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 Policies

Policy # Policy Title Print View
PH-90006 Aldurazyme® (laronidase)
PH-90034 Elaprase® (idursulfase)
PH-90042 Fabrazyme® (agalsidase beta)
PH-90071 Immune Globulins (immunoglobulin): Bivigam; Flebogamma; Gamunex-C; Gammagard Liquid; Gammagard S/D; Gammaked; Gammaplex; Octagam; Privigen; Panzyga
PH-90079 Lumizyme® (alglucosidase alfa)
PH-90080 Leuprolide Suspension: Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Camcevi™, Lutrate Depot™ (Precertification not required)
PH-90089 Nplate® (romiplostim)
PH-90104 Infliximab: Remicade®; Inflectra™; Renflexis™; Avsola™, Infliximab*
PH-90145 Xiaflex® (collagenase)
PH-90277 Kanuma™ (sebelipase alfa)
PH-90299 Brineura (cerliponase alfa)
PH-90312 Injectafer® (ferric carboxymaltose injection)
PH-90346 Mepsevii® (vestronidase alfa-vjbk)
PH-90350 Luxturna® (voretigene neparvovec-rzyl)
PH-90421 Gamifant™ (emapalumab-lzsg)
PH-90427 Ultomiris® (ravulizumab-cwvz)
PH-90512 Scenesse® (afamelanotide)
PH-90514 Givlaari (givosiran)
PH-90524 Monoferric™ (ferric derisomaltose)
PH-90527 Vyepti® (eptinezumab-jjmr)
PH-90615 Nexviazyme™ (avalglucosidase alfa-ngpt)
PH-90648 Rethymic® (allogeneic processed thymus tissue-agdc)
PH-90649 Vyvgart™ (efgartigimod alfa-fcab)
PH-90660 Enjaymo™ (sutimlimab-jome)
PH-90673 Xenpozyme™ (olipudase alfa)
PH-90676 Rolvedon™ (eflapegrastim-xnst)
PH-90677 Skysona® (elivaldogene autotemcel)
PH-90687 Tzield™ (teplizumab-mzwv)
PH-90688 Hemgenix® (etranacogene dezaparvovec-drlb)
PH-90693 Briumvi™ (ublituximab-xiiy)
PH-90694 Leqembi™ (lecanemab-irmb)