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) |
|
