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Provider-Administered Drug Claim Edit Policies

For the provider-administered drugs listed 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.

Note: Coverage is subject to member’s specific benefits. Group-specific policies will supersede these policies when applicable. Please contact the customer service number on the back of the member’s ID card for group-specific policies and benefits.

Precertification criteria does not apply for these policies.

Policy # Policy Title Print View
PH-0036 Emend® (fosaprepitant dimeglumine)
PH-0052 Alpha-1-Proteinase Inhibitors: Aralast NP®; Glassia®; Prolastin®-C; Zemaira®
PH-0080 Leuprolide Suspension: Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Camcevi™, Lutrate Depot™, Leuprolide Acetate Depot Ψ
PH-0098 Denosumab: Prolia®; Xgeva®
PH-0111 Sandostatin® LAR
PH-0131 Trelstar® (triptorelin)
PH-0135 Vantas® (histrelin acetate)
PH-0137 Bortezomib Velcade®; Bortezomib§
PH-0151 Zoladex® (goserelin acetate)
PH-0183 Levoleucovorin: Fusilev®; Khapzory™
PH-0239 Dysport® (abobotulinumtoxinA)
PH-0241 Xeomin® (incobotulinumtoxinA)
PH-0242 Aranesp® (darbepoetin alfa)
PH-0244 Mircera® (methoxy polyethylene glycol-epoetin beta)
PH-0351 Bortezomib*
VP-036 Fosaprepitant: Emend®; Fosaprepitant Ψ (Intravenous)