Provider-Administered Drug Policies 

Provider-administered drugs 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. 

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. 

Browse Policies by Category

Use the navigation on the left to view specific medical policy information by category.

Note: Members can request a copy of a drug policy by calling the Customer Service number on their ID card.

Provider-Administered Drugs Requiring Precertification

Precertification for the provider-administered drugs on the following list is required when administered in a provider’s office, outpatient facility, or home infusion setting. Exceptions to this include: Gene and Cell therapies, and particular oncology treatments requiring an initial inpatient stay.

Provider-Administered Drug Precertification List 

How to submit a precertification request to Prime Therapeutics:

Online

Go to your local plan's provider portal to initiate pre-service review (Electronic Provider Access) for these services for out-of-area members. Contact your local Blue Plan for more information on how to access this functionality in your local provider portal.

By Phone

• Call Prime Therapeutics at 1-800-424-8270
• Urgent requests must be called in to Prime Therapeutics. Do not submit urgent requests online.

Provider-Administered Specialty Drugs

The provider-administered specialty medications on the list below must be obtained and billed by an in-network medical specialty pharmacy.

Provider-Administered Specialty Pharmacy Drug List

Non-Covered Provider-Administered Drug Exception Authorization Request Form

To request prior authorization for non-covered provider-administered drugs ONLY, complete the Non-Covered Provider-Administered Drug Exception Authorization Request form.