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-0614 Saphnelo™ (anifrolumab-fnia)
PH-0615 Nexviazyme™ (avalglucosidase alfa-ngpt)
PH-90002 Actemra® (tocilizumab)
PH-90018 Berinert® (C1 Esterase Inhibitor, Human)
PH-90026 Eylea® (aflibercept)
PH-90027 Cerezyme® (imiglucerase)
PH-90028 Cimzia® (certolizumab pegol)
PH-90059 SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify®
PH-90061 Hyaluronic Acid Derivatives: Durolane®, Euflexxa™, Gel-One®, GelSyn-3™, GenVisc 850®, Hyalgan™, Hymovis®, Monovisc®, Orthovisc™, Supartz/Supartz FX™, Synvisc™, Synvisc-One™, Triluron™, TriVisc™, VISCO-3™, & sodium hyaluronate 1%
PH-90071 Immune Globulins (Asceniv, Bivigam, Carimune NF, Flebogamma, Gamunex-C, Gammagard Liquid, Gammagard S/D, Gamaked, Gammaplex, Octagam, Privigen, Panzyga)
PH-90078 Ranibizumab: Lucentis®; Byooviz™
PH-90079 Lumizyme® (alglucosidase alfa)
PH-90081 Macugen® (pegaptanib)
PH-90105 Elelyso™ (taliglucerase alfa)
PH-90109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-90114 Soliris (eculizumab)
PH-90117 Stelara® (ustekinumab)
PH-90120 Synagis® (palivizumab)
PH-90133 Tysabri® (natalizumab)
PH-90141 VPRIV® (velaglucerase alfa)
PH-90158 Krystexxa® (pegloticase)
PH-90167 Kalbitor® (ecallantide)
PH-90168 Cinryze® (C1 Esterase Inhibitor, Human)
PH-90169 Firazyr® (icatibant)
PH-90202 Entyvio® (vedolizumab)
PH-90207 Ruconest® (C1 Esterase Inhibitor [recombinant])
PH-90223 Lemtrada® (alemtuzumab)
PH-90273 Cinqair® (reslizumab)
PH-90282 Testopel® (testosterone pellets)
PH-90298 Ocrevus™ (ocrelizumab)
PH-90307 Haegarda® (C1 Esterase Inhibitor Subcutaneous [Human])
PH-90379 Onpattro® (patisiran lipid complex)
PH-90392 Takhzyro™ (lanadelumab-flyo)
PH-90427 Ultomiris® (ravulizumab-cwvz)
PH-90497 Beovu® (brolucizumab-dbll)
PH-90549 Uplizna™ (inebilizumab-cdon)