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March 2026 Provider News

Date: 03/31/26

In this issue: 

  • General Updates - OneHealthPort connection ending April 30th, Cultural Humility Annual Reminder, Mental Health EBP
  • Quality - Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents, Well-Child Visits in the First 30 Months of Life (W30), Adolescent Immunization Action Week – Apri 6-10, HEDIS resources, CAHPS Measure of the Month: Access to Care, Wellcare quality
  • Tribal - Resource for Assistance
  • Behavioral Health - Prior Auth updates eff 07/01/2026
  • Clinical & Payment Policies and Prior Authorization Updates - Clinical Policy and Prior Authorization Updates
  • Wellcare - 6 degrees health
  • Apple Health Core Connections  - EPSDT Higher Rate with TJ Modifier
  • Training/Education - No-Cost TF-CBT Training on May 4-5
  • Pharmacy Updates - NPI Prescriber Enforcement for Pharmacy Claims, Concurrent Use of a GLP-1 Receptor Agonist & DPP-4 Inhibitor, Pharmacy Clinical Policy Updates

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General Updates

Provider Portal Access Update: OneHealthPort Connection Ending April 30th

Effective the evening of April 30, the OneHealthPort connection for all Coordinated Care portals will be retired. Starting May 1, please access the Provider Portal(s) via Availity or by using the direct portal links.

No action is needed prior to May 1, and Provider Portal functionality will remain available.

What you need to do

Questions or need support? The Resources Catalogue within Availity is a great place to start – look under Help and Training in the top right corners.  You can always contact your Provider Engagement representative, we’re here to help.

Annual Training Reminder: Culturally Appropriate Care

We appreciate the important role you play in delivering care that respects each patient’s cultural background, preferences, and experiences. Ongoing cultural humility training supports strong communication and patient‑centered care.

If you haven’t already, please complete your annual cultural humility training. Below are accredited training options available to support you:

Culturally Appropriate Care & Health Equity
Centene Clinical Training (1 CE Credit)
Culturally Appropriate Care & Health Equity | Centene Clinical Training (1 CE Credit)

Centene Institute Training Catalog
CenteneInstitute.com/catalog

Have questions or need assistance? We’re here to help:
Provider Services:  1-877-644-4613 (TTY: 711) (8 am - 5 pm PT)

Mental Health EBP Reporting for Behavioral Health Providers

Coordinated Care would like to remind all clinics and providers who deliver Children’s Mental Health Evidence Based Practices (EBPs) to clients under age 18 that they should include the appropriate SERI code for Mental Health providers when billing for these services. EBP codes are specially designated identifiers on a claim or encounter that are used to report specific research- or evidence-based practices for children’s public mental health care provided by licensed or certified mental health providers to children and youth under 18 in Washington State. Coordinated Care is required by law to track and report to HCA quarterly all children’s mental health visits and how many of these visits were billed as an Evidence Based Practice. EBP codes and all associated history and criteria can be found in the Evidence-Based Practices Reporting Guide (PDF). The utilization of EBP codes does not impact payment of your claims. Coordinated Care will not deny any claims due to EBP code utilization. Additionally, please know that billing correctly also helps Coordinated Care to be able to refer new clients to you for Evidence Based Practices.

Please reach out to your Provider Network Specialist if you have any questions/concerns about billing with EBP codes.

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Quality

Medicaid Quality

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)

Below are the ICD-10 codes that can be used to close the WCC care gap.

WCC Component

ICD-10 Code

BMI <5TH percentile

Z68.51

BMI 5TH to <85th percentile

Z68.52

BMI 85th to <95th percentile

Z68.53

BMI > or = to 95th percentile

Z68.54

Nutritional Counseling

Z71.54

Physical Activity Counseling

Z71.82, Z02.5

Well-Child Visits in the First 30 Months of Life (W30)

A total of eight well-care visits is recommended from the time the child is born to the time they reach 15 months old. The visits that occur before the 15-month birthday are of particular importance because this is the period when an infant undergoes substantial changes in abilities, physical growth, motor skills, hand-eye coordination and social and emotional growth. They are foundational to preventive health care, such as evidence-based screenings and immunizations, because they promote better social, developmental and health outcomes.

Well-Child Visits in the First 30 Months of Life (W30) - NCQA

Adolescent Immunization Action Week – Apri 6-10 

Adolescent Immunization Action Week (April 6–10) highlights the vital role healthcare providers play in keeping adolescents healthy by ensuring they are up to date on recommended vaccines. Trusted, clear, and compassionate guidance from providers is especially important now, as parents rely on them to navigate information and make science‑based decisions for their adolescents’ health.

HEDIS Help – Immunizations for Adolescents (IMA-E)

Coordinated Care of Washington, Inc. would like to help improve your quality scores on the Immunizations for Adolescents (IMA-E) Healthcare Effectiveness Data and Information Set (HEDIS) measure that assesses the percentage of teens 13 years old who received the following vaccines prior to their 13th birthday:

Vaccine

Routine Recommendation

Tdap

1 dose at age 11–12 years

HPV (Human Pap

2-dose series starting at age 9–14 (0, 6–12 months)

MenACWY (Meningococcal ACWY)

1 dose at 11–12 years

The Washington State Department of Health in alignment with the West Coast Health Alliance continues to recommend the American Academy of Pediatrics (AAP) Recommended Child and Adolescent Immunization Schedule (PDF).

HEDIS Help – Prenatal and Postpartum Care (PPC)

The PPC Healthcare Effectiveness Data and Information Set (HEDIS) measure assesses the percentage of deliveries that received a prenatal care visit in the first trimester and a postpartum visit on or between 7-84 days after delivery with an OBGYN or PCP.

Providers are required to use the most appropriate global, bundled, or individual maternity CPT codes as directed by the HCA’s most recent Pregnancy Related Services Billing Guide. Adding the CPT Category II “F” code as a no-charge line item can help to identify and document prenatal and postpartum visits and close prenatal and postpartum care gaps.

PPC Visit Type

CPT Category II “F” Code

Initial Prenatal Care Visit

0500F

0501F – if prenatal flow sheet is documented in the medical record during the first prenatal visit

Subsequent Prenatal Care Visit

0502F – should not be used for non-pregnancy related visits

Postpartum Care Visit

0503F


Clinical Tools and Materials

If you need additional materials, staff training, or updated community resources, please reach out to the Quality team at Coordinated Care.

Upper Respiratory Infection Resources

According to the CDC 30% of outpatient antibiotic prescriptions in the US are unnecessary. Approximately half of outpatient antibiotic prescribing in humans may be inappropriate. Patients who are unnecessarily exposed to antibiotics are placed at risk for those adverse events with no benefit. By reducing unnecessary antibiotic prescribing, antimicrobial stewardship programs can prevent avoidable adverse events resulting from antibiotics.

Clinician Checklist for Outpatient Antibiotic Stewardship: The Core Elements of Outpatient Antibiotic Stewardship (PDF)

Facility Checklist for Outpatient Antibiotic Stewardship: The Core Elements of Outpatient Antibiotic Stewardship (PDF)

Core Elements of Antibiotic Stewardship for Nursing Homes: core-elements-outpatient-508.pdf (PDF)

Source: Resources for Outpatient Clinics | Washington State Department of Health

Low Back Pain

The percentage of persons 18–75 years of age with a principal diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.

Clinical guidelines for treating patients with acute low back pain strongly recommend against the use of imaging in the absence of “red flags” (i.e., indications of a serious underlying pathology such as a fracture or tumor)4. Routine imaging is problematic because it is not associated with improved outcomes and exposes patients to harms such as radiation exposure and unnecessary treatment5. Red flag conditions include history of cancer, osteoporosis and IV drug use.

Use of Imaging Studies for Low Back Pain (LBP) - NCQA

Chlamydia Screening - HEDIS

The percentage of persons 16–24 years of age who were recommended for routine chlamydia screening, were identified as sexually active and had at least one test for chlamydia during the measurement period.

Chlamydia Screening (CHL) - NCQA

Eye Exam for Patients with Diabetes- HEDIS

Diabetes is the leading cause of blindness in people 18–64 years old—and there are often no obvious signs or symptoms.

Eye Health and Diabetes | ADA

Eye Exam for Patients With Diabetes (EED) - NCQA

CAHPS Measure of the Month: Access to Care

Access to medical care, including primary care and specialist services, are key elements of quality care.

Each year, the CAHPS® survey asks questions like:

  • In the last 6 months, how often did you get an appointment to see a specialist as soon as you needed?
  • In the last 6 months, how often was it easy to get the care, tests or treatment you needed?
  • In the last 6 months, when you needed care right away, how often did you get care as soon as you needed?
  • In the last 6 months, how often did you get an appointment for a check-up or routine care as soon as you needed?

Ensure your patients are satisfied with their ease of access by:

  • Seeing patients within access and availability standards
  • Scheduling appointments in a reasonable window for each request
  • Following up with patients after referral to specialists to ensure care is coordinated
  • Ensuring all information for specialists, tests, and procedure authorizations is provided and following up as necessary
  • Reducing time in the waiting room to no more than 15 minutes from appointment time

Helpful tips to provide the needed care to your patients: Coordinated Care continually monitors and evaluates measures that reflect appropriate coordination of care practices. These include:

  • Reviewing medications with your patients
  • Offering to schedule specialist and lab appointments while your patients are in the office
  • Reminding your patients about annual flu shots and other immunizations
  • Making sure your patients know you also are working with specialists on their care. Ensure you receive notes from specialists about the patient’s care and reach out to specialists if you have not gotten consultation notes. Follow up on all authorizations requested for your patient. Tell your patient the results of all test and procedures. 
  • Contacting your patients to remind them when it’s time for preventive care services such as annual wellness exams, recommended cancer screenings, and follow-up care for ongoing conditions such as hypertension and diabetes

Quick Tips on Improving Access to Care

At Coordinated Care, we value everything you do to deliver quality care to our patients and ensure they have a positive healthcare experience.

Below are some tips you can reference to improve on the quality measures listed below:

Getting Needed Care

  • For urgent specialty appointments, office staff might be able to help patients coordinate with the appropriate specialty office
  • If a patient portal is available, encourage patients and caregivers to view results there

Getting Appointments and Care Quickly

  • Maintain an effective triage system to ensure that frail and/or very sick patients are seen right away or provide alternate care via phone and urgent care
  • For patients who want to be seen on short notice but cannot access their doctor, offer appointments with a nurse practitioner or physician assistant
  • Ensure a few open appointments each day are available to accommodate urgent visits
  • Keep patients informed if there is a longer wait time and give them the opportunity to reschedule
  • Remind patients of other healthcare options, like Telehealth and 24/7 Nurse Lines.

Wellcare Quality

2026 Preferred Glucose Meters and Test Strips

2026 Preferred Blood Glucose Meters and Strips

Restrictions

Blood Glucose Monitors

  • Accu-Chek Guide Meter     
  • True Metrix Meter*
  • Accu-Chek Guide Me Meter   
  • True Metrix Air Meter*
Quantity Limit:
  • 1 meter kit per 365 days (1 per calendar year)
  • 4 strips per day

Test Strips

  • Accu-Chek Guide       
  • True Metrix*

 *Includes Relion labeled products

Continuous Glucose Monitoring (CGM) Systems

  • FreeStyle Libre or DexCom are preferred–PA required
  • PA criteria (ALL 1–4):
    1. DM diagnosis.
    2. Insulin-treated, OR has problematic hypoglycemia documented by ONE (a. OR b.) of the following:
      • More than one level 2 hypoglycemic event (BG < 54 mg/dL) that persists despite more than one attempt to adjust medications and/or modify diabetes treatment plan. OR
      • One level 3 hypoglycemic event (BG <54 mg/dL) characterized by altered mental and/or physical state requiring third-party assistance for treatment.
    3. Seen by provider in last 6 months.
    4. Will have follow-up appointments every 6 months to document adherence to both the CGM regimen and diabetes treatment plan. The Coverage Determination form for PA request is available on our website.

Formulary Coverage of Diabetes Medications

  • Subject to evidence of coverage
  • Tiers 3–5: Deductibles will apply
  • Tier 6: Initial Coverage
    • $0 copay of all other plans
  • D-SNP plans: $0 copays across all phases of coverage
  • No coverage gap (donut hole) in 2026
  • Max $35 monthly for insulin products

Drug Class

Medications

Wellcare Dual Liberty Sync, Wellcare Dual Access, Wellcare Dual Reserve

(HMO-POS D-SNP)

Wellcare Giveback, Wellcare Simple (HMO-POS)

Wellcare Dual Liberty Sync Open, Wellcare Dual Access Open (PPO D-SNP)

Wellcare Simple Open (PPO)

Insulins

Fast Acting: Merilog U-100, Merilog SoloStar U-100, NovoLog FlexPen U-100, NovoLog U-100, NovoLog Penfill U-100, Fiasp FlexTouch U-100, Fiasp U-100, Fiasp Penfill U-100

Tier 3

Tier 3

Tier 3

Tier 3

Short Acting: Humulin R KwikPen U-500, Novolin R FlexPen U-100, Novolin R U100

Tier 3

Tier 3

Tier 3

Tier 3

Intermediate Acting: Novolin N FlexPen U-100, Novolin N U-100

Tier 3

Tier 3

Tier 3

Tier 3

Long Acting: Insulin Glargine Max SoloStar U-300, Insulin Glargine SoloStar U-300, Insulin Glargine-yfgn U-100, Insulin Glargine-yfgn U-100

Tier 3

Tier 3

Tier 3

Tier 3

Combinations: NovoLog Mix 70-30 FlexPen, NovoLog Mix 70-30 vial, Novolin 70-30 FlexPen, Novolin 70-30

Tier 3

Tier 3

Tier 3

Tier 3

Other Insulin Combinations: Soliqua

Tier 3

Tier 3

Tier 3

Tier 3

Orals

·        Biguanide: Metformin, Metformin ER (generic for Glucophage XR only)

·        2nd Generation Sulfonylurea:

Glipizide, Glipizide XR, Glimepiride

Thiazolidinedione: Pioglitazone

Alpha-Glucosidase inhibitor:

Acarbose

Meglitinide analogue: Nateglinide, Repaglinide

Combinations: Glipizide/Metformin, Pioglitazone/Metformin, Pioglitazone/ Glimepiride

Tier 6

Tier 6

Tier 6

Tier 6

DPP-4

Inhibitors

Januvia, Tradjenta, Saxagliptan

Tier 3

Tier 3

Tier 3

Tier 3

Combinations with DPP-4 Inhibitors

Glyxambi, Trijardy, Janumet, Janumet XR, Jentadueto, Jentadueto XR

Tier 3

Tier 3

Tier 3

Tier 3

SGTL2

Inhibitors

Farxiga, Jardiance, Invokana

Tier 3: Farxiga, Jardiance, Invokana

Tier 3: Farxiga, Jardiance

Tier 4: Invokana

Tier 3: Farxiga, Jardiance, Invokana

Tier 3: Farxiga, Jardiance

Tier 4: Invokana

Combinations with SGLT-2 Inhibitors

Xigduo, Glyxambi, Synjardy, Synjardy XR, Trijardy, Invokamet, Invokamet XR

Tier 3

Tier 3: Xigduo, Glyxambi, Synjardy, Synjardy XR, Trijardy

Tier 4: Invokamet, Invokamet XR

Tier 3

Tier 3: Xigduo, Glyxambi, Synjardy, Synjardy XR, Trijardy

Tier 4: Invokamet, Invokamet XR

GLP-1

Agonists

Ozempic, Mounjaro, Rybelsus, Trulicity

Tier 3

Tier 3

Tier 3

Tier 3

Breast Cancer Screening-HEDIS

This HEDIS measure assesses women 50–74 years of age who had at least one mammogram to screen for breast cancer in the past two years.

The Breast Cancer Screening measure is also available in an ECDS format. Please visit ECDS webpage and NCQA Store for more information.

American Cancer Society. 2017. “American Cancer Society Recommendations for the Early Detection of Breast Cancer.” Source (PDF)

Eye Exam for Patients with Diabetes- HEDIS

Diabetes is the leading cause of blindness in people 18–64 years old—and there are often no obvious signs or symptoms.

Eye Health and Diabetes | ADA

Eye Exam for Patients With Diabetes (EED) - NCQA

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Tribal

Resource for Assistance

IHCPs have access to a dedicated email inbox for inquires regarding all lines of business at Coordinated Care (Medicaid, Marketplace/Exchange, and Medicare Advantage). Please don’t hesitate to reach out to IndianHealthCareProviderAssistance@coordinatedcarehealth.com and the team monitoring the inbox will assist or connect you with the appropriate contacts to resolve your questions.

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Behavioral Health

Important Prior Authorization Updates - (Effective July 1, 2026)

As part of our ongoing work to improve the prior authorization (PA) process for providers and members, Coordinated Care of Washington, Inc. wants to share some important updates to our PA requirements. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care.

Code change details are noted in the table below. The changes may include:

  • Removing PA requirements based on criticality of review and clinical need
  • Creating a more uniform set of PA requirements across our markets and lines of businesses, including adding and changing some PA requirements, to simplify processes, reduce confusion for providers, and support future efforts to expand real-time responses to requests.

For questions about specific prior authorization codes or how these changes may affect your practice, please reach out to your Provider Engagement representative.

Service Category

PA Rule

Services

Procedure codes

Behavioral Health

PA Required after 8 hours per calendar year limit across codes 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139 and 96146

 

Psychological & Neuropsychological Testing

96138, 96139, 96146

 

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Clinical & Payment Policies and Prior Authorization Updates

Clinical Policy Updates 

The following policies are updated as of the listed Effective Date.

Policies are posted on the Coordinated Care of Washington Policy webpage. Evolent policies are available here and will be accessible via the Evolent landing page found on the Coordinated Care Prior Authorization webpage. 

New to List?

Policy #

Policy Title

Line of Business

Change Type

Effective Date

X

CP.MP.100

Allergy Testing and Therapy

Apple Health, Ambetter 

Revised

4/1/2026

X

CP.MP.106

Endometrial ablation

Apple Health, Ambetter 

Revised

4/1/2026

X

CP.MP.110

Bronchial Thermoplasty

Apple Health, Ambetter 

Revised

4/1/2026

X

CP.MP.113

Holter Monitors

Apple Health, Ambetter 

Revised

4/1/2026

X

CP.MP.121

Homocysteine Testing

Apple Health, Ambetter 

Revised

4/1/2026

X

CP.MP.123

Excimer Laser Therapy for Skin Conditions

Apple Health, Ambetter 

Revised

4/1/2026

X

CP.MP.134

Evoked Potential Testing

Apple Health, Ambetter 

Revised

4/1/2026

X

CP.MP.139

Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy

Ambetter

Revised

4/1/2026

X

CP.MP.143

Wireless Motility Capsule

Ambetter 

Revised

4/1/2026

X

CP.MP.152

Vitamin D Testing

Apple Health, Ambetter 

Revised

4/1/2026

X

CP.MP.153

H. Pylori Testing

Apple Health, Ambetter 

Revised

4/1/2026

X

CP.MP.154

Thyroid Hormones and Insulin Testing in Pediatrics

Apple Health, Ambetter 

Revised

4/1/2026

X

CP.MP.155

EEG in Evaluation of Headache

Apple Health, Ambetter 

Revised

4/1/2026

X

CP.MP.156

Cardiac Biomarker Testing for Acute MI

Apple Health, Ambetter 

Revised

4/1/2026

 

CP.MP.185

Skin Substitutes for Chronic Wounds

Ambetter 

Revised

4/1/2026

 

CP.MP.188

Pediatric Oral Function Therapy

Apple Health, Ambetter 

Revised

4/1/2026

 

CP.MP.247

Transplant Service Documentation Requirements

Apple Health, Ambetter 

Revised

4/1/2026

 

CP.MP.248

Facility Based Sleep Studies for Obstructive Sleep Apnea

Ambetter 

Revised

4/1/2026

X

CP.MP.50

Drugs of Abuse:  Definitive Testing

Apple Health, Ambetter 

Revised

4/1/2026

X

WA.CP.MP.515

Fecal Microbiota Transplantation

Apple Health, Ambetter 

Revised

4/1/2026

X

WA.CP.MP.526

Stem Cell Therapy for Musculoskeletal Conditions

Apple Health, Ambetter 

Revised

4/1/2026

 

CP.BH.105

Applied Behavioral Analysis Documentation Requirements

Apple Health, Ambetter 

Revised

5/1/2026

 

CP.MP.168

Biofeedback

Ambetter 

Revised

5/1/2026

 

CP.MP.180

Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

Ambetter 

Revised

5/1/2026

 

CP.MP.185

Skin Substitutes for Chronic Wounds

Ambetter 

Revised

5/1/2026

 

CP.MP.190

Outpatient Oxygen Use

Ambetter 

Revised

5/1/2026

 

CP.MP.91

Obstetrical Home Health Care Programs

Ambetter 

Revised

5/1/2026

 

WA.CP.MP.117

Peripheral and Percutaneous Electrical Nerve Stimulation

Apple Health, Ambetter 

Revised

5/1/2026

 

CP.BH.124

ADHD Assessment and Treatment

Apple Health, Ambetter 

Revised

6/1/2026

 

CP.MP.38

Ultrasound in Pregnancy

Apple Health

Revised

6/1/2026

 

WA.CP.MP.38

Ultrasound in Pregnancy

Ambetter

Revised

6/1/2026

 

ECG_7000

Evolent - Radiation Therapy Services

Ambetter

New

6/1/2026

 

ECG_7001

Evolent - Proton Beam Radiation Therapy and Neutron Beam Radiation Therapy Services

Ambetter

New

6/1/2026


Prior Authorization Updates

Future changes to Pre-Authorization requirements are noted below. Utilize our Pre-Auth Check tool for real time response to pre-authorization requirements.

Code

Description

Line of Business

Effective Date

Notes

96130

PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR

Apple Health

4/1/2026

PA Required for greater than 8 hours per calendar year and all non-Behavioral Health diagnoses

96131

PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR

Apple Health

4/1/2026

PA Required for greater than 8 hours per calendar year and all non-Behavioral Health diagnoses

96132

NEUROPSYCHOLOGICAL TST EVAL PHYS/QHP 1ST HOUR

Apple Health

4/1/2026

PA Required for greater than 8 hours per calendar year and all non-Behavioral Health diagnoses

96133

NEUROPSYCHOLOGICAL TST EVAL PHYS/QHP EA ADDL HR

Apple Health

4/1/2026

PA Required for greater than 8 hours per calendar year and all non-Behavioral Health diagnoses

96136

PSYL/NRPSYCL TST PHYS/QHP 2+ TST 1ST 30 MIN

Apple Health

4/1/2026

PA Required for greater than 8 hours per calendar year and all non-Behavioral Health diagnoses

96137

PSYCL/NRPSYCL TST PHYS/QHP 2+ TST EA ADDL 30 MIN

Apple Health

4/1/2026

PA Required for greater than 8 hours per calendar year and all non-Behavioral Health diagnoses

97156

FAMILY ADAPT BHV TX GDN PHYS/QHP EA 15 MIN

Apple Health

4/1/2026

 

97157

MULTIPLE FAM GROUP BHV TX GDN PHYS/QHP EA 15 MIN

Apple Health

4/1/2026

 

97158

GRP ADAPT BHV PRTCL MODIFCAJ PHYS/QHP EA 15 MIN

Apple Health

4/1/2026

 

0362T

BEHAVIOR ID SUPPORT ASSMT EA 15 MIN TECH TIME

Apple Health

4/1/2026

 

0373T

ADAPT BHV TX PRTCL MODIFICAJ EA 15 MIN TECH TIME

Apple Health

4/1/2026

 

L1832

KNEE ORTHOS IMMOBLZR ADJUST PREFAB

Apple Health

4/1/2026

 

L2280

ADD LOW EXTREM MOLDED INNR BOOT

Apple Health

4/1/2026

 

E0781

AMB INFUS PUMP 1/MX CHANNL W/ADMIN

Apple Health

4/1/2026

 

E1390

O2 CONC 85%/>02 CONC PRSC FLW RATE

Apple Health

4/1/2026

 

E1028

WHEELCHAIR ACC MAN SWAWY RET/REM MTG HW OTHER

Apple Health

4/1/2026

 

E2609

CUSTOM FAB WHLCHAIR SEAT CUSHN SIZE

Apple Health

4/1/2026

 

E2617

CSTM FAB WC BACK CUSHION ANY SIZE

Apple Health

4/1/2026

 

E2620

PSTN WC BACK CUSHN PLANAR WD <22 IN

Apple Health

4/1/2026

 

E2621

PSTN WC BACK CUSHN PLANAR WD 22IN/>

Apple Health

4/1/2026

 

K0831

PWR WC 2 SEAT ELEV CAPT PT TO 300

Apple Health

4/1/2026

 

K0836

PWR WC 2 1 PWR CAPT CHAIR PT TO 300

Apple Health

4/1/2026

 

B9998

NOC FOR ENTERAL SUPPLIES

Apple Health

4/1/2026

PA Required for services beyond benefit limit

L2330

ADD LOW EXT LACER MOLD PT CSTM ONLY

Apple Health

4/1/2026

PA Required for Non-Par Providers Only

S9351

HIT CONT ANTI-EMETIC PER DIEM

Apple Health

4/1/2026

 

95700

EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS

Apple Health

4/1/2026

 

95712

VEEG BY TECH 2-12 HR INTERMITTENT MONITORING

Apple Health

4/1/2026

 

95713

VEEG BY TECH 2-12 HR CONTINUOUS R-T MONITORING

Apple Health

4/1/2026

 

95714

VEEG BY TECH EA INCR 12-26 HR UNMONITORED

Apple Health

4/1/2026

 

95715

VEEG BY TECH EA INCR 12-26 HR INTERMITTENT MNTR

Apple Health

4/1/2026

 

95716

VEEG BY TECH EA INCR 12-26 HR CONT R-T MNTR

Apple Health

4/1/2026

 

95718

EEG PHYS/QHP 2-12 HR WITH VEEG

Apple Health

4/1/2026

 

95720

EEG PHYS/QHP EA INCR>12HR<26HR AFTER 24HR W/VEEG

Apple Health

4/1/2026

 

95721

EEG COMPLETE STD PHYS/QHP>36 HR<60 HR W/O VIDEO

Apple Health

4/1/2026

 

95722

EEG COMPLETE STD PHYS/QHP>36 HR<60 HR W/VEEG

Apple Health

4/1/2026

 

95723

EEG COMPLETE STD PHYS/QHP>60 HR<84 HR W/O VIDEO

Apple Health

4/1/2026

 

95724

EEG COMPLETE STD PHYS/QHP>60 HR<84 HR W/VEEG

Apple Health

4/1/2026

 

95725

EEG COMPLETE STD PHYS/QHP>84 HR W/O VID

Apple Health

4/1/2026

 

95726

EEG COMPLETE STD PHYS/QHP>84 HR W/VEEG

Apple Health

4/1/2026

 

15736

MUSCLE-SKIN GRAFT ARM

Apple Health

4/1/2026

 

15738

MUSCLE-SKIN GRAFT LEG

Apple Health

4/1/2026

 

15271

SKIN SUB GRAFT TRNK/ARM/LEG

Apple Health

4/1/2026

 

15274

SKN SUB GRFT T/A/L CHILD ADD

Apple Health

4/1/2026

 

15275

SKIN SUB GRAFT FACE/NK/HF/G

Apple Health

4/1/2026

 

15276

SKIN SUB GRAFT F/N/HF/G ADDL

Apple Health

4/1/2026

 

14060

TIS TRNFR E/N/E/L 10 SQ CM/<
 

Apple Health

4/1/2026

PA required with diagnosis of gender dysphoria
For all other diagnoses, PA required for Non-Par Providers Only

14061

TIS TRNFR E/N/E/L101-30SQCM
 

Apple Health

4/1/2026

PA required with diagnosis of gender dysphoria
For all other diagnoses, PA required for Non-Par Providers Only

15100

SKIN SPLT GRFT TRNK/ARM/LEG
 

Apple Health

4/1/2026

PA required with diagnosis of gender dysphoria
For all other diagnoses, PA required for Non-Par Providers Only

15101

SKIN SPLT GRFT T/A/L ADD-ON
 

Apple Health

4/1/2026

PA required with diagnosis of gender dysphoria
For all other diagnoses, PA required for Non-Par Providers Only

15120

SKN SPLT A-GRFT FAC/NCK/HF/G

Apple Health

4/1/2026

PA required with diagnosis of gender dysphoria
For all other diagnoses, PA required for Non-Par Providers Only

11043

DEB MUSC/FASCIA 20 SQ CM/<

Apple Health

4/1/2026

PA required after 12 visits per calendar year

21235

EAR CARTILAGE GRAFT

Apple Health

4/1/2026

 

30460

REVISION OF NOSE

Apple Health

4/1/2026

 

30462

REVISION OF NOSE

Apple Health

4/1/2026

 

22848

INSERT PELV FIXATION DEVICE

Apple Health

4/1/2026

 

22849

REINSERT SPINAL FIXATION

Apple Health

4/1/2026

 

43659

LAPAROSCOPE PROC STOM

Apple Health

4/1/2026

 

60240

REMOVAL OF THYROID

Apple Health

4/1/2026

 

60252

REMOVAL OF THYROID

Apple Health

4/1/2026

 

60500

EXPLORE PARATHYROID GLANDS

Apple Health

4/1/2026

 

30130

EXCISE INFERIOR TURBINATE

Apple Health

4/1/2026

 

30140

RESECT INFERIOR TURBINATE

Apple Health

4/1/2026

 

31253

NSL/SINS NDSC TOTAL

Apple Health

4/1/2026

 

31254

NSL/SINS NDSC W/PRTL ETHMDCT

Apple Health

4/1/2026

 

31255

NSL/SINS NDSC W/TOT ETHMDCT

Apple Health

4/1/2026

 

31256

EXPLORATION MAXILLARY SINUS

Apple Health

4/1/2026

 

31257

NSL/SINS NDSC TOT W/SPHENDT

Apple Health

4/1/2026

 

31259

NSL/SINS NDSC SPHN TISS RMVL

Apple Health

4/1/2026

 

31267

ENDOSCOPY MAXILLARY SINUS

Apple Health

4/1/2026

 

31276

NSL/SINS NDSC FRNT TISS RMVL

Apple Health

4/1/2026

 

58260

VAGINAL HYSTERECTOMY

Apple Health

4/1/2026

PA required with diagnosis of gender dysphoria
For all other diagnoses, PA required for Non-Par Providers Only

58262

VAG HYST INCLUDING T/O
 

Apple Health

4/1/2026

PA required with diagnosis of gender dysphoria
For all other diagnoses, PA required for Non-Par Providers Only

58550

LAPARO-ASST VAG HYSTERECTOMY
 

Apple Health

4/1/2026

PA required with diagnosis of gender dysphoria
For all other diagnoses, PA required for Non-Par Providers Only

58552

LAPARO-VAG HYST INCL T/O
 

Apple Health

4/1/2026

PA required with diagnosis of gender dysphoria
For all other diagnoses, PA required for Non-Par Providers Only

58553

LAPARO-VAG HYST COMPLEX
 

Apple Health

4/1/2026

PA required with diagnosis of gender dysphoria
For all other diagnoses, PA required for Non-Par Providers Only

58554

LAPARO-VAG HYST W/T/O COMPL
 

Apple Health

4/1/2026

PA required with diagnosis of gender dysphoria
For all other diagnoses, PA required for Non-Par Providers Only

54520

REMOVAL OF TESTIS
 

Apple Health

4/1/2026

PA required with diagnosis of gender dysphoria
For all other diagnoses, PA required for Non-Par Providers Only

25111

REMOVE WRIST TENDON LESION

Ambetter

4/1/2026

 

93580

CORONARY ARTERY DISEASE SURGERY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

C1722

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

93505

CARDIAC CATHETERIZATION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

92960

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

93451

CARDIAC CATHETERIZATION

Apple Health, Ambetter

4/1/2026

N PA requirement removed; No PA Required eff 4/1

C1882

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

C1732

CORONARY ARTERY DISEASE SURGERY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

37766

INTERRUPTION/LIGATION/STRIPPING ETC.

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33224

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

76937

ANGIOGRAPHY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33225

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

75736

ANGIOGRAPHY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

C1895

CORONARY ARTERY DISEASE SURGERY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

C1760

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

93662

ELECTROPHYSIOLOGY STUDIES (EPS)

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33271

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

37765

INTERRUPTION/LIGATION/STRIPPING ETC.

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

93571

CARDIAC CATHETERIZATION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

C1785

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33217

CORONARY ARTERY DISEASE SURGERY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

36253

ANGIOGRAPHY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33223

CORONARY ARTERY DISEASE SURGERY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33226

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33222

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

93567

CARDIAC CATHETERIZATION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33418

INTERVENTIONAL CARDIOLOGY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35883

EXCISION EXPLORATION REPAIR REVISION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35656

BYPASS GRAFT IN-SITU VEIN

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

C1730

ELECTROPHYSIOLOGY STUDIES (EPS)

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33215

CORONARY ARTERY DISEASE SURGERY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35621

BYPASS GRAFT IN-SITU VEIN

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35355

THROMBOENDARTERECTOMY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33218

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35011

REPAIR/EXCISION FOR ANEURYSM OCCLUSIVE DISEASE ETC.

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

93292

DEVICE MONITORING

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

93650

CORONARY ARTERY DISEASE SURGERY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33477

PULMONARY VALVE SURGERY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

36254

ANGIOGRAPHY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35661

BYPASS GRAFT IN-SITU VEIN

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33286

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35303

THROMBOENDARTERECTOMY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35881

EXCISION EXPLORATION REPAIR REVISION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35302

THROMBOENDARTERECTOMY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33202

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

93590

INTERVENTIONAL CARDIOLOGY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33361

TAVR

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35556

BYPASS GRAFT VEIN

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

36218

ANGIOGRAPHY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

92961

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35371

THROMBOENDARTERECTOMY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

93583

CORONARY ARTERY DISEASE SURGERY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

C1900

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33236

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33362

TAVR

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33363

TAVR

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33364

TAVR

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33365

TAVR

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33366

TAVR

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33369

TAVR

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33475

PULMONARY VALVE SURGERY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33820

CONGENITAL HEART DISESE SURGERY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35001

REPAIR/EXCISION FOR ANEURYSM OCCLUSIVE DISEASE ETC.

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35141

REPAIR/EXCISION FOR ANEURYSM OCCLUSIVE DISEASE ETC.

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35151

REPAIR/EXCISION FOR ANEURYSM OCCLUSIVE DISEASE ETC.

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35305

CORONARY ARTERY DISEASE SURGERY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35372

THROMBOENDARTERECTOMY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35558

BYPASS GRAFT VEIN

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35566

BYPASS GRAFT VEIN

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35571

BYPASS GRAFT VEIN

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35583

BYPASS GRAFT IN-SITU VEIN

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35585

BYPASS GRAFT IN-SITU VEIN

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35587

BYPASS GRAFT IN-SITU VEIN

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35671

BYPASS GRAFT IN-SITU VEIN

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35700

EXCISION EXPLORATION REPAIR REVISION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35884

CORONARY ARTERY DISEASE SURGERY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

93581

INTERVENTIONAL CARDIOLOGY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

93745

THERAPEUTIC SERVICES

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

K0606

DEVICE MONITORING

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

93565

CARDIAC CATHETERIZATION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35646

BYPASS GRAFT IN-SITU VEIN

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33465

TRICUSPID VALVE SURGERY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

93566

CARDIAC CATHETERIZATION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35654

BYPASS GRAFT IN-SITU VEIN

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35666

BYPASS GRAFT IN-SITU VEIN

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35351

THROMBOENDARTERECTOMY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33220

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

93563

CARDIAC CATHETERIZATION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33234

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33405

CORONARY ARTERY DISEASE SURGERY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

93568

CARDIAC CATHETERIZATION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

35301

THROMBOENDARTERECTOMY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33235

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

93591

INTERVENTIONAL CARDIOLOGY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33275

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

92987

INTERVENTIONAL CARDIOLOGY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33233

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

C2621

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33227

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

C1759

CARDIAC CATHETERIZATION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

92997

INTERVENTIONAL CARDIOLOGY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

36837

INTERVENTIONAL RADIOLOGY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33229

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

75580

ANGIOGRAPHY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33228

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

33274

DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

36836

INTERVENTIONAL RADIOLOGY

Apple Health, Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

93452

CORONARY ARTERY DISEASE SURGERY

Ambetter

4/1/2026

PA requirement removed; No PA Required eff 4/1

76965

Ultrasonic guidance for interstitial radioelement application

Ambetter

6/1/2026

 

77011

Computed tomography guidance for stereotactic localization

Ambetter

6/1/2026

 

77262

Therapeutic radiology treatment planning; simple

Ambetter

6/1/2026

 

77262

Therapeutic radiology treatment planning; intermediate

Ambetter

6/1/2026

 

77263

Therapeutic radiology treatment planning; complex

Ambetter

6/1/2026

 

77280

Therapeutic radiology simulation-aided field setting; simple

Ambetter

6/1/2026

 

77285

Therapeutic radiology simulation-aided field setting; intermediate

Ambetter

6/1/2026

 

77290

Therapeutic radiology simulation-aided field setting; complex

Ambetter

6/1/2026

 

77293

Respiratory motion management simulation (List separately in addition to code for primary procedure)

Ambetter

6/1/2026

 

77295

3-dimensional radiotherapy plan, including dose-volume histograms

Ambetter

6/1/2026

 

77299

Unlisted procedure, therapeutic radiology clinical treatment planning

Ambetter

6/1/2026

 

77300

Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician

Ambetter

6/1/2026

 

77301

Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications

Ambetter

6/1/2026

 

77306

Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calculation(s)

Ambetter

6/1/2026

 

77307

Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s)

Ambetter

6/1/2026

 

77316

Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s)

Ambetter

6/1/2026

 

77317

Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s)

Ambetter

6/1/2026

 

77318

Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s)

Ambetter

6/1/2026

 

77321

Special teletherapy port plan, particles, hemibody, total body

Ambetter

6/1/2026

 

77331

Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating physician

Ambetter

6/1/2026

 

77332

Treatment devices, design and construction; simple (simple block, simple bolus)

Ambetter

6/1/2026

 

77333

Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus)

Ambetter

6/1/2026

 

77334

Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts)

Ambetter

6/1/2026

 

77336

Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy

Ambetter

6/1/2026

 

77338

Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan

Ambetter

6/1/2026

 

77370

Special medical radiation physics consultation

Ambetter

6/1/2026

 

77387

Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed

Ambetter

6/1/2026

 

77399

Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services

Ambetter

6/1/2026

 

77402

Radiation treatment delivery; Level 1 (eg, single-electron field, multiple-electron fields, or 2D photons), including imaging guidance, when performed

Ambetter

6/1/2026

 

77407

Radiation treatment delivery; Level 2, single-isocenter (eg, 3D or IMRT), photons, including imaging guidance, when performed

Ambetter

6/1/2026

 

77412

Radiation treatment delivery; Level 3, multiple isocenters with photon therapy (eg, 2D, 3D, or IMRT) or a single-isocenter photon therapy (eg, 3D or IMRT) with active motion management, or total skin electrons, or mixed-electron/photon field(s), including imaging guidance, when performed

Ambetter

6/1/2026

 

77417

Therapeutic radiology port image(s)

Ambetter

6/1/2026

 

77427

Radiation treatment management, 5 treatments

Ambetter

6/1/2026

 

77431

Radiation therapy management with complete course of therapy consisting of 1 or 2 fractions only

Ambetter

6/1/2026

 

77432

Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)

Ambetter

6/1/2026

 

77435

Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions

Ambetter

6/1/2026

 

77470

Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation)

Ambetter

6/1/2026

 

77499

Unlisted procedure, therapeutic radiology treatment management

Ambetter

6/1/2026

 

77750

Infusion or instillation of radioelement solution (includes 3-month follow-up care)

Ambetter

6/1/2026

 

77761

Intracavitary radiation source application; simple

Ambetter

6/1/2026

 

77762

Intracavitary radiation source application; intermediate

Ambetter

6/1/2026

 

77763

Intracavitary radiation source application; complex

Ambetter

6/1/2026

 

77767

Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel

Ambetter

6/1/2026

 

77768

Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions

Ambetter

6/1/2026

 

77770

Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel

Ambetter

6/1/2026

 

77771

Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels

Ambetter

6/1/2026

 

77772

Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels

Ambetter

6/1/2026

 

77778

Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source, when performed

Ambetter

6/1/2026

 

77789

Surface application of low dose rate radionuclide source

Ambetter

6/1/2026

 

77790

Supervision, handling, loading of radiation source

Ambetter

6/1/2026

 

77799

Unlisted procedure, clinical brachytherapy

Ambetter

6/1/2026

 

G0458

Services, low dose rate (LDR) prostate brachytherapy (insertion of radioactive seeds)

Ambetter

6/1/2026

 

     

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    ______________________________________________________________________________________

    Wellcare

    Vendor Transition: 6 Degrees Health: Effective March 30, 2026 

    This serves to inform you that Wellcare will be transitioning from Optum to a new vendor, 6 Degrees Health, effective 3/30/2026.

    This change reflects our commitment to improving service efficiency and providing comprehensive cost-containment solutions. 

    About 6 Degrees Health 

    6 Degrees Health is a trusted leader in cost-containment solutions for the healthcare industry. Their mission is to provide transparent, data driven services that benefit providers, payers, and members alike. Key highlights of their services include: 

    • Offering fair pricing aligned with industry benchmarks 
    • Led by physicians to ensure high-quality care and cost management 
    • Ensuring claims accuracy and fairness in reimbursements 
    • Dedicated to building positive relationships with providers to enhance patient care 
    • Providing actionable insights to improve efficiency and reduce costs 

    What This Means for You 

    Starting 3/30/2026, all claims, reimbursements, and associated processes will be managed through 6 Degrees Health. The transition is designed to be as smooth as possible, with no interruption to your current workflow. You will receive detailed instructions and support during this period to ensure seamless transition. 
     

    Back to Top

    ______________________________________________________________________________________

    Apple Health Core Connections 

    Coordinated Care is the single managed care organization to administer the Integrated Managed Care Apple Health Foster Care program serving children and youth in foster care, adoption support, guardianship assistance program, alumni of foster care (ages 18-26), children reunified with their parents, and youth in the Unaccompanied Refugee Minor program. Coordinated Care’s program is named “Apple Health Core Connections.” For questions or care coordination referrals you can reach us at 1-844-354-9876 or AHCCTeam@coordinatedcarehealth.com.

    EPSDT: When youth are removed from their home, they need to have an EPSDT exam completed within 30 days. The appointment must be billed as an EPSDT exam, not as establishing care or office visit. Coordinated Care has NO benefit maximum on EPSDT exams for this population. If asked to schedule an EPSDT, please set the appointment even if the patient has had an EPSDT recently. Payment for the EPSDT will be made even if the provider is not the assigned PCP. An EPSDT exam may also be needed after a child changes placement (moves from one caregiving home to another).

    Reminder for Billing Teams: Please use the TJ modifier (PDF) for youth for Apple Health Core Connections members to receive an increased rate for EPSDT visits. 

    Washington State Health Care Authority (HCA)

    ESPDT Fee Schedule

    Effective October 1, 2025

    For all other payable procedure codes, refer to the Physician-Related Services Fee Schedule.

    For all payable drugs and biologicals, refer to the Professional Administered Drugs Fee Schedule.

    Code Status Indicator

    Code

    Modifier

    Maximum Allowable NFS Fee

    Maximum Allowable FS Fee

    Foster Care Clients – Must use Mod TJ

    R

    99381

     

    $80.42

    $51.98

    $120.00**

    R

    99382

     

    $84.14

    $55.94

    $120.00**

    R

    99383

     

    $87.17

    $59.20

    $120.00**

    R

    99384

     

    $97.66

    $69.93

    $120.00**

    R

    99385

     

    $95.10

    $67.13

    $120.00**

    R

    99391

     

    $72.02

    $47.55

    $120.00**

    R

    99392

     

    $76.45

    $51.98

    $120.00**

    R

    99393

     

    $76.45

    $51.98

    $120.00**

    R

    99394

     

    $83.45

    $59.20

    $120.00**

    R

    99395

     

    $85.78

    $61.30

    $120.00**

    **For ages 0-20, please see the Enhanced Pediatric fee schedule. For foster care preventative visits, continue to use mod TJ to receive the enhancement.

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    ______________________________________________________________________________________

    Training/Education

    No-Cost Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): Coordinated Care is hosting a no-cost Trauma Focused Cognitive Behavioral Therapy Training in person on May 4-5, 2026 from 8:30AM – 5:00PM at Community Health Care in Puyallup, WA. TF-CBT is an evidenced based treatment for children and adolescents (ages 3-18) impacted by trauma that includes participation by their parents or caregivers. This training is open to contracted, in-network Coordinated Care providers and all Indian Health Care Providers with a master's degree or above in a mental health discipline, professional licensure (or under supervision for licensure), and actively treating children/adolescents involved in the child welfare system. As part of the certification, providers must commit to and participate in the follow-up TF-CBT Consultation Call Program. Participants must also complete two pre-training requirements. Providers may receive 14 CEUs. Learn more and register here.

    Components for Enhancing Career Experience and Reducing Trauma (CE-CERT): Staff retention, burnout and secondary trauma are epidemic for organizations and staff working with exploited and trauma exposed populations. Regrettably the best advice usually offered is: “Do more self-care!” Keeping good staff means more than just ‘surviving’ and ‘not burning-out’. A new evidence-informed model, Components for Enhancing Career Experience and Reducing Trauma (CE-CERT), is a skills-based approach identifying five key clinical practice and supervision skills. Objectives include:

    • Increase awareness of how developing experiential engagement around negative emotions plays a role in job satisfaction.
    • List five key skills for managing intense affect and reducing post-work agitation.
    • Understand how intense negative feelings can be "metabolized" so they do not produce negative and long-term effects.
    • Have opportunity to commit to one or more key strategies that will change the participant's way of engaging in their work when they return to direct service activities.

    Join this virtual training on May 13, 2026 from 8:30AM – 4:30PM. Providers may receive 6.5 CEUS. Learn more and register here.

    Naloxone and Fentanyl: A detailed discussion: Naloxone has become a popular item for folks to carry and use in case of an Opioid overdose in users, but many do not really know what it does or the best way to use it. In addition, the Opioid Fentanyl has grown in popularity for adults, and it is often added to other drugs unbeknownst to the user, (often youth), which makes it even more dangerous. Learn more about the history of Fentanyl in this training, details of how to use Naloxone and how people may react, and recommendations on how to provide aid to others. Apr 3, 2026 12:00 – 02:00pm Register here.
     

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    ______________________________________________________________________________________

    Pharmacy Updates

    NPI Prescriber Enforcement for Pharmacy Claims

    Action Required: In accordance with 42 CFR 438.602(b), all prescribers must be enrolled with the Health Care Authority (HCA). Effective April 1, 2026, any prescription submitted by a prescriber not recognized by the HCA will be rejected at pharmacy point of sale, some exceptions may apply. Click here for more information on how to enroll as a provider with the HCA. 

    Concurrent Use of a GLP-1 Receptor Agonist & DPP-4 Inhibitor

    Effective 04/01/2026, concurrent use of a GLP-1 Receptor Agonist & DPP-4 Inhibitor will require prior authorization. Diabetes care guidelines advise against taking medications from these two drug classes together because it can increase the risk of side effects and does not provide any added benefit in treating diabetes.  

    Pharmacy Clinical Policy Updates 

    The following pharmacy policies have been updated or will be new. Policies will be posted on the policy site, including a description of revisions.

    Policy Number

    Policy Title

    Effective Date

    Line of Business

    CP.PHAR.40

    Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Mycapssa)

     

    03/01/2026

    Ambetter

    CP.PCH.06

     

    Valganciclovir (Valcyte)

     

    03/01/2026

    Ambetter

    CP.PCH.49

    Omalizumab (Xolair)

     

    03/01/2026

    Ambetter

    CP.PCH.53

     

    Leuprolide Acetate (Eligard, Fensolvi, Lupron Depot, Lupron Depot-Ped), Leuprolide Mesylate (Camcevi, Camcevi ETM)

     

    03/01/2026

    Ambetter

    CP.PCH.55

     

    Epinephrine (Epipen, Epipen Jr, Neffy, Auvi-Q)

     

    03/01/2026

    Ambetter

    CP.PCH.56

    Delandistrogene moxeparvovec-rokl (Elevidys)

     

    01/01/2026

    Ambetter

    CP.PHAR.24

    Fostamatinib (Tavalisse)

     

    03/01/2026

    Ambetter

    CP.PHAR.52

    Interferon Gamma- 1b (Actimmune)

     

    03/01/2026

    Ambetter

    CP.PHAR.80

     

    Vandetanib (Caprelsa)

     

    03/01/2026

    Ambetter

    CP.PHAR.84

     

    Abiraterone (Zytiga, Yonsa)

    03/01/2026

    Ambetter

    CP.PHAR.91

    Vemurafenib (Zelboraf)

     

    03/01/2026

    Ambetter

    CP.PHAR.94

     

    Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira)

     

    03/01/2026

    Ambetter

    CP.PHAR.96

    Naltrexone (Vivitrol)

     

    03/01/2026

    Ambetter

    CP.PHAR.97

     

    Eculizumab (Soliris), Eculizumab-aeeb (Bkemv), Eculizumab-aagh (Epysqli)

     

    03/01/2026

    Ambetter

    CP.PHAR.100

    Axitinib (Inlyta)

     

    03/01/2026

    Ambetter

    CP.PHAR.106

    Enzalutamide (Xtandi)

     

    03/01/2026

    Ambetter

    CP.PHAR.111

    Cabozantinib (Cabometyx, Cometriq)

     

    03/01/2026

    Ambetter

    CP.PHAR.115

    Pegloticase (Krystexxa)

     

    03/01/2026

    Ambetter

    CP.PHAR.126

     

    Ibrutinib (Imbruvica)

    03/01/2026

    Ambetter

    CP.PHAR.179

    Romiplostim (Nplate)

     

    03/01/2026

    Ambetter

    CP.PHAR.180

    Eltrombopag (Alvaiz, Promacta)

     

    03/01/2026

    Ambetter

    CP.PHAR.190

    Ambrisentan (Letairis)

     

    03/01/2026

    Ambetter

    CP.PHAR.191

    Bosentan (Tracleer)

     

    03/01/2026

    Ambetter

    CP.PHAR.193

    Iloprost (Ventavis)

     

    03/01/2026

    Ambetter

    CP.PHAR.194

     

    Macitentan (Opsumit)

    03/01/2026

    Ambetter

    CP.PHAR.195

    Riociguat (Adempas)

     

    03/01/2026

    Ambetter

    CP.PHAR.196

    Selexipag (Uptravi)

     

    03/01/2026

    Ambetter

    CP.PHAR.197

    Sildenafil (Revatio, Liqrev)

     

    03/01/2026

    Ambetter

    CP.PHAR.198

    Tadalafil (Adcirca, Alyq, Tadliq)

     

    03/01/2026

    Ambetter

    CP.PHAR.199

    Treprostinil (Orenitram, Remodulin, Tyvaso, Tyvaso DPI, Yutrepia)

     

    03/01/2026

    Ambetter

    CP.PHAR.207

    Glycerol Phenylbutyrate (Ravicti)

     

    03/01/2026

    Ambetter

    CP.PHAR.208

    Sodium Phenylbutyrate (Buphenyl, Pheburane, Olpruva)

     

    03/01/2026

    Ambetter

    CP.PHAR.215

    Factor VIII (Human, Recombinant)

     

    03/01/2026

    Ambetter

    CP.PHAR.216

    Factor VIII/von Willebrand Factor Complex (Human – Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi)

     

    03/01/2026

    Ambetter

    CP.PHAR.217

    Anti-Inhibitor Coagulant Complex, Human (Feiba)

     

    03/01/2026

    Ambetter

    CP.PHAR.218

    Factor IX (Human, Recombinant)

     

    03/01/2026

    Ambetter

    CP.PHAR.219

    Factor IX Complex, Human (Profilnine)

     

    03/01/2026

    Ambetter

    CP.PHAR.220

    Factor VIIa, Recombinant (NovoSeven RT, SevenFact)

     

    03/01/2026

    Ambetter

    CP.PHAR.221

    Factor XIII, Human (Corifact)

     

    03/01/2026

    Ambetter

    CP.PHAR.222

    Factor XIII A-Subunit, Recombinant (Tretten)

     

    03/01/2026

    Ambetter

    CP.PHAR.223

    Reslizumab (Cinqair)

     

    03/01/2026

    Ambetter

    CP.PHAR.288

    Eteplirsen (Exondys 51)

     

    03/01/2026

    Ambetter

    CP.PHAR.289

    Buprenorphine Injection (Sublocade, Brixadi)

     

    03/01/2026

    Ambetter

    CP.PHAR.296

     

    Pegfilgrastim (Neulasta, Neulasta Onpro), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-pbbk (Fylnetra), Pegfilgrastim-apgf (Nyvepria), Eflapegrastim-xnst (Rolvedon), Efbemalenograstim alfa-vuxw (Ryzneuta), Pegfilgrastim-fpgk (Stimufend), Pegfilgrastim-cbq

     

    03/01/2026

    Ambetter

    CP.PHAR.331

    Deflazacort (Emflaza)

     

    03/01/2026

    Ambetter

    CP.PHAR.332

    Pasireotide (Signifor, Signifor LAR)

     

    03/01/2026

    Ambetter

    CP.PHAR.345

    Abaloparatide (Tymlos)

     

    03/01/2026

    Ambetter

    CP.PHAR.361

    Tisagenlecleucel (Kymriah

     

    03/01/2026

    Ambetter

    CP.PHAR.362

     

    Axicabtagene Ciloleucel (Yescarta)

     

    03/01/2026

    Ambetter

    CP.PHAR.366

    Acalabrutinb (Calquence)

     

    03/01/2026

     

    Ambetter

    CP.PHAR.370

    Emicizumab-kxwh (Hemlibra)

     

    03/01/2026

    Ambetter

    CP.PHAR.372

    Voretigene Neparvovec-rzyl (Luxturna)

     

    03/01/2026

    Ambetter

    CP.PHAR.391

    Lanreotide (Somatuline Depot and Unbranded)

     

    03/01/2026

    Ambetter

    CP.PHAR.114

    Teduglutide (Gattex)

     

    03/01/2026

    Ambetter

    CP.PHAR.160

    Alglucosidase Alfa (Lumizyme)

     

    03/01/2026

    Ambetter

    CP.PHAR.188

    Teriparatide (Forteo, Bonsity)

     

    03/01/2026

    Ambetter

    CP.PHAR.189

    Ibandronate Injection (formerly Boniva)

     

    03/01/2026

    Ambetter

    CP.PHAR.206

    Carglumic Acid (Carbaglu)

     

    03/01/2026

    Ambetter

    CP.PHAR.402

     

    Emapalumab-lzsg (Gamifant)

    03/01/2026

    Ambetter

    CP.PHAR.407

    Lusutrombopag (Mulpleta)

     

    03/01/2026

    Ambetter

    CP.PHAR.411

    Amifampridine (Firdapse)

     

    03/01/2026

    Ambetter

    CP.PHAR.412

    Gilteritinib (Xospata)

    03/01/2026

     

    Ambetter

    CP.PHAR.421

    Onasemnogene Abeparvovec (Zolgensma, Itvisma)

     

    03/01/2026

    Ambetter

    CP.PHAR.428

     

    Romosozumab-aqqg (Evenity)

    03/01/2026

    Ambetter

    CP.PHAR.444

    Afamelanotide (Scenesse)

     

    03/01/2026

    Ambetter

    CP.PHAR.449

    Crizanlizumab-tmca (Adakveo)

     

    03/01/2026

    Ambetter

    CP.PHAR.450

    Luspatercept-aamt (Reblozyl)

     

    03/01/2026

    Ambetter

    CP.PHAR.453

    Golodirsen (Vyondys 53)

     

    03/01/2026

    Ambetter

    CP.PHAR.454

    Avapritinib (Ayvakit)

     

    03/01/2026

    Ambetter

    CP.PHAR.457

    Givosiran (Givlaari)

     

    03/01/2026

    Ambetter

    CP.PHAR.465

    Teprotumumab (Tepezza)

     

    03/01/2026

    Ambetter

    CP.PHAR.466

    Valoctocogene Roxaparvovec-rvox (Roctavian)

     

    03/01/2026

    Ambetter

    CP.PHAR.467

    Zanubrutinib (Brukinsa)

     

    03/01/2026

    Ambetter

    CP.PHAR.470

    Casimersen (Amondys 45)

     

    03/01/2026

    Ambetter

    CP.PHAR.472

    Brexucabtagene Autoleucel (Tecartus)

     

    03/01/2026

    Ambetter

    CP.PHAR.473

    Lumasiran (Oxlumo)

     

    03/01/2026

    Ambetter

    CP.PHAR.474

    Remestemcel-L-rknd (Ryoncil)

     

    01/01/2026

    Ambetter

    CP.PHAR.481

    Idecabtagene Vicleucel (Abecma)

     

    01/01/2026

    Ambetter

    CP.PHAR.483

     

    Lisocabtagene Maraleucel (Breyanzi)

     

    03/01/2026

    Ambetter

    CP.PHAR.484

    Viltolarsen (Viltepso)

     

    03/01/2026

    Ambetter

    CP.PHAR.491

    Setmelanotide (Imcivree)

     

    03/01/2026

    Ambetter

    CP.PHAR.492

    Teplizumab-mzwv (Tzield)

     

    03/01/2026

    Ambetter

    CP.PHAR.499

    Lonafarnib (Zokinvy)

     

    03/01/2026

    Ambetter

    CP.PHAR.515

    Avacopan (Tavneos)

     

    03/01/2026

    Ambetter

    CP.PHAR.521

    Avalglucosidase Alfa-ngpt (Nexviazyme)

     

    03/01/2026

    Ambetter

    CP.PHAR.525

    Vosoritide (Voxzogo)

     

    03/01/2026

    Ambetter

    CP.PHAR.527

     

    Narsoplimab-wuug (Yartemlea)

    03/01/2026

    Ambetter

    CP.PHAR.533

    Ciltacabtagene Autoleucel (Carvykti)

     

    01/01/2026

    Ambetter

    CP.PHAR.545

    Betibeglogene Autotemcel (Zynteglo)

     

    01/01/2026

    Ambetter

    CP.PHAR.555

    Efgartigimod Alfa-fcab, Efgartigimod/Hyaluronidase-qvfc (Vyvgart, Vyvgart Hytrulo)

     

    03/01/2026

    Ambetter

    CP.PHAR.563

     

    Allogenic Processed Thymus Tissue-agdc (Rethymic)

     

    03/01/2026

    Ambetter

    CP.PHAR.565

    Asciminib (Scemblix)

     

    03/01/2026

    Ambetter

    CP.PHAR.567

    Cipaglucosidase Alfa-atga + Miglustat (Pombiliti + Opfolda)

     

    03/01/2026

    Ambetter

    CP.PHAR.573

    Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva)

     

    03/01/2026

    Ambetter

    CP.PHAR.580

    Etranacogene Dezaparvovec-drlb (Hemgenix)

     

    03/01/2026

    Ambetter

    CP.PHAR.595

     

    Eladocagene Exuparvovec-tneq (Kebilidi)

     

    03/01/2026

    Ambetter

    CP.PHAR.602

    Atidarsagene Autotemcel (Lenmeldy)

     

    03/01/2026

    Ambetter

    CP.PHAR.603

     

    Exagamglogene Autotemcel (Casgevy)

     

    03/01/2026

    Ambetter

    CP.PHAR.616

    Zilucoplan (Zilbrysq)

     

    03/01/2026

    Ambetter

    CP.PHAR.619

    Nedosiran (Rivfloza)

     

    03/01/2026

    Ambetter

    CP.PHAR.627

     

    Lovotibeglogene Autotemcel (Lyfgenia)

     

    03/01/2026

    Ambetter

    CP.PHAR.643

    Fidanacogene Elaparvovec-dzkt (Beqvez)

    01/01/2026

    Ambetter

    CP.PHAR.663

    Capivasertib (Truqap)

     

    03/01/2026

    Ambetter

    CP.PHAR.669

    Birch Triterpenes (Filsuvez)

     

    03/01/2026

    Ambetter

    CP.PHAR.674

    Marstacimab-hncq (Hympavzi)

     

    03/01/2026

    Ambetter

    CP.PHAR.675

     

    Obecabtagene Autoleucel (Aucatzyl)

     

    03/01/2026

    Ambetter

    CP.PHAR.678

    Afamitresgene Autoleucel (Tecelra)

     

    01/01/2026

    Ambetter

    CP.PHAR.697

    Revakinagene Taroretcel-lwey (Encelto)

     

    01/01/2026

    Ambetter

    CP.PHAR.706

    Fitusiran (Qfitlia)

     

    03/01/2026

    Ambetter

    CP.PHAR.708

    Sepiapterin (Sephience)

     

    03/01/2026

    Ambetter

    CP.PHAR.730

     

    Zopapogene Imadenovec-drba (Papzimeos)

     

    01/01/2026

    Ambetter

    CP.PHAR.751

     

    Rilzabrutinib (Wayrilz)

     

    03/01/2026

    Ambetter

    CP.PHAR.764

    Sevabertinib (Hyrnuo)

     

    03/01/2026

    Ambetter

    CP.PMN.57

    Febuxostat (Uloric)

     

    03/01/2026

    Ambetter

    CP.PMN.70

    Ivabradine (Corlanor)

     

    03/01/2026

    Ambetter

    CP.PMN.73

    Lifitegrast (Xiidra)

     

    03/01/2026

    Ambetter

    CP.PMN.81

    Buprenorphine/Naloxone (Suboxone, Zubsolv)

     

    03/01/2026

    Ambetter

    CP.PMN.82

    Buprenorphine (Subutex)

     

    02/05/2026

    Ambetter

    CP.PMN.88

    Alendronate (Binosto, Fosamax Plus D)

     

    03/01/2026

    Ambetter

    CP.PMN.92

    CNS Stimulants

     

    03/01/2026

    Ambetter

    CP.PMN.100

    Risedronate (Actonel, Atelvia)

     

    03/01/2026

    Ambetter

    CP.PMN.104

    Tasimelteon (Hetlioz, Hetlioz LQ)

     

    03/01/2026

    Ambetter

    CP.PMN.107

    Topical Immunomodulators

     

    03/01/2026

    Ambetter

    CP.PMN.129

    Pramlintide (Symlin)

     

    03/01/2026

    Ambetter

    CP.PMN.186

    Cenegermin-bkbj (Oxervate)

     

    03/01/2026

    Ambetter

    CP.PMN.187

    Icosapent Ethyl (Vascepa)

    03/01/2026

    Ambetter

    CP.PMN.295

     

    Semaglutide (Wegovy)

     

    03/01/2026

    Ambetter

    HIM.PA.34

    Non-Formulary Test Strips

     

    03/01/2026

    Ambetter

    HIM.PA.53

    Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists

     

    03/01/2026

    Ambetter

    HIM.PA.58

    Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

     

    03/01/2026

    Ambetter

    HIM.PA.91

    Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors

     

    03/01/2026

    Ambetter

    HIM.PA.143

    Potassium Chloride for Oral Solution (Klor-Con Powder)

     

    03/01/2026

    Ambetter

    HIM.PA.146

     

    Vorapaxar (Zontivity)

     

    03/01/2026

    Ambetter

    HIM.PA.153

    Inhaled Agents for Asthma and COPD

     

    03/01/2026

    Ambetter

    HIM.PA.156

     

    Evolocumab (Repatha)

     

    03/01/2026

    Ambetter

    HIM.PA.161

    Human Growth Hormone (Somapacitan, Somatrogon, Somatropin)

     

    03/01/2026

    Ambetter

    HIM.PA.166

    Evinacumab-dgnb (Evkeeza)

     

    03/01/2026

    Ambetter

    HIM.PA.175

    Mepolizumab (Nucala)

     

    03/01/2026

    Ambetter

    HIM.PA.176

    Tezepelumab (Tezspire)

     

    03/01/2026

    Ambetter

    HIM.PA.178

     

    Immune Globulins

     

    03/01/2026

    Ambetter

    HIM.PA.179

    Depemokimab-ulaa (Exdensur)

     

    03/01/2026

    Ambetter

    HIM.PA.SP69

    Dupilumab (Dupixent)

     

    03/01/2026

    Ambetter

    HIM.PA.SP70

    Benralizumab (Fasenra)

     

    03/01/2026

    Ambetter

    CP.PHAR.103

     

    Immune Globulins

     

    03/01/2026

    Medicaid

    CP.PHAR.173

     

    Leuprolide Acetate (Eligard, Fensolvi, Lupron Depot, Lupron Depot-Ped), Leuprolide Mesylate (Camcevi, Camcevi ETM)

     

    03/01/2026

    Medicaid

    CP.PHAR.576

    Tezepelumab-ekko (Tezspire)

     

    03/01/2026

    Medicaid

    CP.PHAR.767

    Depemokimab-ulaa (Exdensur)

     

    03/01/2026

    Medicaid

    CP.PMN.05

    Rifapentine (Priftin)

    03/01/2026

    Medicaid

    CP.PMN.14

     

    Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors

     

    03/01/2026

    Medicaid

    CP.PMN.34

     

    Ranolazine (Ranexa, Aspruzyo Sprinkle)

     

    03/01/2026

    Medicaid

    CP.PMN.52

     

    Omega-3-Acid Ethyl Esters (Lovaza)

     

    03/01/2026

    Medicaid

    CP.PMN.101

    Rivastigmine (Exelon)

     

    03/01/2026

    Medicaid

    CP.PMN.227

    Edoxaban (Savaysa)

     

    03/01/2026

    Medicaid

    CP.PMN.274

    Diclofenac (Pennsaid)

     

    03/01/2026

    Medicaid

    WA.PHAR.49.AB

    IL4 IL 13 Inhibitors

     

    04/01/2026

    Medicaid

    WA.PHAR.49.AE

    CAM-IL17 Inhibitors

     

    04/01/2026

    Medicaid

    WA.PHAR.49.AG

    CAM-T Lymphocyte Inhibitors

     

    04/01/2026

    Medicaid

    WA.PHAR.49.AH

    CAM-JAK Inhibitors

     

    04/01/2026

    Medicaid

    CP.PHAR.58

    Denosumab (Prolia, Xgeva), Denosumab-bbdz (Jubbonti, Wyost), Denosumab-dssb (Ospomyv, Xbryk), Denosumab-bmwo

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.59

    Zoledronic Acid (Reclast)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.63

    Everolimus (Afinitor, Afinitor Disperz, Zortress)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.98

    Ruxolitinib (Jakafi, Opzelura)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.101

     

    Mifepristone (Korlym)

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.119

    Ramucirumab (Cyramza)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.121

    Nivolumab (Opdivo), Nivolumab/Hyaluronidase-nvhy (Opdivo Qvantig)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.165

    Ferumoxytol (Feraheme)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.181

    Hemin (Panhematin)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.184

    Aflibercept (Eylea, Eylea HD), Aflibercept-mrbb (Ahzantive), Aflibercept-abzv (Enzeevu), Aflibercept-boav (Eydenzelt), Aflibercept-yszy (Opuviz), Aflibercept-ayyh (Pavblu), Aflibercept-jbvf (Yesafili)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.186

    Ranibizumab (Byooviz, Cimerli, Lucentis, Nufymco, Susvimo)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.187

    Verteporfin (Visudyne)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.192

    Epoprostenol (Flolan, Veletri)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.203

    Cosyntropin (Cortrosyn)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.204

    Trabectedin (Yondelis)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.214

    Desmopressin Acetate (DDAVP, Stimate, Nocdurna)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.224

    Enoxaparin (Lovenox)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.225

    Dalteparin (Fragmin)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.226

    Fondaparinux (Arixtra)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.232

     

    OnabotulinumtoxinA (Botox)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.234

    Ferric Carboxymaltose (Injectafer)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.235

    Atezolizumab (Tecentriq), Atezolizumab-Hyaluronidase (Tecentriq Hybreza)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.260

    Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab/Hyaluronidase (Rituxan Hycela)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.282

    Parathyroid Hormone (Natpara)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.300

    Bezlotoxumab (Zinplava)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.301

    Erwinia Asparaginase (Rylaze)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.329

    Siltuximab (Sylvant)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.330

    Protein C Concentrate, Human (Ceprotin)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.333

    Avelumab (Bavencio)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.350

    Rucaparib (Rubraca)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.360

    Olaparib (Lynparza)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.367

    Letermovir (Prevymis)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.368

    Pemetrexed (Alimta, Pemfexy, Axtle)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.371

    Triamcinolone ER Injection (Zilretta)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.389

     

    Pegvisomant (Somavert)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.408

    Niraparib (Zejula)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.409

    Talazoparib (Talzenna)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.410

    Bortezomib (Boruzu, Velcade)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.413

    Glasdegib (Daurismo)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.414

    Larotrectinib (Vitrakvi)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.416

    Caplacizumab-yhdp (Cablivi)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.431

    Selinexor (Xpovio)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.445

    Brolucizumab-dbll (Beovu)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.451

    Voxelotor (Oxbryta)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.452

    Tazemetostat (Tazverik)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.455

    Enfortumab Vedotin-ejfv (Padcev)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.456

    Fam-Trastuzumab Deruxtecan-nxki (Enhertu)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.459

    Iobenguane I-131 (Azedra)

     

    02/05/2026

    Ambetter & Medicaid

    CP.PHAR.522

    Margetuximab-cmkb (Margenza)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.544

    Amivantamab-vmjw (Rybrevant)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.556

    Elivaldogene Autotemcel (Skysona)

     

    02/01/2026

    Ambetter & Medicaid

    CP.PHAR.562

    Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.464

    Selumetinib (Koselugo)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.469

    Belantamab Mafodotin-blmf (Blenrep)

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.516

    Fostemsavir (Rukobia)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.523

    Naxitamab-gqgk (Danyelza)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.564

    Antithrombin III (ATryn, Thrombate III)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.568

    Inclisiran (Leqvio)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.570

    Ropeginterferon Alfa-2b-njft (BESREMi)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.572

    Budesonide (Tarpeyo)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.574

    Sirolimus Protein-Bound Particles (Fyarro), Topical Gel (Hyftor)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.581

    Faricimab-svoa (Vabysmo)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.598

    Lifileucel (Amtagvi)

     

    01/01/2026

    Ambetter & Medicaid

    CP.PHAR.604

    Futibatinib (Lytgobi)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.605

    Adagrasib (Krazati)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.608

    Furosemide (Furoscix)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.609

    Prademagene Zamikeracel (Zevaskyn)

     

    02/01/2026

    Ambetter & Medicaid

    CP.PHAR.610

    Sodium Thiosulfate (Pedmark)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.611

    Teclistamab-cqyv (Tecvayli)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.612

    Tremelimumab-actl (Imjudo)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.613

    Fecal Microbiota, Live-jslm (Rebyota)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.615

    Olutasidenib (Rezlidhia)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.617

    Mirvetuximab Soravatansine-gynx (Elahere)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.618

    Mosunetuzumab-axgb (Lunsumio)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.635

    ADAMTS13, Recombinant-krhn (Adzynma)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.645

    Niraparib and Abiraterone Acetate (Akeega)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.657

    Sotatercept (Winrevair)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.659

    Vamorolone (Agamree)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.666

    Fruquintinib (Fruzaqla)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.667

    Repotrectinib (Augtyro)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.668

    Toripalimab-tpzi (Loqtorzi)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.670

    Eflornithine (Iwilfin)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.671

    Nirogacestat (Ogsiveo)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.672

    Travoprost Implant (iDose TR)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.707

    Revumenib (Revuforj)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.709

    Zanidatamab-hrii (Ziihera)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.710_PEPP

     

    Ataluren (Translarna)_PEPP

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.711

    Cosibelimab-Ipdl (Unloxcyt)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.712

    Ensartinib (Ensacove)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.713

    Zenocutuzumab-zbco (Bizengri)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.721

    Plozasiran (Redemplo)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.735

    Etuvetidigene Autotemcel (Waskyra)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.738

     

    Doxecitine and doxribtimine (Kygevvi)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.755

     

    Paltusotide (Palsonify)

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.769_PEPP

     

    Anitocabtagene autoleucel (KITE-772)_PEPP

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.770_PEPP

     

    Hematopoietic Stem and Progenitor Cells, High-Purity Regulatory T-Cells, and Conventional T-Cells (Orca-T)_PEPP

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.762_PEPP

     

    Pariglasgene Brecaparvovec (DTX401)_PEPP

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.761_PEPP

     

    Ifezuntirgene Inilparvovec (AMT-130)_PEPP

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.765

    Ziftomenib (Komzifti)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.766

    Aficamten (Myqorzo)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PHAR.768

    Lerodalcibep-liga (Lerochol)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.04

    Non-Calcium Phosphate Binders

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.20

    Aspirin/Dipyridamole

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.24

    Ciclopirox Topical Solution 8%

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.25

    Efinaconazole (Jublia)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.64

    Quetiapine Extended-Release (Seroquel XR)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.72

    Metformin ER (Fortamet, Glumetza)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.89

    Amantadine ER (Gocovri)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.90

    Benznidazole

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.93

    Dextromethorphan-Quinidine (Nuedexta)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.99

    Prasterone (Intrarosa)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.103

    Secnidazole (Solosec)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.105

    Tavaborole (Kerydin)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.113

    Safinamide (Xadago)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.123

    Colchicine (Lodoco)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.156

    Perampanel (Fycompa)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.166

    Luliconazole Cream (Luzu)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.189

    Sarecycline (Seysara)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.212

    Bedaquiline (Sirturo)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.213

    Ferric Maltol (Accrufer)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.217

    Istradefylline (Nourianz)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.218

    Lasmiditan (Reyvow)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.222

    Pretomanid

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.223

    Rifabutin (Mycobutin)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.224

    Tenapanor (Ibsrela, Xphozah)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.225

    Trifarotene (Aklief)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.231

    Cenobamate (Xcopri)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.237

    Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.257

    Clascoterone (Winlevi)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.258

    Conjugated Estrogens/Bazedoxifene (Duavee)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.260

    Loteprednol etabonate (Eysuvis)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.261

    Dichlorphenamide (Keveyis)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.271

    Maribavir (Livtencity)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.273

    Varenicline (Tyrvaya)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.286

    Glaucoma Agents

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.299

    Xanomeline/Trospium Chloride (Cobenfy)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.300

    Aripiprazole Orally Disintegrating Tablet, Oral Film (Opipza)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.304

    Elinzanetant (Lynkuet)

     

    03/01/2026

    Ambetter & Medicaid

    CP.PMN.306

    Etripamil (Cardamyst)

     

    03/01/2026

    Ambetter & Medicaid

     

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