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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 Tocilizumab: Actemra®; Tofidence™; Tyenne®
PH-90003 Corticotropin-ACTH: Acthar® Gel (repository corticotropin injection) Cortrophin® Gel (repository corticotropin injection)
PH-90017 Benlysta® (belimumab)
PH-90036 Fosaprepitant: Emend®; Fosaprepitant Ψ; Focinvez Ψ
PH-90052 Alpha-1-Proteinase Inhibitors: Aralast NP®; Glassia®; Prolastin®-C; Zemaira®
PH-90080 Leuprolide Suspension: Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Camcevi™, Lutrate Depot™, Leuprolide Acetate Depot Ψ(Precertification not required)
PH-90098 Denosumab: Prolia®; Jubbonti®; Xgeva®; Wyost®
PH-90109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-90111 Sandostatin® LAR (octreotide suspension) (Precertification not required)
PH-90131 Trelstar® (triptorelin) (Precertification not required)
PH-90146 Xolair® (omalizumab)
PH-90151 Zoladex® (goserelin acetate) (Precertification not required)
PH-90183 Levoleucovorin: Fusilev®; Khapzory™
PH-90234 Long-Acting Granulocyte Colony Stimulating Factors (LA-gCSF): Neulasta®; Fulphila®; Udenyca®; Ziextenzo®; Nyvepria™; Fylnetra®; Stimufend®; Rolvedon®; Ryzneuta®
PH-90235 Colony Stimulating Factors: Filgrastim (Neupogen®); Filgrastim-aafi (Nivestym™); Filgrastim-sndz (Zarxio®); Filgrastim-ayow (Releuko®); Tbo-Filgrastim (Granix®)
PH-90237 Leukine® (sargramostim)
PH-90503 Reblozyl® (luspatercept-aamt)
PH-90591 Evkeeza™ (evinacumab-dgnb)
PH-90614 Saphnelo™ (anifrolumab-fnia)
PH-90652 Leqvio® (inclisiran)
PH-90672 Zynteglo® (betibeglogene autotemcel)
PH-90674 Spevigo® (spesolimab)
PH-90696 Lamzede® (velmanase alfa-tycv)
PH-90713 Elevidys® (delandistrogene moxeparvovec-rokl)
PH-90751 Lenmeldy™ (atidarsagene autotemcel)
PH-91154 Empaveli (pegcetacoplan) Prior Authorization with Quantity Limit Program Summary
PH-91166 Lupus Prior Authorization with Quantity Limit Program Summary
PH-91175 Pyrukynd (mitapivat) Prior Authorization with Quantity Limit Program Summary