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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.

Note: Coverage is subject to the member's specific benefits. Group-specific benefits will supersede these policies when applicable. Always check eligibility and benefits through your local Blue Plan provider portal or your practice management system to confirm member-specific benefits.

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-1242 Efgartigimod Prior Authorization with Quantity Limit Program Summary
PH-1243 Vanrafia Prior Authorization with Quantity Limit Program Summary
PH-91002 Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-910021 Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-910022 Biologic Immunomodulators Prior Authorization with Quantity Limit 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-91024 Oral Anticoagulant - Eliquis (apixaban), Pradaxa (dabigatran), Savaysa (edoxaban), Xarelto (rivaroxaban) Quantity Limit Program Summary
PH-91026 Anti-Influenza Agents Quantity Limit Program Summary
PH-91029 Atypical Antipsychotics Step Therapy with Quantity Limit Program Summary
PH-91030 Bonjesta, Diclegis Prior Authorization with Quantity Limit Program Summary
PH-91036 Constipation Agents Prior Authorization with Quantity Limit Program Summary
PH-91039 Endari (L-glutamine) Prior Authorization Program Summary
PH-91041 Gattex (teduglutide) Prior Authorization Program Summary
PH-91043 Growth Hormone Prior Authorization Program Summary
PH-91044 Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker (Corlanor) Prior Authorization with Quantity Limit Program Summary
PH-91063 Pulmonary Hypertension Agents Prior Authorization 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-91077 Topiramate ER Prior Authorization with Quantity Limit Program Summary
PH-91092 Jynarque Prior Authorization with Quantity Limit Program Summary
PH-91094 Elmiron® (pentosan polysulfate sodium) Prior Authorization Program Summary
PH-91101 Antidepressant Agents Step Therapy and Quantity Limit Program Summary
PH-91104 Neurotrophic Keratitis Prior Authorization with Quantity Limit Program Summary
PH-91110 Alinia Quantity Limit Program Summary
PH-91119 Interleukin-4 (IL-4) Inhibitor Prior Authorization with Quantity Limit Program Summary
PH-91120 Hepatitis C Direct Acting Antivirals Prior Authorization with Quantity Limit Program Summary
PH-91122 Wakix (pitolisant) Prior Authorization with Quantity Limit Program Summary
PH-91139 DPP-4 Inhibitors and Combinations Step Therapy with Quantity Limit Program Summary
PH-91141 Rho Kinase Inhibitor Quantity Limit Program Summary
PH-91148 Verquvo Prior Authorization with Quantity Limit Program Summary
PH-91157 Cholestasis Pruritus Prior Authorization Program Summary
PH-91158 Kerendia (finerenone) Prior Authorization with Quantity Limit Program Summary
PH-91160 Rapid to Intermediate Acting Insulin Prior Authorization Program Summary
PH-91163 Tavneos (avacopan) Prior Authorization with Quantity Limit Program Summary
PH-91165 Imcivree Prior Authorization with Quantity Limit Program Summary
PH-91166 Lupus Prior Authorization with Quantity Limit Program Summary
PH-91170 Interleukin-13 (IL-13) Antagonist Prior Authorization with Quantity Limit Program Summary
PH-91173 Bempedoic Acid Prior Authorization with Quantity Limit Program Summary
PH-91174 Cibinqo (abrocitinib) Prior Authorization with Quantity Limit Program Summary
PH-91177 Tarpeyo Prior Authorization with Quantity Limit Program Summary
PH-91180 Camzyos (mavacamten) Prior Authorization with Quantity Limit Program Summary
PH-91183 Radicava (edaravone) Prior Authorization with Quantity Limit Program Summary
PH-91191 Oral Inhalers Prior Authorization with Quantity Limit Program Summary
PH-91196 Furoscix (furosemide) Prior Authorization with Quantity Limit Program Summary
PH-91198 Vijoice (alpelisib) Prior Authorization with Quantity Limit Program Summary
PH-91199 Antiretroviral Quantity Limit Program Summary
PH-91200 CMV (cytomegalovirus) Quantity Limit Program Summary
PH-91202 Filspari (sparsentan) Prior Authorization with Quantity Limit Program Summary
PH-91205 Ophthalmic Prostaglandins Quantity Limit Program Summary
PH-91214 Vowst (fecal microbiota spores, live-brpk) Prior Authorization with Quantity Limit Program Summary
PH-91215 Resmetirom Prior Authorization with Quantity Limit Program Summary
PH-91216 Rivfloza (nedosiran) Prior Authorization with Quantity Limit Program Summary
PH-91217 Xdemvy Step Therapy with Quantity Limit Program Summary
PH-91218 Fabhalta (iptacopan) Prior Authorization with Quantity Limit Program Summary
PH-91220 Xphozah (tenapanor) Prior Authorization with Quantity Limit Program Summary
PH-91221 Dry Eye Disease Prior Authorization with Quantity Limit Program Summary
PH-91222 Eohilia Prior Authorization with Quantity Limit Program Summary
PH-91223 Verkazia Prior Authorization with Quantity Limit Program Summary
PH-91224 Zelsuvmi (berdazimer) Prior Authorization with Quantity Limit Program Summary
PH-91225 Anti-COVID19 Quantity Limit Program Summary
PH-91228 Weight Management Prior Authorization with Quantity Limit Program Summary
PH-91229 Zilbrysq (zilucoplan) Prior Authorization with Quantity Limit Program Summary
PH-91230 Primary Biliary Cholangitis Prior Authorization with Quantity Limit Program Summary
PH-91233 Xolremdi (mavorixafor) Prior Authorization with Quantity Limit Program Summary
PH-91235 Yorvipath Prior Authorization with Quantity Limit Program Summary
PH-91238 TRYVIO Prior Authorization with Quantity Limit Program Summary
PH-91240 Crenessity Prior Authorization with Quantity Limit Program Summary
PH-91244 Brensocatib Prior Authorization with Quantity Limit Program Summary
PH-91245 Ctexli Prior Authorization with Quantity Limit Program Summary
PH-91246 Journavx Quantity Limit Program Summary
PH-91247 Vykat XR Prior Authorization with Quantity Limit Program Summary
PH-991236 Interleukin-31 (IL-31) Inhibitor Prior Authorization with Quantity Limit Program Summary