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.

 

Policy # Policy Title Print View
PH-0150 Zofran® (ondansetron) (Precertification not required)
PH-0183 Levoleucovorin: Fusilev®; Khapzory™ (Precertification not required)
PH-0242 Aranesp® (darbepoetin alfa) (Precertification not required)
PH-0243 Epoetin alfa: Epogen®; Procrit®; Retacrit™ (Precertification not required)
PH-0244 Mircera® (methoxy polyethylene glycol-epoetin beta) (Precertification not required)
PH-0591 Evkeeza™ (evinacumab-dgnb)
PH-0593 Amondys-45™ (casimersen)
PH-0594 Nulibry™ (fosdenopterin)
PH-90017 Benlysta (belimumab)
PH-90026 Eylea® (aflibercept)
PH-90042 Fabrazyme (agalsidase beta)
PH-90052 Alpha-1-Proteinase Inhibitors: Aralast NP®; Glassia®; Prolastin®-C; Zemaira® (Precertification not required.)
PH-90061 Hyaluronic Acid Derivatives
PH-90078 Lucentis® (ranibizumab)
PH-90080 Leuprolide Suspension: Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi® (Precertification not required)
PH-90081 Macugen® (pegaptanib)
PH-90098 Denosumab: Prolia®; Xgeva® (Precertification not required)
PH-90104 Infliximab: Remicade®; Inflectra™; Renflexis™; Avsola™
PH-90105 Elelyso™ (taliglucerase alfa)
PH-90109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-90111 Sandostatin® LAR (octreotide suspension) (Precertification not required)
PH-90117 Stelara® (ustekinumab)
PH-90131 Trelstar® (triptorelin) (Precertification not required)
PH-90135 Vantas® (histrelin acetate) (Precertification not required)
PH-90141 VPRIV® (velaglucerase alfa)
PH-90146 Xolair (omalizumab)
PH-90151 Zoladex® (goserelin acetate) (Precertification not required)
PH-90234 Colony Stimulating Factors – Pegfilgrastim: Neulasta®; Fulphila™; Udenyca®; Ziextenzo™; Nyvepria™
PH-90235 Colony Stimulating Factors: Filgrastim (Neupogen); Filgrastim-aafi (Nivestym); Filgrastim-sndz (Zarxio); Tbo-Filgrastim (Granix)
PH-90237 Colony Stimulating Factors: Leukine (sargramostim)
PH-90239 Dysport™ (abobotulinumtoxinA) (Precertification not required)
PH-90240 Myobloc® (rimabotulinumtoxinB)
PH-90241 Xeomin (incobotulinumtoxinA) (Precertification not required)
PH-90242 Aranesp® (darbepoetin alfa)
PH-90362 Crysvita® (burosumab-twza)
PH-90497 Beovu® (brolucizumab-dbll)
PH-90527 Vyepti (eptinezumab-jjmr)