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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-1215 Resmetirom Prior Authorization with Quantity Limit Program Summary
PH-1221 Dry Eye Disease Prior Authorization with Quantity Limit Program Summary
PH-1222 Eohilia Prior Authorization with Quantity Limit Program Summary
PH-1223 Verkazia Prior Authorization with Quantity Limit Program Summary
PH-1224 Zelsuvmi (berdazimer) Prior Authorization with Quantity Limit Program Summary
PH-91002 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-91022 Afrezza (regular human insulin, inhaled) Prior Authorization with Quantity Limit 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-91027 Angiotensin II Receptor Antagonists (ARBs), Renin Inhibitors, and Combinations Step Therapy Program Summary
PH-91030 Bonjesta, Diclegis Prior Authorization with Quantity Limit Program Summary
PH-91033 Calcitonin Gene-Related Peptide (CGRP) Prior Authorization with Quantity Limit Program Summary
PH-91036 Constipation Agents Prior Authorization with Quantity Limit Program Summary
PH-91038 Emflaza (deflazacort) 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-91044 Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker (Corlanor) Prior Authorization with Quantity Limit Program Summary
PH-91046 Corticotropin Prior Authorization Program Summary
PH-91057 Multiple Sclerosis Agents Step Therapy with Quantity Limit 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-91087 Coverage Exception Program Summary
PH-91094 Elmiron® (pentosan polysulfate sodium) Prior Authorization Program Summary
PH-91096 Hyperhidrosis Prior Authorization with Quantity Limit 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-91112 Ocaliva (obeticholic acid) Prior Authorization with Quantity Limit Program Summary
PH-91117 Opioids Immediate Release (IR) 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-91127 Oxbryta (voxelotor) 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-91142 Enspryng (satralizumab-mwge) Prior Authorization with Quantity Limit Program Summary
PH-91143 Sunosi (solriamfetol) Prior Authorization with Quantity Limit Program Summary
PH-91145 Xhance Prior Authorization with Quantity Limit Program Summary
PH-91147 Zeposia (oxanimod) Prior Authorization with Quantity Limit Program Summary
PH-91148 Verquvo Prior Authorization with Quantity Limit Program Summary
PH-91150 Continuous Glucose Monitor (CGM) Step Therapy with Quantity Limit Program Summary
PH-91152 Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91157 Cholestasis Pruritus Prior Authorization Program Summary
PH-91160 Rapid to Intermediate Acting Insulin Prior Authorization Program Summary
PH-91170 Interleukin-13 (IL-13) Antagonist Prior Authorization with Quantity Limit Program Summary
PH-91171 Xolair (omalizumab) Prior Authorization 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-91194 Zoryve (roflumilast) Prior Authorization 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-91225 Anti-COVID19 Quantity Limit Program Summary
PH-91226 Spevigo (spesolimab-sbzo) Prior Authorization with Quantity Limit Program Summary
PH-91227 Voydeya (danicopan) Prior Authorization with 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