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-0497 Beovu (brolucizumab-dbll)
PH-90002 Actemra (tocilizumab)
PH-90008 Aloxi (palonosetron)
PH-90018 Berinert (C1 Esterase Inhibitor, Human)
PH-90061 Hyaluronic Acid Derivatives
PH-90078 Lucentis (ranibizumab)
PH-90081 Macugen (pegaptanib)
PH-90133 Tysabri® (natalizumab)
PH-90146 Xolair (omalizumab)
PH-90167 Kalbitor (ecallantide)
PH-90168 Cinryze (C1 Esterase Inhibitor Human)
PH-90169 Firazyr (icatibant)
PH-90202 Entyvio (vedolizumab)
PH-90207 Ruconest (C1 Esterase Inhibitor [recombinant])
PH-90239 Dysport™ (abobotulinumtoxinA)
PH-90241 Xeomin® (incobotulinumtoxinA)
PH-90260 Nucala (mepolizumab)
PH-90273 Cinqair (reslizumab)
PH-90283 Sustol (granisetron extended-release)
PH-90298 Ocrevus™ (ocrelizumab)
PH-90307 Haegarda (C1 Esterase Inhibitor Subcutaneous [Human])
PH-90347 Fasenra (benralizumab)
PH-90379 Onpattro (patisiran lipid complex)
PH-90392 Takhzyro (lanadelumab-flyo)
PH-90468 Zolgensma® (onasemnogene abeparvovec-xioi)
PH-990026 Eylea (aflibercept)
PH-990059 SCIG (immune globulin SQ): Hizentra, Gammagard Liquid, Gamunex-C, Gammaked, Hyqvia, Cuvitru, Cutaquig, Xembify
PH-990109 Rituxan (rituximab)
PH-990234 Colony Stimulating Factors: Neulasta (pegfilgrastim)
PH-990238 Botox (onabotulinumtoxinA)
PH-990240 Myobloc (rimabotulinumtoxinB)
PH-990409 Colony Stimulating Factors: Udenyca (pegfilgrastim-cbqv)
PH-990415 Truxima (rituximab-abbs)
PH-99071 Immune Globulins (immunoglobulin)