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Draft Self-Administered Drug Policies

Draft self-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.

How to Submit Comments 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-91002 Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-910022 Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-91007 GLP-1 (glucagon-like peptide-1) Agonists Prior Authorization with Quantity Limit Program Summary
PH-91017 Opioids ER Prior Authorization and Quantity Limit Program Summary
PH-91029 Atypical Antipsychotics Step Therapy with Quantity Limit Program Summary
PH-91033 Calcitonin Gene-Related Peptide (CGRP) Prior Authorization with Quantity Limit Program Summary
PH-91042 Glucose Test Strips and Meters Step Therapy Program Summary
PH-91043 Growth Hormone Prior Authorization Program Summary
PH-91046 Corticotropin Prior Authorization Program Summary
PH-91060 Northera (droxidopa) Prior Authorization with Quantity Limit Program Summary
PH-91063 Pulmonary Hypertension Agents Prior Authorization with Quantity Limit Program Summary
PH-91066 Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
PH-91074 Substrate Reduction Therapy Prior Authorization with Quantity Limit Program Summary
PH-91075 Thrombopoietin Receptor Agonists and Tavalisse Prior Authorization with Quantity Limit Program Summary
PH-91089 Erectile Dysfunction -Phosphodiesterase Type 5 Inhibitors, Quantity Limit Program Summary
PH-91101 Antidepressant Agents Step Therapy and Quantity Limit Program Summary
PH-91107 ATTR (transthyretin amyloid) Amyloidosis Prior Authorization with Quantity Limit Program Summary
PH-91114 Cablivi (caplacizumab-yhdp) Quantity Limit Program Summary
PH-91115 Interleukin-5 (IL-5) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91117 Opioids Immediate Release (IR) Quantity Limit Program Summary
PH-91130 Risdiplam Prior Authorization with Quantity Limit Program Summary
PH-91131 Acute Migraine Agents Prior Authorization with Quantity Limit Program Summary
PH-91151 Iron Chelation Prior Authorization with Quantity Limit Program Summary
PH-91153 Ivermectin Prior Authorization Program Summary
PH-91156 Atypical Antipsychotics – Extended Maintenance Agents Step Therapy and Quantity Limit Program Summary
PH-91179 Attention Deficit [Hyperactivity] Disorder (ADHD/ADD) Agents Quantity Limit Program Summary
PH-91181 Elagolix/Relugolix Prior Authorization with Quantity Limit Program Summary
PH-91182 Penicillamine Step Therapy Program Summary
PH-91185 Vtama (tapinarof) Prior Authorization Program Summary
PH-91199 Antiretroviral Quantity Limit Program Summary
PH-91202 Filspari (sparsentan) Prior Authorization with Quantity Limit Program Summary
PH-91218 Fabhalta (iptacopan) Prior Authorization with Quantity Limit Program Summary
PH-91225 Anti-COVID19 Quantity Limit Program Summary
PH-91229 Zilbrysq (zilucoplan) Prior Authorization with Quantity Limit Program Summary
PH-91230 Primary Biliary Cholangitis Prior Authorization with Quantity Limit Program Summary