Provider-Administered Precertification Drug List
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List of provider-administered drugs that require precertification when given in a provider office, outpatient facility, or home health setting; gene therapy/cellular immunotherapy products require precertification regardless of setting. Affects providers administering these drugs to Blue Cross Blue Shield - Minnesota members.
No material clinical or coverage changes in this revision.
Precertification Coverage Criteria
Precertification criteria
Covered when ALL of the following are met
List enumerates specific products; see source list
Gene therapy/cellular immunotherapy products are indicated with '+' and have broader setting requirement
For Avastin, precertification is required for oncology indications only. This is an exception to the general precertification requirement on the Provider‑Administered Precertification Drug List and applies regardless of the setting.
Provider Responsibilities & Prior Authorization Requirements
Precertification required for listed provider-administered drugs
Precertification (prior authorization) must be obtained for drugs on the Provider-Administered Precertification Drug List when they are administered in a provider's office, outpatient facility, or home health setting. Products designated as Gene Therapy/Cellular Immunotherapy (marked with a +) require precertification in any place of treatment.
Gene therapy/cellular immunotherapy and list updates
Treatments marked with a '+' are Gene Therapy/Cellular Immunotherapy products and require precertification regardless of treatment setting; the drug list is updated monthly and subject to change.
Documentation and setting requirements for precertification
Providers must obtain precertification prior to administration for drugs on the list when given in a provider's office, outpatient facility, or home health setting. For Gene Therapy/Cellular Immunotherapy products (marked with +), precertification is required for administration in any place of treatment.
Denial risk if precertification is not obtained
Lack of the required precertification for listed provider-administered drugs when given in a provider's office, outpatient facility, or home health setting may result in denial of coverage or claim processing delays.
Applicable Treatment Settings
Site-of-care precertification requirement
Precertification is required when these drugs are administered in a provider's office, outpatient facility, or home health setting; gene therapy/cellular immunotherapy products (marked with +) require precertification in any place of treatment.
- Settings called out: provider's office, outpatient facility, home health (home)
- Gene therapy/cellular immunotherapy (+) precertification applies in all settings
Definitions and Notation
Background and Scope
This document functions as an administrative precertification list, not clinical guidance. It identifies products that are subject to the Provider‑Administered Drug Review Program and specifies which drugs require precertification prior to administration. The list is updated monthly and notes that gene therapy/cellular immunotherapy products are identified with a '+' and require precertification in all settings.
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