Asset Publisher

Final 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.

Precertification for these provider-administered drugs is required when administered in a provider’s office, outpatient facility, or home health setting. Exceptions to this include: Luxturna, Kymriah and Yescarta, which require a precertification for any place of treatment.

Urgent precertification requests must be called in to MagellanRx at 1-800-424-8270.

Members can request a copy of a full drug policy by calling the Customer Service number on their ID card

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.

Final Policies

Policy # Policy Title Print View
PH-0002 Tocilizumab: Actemra®; Tofidence™
PH-0003 Corticotropin-ACTH: Acthar® Gel (repository corticotropin injection) Cortrophin® Gel (repository corticotropin injection)
PH-0006 Aldurazyme® (laronidase)
PH-0008 Aloxi (palonosetron)
PH-0017 Benlysta® (belimumab)
PH-0018 Berinert® (C1 Esterase Inhibitor, Human)
PH-0026 Aflibercept: Eylea®; Eylea® HD
PH-0027 Cerezyme® (imiglucerase)
PH-0028 Cimzia® (certolizumab pegol)
PH-0034 Elaprase® (idursulfase)
PH-0042 Fabrazyme® (agalsidase beta)
PH-0057 Trastuzumab: Herceptin®; Ogivri®; Kanjinti™; Trazimera™; Herzuma®; Ontruzant®
PH-0059 SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify®
PH-0061 Hyaluronic Acid Derivatives: Durolane®, Euflexxa™, Gel-One®, GelSyn-3™, GenVisc 850®, Hyalgan™, Hymovis®, Monovisc®, Orthovisc™, Supartz/Supartz FX™, Synojoynt, Synvisc™, Synvisc-One™, Triluron™, TriVisc™, VISCO-3™, & sodium hyaluronate 1%
PH-0071 Immune Globulins (immunoglobulin): Bivigam; Flebogamma; Gamunex-C; Gammagard Liquid; Gammagard S/D; Gammaked; Gammaplex; Octagam; Privigen; Panzyga
PH-0078 Ranibizumab: Lucentis®; Byooviz™; Cimerli™
PH-0079 Lumizyme® (alglucosidase alfa)
PH-0081 Macugen® (pegaptanib)
PH-0084 Naglazyme® (galsulfase)
PH-0089 Nplate® (romiplostim)
PH-0091 Orencia® (abatacept)
PH-0104 Infliximab: Remicade®; Inflectra™; Renflexis™; Avsola™; Infliximab*
PH-0105 Elelyso™ (taliglucerase alfa)
PH-01069 Firazyr® (icatibant)
PH-0109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-0114 Soliris® (eculizumab)
PH-0117 Stelara® (ustekinumab)
PH-0120 Synagis® (palivizumab)
PH-0133 Natalizumab: (Tysabri®; Tyruko®)
PH-0139 Vivitrol® (naltrexone)
PH-0141 VPRIV® (velaglucerase alfa)
PH-0145 Xiaflex® (collagenase)
PH-0146 Xolair® (omalizumab)
PH-0150 Zofran® (ondansetron)
PH-0158 Krystexxa® (pegloticase)
PH-0167 Kalbitor® (ecallantide)
PH-0168 Cinryze® (C1 Esterase Inhibitor, Human)
PH-0169 Firazyr® (icatibant)
PH-0171 Makena® (hydroxyprogesterone caproate)
PH-0176 Simponi ARIA® (golimumab)
PH-0177 Ilaris® (canakinumab)
PH-0181 Visudyne® (verteporfin)
PH-0190 Vimizim® (elosulfase alfa)
PH-0202 Entyvio™ (vedolizumab)
PH-0207 Ruconest® (C1 Esterase Inhibitor [recombinant])
PH-0223 Lemtrada® (alemtuzumab)
PH-0234 Colony Stimulating Factors – Pegfilgrastim: Neulasta®; Fulphila®; Udenyca®; Ziextenzo™; Nyvepria™; Fylnetra®; Stimufend®
PH-0235 Colony Stimulating Factors: Filgrastim (Neupogen®); Filgrastim-aafi (Nivestym™); Filgrastim-sndz (Zarxio™); Filgrastim-ayow (Releuko®); Tbo-Filgrastim (Granix®)
PH-0237 Leukine® (sargramostim)
PH-0238 Botox® (onabotulinumtoxinA)
PH-0240 Myobloc® (rimabotulinumtoxinB)
PH-0243 Epoetin alfa: Epogen®; Procrit®; Retacrit™
PH-0245 Zarxio (filgrastim-sndz)
PH-0260 Nucala® (mepolizumab)
PH-0266 Darzalex® (daratumumab)
PH-0273 Cinqair® (reslizumab)
PH-0277 Kanuma™ (sebelipase alfa)
PH-0282 Testopel® (testosterone pellets)
PH-0283 Sustol (granisetron extended-release)
PH-0284 Exondys-51™ (eteplirsen)
PH-0291 Spinraza™ (nusinersen)
PH-0298 Ocrevus™ (ocrelizumab)
PH-0299 Brineura (cerliponase alfa)
PH-0305 Radicava® (edaravone)
PH-0307 Haegarda® (C1 Esterase Inhibitor Subcutaneous [Human])
PH-0312 Injectafer® (ferric carboxymaltose injection)
PH-0336 Cinvanti (aprepitant)
PH-0346 Mepsevii™ (vestronidase alfa-vjbk)
PH-0347 Fasenra® (benralizumab)
PH-0350 Luxturna® (voretigene neparvovec-rzyl)
PH-0355 Trogarzo™ (ibalizumab-uiyk)
PH-0358 Ilumya® (tildrakizumab-asmn)
PH-0362 Crysvita®
PH-0363 Akynzeo (fosnetupitant/palonosetron)
PH-0375 Nivestym (filgrastim-aafi)
PH-0379 Onpattro (patisiran lipid complex)
PH-0392 Takhzyro® (lanadelumab-flyo)
PH-0421 Gamifant™ (emapalumab-lzsg)nt (emapalumab-lzsg)
PH-0427 Ultomiris® (ravulizumab-cwvz)
PH-0463 Sublocade® (buprenorphine ER)
PH-0464 Probuphine® (buprenorphine)
PH-0468 Zolgensma® (onasemnogene abeparvovec-xioi)
PH-0481 Spravato™ (esketamine)
PH-0482 Polivy (polatuzumab vedotin-piiq)
PH-0497 Beovu® (brolucizumab-dbll)
PH-0503 Reblozyl® (luspatercept-aamt)
PH-0512 Scenesse® (afamelanotide)
PH-0513 Adakveo® (crizanlizumab-tmca)
PH-0514 Givlaari™ (givosiran)
PH-0520 Vyondys-53™ (golodirsen)
PH-0524 Monoferric™ (ferric derisomaltose)
PH-0525 Tepezza® (teprotumumab-trbw)
PH-0527 Vyepti® (eptinezumab-jjmr)
PH-0535 Darzalex Faspro® (daratumumab and hyaluronidase-fihj)
PH-0549 Uplizna™ (inebilizumab-cdon)
PH-0558 Tecartus (brexucabtagene autoleucel)
PH-0562 Viltepso™ (viltolarsen)
PH-0579 Oxlumo™ (lumasiran)
PH-0581 Danyelza® (naxitamab-gqgk)
PH-0591 Evkeeza™ (evinacumab-dgnb)
PH-0593 Amondys-45™ (casimersen)
PH-0594 Nulibry™ (fosdenopterin)
PH-0610 Aduhelm™ (aducanumab-avwa)
PH-0614 Saphnelo® (anifrolumab-fnia)
PH-0615 Nexviazyme™ (avalglucosidase alfa-ngpt)
PH-0622 Compounded Medications
PH-0633 Xipere® (triamcinolone acetonide injectable suspension)
PH-0634 Susvimo™ (ranibizumab)
PH-0635 Dextenza® (dexamethasone insert)
PH-0647 Fyarro™ (sirolimus albumin-bound)
PH-0648 Rethymic® (allogeneic processed thymus tissue-agdc)
PH-0649 Vyvgart™ (efgartigimod alfa-fcab)
PH-0650 Tezspire™ (tezepelumab-ekko)
PH-0652 Leqvio® (inclisiran)
PH-0658 Kimmtrak® (tebentafusp-tebn)
PH-0659 Vabysmo™ (faricimab-svoa)
PH-0660 Enjaymo™ (sutimlimab-jome)
PH-0663 Carvykti™ (ciltacabtagene autoleucel)
PH-0664 Opdualag™ (nivolumab/relatlimab-rmbw)
PH-0670 Amvuttra (vutrisiran)
PH-0671 Skyrizi® (risankizumab-rzaa)
PH-0672 Zynteglo® (betibeglogene autotemcel)
PH-0673 Xenpozyme™ (olipudase alfa)
PH-0674 Spevigo® (spesolimab)
PH-0676 Rolvedon™
PH-0677 Skysona® (elivaldogene autotemcel)
PH-0687 Tzield™ (teplizumab-mzwv)
PH-0688 Hemgenix® (etranacogene dezaparvovec-drlb)
PH-0693 Briumvi™ (ublituximab-xiiy)
PH-0694 Leqembi™ (lecanemab-irmb)
PH-0696 Lamzede® (velmanase alfa-tycv)
PH-0697 Syfovre™ (pegcetacoplan)
PH-0704 Qalsody™ (tofersen)
PH-0708 Elfabrio® (pegunigalsidase alfa-iwxj)
PH-0709 Vyjuvek™ (beremagene geperpavec-svdt)
PH-0712 Vyvgart® Hytrulo (efgartigimod alfa-fcab and hyaluronidase-qvfc)
PH-0713 Elevidys® (delandistrogene moxeparvovec-rokl)
PH-0714 Rystiggo® (rozanolixizumab-noli)
PH-0718 Roctavian® (valoctocogene roxaparvovec-rvox)
PH-0721 Izervay™ (avacincaptad pegol)
PH-0727 Veopoz® (pozelimab-bbfg)
PH-0731 Pombiliti™ (cipaglucosidase alfa-atga)
PH-671 Skyrizi®