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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.

The drugs below require that a member’s medical condition meets the policy requirements prior to being given (precertification) unless otherwise specified. Providers must submit a request for pre-service review in order to be approved. If the provider does not receive approval for precertification, the plan will pay no benefits.

Precertification is required for these provider-administered drugs when administered in a provider’s office, outpatient facility or home health setting. Precertification does not apply to inpatient hospital claims at this time. Exceptions to this include: Luxturna, Kymriah and Yescarta, which require a precertification for any place of treatment.

Members can request a copy of a full drug policy by calling the Customer Service number on their ID card.

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-90002 Actemra® (tocilizumab)
PH-90018 Berinert® (C1 Esterase Inhibitor, Human)
PH-90028 Cimzia® (certolizumab pegol)
PH-90059 SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, 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-90078 Ranibizumab: Lucentis®; Byooviz™; Cimerli™
PH-90098 Denosumab: Prolia®; Xgeva®
PH-90104 Infliximab: Remicade®; Inflectra™; Renflexis™; Avsola™, Infliximab*
PH-90117 Stelara® (ustekinumab)
PH-90146 Xolair® (omalizumab)
PH-90158 Krystexxa® (pegloticase)
PH-90167 Kalbitor® (ecallantide)
PH-90168 Cinryze® (C1 Esterase Inhibitor, Human)
PH-90169 Firazyr® (icatibant)
PH-90176 Simponi ARIA® (golimumab)
PH-90177 Ilaris® (canakinumab)
PH-90202 Entyvio® (vedolizumab)
PH-90207 Ruconest® (C1 Esterase Inhibitor [recombinant])
PH-90223 Lemtrada® (alemtuzumab)
PH-90238 Botox® (onabotulinumtoxinA)
PH-90239 Dysport® (abobotulinumtoxinA)
PH-90240 Myobloc® (rimabotulinumtoxinB)
PH-90241 Xeomin® (incobotulinumtoxinA) (Precertification not required)
PH-90242 Aranesp® (darbepoetin alfa)
PH-90243 Epoetin alfa: Epogen®; Procrit®; Retacrit™
PH-90244 Mircera® (methoxy polyethylene glycol-epoetin beta) (Precertification not required)
PH-90260 Nucala® (mepolizumab)
PH-90273 Cinqair® (reslizumab)
PH-90298 Ocrevus™ (ocrelizumab)
PH-90307 Haegarda® (C1 Esterase Inhibitor Subcutaneous [Human])
PH-90347 Fasenra® (benralizumab)
PH-90379 Onpattro® (patisiran lipid complex)
PH-90392 Takhzyro™ (lanadelumab-flyo)
PH-90497 Beovu® (brolucizumab-dbll)
PH-90503 Reblozyl® (luspatercept-aamt)
PH-90525 Tepezza® (teprotumumab-trbw)
PH-90549 Uplizna™ (inebilizumab-cdon)
PH-90610 Aduhelm™ (aducanumab-avwa)
PH-90634 Susvimo™ (ranibizumab)
PH-90659 Vabysmo™ (faricimab-svoa)
PH-90660 Enjaymo™ (sutimlimab-jome)
PH-90670 Amvuttra (vutrisiran)
PH-90674 Spevigo® (spesolimab)
PH-90687 Tzield™ (teplizumab-mzwv)
PH-90693 Briumvi™ (ublituximab-xiiy)
PH-90697 Syfovre™ (pegcetacoplan)
PH-91154 Empaveli (pegcetacoplan) Prior Authorization with Quantity Limit Program Summary