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.
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 through Prime Therapeutics 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.
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.
To request a copy of a drug policy, members can contact Customer Service by calling the number on their ID card.
Urgent precertification requests must be called in to Prime Therapeutics at 1-800-424-8270.
Policy # |
Policy Title |
Print View |
PH-0002 |
Tocilizumab: Actemra®; Tofidence™; Tyenne® |
|
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-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-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-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-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-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-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-0535 |
Darzalex Faspro® (daratumumab and hyaluronidase-fihj) |
|
PH-0549 |
Uplizna™ (inebilizumab-cdon) |
|
PH-0579 |
Oxlumo™ (lumasiran) |
|
PH-0590 |
Breyanzi® (lisocabtagene maraleucel) |
|
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-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-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-1218 |
Fabhalta (iptacopan) Prior Authorization with Quantity Limit Program Summary |
|
PH-238 |
Botox® (onabotulinumtoxinA) |
|
PH-239 |
Dysport® (abobotulinumtoxinA) |
|
PH-240 |
Myobloc® (rimabotulinumtoxinB) |
|
PH-241 |
Xeomin® (incobotulinumtoxinA) |
|
PH-468 |
Zolgensma® (onasemnogene abeparvovec-xioi) |
|
PH-527 |
Vyepti® (eptinezumab-jjmr) |
|
PH-59 |
SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked™, HyQvia®, Cuvitru®, Cutaquig®, Xembify® |
|
PH-671 |
Skyrizi® |
|
PH-71 |
Immune Globulins (immunoglobulin): Asceniv™; Alyglo™; Bivigam®; Flebogamma®; Gamunex-C®; Gammagard® Liquid; Gammagard® S/D; Gammaked™; Gammaplex®; Octagam®; Privigen®; Panzyga® |
|
PH-713 |
Elevidys® (delandistrogene moxeparvovec-rokl) |
|
VP-0319 |
Kymriah (tisagenlecleucel) (Intravenous) |
|
VP-0333 |
Yescarta™ (axicabtagene ciloleucel) (Intravenous) |
|
VP-0558 |
Tecartus™ (brexucabtagene autoleucel) (Intravenous) |
|
VP-0590 |
Breyanzi® (lisocabtagene maraleucel) (Intravenous) |
|
VP-0598 |
Abecma® (idecabtagene vicleucel) (Intravenous) |
|
VP-0663 |
Carvykti™ (ciltacabtagene autoleucel) (Intravenous) |
|
VP-0691 |
Adstiladrin® (nadofaragene firadenovec-vncg) (Intravesical) |
|
VP-0748 |
Amtagvi® (lifileucel) |
|