Provider-Administered Drug Forms

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. 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 will be required in the outpatient facility setting beginning April 1, 2019. Exceptions to this exist at this time: Luxturna, Kymriah and Yescarta require a precertification for any place of treatment. To request a copy of a full drug policy, members can contact Customer Service by calling the number on their ID card.

 

Non-Oncology Drug Forms:

Actemra Request Form

Akynzeo Request Form

Aldurazyme Request Form

Aloxi Request Form

Aveed Request Form

Benlysta Request Form

Berinert Request Form

Bivigam Request Form

Botox Request Form

Brineura Request Form

Cerezyme Request Form

Cimzia Request Form

Cinryze Request Form

Cinvanti Request Form

Crysvita Request Form

Cuvitru Request Form

Dysport Request Form

Elelyso Request Form

Emend IV Request Form

Entyvio Request Form

Euflexxa Request Form

Eylea Request Form

Fabrazyme Request Form

Firazyr Request Form

Flebogamma Request Form

Fulphila Request Form

GammaSTAN Request Form

Gammagard Request Form

Gammaked Request Form

Gammaplex Request Form

Gamunex Request Form

Granix Request Form

Haegarda Request Form

Hizentra Request Form

H.P. Acthar Request Form

HyQvia Request Form

Ilumya Request Form

Inflectra Request Form

Injectable Asthma Agents Request Form

Kalbitor Request Form

Kanuma Request Form

Krystexxa Request Form

Kymriah Request Form

Lemtrada Request Form

Leukine Request Form

Lucentis Request Form

Lumizyme Request Form

Luxturna Request Form

Macugen Request Form

Makena Request Form

Mepsevii Request Form

Mylotarg Request Form

Myobloc Request Form

Naglazyme Request Form

Neulasta Request Form

Neupogen Request Form

Nplate Request Form

Octagam Request Form

Ocrevus Request Form

Orencia Request Form

Palonosetron Request Form

Panzyga Request Form

Privigen Request Form

Radicava Request Form

Remicade Request Form

Renflexis Request Form

Rituxan Request Form

Ruconest Request Form

Simponi ARIA Request Form

Soliris Request Form

Spinraza Request Form

Stelara Request Form

Sublocade Request Form

Sustol Request Form

Synagis Request Form

Synvisc Request Form

Synvisc-One Request Form

Takhzyro Request Form

Testopel Request Form

Trogarzo Request Form

Tysabri Request Form

Varubi IV Request Form

Vimizin Request Form

Visudyne Request Form

Vivitrol Request Form

Vpriv Request Form

Xeomin Request Form

Xiaflex Request Form

Xolair Request Form

Zarxio Request Form