Provider-Administered Drug Policies (Excluding Oncology) - Blue Advantage

Provider-administered drug policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. On this site we offer our final pharmacy policies and draft pharmacy policies. The draft policies are available for provider comment for 45 days from the posting date listed on the document. We encourage practicing physicians to provide input.

Blue Advantage follows Prime Therapeutics policies for the following Provider-Administered Drugs:

  • Benlysta
  • Brineura
  • Cinvanti (aprepitant injectable Emulsion, for IV use)
  • Colony Stimulating Factor (Applies to Zarxio only)
  • Crysvita
  • H.P. Acthar (For dates of service on or after February 26, 2018, see Palmetto Article A53066)
  • Hereditary Angioedema
    • Berinert, Cinryze, Firazyr, Kalbitor, Ruconest, Haegarda
  • Injectable Asthma
    • Cinqair, Nucala
  • Infusible Biologics
    • Actemra, Cimzia, Entyvio, Ilumya, Orencia, Simponi Aria, Stelara
  • Injectable and Implantable Testosterone (Applies to Aveed Only) (Applies to Testopel as well for dates of service on or after February 26, 2018.)
  • IV Multiple Sclerosis
    • Lemtrada (For dates of service on or after February 26, 2018, see Palmetto Article A55310), Ocrevus, Tysabri
  • Krystexxa
  • Luxturna (voretigene neparvovec-rzyl Intraocular Suspension for Subretinal Injection) (For dates of service June 1, 2018, and after)
  • Lysomal Storage Disorders
    • Mepsevii
  • Makena
  • Nplate
  • Ocular Angiogenesis Inhibitors (Applies to Eylea Only)
  • Radicava
  • Soliris
  • Spinraza
  • Sublocade (For dates of service July 1, 2018, and after)
  • Trogarzo
  • Varubi IV (Antiemetic Policy)
  • Vivitrol
  • Xolair
  • Xiaflex

Note: Coverage is subject to member's specific benefits. Group specific policies will supersede these policies when applicable. Please refer to member's benefit plan.

Provider-Administered Drug Policies Disclaimer:
The purpose of provider-administered drug policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

Draft Provider-Administered Drug Policies and Forms

Final Provider-Administered Drug Policies and Forms