Provider-Administered Drug Policies

The drugs below require that a member’s medical condition meets the policy requirements prior to being given (precertification). 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 for these provider-administered drugs is required when administered in a provider’s office, outpatient facility, or home health setting. To request a copy of a full drug policy, members can contact Customer Service by calling the number on their ID card.

Please use the Search function above to locate specific drug policy information.

Policy # Policy Title Print View
PH-100 Antiemetic Medical Policy Prior Authorization Program Summary (Akynzeo, Aloxi, Cinvanti, Emend IV, Palonosetron, Sustol, Varubi IV)
PH-101 Benlysta Medical Policy Prior Authorization Program Summary
PH-102 Botulinum Toxin Policy Summary (Botox, Dysport, Myobloc, Xeomin)
PH-103 Brineura Policy Summary
PH-104 Hereditary Angioedema Policy Summary (Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest, Takhzyro)
PH-105 Health Care Provider Administered Biologic Immunomodulator Program Summary
PH-106 Immune Globulin Policy Summary (Bivigam, Cuvitru, Flebogamma, GammaSTAN, Gammagard, Gammaked, Gammaplex, Gamunex, Hizentra, HyQvia, Octagam, Panzyga, Privigen)
PH-108 Injectable and Implantable Testosterone Policy Summary (Aveed, Testopel)
PH-109 Injectable Buprenorphine Policy Summary (Sublocade)
PH-110 IV Multiple Sclerosis Medical Policy Prior Authorization Program Summary (Lemtrada, Ocrevus, Tysabri)
PH-111 Luxturna Policy Summary
PH-112 Lysomal Storage Disorders Policy Summary
PH-113 Ocular Angiogenesis Inhibitors Policy Summary (Eylea, Lucentis, Macugen, Visudyne)
PH-114 Oncology Drugs for Non-Oncology Uses Policy Summary (Kymriah, Mylotarg)
PH-115 Rituxan Policy Summary
PH-116 Soliris and Ultomiris Policy Summary
PH-117 Spinraza Policy Summary
PH-118 Synagis Policy Summary
PH-119 Trogarzo Policy Summary
PH-120 Viscosupplement Policy Summary (Synvisc, Synvisc-One, Euflexxa)
PH-121 Vivitrol Policy Summary
PH-122 Xolair Policy Summary
PH-123 Colony Stimulating Factors Policy Summary (Fulphila, Granix, Leukine, Neulasta, Neupogen, Nivestym, Udenyca, Zarxio)
PH-124 Crysvita Policy Summary
PH-125 H.P. Acthar Policy Summary
PH-126 Injectable Asthma Agents Policy Summary (Nucala, Cinqair, Fasenra)
PH-127 Krystexxa Policy Summary
PH-128 Makena Policy Summary
PH-129 Nplate Policy Summary
PH-130 Radicava Policy Summary
PH-131 Xiaflex Policy Summary
PH-132 hATTR Amyloidosis Neuropathy Program Summary