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 Provider-Administered Drug Policies
Draft policies are listed below. If there are no policies listed, it means there are currently no policies in draft status.
Note: Coverage is subject to member's specific benefits. Group specific policies will supersede these policies when applicable. Please refer to member's benefit plan.
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 draft policies.
Comments are accepted for 45 days from the posting date listed on the draft policy.
Make sure your voice is heard by providing feedback directly to us:
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Send comments by mail or fax to:
Birmingham Service Center
Attn: Health Management — Medical Policy
P.O. Box 10527
Birmingham, AL 35202
Fax: 205-220-0878
Policy # |
Policy Title |
Print View |
PH-0765 |
Tecelra® (afamitresgene autoleucel) |
|
PH-0767 |
Niktimvo™ (axatilimab-csfr) |
|
PH-90002 |
Tocilizumab: Actemra®; Tofidence™; Tyenne® |
|
PH-90003 |
Corticotropin-ACTH: Acthar® Gel (repository corticotropin injection) Cortrophin® Gel (repository corticotropin injection) |
|
PH-90008 |
Palonosetron: Aloxi®; Palonosetron Ψ |
|
PH-90017 |
Benlysta® (belimumab) |
|
PH-90018 |
Berinert® (C1 Esterase Inhibitor, Human) |
|
PH-90026 |
Aflibercept: Eylea®; Eylea® HD; Opuviz™; Yesafili™; Ahzantive™ |
|
PH-90027 |
Cerezyme® (imiglucerase) |
|
PH-90052 |
Alpha-1-Proteinase Inhibitors: Aralast NP®; Glassia®; Prolastin®-C; Zemaira® |
|
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-90091 |
Orencia® (abatacept) |
|
PH-90105 |
Elelyso™ (taliglucerase alfa) |
|
PH-90109 |
Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™ |
|
PH-90111 |
Sandostatin® LAR (octreotide suspension) (Precertification not required) |
|
PH-90114 |
Eculizumab: Soliris®; Bkemv™ |
|
PH-90117 |
Ustekinumab: Stelara®; Wezlana™; Selarsdi™; Pyzchiva® |
|
PH-90120 |
Synagis® (palivizumab) |
|
PH-90131 |
Trelstar® (triptorelin) (Precertification not required) |
|
PH-90141 |
VPRIV® (velaglucerase alfa) |
|
PH-90146 |
Xolair® (omalizumab) |
|
PH-90151 |
Zoladex® (goserelin acetate) (Precertification not required) |
|
PH-90167 |
Kalbitor® (ecallantide) |
|
PH-90168 |
Cinryze® (C1 Esterase Inhibitor, Human) |
|
PH-90169 |
Firazyr® (icatibant) |
|
PH-90177 |
Ilaris® (canakinumab) |
|
PH-90207 |
Ruconest® (C1 Esterase Inhibitor [recombinant]) |
|
PH-90229 |
Cosentyx® (secukinumab) |
|
PH-90234 |
Long-Acting Granulocyte Colony Stimulating Factors (LA-gCSF): Neulasta®; Fulphila®; Udenyca®; Ziextenzo®; Nyvepria™; Fylnetra®; Stimufend®; Rolvedon®; Ryzneuta® |
|
PH-90235 |
Short-Acting Granulocyte Colony Stimulating Factors (SA-gCSF): Filgrastim (Neupogen®); Filgrastim-aafi (Nivestym™); Filgrastim-sndz (Zarxio®); Filgrastim-ayow (Releuko®); Tbo-Filgrastim (Granix®); Filgrastim-txid (Nypozi™) |
|
PH-90237 |
Leukine® (sargramostim) |
|
PH-90291 |
Spinraza™ (nusinersen) |
|
PH-90299 |
Brineura (cerliponase alfa) |
|
PH-90307 |
Haegarda® (C1 Esterase Inhibitor Subcutaneous [Human]) |
|
PH-90358 |
Ilumya™ (tildrakizumab-asmn) |
|
PH-90392 |
Takhzyro™ (lanadelumab-flyo) |
|
PH-90468 |
Zolgensma® (onasemnogene abeparvovec-xioi) |
|
PH-90481 |
Spravato (esketamine) |
|
PH-90497 |
Beovu® (brolucizumab-dbll) |
|
PH-90503 |
Reblozyl® (luspatercept-aamt) |
|
PH-90591 |
Evkeeza™ (evinacumab-dgnb) |
|
PH-90614 |
Saphnelo™ (anifrolumab-fnia) |
|
PH-90634 |
Susvimo™ (ranibizumab) |
|
PH-90652 |
Leqvio® (inclisiran) |
|
PH-90659 |
Vabysmo™ (faricimab-svoa) |
|
PH-90671 |
Skyrizi® (risankizumab-rzaa) |
|
PH-90672 |
Zynteglo® (betibeglogene autotemcel) |
|
PH-90674 |
Spevigo® (spesolimab) |
|
PH-90697 |
Syfovre™ (pegcetacoplan) |
|
PH-90751 |
Lenmeldy™ (atidarsagene autotemcel) |
|
PH-90762 |
Piasky ™ (crovalimab-akkz) |
|
PH-90763 |
Kisunla™ (donanemab-azbt) |
|
VP-90001 |
Paclitaxel Albumin-Bound: Abraxane®; Paclitaxel Albumin-Bound Ψ |
|
VP-90004 |
Adcetris® (brentuximab vedotin) |
|
VP-90007 |
Pemetrexed: Alimta®; Pemfexy™; Pemrydi RTU®; Pemetrexed Ψ |
|
VP-90008 |
Palonosetron: Aloxi®; Posfrea™ Ψ |
|
VP-90014 |
Bevacizumab: Avastin®; Mvasi®; Zirabev®; Alymsys®; Vegzelma®; Avzivi® |
|
VP-90038 |
Erbitux® (cetuximab) (Intravenous) |
|
VP-90057 |
Trastuzumab: Herceptin®; Ogivri®; Kanjinti®; Trazimera™; Herzuma®; Ontruzant® |
|
VP-90072 |
Ixempra® (ixabepilone) |
|
VP-90137 |
Bortezomib Velcade®; Bortezomib§ |
|
VP-90301 |
Imfinzi™ (durvalumab) (Intravenous) |
|
VP-90535 |
Darzalex Faspro® (daratumumab and hyaluronidase-fihj) |
|
VP-90547 |
Evomela® (melphalan) |
|
VP-90599 |
Jemperli® (dostarlimab-gxly) |
|
VP-90607 |
Rybrevant® (amivantamab-vmjw) |
|
VP-90710 |
Epkinly™ (epcoritamab-bysp) |
|
VP-90766 |
Lymphir™ (denileukin diftitox-cxdl) |
|