Drug Determination Policies (DDP)

Policy for dosage rounding

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.

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.

Chemotherapy-Induced Myelosuppression Agents: Cosela, Fulphilia, Fylnetra, Granix, Neulasta, Neulasta Onpro, Neupogen, Nivestym, Nyvepria, Releuko, Stimufend, Udenyca, Zarxio, Ziextenzo

Breast Cancer Prevention Agents: Tamoxifen, Raloxifene

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.

Actemra, Benlysta, Bivigam, Briumvi, Carimune, Cinqair, Cuvitru, Entyvio, Evkeeza, Fasenra, Flebogamma, GamaSTAN, Gammagard, Gammaplex, Gamunex-C, Gammaked, Hizentra, HyQvia, Inflectra, Leqvio, Nucala, Ocrevus, Octagam, Orencia, Panzyga, Privigen, Remicade, Renflexis, Simponi Aria, Stelara, Synagis, Tysabri, Vivaglobin, Vyepti, Xolair

Acthar

Afinitor

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

Aptiom, Briviact, Clobazam, Diacomit, Epidiolex, Fintepla, Fycompa, Gabitril, Onfi, Sabril, Sympazan, Tiagabine, Vigabatrin, Xcopri

Praluent, Repatha, Leqvio, Evkeeza

Botox, Dysport, Jeuveau, Myobloc, Xeomin

Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta

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

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

Empaveli, Soliris, Ultomiris

Adlyxin, Alogliptin, Brenzavvy, Byetta/Bydureon, Farxiga, Inpefa, Invokana, Januvia, Jardiance, Mounjaro, Nesina, Onglyza, Ozempic, Rybelsus, Saxagliptin, Steglartro, Tradjenta, Trulicity, Victoza

Entyvio

Aranesp, Epogen, Mircera, Procrit, Retacrit

Dificid, Lotronex, Viberzi, Xifaxan

Evrysdi, Luxturna, Zolgensma

Oriahnn, Orilissa, Myfembree

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

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

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

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

Cibinqo, Rinvoq, Xeljanz

Austedo, Ingrezza, Xenazine

Bruimvi, Dalfampridine, Mavenclad, Ocrevus, Tysabri, Zeposia

Oxervate, Tepezza

Orencia

Evenity, Forteo, Prolia, Reclast, Tymlos

Otezla

Oxlumo

Ryplazim

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

Esbriet, Ofev

Rituxan, Rituxan Hycela, Ruxience, Truxima, Riabni

Scenesse

Lumryz, Sunosi, Wakix, Xyrem, Xyvav, Xywav

Spravato

Synagis

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

Vistogard, Xuriden