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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-1215 Resmetirom Prior Authorization with Quantity Limit Program Summary
PH-1230 Primary Biliary Cholangitis Prior Authorization with Quantity Limit Program Summary
PH-91000 Androgens and Anabolic Steroids Prior Authorization with 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-91005 Contraceptive Prior Authorization 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-91012 Immune Globulins Prior Authorization Program Summary
PH-91013 Mandatory Generic/Member Pays the Difference Exception Prior Authorization Program Summary
PH-91019 Otezla (apremilast) Prior Authorization with Quantity Limit Program Summary
PH-91020 Topical Doxepin 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-91031 Carbaglu (carglumic acid) Prior Authorization Program Summary
PH-91034 Topical Antifungals, itraconazole, terbinafine Prior Authorization with Quantity Limit Program Summary
PH-91037 Topical Actinic Keratosis, Basal Cell Carcinoma, Genital Warts Agents Prior Authorization with Quantity Limit Program Summary
PH-91038 Emflaza (deflazacort) Prior Authorization with Quantity Limit Program Summary
PH-91043 Growth Hormone Prior Authorization Program Summary
PH-91046 Corticotropin Prior Authorization Program Summary
PH-91054 Korlym (mifepristone) Prior Authorization with Quantity Limit Program Summary
PH-91058 Myalept (metreleptin) Prior Authorization Program Summary
PH-91064 Oral Tetracycline Derivatives Step Therapy Program Summary
PH-91065 Parathyroid Hormone Analog for Osteoporosis Prior Authorization with Quantity Limit Program Summary
PH-91066 Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91067 Phenylketonuria Prior Authorization Program Summary
PH-91069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
PH-91073 Strensiq Prior Authorization Program Summary
PH-91080 Urea Cycle Disorders Prior Authorization Program Summary
PH-91083 Oxybate Prior Authorization with Quantity Limit Program Summary
PH-91087 Coverage Exception Program Summary
PH-91088 Copay Waiver for Breast Cancer Primary Prevention Agent ACA Copay Waiver Program Summary – Individual Marketplace, Commercial
PH-91089 Erectile Dysfunction -Phosphodiesterase Type 5 Inhibitors, Quantity Limit Program Summary
PH-91105 Weight Loss Agents Prior Authorization with Quantity Limit Program Summary
PH-91113 Procysbi (cysteamine bitartrate) Prior Authorization Program Summary
PH-91117 Opioids Immediate Release (IR) Quantity Limit Program Summary
PH-91128 Peanut Allergy Prior Authorization with Quantity Limit Program Summary
PH-91129 Copay Waiver for Human Immunodeficiency Virus (HIV) Infection: Pre-exposure Prophylaxis (PrEP) ACA Prevention Copay Waiver Program Summary – Individual Marketplace, Commercial
PH-91133 Isturisa (osilodrostt) Prior Authorization with Quantity Limit Program Summary
PH-91138 Dojolvi Prior Authorization Program Summary
PH-91139 DPP-4 Inhibitors and Combinations Step Therapy with Quantity Limit Program Summary
PH-91142 Enspryng (satralizumab-mwge) Prior Authorization with Quantity Limit Program Summary
PH-91144 Sucraid (sacrosidase) Prior Authorization with Quantity Limit Program Summary
PH-91147 Zeposia (oxanimod) Prior Authorization with Quantity Limit Program Summary
PH-91149 Topical NSAID (Non-Steroidal Anti-Inflammatory Drug) Prior Authorization with Quantity Limit Program Summary
PH-91150 Continuous Glucose Monitor (CGM) Step Therapy with Quantity Limit Program Summary
PH-91153 Ivermectin Prior Authorization Program Summary
PH-91154 Empaveli (pegcetacoplan) Prior Authorization with Quantity Limit Program Summary
PH-91157 Cholestasis Pruritus Prior Authorization Program Summary
PH-91158 Kerendia (finerenone) Prior Authorization with Quantity Limit Program Summary
PH-91160 Rapid to Intermediate Acting Insulin Prior Authorization Program Summary
PH-91162 Opzelura (ruxolitinib) Prior Authorization with Quantity Limit Program Summary
PH-91169 Voxzogo (vosoritide) Prior Authorization with Quantity Limit Program Summary
PH-91170 Interleukin-13 (IL-13) Antagonist Prior Authorization with Quantity Limit Program Summary
PH-91173 Bempedoic Acid Prior Authorization with Quantity Limit Program Summary
PH-91175 Pyrukynd (mitapivat) Prior Authorization with Quantity Limit Program Summary
PH-91176 Recorlev (levoketoconazole) Prior Authorization with Quantity Limit Program Summary
PH-91178 Topical Psoriasis Quantity Limit
PH-91179 Attention Deficit [Hyperactivity] Disorder (ADHD/ADD) Agents Quantity Limit Program Summary
PH-91181 Elagolix/Relugolix Prior Authorization with Quantity Limit Program Summary
PH-91184 Topical Estrogen Quantity Limit Program Summary
PH-91185 Vtama (tapinarof) Prior Authorization Program Summary
PH-91186 Copay Waiver for Statin ACA Prevention Copay Waiver Program Summary – Individual Marketplace, Commercial
PH-91187 ACA Prevention Copay Waiver Contraceptives Program Summary – Individual Marketplace, Commercial
PH-91188 Hyftor (sirolimus) Prior Authorization with Quantity Limit Program Summary
PH-91194 Zoryve (roflumilast) Prior Authorization Program Summary
PH-91201 Winlevi (clascoterone) Step Therapy Program Summary
PH-91209 Qualaquin Quantity Limit Program Summary
PH-91211 Step Therapy Supplement Step Therapy Program Summary
PH-91213 Neurokinin Receptor Antagonists Prior Authorization with Quantity Limit Program Summary
PH-91215 Resmetirom Prior Authorization with Quantity Limit Program Summary
PH-91217 Xdemvy Step Therapy with Quantity Limit Program Summary
PH-91218 Fabhalta (iptacopan) Prior Authorization with Quantity Limit Program Summary
PH-91219 Filsuvez (birch triterpenes) Prior Authorization Program Summary
PH-91220 Xphozah (tenapanor) Prior Authorization with Quantity Limit Program Summary
PH-91224 Zelsuvmi (berdazimer) Prior Authorization with Quantity Limit Program Summary
PH-91227 Voydeya (danicopan) Prior Authorization with Quantity Limit Program Summary
PH-91228 Weight Management Prior Authorization with Quantity Limit Program Summary
PH-91231 Duvyzat Prior Authorization with Quantity Limit Program Summary
PH-91232 Ohtuvayre Prior Authorization with Quantity Limit Program Summary
PH-91233 Xolremdi (mavorixafor) Prior Authorization with Quantity Limit Program Summary
PH-991002 Biologic Immunomodulators Prior Authorization with Quantity Limit with Preferred Products Program Summary