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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 Provider-Administered Drug Policies

Policy # Policy Title Print View
PH-90080 Leuprolide Suspension: Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Lutrate Depot®; Camcevi™, Leuprolide Acetate Depot(Precertification not required)
PH-90098 Denosumab: Prolia®; Jubbonti®; Xgeva®; Wyost®
PH-90109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-90117 Ustekinumab: Stelara®; Wezlana™; Selarsdi™; Pyzchiva®; Otulfi™; Imuldosa®; Yesintek™; Steqeyma®; Ustekinumab-aekn§
PH-90137 Bortezomib Velcade®; Boruzu®; Bortezomib
PH-90181 Visudyne® (verteporfin)
PH-90234 Long-Acting Granulocyte Colony Stimulating Factors (LA-gCSF): Neulasta®; Fulphila®; Udenyca®; Ziextenzo®; Nyvepria™; Fylnetra®; Stimufend®; Rolvedon®; Ryzneuta®; Pegfilgrastim-fpgk§
PH-90239 Dysport® (abobotulinumtoxinA)
PH-90240 Myobloc® (rimabotulinumtoxinB)
PH-90241 Xeomin® (incobotulinumtoxinA) (Precertification not required)
PH-90284 Exondys 51™ (eteplirsen)
PH-90310 Tremfya® (guselkumab)
PH-90312 Injectafer® (ferric carboxymaltose injection)
PH-90481 Spravato® (esketamine)
PH-90503 Reblozyl® (luspatercept-aamt)
PH-90512 Scenesse® (afamelanotide)
PH-90514 Givlaari (givosiran)
PH-90520 Vyondys 53™ (golodirsen)
PH-90524 Monoferric™ (ferric derisomaltose)
PH-90549 Uplizna™ (inebilizumab-cdon)
PH-90562 Viltepso™ (viltolarsen)
PH-90579 Oxlumo® (lumasiran)
PH-90593 Amondys 45™  (casimersen)
PH-90598 Abecma® (idecabtagene vicleucel)
PH-90633 Xipere® (triamcinolone acetonide injectable suspension)
PH-90635 Dextenza® (dexamethasone insert)
PH-90660 Enjaymo™ (sutimlimab-jome)
PH-90670 Amvuttra (vutrisiran)
PH-90688 Hemgenix® (etranacogene dezaparvovec-drlb)
PH-90694 Leqembi™ (lecanemab-irmb)
PH-90712 Vyvgart® Hytrulo (efgartigimod alfa-fcab and hyaluronidase-qvfc)
PH-90721 Izervay™ (avacincaptad pegol)
PH-90762 Piasky ™ (crovalimab-akkz)
PH-90774 Vyloy® (zolbetuximab-clzb)
PH-90781 Ryoncil® (remestemcel-L-rknd)
PH-90794 Qfitlia ™ (fitusiran)
VP-90001 Paclitaxel Albumin-Bound: Abraxane®; Paclitaxel Albumin-Bound Ψ
VP-90004 Adcetris® (brentuximab vedotin)
VP-90007 Pemetrexed: Alimta®; Pemfexy™; Pemrydi RTU®; Pemetrexed Ψ
VP-90014 Bevacizumab: Avastin®; Mvasi®; Zirabev®; Alymsys®; Vegzelma®; Avzivi®; Jobevne™
VP-90038 Erbitux® (cetuximab)
VP-90043 Fulvestrant: Faslodex®; Fulvestrant Ψ (Intramuscular)
VP-90057 Trastuzumab: Herceptin®; Ogivri®; Kanjinti®; Trazimera™; Herzuma®; Ontruzant®
VP-90092 Kadcyla® (ado-trastuzumab emtansine)
VP-90096 Perjeta® (pertuzumab)
VP-90148 Yervoy™ (ipilimumab) (Intravenous)
VP-90157 Kyprolis® (carfilzomib)
VP-90226 Opdivo® (nivolumab)
VP-90266 Darzalex™ (daratumumab)
VP-90268 Empliciti™ (elotuzumab) (Intravenous)
VP-90426 Elzonris™ (tagraxofusp-erzs)
VP-90449 Herceptin Hylecta™ (trastuzumab and hyaluronidase-oysk)
VP-90522 Enhertu® (fam-trastuzumab deruxtecan-nxki)
VP-90528 Sarclisa® (isatuximab-irfc)
VP-90535 Darzalex Faspro® (daratumumab and hyaluronidase-fihj)
VP-90553 Phesgo™ (pertuzumab, trastuzumab and hyaluronidase-zzxf)
VP-90583 Margenza® (margetuximab-cmkb)
VP-90600 Zynlonta® (loncastuximab tesirine-lpyl)
VP-90682 Tecvayli™ (teclistamab-cqyv)
VP-90707 Omisirge® (omidubicel-onlv)
VP-90722 Talvey™ (talquetamab-tgvs)
VP-90724 Elrexfio™ (elranatamab-bcmm)
VP-90761 Rytelo® (imetelstat)
VP-90778 Ziihera® (zanidatamab-hrii)
VP-90779 Bizengri® (zenocutuzumab-zbco)
VP-990014 Bevacizumab: Avastin®; Mvasi®; Zirabev®; Alymsys®; Vegzelma®; Avzivi®; Jobevne™