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Draft Provider-Administered Drug Policies

Draft policies are listed below. If there are no policies listed, it means there are currently no policies in draft status.

Provider-administered oncology drugs require that a member’s medical condition meets the policy requirements prior to being given (precertification) unless otherwise specified.

Providers must submit a request through Prime Therapeutics for pre-service review in order to be approved. If the provider does not receive approval for precertification, the plan will pay no benefits.  

Currently, precertification for these provider-administered drugs is required when administered in a provider’s office, outpatient facility or home health setting; however, this precertification does not apply to inpatient hospital claims at this time.

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.

To request a copy of a drug policy, members can contact Customer Service by calling the number on their ID card.

Comment on Draft Oncology 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 draft policies.

Comments are accepted for 45 days from the posting date listed on the draft policy.

Make sure your voice is heard by providing feedback directly to us:

 

  • Send comments and supporting documentation by mail or fax

Birmingham Service Center
Attn: Health Management - Medical Policy
P.O. Box 10527
Birmingham, AL 35202

Fax: 205-220-0878

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®; Avtozma®; Tocilizumab-anoh§
PH-90028 Cimzia® (certolizumab pegol)
PH-90089 Nplate® (romiplostim)
PH-90091 Orencia® (abatacept)
PH-90104 Infliximab: Remicade®; Inflectra™; Renflexis™; Avsola™, Infliximab*
PH-90109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-90117 Ustekinumab: Stelara®; Wezlana™; Selarsdi™; Pyzchiva®; Otulfi™; Imuldosa®; Ustekinumab-aekn§
PH-90176 Simponi ARIA® (golimumab)
PH-90177 Ilaris® (canakinumab)
PH-90202 Entyvio® (vedolizumab)
PH-90229 Cosentyx® (secukinumab)
PH-90242 Aranesp® (darbepoetin alfa) (Precertification Not Required)
PH-90243 Epoetin alfa: Epogen®; Procrit®; Retacrit™
PH-90244 Mircera® (methoxy polyethylene glycol-epoetin beta) (Precertification not required)
PH-90310 Tremfya® (guselkumab)
PH-90358 Ilumya™ (tildrakizumab-asmn)
PH-90421 Gamifant™ (emapalumab-lzsg)
PH-90481 Spravato® (esketamine)
PH-90514 Givlaari (givosiran)
PH-90579 Oxlumo® (lumasiran)
PH-90598 Abecma® (idecabtagene vicleucel)
PH-90634 Susvimo™ (ranibizumab)
PH-90649 Vyvgart™ (efgartigimod alfa-fcab)
PH-90659 Vabysmo™ (faricimab-svoa)
PH-90671 Skyrizi® (risankizumab-rzaa)
PH-90674 Spevigo® (spesolimab)
PH-90677 Skysona® (elivaldogene autotemcel)
PH-90688 Hemgenix® (etranacogene dezaparvovec-drlb)
PH-90694 Leqembi™ (lecanemab-irmb)
PH-90712 Vyvgart® Hytrulo (efgartigimod alfa-fcab and hyaluronidase-qvfc)
PH-90714 Rystiggo® (rozanolixizumab-noli)
PH-90721 Izervay™ (avacincaptad pegol)
PH-90734 Omvoh™ (mirikizumab-mrkz)
PH-90743 Lyfgenia® (lovotibeglogene autotemcel)
PH-90744 Casgevy™ (exagamglogene autotemcel) (Intravenous)
PH-90744 Casgevy™ (exagamglogene autotemcel)
PH-90751 Lenmeldy™ (atidarsagene autotemcel)
PH-90781 Ryoncil® (remestemcel-L-rknd)
PH-9238 Botox® (onabotulinumtoxinA)
PH-9468 Zolgensma® (onasemnogene abeparvovec-xioi)
VP-90691 Adstiladrin® (nadofaragene firadenovec-vncg)