Provider‑Administered Drug Precertification List (Coverage Criteria)
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This document lists provider‑administered drugs that require precertification when administered in provider offices, outpatient facilities, or home health settings for Blue Cross Blue Shield - Alabama members; gene therapy/cellular immunotherapy products require precertification in any setting. Also notes limited exceptions for PEEHIP members regarding specialty pharmacy access.
No material clinical or coverage changes in this revision.
Coverage Criteria
For PEEHIP members only: coverage excludes the provider‑administered medications listed in this drug policy from being accessed through the payer's specialty pharmacy program. These drugs must be obtained via buy‑and‑bill when furnished to PEEHIP members, except for the named exceptions. Lemtrada is an exception and requires use of a specialty pharmacy. Synagis and Spravato are exceptions and may be obtained either by buy‑and‑bill or through a specialty pharmacy.
Precertification documentation required for listed drugs (gene therapy/cellular immunotherapy require documentation in any setting)
Precertification documentation must be submitted for the provider-administered drugs listed in this policy; for products indicated as Gene Therapy/Cellular Immunotherapy (marked with +) precertification is required regardless of treatment setting. Documentation should accompany the prior authorization request to demonstrate the drug, indication, and site of care as required by the Provider‑Administered Drug Review Program.
- Submit precertification (prior authorization) documentation for listed provider-administered drugs when administered in a provider office, outpatient facility, or home health setting.
- For drugs marked with "+" (Gene Therapy/Cellular Immunotherapy products), submit precertification documentation for any place of treatment.
- Include information sufficient to identify the drug (name and dosage), indication, and treatment setting with the precertification request.
What Providers Must Do
Precertification required before administration (high priority)
Obtain precertification (prior authorization) before administering any drug on the provider‑administered list when care is provided in a provider office, outpatient facility, or via home health. For products marked with a + (gene therapy/cellular immunotherapy), precertification is required regardless of treatment setting.
- Precertification required for drugs on the Provider‑Administered Drug Review Program list when administered in office, outpatient facility, or home health.
- Products marked with + require precertification in any place of treatment.
Reserved — important provider notices
Reserved for additional high‑impact provider requirements or updates; retain source language and list details for any future policy changes or supplementary provider obligations.
- Policy list is updated monthly and subject to change without notice.
- Online policies available at AlabamaBlue.com/Pharmacy under 'Provider-Administered Drug Policies.'
Denial risk if precertification not obtained
Failure to obtain required precertification for drugs on the provider‑administered list when administered in a provider office, outpatient facility, or home health setting may result in denial of coverage or payment.
- Precertification is required for listed provider-administered drugs in office, outpatient, or home health; lack of precertification may lead to denial.
Site of Care Rules
Site‑of‑care precertification requirement
Precertification must be obtained for all drugs on the list when administered in a provider's office, an outpatient facility, or via home health; gene therapy/cellular immunotherapy products (marked with +) require precertification in any setting of care.
- Applies to office, infusion center, home, and outpatient facility settings.
- Gene therapy/cellular immunotherapy products require precertification regardless of where administered.
Symbol Legend & Definitions
Background
This document enumerates the provider-administered medications subject to the plan’s precertification (prior authorization) program. Precertification is required when these agents are administered in a provider’s office, outpatient facility, or home health setting. Products identified as gene therapy/cellular immunotherapy (marked with a + in the list) require precertification regardless of place of treatment. The list also includes product-specific notes (for example, Avastin* is marked to indicate PA is required for oncology indications only) and serves as the reference for which office-, facility-, or home-administered drugs must have prior authorization prior to administration.
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