Current Provider-Administered Drug Policies (Excluding Oncology)

 

  • Botulinum Toxin: See Palmetto Local Coverage Determination (LCD) L33458 and article A56646.
  • Eylea: See Palmetto article A53387
  • Firazyr: See Palmetto article A53066
  • H.P. Acthar: See Palmetto article A53066
  • Haegarda: See Palmetto article A53066
  • Lemtrada: See Palmetto article A55310
  • Luxturna: For dates of service May 16, 2019, and after see Palmetto LCD L37863 and article A56419. For prior dates of service, see policy number PH-111.
  • Orencia-SQ/self-administered: See Palmetto article A53066
  • Orencia-IV/provider-administered: See policy number PH-0091 below.
  • Rituximab: For Riabni, see PH-0109 below. For Rituxan, Truxima and Ruxience, see LCD L35026 and article A56380
  • Sublocade: For dates of service July 1, 2019, and after, see policy number PH-0463 below. For dates of service July 1, 2018-June 30, 2019, see policy number PH-109. For dates of service prior to July 1, 2018, it is noncovered.
  • Testopel: See Palmetto article A53793 for gender reassignment services for gender dysphoria. For all other indications, see policy number PH-0282 below.
  • White Colony Stimulating Factors: See Palmetto LCD L37176

 

For billing and coding information for Infliximab, refer to LCD L35677 and article A56432 for the following drugs:

Avsola

Inflectra

Ixifi

Remicade

Renflexis

 

For billing and coding information for Rituximab, refer to LCD L35026 and article A56380 for the following drugs:

Rituxan

Truxima

Ruxience

Note: Coverage is subject to member's specific benefits. Group-specific policies will supersede these policies when applicable. Please refer to member's benefit plan.


The purpose of provider-administered drug policies is to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

Policy # Policy Title Print View
PH-0002 Actemra® (tocilizumab)
PH-0008 Aloxi (palonosetron)
PH-0017 Benlysta® (belimumab)
PH-0018 Berinert® (C1 Esterase Inhibitor, Human)
PH-0028 Cimzia® (certolizumab pegol)
PH-0036 Emend IV (fosaprepitant dimeglumine)
PH-0059 SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify® Xembify®
PH-0061 Hyaluronic Acid Derivatives: Durolane®, Euflexxa™, Gel-One®, GelSyn-3™, GenVisc 850®, Hyalgan™, Hymovis®, Monovisc®, Orthovisc™, Supartz/Supartz FX™, Synojoynt™, Synvisc™, & Synvisc-One™, TriVisc™, VISCO-3™, Triluron™, sodium hyaluronate 1%
PH-0079 Lumizyme® (alglucosidase alfa)
PH-0089 Nplate® (romiplostim)
PH-0091 Orencia (abatacept)
PH-0105 Elelyso™ (taliglucerase alfa)
PH-0109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-0114 Soliris® (eculizumab)
PH-0117 Stelara® (ustekinumab)
PH-0133 Tysabri® (natalizumab)
PH-0139 Vivitrol® (naltrexone)
PH-0141 VPRIV® (velaglucerase alfa)
PH-0145 Xiaflex® (collagenase)
PH-0146 Xolair® (omalizumab)
PH-0158 Krystexxa® (pegloticase)
PH-0167 Kalbitor® (ecallantide)
PH-0168 Cinryze® (C1 Esterase Inhibitor, Human)
PH-0171 Makena® (hydroxyprogesterone caproate)
PH-0176 Simponi ARIA® (golimumab)
PH-0190 Vimizim® (elosulfase alfa)
PH-0202 Entyvio™ (vedolizumab)
PH-0207 Ruconest® (C1 Esterase Inhibitor [recombinant])
PH-0234 Colony Stimulating Factors – Pegfilgrastim: Neulasta®; Fulphila™; Udenyca®; Ziextenzo™; Nyvepria™
PH-0260 Nucala® (mepolizumab)
PH-0273 Cinqair® (reslizumab)
PH-0282 Testopel® (testosterone pellets)
PH-0284 Exondys-51™ (eteplirsen)
PH-0291 Spinraza™ (nusinersen)
PH-0298 Ocrevus™ (ocrelizumab)
PH-0299 Brineura (cerliponase alfa)
PH-0305 Radicava (edaravone)
PH-0336 Cinvanti (aprepitant)
PH-0346 Mepsevii™ (vestronidase alfa-vjbk)
PH-0347 Fasenra® (benralizumab)
PH-0355 Trogarzo™ (ibalizumab-uiyk)
PH-0358 Ilumya® (tildrakizumab-asmn)
PH-0362 Crysvita (burosumab-twza)
PH-0363 Akynzeo (fosnetupitant/palonosetron)
PH-0379 Onpattro (patisiran lipid complex)
PH-0392 Takhzyro™ (lanadelumab-flyo)
PH-0421 GamifaGamifant™ (emapalumab-lzsg)nt (emapalumab-lzsg)
PH-0427 Ultomiris® (ravulizumab-cwvz)
PH-0463 Sublocade™ (buprenorphine ER injection)
PH-0464 Probuphine® (buprenorphine)
PH-0468 Zolgensma® (onasemnogene abeparvovec-xioi)
PH-0481 Spravato (esketamine)
PH-0497 Beovu® (brolucizumab-dbll)
PH-0503 Reblozyl® (luspatercept-aamt)
PH-0512 Scenesse® (afamelanotide)
PH-0513 Adakveo® (crizanlizumab-tmca)
PH-0514 Givlaari™ (givosiran)
PH-0520 Vyondys-53™ (golodirsen)
PH-0525 Tepezza (teprotumumab-trbw)
PH-0527 Vyepti® (eptinezumab-jjmr)
PH-0549 Uplizna™ (inebilizumab-cdon)
PH-0562 Viltepso™ (viltolarsen)
PH-0579 Oxlumo™ (lumasiran)
PH-260 Nucala® (mepolizumab)