Final Provider-Administered Drug Policies and Forms

 

Blue Advantage follows Prime Therapeutics policies for the following Provider-Administered Drugs:

  • Benlysta
  • Brineura
  • Cinvanti (aprepitant injectable Emulsion, for IV use)
  • Crysvita
  • H.P. Acthar (For dates of service on or after February 26, 2018, see Palmetto Article A53066)
  • Hereditary Angioedema
    • Berinert, Cinryze, Kalbitor, Ruconest (Firazyr and Haegarda- For dates of service on or after February 26, 2018, see Palmetto Article A53066)
  • Injectable Asthma
    • Cinqair, Nucala
  • Infusible Biologics
    • Actemra, Cimzia, Entyvio, Ilumya, Simponi Aria, Stelara (Orencia- For dates of service on or after February 26, 2018, see Palmetto Article A53066)
  • Injectable and Implantable Testosterone (Applies to Testopel for dates of service on or after February 26, 2018.)
  • IV Multiple Sclerosis
    • Ocrevus, Tysabri (Lemtrada - For dates of service on or after February 26, 2018, see Palmetto Article A55310),
  • Krystexxa
  • Luxturna (voretigene neparvovec-rzyl Intraocular Suspension for Subretinal Injection) (For dates of service June 1, 2018, through May 5, 2019. For dates of service May 6, 2019, and after, see Palmetto LCD L37863.)
  • Lysomal Storage Disorders
    • Mepsevii
  • Makena
  • Nplate
  • Ocular Angiogenesis Inhibitors (Applies to Eylea Only - For dates of service on or after February 26, 2018, see Palmetto Article A53387.)
  • Radicava
  • Soliris
  • Spinraza
  • Sublocade (For dates of service July 1, 2018, and after)
  • Trogarzo
  • Ultomiris
  • Vivitrol
  • White Colony Stimulating Factors (For dates of service on or after February 26, 2018, see Palmetto LCD L37176.)
  • Xolair
  • Xiaflex
     

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.

Provider-Administered Drug Policies Disclaimer:
The purpose of provider-administered drug policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.