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 |
|