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-00751 |
Lenmeldy™ (atidarsagene autotemcel) |
|
| PH-0799 |
Emrelis™ (telisotuzumab vedotin-tllv) |
|
| PH-90002 |
Tocilizumab: Actemra®; Tofidence™; Tyenne®; Avtozma®; Tocilizumab-anoh§; Tocilizumab-aazg§ |
|
| PH-90003 |
Corticotropin-ACTH: Acthar® Gel (repository corticotropin injection) Cortrophin® Gel (repository corticotropin injection) |
|
| PH-90008 |
Palonosetron: Aloxi®; Posfrea™ |
|
| PH-90018 |
Berinert® (C1 Esterase Inhibitor, Human) |
|
| PH-90026 |
Aflibercept: Eylea®; Eylea® HD; Opuviz™; Yesafili™; Ahzantive™; Enzeevu™; Pavblu™ |
|
| PH-90057 |
Trastuzumab: Herceptin®; Ogivri®; Kanjinti™; Trazimera™; Herzuma®; Ontruzant®; Hercessi™; Trastuzumab-pkrb§ |
|
| PH-90059 |
SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, Gammagard Liquid ERC®, Gamunex®-C, Gammaked®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify® |
|
| PH-90061 |
Hyaluronic Acid Derivatives: Durolane®, Euflexxa™, Gel-One®, GelSyn-3™, GenVisc 850®, Hyalgan™, Hymovis®, Monovisc®, Orthovisc™, Synojoynt, Supartz/Supartz FX™, Synvisc™, Synvisc-One™, Triluron™, TriVisc™, VISCO-3™ |
|
| PH-90071 |
Immune Globulins (immunoglobulin): Alyglo™; Bivigam®; Flebogamma®; Gamunex-C®; Gammagard® Liquid; Gammagard® S/D; Gammagard Liquid ERC®; Gammaked™; Gammaplex®; Octagam®; Privigen®; Panzyga®, Yimmugo® |
|
| PH-90080 |
Leuprolide Suspension: Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Lutrate Depot®; Camcevi™, Leuprolide Acetate Depot(Precertification not required) |
|
| PH-90098 |
Denosumab: Prolia®; Jubbonti®; Ospomyv™; Stoboclo®; Denosumab-dssb; Conexxence®; Denosumab-bnht; Xgeva®; Wyost®; Xbryk™; Osenvelt®; Bomyntra® |
|
| PH-90109 |
Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™ |
|
| PH-90117 |
Ustekinumab: Stelara®; Wezlana™; Selarsdi™; Pyzchiva®; Otulfi™; Imuldosa®; Yesintek™; Steqeyma®; Starjemza™; Ustekinumab-aekn§; Ustekinumab-ttwe§; Ustekinumab- aauz§; Ustekinumab-stba§; Ustekinumab§ |
|
| PH-90120 |
Synagis® (palivizumab) |
|
| PH-90131 |
Trelstar® (triptorelin) (Precertification not required) |
|
| PH-90137 |
Bortezomib Velcade®; Boruzu®; Bortezomib |
|
| PH-90151 |
Zoladex® (goserelin acetate) (Precertification not required) |
|
| PH-90158 |
Krystexxa® (pegloticase) |
|
| PH-90167 |
Kalbitor® (ecallantide) |
|
| PH-90168 |
Cinryze® (C1 Esterase Inhibitor, Human) |
|
| PH-90169 |
Firazyr® (icatibant) |
|
| PH-90183 |
Levoleucovorin: Fusilev®; Khapzory™ |
|
| PH-90207 |
Ruconest® (C1 Esterase Inhibitor [recombinant]) |
|
| PH-90234 |
Long-Acting Granulocyte Colony Stimulating Factors (LA-gCSF): Neulasta®; Fulphila®; Udenyca®; Ziextenzo®; Nyvepria™; Fylnetra®; Stimufend®; Rolvedon®; Ryzneuta®; Pegfilgrastim-fpgk§ |
|
| PH-90283 |
Sustol (granisetron extended-release) |
|
| PH-90284 |
Exondys 51™ (eteplirsen) |
|
| PH-90305 |
Radicava® (edaravone) |
|
| PH-90307 |
Haegarda® (C1 Esterase Inhibitor Subcutaneous [Human]) |
|
| PH-90310 |
Tremfya® (guselkumab) |
|
| PH-90312 |
Injectafer® (ferric carboxymaltose injection) |
|
| PH-90362 |
Crysvita® (burosumab-twza) |
|
| PH-90379 |
Onpattro® (patisiran lipid complex) |
|
| PH-90392 |
Takhzyro™ (lanadelumab-flyo) |
|
| PH-90421 |
Gamifant™ (emapalumab-lzsg) |
|
| 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-90525 |
Tepezza® (teprotumumab-trbw) |
|
| PH-90549 |
Uplizna™ (inebilizumab-cdon) |
|
| PH-90562 |
Viltepso™ (viltolarsen) |
|
| PH-90579 |
Oxlumo® (lumasiran) |
|
| PH-90591 |
Evkeeza™ (evinacumab-dgnb) |
|
| PH-90593 |
Amondys 45™ (casimersen) |
|
| PH-90598 |
Abecma® (idecabtagene vicleucel) |
|
| PH-90652 |
Leqvio® (inclisiran) |
|
| PH-90659 |
Vabysmo™ (faricimab-svoa) |
|
| PH-90660 |
Enjaymo™ (sutimlimab-jome) |
|
| PH-90670 |
Amvuttra (vutrisiran) |
|
| PH-90688 |
Hemgenix® (etranacogene dezaparvovec-drlb) |
|
| PH-90694 |
Leqembi™ (lecanemab-irmb) |
|
| PH-90704 |
Qalsody™ (tofersen) |
|
| PH-90709 |
Vyjuvek™ (beremagene geperpavec-svdt) |
|
| PH-90712 |
Vyvgart® Hytrulo (efgartigimod alfa-fcab and hyaluronidase-qvfc) |
|
| PH-90713 |
Elevidys® (delandistrogene moxeparvovec-rokl) |
|
| PH-90721 |
Izervay™ (avacincaptad pegol) |
|
| PH-90743 |
Lyfgenia® (lovotibeglogene autotemcel) |
|
| PH-90744 |
Casgevy™ (exagamglogene autotemcel) (Intravenous) |
|
| PH-90762 |
Piasky ™ (crovalimab-akkz) |
|
| PH-90763 |
Kisunla™ (donanemab-azbt) |
|
| PH-90781 |
Ryoncil® (remestemcel-L-rknd) |
|
| PH-90794 |
Qfitlia ™ (fitusiran) |
|
| PH-9238 |
Botox® (onabotulinumtoxinA) |
|
| PH-9468 |
Zolgensma® (onasemnogene abeparvovec-xioi) |
|
| PH-97044 |
Casgevy™ (exagamglogene autotemcel) |
|
| VP-0795 |
Penpulimab-KCQX (penpulimab-kcqx) |
|
| VP-0801 |
Zusduri™ (mitomycin) (Intravesical) |
|
| VP-0803 |
Lynozyfic™ (linvoseltamab-gcpt) |
|
| VP-90004 |
Adcetris® (brentuximab vedotin) |
|
| VP-90038 |
Erbitux® (cetuximab) |
|
| VP-90136 |
Vectibix® (panitumumab) (Intravenous) |
|
| VP-90148 |
Yervoy™ (ipilimumab) (Intravenous) |
|
| VP-90209 |
Keytruda® (pembrolizumab) |
|
| VP-90225 |
Blincyto® (blinatumomab) |
|
| VP-90226 |
Opdivo® (nivolumab) |
|
| VP-90266 |
Darzalex™ (daratumumab) |
|
| VP-90267 |
Portrazza™ (necitumumab) |
|
| VP-90278 |
Tecentriq® (atezolizumab) |
|
| VP-90295 |
Bavencio® (avelumab) (Intravenous) |
|
| VP-90301 |
Imfinzi™ (durvalumab) (Intravenous) |
|
| VP-90367 |
Elitek® (rasburicase) (Intravenous) |
|
| VP-90398 |
Libtayo® (cemiplimab-rwlc) (Intravenous) |
|
| VP-90559 |
Monjuvi® (tafasitamab-cxix) |
|
| VP-90599 |
Jemperli® (dostarlimab-gxly) |
|
| VP-90607 |
Rybrevant® (amivantamab-vmjw) |
|
| VP-90664 |
Opdualag™ (nivolumab/relatlimab-rmbw) |
|
| VP-90679 |
Pedmark® (sodium thiosulfate) |
|
| VP-90683 |
Imjudo® (tremelimumab-actl) (Intravenous) |
|
| VP-90724 |
Elrexfio™ (elranatamab-bcmm) |
|
| VP-90735 |
Loqtorzi™ (toripalimab-tpzi) (Intravenous) |
|
| VP-90750 |
Tevimbra™ (tislelizumab-jsgr) |
|
| VP-90778 |
Ziihera® (zanidatamab-hrii) |
|
| VP-90780 |
Unloxcyt® (cosibelimab-ipdl) |
|
| VP-90785 |
Datroway® (datopotamab deruxtecan-dlnk) (Intravenous) |
|
