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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-90002 Tocilizumab: Actemra®; Tofidence™; Tyenne®; Avtozma®; Tocilizumab-anoh§
PH-90006 Aldurazyme® (laronidase)
PH-90017 Benlysta® (belimumab)
PH-90027 Cerezyme® (imiglucerase)
PH-90028 Cimzia® (certolizumab pegol)
PH-90034 Elaprase® (idursulfase)
PH-90036 Fosaprepitant: Emend®; Fosaprepitant Ψ; Focinvez Ψ
PH-90042 Fabrazyme® (agalsidase beta)
PH-90052 Alpha-1-Proteinase Inhibitors: Aralast NP®; Glassia®; Prolastin®-C; Zemaira®
PH-90079 Lumizyme® (alglucosidase alfa)
PH-90084 Naglazyme® (galsulfase)
PH-90091 Orencia® (abatacept)
PH-90104 Infliximab: Remicade®; Inflectra™; Renflexis™; Avsola™, Infliximab*
PH-90105 Elelyso™ (taliglucerase alfa)
PH-90114 Eculizumab: Soliris®; Bkemv™; Epysqli®
PH-90117 Ustekinumab: Stelara®; Wezlana™; Selarsdi™; Pyzchiva®; Otulfi™; Imuldosa®; Yesintek™; Steqeyma®; Ustekinumab-aekn§
PH-90137 Velcade (bortezomib)
PH-90141 VPRIV® (velaglucerase alfa)
PH-90176 Simponi ARIA® (golimumab)
PH-90190 Vimizim (elosulfase alfa)
PH-90202 Entyvio® (vedolizumab)
PH-90229 Cosentyx® (secukinumab)
PH-90277 Kanuma® (sebelipase alfa)
PH-90298 Ocrevus™ (ocrelizumab)
PH-90299 Brineura (cerliponase alfa)
PH-90310 Tremfya® (guselkumab)
PH-90346 Mepsevii® (vestronidase alfa-vjbk)
PH-90358 Ilumya™ (tildrakizumab-asmn)
PH-90421 Gamifant™ (emapalumab-lzsg)
PH-90463 Sublocade (buprenorphine ER injection)
PH-90481 Spravato® (esketamine)
PH-90514 Givlaari (givosiran)
PH-90579 Oxlumo® (lumasiran)
PH-90594 Nulibry™ (fosdenopterin)
PH-90614 Saphnelo® (anifrolumab-fnia)
PH-90615 Nexviazyme® (avalglucosidase alfa-ngpt)
PH-90634 Susvimo™ (ranibizumab)
PH-90649 Vyvgart™ (efgartigimod alfa-fcab)
PH-90659 Vabysmo™ (faricimab-svoa)
PH-90671 Skyrizi® (risankizumab-rzaa)
PH-90673 Xenpozyme® (olipudase alfa)
PH-90674 Spevigo® (spesolimab)
PH-90694 Leqembi™ (lecanemab-irmb)
PH-90696 Lamzede® (velmanase alfa-tycv)
PH-90708 Elfabrio® (pegunigalsidase alfa-iwxj)
PH-90712 Vyvgart® Hytrulo (efgartigimod alfa-fcab and hyaluronidase-qvfc)
PH-90713 Elevidys® (delandistrogene moxeparvovec-rokl)
PH-90714 Rystiggo® (rozanolixizumab-noli)
PH-90731 Pombiliti® (cipaglucosidase alfa-atga)
PH-90736 Adzynma® (ADAMTS13, recombinant-krhn)
PH-90751 Lenmeldy™ (atidarsagene autotemcel)
PH-90767 Niktimvo™ (axatilimab-csfr)
PH-90793 Encelto™ (revakinagene taroretcel-lwey)
VP-0612 Rylaze® (asparaginase Erwinia chrysanthemi (recombinant)-rywn)
VP-0785 Datroway® (datopotamab deruxtecan-dlnk)
VP-90001 Paclitaxel Albumin-Bound: Abraxane®; Paclitaxel Albumin-Bound Ψ
VP-90007 Pemetrexed: Alimta®; Pemfexy™; Pemrydi RTU®; Pemetrexed Ψ
VP-90014 Bevacizumab: Avastin®; Mvasi®; Zirabev®; Alymsys®; Vegzelma®; Avzivi®
VP-90057 Trastuzumab: Herceptin®; Ogivri®; Kanjinti®; Trazimera™; Herzuma®; Ontruzant®
VP-90074 Cabazitaxel: Jevtana®; Cabazitaxel§
VP-90100 Provenge® (sipuleucel-T)
VP-90148 Yervoy™ (ipilimumab) (Intravenous)
VP-90200 Sylvant® (siltuximab) (Intravenous)
VP-90209 Keytruda® (pembrolizumab)
VP-90295 Bavencio® (avelumab) (Intravenous)
VP-90301 Imfinzi™ (durvalumab) (Intravenous)
VP-90314 Vyxeos® (daunorubicin and cytarabine – liposome)
VP-90320 Mylotarg™ (gemtuzumab ozogamicin)
VP-90336 Cinvanti® (aprepitant)
VP-90363 Akynzeo® (fosnetupitant/palonosetron)
VP-90398 Libtayo® (cemiplimab-rwlc) (Intravenous)
VP-90522 Enhertu® (fam-trastuzumab deruxtecan-nxki)
VP-90599 Jemperli® (dostarlimab-gxly)
VP-90683 Imjudo® (tremelimumab-actl) (Intravenous)
VP-90700 Zynyz™ (retifanlimab-dlwr) (Intravenous)
VP-90735 Loqtorzi™ (toripalimab-tpzi) (Intravenous)
VP-90750 Tevimbra™ (tislelizumab-jsgr)
VP-90766 Lymphir™ (denileukin diftitox-cxdl)
VP-90778 Ziihera® (zanidatamab-hrii)
VP-90780 Unloxcyt® (cosibelimab-ipdl)