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*

Empliciti*

Lartruvo*

Ruconest

Actemra IV

Entyvio

Lemtrada

Simponi ARIA

Adcetris*

Erbitux*

Leukine*

Soliris

Akynzeo*

Euflexxa

Lucentis

Spinraza

Aldurazyme

Eylea

Lumizyme

Spravato

Alimta*

Fabrazyme

Luxturna

Stelara

Aloxi*

Fasenra

Macugen

Sublocade

Arzerra*

Firazyr

Makena

Sustol*

Avastin*

Flebogamma*

Mepsevii

Synagis

Bavencio*

Fulphila*

Mvasi*

Synvisc

Belrapzo*

Gamifant

Mylotarg*

Synvisc-One

Bendeka*

Gammagard S/D*

Myobloc

Takhyzro

Benlysta IV

Gammagard Liquid*

Naglazyme

Tecentriq*

Verinert

Gammaked*

Neulasta*

Testopel

Besponsa*

Gammaplex Liquid*

Neupogen*

Trazimera*

Bivigam*

Gamunex-C*

Nivestym

Treanda

Blincyto*

Gazyva*

Nplate

Trogarzo

bortezomib*

Granix*

Nucala

Truxima*

Botox

H.P. Acthar

Ocrevus

Tysabri

Brineura

Haegarda

Octagam*

Udenyca*

Carimune NF*

Herceptin*

Ogivri*

Ultomiris

Cerezyme

Herceptin Hylecta*

Onpattro

Vectibix*

Cimzia

Herzuma*

Ontruzant*

Velcade*

Cinqair

Hizentra

Opdivo*

Vimzim

Cinryze

HyQvia

Orencica

Visudyne

Cinvanti*

Ilumya

palonosetron*

Vivitrol

Crysvita

Imfinzi*

Panzyga*

Vpriv

Cutaquig

Inflectra

Perjeta*

Xeomin

Cuvitru

Kadcyla*

Privigen*

Xiaflex

Cyramza*

Kalbitor

Provenge*

Xolair

Darzalex*

Kanuma

Radicava

Yervoy*

Dysport

Keytruda*

Remicade

Yescarta*

  Elaprase   Krystexxa   Renflexis   Zaltrap*
  Elelyso   Kymriah*   Rituxan IV*   Zarxio*
  Emend IV*   Kyprolis*   Rituxan Hycela*  

* 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.

PRV20021-1810