Draft Provider-Administered Drug Policies

The drugs below require that a member’s medical condition meets the policy requirements prior to being given (precertification) unless otherwise specified. 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.

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 is also required in the outpatient facility setting. Exceptions to this include: Luxturna, Kymriah and Yescarta, which require a precertification for any place of treatment.

Members can request a copy of a full drug policy, by calling the Customer Service number on their ID card.

 

Policy # Policy Title Print View
PH-0610 Aduhelm™ (aducanumab-avwa)
PH-0614 Saphnelo™ (anifrolumab-fnia)
PH-0615 Nexviazyme™ (avalglucosidase alfa-ngpt)
PH-90027 Cerezyme® (imiglucerase)
PH-90079 Lumizyme® (alglucosidase alfa)
PH-90080 Leuprolide Suspension: Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Camcevi™(Precertification not required)
PH-90091 Orencia® (abatacept)
PH-90104 Infliximab: Remicade®; Inflectra™; Renflexis™; Avsola™
PH-90105 Elelyso™ (taliglucerase alfa)
PH-90109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-90114 Soliris (eculizumab)
PH-90120 Synagis® (palivizumab)
PH-90139 Vivitrol® (naltrexone)
PH-90141 VPRIV® (velaglucerase alfa)
PH-90146 Xolair® (omalizumab)
PH-90176 Simponi ARIA (golimumab)
PH-90235 Colony Stimulating Factors: Filgrastim (Neupogen); Filgrastim-aafi (Nivestym); Filgrastim-sndz (Zarxio); Tbo-Filgrastim (Granix)
PH-90260 Nucala® (mepolizumab)
PH-90284 Exondys-51™ (eteplirsen)
PH-90291 Spinraza™ (nusinersen)
PH-90312 Injectafer® (ferric carboxymaltose injection)
PH-90347 Fasenra® (benralizumab)
PH-90358 Ilumya™ (tildrakizumab-asmn)
PH-90495 Feraheme® (ferumoxytol)
PH-90520 Vyondys-53™ (golodirsen)
PH-90524 Monoferric™ (ferric derisomaltose)
PH-90562 Viltepso™ (viltolarsen)
PH-90593 Amondys-45™ (casimersen)