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 Policies

Policy # Policy Title Print View
PH-0670 Amvuttra (vutrisiran)
PH-90091 Orencia® (abatacept)
PH-90109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-90114 Soliris® (eculizumab)
PH-90117 Stelara® (ustekinumab)
PH-90120 Synagis® (palivizumab)
PH-90131 Trelstar® (triptorelin) (Precertification not required)
PH-90139 Vivitrol® (naltrexone)
PH-90141 VPRIV® (velaglucerase alfa)
PH-90158 Krystexxa® (pegloticase)
PH-90183 Levoleucovorin: Fusilev®; Khapzory™
PH-90234 Colony Stimulating Factors – Pegfilgrastim: Neulasta®; Fulphila™; Udenyca®; Ziextenzo™; Nyvepria™; Fylnetra®
PH-90284 Exondys 51™ (eteplirsen)
PH-90291 Spinraza™ (nusinersen)
PH-90305 Radicava®
PH-90358 Ilumya™ (tildrakizumab-asmn)
PH-90427 Ultomiris® (ravulizumab-cwvz)
PH-90468 Zolgensma® (onasemnogene abeparvovec-xioi)
PH-90497 Beovu®
PH-90520 Vyondys 53™ (golodirsen)
PH-90562 Viltepso™ (viltolarsen)
PH-90593 Amondys 45™  (casimersen)
PH-90610 Aduhelm™ (aducanumab-avwa)