Provider-Administered Precertification Drug List

Provider-Administered Precertification Drug List

The following drugs are included in the Provider-Administered Drug Review Program. Precertification is required for these provider-administered drugs 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.

Abecma*

Erbitux*

Makena

   Spinraza
  Abraxane   Evomela   Margenza*   Spravato

Actemra IV

Evylea

Mepsevii

Stelara
  Adakveo   Fabrazyme   Monjuvi*   Sublocade

Adcetris*

Fasenra

Mvasi*

Sustol*

Akynzeo*

Faslodex*

Mylotarg*

Synagis

Aldurazyme

Firazyr

Myobloc

Synvisc

Alimta*

Flebogamma*

Naglazyme

Synvisc-One

Aloxi*

Fuphila*

Neulasta*

Takhyzro

Arzerra*

fulvestrant*

Neupogen*

Tecentriq*

Asceniv*

Gamifant

Nivestym*

Tecartus*

Avastin*

Gammagard S/D*

Nplate*

Tepezza
  Avsola   Gammagard Liquid*   Nucala   Testopel

Bavencio*

Gammaked*

Nulibry

Trazimera*

Belrapzo*

Gammaplex Liquid*

Nyvepria*

Treanda*

Bendeka*

   Gamunex-C*

Ocrevus

Trodelvy*

Benlysta IV

Gazyva*

Octagam*

Trogarzo

Beovu

Givlaari

Ogivri*

Truxima*

Berinert

Granix*

Onpattro+

Tysabri

Besponsa*

H.P. Acthar

Ontruzant*

Udenyca*

Bivigam*

Haegarda

Opdivo*

Ultomiris
  Blenrep*   Herceptin*   Orencia   Uplizna

Blincyto*

Herceptin Hylecta*

Orthovisc

Vectibix*

bortezomib*

Herzuma*

Oxlumo

Velcade*

Botox

Hizentra

Padcev*

Vimzim

Breyanzi*

HyQvia

palonosetron*

  Visudyne

Brineura

Ilumya

Panzyga*

Vivitrol

Carimune NF*

Imfinzi*

Pepaxto*

Vpriv

Cerezyme

Inflectra

Perjeta*

Vyepti

Cimzia

Jelmyto*

Phesgo*

Xembify

Cinqair

Jemperli*

Polivy*

Xiaflex

Cinryze

Kadcyla*

Provenge*

  Xolair

Cinvanti*

Kalbitor

Radicava

Yervoy*

Crysvita

Kanuma

Reblozyl*

Yescarta*+

Cutaquig

Kanjinti*

Remicade

Yondelis*

Cuvitru

Keytruda*

Renflexis

Zarxio*

Cyramza*

Krystexxa

Riabni*

Zaltrap*
  Danyelza*   Kymriah*+   Rituxan IV*   Zepzelca*
  Darzalex*   Kyprolis*   Rituxan Hycela*   Ziextenzo*
  Darzalex Faspro*   Lemtrada   Ruconest   Zirabev*
  Elaprase   Leukine*   Ruxience*   Zolgensma+
  Elelyso   Libtayo*   Rybrevant*   Zynlota*
  Emend IV*   Lucentis   Sarclisa*   
  Empliciti*   Lumizyme   Scenesse   
  Enhertu*   Luxturna+   Simponi Aria   
  Entyvio   Macugen   Soliris   

+ Indicates Gene Therapy/Cellular Immunotherapy Product

* Included in Oncology Select Program

Product names are the property of their respective owners.

Drug policies can be found at the website shown on the back of the member's identification card. See “Provider-Administered Drug Policies” under Provider.

 

PRV20021-210901