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-0501 Colony Stimulating Factors: Ziextenzo (pegfilgrastim-bmez)
PH-0503 Reblozyl (luspatercept-aamt)
PH-0512 Scenesse (afamelanotide)
PH-0513 Adakveo (crizanlizumab-tmca)
PH-0514 Givlaari (givosiran)
PH-90003 H.P. Acthar Gel (repository corticotropin injection, ACTH)
PH-900117 Stelara (ustekinumab)
PH-900234 Colony Stimulating Factors: Neulasta (pegfilgrastim)
PH-900238 Botox (onabotulinumtoxinA)
PH-900409 Colony Stimulating Factors: Udenyca (pegfilgrastim-cbqv)
PH-90089 Nplate (romiplostim)
PH-90109 Rituxan (rituximab)
PH-90145 Xiaflex® (collagenase)
PH-90291 Spinraza (nusinersen)
PH-90350 Luxturna (voretigene neparvovec-rzyl)
PH-90370 Colony Stimulating Factors: Fulphila (pegfilgrastim-jmdb)
PH-90427 Ultomiris (ravulizumab-cwvz)
PH-9900415 Truxima (rituximab-abbs)
PH-990362 Crysvita (burosumab-twza)