Draft Provider-Administered Drug Policies

The drugs below require that a member’s medical condition meets the policy requirements prior to being given (precertification) unless otherwise specified. 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.

Currently, precertification for these provider-administered drugs is required when administered in a provider’s office or home health setting; however, this precertification does not apply to inpatient hospital claims at this time.

Precertification for the drugs listed below is also required in the outpatient facility setting. Exceptions to this include: Luxturna, Kymriah and Yescarta, which require a precertification for any place of treatment.

Members can request a copy of a full drug policy, by calling the Customer Service number on their ID card.

 

Policy # Policy Title Print View
PH-0312 Injectafer® (ferric carboxymaltose injection)
PH-0495 Feraheme® (ferumoxytol)
PH-0524 Monoferric™ (ferric derisomaltose)
PH-0610 Aduhelm™ (aducanumab-avwa)
PH-90052 Alpha-1-Proteinase Inhibitors: Aralast NP®; Glassia®; Prolastin®-C; Zemaira®
PH-90080 Leuprolide Suspension: Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Camcevi™(Precertification not required)
PH-90091 Orencia® (abatacept)
PH-90098 Denosumab: Prolia®; Xgeva®
PH-90104 Infliximab: Remicade®; Inflectra™; Renflexis™; Avsola™
PH-90139 Vivitrol® (naltrexone)
PH-90146 Xolair® (omalizumab)
PH-90176 Simponi ARIA (golimumab)
PH-90239 Dysport™ (abobotulinumtoxinA)
PH-90241 Xeomin (incobotulinumtoxinA)
PH-90243 Epoetin alfa: Epogen®; Procrit®; Retacrit™
PH-90260 Nucala® (mepolizumab)
PH-90284 Exondys-51™ (eteplirsen)
PH-90291 Spinraza™ (nusinersen)
PH-90347 Fasenra® (benralizumab)
PH-90358 Ilumya™ (tildrakizumab-asmn)
PH-90427 Ultomiris® (ravulizumab-cwvz)
PH-90520 Vyondys-53™ (golodirsen)
PH-90562 Viltepso™ (viltolarsen)
PH-90593 Amondys-45™ (casimersen)