Provider-Administered Drug Policies 

Provider-administered drugs 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. 

Search Policies

Use the search function above to find policies by name, number or keyword.

Browse Policies by Category

Use the navigation on the left to expand the menu and select specific medical policies by category.

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

Provider-Administered Drugs Requiring Precertification

Precertification through Prime Therapeutics is required for the provider-administered drugs on the following list when administered in a provider’s office, outpatient facility or home health setting; precertification does not apply to inpatient hospital claims at this time.

Provider-Administered Precertification Drug List 

How to submit a precertification request to Prime Therapeutics:

Online

• Go to your local Plan's provider portal to initiate pre-service review (Electronic Provider Access) for these services for out-of-area members. Contact your local Blue Plan for more information on how to access this functionality in your local provider portal.

By Phone

• Call Prime Therapeutics at 1-800-424-8270
• Urgent requests must be called in to Prime Therapeutics. Do not submit urgent requests online.

Provider-Administered Specialty Drugs

The provider-administered specialty medications on the list below can be obtained through buy and bill or an in-network medical specialty pharmacy:

Provider-Administered Specialty Pharmacy Drug List

For dates of service before 01/01/24:
Provider-Administered Oncology Drugs Requiring Precertification 

Precertification was required through Carelon Medical Benefits Management as part of the Oncology Select program. 

Non-Covered Provider-Administered Drug Exception Authorization Request Form

To request prior authorization for non-covered provider-administered drugs ONLY, complete the Non-Covered Provider-Administered Drug Exception Authorization Request form.