Drug Determination Policies (DDP)

Our goal is to optimize patient outcomes through the use of medications that have established efficacy and safety data while also providing the greatest value. Certain drugs on the formulary require prior authorization, and will not be approved for payment until the conditions for approval of the drug are met and the authorization has been entered into the system. Below is a list of medications that require prior authorization. Click on the policy to open the criteria required for approval.

General Policies (DDP)




• Dose Rounding and Wastage (DDP-21)

  Policy for dosage rounding
  Effective Date: 02.28.2024

• 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: 02.28.2024

• 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.
  
  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
  
  Effective Date: 02.28.2024

• 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.
  
  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
  
  Effective Date: 08.23.2023



Drug Determination Policies (DDP)




• Acthar Gel (DDP-34)

  Acthar
  Effective Date: 10.25.2023

• Afinitor (DDP-14)

  Afinitor
  Effective Date: 04.26.2023

• Allergic and Asthma Agents (Specialty DDP-27)

  Adbry, Cinqair, Dupixent, Fasenra, Nucala, Tezspire, Xolair
  Effective Date: 04.24.2024

• Anticonvulsants (Third-generation ) (DDP-36)

  Aptiom, Briviact, Clobazam, Diacomit, Epidiolex, Fintepla, Fycompa, Gabitril, Onfi, Sabril, Sympazan, Tiagabine, Vigabatrin, Xcopri
  Effective Date: 06.28.2023

• Antilipemic Agents (Specialty DDP-26)

  Praluent, Repatha, Leqvio, Evkeeza
  Effective Date: 02.28.2024

• Botulinum Toxin (DDP-31)

  Botox, Dysport, Jeuveau, Myobloc, Xeomin
  Effective Date: 06.28.2023

• CAR-T Cell Immunotherapy (DDP-38)

  Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta
  Effective Date: 12.13.2023

• CGRP Antagonists (DDP-47)

  Aimovig, Ajovy, Emgality, Nurtec, Qulipta, Ubrelvy, Vyepti, Zavzpret
  Effective Date: 12.13.2023

• Complement Inhibitors ​(DDP-03)

  Empaveli, Soliris, Ultomiris
  Effective Date: 12.13.2023

• Diabetic Agents - Non-Insulin (DDP-43)

  Adlyxin, Alogliptin, Brenzavvy, Byetta/Bydureon, Farxiga, Inpefa, Invokana, Januvia, Jardiance, Mounjaro, Nesina, Onglyza, Ozempic, Rybelsus, Saxagliptin, Steglartro, Tradjenta, Trulicity, Victoza
  Effective Date: 10.25.2023

• Entyvio (DDP-20)

  Entyvio
  Effective Date: 08.23.2023

• Erythropoietin Stimulating Agents (ESAs) (DDP-18)

  Aranesp, Epogen, Mircera, Procrit, Retacrit
  Effective Date: 04.26.2023

• Gastrointestinal (GI) Agents (Miscellaneous DDP-04)

  Dificid, Lotronex, Viberzi, Xifaxan
  Effective Date: 02.28.2024

• Gonadotropin-Releasing Hormone Receptor Antagonists (DDP-44)

  Oriahnn, Orilissa, Myfembree
  Effective Date: 02.28.2024

• Growth Hormones (DDP-05)

  Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Zomacton
  Effective Date: 10.25.2023

• Hereditary Angioedema Agents (DDP-30)

  Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest, Takhzyro
  Effective Date: 12.13.2023

• Immune globulin (DDP-16)

  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
  Effective Date: 02.28.2024

• Interleukin Inhibitors (DDP-11)

  Actemra, Cosentyx, Ilumya, Kevzara, Siliq, Skyrizi, Stelara, Taltz, Tremfya
  Effective Date: 08.23.2023

• Janus Kinase Inhibitors (DDP-41)

  Cibinqo, Rinvoq, Xeljanz
  Effective Date: 08.23.2023

• Gene Therapy Agents (DDP-39)

  Evrysdi, Luxturna, Zolgensma
  Effective Date: 12.13.2023

• Movement Disorder Agents (DDP-50)

  Austedo, Ingrezza, Xenazine
  Effective Date: 06.28.2023

• Multiple Sclerosis Agents (DDP-35)

  Bruimvi, Dalfampridine, Mavenclad, Ocrevus, Tysabri, Zeposia
  Effective Date: 06.28.2023

• Ophthalmic Specialty Agents (DDP-46)

  Oxervate and Tepezza
  Effective Date: 10.25.2023

• Orencia (DDP-09)

  Orencia
  Effective Date: 08.23.2023

• Osteoporosis Agents (DDP-33)

  Evenity, Forteo, Prolia, Reclast, Tymlos
  Effective Date: 10.25.2023

• Otezla (DDP-10)

  Otezla
  Effective Date: 08.23.2023

• Oxlumo (DDP-51)

  Oxlumo
  Effective Date: 10.25.2023

• Plasminogen Deficiency: Ryplazim (DDP-53)

  Ryplazim
  Effective Date: 04.26.2023

• Pulmonary Arterial Hypertension (PAH) Drugs ​(DDP-29)

  Adcirca, Adempas, Flolan, Letaris,Opsumit, Orenitram, Remodulin, Revatio, Tracleer, Tyvaso, Uptravi, Veletri, Ventavis
  Effective Date: 12.13.2023

• Pulmonary Fibrosis Agents (DDP-24)

  Esbriet, Ofev
  Effective Date: 10.25.2023

• Rituximab (Rituxan) (DDP-17)

  Rituxan, Rituxan Hycela, Ruxience, Truxima, Riabni
  Effective Date: 04.26.2023

• Scenesse (DDP-48)

  Scenesse
  Effective Date: 02.28.2024

• Sleep Disorder Agents (DDP-32)

  Lumryz, Sunosi, Wakix, Xyrem, Xyvav, Xywav
  Effective Date: 12.13.2023

• Spravato (DDP-54)

  Spravato
  Effective Date: 06.28.2023

• Synagis (DDP-28)

  Synagis
  Effective Date: 12.13.2023

• 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

• Uridine Triacetate (DDP-23)

  Vistogard, Xuriden
  Effective Date: 04.26.2023

• Chronic Weight Management​ (DDP-25)

  Alli/Xenical, Contrave, Qsymia, Saxenda, Wegovy, Zepbound
  Effective Date: 02.28.2024