Provider-Administered Drug Policies

Blue Advantage Part B Provider-Administered Drug Precertification Program (Effective August 1, 2023)

Precertification through Prime Therapeutics is required for the provider-administered drugs on the list below when administered in a provider's office, outpatient facility or home health setting. Treatments indicated as gene therapy/cellular immunotherapy require precertification when administered in any place of treatment.

Blue Advantage Part B Provider-Administered Drug Precertification List

Patients receiving medication on the precertification drug list prior to August 1, 2023, have an authorization in our system through December 31, 2023, for continued claims payment. On January 1, 2024, continued coverage will require valid precertification through Prime Therapeutics.

How to Submit a Precertification Request to Prime Therapeutics

Refer to the member’s eligibility and benefits for submitting a pre-service review.

Prime Therapeutics is an independent company providing medical review services on behalf of Patrius Health. 

Current Provider-Administered Drug Policies

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National Coverage Determinations

Refer to the following to search for National Coverage Determinations:

• CMS National Coverage Database

Local Coverage Determinations

For Local Coverage Determinations, refer to the following sites:

• Novitas Solutions
• CIGNA Government Services DME MAC Jurisdiction C Local Coverage Determinations

Reasonable and Necessary Guidelines

In the absence of a National Coverage Determination, Local Coverage Determination or CMS Manual Instruction, reasonable and necessary guidelines still apply.

Refer to the original Medicare manual Pub. 100-02, Chapter 15, Sec. 50 Drugs and Biologicals.