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-91008 Hereditary Angiodema Prior Authorization with Quantity Limit Program Summary
PH-91014 Methotrexate Injectable Step Therapy Program Summary
PH-91017 Opioids ER Prior Authorization and Quantity Limit Program Summary
PH-91018 Opioids Immediate Release (IR) Duration Limit and Quantity Limit Program Summary
PH-91022 Afrezza Prior Authorization with Quantity Limit Program Summary
PH-91023 Ampyra (dalfampridine) Prior Authorization with Quantity Limit Program Summary
PH-91029 Atypical Antipsychotics Step Therapy with Quantity Limit Program Summary
PH-91032 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Prior Authorization with Quantity Limit Program Summary
PH-91036 Constipation Agents Prior Authorization with Quantity Limit Program Summary
PH-91047 Inhaled Antibiotics Duplicate Therapy Prior Authorization with Quantity Limit Program Summary
PH-91050 Insulin Combination Agents (Soliqua, Xultophy) Step Therapy and Quantity Limit Program Summary
PH-91053 Keveyis Prior Authorization with Quantity Limit Program Summary
PH-91056 Metformin ER Step Therapy Program Summary
PH-91057 Multiple Sclerosis Agents Step Therapy with Quantity Limit Program Summary
PH-91064 Oral Tetracycline Derivatives Step Therapy Program Summary
PH-91068 Proton Pump Inhibitors (PPIs) Step Therapy with Quantity Limit Program Summary
PH-91069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
PH-91072 Statin Step Therapy Program Summary
PH-91076 Transmucosal Immediate Release Fentanyl (TIRF) Prior Authorization with Quantity Limit Program Summary
PH-91077 Topiramate ER Prior Authorization with Quantity Limit Program Summary
PH-91081 Xanthine Oxidase Inhibitor Quantity Limit Program Summary
PH-91083 Oxybate Prior Authorization with Quantity Limit Program Summary
PH-91086 Quantity Limit Summary
PH-910861 Quantity Limit Summary Part 2
PH-91090 Amantadine Extended Release Prior Authorization with Quantity Limit Program Summary
PH-91096 Hyperhidrosis Prior Authorization with Quantity Limit Program Summary
PH-91097 Pseudobulbar Affect (PBA) Prior Authorization with Quantity Limit Program Summary
PH-91103 Amifampridine Prior Authorization with Quantity Limit Program Summary
PH-91106 Arikayce Prior Authorization with Quantity Limit Program Summary
PH-91107 ATTR (transthyretin amyloid) Amyloidosis Prior Authorization with Quantity Limit Program Summary
PH-91115 Interleukin-5 (IL-5) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91118 Hypoactive Sexual Desire Disorder (HSDD) Prior Authorization with Quantity Limit 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-91122 Wakix (pitolisant) Prior Authorization with Quantity Limit Program Summary
PH-91124 Interstitial Lung Disease (ILD) Prior Authorization with Quantity Limit Program Summary
PH-91127 Oxbryta (voxelotor) Prior Authorization with Quantity Limit Program Summary
PH-91130 Risdiplam Prior Authorization with Quantity Limit Program Summary
PH-91135 Sodium-glucose Co-transporter 2 (SGLT-2) Inhibitors and Combinations Step Therapy and Quantity Limit Program Summary
PH-91139 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors and Combinations Step Therapy with Quantity Limit Program Summary
PH-91143 Sunosi (solriamfetol) Prior Authorization with Quantity Limit Program Summary
PH-91145 Xhance Prior Authorization with Quantity Limit Program Summary
PH-91147 Zeposia (oxanimod) Prior Authorization with Quantity Limit Program Summary
PH-91150 Continuous Glucose Monitor (CGM) Step Therapy with Quantity Limit Program Summary
PH-91152 Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91155 Insulin Pumps Quantity Limit Program Summary
PH-91158 Kerendia (finerenone) Prior Authorization with Quantity Limit 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-91165 Imcivree Prior Authorization with Quantity Limit Program Summary
PH-91168 Hetlioz (tasimelteon) Prior Authorization with Quantity Limit Program Summary
PH-91171 Xolair (omalizumab) Prior Authorization Program Summary
PH-91179 Attention Deficit [Hyperactivity] Disorder (ADHD/ADD) Agents 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-91189 Nasal Antiepileptics Quantity Limit Program Summary
PH-91190 Nasal Inhalers Quantity Limit Program Summary
PH-91191 Oral Inhalers Quantity Limit Program Summary
PH-91192 Pain Medications (Combination Products) Quantity Limit Program Summary
PH-91193 Relyvrio (sodium phenylbutyrate/taurursodiol) Prior Authorization with Quantity Limit Program Summary
PH-91194 Zoryve (roflumilast) Prior Authorization Program Summary
PH-91195 Antitussive Combination Products Quantity Limit Program Summary