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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-90002 Tocilizumab: Actemra®; Tofidence™; Tyenne®
PH-90003 Corticotropin-ACTH: Acthar® Gel (repository corticotropin injection) Cortrophin® Gel (repository corticotropin injection)
PH-90017 Benlysta® (belimumab)
PH-90036 Fosaprepitant: Emend®; Fosaprepitant Ψ; Focinvez Ψ
PH-90052 Alpha-1-Proteinase Inhibitors: Aralast NP®; Glassia®; Prolastin®-C; Zemaira®
PH-90080 Leuprolide Suspension: Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Camcevi™, Lutrate Depot™, Leuprolide Acetate Depot Ψ(Precertification not required)
PH-90098 Denosumab: Prolia®; Jubbonti®; Xgeva®; Wyost®
PH-90111 Sandostatin® LAR (octreotide suspension) (Precertification not required)
PH-90131 Trelstar® (triptorelin) (Precertification not required)
PH-90146 Xolair® (omalizumab)
PH-90237 Leukine® (sargramostim)
PH-90503 Reblozyl® (luspatercept-aamt)
PH-90591 Evkeeza™ (evinacumab-dgnb)
PH-90614 Saphnelo™ (anifrolumab-fnia)
PH-90652 Leqvio® (inclisiran)
PH-90672 Zynteglo® (betibeglogene autotemcel)
PH-90674 Spevigo® (spesolimab)
PH-90744 Casgevy™ (exagamglogene autotemcel) (Intravenous)
PH-90751 Lenmeldy™ (atidarsagene autotemcel)
PH-91154 Empaveli (pegcetacoplan) Prior Authorization with Quantity Limit Program Summary
PH-91166 Lupus Prior Authorization with Quantity Limit Program Summary
PH-91175 Pyrukynd (mitapivat) Prior Authorization with Quantity Limit Program Summary