Provider-Administered Drug Precertification List / Precertification Requirements
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Lists provider-administered drugs requiring precertification when given in office, outpatient facility, or home health; includes notes on gene therapy/cellular immunotherapy and special handling for PEEHIP members. Affects providers administering these drugs for Blue Cross Blue Shield - Alabama members.
No material clinical or coverage changes in this revision.
Coverage Criteria & Scope Notes
FOR PEEHIP Members Only: coverage excludes the provider-administered medications outlined in this drug policy from being accessed through a specialty pharmacy; these products must be obtained through buy and bill. There are three exceptions: Lemtrada will require the use of a specialty pharmacy, and Synagis and Spravato may be obtained either through buy and bill or through a specialty pharmacy. This PEEHIP-specific channel restriction applies only to the provider-administered drugs listed in this policy and does not change the requirement for precertification when drugs are administered in a provider's office, outpatient facility, or home health setting.
Provider Responsibilities & Precertification Rules
Precertification required for listed provider‑administered drugs
Prior authorization (precertification) is required for administration of the provider‑administered drugs listed in this policy when given in a provider's office, outpatient facility, or home health setting. Products indicated as Gene Therapy/Cellular Immunotherapy (+) require precertification for administration in any place of treatment.
- Precertification applies to all drugs on the Provider‑Administered Drug Review Program list.
- Gene Therapy/Cellular Immunotherapy products (marked with +) require precertification regardless of site of care.
Channel restrictions and special handling for PEEHIP members
For PEEHIP members, the listed provider‑administered medications must be obtained via buy‑and‑bill and are excluded from specialty pharmacy access, except where noted (Lemtrada requires specialty pharmacy; Synagis and Spravato may be obtained either by buy‑and‑bill or specialty pharmacy).
- PEEHIP members: provider‑administered medications are excluded from specialty pharmacy and must be obtained through buy and bill.
- Exceptions: Lemtrada requires specialty pharmacy; Synagis and Spravato may be provided via buy‑and‑bill or specialty pharmacy.
Documentation required for precertification and submission guidance
Submit precertification documentation as required for prior authorization of provider‑administered drugs; gene therapy/cellular immunotherapy products (marked +) must have precertification for administration in any setting. Use the payer's online policies and submission processes available at AlabamaBlue.com/Pharmacy for detailed submission guidance.
- Precertification documentation is required for all listed provider‑administered drugs.
- Gene therapy/cellular immunotherapy products require precertification regardless of place of treatment.
- Refer to AlabamaBlue.com/Pharmacy (Provider‑Administered Drug Policies) for submission instructions and required documentation.
Denial risk and billing impact for failure to precertify
Failure to obtain precertification for listed provider‑administered drugs when administered in a provider's office, outpatient facility, or home health setting may result in denial of coverage. Gene therapy/cellular immunotherapy products will still require precertification even if administered outside those settings.
- Denial risk: lack of precertification may lead to claim denial for services in office, outpatient facility, or home health.
- Gene Therapy/Cellular Immunotherapy (+) remain subject to precertification requirements in all settings.
Where Precertification Applies
Precertification by site of care (office, infusion center, home)
Precertification is required when these drugs are administered in a provider's office, outpatient facility, or during home health care. Gene Therapy/Cellular Immunotherapy products (marked +) require precertification for any place of treatment.
- PEEHIP members: these drugs must be obtained via buy‑and‑bill (specialty pharmacy access is excluded) except for Lemtrada (requires specialty pharmacy) and Synagis and Spravato (may be obtained either way).
- The product list is updated monthly; verify current requirements online at AlabamaBlue.com/Pharmacy.
Key Definitions
Policy Background & Purpose
This document is an administrative precertification list, not clinical guidance. It identifies provider-administered drugs that are subject to the payer's Provider-Administered Drug Review Program and for which precertification is required when administered in a provider's office, outpatient facility, or home health setting. Treatments designated as Gene Therapy/Cellular Immunotherapy (+) require precertification regardless of place of treatment. The list is intended to communicate the scope of the review program and channel restrictions (for example, PEEHIP buy-and-bill requirements) so providers know when prior authorization and appropriate dispensing arrangements are necessary.
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