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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-1218 Fabhalta (iptacopan) Prior Authorization with Quantity Limit Program Summary
PH-1219 Filsuvez (birch triterpenes) Prior Authorization Program Summary (birch triterpenes) Prior Authorization 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-91024 Oral Anticoagulant - Eliquis (apixaban), Pradaxa (dabigatran), Savaysa (edoxaban), Xarelto (rivaroxaban) Quantity Limit Program Summary
PH-91029 Atypical Antipsychotics Step Therapy with Quantity Limit Program Summary
PH-91033 Calcitonin Gene-Related Peptide (CGRP) Prior Authorization with Quantity Limit Program Summary
PH-91035 Hetlioz (tasimelteon) Prior Authorization with Quantity Limit Program Summary
PH-91038 Emflaza (deflazacort) Prior Authorization with Quantity Limit Program Summary
PH-91040 Gabapentin ER (extended-release) [Horizant, Gralise] Step Therapy and Quantity Limit Program Summary
PH-91057 Multiple Sclerosis Agents Step Therapy with Quantity Limit Program Summary
PH-91063 Pulmonary Hypertension Agents Prior Authorization with Quantity Limit Program Summary
PH-91069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
PH-91077 Topiramate ER Prior Authorization with Quantity Limit Program Summary
PH-91092 Jynarque Prior Authorization with Quantity Limit Program Summary
PH-91098 Samsca (tolvaptan) Prior Authorization with Quantity Limit Program Summary
PH-91101 Antidepressant Agents Step Therapy and Quantity Limit Program Summary
PH-91115 Interleukin-5 (IL-5) Inhibitors Prior Authorization with 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-91129 Copay Waiver for Human Immunodeficiency Virus (HIV) Infection: Pre-exposure Prophylaxis (PrEP) ACA Prevention Copay Waiver Program Summary – Individual Marketplace, Commercial
PH-91139 DPP-4 Inhibitors and Combinations Step Therapy with Quantity Limit Program Summary
PH-91140 Fintepla (fenfluramine) Prior Authorization with Quantity Limit Program Summary
PH-91147 Zeposia (oxanimod) Prior Authorization with Quantity Limit Program Summary
PH-91150 Continuous Glucose Monitor (CGM) Step Therapy with Quantity Limit Program Summary
PH-91151 Iron Chelation Prior Authorization with Quantity Limit Program Summary
PH-91158 Kerendia (finerenone) Prior Authorization with Quantity Limit Program Summary
PH-91162 Opzelura (ruxolitinib) Prior Authorization with Quantity Limit Program Summary
PH-91163 Tavneos (avacopan) Prior Authorization with Quantity Limit Program Summary
PH-91164 Tyrvaya (varenicline) Prior Authorization with Quantity Limit Program Summary
PH-91165 Imcivree Prior Authorization with Quantity Limit 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-91179 Attention Deficit [Hyperactivity] Disorder (ADHD/ADD) Agents Quantity Limit Program Summary
PH-91182 Penicillamine Step Therapy Program Summary
PH-91183 Radicava (edaravone) Prior Authorization with Quantity Limit Program Summary
PH-91184 Topical Estrogen Quantity Limit Program Summary
PH-91193 Relyvrio (sodium phenylbutyrate/taurursodiol) Prior Authorization with Quantity Limit Program Summary
PH-91194 Zoryve (roflumilast) Prior Authorization Program Summary
PH-91198 Vijoice (alpelisib) Prior Authorization with Quantity Limit Program Summary
PH-91204 Joenja (leniolisib) Prior Authorization with Quantity Limit Program Summary
PH-91207 Skyclarys (omaveloxolone) Prior Authorization with Quantity Limit Program Summary
PH-91212 Combination NSAID Prior Authorization with Quantity Limit Program Summary
PH-91215 Resmetirom Prior Authorization with Quantity Limit Program Summary
PH-91219 Filsuvez (birch triterpenes) Prior Authorization Program Summary
PH-91220 Xphozah (tenapanor) Prior Authorization with Quantity Limit Program Summary