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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)

Gastrointestinal (GI) Agents (Miscellaneous)

(

DDP-04

)

Dificid, Lotronex, Viberzi, Xifaxan, Zinplava

Effective Date:
3/9/2021

General Policies (DDP)

Gastrointestinal (GI) Agents (Miscellaneous)

(

DDP-04

)

Dificid, Viberzi, Xifaxan, Zinplava

Effective Date:
6/3/2020

General Policies (DDP)

Gastrointestinal (GI) Agents (Miscellaneous)

(

DDP-04

)

Dificid, Viberzi, Xifaxan, Zinplava

Effective Date:
3/17/2020

General Policies (DDP)

Gastrointestinal (GI) Agents (Miscellaneous)

(

DDP-04

)

Dificid, Viberzi, Xifaxan, Zinplava

Effective Date:
6/12/2019

General Policies (DDP)

Gastrointestinal Agents

(

)

Xifaxan, Viberzi

Effective Date:
2/28/2018

General Policies (DDP)

Gonadaptropin - Releasing Hormone Receptor Antagonists

(

DDP-44

)

Oriahnn, Orilissa

Effective Date:
3/9/2021

General Policies (DDP)

Gonadotropin-Releasing Hormone Receptor Antagonists

(

DDP-44

)

Oriahnn, Orilissa, Myfembree

Effective Date:
2/22/2023

General Policies (DDP)

Gonadotropin-Releasing Hormone Receptor Antagonists

(

DDP-44

)

Oriahnn, Orilissa, Myfembree

Effective Date:
2/23/2022

General Policies (DDP)

Gonadotropin-Releasing Hormone Receptor Antagonists

(

DDP-44

)

Oriahnn, Orilissa, Myfembree

Effective Date:
8/31/2021

General Policies (DDP)

Growth Hormones

(

DDP-05

)

Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Somatropin, Zomacton

Effective Date:
10/26/2022

General Policies (DDP)

Growth Hormones

(

DDP-05

)

Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Somatropin, Zomacton

Effective Date:
11/9/2021

General Policies (DDP)

Growth Hormones

(

DDP-05

)

Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Somatropin, Zomacton

Effective Date:
11/10/2020

General Policies (DDP)

Growth Hormones

(

DDP-05

)

Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Somatropin, Zomacton

Effective Date:
3/17/2020

General Policies (DDP)

Growth Hormones

(

DDP-05

)

Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Somatropin, Zomacton

Effective Date:
11/14/2019

General Policies (DDP)

Growth Hormones

(

DDP-05

)

Genotropin, Humatrope, Norditropin, Nutropin, Somatropin

Effective Date:
6/24/2019

General Policies (DDP)

Growth Hormones

(

DDP-05

)

Genotropin, Humatrope, Norditropin, Nutropin

Effective Date:
2/27/2019

General Policies (DDP)

H.P. Acthar Gel

(

)

Acthar

Effective Date:
6/27/2018

General Policies (DDP)

Hepatitis C Agents

(

DDP-06

)

Daklinza, Epclusa, Harvoni, Mavyret, Sofosbuvir-Velpatasvir, Sovaldi, Technivie, Zepatier

Effective Date:
4/26/2023

General Policies (DDP)

Hepatitis C Agents

(

DDP-06

)

Daklinza, Epclusa, Harvoni, Mavyret, Sofosbuvir-Velpatasvir, Sovaldi, Technivie, Zepatier

Effective Date:
5/3/2022

General Policies (DDP)

Hepatitis C Agents

(

DDP-06

)

Daklinza, Epclusa, Harvoni, Mavyret, Sofosbuvir-Velpatasvir, Sovaldi, Technivie, Zepatier

Effective Date:
6/1/2021

General Policies (DDP)

Hepatitis C Agents

(

DDP-06

)

Daklinza, Epclusa, Harvoni, Mavyret, Sofosbuvir-Velpatasvir, Sovaldi, Technivie, Zepatier

Effective Date:
6/3/2020

General Policies (DDP)

Hepatitis C Agents

(

DDP-06

)

Daklinza, Harvoni, Mavyret, Sofosbuvir-Velpatasvir, Viekirea Pack, Sovaldi, Zepatier

Effective Date:
6/4/2019

General Policies (DDP)

Hepatitis C Agents

(

)

Mavyret, Sofosbuvir-Velpatasvir

Effective Date:
2/27/2019

General Policies (DDP)

Hereditary Angioedema Agents

(

DDP-30

)

Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest, Takhzyro

Effective Date:
12/14/2022

General Policies (DDP)

Hereditary Angioedema Agents

(

DDP-30

)

Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest, Takhzyro

Effective Date:
12/14/2022

General Policies (DDP)

Hereditary Angioedema Agents

(

DDP-30

)

Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest, Takhzyro

Effective Date:
1/13/2022

General Policies (DDP)

Hereditary Angioedema Agents

(

DDP-30

)

Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest, Takhzyro

Effective Date:
6/1/2021

General Policies (DDP)

Hereditary Angioedema Agents

(

DDP-30

)

Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest, Takhzyro

Effective Date:
12/15/2020

General Policies (DDP)

Hereditary Angioedema Agents

(

DDP-30

)

Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest, Takhzyro

Effective Date:
8/14/2019

General Policies (DDP)

Hereditary Angioedema Agents

(

)

Cinryze, Berinert, Kalbitor, Firazyr

Effective Date:
10/25/2017

General Policies (DDP)

Hyperhidrosis Agents

(

DDP-42

)

Botox, Qbrexza

Effective Date:
6/27/2022

General Policies (DDP)

Hyperhidrosis Agents

(

DDP-42

)

Botox, Qbrexza

Effective Date:
6/29/2021

General Policies (DDP)

Hyperhidrosis Agents

(

DDP-42

)

Botox, Qbrexza

Effective Date:
6/29/2020

General Policies (DDP)

Hyperhidrosis Agents

(

DDP-42

)

Botox, Qbrexza

Effective Date:
3/17/2020

General Policies (DDP)

Immune globulin

(

DDP-16

)

Asceniv, Bivigram, Carimmune NF, C/Gammarked, Cutaquig, Cuvitru, Febogamma Dif, Gammagard, Gammaplex, GammaSTAN, GammaSTAN S/D, Gamunex, Hizentra, Hyqvia, IVIG lyophilized NOS, IVIG non-lyophilized NOS, Octagam, Panzyga, Privigen, Xembify

Effective Date:
2/22/2023

General Policies (DDP)

Immune globulin

(

DDP-16

)

Asceniv, Bivigram, Carimmune NF, C/Gammarked, Cutaquig, Cuvitru, Febogamma Dif, Gammagard, Gammaplex, GammaSTAN, GammaSTAN S/D, Gamunex, Hizentra, Hyqvia, IVIG lyophilized NOS, IVIG non-lyophilized NOS, Octagam, Panzyga, Privigen, Xembify

Effective Date:
5/5/2022

General Policies (DDP)

Immune globulin

(

DDP-16

)

Asceniv, Bivigram, Carimmune NF, C/Gammarked, Cutaquig, Cuvitru, Febogamma Dif, Gammagard, Gammaplex, GammaSTAN, GammaSTAN S/D, Gamunex, Hizentra, Hyqvia, IVIG lyophilized NOS, IVIG non-lyophilized NOS, Octagam, Panzyga, Privigen, Xembify

Effective Date:
6/1/2021

General Policies (DDP)

Immune globulin

(

DDP-16

)

Asceniv, Bivigram, Carimmune NF, C/Gammarked, Cutaquig, Cuvitru, Febogamma Dif, Gammagard, Gammaplex, GammaSTAN, GammaSTAN S/D, Gamunex, Hizentra, Hyqvia, IVIG lyophilized NOS, IVIG non-lyophilized NOS, Octagam, Panzyga, Privigen, Xembify

Effective Date:
11/10/2020

General Policies (DDP)

Immune globulin

(

)

Asceniv, Bivigram, Carimmune NF, C/Gammarked, Cutaquig, Cuvitru, Febogamma Dif, Gammagard, Gammaplex, GammaSTAN, GammaSTAN S/D, Gamunex, Hizentra, Hyqvia, IVIG lyophilized NOS, IVIG non-lyophilized NOS, Octagam, Panzyga, Privigen, Xembify

Effective Date:
6/3/2020

General Policies (DDP)

Immune globulin

(

)

Bivigram, C/Gammarked, Cuvitra, Febogamma Dif, Gammagard, Gamunex, Hizentra, IVIG lyophilized NOS, IVIG non-lyophilized NOS, Octagam, Privigen

Effective Date:
7/25/2019

General Policies (DDP)

Immune globulin

(

)

Hizentra, Gammagard, Privigen

Effective Date:
4/25/2018

General Policies (DDP)

Interleukin Inhibitors

(

DDP-11

)

Actemra, Cosentyx, Ilumya, Kevzara, Siliq, Skyrizi, Stelara, Taltz, Tremfya

Effective Date:
8/23/2023

General Policies (DDP)

Interleukin Inhibitors

(

DDP-11

)

Actemra, Cosentix, Ilumya, Kevzara, Siliq, Skyrizi, Stelara, Taltz, Tremfya

Effective Date:
3/2/2022

General Policies (DDP)

Interleukin Inhibitors

(

DDP-11

)

Actemra, Cosentix, Ilumya, Kevzara, Siliq, Skyrizi, Stelara, Taltz, Tremfya

Effective Date:
8/31/2021

General Policies (DDP)

Interleukin Inhibitors

(

DDP-11

)

Actemra, Cosentix, Ilumya, Kevzara, Siliq, Skyrizi, Stelara, Taltz, Tremfya

Effective Date:
3/25/2021

General Policies (DDP)

Interleukin Inhibitors

(

DDP-11

)

Actemra, Cosentix, Ilumya, Kevzara, Siliq, Skyrizi, Stelara, Taltz, Tremfya

Effective Date:
9/21/2020

General Policies (DDP)

Interleukin Inhibitors

(

DDP-11

)

Actemra, Cosentix, Ilumya, Skyrizi, Stelara, Taltz, Tremfya

Effective Date:
4/2/2020

General Policies (DDP)

Interleukin Inhibitors

(

DDP-11

)

Actemra, Cosentix, Ilumya, Skyrizi, Stelara, Taltz, Tremfya

Effective Date:
9/9/2019

General Policies (DDP)

Interleukin Inhibitors

(

DDP-11

)

Stelara, Cosentyx

Effective Date:
5/31/2019

General Policies (DDP)

Interleukin Inhibitors

(

)

Stelara, Cosentyx

Effective Date:
2/27/2019

General Policies (DDP)

Janus Kinase Inhibitors

(

DDP-41

)

Cibinqo, Rinvoq, Xeljanz

Effective Date:
8/23/2023

General Policies (DDP)

Janus Kinase Inhibitors

(

DDP-41

)

Cibinqo, Rinvoq, Xeljanz

Effective Date:
10/26/2022

General Policies (DDP)

Janus Kinase Inhibitors

(

DDP-41

)

Rinvoq, Xeljanz

Effective Date:
7/27/2022

General Policies (DDP)

Janus Kinase Inhibitors

(

DDP-41

)

Rinvoq, Xeljanz

Effective Date:
3/1/2022

General Policies (DDP)

Janus Kinase Inhibitors

(

DDP-41

)

Rinvoq, Xeljanz

Effective Date:
1/13/2022

General Policies (DDP)

Janus Kinase Inhibitors

(

DDP-41

)

Rinvoq, Xeljanz

Effective Date:
12/7/2021

General Policies (DDP)

Luxturna Gene Therapy

(

DDP-39

)

Luxturna

Effective Date:
12/14/2022

General Policies (DDP)

Luxturna Gene Therapy

(

DDP-39

)

Luxturna

Effective Date:
12/13/2021

General Policies (DDP)

Luxturna Gene Therapy

(

DDP-39

)

Luxturna

Effective Date:
12/15/2020

General Policies (DDP)

Luxturna Gene Therapy

(

DDP-39

)

Luxturna

Effective Date:
12/26/2019

General Policies (DDP)

Movement Disorder Agents

(

DDP-50

)

Austedo, Ingrezza, Xenazine

Effective Date:
6/28/2023

General Policies (DDP)

Movement Disorder Agents

(

DDP-50

)

Austedo, Ingrezza, Xenazine

Effective Date:
6/30/2022

General Policies (DDP)

Movement Disorder Agents

(

DDP-50

)

Austedo, Ingrezza, Xenazine

Effective Date:
3/9/2021

General Policies (DDP)

Multiple Sclerosis Agents

(

DDP-35

)

Bruimvi, Dalfampridine, Mavenclad, Ocrevus, Tysabri, Zeposia

Effective Date:
6/28/2023

General Policies (DDP)

Multiple Sclerosis Agents

(

DDP-35

)

Ampyra, Mavenclad, Ocrevus, Tysabri

Effective Date:
10/26/2022

General Policies (DDP)

Multiple Sclerosis Agents

(

DDP-35

)

Ampyra, Mavenclad

Effective Date:
6/30/2022

General Policies (DDP)

Multiple Sclerosis Agents

(

DDP-35

)

Ampyra, Mavenclad

Effective Date:
6/29/2021

General Policies (DDP)

Multiple Sclerosis Agents

(

DDP-35

)

Ampyra, Mavenclad

Effective Date:
6/30/2020

General Policies (DDP)

Multiple Sclerosis Agents

(

DDP-35

)

Ampyra, Mavenclad

Effective Date:
11/5/2019

General Policies (DDP)

Multiple Sclerosis Agents

(

)

Ampyra

Effective Date:
12/5/2018

General Policies (DDP)

Opioid-Induced Constipation

(

DDP-01

)

Movantik, Symporic

Effective Date:
2/22/2023

General Policies (DDP)

Opioid-Induced Constipation

(

DDP-01

)

Movantik, Symporic

Effective Date:
2/23/2022

General Policies (DDP)

Opioid-Induced Constipation

(

DDP-01

)

Movantik, Relistor, Symporic

Effective Date:
3/9/2021

General Policies (DDP)

Opioid-Induced Constipation

(

DDP-01

)

Movantik, Relistor, Symporic

Effective Date:
3/17/2020

General Policies (DDP)

Opioid-Induced Constipation

(

DDP-01

)

Movantik, Relistor, Symporic

Effective Date:
6/4/2019

General Policies (DDP)

Opioid-Induced Constipation

(

)

Relistor, Movantik, Symporic

Effective Date:
2/27/2019

General Policies (DDP)

Orencia

(

DDP-09

)

Orencia

Effective Date:
12/7/2021

General Policies (DDP)

Orencia

(

DDP-09

)

Orencia

Effective Date:
8/31/2021

General Policies (DDP)

Orencia

(

DDP-09

)

Orencia

Effective Date:
9/21/2020

General Policies (DDP)

Orencia

(

DDP-09

)

Orencia

Effective Date:
10/3/2019

General Policies (DDP)

Orencia

(

DDP-09

)

Orencia

Effective Date:
6/12/2019

General Policies (DDP)

Orencia

(

)

Orencia

Effective Date:
2/27/2019

General Policies (DDP)

Orilissa Use for Endometriosis

(

DDP-44

)

Orilissa

Effective Date:
6/3/2020

General Policies (DDP)

Osteoporosis Agents

(

DDP-33

)

Evenity, Forteo, Prolia, Reclast, Tymlos

Effective Date:
10/25/2023

General Policies (DDP)

Osteoporosis Agents

(

DDP-33

)

Evenity, Forteo, Prolia, Reclast, Tymlos, Zolendronic Acid

Effective Date:
10/25/2023

General Policies (DDP)

Osteoporosis Agents

(

DDP-33

)

Evenity, Forteo, Prolia, Reclast, Tymlos, Zolendronic Acid

Effective Date:
10/26/2022

General Policies (DDP)

Osteoporosis Agents

(

DDP-33

)

Evenity, Forteo, Prolia, Reclast, Tymlos, Zolendronic Acid

Effective Date:
8/31/2021

General Policies (DDP)

Osteoporosis Agents

(

DDP-33

)

Evenity, Forteo, Prolia, Reclast, Tymlos, Zolendronic Acid

Effective Date:
3/25/2021

General Policies (DDP)

Osteoporosis Agents

(

DDP-33

)

Evenity, Forteo, Prolia, Reclast, Tymlos, Zolendronic Acid

Effective Date:
11/14/2019

General Policies (DDP)

Osteoporosis Agents

(

)

Forteo, Prolia, Tymlos, Zolendronic Acid

Effective Date:
10/24/2018

General Policies (DDP)

Otezla

(

DDP-10

)

Otezla

Effective Date:
8/31/2021

General Policies (DDP)

Otezla

(

DDP-10

)

Otezla

Effective Date:
9/21/2020

General Policies (DDP)

Otezla

(

DDP-10

)

Otezla

Effective Date:
7/30/2019

General Policies (DDP)

Otezla

(

)

Otezla

Effective Date:
8/22/2018

General Policies (DDP)

Oxervate

(

DDP-49

)

Oxervate

Effective Date:
5/5/2022

General Policies (DDP)

Oxervate

(

DDP-49

)

Oxervate

Effective Date:
3/9/2021

General Policies (DDP)

Oxlumo

(

DDP-51

)

Oxlumo

Effective Date:
2/22/2023

General Policies (DDP)

Oxlumo

(

DDP-51

)

Oxlumo

Effective Date:
5/3/2022

General Policies (DDP)

Oxlumo

(

DDP-51

)

Oxlumo

Effective Date:
6/1/2021

General Policies (DDP)

PAH Drugs

(

DDP-29

)

Adcirca, Adempas, Evkeeza, Flolan, Letaris, Opsumit, Orenitram, Remodulin, Revatio, Tracleer, Tyvaso, Uptravi, Veletri, Ventavis

Effective Date:
6/29/2021
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