Final Provider-Administered Drug Policies
The drugs below require that a member’s medical condition meets the policy requirements prior to being given (precertification). Providers must submit a request for pre-service review in order to be approved. If the provider does not receive approval for precertification, the plan will pay no benefits.
Precertification for these provider-administered drugs is required when administered in a provider’s office, outpatient facility, or home health setting. Exceptions to this include: Gene and Cell therapies, and particular oncology treatments requiring an initial inpatient stay.
Urgent precertification requests must be called in to Prime Therapeutics at 1-800-424-8270.
Members can request a copy of a full drug policy by calling the Customer Service number on their ID card
Note: Coverage is subject to the member's specific benefits. Group-specific benefits will supersede these policies when applicable. Always check eligibility and benefits through your local Blue Plan provider portal or your practice management system to confirm member-specific benefits.
Current Provider-Administered Drug Policies
Policy # |
Policy Title |
Print View |
PH-0002 |
Tocilizumab: Actemra®; Tofidence™; Tyenne® |
|
PH-0003 |
Corticotropin-ACTH: Acthar® Gel (repository corticotropin injection) Cortrophin® Gel (repository corticotropin injection) |
|
PH-0006 |
Aldurazyme® (laronidase) |
|
PH-0017 |
Benlysta® (belimumab) |
|
PH-0018 |
Berinert® (C1 Esterase Inhibitor, Human) |
|
PH-0026 |
Aflibercept: Eylea®; Eylea® HD; Opuviz™; Yesafili™; Ahzantive™; Enzeevu™; Pavblu™ |
|
PH-0027 |
Cerezyme® (imiglucerase) |
|
PH-0028 |
Cimzia® (certolizumab pegol) |
|
PH-0034 |
Elaprase® (idursulfase) |
|
PH-0042 |
Fabrazyme® (agalsidase beta) |
|
PH-0059 |
SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify® |
|
PH-0061 |
Hyaluronic Acid Derivatives: Durolane®, Euflexxa™, Gel-One®, GelSyn-3™, GenVisc 850®, Hyalgan™, Hymovis®, Monovisc®, Orthovisc™, Synojoynt, Supartz/Supartz FX™, Synvisc™, Synvisc-One™, Triluron™, TriVisc™, VISCO-3™ |
|
PH-0071 |
Immune Globulins (immunoglobulin): Alyglo™; Bivigam®; Flebogamma®; Gamunex-C®; Gammagard® Liquid; Gammagard® S/D; Gammaked™; Gammaplex®; Octagam®; Privigen®; Panzyga® |
|
PH-0078 |
Ranibizumab: Lucentis®; Byooviz™; Cimerli™ |
|
PH-0079 |
Lumizyme® (alglucosidase alfa) |
|
PH-0081 |
Macugen® (pegaptanib) |
|
PH-0084 |
Naglazyme® (galsulfase) |
|
PH-0089 |
Nplate® (romiplostim) |
|
PH-0091 |
Orencia® (abatacept) |
|
PH-0104 |
Infliximab: Remicade®; Inflectra™; Renflexis™; Avsola™; Infliximab* |
|
PH-0105 |
Elelyso™ (taliglucerase alfa) |
|
PH-0109 |
Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™ |
|
PH-0114 |
Eculizumab: Soliris®; Bkemv™ |
|
PH-0117 |
Ustekinumab: Stelara®; Wezlana™; Selarsdi™; Pyzchiva® |
|
PH-0120 |
Synagis® (palivizumab) |
|
PH-0133 |
Natalizumab: (Tysabri®; Tyruko®) |
|
PH-0139 |
Vivitrol® (naltrexone) |
|
PH-0141 |
VPRIV® (velaglucerase alfa) |
|
PH-0145 |
Xiaflex® (collagenase) |
|
PH-0146 |
Xolair® (omalizumab) |
|
PH-0158 |
Krystexxa® (pegloticase) |
|
PH-0167 |
Kalbitor® (ecallantide) |
|
PH-0168 |
Cinryze® (C1 Esterase Inhibitor, Human) |
|
PH-0169 |
Firazyr® (icatibant) |
|
PH-0176 |
Simponi ARIA® (golimumab) |
|
PH-0177 |
Ilaris® (canakinumab) |
|
PH-0181 |
Visudyne® (verteporfin) |
|
PH-0190 |
Vimizim® (elosulfase alfa) |
|
PH-0202 |
Entyvio™ (vedolizumab) |
|
PH-0207 |
Ruconest® (C1 Esterase Inhibitor [recombinant]) |
|
PH-0223 |
Lemtrada® (alemtuzumab) |
|
PH-0229 |
Cosentyx® (secukinumab) |
|
PH-0234 |
Colony Stimulating Factors – Pegfilgrastim: Neulasta®; Fulphila®; Udenyca®; Ziextenzo™; Nyvepria™; Fylnetra®; Stimufend®; Rolvedon®; Ryzneuta®, |
|
PH-0235 |
Short-Acting Granulocyte Colony Stimulating Factors (SA-gCSF): Filgrastim (Neupogen®); Filgrastim-aafi (Nivestym™); Filgrastim-sndz (Zarxio®); Filgrastim-ayow (Releuko®); Tbo-Filgrastim (Granix®); Filgrastim-txid (Nypozi™) |
|
PH-0237 |
Leukine® (sargramostim) |
|
PH-0238 |
Botox® (onabotulinumtoxinA) |
|
PH-0240 |
Myobloc® (rimabotulinumtoxinB) |
|
PH-0243 |
Epoetin alfa: Epogen®; Procrit®; Retacrit™ |
|
PH-0260 |
Nucala® (mepolizumab) |
|
PH-0266 |
Darzalex® (daratumumab) |
|
PH-0273 |
Cinqair® (reslizumab) |
|
PH-0277 |
Kanuma™ (sebelipase alfa) |
|
PH-0282 |
Testopel® (testosterone pellets) |
|
PH-0284 |
Exondys-51™ (eteplirsen) |
|
PH-0291 |
Spinraza™ (nusinersen) |
|
PH-0298 |
Ocrevus™ (ocrelizumab) |
|
PH-0299 |
Brineura (cerliponase alfa) |
|
PH-0305 |
Radicava® (edaravone) |
|
PH-0307 |
Haegarda® (C1 Esterase Inhibitor Subcutaneous [Human]) |
|
PH-0310 |
Tremfya® (guselkumab) |
|
PH-0312 |
Injectafer® (ferric carboxymaltose injection) |
|
PH-0346 |
Mepsevii™ (vestronidase alfa-vjbk) |
|
PH-0347 |
Fasenra® (benralizumab) |
|
PH-0350 |
Luxturna® (voretigene neparvovec-rzyl) |
|
PH-0355 |
Trogarzo™ (ibalizumab-uiyk) |
|
PH-0358 |
Ilumya® (tildrakizumab-asmn) |
|
PH-0362 |
Crysvita® |
|
PH-0379 |
Onpattro (patisiran lipid complex) |
|
PH-0392 |
Takhzyro® (lanadelumab-flyo) |
|
PH-0421 |
Gamifant™ (emapalumab-lzsg)nt (emapalumab-lzsg) |
|
PH-0427 |
Ultomiris® (ravulizumab-cwvz) |
|
PH-0463 |
Sublocade® (buprenorphine ER) |
|
PH-0464 |
Probuphine® (buprenorphine) |
|
PH-0468 |
Zolgensma® (onasemnogene abeparvovec-xioi) |
|
PH-0481 |
Spravato™ (esketamine) |
|
PH-0497 |
Beovu® (brolucizumab-dbll) |
|
PH-0503 |
Reblozyl® (luspatercept-aamt) |
|
PH-0512 |
Scenesse® (afamelanotide) |
|
PH-0513 |
Adakveo® (crizanlizumab-tmca) |
|
PH-0514 |
Givlaari™ (givosiran) |
|
PH-0520 |
Vyondys-53™ (golodirsen) |
|
PH-0524 |
Monoferric™ (ferric derisomaltose) |
|
PH-0525 |
Tepezza® (teprotumumab-trbw) |
|
PH-0527 |
Vyepti® (eptinezumab-jjmr) |
|
PH-0535 |
Darzalex Faspro® (daratumumab and hyaluronidase-fihj) |
|
PH-0549 |
Uplizna™ (inebilizumab-cdon) |
|
PH-0558 |
Tecartus (brexucabtagene autoleucel) |
|
PH-0562 |
Viltepso™ (viltolarsen) |
|
PH-0579 |
Oxlumo™ (lumasiran) |
|
PH-0581 |
Danyelza® (naxitamab-gqgk) |
|
PH-0590 |
Breyanzi® (lisocabtagene maraleucel) |
|
PH-0591 |
Evkeeza™ (evinacumab-dgnb) |
|
PH-0593 |
Amondys-45™ (casimersen) |
|
PH-0594 |
Nulibry™ (fosdenopterin) |
|
PH-0610 |
Aduhelm™ (aducanumab-avwa) |
|
PH-0614 |
Saphnelo® (anifrolumab-fnia) |
|
PH-0615 |
Nexviazyme™ (avalglucosidase alfa-ngpt) |
|
PH-0622 |
Compounded Medications |
|
PH-0633 |
Xipere® (triamcinolone acetonide injectable suspension) |
|
PH-0634 |
Susvimo™ (ranibizumab) |
|
PH-0647 |
Fyarro™ (sirolimus albumin-bound) |
|
PH-0648 |
Rethymic® (allogeneic processed thymus tissue-agdc) |
|
PH-0649 |
Vyvgart™ (efgartigimod alfa-fcab) |
|
PH-0650 |
Tezspire™ (tezepelumab-ekko) |
|
PH-0652 |
Leqvio® (inclisiran) |
|
PH-0658 |
Kimmtrak® (tebentafusp-tebn) |
|
PH-0659 |
Vabysmo™ (faricimab-svoa) |
|
PH-0660 |
Enjaymo™ (sutimlimab-jome) |
|
PH-0663 |
Carvykti™ (ciltacabtagene autoleucel) |
|
PH-0670 |
Amvuttra (vutrisiran) |
|
PH-0671 |
Skyrizi® (risankizumab-rzaa) |
|
PH-0672 |
Zynteglo® (betibeglogene autotemcel) |
|
PH-0673 |
Xenpozyme™ (olipudase alfa) |
|
PH-0674 |
Spevigo® (spesolimab) |
|
PH-0676 |
Rolvedon™ |
|
PH-0677 |
Skysona® (elivaldogene autotemcel) |
|
PH-0687 |
Tzield™ (teplizumab-mzwv) |
|
PH-0688 |
Hemgenix® (etranacogene dezaparvovec-drlb) |
|
PH-0693 |
Briumvi™ (ublituximab-xiiy) |
|
PH-0694 |
Leqembi™ (lecanemab-irmb) |
|
PH-0696 |
Lamzede® (velmanase alfa-tycv) |
|
PH-0697 |
Syfovre™ (pegcetacoplan) |
|
PH-0704 |
Qalsody™ (tofersen) |
|
PH-0708 |
Elfabrio® (pegunigalsidase alfa-iwxj) |
|
PH-0709 |
Vyjuvek™ (beremagene geperpavec-svdt) |
|
PH-0712 |
Vyvgart® Hytrulo (efgartigimod alfa-fcab and hyaluronidase-qvfc) |
|
PH-0713 |
Elevidys® (delandistrogene moxeparvovec-rokl) |
|
PH-0714 |
Rystiggo® (rozanolixizumab-noli) |
|
PH-0718 |
Roctavian® (valoctocogene roxaparvovec-rvox) |
|
PH-0721 |
Izervay™ (avacincaptad pegol) |
|
PH-0727 |
Veopoz® (pozelimab-bbfg) |
|
PH-0731 |
Pombiliti™ (cipaglucosidase alfa-atga) |
|
PH-0734 |
Omvoh® (mirikizumab-mrkz) |
|
PH-0736 |
Adzynma® (ADAMTS13, recombinant-krhn) |
|
PH-0751 |
Lenmeldy™ (atidarsagene autotemcel) |
|
PH-0755 |
Beqvez™ (fidanacogene elaparvovec-dzkt) |
|
PH-0762 |
Piasky ™ (crovalimab-akkz) |
|
PH-0763 |
Kisunla™ (donanemab-azbt) |
|
PH-0765 |
Tecelra® (afamitresgene autoleucel) |
|
PH-0767 |
Niktimvo™ (axatilimab-csfr) |
|
PH-10743 |
Lyfgenia® (lovotibeglogene autotemcel) |
|
PH-10744 |
Casgevy™ (exagamglogene autotemcel) |
|
PH-1218 |
Fabhalta (iptacopan) Prior Authorization with Quantity Limit Program Summary |
|
PH-671 |
Skyrizi® |
|
VP-0001 |
Paclitaxel Albumin-Bound: Abraxane®; Paclitaxel Albumin-Bound Ψ |
|
VP-0004 |
Adcetris® (brentuximab vedotin) |
|
VP-0007 |
Pemetrexed: Alimta®; Pemfexy™; Pemetrexed Ψ |
|
VP-0008 |
Palonosetron: Aloxi®; Posfrea™ Ψ |
|
VP-0014 |
Bevacizumab: Avastin®; Mvasi®; Zirabev™; Alymsys®; Vegzelma® *ONCOLOGY* |
|
VP-0036 |
Fosaprepitant: Emend®; Fosaprepitant Ψ; Focinvez Ψ |
|
VP-0038 |
Erbitux® (cetuximab) |
|
VP-0043 |
Fulvestrant: Faslodex®; Fulvestrant Ψ |
|
VP-0055 |
Halaven® (eribulin) |
|
VP-0057 |
Trastuzumab: Herceptin®; Ogivri®; Kanjinti®; Trazimera™; Herzuma®; Ontruzant®; Hercessi™ |
|
VP-0072 |
Ixempra® (ixabepilone) (Intravenous) |
|
VP-0074 |
Cabazitaxel: Jevtana®; Cabazitaxel§ |
|
VP-0089 |
Nplate™ (romiplostim) (Subcutaneous) |
|
VP-0092 |
Kadcyla® (ado-trastuzumab emtansine) (Intravenous) |
|
VP-0096 |
Perjeta® (pertuzumab) (Intravenous) |
|
VP-0100 |
Provenge® (sipuleucel-T) (Intravenous) |
|
VP-0130 |
Bendamustine: Treanda®; Bendeka®; Belrapzo®; Vivimusta™; Bendamustine Ψ (Intravenous) |
|
VP-0136 |
Vectibix® (panitumumab) |
|
VP-0137 |
Bortezomib Velcade®; Bortezomib§ |
|
VP-0148 |
Yervoy™ (ipilimumab) |
|
VP-0156 |
Synribo® (omacetaxine mepesuccinate) |
|
VP-0157 |
Kyprolis® (carfilzomib) |
|
VP-0161 |
Zaltrap® (ziv-aflibercept) (Intravenous) |
|
VP-0166 |
Torisel® (temsirolimus) |
|
VP-0184 |
Gazyva (obinutuzumab) |
|
VP-0199 |
Cyramza™ (ramucirumab) (Intravenous) |
|
VP-0200 |
Sylvant™ (siltuximab) (Intravenous) |
|
VP-0205 |
Beleodaq® (belinostat) |
|
VP-0209 |
Keytruda® (pembrolizumab) |
|
VP-0216 |
Folotyn® (pralatrexate) |
|
VP-0225 |
Blincyto® (blinatumomab) (Intravenous) |
|
VP-0226 |
Opdivo® (nivolumab) |
|
VP-0237 |
Colony Stimulating Factors: Leukine® (sargramostim) (Subcutaneous/Intravenous) |
|
VP-0256 |
Onivyde® (irinotecan liposome injection) |
|
VP-0257 |
Yondelis® (trabectedin) (Intravenous) |
|
VP-0266 |
Darzalex™ (daratumumab) |
|
VP-0267 |
Portrazza™ (necitumumab) (Intravenous) |
|
VP-0268 |
Empliciti™ (elotuzumab) (Intravenous) |
|
VP-0274 |
Imlygic™ (talimogene laherparepvec) Intralesional |
|
VP-0278 |
Tecentriq™ (atezolizumab) |
|
VP-0283 |
Sustol® (granisetron extended-release) (Subcutaneous) |
|
VP-0295 |
Bavencio® (avelumab) |
|
VP-0301 |
Imfinzi™ (durvalumab) |
|
VP-0314 |
Vyxeos® (daunorubicin and cytarabine – liposome) |
|
VP-0317 |
Besponsa (inotuzumab ozogamicin) (Intravenous) |
|
VP-0319 |
Kymriah (tisagenlecleucel) (Intravenous) |
|
VP-0320 |
Mylotarg (gemtuzumab ozogamicin) (Intravenous) |
|
VP-0321 |
Aliqopa® (copanlisib) |
|
VP-0322 |
Rituxan Hycela™ (rituximab and hyaluronidase human) (Subcutaneous) |
|
VP-0333 |
Yescarta™ (axicabtagene ciloleucel) (Intravenous) |
|
VP-0336 |
Cinvanti™ (aprepitant) |
|
VP-0363 |
Akynzeo® (fosnetupitant/palonosetron) (Intravenous) |
|
VP-0378 |
Poteligeo® (mogamulizumab-kpkc) |
|
VP-0393 |
Lumoxiti™ (moxetumomab pasudotox-tdfk) (Intravenous) |
|