Asset Publisher

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-90002 Tocilizumab: Actemra®; Tofidence™; Tyenne®
PH-90003 Corticotropin-ACTH: Acthar® Gel (repository corticotropin injection) Cortrophin® Gel (repository corticotropin injection)
PH-90008 Palonosetron: Aloxi®; Palonosetron Ψ
PH-90017 Benlysta® (belimumab)
PH-90028 Cimzia® (certolizumab pegol)
PH-90052 Alpha-1-Proteinase Inhibitors: Aralast NP®; Glassia®; Prolastin®-C; Zemaira®
PH-90059 SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify®
PH-90071 Immune Globulins (immunoglobulin): Alyglo™; Bivigam®; Flebogamma®; Gamunex-C®; Gammagard® Liquid; Gammagard® S/D; Gammaked™; Gammaplex®; Octagam®; Privigen®; Panzyga®, Yimmugo®
PH-90104 Infliximab: Remicade®; Inflectra™; Renflexis™; Avsola™, Infliximab*
PH-90111 Sandostatin® LAR (octreotide suspension) (Precertification not required)
PH-90117 Ustekinumab: Stelara®; Wezlana™; Selarsdi™; Pyzchiva®
PH-90131 Trelstar® (triptorelin) (Precertification not required)
PH-90133 Natalizumab: (Tysabri®; Tyruko®)
PH-90146 Xolair® (omalizumab)
PH-90151 Zoladex® (goserelin acetate) (Precertification not required)
PH-90176 Simponi ARIA® (golimumab)
PH-90202 Entyvio® (vedolizumab)
PH-90234 Long-Acting Granulocyte Colony Stimulating Factors (LA-gCSF): Neulasta®; Fulphila®; Udenyca®; Ziextenzo®; Nyvepria™; Fylnetra®; Stimufend®; Rolvedon®; Ryzneuta®
PH-90237 Leukine® (sargramostim)
PH-90273 Cinqair® (reslizumab)
PH-90347 Fasenra® (benralizumab)
PH-90503 Reblozyl® (luspatercept-aamt)
PH-90527 Vyepti® (eptinezumab-jjmr)
PH-90591 Evkeeza™ (evinacumab-dgnb)
PH-90614 Saphnelo™ (anifrolumab-fnia)
PH-90650 Tezspire™ (tezepelumab-ekko)
PH-90652 Leqvio® (inclisiran)
PH-90671 Skyrizi® (risankizumab-rzaa)
PH-90672 Zynteglo® (betibeglogene autotemcel)
PH-90674 Spevigo® (spesolimab)
PH-90708 Elfabrio® (pegunigalsidase alfa-iwxj)
PH-90727 Veopoz® (pozelimab-bbfg)
PH-90751 Lenmeldy™ (atidarsagene autotemcel)
PH-90769 Tecentriq Hybreza™ (atezolizumab and hyaluronidase-tqjs)
PH-90770 Ocrevus Zunovo™ (ocrelizumab and hyaluronidase-ocsq)
PH-91166 Lupus Prior Authorization with Quantity Limit Program Summary