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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)

PAH Drugs

(

)

Flolan, Letaris, Opsumit, Remodulin, Revatio, Tracleer, Tyvaso, Ventavis

Effective Date:
12/5/2018

General Policies (DDP)

PCSK9 Agents

(

DDP-26

)

Praluent, Repatha

Effective Date:
11/10/2020

General Policies (DDP)

PCSK9 Agents

(

DDP-26

)

Praluent, Repatha

Effective Date:
1/14/2020

General Policies (DDP)

PCSK9 Agents

(

)

Praluent, Repatha

Effective Date:
10/24/2018

General Policies (DDP)

PCSK9 Inhibitors and (ANGPTL3) Inhibitors

(

DDP-26

)

Praluent, Repatha

Effective Date:
6/29/2021

General Policies (DDP)

PDE-5 Inhibitors for Treatment of BPH

(

DDP-00

)

Oxlumo

Effective Date:
1/25/2022

General Policies (DDP)

PDE-5 Inhibitors for Treatment of BPH

(

DDP-07

)

Cialis for daily use

Effective Date:
3/17/2020

General Policies (DDP)

PDE-5 Inhibitors for Treatment of BPH

(

)

Cialis for daily use

Effective Date:
6/6/2018

General Policies (DDP)

Plasminogen Deficiency: Ryplazim

(

DDP-53

)

Ryplazim

Effective Date:
4/26/2023

General Policies (DDP)

Plasminogen Deficiency: Ryplazim

(

DDP-53

)

Ryplazim

Effective Date:
5/6/2022

General Policies (DDP)

Pulmonary Arterial Hypertension (PAH) Drugs

(

DDP-29

)

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

Effective Date:
12/14/2022

General Policies (DDP)

Pulmonary Arterial Hypertension (PAH) Drugs

(

DDP-29

)

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

Effective Date:
12/14/2021

General Policies (DDP)

Pulmonary Fibrosis Agents

(

DDP-24

)

Esbriet, Ofev

Effective Date:
10/26/2022

General Policies (DDP)

Pulmonary Fibrosis Agents

(

DDP-24

)

Esbriet, Ofev

Effective Date:
11/9/2021

General Policies (DDP)

Pulmonary Fibrosis Agents

(

DDP-24

)

Esbriet, Ofev

Effective Date:
11/10/2020

General Policies (DDP)

Pulmonary Fibrosis Agents

(

DDP-24

)

Esbriet, Ofev

Effective Date:
11/14/2019

General Policies (DDP)

Rituximab (Rituxan)

(

DDP-17

)

Rituxan, Rituxan Hycela, Ruxience, Truxima, Riabni

Effective Date:
4/26/2023

General Policies (DDP)

Rituximab (Rituxan)

(

DDP-17

)

Rituxan

Effective Date:
5/6/2022

General Policies (DDP)

Rituximab (Rituxan)

(

DDP-17

)

Rituxan

Effective Date:
6/1/2021

General Policies (DDP)

Rituximab (Rituxan)

(

DDP-17

)

Rituxan

Effective Date:
6/3/2020

General Policies (DDP)

Rituximab (Rituxan)

(

DDP-17

)

Rituxan

Effective Date:
7/12/2019

General Policies (DDP)

Rituximab (Rituxan)

(

)

Rituxan

Effective Date:
4/25/2018

General Policies (DDP)

Scenesse

(

DDP-48

)

Scenesse

Effective Date:
2/22/2023

General Policies (DDP)

Scenesse

(

DDP-48

)

Scenesse

Effective Date:
1/14/2022

General Policies (DDP)

Scenesse

(

DDP-48

)

Scenesse

Effective Date:
3/9/2021

General Policies (DDP)

Sleep Disorder Agents

(

DDP-32

)

Lumryz, Sunosi, Wakix, Xyrem, Xyvav, Xywav

Effective Date:
12/13/2023

General Policies (DDP)

Sleep Disorder Agents

(

DDP-32

)

Amodafinil, Modafinil, Nuvigil, Provigil, Sunosi, Wakix, Xyrem, Xyvav

Effective Date:
6/28/2023

General Policies (DDP)

Sleep Disorder Agents

(

DDP-32

)

Amodafinil, Modafinil, Nuvigil, Provigil, Sunosi, Wakix, Xyrem, Xyvav

Effective Date:
6/27/2022

General Policies (DDP)

Sleep Disorder Agents

(

DDP-32

)

Amodafinil, Modafinil, Nuvigil, Provigil, Sunosi, Wakix, Xyrem, Xyvav

Effective Date:
6/29/2021

General Policies (DDP)

Sleep Disorder Agents

(

DDP-32

)

Amodafinil, Modafinil, Nuvigil, Provigil, Sunosi, Wakix, Xyrem

Effective Date:
12/15/2020

General Policies (DDP)

Sleep Disorder Agents

(

DDP-32

)

Amodafinil, Modafinil, Nuvigil, Provigil, Sunosi, Wakix, Xyrem

Effective Date:
6/3/2020

General Policies (DDP)

Soliris

(

)

Soliris, Ultomiris

Effective Date:
2/27/2019

General Policies (DDP)

Soliris and Ultomiris

(

DDP-03

)

Soliris, Ultomiris

Effective Date:
12/15/2020

General Policies (DDP)

Soliris and Ultomiris

(

DDP-03

)

Soliris, Ultomiris

Effective Date:
3/17/2020

General Policies (DDP)

Soliris and Ultomiris

(

DDP-03

)

Soliris, Ultomiris

Effective Date:
6/4/2019

General Policies (DDP)

Spinal Muscular Atrophy Agents

(

DDP-40

)

Evrysdi, Zolgensma

Effective Date:
12/14/2022

General Policies (DDP)

Spinal Muscular Atrophy Agents

(

DDP-40

)

Evrysdi, Zolgensma

Effective Date:
12/13/2021

General Policies (DDP)

Spravato

(

DDP-54

)

Spravato

Effective Date:
6/28/2023

General Policies (DDP)

Spravato

(

DDP-54

)

Spravato

Effective Date:
6/22/2022

General Policies (DDP)

Synagis

(

DDP-28

)

Synagis

Effective Date:
12/14/2022

General Policies (DDP)

Synagis

(

DDP-28

)

Synagis

Effective Date:
12/15/2021

General Policies (DDP)

Synagis

(

DDP-28

)

Synagis

Effective Date:
12/15/2020

General Policies (DDP)

Synagis

(

DDP-28

)

Synagis

Effective Date:
11/5/2019

General Policies (DDP)

Synagis

(

)

Synagis

Effective Date:
12/5/2018

General Policies (DDP)

TNF Inhibitors

(

DDP-12

)

Cimzia, Enbrel, Humira, Inflectra, Remicade, Simponi

Effective Date:
9/9/2019

General Policies (DDP)

TNF Inhibitors

(

DDP-12

)

Enbrel, Humira, Inflectra, Remicade, Cimzia, Simponi

Effective Date:
6/4/2019

General Policies (DDP)

TNF Inhibitors

(

)

Enbrel, Humira, Inflectra, Remicade, Cimzia, Simponi

Effective Date:
2/27/2019

General Policies (DDP)

Thyroid Eye Disease

(

DDP-46

)

Tepezza

Effective Date:
10/26/2022

General Policies (DDP)

Thyroid Eye Disease

(

DDP-46

)

Tepezza

Effective Date:
11/9/2021

General Policies (DDP)

Thyroid Eye Disease

(

DDP-46

)

Tepezza

Effective Date:
9/21/2020

General Policies (DDP)

Tumor Necrosis Factor (TNF) Inhibitors

(

DDP-12

)

Cimzia, Enbrel, Humira, Inflectra, Remicade, Renflexis, Simponi

Effective Date:
3/29/2021

General Policies (DDP)

Tumor Necrosis Factor (TNF) Inhibitors

(

DDP-12

)

Cimzia, Enbrel, Humira, Inflectra, Remicade, Renflexis, Simponi

Effective Date:
9/21/2020

General Policies (DDP)

Tumor Necrosis Factor (TNF) Inhibitors

(

DDP-12

)

Cimzia, Enbrel, Humira, Inflectra, Remicade, Renflexis, Simponi

Effective Date:
4/17/2020

General Policies (DDP)

Tumor Necrosis Factor (TNF) inhibitors

(

DDP-12

)

Abrilada, Adalimumab-Aacf, Adalimumab-Adaz, Adalimumab-Adbm, Adalimumab-Fkjp, Avsola, Cimzia, Cyltezo, Enbrel, Hadlima, Hulio, Humira, Hyrimiz, Hyrimoz, Idacio, Inflectra, Unbranded Infliximab, Remicade, Renflexis, Simponi, Yuflyma, Yusimry

Effective Date:
12/13/2023

General Policies (DDP)

Tumor Necrosis Factor (TNF) inhibitors

(

DDP-12

)

Abrilada, Adalimumab-Aacf, Adalimumab-Adaz, Adalimumab-Adbm, Adalimumab-Fkjp, Avsola, Cimzia, Cyltezo, Enbrel, Hadlima, Hulio, Humira, Hyrimiz, Hyrimoz, Idacio, Inflectra, Unbranded Infliximab, Remicade, Renflexis, Simponi, Yuflyma, Yusimry

Effective Date:
8/23/2023

General Policies (DDP)

Tumor Necrosis Factor (TNF) inhibitors

(

DDP-12

)

Cimzia, Enbrel, Humira, Inflectra, Remicade, Renflexis, Simponi

Effective Date:
8/31/2021

General Policies (DDP)

Uridine Triacetate

(

DDP-23

)

Vistogard, Xuriden

Effective Date:
4/26/2023

General Policies (DDP)

Uridine Triacetate

(

DDP-23

)

Vistogard, Xuriden

Effective Date:
10/26/2022

General Policies (DDP)

Uridine Triacetate

(

DDP-23

)

Vistogard, Xuriden

Effective Date:
5/2/2022

General Policies (DDP)

Uridine Triacetate

(

DDP-23

)

Vistogard, Xuriden

Effective Date:
11/9/2021

General Policies (DDP)

Uridine Triacetate

(

DDP-23

)

Vistogard, Xuriden

Effective Date:
11/10/2020

General Policies (DDP)

Uridine Triacetate

(

DDP-23

)

Vistogard, Xuriden

Effective Date:
8/13/2019

General Policies (DDP)

Uridine Triacetate

(

)

Vistogard, Xuriden

Effective Date:
10/24/2018

General Policies (DDP)

Weight Loss Medication

(

)

Belviq

Effective Date:
10/24/2018

General Policies (DDP)

Weight Loss Medications

(

DDP-25

)

Adipex, Belviq, Belviq XR, Contrave, Qsymia, Saxenda, Xenical

Effective Date:
11/14/2019

General Policies (DDP)

Weight Loss Medications

(

DDP-25

)

Adipex, Belviq, Belviq XR, Qsymia, Saxenda, Xenical

Effective Date:
8/14/2019

General Policies (DDP)

Weight Loss Products

(

DDP-25

)

Alli/Xenical, Adipex, Qsymia, Saxenda, Suprenza

Effective Date:
3/9/2021

General Policies (DDP)

Weight Loss Products

(

DDP-25

)

Alli/Xenical, Adipex, Qsymia, Saxenda, Suprenza

Effective Date:
9/21/2020

General Policies (DDP)

Weight Management (Chronic)

(

DDP-25

)

Alli/Xenical, Contrave, Qsymia, Saxenda, Wegovy

Effective Date:
8/23/2023

General Policies (DDP)

Weight Management (Chronic)

(

DDP-25

)

Alli/Xenical, Adipex, Contrave, Qsymia, Saxenda, Wegovy

Effective Date:
2/22/2023

General Policies (DDP)

Weight Management (Chronic)

(

DDP-25

)

Alli/Xenical, Adipex, Contrave, Qsymia, Saxenda, Wegovy

Effective Date:
10/26/2022

General Policies (DDP)

Weight Management (Chronic)

(

DDP-25

)

Alli/Xenical, Adipex, Qsymia, Saxenda, Suprenza, Wegovy

Effective Date:
11/9/2021

General Policies (DDP)

Xeljanz

(

DDP-41

)

Xeljanz

Effective Date:
3/17/2020

General Policies (DDP)

Xeljanz

(

)

Xeljanz

Effective Date:
12/5/2018

General Policies (DDP)

Xeljanz and Rinvoq - Janus Kinase Inhibitors

(

DDP-41

)

Rinvoq, Xeljanz

Effective Date:
8/31/2021

General Policies (DDP)

Xeljanz and Rinvoq - Janus Kinase Inhibitors

(

DDP-41

)

Rinvoq, Xeljanz

Effective Date:
9/21/2020

General Policies (DDP)

Xiaflex

(

DDP-37

)

Xiaflex

Effective Date:
6/29/2021

General Policies (DDP)

Xiaflex

(

DDP-37

)

Xiaflex

Effective Date:
6/30/2020

General Policies (DDP)

Xiaflex

(

DDP-37

)

Xiaflex

Effective Date:
11/5/2019

General Policies (DDP)

Xiaflex

(

)

Xiaflex

Effective Date:
7/6/2017

General Policies (DDP)

Zolgensma - Spinal Muscular Atrophy Agents

(

DDP-40

)

Evrysdi, Zolgensma

Effective Date:
3/9/2021

General Policies (DDP)

Zolgensma Gene Therapy

(

DDP-40

)

Zolgensma

Effective Date:
12/31/2020

General Policies (DDP)

Zolgensma Gene Therapy

(

DDP-40

)

Zolgensma

Effective Date:
3/17/2020
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