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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-91000 Androgens and Anabolic Steroids Prior Authorization with Quantity Limit Program Summary
PH-91002 Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-910022 Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-91004 Compounded Medications Prior Authorization Program Summary
PH-91005 Contraceptive Prior Authorization Program Summary
PH-91007 GLP-1 (glucagon-like peptide-1) Agonists Prior Authorization with Quantity Limit Program Summary
PH-91009 Peginterferon Prior Authorization Program Summary
PH-91012 Immune Globulins Prior Authorization Program Summary
PH-91013 Mandatory Generic/Member Pays the Difference Exception Prior Authorization Program Summary
PH-91020 Topical Doxepin Prior Authorization with Quantity Limit Program Summary
PH-91028 Atopic Dermatitis (Elidel [pimecrolimus], Eucrisa, Protopic [tacrolimus]) Step Therapy Program Summary
PH-91029 Atypical Antipsychotics Step Therapy with Quantity Limit Program Summary
PH-91031 Carbaglu (carglumic acid) Prior Authorization Program Summary
PH-91032 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Prior Authorization with Quantity Limit Program Summary
PH-91034 Topical Antifungals, itraconazole, terbinafine Prior Authorization with Quantity Limit Program Summary
PH-91036 Constipation Agents Prior Authorization with Quantity Limit Program Summary
PH-91037 Topical Actinic Keratosis, Basal Cell Carcinoma, Genital Warts Agents Prior Authorization with Quantity Limit Program Summary
PH-91038 Emflaza (deflazacort) Prior Authorization with Quantity Limit Program Summary
PH-91042 Glucose Test Strips and Meters Step Therapy Program Summary
PH-91046 Corticotropin Prior Authorization Program Summary
PH-91054 Korlym (mifepristone) Prior Authorization with Quantity Limit Program Summary
PH-91058 Myalept (metreleptin) Prior Authorization Program Summary
PH-91063 Oral Pulmonary Hypertension Agents Prior Authorization with Quantity Limit Program Summary
PH-91064 Oral Tetracycline Derivatives Step Therapy Program Summary
PH-91065 Parathyroid Hormone Analog for Osteoporosis 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-91067 Phenylketonuria Prior Authorization Program Summary
PH-91069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
PH-91070 Signifor (pasireotide) Prior Authorization with Quantity Limit Program Summary
PH-91073 Strensiq Prior Authorization Program Summary
PH-91080 Urea Cycle Disorders Prior Authorization Program Summary
PH-91087 Coverage Exception Program Summary
PH-91088 Copay Waiver for Breast Cancer Primary Prevention Agent ACA Copay Waiver Program Summary – Individual Marketplace, Commercial
PH-91101 Antidepressant Agents Step Therapy and Quantity Limit Program Summary
PH-91105 Weight Loss Agents Prior Authorization with Quantity Limit Program Summary
PH-91113 Procysbi (cysteamine bitartrate) Prior Authorization Program Summary
PH-91119 Interleukin-4 (IL-4) Inhibitor Prior Authorization with Quantity Limit Program Summary
PH-91121 Baclofen Prior Authorization with Quantity Limit Program Summary
PH-91129 Copay Waiver for Human Immunodeficiency Virus (HIV) Infection: Pre-exposure Prophylaxis (PrEP) ACA Prevention Copay Waiver Program Summary – Individual Marketplace, Commercial
PH-91132 Bempedoic Acid Prior Authorization with Quantity Limit Program Summary
PH-91133 Isturisa (osilodrostt) Prior Authorization with Quantity Limit Program Summary
PH-91138 Dojolvi Prior Authorization Program Summary
PH-91139 DPP-4 Inhibitors and Combinations Step Therapy with Quantity Limit Program Summary
PH-91142 Enspryng (satralizumab-mwge) Prior Authorization with Quantity Limit Program Summary
PH-91144 Sucraid (sacrosidase) Prior Authorization with Quantity Limit Program Summary
PH-91149 Topical NSAID (Non-Steroidal Anti-Inflammatory Drug) 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-91157 Cholestasis Pruritus Prior Authorization Program Summary
PH-91159 Long Acting Insulin Prior Authorization Program Summary
PH-91160 Rapid to Intermediate Acting Insulin Prior Authorization Program Summary
PH-91162 Opzelura (ruxolitinib) Prior Authorization with Quantity Limit Program Summary
PH-91169 Voxzogo (vosoritide) Prior Authorization with Quantity Limit Program Summary
PH-91170 Interleukin-13 (IL-13) Antagonist Prior Authorization with Quantity Limit Program Summary
PH-91174 Cibinqo (abrocitinib) Prior Authorization with Quantity Limit Program Summary
PH-91176 Recorlev (levoketoconazole) Prior Authorization with Quantity Limit Program Summary
PH-91177 Tarpeyo Prior Authorization with Quantity Limit Program Summary
PH-91178 Topical Psoriasis Quantity Limit
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-91184 Topical Estrogen Quantity Limit Program Summary
PH-91185 Vtama (tapinarof) Prior Authorization Program Summary
PH-91186 Copay Waiver for Statin ACA Prevention Copay Waiver Program Summary – Individual Marketplace, Commercial
PH-91187 ACA Prevention Copay Waiver Contraceptives Program Summary – Individual Marketplace, Commercial
PH-91188 Hyftor (sirolimus) Prior Authorization with Quantity Limit Program Summary
PH-91191 Oral Inhalers Quantity Limit Program Summary
PH-91194 Zoryve (roflumilast) Prior Authorization Program Summary
PH-91197 Tezspire (tezepelumab-ekko) Prior Authorization with Quantity Limit Program Summary
PH-91200 CMV (cytomegalovirus) Quantity Limit Program Summary
PH-91201 Winlevi (clascoterone) Step Therapy Program Summary
PH-91203 Jesduvroq (daprodustat) Prior Authorization with Quantity Limit Program Summary
PH-91205 Ophthalmic Prostaglandins Quantity Limit Program Summary
PH-91209 Qualaquin Quantity Limit Program Summary
PH-91210 Miebo (perfluorohexyloctane) Prior Authorization with Quantity Limit Program Summary
PH-91211 Step Therapy Supplement Step Therapy Program Summary
PH-91212 Combination NSAID Prior Authorization with Quantity Limit Program Summary
PH-91213 Neurokinin Receptor Antagonists Prior Authorization with Quantity Limit Program Summary
PH-91214 Vowst (fecal microbiota spores, live-brpk) Prior Authorization with Quantity Limit Program Summary