Provider-Administered Precertification Drug List - Provider-Administered Precertification Drug List - Medical Policies
Provider-Administered Precertification Drug List
The following drugs will be subject to the Provider-Administered Drug Review Program. Precertification for these provider-administered drugs is required when administered in a provider’s office, outpatient facility or home health setting. Treatments indicated as Gene Therapy/Cellular Immunotherapy (+) require precertification when administered in any place of treatment.
Abraxane* |
Erbitux* |
Macugen |
Spravato |
Actemra IV |
Euflexxa |
Makena |
Stelara |
Adakveo | Evomela | Mepsevii | Sublocade |
Adcetris* |
Eylea |
Monjuvi* |
Sustol* |
Akynzeo* |
Fabrazyme |
Mvasi* |
Synagis |
Aldurazyme |
Fasenra |
Mylotarg* |
Synvisc |
Alimta* |
Faslodex* |
Myobloc |
Synvisc-One |
Aloxi* |
Firazyr |
Mvasi* |
Takhyzro |
Arzerra* |
Flebogamma* |
Naglazyme |
Tecentriq* |
Asceniv* |
Fuphila* |
Neulasta* |
Tecartus* |
Avastin* |
fulvestrant* |
Neupogen* |
Tepezza |
Avsola | Gamifant | Nivestym* | Testopel |
Bavencio* |
Gammagard S/D* |
Nplate* |
Trazimera* |
Belrapzo* |
Gammagard Liquid* |
Nucala |
Treanda* |
Bendeka* |
Gammaked* |
Nyvepria |
Trodelvy* |
Benlysta IV |
Gammaplex Liquid* |
Ocrevus |
Trogarzo |
Beovu |
Gamunex-C* |
Octagam* |
Truxima* |
Berinert |
Gazyva* |
Ogivri* |
Tysabri |
Besponsa* |
Givlaari |
Onpattro* |
Udenyca* |
Bivigam* |
Granix* |
Ontruzant* |
Ultomiris |
Blenrep* | H.P. Acthar | Opdivo | Uplizna |
Blincyto* |
Haegarda |
Orencia |
Vectibix* |
bortezomib* |
Herceptin* |
Padcev* |
Velcade* |
Botox |
Herceptin Hylecta* |
palonosetron* |
Vimzim |
Brineura |
Herzuma* |
Panzyga* |
Visudyne |
Carimune NF* |
Hizentra |
Perjeta* |
Vivitrol |
Cerezyme |
HyQvia |
Phesgo* |
Vpriv |
Cimzia |
Ilumya |
Polivy* |
Vyepti |
Cinqair |
Imfinzi* |
Privigen* |
Xembify |
Cinryze |
Infectra |
Provenge* |
Xiaflex |
Cinvanti* |
Kadcyla* |
Radicava |
Xolair |
Crysvita |
Kalbitor |
Reblozyl* |
Yervoy* |
Cutaquig |
Kanuma |
Remicade |
Yescarta*+ |
Cuvitru |
Kanjinti* |
Renfexis |
Yondelis |
Cyramza* |
Keytruda* |
Rituxan IV* |
Zarxio* |
Darzalex* | Krystexxa | Rituxan Hycela* | Zaltrap |
Darzalex Faspro* | Kymriah*+ | Ruconest | Zepzelca* |
Elaprase | Kyprolis* | Ruxience* | Ziextenzo |
Elelyso | Lemtrada | Sarclisa* | Zirabev* |
Emend IV* | Leukine* | Scenesse | Zollgensma+ |
Empliciti | Lucentis | Simponi Aria | |
Enhertu* | Luizyme | Soliris | |
Entyvio | Luxturna* | Spinraza |
+Indicates Gene Therapy/Cellular Immunotherapy Product * Included in Oncology Select Program
Product names are the property of their respective owners.
Online policies can be found at the website shown on the back of your member identification card. See “Provider-Administered Drug Policies” under Provider.
PRV20021-210101