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 expand the menu and browse specific medical and drug policies by category.

Search Policies

Use the search function above to find medical or drug policies by name, number or keyword.

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 through Prime Therapeutics is required for the provider-administered drugs on the following list when administered in a provider’s office, outpatient facility or home health setting; precertification does not apply to inpatient hospital claims at this time.

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.