Provider-Administered Precertification Drug List

 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 indicaated as Gene Therapy/Cellular Immunotherapy (+) require precertification when administered in any place of treatment.

Abraxane*

Erbitux*

Lucentis

  Soliris

Actemra IV

Euflexxa

Lumizyme

Spinraza

  Adakveo   Eylea   Luxturna+   Spravato

Adcetris*

Fabrazyme

Macugen

Stelara

Akynzeo*

Fasenra

Makena

Sublocade

Aldurazyme

Faslodex*

Mepsevii

Sustol*

Alimta*

Firazyr

Mvasi*

Synagis

Aloxi*

Flebogamma*

Mylotarg*

Synvisc

Arzerra*

Fulphila*

Myobloc

Synvisc-One

Asceniv*

fulvestrant*

Naglazyme

Takhzyro

Avastin*

Gamifant

Neulasta*

Tecentriq*

  Avsola   Gammagard S/D*   Neupogen*   Testopel

Bavencio*

Gammagard Liquid*

Nivestym*

Trazimera*

Belrapzo*

Gammaked*

Nplate

Treanda*

Bendeka*

  Gammaplex Liquid*

Nucala

Trogarzo

Benlysta IV

Gamunex-C*

Ocrevus

Truxmia*

Beovu

Gazyva*

Octagam*

Tysabri

Berinert

Givlaari

Ogivri*

Udenyca*

Besponsa*

Granix*

Onpattro

Ultomiris

Bivigam*

H.P. Acthar

Ontruzant*

Vectibix*

Blincyto*

Haegarda

Opdivo*

Velcade*

bortezomib*

Herceptin*

Orencia

Vimzim

Botox

Herceptin Hylecta*

palonosetron*

Visudyne

Brineura

Herzuma*

Panzyga*

Vivitrol

Carimune NF*

Hizentra

Perjeta*

Vpriv

Cerezyme

HyQvia

Polivy

Xembify

Cimzia

Ilumya

Privigen*

Xiaflex

Cinqair

Imfinzi*

Provenge*

Xolair

Cinryze

Inflectra

Radicava

Yervoy*

Cinvanti*

Kadcyla*

Reblozyl

Yescarta*+

Crysvita

Kalbitor

Remicade

Yondelis*

Cutaquig

Kanjinti*

Renflexis

Zaltrap*

Cuvitru

Kanuma

Rituxan IV*

Zarixo*

Cyramza*

Keytruda*

Rituxan Hycela*

Zoextenzo*

  Darzalex*   Krystexxa   Ruconest   Zirabev*
  Elaprase   Kymirah *+   Rituxan Hycela*   Zolgensma+
  Elelyso   Kyprolis*   Ruconest   
  Emend IV*   Lartruvo*   Ruxience*   
  Empliciti*   Lemtrada   Scenesse  
  Entyvio   Leukine*   Simponi ARIA  

* Included in Oncology Select Program

+Indicates Gene Therapy/Cellular Immunotherapy Product

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.

PRV20021-1910