Draft 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. 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.

 

Draft Provider-Administered Non-Oncology Drug Policies

There are currently no draft policies available for review and comment.

Policy # Policy Title Print View
PH-132 DRAFT hATTR Amyloidosis Neuropathy Medical Drug Criteria Program Summary
PH-9105 DRAFT Health Care Provider Administered (HCPA) Biologic Immunomodulator Medical Policy Prior Authorization
PH-9112 Lysosomal Storage Disorders Medical Policy
PH-9123 Colony Stimulating Factors (CSF) Medical Policy Prior Authorization