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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-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-91036 Constipation Agents Prior Authorization with Quantity Limit Program Summary
PH-91096 Hyperhidrosis 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-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-91156 Atypical Antipsychotics – Extended Maintenance Agents Step Therapy and Quantity Limit Program Summary
PH-91171 Xolair (omalizumab) Prior Authorization Program Summary
PH-91172 Antidepressant Agents Step Therapy with Quantity Limit Program Summary
PH-91173 Bempedoic Acid Prior Authorization with Quantity Limit Program Summary
PH-91181 Elagolix/Relugolix Prior Authorization with Quantity Limit Program Summary
PH-91202 Filspari (sparsentan) Prior Authorization with Quantity Limit Program Summary
PH-91235 Yorvipath Prior Authorization with Quantity Limit Program Summary