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.
|
Abraxane* |
Empliciti* |
Lartruvo* |
Ruconest |
|
Actemra IV |
Entyvio |
Lemtrada |
Simponi ARIA |
|
Adcetris* |
Erbitux* |
Leukine* |
Soliris |
|
Akynzeo* |
Euflexxa |
Lucentis |
Spinraza |
|
Aldurazyme |
Eylea |
Lumizyme |
Spravato |
|
Alimta* |
Fabrazyme |
Luxturna |
Stelara |
|
Aloxi* |
Fasenra |
Macugen |
Sublocade |
|
Arzerra* |
Firazyr |
Makena |
Sustol* |
|
Avastin* |
Flebogamma* |
Mepsevii |
Synagis |
|
Bavencio* |
Fulphila* |
Mvasi* |
Synvisc |
|
Belrapzo* |
Gamifant |
Mylotarg* |
Synvisc-One |
|
Bendeka* |
Gammagard S/D* |
Myobloc |
Takhyzro |
|
Benlysta IV |
Gammagard Liquid* |
Naglazyme |
Tecentriq* |
|
Verinert |
Gammaked* |
Neulasta* |
Testopel |
|
Besponsa* |
Gammaplex Liquid* |
Neupogen* |
Trazimera* |
|
Bivigam* |
Gamunex-C* |
Nivestym |
Treanda |
|
Blincyto* |
Gazyva* |
Nplate |
Trogarzo |
|
bortezomib* |
Granix* |
Nucala |
Truxima* |
|
Botox |
H.P. Acthar |
Ocrevus |
Tysabri |
|
Brineura |
Haegarda |
Octagam* |
Udenyca* |
|
Carimune NF* |
Herceptin* |
Ogivri* |
Ultomiris |
|
Cerezyme |
Herceptin Hylecta* |
Onpattro |
Vectibix* |
|
Cimzia |
Herzuma* |
Ontruzant* |
Velcade* |
|
Cinqair |
Hizentra |
Opdivo* |
Vimzim |
|
Cinryze |
HyQvia |
Orencica |
Visudyne |
|
Cinvanti* |
Ilumya |
palonosetron* |
Vivitrol |
|
Crysvita |
Imfinzi* |
Panzyga* |
Vpriv |
|
Cutaquig |
Inflectra |
Perjeta* |
Xeomin |
|
Cuvitru |
Kadcyla* |
Privigen* |
Xiaflex |
|
Cyramza* |
Kalbitor |
Provenge* |
Xolair |
|
Darzalex* |
Kanuma |
Radicava |
Yervoy* |
|
Dysport |
Keytruda* |
Remicade |
Yescarta* |
| Elaprase | Krystexxa | Renflexis | Zaltrap* |
| Elelyso | Kymriah* | Rituxan IV* | Zarxio* |
| Emend IV* | Kyprolis* | Rituxan Hycela* |
* 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.
PRV20021-1810