Opioids IR Quantity Limit Program Summary
PH-91119 Interleukin-4 (IL-4) Inhibitor Prior Authorization with Quantity Limit Program Summary
PH-91120 Hepatitis C Direct Acting Antivirals Prior Authorization with Quantity Limit Through Preferred Agent(s) Program Summary
PH-91128 Peanut allergy Prior Authorization with Quantity Limit
PH-91134 Ophthalmic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-91135 Sodium-glucose Co-transporter 2 (SGLT-2) Inhibitors and Combinations Step Therapy and Quantity Limit Program Summary
PH-91136 Atypical Antipsychotics - Extended Maintenance Agents Step Therapy and Quantity Limit Program Summary
PH-91138 Dojolvi Prior Authorization Program Summary
PH-91140 Fintepla (fenfluramine) Prior Authorization with Quantity Limit Program Summary
PH-91142 Enspryng (satralizumab-mwge) Prior Authorization with Quantity Limit Program Summary
PH-91149 Topical NSAID (Non-Steroidal Anti-Inflammatory Drug) Prior Authorization with Quantity Limit Program Summary
PH-91151 Iron Chelation Prior Authorization with Quantity Limit Program Summary
PH-91153 Ivermectin Prior Authorization Program Summary
PH-91201 Winlevi (clascoterone) Step Therapy Program Summary
PH-991001 Lupus Prior Authorization with Quantity Limit Program Summary
PH-991035 Hetlioz (tasimelteon) Prior Authoriztaion with Quantity Limit Program Summary
PH-991045 Homozygous Familial Hpercholesterolemia Agents (HoFH) Prior Authorization with Quantity Limit Program Summary
PH-991053 Keveyis Prior Authorization with Quantity Limit Program Summary
PH-991055 Lyrica CR® (pregabalin CR) Prior Authorization with Quantity Limit Program Summary
PH-991057 Multiple Sclerosis Agents Step Therapy with Quantity Limit Program Summary
PH-991060 Northera® (droxidopa) Prior Authorization with Quantity Limit Program Summary
PH-991071 Selective Serotonin Inverse Agonist (SSIA) Prior Authorization with Quantity Limit Program Summary
PH-991074 Substrate Reduction Therapy Prior Authorization with Quantity Limit Program Summary
PH-991089 Erectile Dysfunction - Phosphodiesterase Type 5 Inhibitors, Topical Prostaglandin Quantity Limit
PH-991090 Amantadine Extended Release Prior Authorization with Wuantity Limit Program Summary
PH-991092 Jynarque Prior Authorization with Quantity Limit
PH-991101 Antidepressant Agents Step Therapy and Quantity Limit Program Summary
PH-991117 Opioids IR Quantity Limit
PH-991131 Acute Migraine Agents Prior Authorization with Quantity Limit Program Summary
PH-991137 Atypical Antipsychotics Step Therapy and Quantity Limit Program Summary
PH-9991031 Carbaglu (carglumic acid) Prior Authorization Criteria
PH-9991033 CGRP Prior Authorization with Quantity Limit Program Summary
PH-9991037 Topical Actinic Keratosis, Basal Cell Carcinoma, Genital Warts Agents Prior Authorization with Quantity Limit and Quantity Limit Program Summary
PH-9991063 Oral Pulmonary Arterial Hypertension Agents Prior Authorization with Quantity Limit
PH-9991065 Parathyroid Hormone Analog for Osteoporosis Prior Authorization through Preferred with Quantity Limit Program Summary
PH-9991066 Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) Inhibitors Prior Authorization with Quantity Limit-Through Preferred Agent(s)
PH-9991072 Statin Step Therapy Program Summary
PH-9991077 Topiramate ER Prior Authorization with Quantity Limit Program Summary
PH-9991078 Triptan Step Therapy and Quantity Limit Program Summary
PH-9991098 Samsca (tolvaptan) Prior Authorization with Quantity Limit Program Summary
PH-9991100 Cannabidiol Prior Authorization Prgram Summary
PH-9991105 Weight Loss Agents Prior Authorization with Quantity Limit Program Summary
PH-99991018 Opioids Immediate Release Duration Limit and Quantity Limit Program Summary
PH-99991075 Thrombopoietin Receptor Agonists Prior Authorization with Quantity Limit Program Summary
PH-999991000 Androgens and Anabolic Steroids Prior Authorization with Quantity Limit Through Generic Program Summary
PH-999991017 Opioids ER Prior Authorization and Quantity Limit Program Summary
PH-9999991069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
PH-99999991002 Biologic Immunomodulators Prior Authorization with Quantity Limit with Preferred Products Program Summary
PH-99999991003 Buprenorphine and Buprenorphine/Naloxone for Opioid Dependence Prior Authorization, Quantity Limit and Concomitant Use of Opioid Products Program Summary