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Medical & Drug Policies

Medical Benefit Coverage Policies (BCP)Drug Determination Policies (DDP)Archived Medical Benefit Coverage Policies (BCP)Archived Drug Determination Policies (DDP)

Archived Drug Determination Policies (DDP)

Attention - Physicians Health Plan (PHP) is now University of Michigan Health Plan (UM Health Plan). Documents published before this change may still have references to the PHP brand.
Archived

Archived General Policies (DDP)

Dose Rounding and Wastage

(

DDP-21

)

Policy for dosage rounding

Effective Date:
4/26/2023

Dose Rounding and Wastage

(

DDP-21

)

Policy for dosage rounding

Effective Date:
2/22/2023

Dose Rounding and Wastage

(

DDP-21

)

Policy for dosage rounding

Effective Date:
12/14/2022

Dose Rounding and Wastage

(

DDP-21

)

Policy for dosage rounding

Effective Date:
1/14/2022

Dose Rounding and Wastage

(

DDP-21

)

Policy for dosage rounding

Effective Date:
3/9/2021

Dose Rounding and Wastage

(

DDP-21

)

Policy for dosage rounding

Effective Date:
9/5/2016

Dose rounding

(

)

Policy for dosage rounding

Effective Date:
8/22/2018

Formulary Alternatives and Exclusions

(

DDP-02

)

Based upon benefit design, a list of these medications may be found in the prescription drug list, in the HCPCS notification table for provider-administered medications or by calling PHP customer service.

Effective Date:
4/26/2023

Formulary Alternatives and Exclusions

(

DDP-02

)

Based upon benefit design, a list of these medications may be found in the prescription drug list, in the HCPCS notification table for provider-administered medications or by calling PHP customer service.

Effective Date:
2/22/2023

Formulary Alternatives and Exclusions

(

DDP-02

)

Based upon benefit design, a list of these medications may be found in the prescription drug list, in the HCPCS notification table for provider-administered medications or by calling PHP customer service.

Effective Date:
12/14/2022

Formulary Alternatives and Exclusions

(

DDP-02

)

Based upon benefit design, a list of these medications may be found in the prescription drug list, in the HCPCS notification table for provider-administered medications or by calling PHP customer service.

Effective Date:
1/14/2022

Formulary Alternatives and Exclusions

(

DDP-02

)

Based upon benefit design, a list of these medications may be found in the prescription drug list, in the HCPCS notification table for provider-administered medications or by calling PHP customer service.

Effective Date:
6/29/2021

Formulary Alternatives and Exclusions

(

DDP-02

)

Based upon benefit design, a list of these medications may be found in the prescription drug list, in the HCPCS notification table for provider-administered medications or by calling PHP customer service.

Effective Date:
3/9/2021

Formulary Alternatives and Exclusions

(

DDP-02

)

Based upon benefit design, a list of these medications may be found in the prescription drug list, in the HCPCS notification table for provider-administered medications or by calling PHP customer service.

Effective Date:
6/29/2020

Formulary Alternatives and Exclusions

(

DDP-02

)

Based upon benefit design, a list of these medications may be found in the prescription drug list, in the HCPCS notification table for provider-administered medications or by calling PHP customer service.

Effective Date:
10/14/2019

Formulary Alternatives and Exclusions

(

DDP-02

)

Based upon benefit design, a list of these medications may be found in the prescription drug list, in the HCPCS notification table for provider-administered medications or by calling PHP customer service.

Effective Date:
6/4/2019

Oncology Products

(

DDP-52

)

Based upon benefit design, a list of these oncology medications may be found in the prescription drug list, in the HCPCS notification table for provider-administered medications or by calling PHP customer service.

Effective Date:
8/23/2023

Oncology Products

(

DDP-52

)

Based upon benefit design, a list of these oncology medications may be found in the prescription drug list, in the HCPCS notification table for provider-administered medications or by calling PHP customer service.

Effective Date:
12/13/2021

Policy on Use of Formulary Alternatives

(

)

Based upon benefit design, a list of these medications may be found in the prescription drug list, in the HCPCS notification table for provider-administered medications or by calling PHP customer service.

Effective Date:
2/27/2019

Site of Care for Administration of Parenteral Specialty Drugs

(

DDP-08

)

Determination process for coverage of specific specialty medications at an outpatient facility that bills with a facility fee. Medications included in this policy must also meet medication prior approval criteria for coverage, regardless of the site of service.

Effective Date:
10/25/2023

Site of Care for Administration of Parenteral Specialty Drugs

(

DDP-08

)

Determination process for coverage of specific specialty medications at an outpatient facility that bills with a facility fee. Medications included in this policy must also meet medication prior approval criteria for coverage, regardless of the site of service.

Effective Date:
4/26/2023

Site of Care for Administration of Parenteral Specialty Drugs

(

DDP-08

)

Determination process for coverage of specific specialty medications at an outpatient facility that bills with a facility fee. Medications included in this policy must also meet medication prior approval criteria for coverage, regardless of the site of service.

Effective Date:
2/22/2023

Site of Care for Administration of Parenteral Specialty Drugs

(

DDP-08

)

Determination process for coverage of specific specialty medications at an outpatient facility that bills with a facility fee. Medications included in this policy must also meet medication prior approval criteria for coverage, regardless of the site of service.

Effective Date:
11/23/2022

Site of Care for Administration of Parenteral Specialty Drugs

(

DDP-08

)

Determination process for coverage of specific specialty medications at an outpatient facility that bills with a facility fee. Medications included in this policy must also meet medication prior approval criteria for coverage, regardless of the site of service.

Effective Date:
8/24/2022

Site of Care for Administration of Parenteral Specialty Drugs

(

DDP-08

)

Determination process for coverage of specific specialty medications at an outpatient facility that bills with a facility fee. Medications included in this policy must also meet medication prior approval criteria for coverage, regardless of the site of service.

Effective Date:
1/14/2022

Site of Care for Administration of Parenteral Specialty Drugs

(

DDP-08

)

Determination process for coverage of specific specialty medications at an outpatient facility that bills with a facility fee. Medications included in this policy must also meet medication prior approval criteria for coverage, regardless of the site of service.

Effective Date:
3/9/2021

Site of Care for Administration of Parenteral Specialty Drugs

(

DDP-08

)

Determination process for coverage of specific specialty medications at an outpatient facility that bills with a facility fee. Medications included in this policy must also meet medication prior approval criteria for coverage, regardless of the site of service.

Effective Date:
7/1/2019

Specialty and High Cost Agents

(

DDP-45

)

Subject to benefit design.

Effective Date:
5/2/2022

Specialty and High Cost Agents

(

DDP-45

)

Subject to benefit design.

Effective Date:
6/1/2021

Specialty and High Cost Agents

(

DDP-45

)

Subject to benefit design.

Effective Date:
4/17/2020

Specialty and High Cost Agents

(

)

Subject to benefit design.

Effective Date:
7/6/2017
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Archived

Archived Drug Determination Policies (DDP)

General Policies (DDP)

Acthar Gel

(

DDP-34

)

Acthar

Effective Date:
2/22/2023

General Policies (DDP)

Acthar Gel

(

DDP-34

)

Acthar

Effective Date:
5/4/2022

General Policies (DDP)

Acthar Gel

(

DDP-34

)

Acthar

Effective Date:
6/29/2021

General Policies (DDP)

Acthar Gel

(

DDP-34

)

Acthar

Effective Date:
6/29/2020

General Policies (DDP)

Acthar Gel

(

DDP-34

)

Acthar

Effective Date:
11/5/2019

General Policies (DDP)

Afinitor

(

DDP-14

)

Afinitor

Effective Date:
4/26/2023

General Policies (DDP)

Afinitor

(

DDP-14

)

Afinitor

Effective Date:
5/4/2022

General Policies (DDP)

Afinitor

(

DDP-14

)

Afinitor

Effective Date:
6/1/2021

General Policies (DDP)

Afinitor

(

DDP-14

)

Afinitor

Effective Date:
4/2/2020

General Policies (DDP)

Afinitor

(

DDP-14

)

Afinitor

Effective Date:
6/12/2019

General Policies (DDP)

Afinitor

(

)

Afinitor

Effective Date:
4/25/2018

General Policies (DDP)

Allergic and Asthma Agents

(

DDP-27

)

Adbry, Cinqair, Dupixent, Fasenra, Nucala, Tezspire, Xolair

Effective Date:
12/13/2023

General Policies (DDP)

Allergic and Asthma Agents

(

DDP-27

)

Adbry, Cinqair, Dupixent, Fasenra, Nucala, Tezspire, Xolair

Effective Date:
8/23/2023

General Policies (DDP)

Allergic and Asthma Agents

(

DDP-27

)

Cinqair, Dupixent, Fasenra, Nucala, Xolair

Effective Date:
8/24/2022

General Policies (DDP)

Allergic and Asthma Agents

(

DDP-27

)

Cinqair, Dupixent, Fasenra, Nucala, Xolair

Effective Date:
12/15/2021

General Policies (DDP)

Allergic and Asthma Agents - Specialty

(

DDP-27

)

Cinqair, Dupixent, Fasenra, Nucala, Xolair

Effective Date:
3/25/2021

General Policies (DDP)

Allergic and Asthma Agents - Specialty

(

DDP-27

)

Cinqair, Dupixent, Fasenra, Nucala, Xolair

Effective Date:
12/15/2020

General Policies (DDP)

Allergic and Asthma Agents - Specialty

(

DDP-27

)

Cinqair, Dupixent, Fasenra, Nucala, Xolair

Effective Date:
11/5/2019

General Policies (DDP)

Anticonvulsants (Third-generation)

(

DDP-36

)

Aptiom, Briviact, Diacomit, Epidiolex, Fintepla, Fycompa, Gabitril, Onfi, Potiga, Sabril, Sympazan, Vimpat, Xcorpi

Effective Date:
6/22/2022

General Policies (DDP)

Anticonvulsants (Third-generation)

(

DDP-36

)

Aptiom, Briviact, Diacomit, Epidiolex, Fintepla, Fycompa, Gabitril, Onfi, Potiga, Sabril, Sympazan, Vimpat, Xcorpi

Effective Date:
6/29/2021

General Policies (DDP)

Anticonvulsants - Third-generation

(

DDP-36

)

Aptiom, Briviact, Diacomit, Epidiolex, Fintepla, Fycompa, Gabitril, Onfi, Potiga, Sabril, Sympazan, Vimpat, Xcorpi

Effective Date:
12/15/2020

General Policies (DDP)

Anticonvulsants - Third-generation

(

DDP-36

)

Aptiom, Briviact, Diacomit, Epidiolex, Fycompa, Gabitril, Onfi, Potiga, Sabril, Sympazan, Vimpat, Xcorpi

Effective Date:
6/30/2020

General Policies (DDP)

Anticonvulsants - Third-generation

(

DDP-36

)

Aptiom, Briviact, Diacomit, Epidolex, Fycompa, Gabitril, Onfi, Potiga, Sabril, Sympazan, Vimpat

Effective Date:
11/5/2019

General Policies (DDP)

Anticonvulsants - Third-generation

(

)

Aptiom, Briviact, Epidiolex, Fycompa, Gabitril, Potiga, Sabril, Vimpat

Effective Date:
12/5/2018

General Policies (DDP)

Antilipemic Agents (Specialty)

(

DDP-26

)

Praluent, Repatha, Leqvio, Evkeeza

Effective Date:
12/13/2023

General Policies (DDP)

Antilipemic Agents (Specialty)

(

DDP-26

)

Praluent, Repatha, Leqvio, Evkeeza

Effective Date:
10/26/2022

General Policies (DDP)

Antilipemic Agents (Specialty)

(

DDP-26

)

Praluent, Repatha

Effective Date:
1/13/2022

General Policies (DDP)

Antilipemic Agents (Specialty)

(

DDP-26

)

Praluent, Repatha

Effective Date:
8/31/2021

General Policies (DDP)

Asthma Agents - Specialty

(

)

Cinqair, Dupixent, Fasenra, Nucala, Xolair

Effective Date:
12/5/2018

General Policies (DDP)

Atopic Dermatitis Agents

(

DDP-22

)

Dupixent, Eucrisa, Rinvoq, Skyrizi

Effective Date:
3/1/2022

General Policies (DDP)

Atopic Dermatitis Agents

(

DDP-22

)

Dupixent, Eucrisa

Effective Date:
8/31/2021

General Policies (DDP)

Atopic Dermatitis Agents

(

DDP-22

)

Dupixent, Eucrisa

Effective Date:
9/21/2020

General Policies (DDP)

Atopic Dermatitis Agents

(

DDP-22

)

Dupixent, Eucrisa

Effective Date:
9/5/2019

General Policies (DDP)

Atopic Dermatitis Agents

(

)

Dupixent, Eucrisat

Effective Date:
8/22/2018

General Policies (DDP)

BPH Treatment - PDE-5 Inhibitors

(

DDP-07

)

Cialis for daily use

Effective Date:
3/9/2021

General Policies (DDP)

Benign Prostatic Hyperplasia

(

)

Cialis for daily use

Effective Date:
2/27/2019

General Policies (DDP)

Benlysta

(

DDP-19

)

Benlysta

Effective Date:
8/23/2023

General Policies (DDP)

Benlysta

(

DDP-19

)

Benlysta

Effective Date:
8/31/2021

General Policies (DDP)

Benlysta

(

DDP-19

)

Benlysta

Effective Date:
9/21/2020

General Policies (DDP)

Benlysta

(

DDP-19

)

Benlysta

Effective Date:
9/5/2019

General Policies (DDP)

Benlysta

(

)

Benlysta

Effective Date:
8/22/2018

General Policies (DDP)

Botulinum Toxin

(

DDP-31

)

Botox, Dysport, Jeuveau, Myobloc, Xeomin

Effective Date:
6/28/2023

General Policies (DDP)

Botulinum Toxin

(

DDP-31

)

Botox, Dysport, Jeuveau, Myobloc, Xeomin

Effective Date:
10/26/2022

General Policies (DDP)

Botulinum Toxin

(

DDP-31

)

Botox, Dysport, Jeuveau, Myobloc, Xeomin

Effective Date:
6/22/2022

General Policies (DDP)

Botulinum Toxin

(

DDP-31

)

Botox, Dysport, Jeuveau, Myobloc, Xeomin

Effective Date:
6/29/2021

General Policies (DDP)

Botulinum Toxin

(

DDP-31

)

Botox, Dysport, Jeuveau, Myobloc, Xeomin

Effective Date:
3/25/2021

General Policies (DDP)

Botulinum Toxin

(

DDP-31

)

Botox, Dysport, Jeuveau, Myobloc, Xeomin

Effective Date:
12/15/2020

General Policies (DDP)

Botulinum Toxin

(

DDP-31

)

Botox, Dysport, Jeuveau, Myobloc, Xeomin

Effective Date:
6/29/2020

General Policies (DDP)

Botulinum Toxin A

(

)

Botox, Dysport, Xeomin

Effective Date:
6/6/2017

General Policies (DDP)

Breast Cancer Prevention

(

DDP-13

)

Evista, Soltamox, Tamoxifen

Effective Date:
5/4/2022

General Policies (DDP)

Breast Cancer Prevention

(

DDP-13

)

Evista, Soltamox, Tamoxifen

Effective Date:
6/1/2021

General Policies (DDP)

Breast Cancer Prevention

(

DDP-13

)

Evista, Soltamox, Tamoxifen

Effective Date:
6/3/2020

General Policies (DDP)

Breast Cancer Prevention

(

DDP-13

)

Evista, Soltamox, Tamoxifen

Effective Date:
5/28/2019

General Policies (DDP)

CAR-T Cell Immunotherapy

(

DDP-38

)

Abecma, Breyanzi, Kymriah, Tecartus, Yescarta

Effective Date:
12/14/2022

General Policies (DDP)

CAR-T Cell Immunotherapy

(

DDP-38

)

Abecma, Breyanzi, Kymriah, Tecartus, Yescarta

Effective Date:
12/15/2021

General Policies (DDP)

CAR-T Cell Immunotherapy

(

DDP-38

)

Breyanzi, Kymriah, Yescarta

Effective Date:
6/1/2021

General Policies (DDP)

CAR-T Cell Immunotherapy

(

DDP-38

)

Kymriah, Yescarta

Effective Date:
12/15/2020

General Policies (DDP)

CAR-T Cell Immunotherapy

(

DDP-38

)

Kymriah, Yescarta

Effective Date:
11/14/2019

General Policies (DDP)

CAR-T Cell Immunotherapy

(

)

Kymriah, Yescarta

Effective Date:
6/27/2018

General Policies (DDP)

CGRP Antagonists

(

DDP-47

)

Aimovig, Ajovy, Emgality, Nurtec, Qulipta, Ubrelvy, Vyepti, Zavzpret

Effective Date:
12/13/2023

General Policies (DDP)

CGRP Antagonists

(

DDP-47

)

Aimovig, Ajovy, Emgality, Nurtec, Qulipta, Ubrelvy, Vyepti

Effective Date:
6/28/2023

General Policies (DDP)

CGRP Antagonists

(

DDP-47

)

Aimovig, Ajovy, Emgality, Nurtec, Ubrevly, Vyepti

Effective Date:
2/22/2023

General Policies (DDP)

CGRP Antagonists

(

DDP-47

)

Aimovig, Ajovy, Emgality, Nurtec, Ubrevly, Vyepti

Effective Date:
12/14/2022

General Policies (DDP)

CGRP Antagonists

(

DDP-47

)

Aimovig, Ajovy, Emgality, Nurtec, Ubrevly, Vyepti

Effective Date:
6/22/2022

General Policies (DDP)

CGRP Antagonists

(

DDP-47

)

Aimovig, Ajovy, Emgality, Nurtec, Ubrevly, Vyepti

Effective Date:
12/28/2021

General Policies (DDP)

CGRP Antagonists

(

DDP-47

)

Aimovig, Ajovy, Emgality, Nurtec, Ubrevly, Vyepti, effective

Effective Date:
8/31/2021

General Policies (DDP)

CGRP Antagonists

(

DDP-47

)

Aimovig, Ajovy, Emgality, Nurtec, Ubrevly, Vyepti, effective

Effective Date:
6/29/2021

General Policies (DDP)

CGRP Antagonists

(

DDP-47

)

Aimovig, Ajovy, Emgality, Nurtec, Ubrevly, Vyepti, effective

Effective Date:
5/5/2021

General Policies (DDP)

CNS Stimulant Medications

(

)

Nuvigil, Provigil

Effective Date:
6/27/2018

General Policies (DDP)

Central Nervous System Stimulant Medications

(

DDP-32

)

Nuvigil, Provigil

Effective Date:
11/5/2019

General Policies (DDP)

Chemotherapy-Induced Myelosuppressio agents

(

DDP-15

)

Cosela, Fulphila, Granix, Neulasta, Neupogen, Nivestym, Udencya, Zarsio, Ziextenzo

Effective Date:
5/2/2022

General Policies (DDP)

Chemotherapy-Induced Myelosuppressio agents

(

DDP-15

)

Cosela, Fulphila, Granix, Neulasta, Neupogen, Nivestym, Udencya, Zarsio, Ziextenzo

Effective Date:
6/29/2021

General Policies (DDP)

Complement Inhibitors

(

DDP-03

)

Empavel, Soliris, Ultomiris

Effective Date:
6/28/2023

General Policies (DDP)

Complement Inhibitors

(

DDP-03

)

Empavel, Soliris, Ultomiris

Effective Date:
12/14/2022

General Policies (DDP)

Complement Inhibitors

(

DDP-03

)

Empavel, Soliris, Ultomiris

Effective Date:
12/15/2021

General Policies (DDP)

Diabetic Agents - Non-Insulin

(

DDP-43

)

Adlyxin, Byetta/Bydureon, Farxiga, Invokana, Januvia, Jardiance, Metformin, Mounjaro, Nesina, Onglyza, Ozempic, Rybelsus, Steglartro, Tradjenta, Trulicity, Victoza

Effective Date:
4/26/2023

General Policies (DDP)

Diabetic Agents - Non-Insulin

(

DDP-43

)

Adlyxin, Byetta/Bydureon, Farxiga, Invokana, Januvia, Jardiance, Metformin, Mounjaro, Nesina, Onglyza, Ozempic, Rybelsus, Steglartro, Tradjenta, Trulicity, Victoza

Effective Date:
10/26/2022

General Policies (DDP)

Diabetic Agents - Non-Insulin

(

DDP-43

)

Adlyxin, Byetta/Bydureon, Farxiga, Invokana, Januvia, Jardiance, Metformin, Nesina, Onglyza, Ozempic, Rybelsus, Steglartro, Tradjenta, Trulicity, Victoza

Effective Date:
6/22/2022

General Policies (DDP)

Diabetic Agents - Non-Insulin

(

DDP-43

)

Adlyxin, Byetta/Bydureon, Farxiga, Invokana, Januvia, Jardiance, Metformin, Nesina, Onglyza, Ozempic, Rybelsus, Steglartro, Tradjenta, Trulicity, Victoza

Effective Date:
11/9/2021

General Policies (DDP)

Diabetic Agents - Non-Insulin

(

DDP-43

)

Adlyxin, Byetta/Bydureon, Farxiga, Invokana, Januvia, Jardiance, Metformin, Nesina, Onglyza, Ozempic, Rybelsus, Steglartro, Tradjenta, Trulicity, Victoza

Effective Date:
11/10/2020

General Policies (DDP)

Diabetic Agents - Non-Insulin

(

DDP-43

)

Adlyxin, Byetta/Bydureon, Farxiga, Invokana, Januvia, Jardiance, Metformin, Nesina, Onglyza, Ozempic, Steglartro, Tradjenta, Trulicity, Victoza

Effective Date:
3/17/2020

General Policies (DDP)

Entyvio

(

DDP-20

)

Entyvio

Effective Date:
8/23/2023

General Policies (DDP)

Entyvio

(

DDP-20

)

Entyvio

Effective Date:
9/21/2020

General Policies (DDP)

Entyvio

(

DDP-20

)

Entyvio

Effective Date:
6/3/2020

General Policies (DDP)

Entyvio

(

DDP-20

)

Entyvio

Effective Date:
9/5/2019

General Policies (DDP)

Entyvio

(

)

Entyvio

Effective Date:
8/22/2018

General Policies (DDP)

Erythropoietin Stimulating Agents (ESAs)

(

DDP-18

)

Aranesp, Epogen, Mircera, Procrit, Retacrit

Effective Date:
4/26/2023

General Policies (DDP)

Erythropoietin Stimulating Agents (ESAs)

(

DDP-18

)

Aranesp, Epogen, Mircera, Procrit, Retacrit

Effective Date:
6/1/2021

General Policies (DDP)

Erythropoietin Stimulating Agents (ESAs)

(

DDP-18

)

Aranesp, Epogen, Mircera, Procrit, Retacrit

Effective Date:
6/3/2020

General Policies (DDP)

Erythropoietin Stimulating Agents (ESAs)

(

DDP-18

)

Aranesp, Epogen, Mircera, Procrit

Effective Date:
7/12/2019

General Policies (DDP)

Erythropoietin Stimulating Agents (ESAs)

(

)

Procrit, Epogen, Aranesp, Mircera

Effective Date:
4/25/2018

General Policies (DDP)

G-CSF Agents

(

DDP-15

)

Fulphila, Granix, Neulasta, Neupogen, Nivestym, Udencya, Zarsio, Ziextenzo

Effective Date:
12/15/2020

General Policies (DDP)

G-CSF Agents

(

DDP-15

)

Fulphila, Granix, Neulasta, Neupogen, Nivestym, Udencya, Zarsio, Ziextenzo

Effective Date:
6/3/2020

General Policies (DDP)

G-CSF Agents

(

DDP-15

)

Fulphila, Granix, Neulasta, Neupogen, Nivestym, Udencya, Zarxio, Ziextenzo

Effective Date:
1/14/2020

General Policies (DDP)

G-CSF Agents

(

DDP-15

)

Granix, Neulasta, Neupogen, Pegfilgrastim, Udencya, Zarxio

Effective Date:
7/12/2019

General Policies (DDP)

G-CSF Agents

(

)

Neupogen, Zarxio, Neulasta, Granix

Effective Date:
4/25/2018

General Policies (DDP)

Gastrointestinal (GI) Agents (Miscellaneous)

(

DDP-04

)

Dificid, Lotronex, Viberzi, Xifaxan

Effective Date:
2/22/2023

General Policies (DDP)

Gastrointestinal (GI) Agents (Miscellaneous)

(

DDP-04

)

Dificid, Lotronex, Viberzi, Xifaxan, Zinplava

Effective Date:
3/3/2022

General Policies (DDP)

Gastrointestinal (GI) Agents (Miscellaneous)

(

DDP-04

)

Dificid, Lotronex, Viberzi, Xifaxan, Zinplava

Effective Date:
6/29/2021

General Policies (DDP)

Gastrointestinal (GI) Agents (Miscellaneous)

(

DDP-04

)

Dificid, Lotronex, Viberzi, Xifaxan, Zinplava

Effective Date:
3/9/2021
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