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.
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
| Policy # |
Policy Title |
Print View |
| PH-90018 |
Berinert® (C1 Esterase Inhibitor, Human) |
|
| PH-90061 |
Hyaluronic Acid Derivatives: Durolane®, Euflexxa™, Gel-One®, GelSyn-3™, GenVisc 850®, Hyalgan™, Hymovis®, Monovisc®, Orthovisc™, Synojoynt, Supartz/Supartz FX™, Synvisc™, Synvisc-One™, Triluron™, TriVisc™, VISCO-3™ |
|
| PH-90078 |
Ranibizumab: Lucentis®; Byooviz™; Cimerli™ |
|
| PH-90080 |
Leuprolide Suspension: Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Lutrate Depot®; Camcevi™, Leuprolide Acetate Depot; Vabrinty™(Precertification not required) |
|
| PH-90098 |
Denosumab: Prolia®; Jubbonti®; Ospomyv™; Stoboclo®; Denosumab-dssb; Conexxence®; Denosumab-bnht; Xgeva®; Wyost®; Xbryk™; Osenvelt®; Bomyntra® |
|
| PH-90109 |
Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™ |
|
| PH-90117 |
Ustekinumab: Stelara®; Wezlana™; Selarsdi™; Pyzchiva®; Otulfi™; Imuldosa®; Yesintek™; Steqeyma®; Starjemza™; Ustekinumab-aekn§; Ustekinumab-ttwe§; Ustekinumab- aauz§; Ustekinumab-stba§; Ustekinumab§ |
|
| PH-90120 |
Synagis® (palivizumab) |
|
| PH-90167 |
Kalbitor® (ecallantide) |
|
| PH-90168 |
Cinryze® (C1 Esterase Inhibitor, Human) |
|
| PH-90207 |
Ruconest® (C1 Esterase Inhibitor [recombinant]) |
|
| PH-90260 |
Nucala® (mepolizumab) |
|
| PH-90284 |
Exondys 51™ (eteplirsen) |
|
| PH-90310 |
Tremfya® (guselkumab) |
|
| PH-90312 |
Injectafer® (ferric carboxymaltose injection) |
|
| PH-90421 |
Gamifant™ (emapalumab-lzsg) |
|
| PH-90481 |
Spravato® (esketamine) |
|
| PH-90497 |
Beovu® (brolucizumab-dbll) |
|
| PH-90503 |
Reblozyl® (luspatercept-aamt) |
|
| PH-90512 |
Scenesse® (afamelanotide) |
|
| PH-90514 |
Givlaari (givosiran) |
|
| PH-90520 |
Vyondys 53™ (golodirsen) |
|
| PH-90524 |
Monoferric™ (ferric derisomaltose) |
|
| PH-90525 |
Tepezza® (teprotumumab-trbw) |
|
| PH-90549 |
Uplizna™ (inebilizumab-cdon) |
|
| PH-90562 |
Viltepso™ (viltolarsen) |
|
| PH-90579 |
Oxlumo® (lumasiran) |
|
| PH-90591 |
Evkeeza™ (evinacumab-dgnb) |
|
| PH-90593 |
Amondys 45™ (casimersen) |
|
| PH-90598 |
Abecma® (idecabtagene vicleucel) |
|
| PH-90634 |
Susvimo™ (ranibizumab) |
|
| PH-90652 |
Leqvio® (inclisiran) |
|
| PH-90660 |
Enjaymo™ (sutimlimab-jome) |
|
| PH-90670 |
Amvuttra (vutrisiran) |
|
| PH-90688 |
Hemgenix® (etranacogene dezaparvovec-drlb) |
|
| PH-90694 |
Leqembi™ (lecanemab-irmb) |
|
| PH-90697 |
Syfovre™ (pegcetacoplan) |
|
| PH-90712 |
Vyvgart® Hytrulo (efgartigimod alfa-fcab and hyaluronidase-qvfc) |
|
| PH-90713 |
Elevidys® (delandistrogene moxeparvovec-rokl) |
|
| PH-90721 |
Izervay™ (avacincaptad pegol) |
|
| PH-90744 |
Casgevy™ (exagamglogene autotemcel) (Intravenous) |
|
| PH-90762 |
Piasky ™ (crovalimab-akkz) |
|
| PH-90763 |
Kisunla™ (donanemab-azbt) |
|
| PH-90781 |
Ryoncil® (remestemcel-L-rknd) |
|
| PH-90794 |
Qfitlia ™ (fitusiran) |
|
| PH-9238 |
Botox® (onabotulinumtoxinA) |
|
| PH-9468 |
Zolgensma® (onasemnogene abeparvovec-xioi) |
|
| PH-97044 |
Casgevy™ (exagamglogene autotemcel) |
|
| VP-0795 |
Penpulimab-KCQX (penpulimab-kcqx) |
|
| VP-90225 |
Blincyto® (blinatumomab) |
|
| VP-90267 |
Portrazza™ (necitumumab) |
|
| VP-90607 |
Rybrevant® (amivantamab-vmjw) |
|
