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.
Final Policies
PH-0002 | Actemra® (tocilizumab) | |
PH-0003 | H.P. Acthar® Gel (repository corticotropin injection, ACTH) | |
PH-0006 | Aldurazyme® (laronidase) | |
PH-0008 | Aloxi (palonosetron) | |
PH-0017 | Benlysta® (belimumab) | |
PH-0018 | Berinert® (C1 Esterase Inhibitor, Human) | |
PH-0026 | Eylea® (aflibercept) | |
PH-0027 | Cerezyme® (imiglucerase) | |
PH-0028 | Cimzia® (certolizumab pegol) | |
PH-0034 | Elaprase® (idursulfase) | |
PH-0036 | Emend IV (fosaprepitant dimeglumine) | |
PH-0042 | Fabrazyme® (agalsidase beta) | |
PH-0057 | Trastuzumab: Herceptin®; Ogivri®; Kanjinti™; Trazimera™; Herzuma®; Ontruzant® | |
PH-0059 | SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify® Xembify® | |
PH-0061 | Hyaluronic Acid Derivatives: Durolane®, Euflexxa™, Gel-One®, GelSyn-3™, GenVisc 850®, Hyalgan™, Hymovis®, Monovisc®, Orthovisc™, Supartz/Supartz FX™, Synvisc™, Synvisc-One™, Triluron™, TriVisc™, VISCO-3™, & sodium hyaluronate 1% | |
PH-0071 | Immune Globulins (immunoglobulin): Asceniv, Bivigam, Carimune NF, Flebogamma, Gamunex-C, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Octagam, Privigen, Panzyga | |
PH-0078 | Ranibizumab: Lucentis®; Byooviz™ | |
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-01068 | Cinryze® (C1 Esterase Inhibitor, Human) | |
PH-01069 | Firazyr® (icatibant) | |
PH-0109 | Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™ | |
PH-0114 | Soliris® | |
PH-0117 | Stelara® | |
PH-0120 | Synagis® (palivizumab) | |
PH-0133 | Tysabri® (natalizumab) | |
PH-0137 | Velcade (bortezomib) (Intravenous/Subcutaneous) | |
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-0171 | Makena® (hydroxyprogesterone caproate) | |
PH-0176 | Simponi ARIA® (golimumab) | |
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-0234 | Colony Stimulating Factors – Pegfilgrastim: Neulasta®; Fulphila™; Udenyca®; Ziextenzo™; Nyvepria™; Fylnetra® | |
PH-0235 | Colony Stimulating Factors: Filgrastim (Neupogen®); Filgrastim-aafi (Nivestym™); Filgrastim-sndz (Zarxio™); Filgrastim-ayow (Releuko®); Tbo-Filgrastim (Granix®) | |
PH-0237 | Colony Stimulating Factors: Leukine® (sargramostim) | |
PH-0238 | Botox® | |
PH-0240 | Myobloc® | |
PH-0243 | Epoetin alfa: Epogen®; Procrit®; Retacrit™ | |
PH-0245 | Zarxio (filgrastim-sndz) | |
PH-0260 | Nucala® (mepolizumab) | |
PH-0266 | Darzalex® (daratumumab) | |
PH-0273 | Cinqair® (reslizumab) | |
PH-0277 | Kanuma™ (sebelipase alfa) | |
PH-0282 | Testopel® (testosterone pellets) | |
PH-0283 | Sustol (granisetron extended-release) | |
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-0312 | Injectafer® (ferric carboxymaltose injection) | |
PH-0336 | Cinvanti (aprepitant) | |
PH-0346 | Mepsevii™ (vestronidase alfa-vjbk) | |
PH-0347 | Fasenra® (benralizumab) | |
PH-0350 | Luxturna® (voretigene neparvovec-rzyl) | |
PH-0351 | Bortezomib* | |
PH-0355 | Trogarzo™ (ibalizumab-uiyk) | |
PH-0358 | Ilumya® (tildrakizumab-asmn) | |
PH-0362 | Crysvita® | |
PH-0363 | Akynzeo (fosnetupitant/palonosetron) | |
PH-0375 | Nivestym (filgrastim-aafi) | |
PH-0379 | Onpattro (patisiran lipid complex) | |
PH-0392 | Takhzyro™ (lanadelumab-flyo) | |
PH-0421 | Gamifant™ (emapalumab-lzsg)nt (emapalumab-lzsg) | |
PH-0427 | Ultomiris® | |
PH-0463 | Sublocade™ (buprenorphine ER injection) | |
PH-0464 | Probuphine® (buprenorphine) | |
PH-0468 | Zolgensma® (onasemnogene abeparvovec-xioi) | |
PH-0481 | Spravato™ (esketamine) | |
PH-0482 | Polivy (polatuzumab vedotin-piiq) | |
PH-0495 | Feraheme® (ferumoxytol) | |
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-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-0635 | Dextenza® (dexamethasone insert) | |
PH-0647 | Fyarro™ (sirolimus albumin-bound) | |
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-0664 | Opdualag™ (nivolumab/relatlimab-rmbw) | |
PH-0670 | Amvuttra (vutrisiran) | |
PH-671 | Skyrizi® |