Draft Provider-Administered Drug Policies
There are currently no policies in draft status.
Comment on Draft Policies
To ensure that the development of medical policies occurs through an open, collaborative process, we welcome comments about medical policies that are in the draft stage.
Participating providers are invited to submit scientific, evidence-based information, professional consensus opinions, and other information supported by medical literature relevant to these draft policies for consideration. Comments are accepted for 45 days from the posting date listed on the draft policy.
Make sure your voice is heard by providing feedback directly to us through one of the following methods:
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Send comments by mail or fax to:
Patrius Health
Attn: Health Management - Medical Policy
P.O. Box 12364
Birmingham, AL 35202-2364
Fax: 205-220-0878
| Policy # |
Policy Title |
Print View |
| PH-90712 |
Vyvgart® Hytrulo (efgartigimod alfa-fcab and hyaluronidase-qvfc) |
|
| PH-90649 |
Vyvgart™ (efgartigimod alfa-fcab) |
|
| PH-90549 |
Uplizna™ (inebilizumab-cdon) |
|
| PH-90427 |
Ultomiris® (ravulizumab-cwvz) |
|
| PH-90714 |
Rystiggo® (rozanolixizumab-noli) |
|
| PH-90762 |
Piasky ™ (crovalimab-akkz) |
|
| PH-90797 |
Imaavy™ (nipocalimab-aahu) |
|
| PH-90114 |
Eculizumab: Soliris®; Bkemv™; Epysqli® |
|
| VP-90057 |
Trastuzumab: Herceptin®; Ogivri®; Kanjinti®; Trazimera™; Herzuma®; Ontruzant® |
|
| VP-90007 |
Pemetrexed: Alimta®; Pemfexy™; Pemrydi RTU®; Pemetrexed Ψ |
|
| VP-90014 |
Bevacizumab: Avastin®; Mvasi®; Zirabev®; Alymsys®; Vegzelma®; Avzivi®; Jobevne™ |
|
| VP-90130 |
Bendamustine: Treanda®; Bendeka®; Belrapzo®; Vivimusta™; Bendamustine Ψ |
|
| VP-90550 |
Zepzelca® (lurbinectedin) |
|
| VP-90161 |
Zaltrap® (ziv-aflibercept) |
|
| VP-90257 |
Yondelis® (trabectedin) |
|
| PH-90794 |
Qfitlia ™ (fitusiran) |
|
| VP-90001 |
Paclitaxel Albumin-Bound: Abraxane®; Paclitaxel Albumin-Bound Ψ |
|
| PH-90697 |
Syfovre™ (pegcetacoplan) |
|
| VP-90072 |
Ixempra® (ixabepilone) |
|
| PH-90634 |
Susvimo™ (ranibizumab) |
|
| VP-90055 |
Halaven® (eribulin) |
|
| PH-90078 |
Ranibizumab: Lucentis®; Byooviz™; Cimerli™ |
|
| PH-90260 |
Nucala® (mepolizumab) |
|
| VP-90547 |
Evomela® (melphalan) |
|
| VP-90686 |
Elahere™ (mirvetuximab soravtansine-gynx) |
|
| PH-90497 |
Beovu® (brolucizumab-dbll) |
|
| VP-90199 |
Cyramza® (ramucirumab) |
|
| PH-90080 |
Leuprolide Suspension: Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Lutrate Depot®; Camcevi™, Leuprolide Acetate Depot; Vabrinty™(Precertification not required) |
|
| PH-90774 |
Vyloy® (zolbetuximab-clzb) |
|
| PH-90117 |
Ustekinumab: Stelara®; Wezlana™; Selarsdi™; Pyzchiva®; Otulfi™; Imuldosa®; Yesintek™; Steqeyma®; Starjemza™; Ustekinumab-aekn§; Ustekinumab-ttwe§; Ustekinumab- aauz§; Ustekinumab-stba§; Ustekinumab§ |
|
| PH-90098 |
Denosumab: Prolia®; Jubbonti®; Ospomyv™; Stoboclo®; Denosumab-dssb; Conexxence®; Denosumab-bnht; Xgeva®; Wyost®; Xbryk™; Osenvelt®; Bomyntra® |
|
| VP-90785 |
Datroway® (datopotamab deruxtecan-dlnk) (Intravenous) |
|
| PH-90059 |
SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, Gammagard Liquid ERC®, Gamunex®-C, Gammaked®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify® |
|
| VP-0803 |
Lynozyfic™ (linvoseltamab-gcpt) |
|
| PH-90071 |
Immune Globulins (immunoglobulin): Alyglo™; Bivigam®; Flebogamma®; Gamunex-C®; Gammagard® Liquid; Gammagard® S/D; Gammagard Liquid ERC®; Gammaked™; Gammaplex®; Octagam®; Privigen®; Panzyga®, Yimmugo® |
|
| PH-90525 |
Tepezza® (teprotumumab-trbw) |
|
| PH-90207 |
Ruconest® (C1 Esterase Inhibitor [recombinant]) |
|
| PH-90109 |
Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™ |
|
| PH-90167 |
Kalbitor® (ecallantide) |
|
| PH-90421 |
Gamifant™ (emapalumab-lzsg) |
|
| PH-90591 |
Evkeeza™ (evinacumab-dgnb) |
|
| VP-90724 |
Elrexfio™ (elranatamab-bcmm) |
|
| VP-90225 |
Blincyto® (blinatumomab) |
|
| VP-90136 |
Vectibix® (panitumumab) (Intravenous) |
|
| VP-90607 |
Rybrevant® (amivantamab-vmjw) |
|
| VP-90267 |
Portrazza™ (necitumumab) |
|
| VP-90559 |
Monjuvi® (tafasitamab-cxix) |
|
| VP-90038 |
Erbitux® (cetuximab) |
|
| VP-90266 |
Darzalex™ (daratumumab) |
|
| VP-90004 |
Adcetris® (brentuximab vedotin) |
|
| PH-90713 |
Elevidys® (delandistrogene moxeparvovec-rokl) |
|
| PH-90307 |
Haegarda® (C1 Esterase Inhibitor Subcutaneous [Human]) |
|
| PH-90168 |
Cinryze® (C1 Esterase Inhibitor, Human) |
|
| PH-90018 |
Berinert® (C1 Esterase Inhibitor, Human) |
|
| PH-90392 |
Takhzyro™ (lanadelumab-flyo) |
|
| PH-90120 |
Synagis® (palivizumab) |
|
| PH-90481 |
Spravato® (esketamine) |
|
| PH-90652 |
Leqvio® (inclisiran) |
|
| PH-90763 |
Kisunla™ (donanemab-azbt) |
|
| PH-90061 |
Hyaluronic Acid Derivatives: Durolane®, Euflexxa™, Gel-One®, GelSyn-3™, GenVisc 850®, Hyalgan™, Hymovis®, Monovisc®, Orthovisc™, Synojoynt, Supartz/Supartz FX™, Synvisc™, Synvisc-One™, Triluron™, TriVisc™, VISCO-3™ |
|
| PH-90169 |
Firazyr® (icatibant) |
|
| PH-90003 |
Corticotropin-ACTH: Acthar® Gel (repository corticotropin injection) Cortrophin® Gel (repository corticotropin injection) |
|
| PH-97044 |
Casgevy™ (exagamglogene autotemcel) |
|
| VP-0795 |
Penpulimab-KCQX (penpulimab-kcqx) |
|
| PH-90721 |
Izervay™ (avacincaptad pegol) |
|
| PH-90524 |
Monoferric™ (ferric derisomaltose) |
|
| PH-90503 |
Reblozyl® (luspatercept-aamt) |
|
| PH-90312 |
Injectafer® (ferric carboxymaltose injection) |
|
| PH-90234 |
Long-Acting Granulocyte Colony Stimulating Factors (LA-gCSF): Neulasta®; Fulphila®; Udenyca®; Ziextenzo®; Nyvepria™; Fylnetra®; Stimufend®; Rolvedon®; Ryzneuta®; Pegfilgrastim-fpgk§ |
|
| PH-90284 |
Exondys 51™ (eteplirsen) |
|
| PH-90670 |
Amvuttra (vutrisiran) |
|
| PH-90593 |
Amondys 45™ (casimersen) |
|
| PH-90512 |
Scenesse® (afamelanotide) |
|
| PH-90781 |
Ryoncil® (remestemcel-L-rknd) |
|
| PH-90137 |
Bortezomib Velcade®; Boruzu®; Bortezomib |
|
| PH-90520 |
Vyondys 53™ (golodirsen) |
|
| PH-90660 |
Enjaymo™ (sutimlimab-jome) |
|
| PH-90562 |
Viltepso™ (viltolarsen) |
|
| PH-90310 |
Tremfya® (guselkumab) |
|
| VP-90778 |
Ziihera® (zanidatamab-hrii) |
|
| PH-90694 |
Leqembi™ (lecanemab-irmb) |
|
| PH-90688 |
Hemgenix® (etranacogene dezaparvovec-drlb) |
|
| PH-90579 |
Oxlumo® (lumasiran) |
|
| PH-90514 |
Givlaari (givosiran) |
|
| PH-90598 |
Abecma® (idecabtagene vicleucel) |
|
