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*

Luxturna*

  Spravato

Actemra IV

Euflexxa

Macugen

Stelara

  Adakveo   Evomela   Makena   Sublocade

Adcetris*

Eylea

Mepsevii

Sustol*

Akynzeo*

Fabrazyme

Mvasi*

Synagis

Aldurazyme

Fasenra

Mylotarg*

Synvisc

Alimta*

Faslodex*

Myobloc

Synvisc-One

Aloxi*

Firazyr

Mvasi*

Takhyrzo

Arzerra*

Flebogamma*

Naglazyme

Tecentriq*

Asceniv*

Fuphila*

Neulasta*

Tepezza

Avastin*

fulvestrant*

Neupogen*

Testopel

  Avsola   Gamifant   Nivestym*   Trazimera*

Bavencio*

Gammagard S/D*

Nplate*

Treanda*

Belrapzo*

Gammagard Liquid*

Nucala

Trodelvy*

Bendeka*

  Gammaked*

Nyvepria

Trogarzo

Benlysta IV

Gammaplex Liquid*

Ocrevus

Truxima*

Beovu

Gamunex-C*

Octagam*

Tysabri

Berinert

Gazyva*

Ogivri*

Udenyca*

Besponsa*

Givlaari

Onpattro*

Ultomiris

Bivigam*

Granix*

Ontruzant*

Uplinza

Blincyto*

H.P. Acthar

Opdivo

Vectibix*

bortezomib*

Haegarda

Orencia

Velcade*

Botox

Herceptin*

Padcev*

Vimzim

Brineura

Herceptin Hylecta*

palonosetron*

Visudyne

Carimune NF*

Herzuma*

Panzyga*

Vivitrol

Cerezyme

Hizntra

Perjeta*

Vpriv

Cimzia

HyQvia

Polivy*

Vyepti

Cinqair

Ilumya

Privigen*

Xembify

Cinryze

Imfinzi*

Provenge*

Xiaflex

Cinvanti*

Inflectra

Radicava

Xolair

Crysvita

Kadcyla*

Reblozyl*

Yervoy*

Cutaquig

Kalbitor

Remicade

Yescarta*+

Cuvitru

Kanuma

Renflexis

Yondelis*

Cyramza*

Kanjinti*

Rituxan IV*

Zarixo*

  Darzalex*   Keytruda*   Rituxan Hycela*   Zaltrap*
  Darzalex Faspro*   Krystexxa   Ruconest   Zepzelca*
  Elaprase   Kymriah*+   Ruxienc*   Ziextenzo*
  Elelyso   Kyprolis*   Sarclisa*   Zirabev*
  Emend IV*   Lemtrada   Scenesse   Zolgensma+
  Empliciti    Leukine*   Simponi Aria  
  Enhertu*    Lucentis   Soliris  
  Entyvio    Lumizyme   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.

PRV20021-20010