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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.

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-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-90181 Visudyne® (verteporfin)
PH-90239 Dysport® (abobotulinumtoxinA)
PH-90240 Myobloc® (rimabotulinumtoxinB)
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-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-90744 Casgevy™ (exagamglogene autotemcel) (Intravenous)
PH-90762 Piasky ™ (crovalimab-akkz)
PH-90781 Ryoncil® (remestemcel-L-rknd)
PH-9238 Botox® (onabotulinumtoxinA)
PH-9468 Zolgensma® (onasemnogene abeparvovec-xioi)