Current Provider-Administered Drug Policies (Excluding Oncology)

  • Eylea: For dates of service on or after February 26, 2018, see Palmetto article A53387. For dates of service prior to February 26, 2018, see PH-113.
  • Firazyr: For dates of service on or after February 26, 2018, see Palmetto article A53066. For dates of service prior to February 26, 2018, see PH-104.
  • H.P. Acthar: For dates of service on or after February 26, 2018, see Palmetto article A53066. For dates of service prior to February 26, 2018, see PH-125.
  • Haegarda: For dates of service on or after February 26, 2018, see Palmetto article A53066. For dates of service prior to February 26, 2018, see PH-104.
  • Lemtrada: For dates of service on or after February 26, 2018, see Palmetto article A55310. For dates of service prior to February 26, 2018, see PH-110.
  • Luxturna: For dates of service May 16, 2019, and after see Palmetto L37863 and A56419. For dates of service prior, see PH-111.
  • Orencia: For dates of service on or after February 26, 2018, see Palmetto article A53066. For dates of service prior to February 26, 2018, see PH-105.
  • Sublocade: For dates of service July 1, 2018, and after, see PH-109. For dates of service prior to July 1, 2018, it is noncovered.
  • Testopel: For dates of service on or after February 26, 2018, see Palmetto article A53793 for gender reassignment services for gender dysphoria. See PH-108 for all other injectable and implantable testosterone services. For dates of service prior to February 26, 2018, see Cahaba LCD L35658 and L35298.
  • White Colony Stimulating Factors: For dates of service on or after February 26, 2018, see Palmetto LCD L37176. For dates of service prior to February 26, 2018, see PH-123.

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-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-0202 Entyvio (vedolizumab)
PH-0207 Ruconest (C1 esterase inhibitor [recombinant])
PH-0273 Cinqair (reslizumab)
PH-0282 Testopel (testosterone pellets)
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-0350 Luxturna (voretigene neparvovec-rzyl)
PH-0355 Trogarzo (ibalizumab-uiyk)
PH-0358 Ilumya (tildrakizumab-asmn)
PH-0362 Crysvita (burosumab-twza)
PH-0427 Ultomiris (ravulizumab-cwvz)
PH-0463 Sublocade (buprenorphine ER injection)
PH-100 Antiemetic Medical Policy Prior Authorization Program Summary (Akynzeo, Aloxi, Cinvanti, Emend IV, Palonosetron, Sustol, Varubi IV)
PH-101 Benlysta Medical Policy Prior Authorization Program Summary
PH-103 Brineura Policy Summary
PH-104 Hereditary Angioedema Policy Summary (Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest, Takhzyro)
PH-105 Health Care Provider Administered Biologic Immunomodulator Program Summary
PH-108 Injectable and Implantable Testosterone Policy Summary (Aveed, Testopel)
PH-109 Injectable Buprenorphine Policy Summary (Sublocade)
PH-110 IV Multiple Sclerosis Medical Policy Prior Authorization Program Summary (Lemtrada, Ocrevus, Tysabri)
PH-111 Luxturna Policy Summary
PH-112 Lysomal Storage Disorders Policy Summary
PH-113 Ocular Angiogenesis Inhibitors Policy Summary (Eylea, Lucentis, Macugen, Visudyne)
PH-116 Soliris and Ultomiris Policy Summary
PH-117 Spinraza Policy Summary
PH-119 Trogarzo Policy Summary
PH-121 Vivitrol Policy Summary
PH-122 Xolair Policy Summary
PH-124 Crysvita Policy Summary
PH-125 H.P. Acthar Policy Summary
PH-126 Injectable Asthma Agents Policy Summary (Nucala, Cinqair, Fasenra)
PH-127 Krystexxa Policy Summary
PH-128 Makena Policy Summary
PH-129 Nplate Policy Summary
PH-130 Radicava Policy Summary
PH-131 Xiaflex Policy Summary
PH-260 Nucala (mepolizumab)