The Physician Administered Drug Program (PDP) covers certain medications that are purchased and administered by a medical professional in office or in an outpatient clinic setting.
As defined by Clinical Coverage Policy 1B, the PDP program primarily covers certain injectable drugs, including biologic agents, immune globulins, vaccines, some implantable drugs and therapeutic radiopharmaceutical agents.
Unless otherwise indicated, the PDP catalog contains procedure codes representing drugs, biologics, devices and vaccines which are only covered for FDA approved indications.
For non-FDA approved indications, please submit an off-label use request, as described below.
No. A full list of approved indications with billing parameters are available in the Physician Administered Drug Program Catalog. Indications approved by the Federal Drug Administration (FDA) are generally covered under the PDP, where coverage is not restricted to receipt from the Outpatient Pharmacy Benefit.
A prior authorization is not required for a Carolina Complete Health provider administering a PDP drug for an FDA approved indication. However, please see coverage limitations in the Physician Administered Drug Program Catalog. Off-labeled use, where not listed on the PDP catalog, requires a case-by-case review via PA request.
Providers who determine the indications or dosing for a particular drug is medically necessary for a member, but those parameters fall outside of the predetermined standards for that drug, may submit member medical records, official compendia or peer-reviewed medical literature supporting its use to Carolina Complete Health.
The preferred and fastest way for providers to submit PDP off-label use medication requests is through the Carolina Complete Health Provider Portal under the service type, “BIOPHARMACY.”
Requests may also be made by faxing our completed Prior Authorization (PA) Request Form (PDF) to 833-465-1703.
Max daily and monthly quantity limits apply to PDP drugs. National Drug Code (NDC) must be included with the Healthcare Common Procedure Coding System (HCPCS) code for the PDP product when billed. Drugs submitted must be manufactured by a company that has signed a National Medical Drug Rebate Agreement with the Centers for Medicare and Medicaid Services (CMS). Crofab, vaccines and radiopharmaceuticals are excepted from the CMS rebate requirement.
Drugs covered through the PDP and the reimbursement rates are available on the Physician Administered Drug Program Fee Schedule.