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.
Urgent requests must be called in to MRx at 1-800-424-8270.
| Policy # |
Policy Title |
Print View |
| PH-0002 |
Actemra IV (tocilizumab) |
|
| PH-0003 |
H.P. Acthar Gel (repository corticotropin injection, ACTH) |
|
| PH-0006 |
Aldurazyme (laronidase) |
|
| PH-0008 |
Aloxi (palonosetron) |
|
| PH-0017 |
Benlysta IV (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 IV (fosaprepitant dimeglumine) |
|
| PH-0042 |
Fabrazyme (agalsidase beta) |
|
| PH-0059 |
SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify® Xembify® |
|
| PH-0061 |
Durolane®, Euflexxa™, Gel-One®, GelSyn-3™, GenVisc 850®, Hyalgan™, Hymovis®, Monovisc®, Orthovisc™, Supartz/Supartz FX™, Synojoynt™, Synvisc™, & Synvisc-One™, TriVisc™, VISCO-3™, Triluron™, sodium hyaluronate 1% |
|
| PH-0071 |
Immune Globulins IV (Asceniv, Bivigam, Carimune NF, Flebogamma 10% DIF, Flebogamma 5% DIF, Gamunex-C, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Octagam, Privigen, Panzyga) |
|
| PH-0078 |
Lucentis (ranibizumab) |
|
| 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™ |
|
| PH-0105 |
Elelyso (taliglucerase alfa) |
|
| PH-0109 |
Rituximab: Rituxan®, Truxima®, Ruxience® |
|
| PH-0114 |
Soliris (eculizumab) |
|
| PH-0117 |
Stelara (ustekinumab) |
|
| PH-0120 |
Synagis (palivizumab) |
|
| PH-0133 |
Tysabri (natalizumab) |
|
| PH-0137 |
Velcade (bortezomib) (Intravenous/Subcutaneous) |
|
| PH-0139 |
Vivitrol (naltrexone) |
|
| PH-0141 |
VPRIV (velaglucerase alfa) |
|
| PH-0145 |
Xiaflex (collagenase) |
|
| PH-0146 |
Xolair (omalizumab) |
|
| 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-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™ |
|
| PH-0235 |
Colony Stimulating Factors: Filgrastim (Neupogen®); Filgrastim-aafi (Nivestym™); Filgrastim-sndz (Zarxio™); Tbo-Filgrastim (Granix®) |
|
| PH-0236 |
Granix (tbo-filgrastim) |
|
| PH-0237 |
Colony Stimulating Factors: Leukine® (sargramostim) |
|
| PH-0238 |
Botox (onabotulinumtoxinA) |
|
| PH-0240 |
Myobloc (rimabotulinumtoxinB) |
|
| PH-0245 |
Zarxio (filgrastim-sndz) |
|
| PH-0260 |
Nucala (mepolizumab) |
|
| PH-0273 |
Cinqair (reslizumab) |
|
| PH-0275 |
Inflectra (infliximab-dyyb) |
|
| 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-0300 |
Renflexis (infliximab-abda) |
|
| PH-0305 |
Radicava (edaravone) |
|
| PH-0307 |
Haegarda (C1 Esterase Inhibitor Subcutaneous [Human]) |
|
| 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 (burosumab-twza) |
|
| 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) |
|
| PH-0427 |
Ultomiris (ravulizumab-cwvz) |
|
| PH-0463 |
Sublocade (buprenorphine ER injection) |
|
| 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-0515 |
Avsola (infliximab-axxq) |
|
| PH-0520 |
Vyondys-53 (golodirsen) |
|
| PH-0525 |
Tepezza (teprotumumab-trbw) |
|
| PH-0527 |
Vyepti (eptinezumab-jjmr) |
|
| PH-0549 |
Uplizna™ (inebilizumab-cdon) |
|
| PH-0562 |
Viltepso (viltolarsen) |
|
| PH-260 |
Nucala (mepolizumab) |
|
