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PHP Medical & Drug Policies

Archived Drug Determination Policies (DDP)

Archived General Policies (DDP)

Dose Rounding and Wastage (DDP-21)
Policy for dosage rounding
Effective Date: 04.26.2023
Dose Rounding and Wastage (DDP-21)
Policy for dosage rounding
Effective Date: 02.22.2023
Dose Rounding and Wastage (DDP-21)
Policy for dosage rounding
Effective Date: 12.14.2022
Dose Rounding and Wastage (DDP-21)
Policy for dosage rounding
Effective Date: 1/14/2022
Dose Rounding and Wastage (DDP-21)
Policy for dosage rounding
Effective Date: 3/9/2021
Dose Rounding and Wastage (DDP-21)
Policy for dosage rounding
Effective Date: 9/5/2019
Dose rounding
Policy for dosage rounding
Effective Date: 8/22/2018
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: 04.26.2023
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: 02.22.2023
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: 12.14.2022
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: 1/14/2022
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: 06/29/2021
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: 3/09/2021
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: 6/29/2020
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: 10/14/2019
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: 06/4/2019
Policy on Use of Formulary Alternatives
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: 2/27/2019
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
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.
Effective Date: 12.13.2021
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: 10.25.2023
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.
Effective Date: 04.26.2023
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.
Effective Date: 02.22.2023
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.
Effective Date: 11.23.2022
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.
Effective Date: 08/24/2022
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.
Effective Date: 01/14/2022
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.
Effective Date: 3/9/2021
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.
Effective Date: 7/01/2019
Specialty and High Cost Agents (DDP-45)
Subject to benefit design.
Effective Date: 05.02.2022
Specialty and High Cost Agents (DDP-45)
Subject to benefit design.
Effective Date: 06/1/2021
Specialty and High Cost Agents (DDP-45)
Subject to benefit design.
Effective Date: 4/17/2020
Specialty and High Cost Agents
Subject to benefit design.
Effective Date: 7/6/2017

Archived Drug Determination Policies (DDP)

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1301 N. Hagadorn Rd., Suite 1E
East Lansing, MI 48823
517.364.8400 or 800.562.6197

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1400 East Michigan Avenue
Lansing, MI 48912
517.364.8400 or 800.562.6197

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