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 your provider does not receive approval for precertification, your plan will pay no benefits. Currently, precertification for these provider-administered drugs is required when administered in a provider’s office or home health setting; however, this precertification does not apply to inpatient hospital claims at this time. Precertification for the drugs listed below will be required in the outpatient facility setting beginning April 1, 2019. Exceptions to this exist at this time: Luxturna, Kymriah and Yescarta require a precertification for any place of treatment. To request a copy of a full drug policy, members can contact Customer Service by calling the number on their ID card.

 

Non-Oncology Policies

Policy # Policy Title Print View
PH-100 Antiemetic Medical Policy Prior Authorization Program Summary (Akynzeo, Aloxi, Cinvanti, Emend IV, Palonosetron, Sustol, Varubi IV)
PH-101 Benlysta Medical Policy Prior Authorization Program Summary
PH-102 Botulinum Toxin Policy Summary (Botox, Dysport, Myobloc, Xeomin)
PH-103 Brineura Policy Summary
PH-104 Hereditary Angioedema Policy Summary (Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest, Takhzyro)
PH-105 Health Care Provider Administered Biologic Immunomodulator Program Summary (Actemra, Cimzia, Entyvio, Orencia, Remicade, Simponi ARIA, Stelara, Ilumya, Inflectra, Renflexis)
PH-106 Immune Globulin Policy Summary (Bivigam, Cuvitru, Flebogamma, GammaSTAN, Gammagard, Gammaked, Gammaplex, Gamunex, Hizentra, HyQvia, Octagam, Panzyga, Privigen)
PH-108 Injectable and Implantable Testosterone Policy Summary (Aveed, Testopel)
PH-109 Injectable Buprenorphine Policy Summary (Sublocade)
PH-110 IV Multiple Sclerosis Medical Policy Prior Authorization Program Summary (Lemtrada, Ocrevus, Tysabri)
PH-111 Luxturna Policy Summary
PH-112 Lysomal Storage Disorders Policy Summary (Aldurazyme, Cerezyme, Elelyso, Fabrazyme, Kanuma, Lumizyme, Mepsevii, Naglazyme, Vimizin, Vpriv)
PH-113 Ocular Angiogenesis Inhibitors Policy Summary (Eylea, Lucentis, Macugen, Visudyne)
PH-114 Oncology Drugs for Non-Oncology Uses Policy Summary (Kymriah, Mylotarg)
PH-115 Rituxan Policy Summary
PH-116 Soliris Policy Summary
PH-117 Spinraza Policy Summary
PH-118 Synagis Policy Summary
PH-119 Trogarzo Policy Summary
PH-120 Viscosupplement Policy Summary (Synvisc, Synvisc-One, Euflexxa)
PH-121 Vivitrol Policy Summary
PH-122 Xolair Policy Summary
PH-123 Colony Stimulating Factors Policy Summary (Fulphila, Granix, Leukine, Neulasta, Neupogen, Zarixo)
PH-124 Crysvita Policy Summary
PH-125 H.P. Acthar Policy Summary
PH-126 Injectable Asthma Agents Policy Summary (Nucala, Cinqair, Fasenra)
PH-127 Krystexxa Policy Summary
PH-128 Makena Policy Summary
PH-129 Nplate Policy Summary
PH-130 Radicava Policy Summary
PH-131 Xiaflex Policy Summary