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Changes to our National Precertification List (NPL)

 

Important NPL updates 

The following new-to-market drugs require precertification:  

  

  • Cutaquig® (IVIG) — precertification for both the drug and the site of care required effective August 1, 2019.
  • PolivyTM (polatuzumab vedotin-piiq) — precertification required effective September 13, 2019.
  • KanjintiTM (trastuzumab-anns) — precertification required effective November 1, 2019.  

 

The following drugs will require precertification, including Part B step therapy review, effective January 1, 2020, for Medicare Advantage members only:

 

  • Abraxane® (paclitaxel)  
  • Orencia® (abatacept)  
  • Eylea® (aflibercept)  
  • Lemtrada® (alemtuzumab)  
  • Botox® (onabotulinumtoxinA)  
  • Myobloc® (rimabotulinumtoxinB)  
  • Xeomin® (incobotulinumtoxinA)  
  • Aranesp® (darbepoetin alfa)  
  • Epogen®, Procrit® (epoetin alfa)  
  • Xgeva® (denosumab)  
  • Neupogen® (filgrastim [G-CSF])  
  • CuvitruTM (immune globulin)  
  • Bivigam® (immune globulin)  
  • Gammaplex® (immune globulin)  
  • Gamunex®-C/Gammaked® (immune globulin)  
  • Carimune NF® (immune globulin)  
  • Octagam® (immune globulin)  
  • Gammagard® (immune globulin)  
  • Flebogamma®/Flebogamma® DIF (immune globulin)  
  • Hyqvia® (immune globulin/hyaluronidase)  
  • Panzyga® (immune globulin)  
  • Remicade® (infliximab)  
  • Tysabri® (natalizumab)  
  • Neulasta® (pegfilgrastim)  
  • Lucentis® (ranibizumab)  
  • IlumyaTM (tildrakizumab)  
  • Actemra® (tocilizumab)  
  • Stelara® (ustekinumab)  
  • Entyvio® (vedolizumab)  
  • Remodulin® (treprostinil sodium)  
  • Durolane® (hyaluronan or derivative)  
  • GenVisc® (hyaluronan or derivative)  
  • Hyalgan® (hyaluronan or derivative)  
  • Hymovis® (hyaluronan or derivative)  
  • EuflexxaTM (hyaluronan or derivative)  
  • Orthovisc® (hyaluronan or derivative)  
  • Synvisc® or Synvisc-One® (hyaluronan or derivative)  
  • Monovisc® (hyaluronan or derivative)  
  • Gelsyn-3TM (hyaluronan or derivative)  
  • TriVisc® (hyaluronan or derivative)  
  • Rituxan® (rituximab)  
  • Herceptin HylectaTM (trastuzumab, 10 mg; and hyaluronidase-oysk)  
  • Inflectra® (infliximab-dyyb, biosimilar)  
  • Renflexis® (infliximab-abda, biosimilar)  
  • FulphilaTM (pegfilgrastim-jmdb, biosimilar)  
  • NivestymTM (filgrastim-aafi, biosimilar)  

   

We encourage you to submit precertification requests at least two weeks before the scheduled services.   

 

To save time, request precertification electronically — it’s fast and simple. Most precertification requests can be submitted electronically through the provider website or by using your Electronic Medical Record (EMR) system portal. 

 

You can find more information about precertification under the General Information section of the NPL.