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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: Luxturna, Kymriah and Yescarta, which require a precertification for any place of treatment.

Urgent precertification requests must be called in to MagellanRx 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. 

Final Policies

Policy # Policy Title Print View
PH-0002 Tocilizumab: Actemra®; Tofidence™
PH-0006 Aldurazyme® (laronidase)
PH-0017 Benlysta® (belimumab)
PH-0018 Berinert® (C1 Esterase Inhibitor, Human)
PH-0026 Aflibercept: Eylea®; Eylea® HD
PH-0027 Cerezyme® (imiglucerase)
PH-0028 Cimzia® (certolizumab pegol)
PH-0034 Elaprase® (idursulfase)
PH-0042 Fabrazyme® (agalsidase beta)
PH-0061 Hyaluronic Acid Derivatives: Durolane®, Euflexxa™, Gel-One®, GelSyn-3™, GenVisc 850®, Hyalgan™, Hymovis®, Monovisc®, Orthovisc™, Supartz/Supartz FX™, Synojoynt, Synvisc™, Synvisc-One™, Triluron™, TriVisc™, VISCO-3™, & sodium hyaluronate 1%
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-0114 Soliris® (eculizumab)
PH-0117 Ustekinumab: Stelara®; Wezlana™
PH-0120 Synagis® (palivizumab)
PH-0133 Natalizumab: (Tysabri®; Tyruko®)
PH-0141 VPRIV® (velaglucerase alfa)
PH-0146 Xolair® (omalizumab)
PH-0158 Krystexxa® (pegloticase)
PH-0167 Kalbitor® (ecallantide)
PH-0168 Cinryze® (C1 Esterase Inhibitor, Human)
PH-0176 Simponi ARIA® (golimumab)
PH-0177 Ilaris® (canakinumab)
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-0243 Epoetin alfa: Epogen®; Procrit®; Retacrit™
PH-0260 Nucala® (mepolizumab)
PH-0273 Cinqair® (reslizumab)
PH-0277 Kanuma™ (sebelipase alfa)
PH-0291 Spinraza™ (nusinersen)
PH-0298 Ocrevus™ (ocrelizumab)
PH-0299 Brineura (cerliponase alfa)
PH-0305 Radicava® (edaravone)
PH-0312 Injectafer® (ferric carboxymaltose injection)
PH-0346 Mepsevii™ (vestronidase alfa-vjbk)
PH-0347 Fasenra® (benralizumab)
PH-0350 Luxturna® (voretigene neparvovec-rzyl)
PH-0358 Ilumya® (tildrakizumab-asmn)
PH-0362 Crysvita®
PH-0379 Onpattro (patisiran lipid complex)
PH-0421 Gamifant™ (emapalumab-lzsg)nt (emapalumab-lzsg)
PH-0427 Ultomiris® (ravulizumab-cwvz)
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-0535 Darzalex Faspro® (daratumumab and hyaluronidase-fihj)
PH-0549 Uplizna™ (inebilizumab-cdon)
PH-0579 Oxlumo™ (lumasiran)
PH-0593 Amondys-45™ (casimersen)
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-0635 Dextenza® (dexamethasone insert)
PH-0648 Rethymic® (allogeneic processed thymus tissue-agdc)
PH-0649 Vyvgart™ (efgartigimod alfa-fcab)
PH-0650 Tezspire™ (tezepelumab-ekko)
PH-0652 Leqvio® (inclisiran)
PH-0659 Vabysmo™ (faricimab-svoa)
PH-0660 Enjaymo™ (sutimlimab-jome)
PH-0670 Amvuttra (vutrisiran)
PH-0671 Skyrizi® (risankizumab-rzaa)
PH-0673 Xenpozyme™ (olipudase alfa)
PH-0674 Spevigo® (spesolimab)
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-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-0743 Lyfgenia® (lovotibeglogene autotemcel)
PH-0744 Casgevy™ (exagamglogene autotemcel)
PH-400 Botulinum Toxin
PH-401 Spravato (esketamine)
PH-402 Vyepti (eptinezumab)
PH-403 Immunoglobulin Therapy
PH-405 Onasemnogene Abeparvovec (Zolgensma)
PH-406 Rituximab
PH-671 Skyrizi®
PH-713 Elevidys® (delandistrogene moxeparvovec-rokl)