Provider-Administered Drug  Claim Edit Policies

For the provider-administed drugs identified below, claims submitted to the plan must include an appropriate diagnosis code within the drug's policy criteria for claims to process.  Any claims submitted with a diagnosis code not found within the policy for that drug, will reject as non-covered.

Precertification criteria does not apply for these policies.


Policy # Policy Title Print View
PH-0239 Dysport (abobotulinumtoxinA)
PH-0241 Xeomin (incobotulinumtoxinA)