November 2025 Provider News

ECG_7252 

Evolent - Ambulatory Rhythm Monitoring 

ECG_7254 

Evolent - Coronary Artery Bypass Graft 

ECG_7255 

Evolent - Aortic Valve Replacement 

ECG_7258 

Evolent - Device Interrogation and Programming 

ECG_7261 

Evolent - Device (AICD, CRT and/or Pacemaker) Battery Replacement 

ECG_7262 

Evolent - Diagnostic Electrophysiologic Testing 

ECG_7263 

Evolent - Cardiac Resynchronization Therapy 

ECG_7264 

Evolent - Renal Angiography and Intervention 

ECG_7266 

Evolent - Carotid Artery Stenting 

ECG_7268 

Evolent - Carotid Endarterectomy 

ECG_7269 

Evolent - Catheter Based Carotid & Brachiocephalic Arteriography, Venography & Intervention 

ECG_7282 

Evolent - Atrial Fibrillation Ablation 

ECG_7283 

Evolent - Abdominal Aortography w Bilateral Iliofemoral Lower Extremity Runoff 

ECG_7284 

Evolent - Catheter Ablation of Reentrant or Focal Tachydysrhythmias 

ECG_7286 

Evolent - Endomyocardial Biopsy 

ECG_7287 

Evolent - Endovascular Femoropopliteal Interventions 

ECG_7288 

Evolent - Endovascular Aortoiliac Interventions 

ECG_7289 

Evolent - Endovascular Infrapopliteal (Tibioperoneal) Interventions 

ECG_7290 

Evolent - Treatment of Varicose Veins 

ECG_7292 

Evolent - Infra-inguinal Open Arterial Vascular Surgery 

ECG_7295 

Evolent - Hearth Catheterization 

ECG_7299 

Evolent - Hemodialysis Access Creation 

ECG_7301 

Evolent - Implantable Cardioverter Defibrillator 

ECG_7302 

Evolent - Percutaneous Coronary Interventions 

ECG_7303 

Evolent - Interventions for Adults with Congenital Heart Defects 

ECG_7305 

Evolent - Introduction of Inferior Vena Cava Filter Device 

ECG_7310 

Evolent - Mitral Valve Surgery 

ECG_7315 

Evolent - Pacemaker Insertion 

ECG_7319 

Evolent - Percutaneous Iliocaval Interventions 

ECG_7320 

Evolent - Percutaneous Left Atrial Appendage Closure 

ECG_7327 

Evolent - Standalone Right Heart Catheterization 

ECG_7334 

Evolent - Transcatheter Aortic Valve Replacement (TAVR) 

ECG_7335 

Evolent - Transcatheter Edge to Edge Repair (TEER) of Mitral Valve 

ECG_7338 

Evolent - Tricuspid Valve Surgery 

ECG_7339 

Evolent - Ultrasound-Guided Vascular Access 

ECG_7341 

Evolent - Venogram Invasive Vein Mapping 

ECG_7345 

Evolent - Wireless Pulmonary Artery Pressure Device Placement and Monitoring 

Policy Number

Policy Title

Effective Date

Line of Business

WA.CP.MP.54 

Hospice Services  

12/1/25 

Apple Health 

CP.MP.49 

Physical, Occupational and Speech Therapy Services 

12/1/25 

Apple Health & Ambetter 

WA.CP.MP.185 

Skin and Soft Tissue Substitutes 

12/1/25 

Apple Health 

CP.MP.185 

Skin and Soft Tissue Substitutes for Chronic Wounds 

12/1/25 

Ambetter 

WA.CP.MP.527 

Vitamin D Testing 

1/1/26 

Apple Health & Ambetter 

CP.MP.93 

Bone-anchored hearing aid 

1/1/26 

Apple Health & Ambetter 

CG.CP.MP.01 

Infection Disease: Respiratory Lab Testing 

1/1/26 

Apple Health & Ambetter 

CG.CP.MP.02 

Infectious Disease: Multisystems Lab Testing 

1/1/26 

Apple Health & Ambetter 

CG.CP.MP.03 

Infectious Dz Dermatologic Lab Testing 

1/1/26 

Apple Health & Ambetter 

CG.CP.MP.04 

Infectious Dz Gastroenterologic Lab Testing 

1/1/26 

Apple Health & Ambetter 

CG.CP.MP.05 

ID Primary Care Preventive Lab Testing 

1/1/26 

Apple Health & Ambetter 

CG.CP.MP.06 

ID Vector-Borne and Tropical Dz Lab Testing 

1/1/26 

Apple Health & Ambetter 

CG.PP.551A 

Concert Genetic and Molecular Testing Payment Policy 

1/1/26 

Apple Health & Ambetter 

CG.CC.PP.01 

Concert Lab Payment Policy 

1/1/26 

Apple Health & Ambetter 

CP.MP.107 

DME 

2/1/26

Apple Health & Ambetter 

CP.MP.202 

Orthognathic Surgery 

2/1/26

Apple Health & Ambetter 

Policy Number

Policy Title

Effective Date

Line of Business

WA.HIM.CP.MP.92 

Acupuncture 

12/31/25 

Ambetter 

CC.PP.018 

Inpatient Only Procedures 

12/31/25 

Apple Health

MP.PP.018 

Inpatient Only Procedures 

12/31/25 

Ambetter 

WA.CP.MP.516 

Carotid Artery Stenting 

12/31/25 

Apple Health & Ambetter 

WA.CP.MP.525 

Catheter Ablation for SVTA 

12/31/25 

Apple Health & Ambetter 

WA.CP.MP.522 

Varicose Vein Treatment 

12/31/25 

Apple Health & Ambetter 

WA.CP.MP.513 

Cardiac Stents 

12/31/25 

Apple Health & Ambetter 

Line of Business

Code

Description

Apple Health

69714

Implantation, osseo-integrated implant, skull; with percutaneous attachment to external speech processor

Apple Health

69729

Implantation, osseo-integrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside of the mastoid and resulting in removal of greater than or equal to 100 sq mm surface area of bone deep to the outer cranial cortex

Evolent Interventional Cardiology Program Prior Authorization Requirements

Code

Description

33202

Insertion of epicardial electrode(s); open incision (eg, thoracotomy, median sternotomy, subxiphoid approach)

33203

Insertion of epicardial electrode(s); endoscopic approach (eg, thoracoscopy, pericardioscopy)

33206

Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial

33207

Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular

33208

Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular

33210

Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure)

33211

Insertion or replacement of temporary transvenous dual chamber pacing electrodes (separate procedure)

33212

Insertion of pacemaker pulse generator only; with existing single lead

33213

Insertion of pacemaker pulse generator only; with existing dual leads

33214

Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator)

33215

Repositioning of previously implanted transvenous pacemaker or implantable defibrillator (right atrial or right ventricular) electrode

33216

Insertion of a single transvenous electrode, permanent pacemaker or implantable defibrillator

33217

Insertion of 2 transvenous electrodes, permanent pacemaker or implantable defibrillator

33218

Repair of single transvenous electrode, permanent pacemaker or implantable defibrillator

33220

Repair of 2 transvenous electrodes for permanent pacemaker or implantable defibrillator

33221

Insertion of pacemaker pulse generator only; with existing multiple leads

33222

Relocation of skin pocket for pacemaker

33223

Relocation of skin pocket for implantable defibrillator

33224

Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator)

33225

Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (List separately in addition to code for primary procedure)

33226

Repositioning of previously implanted cardiac venous system (left ventricular) electrode (including removal, insertion and/or replacement of existing generator)

33227

Removal of Permanent Pacemaker Pulse Generator with Replacement of Pacemaker Pulse Generator; single Lead System

33228

Removal of Permanent Pacemaker Pulse Generator with Replacement of Pacemaker Pulse Generator; Dual Lead System

33229

Removal of Permanent Pacemaker Pulse Generator with Replacement of Pacemaker Pulse Generator; Multiple Lead System

33230

Insertion of implantable defibrillator pulse generator only; with existing dual leads

33231

Insertion of implantable defibrillator pulse generator only; with existing multiple leads

33233

Removal of permanent pacemaker pulse generator only

33234

Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular

33235

Removal of transvenous pacemaker electrode(s); dual lead system

33236

Removal of permanent epicardial pacemaker and electrodes by thoracotomy; single lead system, atrial or ventricular

33237

Removal of permanent epicardial pacemaker and electrodes by thoracotomy; dual lead system

33240

Insertion of implantable defibrillator pulse generator only; with existing single lead

33241

Removal of implantable defibrillator pulse generator only

33243

Removal of single or dual chamber implantable defibrillator electrode(s); by thoracotomy

33244

Removal of single or dual chamber implantable defibrillator electrode(s); by transvenous extraction

33249

Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or dual chamber

33262

Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; single lead system

33263

Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; dual lead system

33264

Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; multiple lead system

33270

Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed

33271

Insertion of subcutaneous implantable defibrillator electrode

33272

Removal of subcutaneous implantable defibrillator electrode

33273

Repositioning of previously implanted subcutaneous implantable defibrillator electrode

33274

Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed

33275

Transcatheter removal of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography), when performed

33285

Insertion, subcutaneous cardiac rhythm monitor, including programming

33286

Removal, subcutaneous cardiac rhythm monitor

33289

Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed

33340

Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation

33361

Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach

33362

Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach

33363

Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach

33364

Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open iliac artery approach

33365

Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (eg, median sternotomy, mediastinotomy)

33366

Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transapical exposure (eg, left thoracotomy)

33367

Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with percutaneous peripheral arterial and venous cannulation (eg, femoral vessels) (List separately in addition to code for primary procedure)

33368

Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with open peripheral arterial and venous cannulation (eg, femoral, iliac, axillary vessels) (List separately in addition to code for primary procedure)

33369

Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with central arterial and venous cannulation (eg, aorta, right atrium, pulmonary artery) (List separately in addition to code for primary procedure)

33405

Replacement, aortic valve, open, with cardiopulmonary bypass; with prosthetic valve other than homograft or stentless valve

33406

Replacement, aortic valve, open, with cardiopulmonary bypass; with allograft valve (freehand)

33410

Replacement, aortic valve, open, with cardiopulmonary bypass; with stentless tissue valve

33411

Replacement, aortic valve; with aortic annulus enlargement, noncoronary sinus

33412

Replacement, aortic valve; with transventricular aortic annulus enlargement (Konno procedure)

33413

Replacement, aortic valve; by translocation of autologous pulmonary valve with allograft replacement of pulmonary valve (Ross procedure)

33418

Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis

33419

Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure)

33425

Valvuloplasty, mitral valve, with cardiopulmonary bypass;

33426

Valvuloplasty, mitral valve, with cardiopulmonary bypass; with prosthetic ring

33427

Valvuloplasty, mitral valve, with cardiopulmonary bypass; radical reconstruction, with or without ring

33430

Replacement, mitral valve, with cardiopulmonary bypass

33440

Replacement, aortic valve; by translocation of autologous pulmonary valve and transventricular aortic annulus enlargement of the left ventricular outflow tract with valved conduit replacement of pulmonary valve (Ross-Konno procedure)

33465

Replacement, Tricuspid Valve, with Cardiopulmonary Bypass

33475

Replacement, Pulmonary Valve

33477

Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed

33510

Coronary artery bypass, vein only; single coronary venous graft

33511

Coronary artery bypass, vein only; 2 coronary venous grafts

33512

Coronary artery bypass, vein only; 3 coronary venous grafts

33513

Coronary artery bypass, vein only; 4 coronary venous grafts

33514

Coronary artery bypass, vein only; 5 coronary venous grafts

33516

Coronary artery bypass, vein only; 6 or more coronary venous grafts

33517

Coronary artery bypass, using venous graft(s) and arterial graft(s); single vein graft (List separately in addition to code for primary procedure)

33518

Coronary artery bypass, using venous graft(s) and arterial graft(s); 2 venous grafts (List separately in addition to code for primary procedure)

33519

Coronary artery bypass, using venous graft(s) and arterial graft(s); 3 venous grafts (List separately in addition to code for primary procedure)

33521

Coronary artery bypass, using venous graft(s) and arterial graft(s); 4 venous grafts (List separately in addition to code for primary procedure)

33522

Coronary artery bypass, using venous graft(s) and arterial graft(s); 5 venous grafts (List separately in addition to code for primary procedure)

33523

Coronary artery bypass, using venous graft(s) and arterial graft(s); 6 or more venous grafts (List separately in addition to code for primary procedure)

33530

Reoperation, coronary artery bypass procedure or valve procedure, more than 1 month after original operation (List separately in addition to code for primary procedure)

33533

Coronary artery bypass, using arterial graft(s); single arterial graft

33534

Coronary artery bypass, using arterial graft(s); 2 coronary arterial grafts

33535

Coronary artery bypass, using arterial graft(s); 3 coronary arterial grafts

33536

Coronary artery bypass, using arterial graft(s); 4 or more coronary arterial grafts

33572

Coronary endarterectomy, open, any method, of left anterior descending, circumflex, or right coronary artery performed in conjunction with coronary artery bypass graft procedure, each vessel (List separately in addition to primary procedure)

33641

Repair atrial septal defect, secundum, with cardiopulmonary bypass, with or without patch

33768

Anastomosis, cavopulmonary, second superior vena cava (List separately in addition to primary procedure)

33820

Repair of patent ductus arteriosus; by ligation

33840

Excision of coarctation of aorta, with or without associated patent ductus arteriosus; with direct anastomosis

33900

Percutaneous pulmonary artery revascularization by stent placement, initial; normal native connections, unilateral

33901

Percutaneous pulmonary artery revascularization by stent placement, initial; normal native connections, bilateral

33902

Percutaneous pulmonary artery revascularization by stent placement, initial; abnormal connections, unilateral

33903

Percutaneous pulmonary artery revascularization by stent placement, initial; abnormal connections, bilateral

33904

Percutaneous pulmonary artery revascularization by stent placement, each additional vessel or separate lesion, normal or abnormal connections (List separately in addition to code for primary procedure)

33917

Repair of pulmonary artery stenosis by reconstruction with patch or graft

33924

Ligation and takedown of a systemic-to-pulmonary artery shunt, performed in conjunction with a congenital heart procedure (List separately in addition to code for primary procedure)

35001

Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm and associated occlusive disease, carotid, subclavian artery, by neck incision

35011

Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm and associated occlusive disease, axillary-brachial artery, by arm incision

35141

Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, common femoral artery (profunda femoris, superficial femoral)

35151

Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, popliteal artery

35301

Thromboendarterectomy, including patch graft, if performed; carotid, vertebral, subclavian, by neck incision

35302

Thromboendarterectomy, including patch graft, if performed; superficial femoral artery

35303

Thromboendarterectomy, including patch graft, if performed; popliteal artery

35304

Thromboendarterectomy, including patch graft, if performed; tibioperoneal trunk artery

35305

Thromboendarterectomy, including patch graft, if performed; tibial or peroneal artery, initial vessel

35306

Thromboendarterectomy, including patch graft, if performed; each additional tibial or peroneal artery (List separately in addition to code for primary procedure)

35351

Thromboendarterectomy, including patch graft, if performed; iliac

35355

Thromboendarterectomy, including patch graft, if performed; iliofemoral

35371

Thromboendarterectomy, including patch graft, if performed; common femoral

35372

Thromboendarterectomy, including patch graft, if performed; deep (profunda) femoral

35390

Reoperation, carotid, thromboendarterectomy, more than 1 month after original operation (List separately in addition to code for primary procedure)

35400

Angioscopy (noncoronary vessels or grafts) during therapeutic intervention (List separately in addition to code for primary procedure)

35500

Harvest of upper extremity vein, 1 segment, for lower extremity or coronary artery bypass procedure (List separately in addition to code for primary procedure)

35556

Bypass graft, with vein; femoral-popliteal

35558

Bypass graft, with vein; femoral-femoral

35566

Bypass graft, with vein; femoral-anterior tibial, posterior tibial, peroneal artery or other distal vessels

35571

Bypass graft, with vein; popliteal-tibial, -peroneal artery or other distal vessels

35572

Harvest of femoropopliteal vein, 1 segment, for vascular reconstruction procedure (eg, aortic, vena caval, coronary, peripheral artery) (List separately in addition to code for primary procedure)

35583

In-situ vein bypass; femoral-popliteal

35585

In-situ vein bypass; femoral-anterior tibial, posterior tibial, or peroneal artery

35587

In-situ vein bypass; popliteal-tibial, peroneal

35600

Harvest of upper extremity artery, 1 segment, for coronary artery bypass procedure, open

35621

Bypass graft, with other than vein; axillary-femoral

35646

Bypass graft, with other than vein; aortobifemoral

35654

Bypass graft, with other than vein; axillary-femoral-femoral

35656

Bypass graft, with other than vein; femoral-popliteal

35661

Bypass graft, with other than vein; femoral-femoral

35665

Bypass graft, with other than vein; Iliofemoral

35666

Bypass graft, with other than vein; femoral-anterior tibial, posterior tibial, or peroneal artery

35671

Bypass graft, with other than vein; popliteal-tibial or -peroneal artery

35700

Reoperation, femoral-popliteal or femoral (popliteal)-anterior tibial, posterior tibial, peroneal artery, or other distal vessels, more than 1 month after original operation (List separately in addition to code for primary procedure)

35881

Revision, lower extremity arterial bypass, without thrombectomy, open; with segmental vein interposition

35883

Revision, femoral anastomosis of synthetic arterial bypass graft in groin, open; with nonautogenous patch graft (eg, Dacron, ePTFE, bovine pericardium)

35884

Revision, femoral anastomosis of synthetic arterial bypass graft in groin, open; with autogenous vein patch graft

36005

Injection procedure for extremity venography (including introduction of needle or intracatheter)

36140

Introduction of needle or intracatheter, upper or lower extremity artery

36200

Introduction of catheter, aorta

36215

Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family

36216

Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family

36217

Selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, within a vascular family

36218

Selective catheter placement, arterial system; additional second order, third order, and beyond, thoracic or brachiocephalic branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate)

36221

Non-selective catheter placement, thoracic aorta, with angiography of the extracranial carotid, vertebral, and/or intracranial vessels, unilateral or bilateral, and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed

36245

Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family

36246

Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family

36247

Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family

36251

Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral

36252

Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; bilateral

36253

Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral

36254

Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; bilateral

36465

Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (eg, great saphenous vein, accessory saphenous vein)

36466

Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (eg, great saphenous vein, accessory saphenous vein), same leg

36473

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated

36474

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

36475

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated

36476

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

36478

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated

36479

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

36482

Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated

36483

Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

36836

Percutaneous arteriovenous fistula creation, upper extremity, single access of both the peripheral artery and peripheral vein, including fistula maturation procedures (eg, transluminal balloon angioplasty, coil embolization) when performed, including all vascular access, imaging guidance and radiologic supervision and interpretation

36837

Percutaneous arteriovenous fistula creation, upper extremity, separate access sites of the peripheral artery and peripheral vein, including fistula maturation procedures (eg, transluminal balloon angioplasty, coil embolization) when performed, including all vascular access, imaging guidance and radiologic supervision and interpretation

37215

Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with distal embolic protection

37220

Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty

37221

Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

37224

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty

37225

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed

37226

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

37227

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed

37228

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty

37229

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed

37230

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

37231

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed

37232

Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (List separately in addition to code for primary procedure)

37233

Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)

37234

Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)

37235

Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)

37236

Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery

37237

Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s)  for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; each additional artery (List separately in addition to code for primary procedure)

37238

Transcatheter Placement of An Intravascular Stent(S), Open or Percutaneous, including Radiological Supervision and Interpretation and including Angioplasty within the Same Vessel, when Performed; initial Vein

37239

Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; each additional vein (List separately in addition to code for primary procedure)

37246

Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery; initial artery

37247

Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery; each additional artery (List separately in addition to code for primary procedure)

37248

Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; initial vein

37249

Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; each additional vein (List separately in addition to code for primary procedure)

37765

Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions

37766

Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions

4110F

Internal mammary artery graft performed for primary, isolated coronary artery bypass graft procedure (CABG)

75580

Noninvasive estimate of coronary fractional flow reserve (FFR) derived from augmentative software analysis of the data set from a coronary computed tomography angiography, with interpretation and report by a physician or other qualified health care professional

75625

Aortography, abdominal, by serialography, radiological supervision and interpretation

75630

Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation

75710

Angiography, extremity, unilateral, radiological supervision and interpretation

75716

Angiography, extremity, bilateral, radiological supervision and interpretation

75726

Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and interpretation

75736

Angiography, pelvic, selective or supraselective, radiological supervision and interpretation

76937

Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure)

76984

Ultrasound, intraoperative thoracic aorta (eg, epiaortic), diagnostic

76987

Intraoperative epicardial cardiac ultrasound (ie, echocardiography) for congenital heart disease, diagnostic; including placement and manipulation of transducer, image acquisition, interpretation and report

76988

Intraoperative epicardial cardiac ultrasound (ie, echocardiography) for congenital heart disease, diagnostic; placement, manipulation of transducer, and image acquisition only

76989

Intraoperative epicardial cardiac ultrasound (ie, echocardiography) for congenital heart disease, diagnostic; interpretation and report only

92920

Percutaneous transluminal coronary angioplasty; single major coronary artery or branch

92921

Percutaneous transluminal coronary angioplasty; each additional branch of a major coronary artery (List separately in addition to code for primary procedure)

92924

Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; single major coronary artery or branch

92925

Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure)

92928

Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch

92929

Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure)

92933

Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch

92934

Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure)

92937

Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel

92938

Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure)

92943

Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; single vessel

92944

Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure)

92960

Cardioversion, elective, electrical conversion of arrhythmia; external

92961

Cardioversion, elective, electrical conversion of arrhythmia; internal (separate procedure)

92972

Percutaneous transluminal coronary lithotripsy (List separately in addition to code for primary procedure)

92973

Percutaneous transluminal coronary thrombectomy mechanical (List separately in addition to code for primary procedure)

92974

Transcatheter placement of radiation delivery device for subsequent coronary intravascular brachytherapy (List separately in addition to code for primary procedure)

92978

Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; initial vessel (List separately in addition to code for primary procedure)

92979

Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; each additional vessel (List separately in addition to code for primary procedure)

92986

Percutaneous balloon valvuloplasty; aortic valve

92987

Percutaneous balloon valvuloplasty; mitral valve

92997

Percutaneous transluminal pulmonary artery balloon angioplasty; single vessel

92998

Percutaneous transluminal pulmonary artery balloon angioplasty; each additional vessel (List separately in addition to code for primary procedure)

93292

Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; wearable defibrillator system

93451

Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed

93452

Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed

93453

Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed

93454

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation;

93455

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography

93456

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization

93457

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization

93458

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed

93459

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography

93460

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed

93461

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography

93462

Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (List separately in addition to code for primary procedure)

93463

Pharmacologic agent administration (eg, inhaled nitric oxide, intravenous infusion of nitroprusside, dobutamine, milrinone, or other agent) including assessing hemodynamic measurements before, during, after and repeat pharmacologic agent administration, when performed (List separately in addition to code for primary procedure)

93464

Physiologic exercise study (eg, bicycle or arm ergometry) including assessing hemodynamic measurements before and after (List separately in addition to code for primary procedure)

93505

Endomyocardial Biopsy

93563

Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective coronary angiography during congenital heart catheterization (List separately in addition to code for primary procedure)

93564

Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective opacification of aortocoronary venous or arterial bypass graft(s) (eg, aortocoronary saphenous vein, free radial artery, or free mammary artery graft) to one or more coronary arteries and in situ arterial conduits (eg, internal mammary), whether native or used for bypass to one or more coronary arteries during congenital heart catheterization, when performed (List separately in addition to code for primary procedure)

93565

Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective left ventricular or left atrial angiography (List separately in addition to code for primary procedure)

93566

Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective right ventricular or right atrial angiography (List separately in addition to code for primary procedure)

93567

Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for supravalvular aortography (List separately in addition to code for primary procedure)

93568

Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for pulmonary angiography (List separately in addition to code for primary procedure)

93569

Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective pulmonary arterial angiography, unilateral (List separately in addition to code for primary procedure)

93571

Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; initial vessel (List separately in addition to code for primary procedure)

93572

Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; each additional vessel (List separately in addition to code for primary procedure)

93573

Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective pulmonary arterial angiography, bilateral (List separately in addition to code for primary procedure)

93574

Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective pulmonary venous angiography of each distinct pulmonary vein during cardiac catheterization (List separately in addition to code for primary procedure)

93575

Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective pulmonary angiography of major aortopulmonary collateral arteries (MAPCAs) arising off the aorta or its systemic branches, during cardiac catheterization for congenital heart defects, each distinct vessel (List separately in addition to code for primary procedure)

93580

Percutaneous transcatheter closure of congenital interatrial communication (ie, Fontan fenestration, atrial septal defect) with implant

93581

Percutaneous transcatheter closure of a congenital ventricular septal defect with implant

93582

Percutaneous transcatheter closure of patent ductus arteriosus

93583

Percutaneous Transcatheter Septal Reduction therapy (Eg, Alcohol Septal Ablation) including Temporary Pacemaker Insertion when Performed

93590

Percutaneous transcatheter closure of paravalvular leak; initial occlusion device, mitral valve

93591

Percutaneous transcatheter closure of paravalvular leak; initial occlusion device, aortic valve

93592

Percutaneous transcatheter closure of paravalvular leak; each additional occlusion device (List separately in addition to code for primary procedure)

93609

Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia (List separately in addition to code for primary procedure)

93613

Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure)

93619

Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters, without induction or attempted induction of arrhythmia

93620

Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording

93621

Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separately in addition to code for primary procedure)

93622

Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left ventricular pacing and recording (List separately in addition to code for primary procedure)

93623

Programmed stimulation and pacing after intravenous drug infusion (List separately in addition to code for primary procedure)

93650

Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement

93653

Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry

93654

Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; with treatment of ventricular tachycardia or focus of ventricular ectopy including left ventricular pacing and recording, when performed

93655

Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia (List separately in addition to code for primary procedure)

93656

Comprehensive electrophysiologic evaluation with transseptal catheterizations, insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia including left or right atrial pacing/recording, and intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation, including intracardiac electrophysiologic 3-dimensional mapping, intracardiac echocardiography with imaging supervision and interpretation, right ventricular pacing/recording, and His bundle recording, when performed

93657

Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (List separately in addition to code for primary procedure)

93662

Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation (List separately in addition to code for primary procedure)

93745

Initial set-up and programming by a physician or other qualified health care professional of wearable cardioverter-defibrillator includes initial programming of system, establishing baseline electronic ECG, transmission of data to data repository, patient instruction in wearing system and patient reporting of problems or events

C1721

Cardioverter-defibrillator, dual chamber

C1722

Cardioverter-defibrillator, single chamber

C1730

Catheter, electrophysiology, diagnostic, other than 3D mapping, 19 or fewer electrodes

C1731

Catheter, electrophysiology, diagnostic, other than 3D mapping, 20 or more electrodes

C1732

Catheter, electrophysiology, diagnostic/ablation, 3D or vector mapping

C1733

Catheter, electrophysiology, diagnostic/ablation, other than 3D or vector mapping other than cool-tip

C1753

Catheter, intravascular ultrasound

C1759

Catheter, intracardiac echocardiography

C1760

Closure device, vascular

C1764

Event recorder, cardiac

C1768

Graft, vascular

C1777

Lead, cardioverter-defibrillator, endocardial single coil

C1779

Lead, pacemaker, transvenous VDD single pass

C1785

Pacemaker, dual chamber, rate-responsive

C1786

Pacemaker, single chamber, rate-responsive

C1876

Stent, noncoated/noncovered, with delivery system

C1877

Stent, noncoated/noncovered, without delivery system

C1882

Cardioverter-defibrillator, other than single or dual chamber

C1895

Lead, cardioverter-defibrillator, endocardial dual coil

C1896

Lead, cardioverter-defibrillator, other than endocardial dual coil

C1898

Lead, pacemaker, other than transvenous VDD single pass

C1899

Lead, pacemaker/cardioverter-defibrillator combination

C1900

Lead, left ventricular coronary venous system

C2617

Stent, noncoronary, temporary, without delivery system

C2619

Pacemaker, dual chamber, nonrate-responsive

C2620

Pacemaker, single chamber, nonrate-responsive

C2621

Pacemaker, other than single or dual chamber

C2623

Catheter, transluminal angioplasty, drug-coated, nonlaser

C2624

Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components

C2630

Catheter, electrophysiology, diagnostic/ablation, other than 3D or vector mapping, cool-tip

C9600

Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch

C9601

Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery

C9602

Percutaneous transluminal coronary atherectomy with drug eluting intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch

C9603

Percutaneous transluminal coronary atherectomy with drug eluting intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery

C9604

Percutaneous transluminal revascularization of or through coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel

C9605

Percutaneous transluminal revascularization of or through coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft

C9606

Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, single vessel

C9607

Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel

C9608

Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, each additional coronary artery, coronary artery branch, or bypass graft

E0616

Implantable cardiac event recorder with memory, activator, and programmer

G0278

Iliac and/or femoral artery angiography, nonselective, bilateral or ipsilateral to catheter insertion, performed at the same time as cardiac catheterization and/or coronary angiography

G0448

Insertion or replacement of a permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber with insertion of pacing electrode, cardiac venous system, for left ventricular pacing

K0606

Automatic external defibrillator, with integrated electrocardiogram analysis, garment type

K0607

Replacement battery for automated external defibrillator, garment type only, each

K0608

Replacement garment for use with automated external defibrillator, each

K0609

Replacement electrodes for use with automated external defibrillator, garment type only, each

S2205

Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using arterial graft(s), single coronary arterial graft

S2206

Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using arterial graft(s), two coronary arterial grafts

S2207

Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using venous graft only, single coronary venous graft

S2208

Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using single arterial and venous graft(s), single venous graft

S2209

Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using two arterial grafts and single venous graft

Drug Class

Drug Name

Preferred Alternative(s)

ANTICOAGULANTS- Blood Thinners: Thrombin Inhibitors

Pradaxa CAPS (dabigatran etexilate mesylate)

dabigatran etexilate mesylate CAPS (generic for Pradaxa)

THYROID AGENTS - Drugs to Regulate Thyroid Hormones: Thyroid Hormones

Adthyza TABS, Armour Thyroid TABS, Niva Thyroid TABS, NP Thyroid TABS, Renthyroid TABS, and Thyroid TABS

Levothyroxine Sodium TABS and Liothyronine Sodium TABS

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES- Drugs to Treat Cancer: Antimetabolites

Purixan SUSP 2000 MG/100ML (mercaptopurine)

Mercaptopurine SUSP 2000 MG/100MG (generic for Purixan)

Policy Number

Policy Title

Effective Date

WA.PHAR.66

Antibiotics Anti-Infective Agents- Oral rifaximin (XIFAXAN)

10/01/2025

Medicaid

WA.PHAR.72

Hematopoietic Agents Granulocyte Colony Stimulating Factors (G-CSF)

10/01/2025

Medicaid

WA.PHAR.106

Migraine Agents- CGRP Receptor Antagonists

10/01/2025

Medicaid

HIM.PA.139

Opioid Analgesics*

11/01/2025

Ambetter

HIM.PA.156

Evolocumab (Repatha)

11/01/2025

Ambetter

HIM.PA.161

Human Growth Hormone (Somapacitan, Somatrogon, Somatropin)

11/01/2025

Ambetter

HIM.PA.166

Evinacumab-dgnb (Evkeeza)

11/01/2025

Ambetter

CP.PHAR.59

Zoledronic Acid (Reclast)

11/01/2025

Ambetter & Medicaid

CP.PHAR.98

Ruxolitinib (Jakafi, Opzelura)

11/01/2025

Ambetter & Medicaid

CP.PHAR.103

Immune Globulins

11/01/2025

Ambetter & Medicaid

CP.PHAR.184

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

11/01/2025

Ambetter & Medicaid

CP.PHAR.216

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

11/01/2025

Ambetter

CP.PHAR.287

Obeticholic Acid (Ocaliva)

11/01/2025

Ambetter

CP.PHAR.290

Aripiprazole Long-Acting Injections (Abilify Maintena, Abilify Asimtufii, Aristada, Aristada Initio)

11/01/2025

Ambetter & Medicaid

CP.PHAR.322

Pembrolizumab (Keytruda)

11/01/2025

Ambetter & Medicaid

CP.PHAR.367

Letermovir (Prevymis)

11/01/2025

Ambetter & Medicaid

CP.PHAR.371

Triamcinolone ER Injection (Zilretta)

11/01/2025

Ambetter & Medicaid

CP.PHAR.410

Bortezomib (Velcade)

11/01/2025

Ambetter & Medicaid

CP.PHAR.464

Selumetinib (Koselugo)

11/01/2025

Ambetter & Medicaid

CP.PHAR.465

Teprotumumab (Tepezza)

11/01/2025

Ambetter

CP.PHAR.483

Lisocabtagene Maraleucel (Breyanzi)

11/01/2025

Ambetter

CP.PHAR.592

Beremagene geperpavec-svdt (Vyjuvek)

11/01/2025

Ambetter

CP.PMN.04

Non-Calcium Phosphate Binders

11/01/2025

Ambetter & Medicaid

CP.PMN.99

Prasterone (Intrarosa)

11/01/2025

Ambetter & Medicaid

CP.PMN.100

Risedronate (Actonel, Atelvia)

11/01/2025

Ambetter

CP.PMN.104

Tasimelteon (Hetlioz, Hetlioz LQ)

11/01/2025

Ambetter

CP.PMN.212

Bedaquiline (Sirturo)

11/01/2025

Ambetter & Medicaid

CP.PMN.218

Lasmiditan (Reyvow)

11/01/2025

Ambetter & Medicaid

CP.PMN.223

Rifabutin (Mycobutin)

11/01/2025

Ambetter & Medicaid

CP.PMN.258

Conjugated Estrogens/Bazedoxifene (Duavee)

11/01/2025

Ambetter & Medicaid

WA.PHAR.49.AB

IL4 IL 13 Inhibitors

12/01/2025

Medicaid

WA.PHAR.49.AH

CAM-JAK Inhibitors

12/01/2025

Medicaid

WA.PHAR.50

Growth Hormone Agents

12/01/2025

Medicaid

WA.PHAR.122

Antidiabetics- GLP-1 Agonists

12/01/2025

Medicaid

CP.PCH.09

Penicillamine (Cuprimine)

12/01/2025

Ambetter

CP.PCH.28

Diclofenac (Cambia, Flector, Licart, Pennsaid, Solaraze, Zipsor, Zorvolex)

12/01/2025

Ambetter

CP.PCH.32

Dapsone (Aczone Gel)

12/01/2025

Ambetter

CP.PCH.53

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

12/01/2025

Ambetter

CP.PCH.43

Colonoscopy Preparation Products

12/01/2025

Ambetter

CP.PCH.44

Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep)

12/01/2025

Ambetter

CP.PCH.57

Abrocitinib (Cibinqo)

12/01/2025 (new policy)

Ambetter

CP.PCH.58

Lebrikizumab (Ebglyss)

12/01/2025 (new policy)

Ambetter

CP.PCH.59

Nemolizumab-ilto (Nemluvio)

12/01/2025 (new policy)

Ambetter

CP.PCH.60

Tralokinumab-ldrm (Adbry)

12/01/2025 (new policy)

Ambetter

CP.PHAR.05

Hyaluronate Derivatives

12/01/2025

Ambetter & Medicaid

CP.PHAR.43

Sapropterin Dihydrochloride (Kuvan, Javygtor)

12/01/2025

Ambetter

CP.PHAR.58

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

12/01/2025

Ambetter & Medicaid

CP.PHAR.79

Lapatinib (Tykerb)

12/01/2025

Ambetter

CP.PHAR.93

Bevacizumab (Alymsys, Avastin, Avzivi, Jobevne, Mvasi, Vegzelma, Zirabev)

12/01/2025

Ambetter & Medicaid

CP.PHAR.116

Pomalidomide (Pomalyst)

12/01/2025

Ambetter

CP.PHAR.129

Venetoclax (Venclexta)

12/01/2025

Ambetter & Medicaid

CP.PHAR.130

Avatrombopag (Doptelet, Doptelet Sprinkle)

12/01/2025

Ambetter

CP.PHAR.131

Infertility and Fertility Preservation

12/01/2025

Ambetter

CP.PHAR.132

Nitisinone (Harliku, Nityr, Orfadin)

12/01/2025

Ambetter

CP.PHAR.133

Idelalisib (Zydelig)

12/01/2025

Ambetter & Medicaid

CP.PHAR.134

Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex, Jylamvo)

12/01/2025

Ambetter & Medicaid

CP.PHAR.136

Elagolix (Orilissa), Elagolix/Estradiol/Norethinedrone (Oriahnn)

12/01/2025

Ambetter & Medicaid

CP.PHAR.137

Ivosidenib (Tibsovo)

12/01/2025

Ambetter & Medicaid

CP.PHAR.138

Lenvatinib (Lenvima)

12/01/2025

Ambetter

CP.PHAR.139

Mogamulizumab-kpkc (Poteligeo)

12/01/2025

Ambetter & Medicaid

CP.PHAR.140

Pegvaliase-pqpz (Palynziq)

12/01/2025

Ambetter

CP.PHAR.141

Ribavirin

12/01/2025

Ambetter & Medicaid

CP.PHAR.142

Adefovir (Hepsera)

12/01/2025

Ambetter & Medicaid

CP.PHAR.143

Betaine (Cystadane)

12/01/2025

Ambetter & Medicaid

CP.PHAR.149

Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispah, Ozobax/Ozobax DS)

12/01/2025

Ambetter & Medicaid

CP.PHAR.151

Levoleucovorin (Fusilev, Khapzory)

12/01/2025

Ambetter & Medicaid

CP.PHAR.170

Degarelix Acetate (Firmagon)

12/01/2025

Ambetter & Medicaid

CP.PHAR.171

Goserelin Acetate (Zoladex)

12/01/2025

Ambetter & Medicaid

CP.PHAR.175

Triptorelin Pamoate (Trelstar, Triptodur)

12/01/2025

Ambetter & Medicaid

CP.PHAR.173

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

12/01/2025

Medicaid

CP.PHAR.201

Belatacept (Nulojix)

12/01/2025

Ambetter

CP.PHAR.246

Canakinumab (Ilaris)

12/01/2025

Ambetter

CP.PHAR.259

Natalizumab (Tysabri), Natalizumab-sztn (Tyruko)

12/01/2025

Ambetter

CP.PHAR.260

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

12/01/2025

Ambetter & Medicaid

CP.PHAR.293

Risperidone Long-Acting Injection (Perseris, Risperdal Consta, Rykindo, Uzedy)

12/01/2025

Ambetter & Medicaid

CP.PHAR.304

Irinotecan Liposome (Onivyde)

12/01/2025

Ambetter & Medicaid

CP.PHAR.305

Obinutuzumab (Gazyva)

12/01/2025

Ambetter & Medicaid

CP.PHAR.307

Bendamustine (Belrapzo, Bendeka, Treanda, Vivimusta)

12/01/2025

Ambetter & Medicaid

CP.PHAR.308

Elotuzumab (Empliciti)

12/01/2025

Ambetter & Medicaid

CP.PHAR.309

Carfilzomib (Kyprolis)

12/01/2025

Ambetter & Medicaid

CP.PHAR.311

Belinostat (Beleodaq)

12/01/2025

Ambetter & Medicaid

CP.PHAR.313

Pralatrexate (Folotyn)

12/01/2025

Ambetter & Medicaid

CP.PHAR.314

Romidepsin (Istodax)

12/01/2025

Ambetter & Medicaid

CP.PHAR.317

Cetuximab (Erbitux)

12/01/2025

Ambetter & Medicaid

CP.PHAR.318

Eribulin Mesylate (Halaven)

12/01/2025

Ambetter & Medicaid

CP.PHAR.320

Necitumumab (Portrazza)

12/01/2025

Ambetter & Medicaid

CP.PHAR.321

Panitumumab (Vectibix)

12/01/2025

Ambetter & Medicaid

CP.PHAR.324

Temsirolimus (Torisel)

12/01/2025

Ambetter & Medicaid

CP.PHAR.325

Ziv-Aflibercept (Zaltrap)

12/01/2025

Ambetter & Medicaid

CP.PHAR.328

Asfotase Alfa (Strensiq)

12/01/2025

Ambetter

CP.PHAR.332

Pasireotide (Signifor, Signifor LAR)

12/01/2025

Ambetter & Medicaid

CP.PHAR.334

Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara)

12/01/2025

Ambetter

CP.PHAR.352

Daunorubicin/Cytarabine (Vyxeos)

12/01/2025

Ambetter & Medicaid

CP.PHAR.353

Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas)

12/01/2025

Ambetter & Medicaid

CP.PHAR.354

Testosterone (Testopel, Jatenzo, Kyzatrex, Tlando)

12/01/2025

Ambetter

CP.PHAR.355

Abemaciclib (Verzenio)

12/01/2025

Ambetter

CP.PHAR.358

Gemtuzumab Ozogamicin (Mylotarg)

12/01/2025

Ambetter & Medicaid

CP.PHAR.359

Inotuzumab Ozogamicin (Besponsa)

12/01/2025

Ambetter & Medicaid

CP.PHAR.363

Enasidenib (Idhifa)

12/01/2025

Ambetter & Medicaid

CP.PHAR.365

Neratinib (Nerlynx)

12/01/2025

Ambetter

CP.PHAR.368

Pemetrexed (Alimta, Pemfexy)

12/01/2025

Ambetter & Medicaid

CP.PHAR.387

Azacitidine (Onureg, Vidaza)

12/01/2025

Ambetter & Medicaid

CP.PHAR.389

Pegvisomant (Somavert)

12/01/2025

Ambetter & Medicaid

CP.PHAR.390

Cholic Acid (Cholbam)

12/01/2025

Ambetter

CP.PHAR.391

Lanreotide (Somatuline Depot and Unbranded)

12/01/2025

Ambetter & Medicaid

CP.PHAR.393

Leucovorin Injection

12/01/2025

Ambetter & Medicaid

CP.PHAR.397

Cemiplimab-rwlc (Libtayo)

12/01/2025

Ambetter & Medicaid

CP.PHAR.399

Dacomitinib (Vizimpro)

12/01/2025

Ambetter

CP.PHAR.400

Duvelisib (Copiktra)

12/01/2025

Ambetter & Medicaid

CP.PHAR.434

Bremelanotide (Vyleesi)

12/01/2025

Medicaid

CP.PHAR.435

Darolutamide (Nubeqa)

12/01/2025

Ambetter

CP.PHAR.436

Pexidartinib (Turalio)

12/01/2025

Ambetter

CP.PHAR.437

Thioguanine (Tabloid)

12/01/2025

Ambetter & Medicaid

CP.PHAR.438

Trientine (Cuvrior, Syprine)

12/01/2025

Ambetter & Medicaid

CP.PHAR.439

Valrubicin (Valstar)

12/01/2025

Ambetter & Medicaid

CP.PHAR.441

Entrectinib (Rozlytrek)

12/01/2025

Ambetter & Medicaid

CP.PHAR.442

Fedratinib (Inrebic)

12/01/2025

Ambetter & Medicaid

CP.PHAR.446

Flibanserin (Addyi)

12/01/2025

Medicaid

CP.PHAR.461

Nadofaragene Firadenovec-vncg (Adstiladrin)

12/01/2025

Ambetter & Medicaid

CP.PHAR.462

Ozanimod (Zeposia)

12/01/2025

Ambetter

CP.PHAR.490

Rimegepant (Nurtec ODT)

12/01/2025

Ambetter

CP.PHAR.506

Antithymocyte Globulin (Atgam, Thymoglobulin)

12/01/2025

Ambetter & Medicaid

CP.PHAR.507

Lomustine (Gleostine)

12/01/2025

Ambetter & Medicaid

CP.PHAR.508

Tafasitamab-cxix (Monjuvi)

12/01/2025

Ambetter & Medicaid

CP.PHAR.509

Triheptanoin (Dojolvi)

12/01/2025

Ambetter

CP.PHAR.510

Arimoclomol (Miplyffa)

12/01/2025

Ambetter

CP.PHAR.513

Plasminogen, Human-tvmh (Ryplazim)

12/01/2025

Ambetter

CP.PHAR.551

Anifrolumab-fnia (Saphnelo)

12/01/2025

Ambetter & Medicaid

CP.PHAR.552

Belumosudil (Rezurock)

12/01/2025

Ambetter

CP.PHAR.553

Belzutifan (Welireg)

12/01/2025

Ambetter & Medicaid

CP.PHAR.554

Chlorambucil (Leukeran)

12/01/2025

Ambetter & Medicaid

CP.PHAR.556

Elivaldogene Autotemcel (Skysona)

12/01/2025

Ambetter

CP.PHAR.558

Mitapivat (Pyrukynd)

12/01/2025

Ambetter

CP.PHAR.559

Mobocertinib (Exkivity)

12/01/2025

Ambetter

CP.PHAR.561

Tisotumab Vedotin-tftv (Tivdak)

12/01/2025

Ambetter & Medicaid

CP.PHAR.566

Atogepant (Qulipta)

12/01/2025

Ambetter

CP.PHAR.591

Tofersen (Qalsody)

12/01/2025

Ambetter

CP.PHAR.594

Donanemab (Kisunla)

12/01/2025

Ambetter

CP.PHAR.596

Lecanemab-irmb (Leqembi)

12/01/2025

Ambetter

CP.PHAR.597

Leniolisib (Joenja)

12/01/2025

Ambetter

CP.PHAR.598

Lifileucel (Amtagvi)

12/01/2025

Ambetter & Medicaid

CP.PHAR.622

Lenacapavir (Sunlenca, Yeztugo)

12/01/2025

Ambetter

CP.PHAR.630

Zavegepant (Zavzpret)

12/01/2025

Ambetter

CP.PHAR.641

Avacincaptad Pegol (Izervay)

12/01/2025

Ambetter & Medicaid

CP.PHAR.643

Fidanacogene Elaparvovec-dzkt (Beqvez)

12/01/2025

Ambetter

CP.PHAR.645

Niraparib and Abiraterone Acetate (Akeega)

12/01/2025

Ambetter & Medicaid

CP.PHAR.646

Quizartinib (Vanflyta)

12/01/2025

Ambetter & Medicaid

CP.PHAR.647

Resmetirom (Rezdiffra)

12/01/2025

Ambetter & Medicaid

CP.PHAR.648

Rozanolixizumab-noli (Rystiggo)

12/01/2025

Ambetter

CP.PHAR.649

Talquetamab-tgvs (Talvey)

12/01/2025

Ambetter & Medicaid

CP.PHAR.651

DaxibotulinumtoxinA-lanm (Daxxify)

12/01/2025

Ambetter & Medicaid

CP.PHAR.652

Elranatamab-bcmm (Elrexfio)

12/01/2025

Ambetter & Medicaid

CP.PHAR.653

Melphalan (Hepzato)

12/01/2025

Ambetter & Medicaid

CP.PHAR.654

Momelotinib (Ojjaara)

12/01/2025

Ambetter & Medicaid

CP.PHAR.655

Motixafortide (Aphexda)

12/01/2025

Ambetter & Medicaid

CP.PHAR.673

Garadacimab-gxii (Andembry)

12/01/2025

Ambetter

CP.PHAR.678

Afamitresgene Autoleucel (Tecelra)

12/01/2025

Ambetter

CP.PHAR.682

Levacetylleucine (Aqneursa)

12/01/2025

Ambetter

CP.PHAR.691

Axatilimab-csfr (Niktimvo)

12/01/2025

Ambetter

CP.PHAR.692

Crinecerfont (Crenessity)

12/01/2025

Ambetter

CP.PHAR.693

Denileukin Diftitox-cxdl (Lymphir)

12/01/2025

Ambetter & Medicaid

CP.PHAR.695

Lazertinib (Lazcluze)

12/01/2025

Ambetter & Medicaid

CP.PHAR.696

Palopegteriparatide (Yorvipath)

12/01/2025

Ambetter & Medicaid

CP.PHAR.697

Revakinagene Taroretcel-lwey (Encelto)

12/01/2025

Ambetter

CP.PHAR.698

Seladelpar (Livdelzi)

12/01/2025

Ambetter

CP.PHAR.699

Vorasidenib (Voranigo)

12/01/2025

Ambetter & Medicaid

CP.PHAR.700

Vanzacaftor/Tezacaftor/Deutivacaftor (Alyftrek)

12/01/2025

Ambetter

CP.PHAR.701

Diazoxide Choline (Vykat XR)

12/01/2025

Ambetter

CP.PHAR.702

Inavolisib (Itovebi)

12/01/2025

Ambetter & Medicaid

CP.PHAR.705

Zolbetuximab-clzb (Vyloy)

12/01/2025

Ambetter & Medicaid

CP.PHAR.730

Zopapogene Imadenovec-drba (Papzimeos)

12/01/2025

Ambetter

CP.PHAR.744

Delgocitinib (Anzupgo)

12/01/2025 (new policy)

Ambetter

CP.PHAR.745

Dordaviprone (Modeyso)

12/01/2025 (new policy)

Ambetter & Medicaid

CP.PHAR.750

Zongertinib (Hernexeos)

12/01/2025 (new policy)

Ambetter & Medicaid

CP.PHAR.751

Rilzabrutinib (Wayrilz)

12/01/2025 (new policy)

Ambetter

CP.PHAR.753

Gemcitabine Intravesical System (Inlexzo)

12/01/2025 (new policy)

Ambetter & Medicaid

CP.PHAR.754

Imlunestrant (Inluriyo)

12/01/2025 (new policy)

Ambetter & Medicaid

CP.PHAR.755

Paltusotide (Palsonify)

12/01/2025 (new policy)

Ambetter & Medicaid

CP.PHAR.756

Remibrutinib (Rhapsido)

12/01/2025 (new policy)

Ambetter

CP.PMN.08

Lidocaine Transdermal (Lidoderm, ZTlido)

12/01/2025

Ambetter & Medicaid

CP.PMN.17

Droxidopa (Northera)

12/01/2025

Medicaid

CP.PMN.46

Roflumilast (Daliresp, Zoryve)

12/01/2025

Ambetter & Medicaid

CP.PMN.47

Rifaximin (Xifaxan)

12/01/2025

Ambetter

CP.PMN.53

Off-Label Use

12/01/2025

Medicaid

CP.PMN.54

Clobazam (Onfi, Sympazan)

12/01/2025

Ambetter & Medicaid

CP.PMN.59

Quantity Limit Override and Dose Optimization

12/01/2025

Ambetter

CP.PMN.95

Fluticasone Propionate (Xhance)

12/01/2025

Ambetter

CP.PMN.109

Suvorexant (Belsomra)

12/01/2025

Ambetter & Medicaid

CP.PMN.110

Crisaborole (Eucrisa)

12/01/2025

Ambetter

CP.PMN.112

Naldemedine (Symproic)

12/01/2025

Ambetter

CP.PMN.116

L-glutamine (Endari)

12/01/2025

Ambetter

CP.PMN.142

Lubiprostone (Amitiza)

12/01/2025

Ambetter

CP.PMN.143

Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane)

12/01/2025

Ambetter & Medicaid

CP.PMN.165

Fluorouracil Cream (Tolak)

12/01/2025

Ambetter & Medicaid

CP.PMN.167

Neomycin/Fluocinolone Cream (Neo-Synalar)

12/01/2025

Ambetter & Medicaid

CP.PMN.168

Ospemifene (Osphena)

12/01/2025

Ambetter & Medicaid

CP.PMN.169

Methylnaltrexone Bromide (Relistor)

12/01/2025

Ambetter

CP.PMN.170

Eluxadoline (Viberzi)

12/01/2025

Ambetter

CP.PMN.172

Zolpidem Tartrate (Edluar, Zolpimist)

12/01/2025

Medicaid

CP.PMN.173

Ramelteon (Rozerem)

12/01/2025

Medicaid

CP.PMN.174

Perindopril/Amlodipine (Prestalia)

12/01/2025

Medicaid

CP.PMN.175

Doxepin (Silenor)

12/01/2025

Medicaid

CP.PMN.176

Amlodipine/Atorvastatin (Caduet)

12/01/2025

Medicaid

CP.PMN.177

Glycopyrronium (Qbrexza)

12/01/2025

Medicaid

CP.PMN.179

Megestrol Acetate

12/01/2025

Ambetter & Medicaid

CP.PMN.180

Halobetasol Propionate (Bryhali, Lexette, Ultravate)

12/01/2025

Ambetter & Medicaid

CP.PMN.181

Calcipotriene/Betamethasone Dipropionate Foam (Enstilar)

12/01/2025

Ambetter & Medicaid

CP.PMN.182

Betamethasone Dipropionate Spray (Sernivo)

12/01/2025

Ambetter & Medicaid

CP.PMN.184

Stiripentol (Diacomit)

12/01/2025

Ambetter & Medicaid

CP.PMN.185

Baloxavir Marboxil (Xofluza)

12/01/2025

Ambetter & Medicaid

CP.PMN.210

Acyclovir Buccal Tablet (Sitavig)

12/01/2025

Ambetter & Medicaid

CP.PMN.213

Ferric Maltol (Accrufer)

12/01/2025

Ambetter & Medicaid

CP.PMN.214

Continuous Glucose Monitors

12/01/2025

Ambetter

CP.PMN.215

Non-Preferred Blood Glucose Monitors/Test Strips

12/01/2025

Medicaid

CP.PMN.216

Diazepam (Libervant, Valtoco)

12/01/2025

Ambetter & Medicaid

CP.PMN.226

Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep)

12/01/2025

Medicaid

CP.PMN.244

Tazarotene (Arazlo, Fabior, Tazorac)

12/01/2025

Ambetter & Medicaid

CP.PMN.249

Ciprofloxacin/Fluocinolone (Otovel)

12/01/2025

Ambetter & Medicaid

CP.PMN.250

Colesevelam (Welchol)

12/01/2025

Ambetter & Medicaid

CP.PMN.251

Lactic Acid/Citric Acid/Potassium Bitartrate (Phexxi)

12/01/2025

Medicaid

CP.PMN.252

Metoclopramide (Gimoti)

12/01/2025

Ambetter & Medicaid

CP.PMN.255

No Coverage Criteria, Recent Label Changes Pending Clinical Policy Update

12/01/2025

Medicaid

CP.PMN.256

Nifurtimox (Lampit)

12/01/2025

Ambetter & Medicaid

CP.PMN.266

Finerenone (Kerendia)

12/01/2025

Ambetter & Medicaid

CP.PMN.267

Levodopa Inhalation Powder (Inbrija)

12/01/2025

Ambetter & Medicaid

CP.PMN.268

Tenofovir Alafenamide Fumarate (Vemlidy)

12/01/2025

Ambetter & Medicaid

CP.PMN.270

Pilocarpine (Qlosi, Vuity)

12/01/2025

Ambetter & Medicaid

CP.PMN.282

Ketorolac Nasal Spray (Sprix)

12/01/2025

Ambetter & Medicaid

CP.PMN.283

Tapinarof (Vtama)

12/01/2025

Ambetter & Medicaid

CP.PMN.284

Dextromethorphan/Bupropion (Auvelity)

12/01/2025

Ambetter & Medicaid

CP.PMN.286

Glaucoma Agents

12/01/2025

Ambetter & Medicaid

CP.PMN.291

Lotilaner (Xdemvy)

12/01/2025

Ambetter & Medicaid

CP.PMN.295

Semaglutide (Wegovy)

12/01/2025

Ambetter

CP.PMN.297

Brivaracetam (Briviact)

12/01/2025

Ambetter & Medicaid

CP.PMN.298

Tirzepatide (Zepbound)

12/01/2025

Ambetter

CP.PMN.302

Aceclidine (Vizz)

12/01/2025 (new policy)

Ambetter & Medicaid

CP.PMN.303

Brensocatib (Brinsupri)

12/01/2025 (new policy)

Ambetter & Medicaid

HIM.PA.03

Ophthalmic Corticosteroids

12/01/2025

Ambetter

HIM.PA.09

Insulin Glargine (Basaglar, Lantus/unbranded Lantus, Rezvoglar, Toujeo/unbranded Toujeo)

12/01/2025

Ambetter

HIM.PA.17

Methoxsalen (Uvadex)

12/01/2025

Ambetter

HIM.PA.20

Halcinonide (Halog)

12/01/2025

Ambetter

HIM.PA.33

No Coverage Criteria, Recent Label Changes Pending Clinical Policy Update

12/01/2025

Ambetter

HIM.PA.71

Topical Acne Treatment

12/01/2025

Ambetter

HIM.PA.87

Testosterone (Androderm)

12/01/2025

Ambetter

HIM.PA.103

Brand Name Override and Non-Formulary Medications

12/01/2025

Ambetter

HIM.PA.119

Azelaic Acid (Finacea Topical Gel/Foam)

12/01/2025

Ambetter

HIM.PA.130

Naproxen Oral Suspension (Naprosyn)

12/01/2025

Ambetter

HIM.PA.147

Doxepin (Silenor, Prudoxin, Zonalon)

12/01/2025

Ambetter

HIM.PA.152

Nitazoxanide (Alinia)

12/01/2025

Ambetter

HIM.PA.154

Off-Label Drug Use

12/01/2025

Ambetter

HIM.PA.159

Prucalopride (Motegrity)

12/01/2025

Ambetter

HIM.PA.167

Naloxegol (Movantik)

12/01/2025

Ambetter

HIM.PA.171

Insulin detemir (Levemir)

12/01/2025

Ambetter

HIM.PA.173

Palbociclib (Ibrance)

12/01/2025

Ambetter

HIM.PA.176

Tezepelumab (Tezspire)

12/01/2025

Ambetter

HIM.PA.SP55

Uridine Triacetate (Vistogard)

12/01/2025

Ambetter

HIM.PA.SP60

Biologic and Non-biologic DMARDs

12/01/2025

Ambetter

HIM.PA.SP64

Eptinezumab-jjmr (Vyepti)

12/01/2025

Ambetter

HIM.PA.SP65

Erenumab-aooe (Aimovig)

12/01/2025

Ambetter

HIM.PA.SP66

Fremanezumab-vfrm (Ajovy)

12/01/2025

Ambetter

HIM.PA.SP67

Galcanezumab-gnlm (Emgality)

12/01/2025

Ambetter

HIM.PA.SP69

Dupilumab (Dupixent)

12/01/2025

Ambetter

HIM.PA.SP70

Benralizumab (Fasenra)

12/01/2025

Ambetter

WA.CP.PMN.151

QL of Blood Glucose Test Strips and Lancets Not Receiving Insulin

12/15/2025

Medicaid

WA.PHAR.14

Second Opinion Network (SON)

12/15/2025

Medicaid

WA.PHAR.126

Non-Contracted Drugs

12/15/2025

Medicaid

WA.PHAR.129

Appropriate Use and Safety

12/15/2025

Medicaid

WA.CP.PMN.234

EPSDT Benefit for Pediatric Members

01/01/2026

Medicaid

CC.PHAR.01

72-Hour Supply of Medication

01/01/2026

Medicaid

WA.PHAR.49.AL

Cytokine and CAM Antagonisists- IL-36 inhibitors

02/01/2026 (new policy)

Medicaid

WA.PHAR.151

Oncology Agents- BRAF Kinase Inhibitors- Oral

02/01/2026 (new policy)

Medicaid

WA.PHAR.152

Oncology Agents- Phosphatidylinositol 3-Kinase (P13K) Inhibitors

02/01/2026 (new policy)

Medicaid

WA.PHAR.153

Endocrine and Metabolic Agents- Somatostatic Agents

02/01/2026 (new policy)

Medicaid

WA.PHAR.154

Medical Necessity

02/01/2026 (new policy)