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

   Spravato

Actemra IV

Euflexxa

Makena

Stelara
  Adakveo   Evomela   Mepsevii   Sublocade

Adcetris*

Eylea

Monjuvi*

Sustol*

Akynzeo*

Fabrazyme

Mvasi*

Synagis

Aldurazyme

Fasenra

Mylotarg*

Synvisc

Alimta*

Faslodex*

Myobloc

Synvisc-One

Aloxi*

Firazyr

Mvasi*

Takhyzro

Arzerra*

Flebogamma*

Naglazyme

Tecentriq*

Asceniv*

Fuphila*

Neulasta*

Tecartus*

Avastin*

fulvestrant*

Neupogen*

Tepezza
  Avsola   Gamifant   Nivestym*   Testopel

Bavencio*

Gammagard S/D*

Nplate*

Trazimera*

Belrapzo*

Gammagard Liquid*

Nucala

Treanda*

Bendeka*

   Gammaked*

Nyvepria

Trodelvy*

Benlysta IV

Gammaplex Liquid*

Ocrevus

Trogarzo

Beovu

Gamunex-C*

Octagam*

Truxima*

Berinert

Gazyva*

Ogivri*

Tysabri

Besponsa*

Givlaari

Onpattro*

Udenyca*

Bivigam*

Granix*

Ontruzant*

Ultomiris
  Blenrep*   H.P. Acthar   Opdivo   Uplizna

Blincyto*

Haegarda

Orencia

Vectibix*

bortezomib*

Herceptin*

Padcev*

Velcade*

Botox

Herceptin Hylecta*

palonosetron*

Vimzim

Brineura

Herzuma*

Panzyga*

Visudyne

Carimune NF*

Hizentra

Perjeta*

Vivitrol

Cerezyme

HyQvia

Phesgo*

Vpriv

Cimzia

Ilumya

Polivy*

Vyepti

Cinqair

Imfinzi*

Privigen*

Xembify

Cinryze

Infectra

Provenge*

Xiaflex

Cinvanti*

Kadcyla*

Radicava

Xolair

Crysvita

Kalbitor

Reblozyl*

Yervoy*

Cutaquig

Kanuma

Remicade

Yescarta*+

Cuvitru

Kanjinti*

Renfexis

Yondelis

Cyramza*

Keytruda*

Rituxan IV*

Zarxio*
  Darzalex*   Krystexxa   Rituxan Hycela*   Zaltrap
  Darzalex Faspro*   Kymriah*+   Ruconest   Zepzelca*
  Elaprase   Kyprolis*   Ruxience*   Ziextenzo
  Elelyso   Lemtrada   Sarclisa*   Zirabev*
  Emend IV*   Leukine*   Scenesse   Zollgensma+
  Empliciti    Lucentis   Simponi Aria   
  Enhertu*    Luizyme   Soliris   
  Entyvio   Luxturna*   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.

PRV20021-210101