Final 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. Exceptions to this include: Luxturna, Kymriah and Yescarta, which require a precertification for any place of treatment.
Urgent precertification requests must be called in to MagellanRx at 1-800-424-8270.
Members can request a copy of a full drug policy by calling the Customer Service number on their ID card.
Final Policies
| Policy # |
Policy Title |
Print View |
| PH-0002 |
Actemra® (tocilizumab) |
|
| PH-0003 |
Corticotropin-ACTH: Acthar® Gel (repository corticotropin injection) Cortrophin® Gel (repository corticotropin injection) |
|
| PH-0006 |
Aldurazyme® (laronidase) |
|
| PH-0008 |
Aloxi (palonosetron) |
|
| PH-0017 |
Benlysta® (belimumab) |
|
| PH-0018 |
Berinert® (C1 Esterase Inhibitor, Human) |
|
| PH-0026 |
Eylea® (aflibercept) |
|
| PH-0027 |
Cerezyme® (imiglucerase) |
|
| PH-0028 |
Cimzia® (certolizumab pegol) |
|
| PH-0034 |
Elaprase® (idursulfase) |
|
| PH-0036 |
Emend® (fosaprepitant dimeglumine) |
|
| PH-0042 |
Fabrazyme® (agalsidase beta) |
|
| PH-0057 |
Trastuzumab: Herceptin®; Ogivri®; Kanjinti™; Trazimera™; Herzuma®; Ontruzant® |
|
| PH-0059 |
SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify® |
|
| PH-0061 |
Hyaluronic Acid Derivatives: Durolane®, Euflexxa™, Gel-One®, GelSyn-3™, GenVisc 850®, Hyalgan™, Hymovis®, Monovisc®, Orthovisc™, Supartz/Supartz FX™, Synojoynt, Synvisc™, Synvisc-One™, Triluron™, TriVisc™, VISCO-3™, & sodium hyaluronate 1% |
|
| PH-0071 |
Immune Globulins (immunoglobulin): Bivigam; Flebogamma; Gamunex-C; Gammagard Liquid; Gammagard S/D; Gammaked; Gammaplex; Octagam; Privigen; Panzyga |
|
| PH-0078 |
Ranibizumab: Lucentis®; Byooviz™; Cimerli™ |
|
| PH-0079 |
Lumizyme® (alglucosidase alfa) |
|
| PH-0081 |
Macugen® (pegaptanib) |
|
| PH-0084 |
Naglazyme® (galsulfase) |
|
| PH-0089 |
Nplate® (romiplostim) |
|
| PH-0091 |
Orencia® (abatacept) |
|
| PH-0104 |
Infliximab: Remicade®; Inflectra™; Renflexis™; Avsola™; Infliximab* |
|
| PH-0105 |
Elelyso™ (taliglucerase alfa) |
|
| PH-01069 |
Firazyr® (icatibant) |
|
| PH-0109 |
Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™ |
|
| PH-0114 |
Soliris® (eculizumab) |
|
| PH-0117 |
Stelara® (ustekinumab) |
|
| PH-0120 |
Synagis® (palivizumab) |
|
| PH-0133 |
Tysabri® (natalizumab) |
|
| PH-0139 |
Vivitrol® (naltrexone) |
|
| PH-0141 |
VPRIV® (velaglucerase alfa) |
|
| PH-0145 |
Xiaflex® (collagenase) |
|
| PH-0146 |
Xolair® (omalizumab) |
|
| PH-0150 |
Zofran® (ondansetron) |
|
| PH-0158 |
Krystexxa® (pegloticase) |
|
| PH-0167 |
Kalbitor® (ecallantide) |
|
| PH-0168 |
Cinryze® (C1 Esterase Inhibitor, Human) |
|
| PH-0169 |
Firazyr® (icatibant) |
|
| PH-0171 |
Makena® (hydroxyprogesterone caproate) |
|
| PH-0176 |
Simponi ARIA® (golimumab) |
|
| PH-0177 |
Ilaris® (canakinumab) |
|
| PH-0181 |
Visudyne® (verteporfin) |
|
| PH-0190 |
Vimizim® (elosulfase alfa) |
|
| PH-0202 |
Entyvio™ (vedolizumab) |
|
| PH-0207 |
Ruconest® (C1 Esterase Inhibitor [recombinant]) |
|
| PH-0223 |
Lemtrada® (alemtuzumab) |
|
| PH-0234 |
Colony Stimulating Factors – Pegfilgrastim: Neulasta®; Fulphila®; Udenyca®; Ziextenzo™; Nyvepria™; Fylnetra®; Stimufend® |
|
| PH-0235 |
Colony Stimulating Factors: Filgrastim (Neupogen®); Filgrastim-aafi (Nivestym™); Filgrastim-sndz (Zarxio™); Filgrastim-ayow (Releuko®); Tbo-Filgrastim (Granix®) |
|
| PH-0237 |
Leukine® (sargramostim) |
|
| PH-0238 |
Botox® (onabotulinumtoxinA) |
|
| PH-0240 |
Myobloc® (rimabotulinumtoxinB) |
|
| PH-0243 |
Epoetin alfa: Epogen®; Procrit®; Retacrit™ |
|
| PH-0245 |
Zarxio (filgrastim-sndz) |
|
| PH-0260 |
Nucala® (mepolizumab) |
|
| PH-0266 |
Darzalex® (daratumumab) |
|
| PH-0273 |
Cinqair® (reslizumab) |
|
| PH-0277 |
Kanuma™ (sebelipase alfa) |
|
| PH-0282 |
Testopel® (testosterone pellets) |
|
| PH-0283 |
Sustol (granisetron extended-release) |
|
| PH-0284 |
Exondys-51™ (eteplirsen) |
|
| PH-0291 |
Spinraza™ (nusinersen) |
|
| PH-0298 |
Ocrevus™ (ocrelizumab) |
|
| PH-0299 |
Brineura (cerliponase alfa) |
|
| PH-0305 |
Radicava® (edaravone) |
|
| PH-0307 |
Haegarda® (C1 Esterase Inhibitor Subcutaneous [Human]) |
|
| PH-0312 |
Injectafer® (ferric carboxymaltose injection) |
|
| PH-0336 |
Cinvanti (aprepitant) |
|
| PH-0346 |
Mepsevii™ (vestronidase alfa-vjbk) |
|
| PH-0347 |
Fasenra® (benralizumab) |
|
| PH-0350 |
Luxturna® (voretigene neparvovec-rzyl) |
|
| PH-0351 |
Bortezomib* |
|
| PH-0355 |
Trogarzo™ (ibalizumab-uiyk) |
|
| PH-0358 |
Ilumya® (tildrakizumab-asmn) |
|
| PH-0362 |
Crysvita® |
|
| PH-0363 |
Akynzeo (fosnetupitant/palonosetron) |
|
| PH-0375 |
Nivestym (filgrastim-aafi) |
|
| PH-0379 |
Onpattro (patisiran lipid complex) |
|
| PH-0392 |
Takhzyro® (lanadelumab-flyo) |
|
| PH-0421 |
Gamifant™ (emapalumab-lzsg)nt (emapalumab-lzsg) |
|
| PH-0427 |
Ultomiris® (ravulizumab-cwvz) |
|
| PH-0463 |
Sublocade® (buprenorphine ER) |
|
| PH-0464 |
Probuphine® (buprenorphine) |
|
| PH-0468 |
Zolgensma® (onasemnogene abeparvovec-xioi) |
|
| PH-0481 |
Spravato™ (esketamine) |
|
| PH-0482 |
Polivy (polatuzumab vedotin-piiq) |
|
| PH-0497 |
Beovu® (brolucizumab-dbll) |
|
| PH-0503 |
Reblozyl® (luspatercept-aamt) |
|
| PH-0512 |
Scenesse® (afamelanotide) |
|
| PH-0513 |
Adakveo® (crizanlizumab-tmca) |
|
| PH-0514 |
Givlaari™ (givosiran) |
|
| PH-0520 |
Vyondys-53™ (golodirsen) |
|
| PH-0524 |
Monoferric™ (ferric derisomaltose) |
|
| PH-0525 |
Tepezza® (teprotumumab-trbw) |
|
| PH-0527 |
Vyepti® (eptinezumab-jjmr) |
|
| PH-0535 |
Darzalex Faspro® (daratumumab and hyaluronidase-fihj) |
|
| PH-0549 |
Uplizna™ (inebilizumab-cdon) |
|
| PH-0558 |
Tecartus (brexucabtagene autoleucel) |
|
| PH-0562 |
Viltepso™ (viltolarsen) |
|
| PH-0579 |
Oxlumo™ (lumasiran) |
|
| PH-0581 |
Danyelza® (naxitamab-gqgk) |
|
| PH-0591 |
Evkeeza™ (evinacumab-dgnb) |
|
| PH-0593 |
Amondys-45™ (casimersen) |
|
| PH-0594 |
Nulibry™ (fosdenopterin) |
|
| PH-0610 |
Aduhelm™ (aducanumab-avwa) |
|
| PH-0614 |
Saphnelo® (anifrolumab-fnia) |
|
| PH-0615 |
Nexviazyme™ (avalglucosidase alfa-ngpt) |
|
| PH-0622 |
Compounded Medications |
|
| PH-0633 |
Xipere® (triamcinolone acetonide injectable suspension) |
|
| PH-0634 |
Susvimo™ (ranibizumab) |
|
| PH-0635 |
Dextenza® (dexamethasone insert) |
|
| PH-0647 |
Fyarro™ (sirolimus albumin-bound) |
|
| PH-0648 |
Rethymic® (allogeneic processed thymus tissue-agdc) |
|
| PH-0649 |
Vyvgart™ (efgartigimod alfa-fcab) |
|
| PH-0650 |
Tezspire™ (tezepelumab-ekko) |
|
| PH-0652 |
Leqvio® (inclisiran) |
|
| PH-0658 |
Kimmtrak® (tebentafusp-tebn) |
|
| PH-0659 |
Vabysmo™ (faricimab-svoa) |
|
| PH-0660 |
Enjaymo™ (sutimlimab-jome) |
|
| PH-0663 |
Carvykti™ (ciltacabtagene autoleucel) |
|
| PH-0664 |
Opdualag™ (nivolumab/relatlimab-rmbw) |
|
| PH-0670 |
Amvuttra (vutrisiran) |
|
| PH-0671 |
Skyrizi® (risankizumab-rzaa) |
|
| PH-0672 |
Zynteglo® (betibeglogene autotemcel) |
|
| PH-0673 |
Xenpozyme™ (olipudase alfa) |
|
| PH-0674 |
Spevigo® |
|
| PH-0676 |
Rolvedon™ |
|
| PH-0677 |
Skysona® (elivaldogene autotemcel) |
|
| PH-0687 |
Tzield™ (teplizumab-mzwv) |
|
| PH-0688 |
Hemgenix® (etranacogene dezaparvovec-drlb) |
|
| PH-0693 |
Briumvi™ (ublituximab-xiiy) |
|
| PH-0694 |
Leqembi™ (lecanemab-irmb) |
|
| PH-0696 |
Lamzede® (velmanase alfa-tycv) |
|
| PH-0697 |
Syfovre™ (pegcetacoplan) |
|
| PH-0704 |
Qalsody™ (tofersen) |
|
| PH-0708 |
Elfabrio® (pegunigalsidase alfa-iwxj) |
|
| PH-671 |
Skyrizi® |
|
