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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.

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:
 

Credence Blue Cross and Blue Shield Service Center
Attn: Pharmacy Department
P.O. Box 10447
Birmingham, AL 35202

Fax: 205-220-9576

Draft Policies

Policy # Policy Title Print View
PH-1239 Insulin Pumps 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-91003 Buprenorphine and Buprenorphine/Naloxone for Opioid Dependence Prior Authorization, Quantity Limit and Concomitant Use of Opioid Products Program Summary
PH-91007 GLP-1 (glucagon-like peptide-1) Agonists Prior Authorization with Quantity Limit Program Summary
PH-91008 Hereditary Angiodema Prior Authorization with Quantity Limit Program Summary
PH-91017 Opioids ER Prior Authorization and Quantity Limit Program Summary
PH-91022 Afrezza (regular human insulin, inhaled) Prior Authorization with Quantity Limit Program Summary
PH-91028 Atopic Dermatitis (Elidel [pimecrolimus], Eucrisa, Protopic [tacrolimus]) Step Therapy Program Summary
PH-91029 Atypical Antipsychotics Step Therapy with Quantity Limit Program Summary
PH-91032 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Prior Authorization with Quantity Limit Program Summary
PH-91035 Hetlioz (tasimelteon) Prior Authorization with Quantity Limit Program Summary
PH-91036 Constipation Agents Prior Authorization with Quantity Limit Program Summary
PH-91046 Corticotropin Prior Authorization Program Summary
PH-91050 Insulin Combination Agents (Soliqua, Xultophy) Step Therapy and Quantity Limit Program Summary
PH-91056 Metformin ER Step Therapy Program Summary
PH-91057 Multiple Sclerosis Agents Step Therapy with Quantity Limit Program Summary
PH-91064 Oral Tetracycline Derivatives Step Therapy 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-91074 Substrate Reduction Therapy Prior Authorization with Quantity Limit Program Summary
PH-91076 Transmucosal Immediate Release Fentanyl (TIRF) Prior Authorization with Quantity Limit Program Summary
PH-91083 Oxybate Prior Authorization with Quantity Limit Program Summary
PH-91096 Hyperhidrosis Prior Authorization with Quantity Limit Program Summary
PH-91097 Pseudobulbar Affect (PBA) Prior Authorization with Quantity Limit Program Summary
PH-91103 Amifampridine Prior Authorization with Quantity Limit Program Summary
PH-91106 Arikayce Prior Authorization with Quantity Limit Program Summary
PH-91107 ATTR (transthyretin amyloid) Amyloidosis Prior Authorization with Quantity Limit Program Summary
PH-91115 Interleukin-5 (IL-5) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91117 Opioids Immediate Release (IR) Quantity Limit Program Summary
PH-91118 Hypoactive Sexual Desire Disorder (HSDD) Prior Authorization with Quantity Limit Program Summary
PH-91119 Interleukin-4 (IL-4) Inhibitor Prior Authorization with Quantity Limit Program Summary
PH-91122 Wakix (pitolisant) Prior Authorization with Quantity Limit Program Summary
PH-91124 Interstitial Lung Disease (ILD) Prior Authorization with Quantity Limit Program Summary
PH-91130 Risdiplam Prior Authorization with Quantity Limit Program Summary
PH-91135 Sodium-glucose Co-transporter (SGLT) Inhibitors and Combinations Step Therapy with Quantity Limit Program Summary
PH-91139 DPP-4 Inhibitors and Combinations Step Therapy 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-91152 Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91156 Atypical Antipsychotics – Extended Maintenance Agents Step Therapy and Quantity Limit Program Summary
PH-91158 Kerendia (finerenone) Prior Authorization with Quantity Limit Program Summary
PH-91159 Long Acting Insulin 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-91174 Cibinqo (abrocitinib) Prior Authorization with Quantity Limit Program Summary
PH-91178 Topical Psoriasis Quantity Limit
PH-91181 Elagolix/Relugolix Prior Authorization with Quantity Limit Program Summary
PH-91191 Oral Inhalers Prior Authorization with Quantity Limit Program Summary
PH-91192 Pain Medications (Combination Products) Quantity Limit Program Summary
PH-91194 Zoryve (roflumilast) Prior Authorization Program Summary
PH-91195 Antitussive Combination Products Quantity Limit Program Summary
PH-91197 Tezspire (tezepelumab-ekko) Prior Authorization with Quantity Limit Program Summary
PH-91200 CMV (cytomegalovirus) Quantity Limit Program Summary
PH-91202 Filspari (sparsentan) Prior Authorization with Quantity Limit Program Summary
PH-91206 Rezurock (belumosudil) Prior Authorization with Quantity Limit Program Summary
PH-91208 Daybue (trofinetide) Prior Authorization with Quantity Limit Program Summary
PH-91228 Weight Management Prior Authorization with Quantity Limit Program Summary
PH-91230 Primary Biliary Cholangitis Prior Authorization with Quantity Limit Program Summary
PH-91235 Yorvipath Prior Authorization with Quantity Limit Program Summary
PH-91236 Interleukin-31 (IL-31) Inhibitor Prior Authorization with Quantity Limit Program Summary
PH-91237 Niemann-Pick Disease Type C Agents Prior Authorization with Quantity Limit Program Summary
PH-91238 TRYVIO Prior Authorization with Quantity Limit Program Summary