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-90059 SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify®
PH-90071 Immune Globulins (Bivigam, Carimune NF, Flebogamma, Gamunex-C, Gammagard Liquid, Gammagard S/D, Gamaked, Gammaplex, Octagam, Privigen, Panzyga)
PH-90078 Ranibizumab: Lucentis®; Byooviz™
PH-90109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-90145 Xiaflex® (collagenase)
PH-90277 Kanuma™ (sebelipase alfa)
PH-90305 Radicava (edaravone)
PH-90312 Injectafer® (ferric carboxymaltose injection)
PH-90495 Feraheme® (ferumoxytol)
PH-90524 Monoferric™ (ferric derisomaltose)
PH-90633 Xipere® (triamcinolone acetonide injectable suspension)
PH-90634 Susvimo™ (ranibizumab)
PH-90635 Dextenza® (dexamethasone insert)