Current Provider-Administered Drug Policies (Excluding Oncology)

  • 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 L37863 and A56419. For dates of service prior, see PH-111.
  • Orencia: See Palmetto article A53066. 
  • Sublocade: For dates of service July 1, 2019, and after, see PH-0463. For dates of service July 1, 2018-June 30, 2019, see 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.  
  • White Colony Stimulating Factors: See Palmetto LCD L37176. 

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.

Provider-Administered Drug Policies Disclaimer:
The purpose of provider-administered drug policies are 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 IV (tocilizumab)
PH-0017 Benlysta IV (belimumab)
PH-0018 Berinert (C1 esterase inhibitor, human)
PH-0028 Cimzia (certolizumab pegol)
PH-0059 SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify® Xembify®
PH-0089 Nplate ( romiplostim)
PH-0114 Soliris (eculizumab)
PH-0117 Stelara (ustekinumab)
PH-0133 Tysabri (natalizumab)
PH-0139 Vivitrol (naltrexone)
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-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-0421 Gamifant (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-0501 Colony Stimulating Factors: Ziextenzo (pegfilgrastim-bmez)
PH-0503 Reblozyl (luspatercept-aamt)
PH-0512 Scenesse (afamelanotide)
PH-0513 Adakveo (crizanlizumab-tmca)
PH-0514 Givlaari (givosiran)
PH-0515 Avsola (infliximab-axxq)
PH-0520 Vyondys-53 (golodirsen)
PH-0525 Tepezza® (teprotumumab-trbw)
PH-260 Nucala (mepolizumab)
VP-0336 Cinvanti™ (aprepitant) (Intravenous)