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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:

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-90098 Denosumab: Prolia®; Jubbonti®; Xgeva®; Wyost®
VP-90449 Herceptin Hylecta™ (trastuzumab and hyaluronidase-oysk)
VP-90057 Trastuzumab: Herceptin®; Ogivri®; Kanjinti®; Trazimera™; Herzuma®; Ontruzant®
VP-90007 Pemetrexed: Alimta®; Pemfexy™; Pemrydi RTU®; Pemetrexed Ψ
VP-990014 Bevacizumab: Avastin®; Mvasi®; Zirabev®; Alymsys®; Vegzelma®; Avzivi®; Jobevne™
VP-90600 Zynlonta® (loncastuximab tesirine-lpyl)
VP-90553 Phesgo™ (pertuzumab, trastuzumab and hyaluronidase-zzxf)
VP-90096 Perjeta® (pertuzumab)
VP-90001 Paclitaxel Albumin-Bound: Abraxane®; Paclitaxel Albumin-Bound Ψ
VP-90583 Margenza® (margetuximab-cmkb)
VP-90092 Kadcyla® (ado-trastuzumab emtansine)
VP-90043 Fulvestrant: Faslodex®; Fulvestrant Ψ (Intramuscular)
VP-90522 Enhertu® (fam-trastuzumab deruxtecan-nxki)
VP-90779 Bizengri® (zenocutuzumab-zbco)
PH-90241 Xeomin® (incobotulinumtoxinA) (Precertification not required)
PH-90240 Myobloc® (rimabotulinumtoxinB)
PH-90239 Dysport® (abobotulinumtoxinA)
PH-90774 Vyloy® (zolbetuximab-clzb)
PH-90633 Xipere® (triamcinolone acetonide injectable suspension)
PH-90181 Visudyne® (verteporfin)
PH-90794 Qfitlia ™ (fitusiran)
VP-90226 Opdivo® (nivolumab)
PH-90117 Ustekinumab: Stelara®; Wezlana™; Selarsdi™; Pyzchiva®; Otulfi™; Imuldosa®; Yesintek™; Steqeyma®; Ustekinumab-aekn§
VP-90682 Tecvayli™ (teclistamab-cqyv)
VP-90722 Talvey™ (talquetamab-tgvs)
VP-90724 Elrexfio™ (elranatamab-bcmm)
VP-90528 Sarclisa® (isatuximab-irfc)
VP-90157 Kyprolis® (carfilzomib)
VP-90268 Empliciti™ (elotuzumab) (Intravenous)
VP-90535 Darzalex Faspro® (daratumumab and hyaluronidase-fihj)
VP-90426 Elzonris™ (tagraxofusp-erzs)
PH-90109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™
PH-90721 Izervay™ (avacincaptad pegol)
VP-90761 Rytelo® (imetelstat)
VP-90014 Bevacizumab: Avastin®; Mvasi®; Zirabev®; Alymsys®; Vegzelma®; Avzivi®; Jobevne™
PH-90549 Uplizna™ (inebilizumab-cdon)
VP-90148 Yervoy™ (ipilimumab) (Intravenous)
PH-90762 Piasky ™ (crovalimab-akkz)
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)
VP-90038 Erbitux® (cetuximab)
PH-90670 Amvuttra (vutrisiran)
PH-90593 Amondys 45™  (casimersen)
PH-90512 Scenesse® (afamelanotide)
VP-90266 Darzalex™ (daratumumab)
PH-90781 Ryoncil® (remestemcel-L-rknd)
PH-90137 Bortezomib Velcade®; Boruzu®; Bortezomib
VP-90707 Omisirge® (omidubicel-onlv)
VP-90004 Adcetris® (brentuximab vedotin)
PH-90080 Leuprolide Suspension: Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Lutrate Depot®; Camcevi™, Leuprolide Acetate Depot(Precertification not required)
PH-90520 Vyondys 53™ (golodirsen)
PH-90660 Enjaymo™ (sutimlimab-jome)
PH-90562 Viltepso™ (viltolarsen)
PH-90635 Dextenza® (dexamethasone insert)
PH-90310 Tremfya® (guselkumab)
VP-90778 Ziihera® (zanidatamab-hrii)
PH-90694 Leqembi™ (lecanemab-irmb)
PH-90712 Vyvgart® Hytrulo (efgartigimod alfa-fcab and hyaluronidase-qvfc)
PH-90688 Hemgenix® (etranacogene dezaparvovec-drlb)
PH-90481 Spravato® (esketamine)
PH-90579 Oxlumo® (lumasiran)
PH-90514 Givlaari (givosiran)
PH-90598 Abecma® (idecabtagene vicleucel)