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

Abraxane*

Erbitux*

Macugen

  Stelara

Actemra IV

Euflexxa

Makena

Sublocade

  Adakveo   Evomela   Margenza   Sustol*

Adcetris*

Eylea

Mepsevii

Synagis

Akynzeo*

Fabrazyme

Monjuvi*

Synvisc

Aldurazyme

Fasenra

Mvasi*

Synvisc-One

Alimta*

Faslodex*

Mylotarg*

Takhyrzo

Aloxi*

Firazyr

Myobloc

Tecentriq*

Arzerra*

Flebogamma*

Naglazyme

Tecartus*

Asceniv*

Fuphila*

Neulasta*

Tepezza

Avastin*

fulvestrant*

Neupogen*

Testopl

  Avsola   Gamifant   Nivestym*   Trazimera*

Bavencio*

Gammagard S/D*

Nplate*

Treanda*

Belrapzo*

Gammagard Liquid*

Nucala

Trodelvy*

Bendeka*

  Gammaked*

Nyvepria*

Trogarzo

Benlysta IV

Gammaplex Liquid*

Ocrevus

Trouxima*

Beovu

Gamunex-C*

Octagam*

Tysabri

Berinert

Gazyva*

Ogivri*

Udenyca*

Besponsa*

Givlaari

Onpattro+

Ultomiris

Bivigam*

Granix*

Ontruzant*

Uplizna

  Blenrep*   H.P. Acthar   Opdivo*   Vectibix*

Blincyto*

Haegarda

Orencia

Velcade*

bortezomib*

Herceptin*

Oxlumo

Vimzim

Botox

Herceptin Hylecta*

Padcev*

Visudyne

   Breyanzi*   Herzuma*   palonosetron*   Vivitrol

Brineura

Hizentra

Panzyga*

Vpriv

Carimune NF*

HyQvia

Perjeta*

Vyepti

Cerezyme

Ilumya

Phesgo*

Xembify

Cimzia

Imfinzi*

Polivy*

Xiaflex

Cinqair

Inflectra

Privigen*

Xolair

Cinryze

Jelmyto*

Provenge*

Yervoy*

Cinvanti*

Kadcyla*

Radicava

Yescarta*+

Crysvita

Kalbitor

Reblozyl*

Yondelis

Cutaquig

Kanuma

Remicade

Zarxio*

Cuvitru

Kanjinti*

Renflexis

Zaltrap*

Cyramza*

Keytruda*

Riabni*

Zepzelca*

  Danyelza*   Krystexxa   Rituxan IV*   Ziextenzo*
  Darzalex*   Kymurah*+   Rituxan Hycela*   Zirabev*
  Darzalex Faspro*   Kyprolis*   Ruconest   Zolgensma+
  Elaprase   Lemtrada   Ruxience*   
  Elelyso   Leukine*   Sarclisa*   
  Emend IV*   Libtayo*   Simponi Aria   
  Empliciti*    Lucentis   Soliris   
  Enhertu*    Lumizyme   Spinraza   
  Entyvio   Luxturna+  Spravato   

 

+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.

PRV20021-210601