Provider-Administered Precertification Drug List
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Lists provider‑administered drugs that require precertification when given in provider offices, outpatient facilities, or home health settings; gene therapy/cellular immunotherapy products require precertification in any setting. Also notes limited pharmacy access rules for PEEHIP members.
No material clinical or coverage changes in this revision.
Precertification and Coverage Rules
Precertification requirement
Covered when ALL of the following are met
Gene Therapy/Cellular Immunotherapy products (marked '+') require precertification in any place of treatment; Avastin requires PA for oncology indications only.
For PEEHIP members, provider-administered medications listed on the Provider-Administered Precertification Drug List are excluded from access through a specialty pharmacy and must be obtained via buy-and-bill, except for specified exceptions. Lemtrada requires use of a specialty pharmacy, while Synagis and Spravato may be obtained either by buy-and-bill or through a specialty pharmacy. This exclusion applies only to PEEHIP members and the drugs outlined in this policy.
What Providers Must Do
Prior Authorization Required
Precertification is required for provider‑administered drugs listed on the Provider‑Administered Precertification Drug List when administered in a provider's office, outpatient facility, or home health setting. Gene therapy and cellular immunotherapy products (marked with a + on the drug list) require precertification when administered in any place of treatment.
- Applies to all drugs on the Provider‑Administered Precertification Drug List.
- Gene therapy/cellular immunotherapy products (+) require PA in any treatment setting.
Action Required Before Treatment
Providers must obtain precertification prior to administration to avoid claim denials or delays in reimbursement.
- Precertification must be secured before the drug is administered in office, outpatient facility, or home health.
- Failure to precertify may result in denial of coverage or payment delays.
Documentation / Precertification
Documentation supporting medical necessity should be submitted with the precertification request. For Gene Therapy/Cellular Immunotherapy products (+), precertification and complete documentation are required regardless of the site of care.
- Include indication, prior treatments, relevant clinical records, and any specialty‑therapy specific documentation as requested.
- Gene therapy/cellular immunotherapy products marked with + require PA and full documentation in any setting.
Precertification and Site‑of‑Care Billing Rules
For PEEHIP members, provider‑administered medications in this policy must be obtained through buy‑and‑bill and are excluded from specialty pharmacy access, except Lemtrada (must use specialty pharmacy), and Synagis and Spravato (may be obtained via buy‑and‑bill or specialty pharmacy). For Avastin, PA is required for oncology indications only.
- PEEHIP coverage: drugs on this list cannot be accessed through specialty pharmacy — obtain via buy‑and‑bill unless specifically noted.
- Lemtrada: specialty pharmacy required for PEEHIP members.
- Synagis and Spravato: may be obtained via buy‑and‑bill or specialty pharmacy for PEEHIP members.
- Avastin: PA required only for oncology indications.
Settings Requiring Precertification
Site-of-care precertification requirement
Precertification is required when these drugs are administered in a provider's office, outpatient facility, or home health setting. Gene Therapy/Cellular Immunotherapy products (marked '+') require precertification in any setting.
- Applies to provider office, outpatient facility, and home health.
- Gene therapy/cellular immunotherapy products require PA regardless of site of care.
- For PEEHIP members, listed provider-administered medications are excluded from specialty pharmacy access and must be obtained via buy-and-bill, with specified exceptions (Lemtrada, Synagis, Spravato).
List Flags and Notation
Policy Purpose and Scope
This document is an administrative Provider-Administered Precertification Drug List and is intended to define which provider‑administered drugs require precertification and the settings in which precertification is required; it does not provide clinical practice guidelines or therapeutic indications. Precertification is required when listed drugs are administered in a provider's office, outpatient facility, or home health setting. Products designated as Gene Therapy/Cellular Immunotherapy (marked with a '+') require precertification in any place of treatment. The precertification roster is maintained as the operative administrative list of drugs subject to the Provider-Administered Drug Review Program.
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