Provider-Administered Precertification Drug List
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List of provider-administered drugs that require precertification when given in office, outpatient facility, or home health settings; gene therapy/cellular immunotherapy products on the list require precertification regardless of place of treatment.
No material clinical or coverage changes in this revision.
Precertification Coverage Criteria
Precertification requirement
Covered when administrative precertification requirements are met for listed drugs:
Products marked with + require precertification in any place of treatment
For Avastin, prior authorization is required for oncology indications only. This policy requires precertification for drugs on the provider‑administered list when administered in a provider’s office, outpatient facility, or home health setting; gene therapy/cellular immunotherapy products (marked with a +) require precertification regardless of place of treatment.
Provider Requirements and Actions
Prior Authorization Required
Precertification (prior authorization) is required for the drugs on the Provider‑Administered Precertification Drug List when administered in a provider's office, outpatient facility, or home health setting. Treatments marked with a plus (+) are Gene Therapy/Cellular Immunotherapy products and require precertification when administered in any place of treatment.
- Precertification required for all listed provider-administered drugs when administered in a provider office, outpatient facility, or home health setting.
- Products marked with + (Gene Therapy/Cellular Immunotherapy) require precertification for administration in any place of treatment.
- For Avastin (*), precertification is required for oncology indications only.
Documentation Requirement
Precertification documentation must be submitted for listed provider-administered drugs as part of the prior authorization request. Include clinical rationale, indication, treatment setting, dose and schedule, and copies of relevant medical records. For products marked with +, include documentation specific to gene therapy/cellular immunotherapy administration and any required companion diagnostic or registry information.
- Include clinical indication, dosing regimen, and treatment setting.
- Attach supporting medical records and any required specialty documentation for + products.
Precertification Failure May Result in Denial
Failure to obtain required precertification may result in claim denial or member financial liability when drugs from the Provider‑Administered Precertification Drug List are administered in a provider office, outpatient facility, or home health setting. Providers are responsible for verifying PA approval prior to administration.
- Claims for non‑precertified administrations of listed drugs may be denied.
- Providers may be financially responsible for services rendered without prior authorization.
Reference — Full List and Policy Details
See the online Provider‑Administered Drug Policies for the complete, monthly‑updated list of affected products and any product‑specific precertification instructions or exceptions.
- Online policies: MN-Policies.Exploremyplan.com (select 'Provider‑Administered Drug Policies')
Applicable Sites of Care
Site‑of‑care precertification requirement
Precertification is required when the listed drugs are administered in a provider's office, outpatient facility, or home health setting; gene therapy/cellular immunotherapy products (marked +) require precertification in any place of treatment.
- Covered settings: office, infusion center/outpatient facility, home health (hospital outpatient is included on the list header)
- Products marked + are subject to PA regardless of treatment location
Key Definitions
Policy Background
This document is an administrative list identifying which provider‑administered drugs require prior precertification under the payer’s Provider‑Administered Drug Review Program. The list is updated monthly and subject to change. Products indicated as Gene Therapy/Cellular Immunotherapy are marked with a + and require precertification in any place of treatment. Failure to obtain required precertification when drugs are administered in a provider’s office, outpatient facility, or home health setting may result in denial of coverage.
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