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 Immune Globulins SC (Hizientra, Gammagard Liquid, Gamunex-C, Gammaked, Hyqvia, Cuvitru)
PH-0061 Hyaluronic Acid Derivatives (Durolane®, Euflexxa™, Gel-One®, GelSyn-3™, GenVisc 850®, Hyalgan™, Hymovis®, Monovisc®, Orthovisc™, Supartz/Supartz FX™, Synvisc™, & Synvisc-One™, TriVisc™, Visco-3™)
PH-0071 Immune Globulins IV (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 Remicade (infliximab)
PH-0105 Elelyso (taliglucerase alfa)
PH-0109 Rituxan IV (rituximab)
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 Neulasta (pegfilgrastim)
PH-0235 Neupogen (filgrastim)
PH-0236 Granix (tbo-filgrastim)
PH-0237 Leukine (sargramostim)
PH-0238 Botox (onabotulinumtoxinA)
PH-0239 Dysport (abobotulinumtoxinA)
PH-0240 Myobloc (rimabotulinumtoxinB)
PH-0241 Xeomin (incobotulinumtoxinA)
PH-0245 Zarxio (filgrastim-sndz)
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-0355 Trogarzo (ibalizumab-uiyk)
PH-0358 Ilumya (tildrakizumab-asmn)
PH-0362 Crysvita (burosumab-twza)
PH-0363 Akynzeo (fosnetupitant/palonosetron)
PH-0370 Fulphila (pegfilgrastim-jmdb )
PH-0375 Nivestym (filgrastim-aafi)
PH-0379 Onpattro (patisiran lipid complex)
PH-0392 Takhzyro (lanadelumab-flyo)
PH-0409 Udenyca (pegfilgrastim-cbqv)
PH-0421 Gamifant (emapalumab-lzsg)
PH-0427 Ultomiris (ravulizumab-cwvz)
PH-0463 Sublocade (buprenorphine ER injection)
PH-0464 Probuphine (buprenorphine)
PH-260 Nucala (mepolizumab)