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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 required in the outpatient facility setting. Exceptions to this include: Luxturna, Kymriah and Yescarta, which 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.