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-91174 Cibinqo (abrocitinib) Prior Authorization with Quantity Limit Program Summary
PH-1170 Interleukin-13 (IL-13) Antagonist Prior Authorization with Quantity Limit Program Summary
PH-1171 Xolair (omalizumab) Prior Authorization Program Summary
PH-1175 Pyrukynd (mitapivat) Prior Authorization with Quantity Limit Program Summary
PH-1176 Recorlev (levoketoconazole) Prior Authorization with Quantity Limit Program Summary
PH-91002 Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-91007 GLP-1 (glucagon-like peptide-1) Agonists Step Therapy and Quantity Limit Program Summary
PH-91009 Peg-interferon Prior Authorization Program Summary
PH-91018 Opioids Immediate Release (IR) Duration Limit and Quantity Limit Program Summary
PH-91024 Oral Anticoagulant - Eliquis (apixaban), Pradaxa (dabigatran), Savaysa (edoxaban), Xarelto (rivaroxaban) Quantity Limit Program Summary
PH-91025 Antiemetic Step Therapy with Quantity Limit Program Summary
PH-91026 Anti-Influenza Agents Quantity Limit Program Summary
PH-91027 Angiotensin II Receptor Antagonists (ARBs), Renin Inhibitors, and Combinations Step Therapy 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-91033 Calcitonin Gene-Related Peptide (CGRP) 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-91041 Gattex (teduglutide) Prior Authorization Program Summary
PH-91044 Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker (Corlanor) Prior Authorization with Quantity Limit Program Summary
PH-91050 Insulin Combination Agents (Soliqua, Xultophy) Step Therapy and Quantity Limit Program Summary
PH-91057 Multiple Sclerosis Agents Step Therapy with Quantity Limit Program Summary
PH-91063 Oral Pulmonary Hypertension Agents Prior Authorization with Quantity Limit Program Summary
PH-91068 Proton Pump Inhibitors (PPIs) Step Therapy and Quantity Limit Program Summary
PH-91069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
PH-91072 Statin Step Therapy Program Summary
PH-91086 Quantity Limit Summary
PH-910861 Quantity Limit Summary Part 2
PH-91094 Elmiron® (pentosan polysulfate sodium) Prior Authorization Program Summary
PH-91098 Samsca (tolvaptan) Prior Authorization with Quantity Limit Program Summary
PH-91099 Sucralfate Suspension Prior Authorization with Quantity Limit Program Summary
PH-91102 Nocturia Prior Authorization with Quantity Limit Program Summary
PH-91104 Neurotrophic Keratitis Prior Authorization with Quantity Limit Program Summary
PH-91108 Eysuvis (loteprednol etabonate) Prior Authorization with Quantity Limit Program Summary
PH-91110 Alinia Quantity Limit Program Summary
PH-91112 Ocaliva (obeticholic acid) Prior Authorization with Quantity Limit Program Summary
PH-91115 Interleukin-5 (IL-5) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91117 Opioids Immediate Release (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 Program Summary
PH-91121 Baclofen Prior Authorization with Quantity Limit Program Summary
PH-91127 Oxbryta (voxelotor) Prior Authorization with Quantity Limit Program Summary
PH-91134 Ophthalmic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-91139 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors and Combinations Step Therapy with Quantity Limit Program Summary
PH-91140 Fintepla (fenfluramine) Prior Authorization with Quantity Limit Program Summary
PH-91141 Rho Kinase Inhibitor Step Therapy and Quantity Limit Program Summary
PH-91148 Verquvo Prior Authorization with Quantity Limit Program Summary
PH-91150 Continuous Glucose Monitor (CGM) Step Therapy with Quantity Limit Program Summary
PH-91151 Iron Chelation Prior Authorization with Quantity Limit Program Summary
PH-91157 Cholestasis Pruritus Prior Authorization Program Summary
PH-91158 Kerendia (finerenone) Prior Authorization with Quantity Limit Program Summary
PH-91163 Tavneos (avacopan) Prior Authorization with Quantity Limit Program Summary
PH-91164 Tyrvaya (varenicline) Prior Authorization with Quantity Limit Program Summary
PH-91170 Interleukin-13 (IL-13) Antagonist Prior Authorization with Quantity Limit Program Summary
PH-91172 Antidepressant Agents Step Therapy with Quantity Limit Program Summary
PH-91173 Bempedoic Acid Prior Authorization with Quantity Limit Program Summary
PH-91177 Tarpeyo Prior Authorization with Quantity Limit Program Summary