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-90071 Immune Globulins (immunoglobulin): Bivigam; Flebogamma; Gamunex-C; Gammagard Liquid; Gammagard S/D; Gammaked; Gammaplex; Octagam; Privigen; Panzyga
PH-90109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-90145 Xiaflex® (collagenase)
PH-90282 Testopel® (testosterone pellets)
PH-90355 Trogarzo™ (ibalizumab-uiyk)
PH-90495 Feraheme® (ferumoxytol)
PH-90524 Monoferric™ (ferric derisomaltose)
PH-90579 Oxlumo® (lumasiran)
PH-90676 Rolvedon™ (eflapegrastim-xnst)