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-0027999 Cerezyme®
PH-0059999 SCIG (immune globulin SQ)
PH-0061999 Hyaluronic Acid Derivatives
PH-0104999 Remicade®
PH-0105999 Elelyso™
PH-0141999 VPRIV®
PH-0181999 Visudyne®
PH-0238999 Botox®
PH-0275999 Inflectra®
PH-0282999 Testopel®
PH-0291999 Spinraza™
PH-0300999 Renflexis™
PH-0468999 Zolgensma®
PH-0486999 Ruxience®
PH-90026 Eylea®(aflibercept)
PH-90109 Rituxan (rituximab)
PH-90234 Neulasta (pegfilgrastim)
PH-90370 Fulphila (pegfilgrastim-jmdb)
PH-90409 Udenyca™ (pegfilgrastim-cbqv)
PH-90415 Truxima® (rituximab-abbs)