angle-left 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.

Abraxane*

Erbitux*

Leukine*

  Soliris

Actemra IV

Euflexxa

Lucentis

Spinraza

Adcetris*

Eylea

Lumizyme

Spravato

Akynzeo*

Fabrazyme

Luxturna

Stelara

Aldurazyme

Fasenra

Macugen

Sublocade

Alimta*

Faslodex*

Makena

Sustol*

Aloxi*

Firazyr

Mepsevii

Synagis

Arzerra*

Flebogamma*

Mvasi*

Synvisc

Avastin*

Fulphila*

Mylotarg*

Synvisc-One

Bavencio*

fulvestrant*

Myobloc

Takhyzro

Belrapzo*

Gamifant

Naglazyme

Tecentriq*

Bendeka*

Gammagard S/D*

Neulasta*

Testopel

Benlysta IV

  Gammagard Liquid*

Neupogen*

Trazimera*

Verinert

Gammaked*

Nivestym*

Treanda*

Besponsa*

Gammaplex Liquid*

Nplate

Trogarzo

Bivigam*

Gamunex-C*

Nucala

Truxima*

Blincyto*

Gazyva*

Ocrevus

Tysabri

bortezomib*

Granix*

Octagam*

Udenyca*

Botox

H.P. Acthar

Ogivri*

Ultomiris

Brineura

Haegarda

Onpattro

Vectibix*

Carimune NF*

Herceptin*

Ontruzant*

Velcade*

Cerezyme

Herceptin Hylecta*

Opdivo*

Vimzim

Cimzia

Herzuma*

Orencia

Visudyne

Cinqair

Hizentra

palonosetron*

Vivitrol

Cinryze

HyQvia

Panzyga*

Vpriv

Cinvanti*

Ilumya

Perjeta*

Xembify

Crysvita

Imfinzi*

Polivy*

Xiaflex

Cutaquig

Inflectra

Privigen*

Xolair

Cuvitru

Kadcyla*

Provenge*

Yervoy*

Cyramza*

Kalbitor

Radicava

Yescarta*

Darzalex*

Kanjinti*

Remicade

Zaltrap*

Dysport

Kanuma

Renflexis

Zarxio*

  Elaprase   Keytruda*   Rituxan IV*   Zirabev*
  Elelyso   Krystexxa   Rituxan Hycela*   Zolgensma
  Emend IV*   Kymriah*   Ruconest  
  Empliciti*   Kyprolis*   Ruxience*  
  Entyvio   Lemtrada   Simponi ARIA  

* 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.

PRV20021-1910