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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-90006 Aldurazyme® (laronidase)
PH-90017 Benlysta® (belimumab)
PH-90027 Cerezyme® (imiglucerase)
PH-90034 Elaprase® (idursulfase)
PH-90036 Fosaprepitant: Emend®; Fosaprepitant Ψ; Focinvez Ψ
PH-90042 Fabrazyme® (agalsidase beta)
PH-90052 Alpha-1-Proteinase Inhibitors: Aralast NP®; Glassia®; Prolastin®-C; Zemaira®
PH-90079 Lumizyme® (alglucosidase alfa)
PH-90080 Leuprolide Suspension: Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Lutrate Depot®; Camcevi™, Leuprolide Acetate Depot(Precertification not required)
PH-90084 Naglazyme® (galsulfase)
PH-90105 Elelyso™ (taliglucerase alfa)
PH-90109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-90114 Eculizumab: Soliris®; Bkemv™; Epysqli®
PH-90117 Ustekinumab: Stelara®; Wezlana™; Selarsdi™; Pyzchiva®; Otulfi™; Imuldosa®; Yesintek™; Steqeyma®; Ustekinumab-aekn§
PH-90141 VPRIV® (velaglucerase alfa)
PH-90190 Vimizim (elosulfase alfa)
PH-90277 Kanuma® (sebelipase alfa)
PH-90284 Exondys 51™ (eteplirsen)
PH-90298 Ocrevus™ (ocrelizumab)
PH-90299 Brineura (cerliponase alfa)
PH-90310 Tremfya® (guselkumab)
PH-90312 Injectafer® (ferric carboxymaltose injection)
PH-90346 Mepsevii® (vestronidase alfa-vjbk)
PH-90463 Sublocade (buprenorphine ER 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-90614 Saphnelo® (anifrolumab-fnia)
PH-90615 Nexviazyme® (avalglucosidase alfa-ngpt)
PH-90635 Dextenza® (dexamethasone insert)
PH-90660 Enjaymo™ (sutimlimab-jome)
PH-90670 Amvuttra (vutrisiran)
PH-90673 Xenpozyme® (olipudase alfa)
PH-90688 Hemgenix® (etranacogene dezaparvovec-drlb)
PH-90694 Leqembi™ (lecanemab-irmb)
PH-90696 Lamzede® (velmanase alfa-tycv)
PH-90708 Elfabrio® (pegunigalsidase alfa-iwxj)
PH-90712 Vyvgart® Hytrulo (efgartigimod alfa-fcab and hyaluronidase-qvfc)
PH-90721 Izervay™ (avacincaptad pegol)
PH-90731 Pombiliti® (cipaglucosidase alfa-atga)
PH-90736 Adzynma® (ADAMTS13, recombinant-krhn)
PH-90744 Casgevy™ (exagamglogene autotemcel) (Intravenous)
PH-90751 Lenmeldy™ (atidarsagene autotemcel)
PH-90762 Piasky ™ (crovalimab-akkz)
PH-90781 Ryoncil® (remestemcel-L-rknd)
PH-90793 Encelto™ (revakinagene taroretcel-lwey)
PH-9238 Botox® (onabotulinumtoxinA)
PH-9468 Zolgensma® (onasemnogene abeparvovec-xioi)
VP-90336 Cinvanti® (aprepitant)
VP-90363 Akynzeo® (fosnetupitant/palonosetron)