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.

Please use the Search function above to locate specific drug policy information.

 

Policy # Policy Title Print View
PH-90091 Orencia (abatacept)
PH-90114 Soliris (eculizumab)
PH-90120 Synagis® (palivizumab)
PH-90139 Vivitrol (naltrexone)
PH-90282 Testopel (testosterone pellets)
PH-90355 Trogarzo (ibalizumab-uiyk)
PH-90481 Spravato (esketamine)