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.

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.

 

Use the navigation on the left to locate specific policy information or search using the policy title, policy number or keywords.

 

Policy # Policy Title Print View
PH-0002 Actemra® (tocilizumab)
PH-0003 H.P. Acthar® Gel (repository corticotropin injection, ACTH)
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 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 Hyaluronic Acid Derivatives: 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 (immunoglobulin): Asceniv, Bivigam, Carimune NF, Flebogamma, 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-01068 Cinryze® (C1 Esterase Inhibitor, Human)
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-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-0243 Epoetin alfa: Epogen®; Procrit®; Retacrit™
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-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 (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 GamifaGamifant™ (emapalumab-lzsg)nt (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-0495 Feraheme® (ferumoxytol)
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-0524 Monoferric™ (ferric derisomaltose)
PH-0525 Tepezza (teprotumumab-trbw)
PH-0527 Vyepti® (eptinezumab-jjmr)
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-0622 Compounded Medications
PH-260 Nucala® (mepolizumab)