Clinical & Payment Policies
Clinical Policies
Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information.
All policies found in the Coordinated Care Clinical Policy Manual apply to Coordinated Care members. Policies in the Coordinated Care Clinical Policy Manual may have either a Coordinated Care or a “Centene” heading. Coordinated Care utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Coordinated Care clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Coordinated Care. In addition, Coordinated Care may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or InterQual®criteria is payable by Coordinated Care.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Ambetter Clinical Policies Listing
- Acupuncture (PDF) (CP.MP.92)
- ADHD Assessment and Treatment (PDF) (CP.MP.124)
- Air Ambulance (PDF) (CP.MP.175)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-Thalassemia (PDF) (CP.MP.108)
- Applied Behavior Analysis (PDF) (CP.BH.104)
- Bariatric Surgery (PDF) (CP.MP.37)
- BH Treatment Documentation Requirements (PDF) (CP.BH.500)
- Biofeedback (PDF) (CP.MP.168)
- Bone-anchored Hearing Aid (PDF) (CP.MP.93)
- Bronchial Thermoplasty (PDF) (CP.MP.110)
- Burn Surgery (PDF) (CP.MP.186)
- Cardiac Biomarker Testing for Acute MI (PDF) (CP.MP.156)
- Clinical Trials (PDF) (CP.MP.94)
- Cochlear Implant Replacements (PDF) (CP.MP.14)
- Cosmetic and Reconstructive Surgery (PDF) (CP.MP.31)
- Deep TMS for OCD (PDF) (CP.BH.201) - effective 9/1/23
- Diaphragmatic/Phrenic Nerve Stimulation (PDF) (CP.MP.203)
- Digital Analysis of EEG (PDF) (CP.MP.105)
- Discography (PDF) (CP.MP.115)
- Donor Lymphocyte Infusion (PDF) (CP.MP.101)
- Drugs of Abuse: Definitive Testing (PDF) (CP.MP.50)
- Durable Medical Equipment (DME) (PDF) (CP.MP.107)
- Electric Tumor Treating Fields (PDF) (CP.MP.145)
- Electroencephalography in the Evaluation of Headache (PDF) (CP.MP.155)
- Endometrial Ablation (PDF) (CP.MP.106)
- Evoked Potential Testing (PDF) (CP.MP.134)
- Experimental Technologies (PDF) (CP.MP.36)
- Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF) (CP.MP.248)
- Fecal Incontinence Treatments (PDF) (CP.MP.137)
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) (CP.MP.129) - effective through 11/30/23
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) (CP.MP.129) - effective 12/1/23
- Gender Affirming Procedures (PDF) (WA.CP.MP.95)
- Gastric Electrical Stimulation (PDF) (CP.MP.40)
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) (CP.MP.209)
- Concer Genetic Testing Aortopathies & Connective Tissue Disorders (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Cardiac Disorders (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Dermatologic Conditions (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Epilepsy Neurodegenerative and Neuromuscular Conditions (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Exome and Genome Sequencing for DX of Genetic Disorders (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Eye Disorders (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Gastroenterologic Disorders Non-cancerous (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing General Approach to Genetic Testing (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Hearing Loss (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Hematologic Conditions Non-cancerous (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Hereditary Cancer Susceptibility (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Immune Autoimmune and Rheumatoid Disorders (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Kidney Disorders (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Lung Disorders (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Metabolic Endocrine Mitochondrial Disorders (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Non-Invasive Prenatal Screening (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Pharmacogenetics (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Preimplantation Genetic Testing (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Prenatal and Preconception Carrier Screening (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Prenatal Diagnosis Pregnancy Loss (PDF) (V2.2023) - effective 9/1/23
- Concert Genetic Testing Skeletal Dysplasia Rare Bone Disorders (PDF) (V2.2023) - effective 9/1/23
- Concert Genetics Oncology Algorithmic Testing (PDF) (V2.2023) - effective 9/1/23
- Concert Genetics Oncology Cancer Screening (PDF) (V2.2023) - effective 9/1/23
- Concert Genetics Oncology Circulating Tumor DNA Tumor Cells Liquid Biopsy (PDF) (V2.2023) - effective 9/1/23
- Concert Genetics Oncology Cytogenetic Testing (PDF) (V2.2023) - effective 9/1/23
- Concert Genetics Oncology Molecular Analysis Solid Tumors & Hematolgic Malignancies (PDF) (V2.2023) - effective 9/1/23
- H. Pylori serology testing (PDF) (CP.MP.153)
- Heart-Lung Transplant (PDF) (CP.MP.132)
- Holter Monitors (PDF) (CP.MP.113)
- Home Birth (PDF) (CP.MP.136)
- Home Ventilators (PDF) (CP.MP.184)
- Homocysteine testing (PDF) (CP.MP.121)
- Hospice Services (PDF) (CP.MP.54)
- Hyperhidrosis Treatments (PDF) (CP.MP.62)
- Implantable Hypoglossal Nerve Stimulation (PDF) (CP.MP.180)
- Implantable Intrathecal or Epidural Pain Pump (PDF) (CP.MP.173)
- Implantable Loop Recorder (CP.MP.243)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) (CP.MP.160)
- Inhaled Nitric Oxide (PDF) (CP.MP.87)
- Intensity-Modulated Radiotherapy (PDF) (CP.MP.69)
- Intestinal and Multivisceral Transplant (PDF) (CP.MP.58)
- Intradiscal Steroid Injections for Pain Management (PDF) (CP.MP.167)
- IV Moderate Sedation, IV Deep Sedation and General Anesthesia for Dental Procedures (PDF) (CP.MP.61)
- Laser therapy for skin conditions (PDF) (CP.MP.123)
- Liposuction of Lipedema (PDF) (CP.MP.244)
- Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF) (CP.MP.139)
- Lung Transplantation (PDF) (CP.MP.57)
- Lysis of Epidural Lesions (PDF) (CP.MP.116)
- Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) (CP.MP.144)
- Multiple Sleep Latency Testing (PDF) (CP.MP.24)
- Neonatal Abstinence Syndrome Guidelines (PDF) (CP.MP.86)
- Neonatal Sepsis Management Guidelines (PDF) (CP.MP.85)
- Nerve Blocks for Pain Management (PDF) (CP.MP.170)
- Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF) (CP.MP.48)
- NICU Apnea Bradycardia Guidelines (PDF) (CP.MP.82)
- NICU Discharge Guidelines (PDF) (CP.MP.81)
- Nonmyeloablative allogeneic SCT (PDF) (CP.MP.141)
- Obstetrical Home Health Care Programs (PDF) (CP.MP.91)
- Omisirge (Omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF) (CP.MP.249)
- Orthognathic Surgery (PDF) (CP.MP.202)
- Osteogenic Stimulation (PDF) (CP.MP.194)
- Outpatient Cardiac Rehabilitation (PDF) (CP.MP.176)
- Outpatient Oxygen Use (PDF) (CP.MP.190)
- Pancreas Transplantation (PDF) (CP.MP.102)
- Panniculectomy (PDF) (CP.MP.109)
- Pediatric Heart Transplant (PDF) (CP.MP.138)
- Pediatric Liver Transplant (PDF) (CP.MP.120)
- Pediatric Kidney Transplant (PDF) (CP.MP.246)
- Pediatric Oral Function Therapy (PDF) (CP.MP.188)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) (CP.MP.147)
- Peripheral and Percutaneous Nerve Stimulation (PDF) (WA.CP.MP.117)
- Photherapy for Neonatal Hyperbilirubinemia (PDF) (CP.MP.150)
- Physical, Occupational and Speech Therapy Services (PDF) (CP.MP.49)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) (CP.MP.181)
- Posterior tibial nerve stimulation for voiding dysfunction (PDF) (CP.MP.133)
- Proton and Neutron Beam Therapy (PDF) (CP.MP.70)
- Pulmonary Function Testing (PDF) (CP.MP.242)
- Reduction Mammoplasty and Gynecomastia Surgery (PDF) (CP.MP.51)
- Repair of Nasal Valve Compromise (PDF) (CP.MP.210)
- Sclerotherapy for Varicose Veins (PDF) (CP.MP.146) - effective 9/1/23
- Short Inpatient Hospital Stay (PDF) (CP.MP.182) - effective through 9/30/23
- Short Inpatient Hospital Stay (PDF) (CP.MP.182) - effective 10/1/23
- Skilled Nursing Facility Leveling (PDF) (CP.MP.206)
- Skin Substitutes for Chronic Wounds (PDF) (CP.MP.185)
- Stereotactic Body Radiation Therapy (PDF) (CP.MP.22)
- Substance Use Treatment and Services (PDF) (CP.BH.100)
- Tandem Transplant (PDF) (CP.MP.162)
- Thyroid hormones and insulin testing in pediatrics (PDF) (CP.MP.154)
- Total Artificial Heart (PDF) (CP.MP.127)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) (CP.MP.163)
- Transcatheter Closure of Patent Foramen Ovale (PDF) (CP.MP.151)
- Transcranial Magnetic Stimulation (PDF) (CP.BH.200) - effective 9/1/23
- Transplant Service Documentation Requirements (PDF) (CP.MP.247)
- Trigger Point Injections for Pain Management (PDF) (CP.MP.169)
- Ultrasound in Pregnancy (PDF) (WA.CP.MP.38) - effective through 10/31/23
- Ultrasound in Pregnancy (PDF) (WA.CP.MP.38) - effective 11/1/23
- Urinary Incontinence Devices and Treatments (PDF) (CP.MP.142)
- Urodynamic testing (PDF) (CP.MP.98)
- Vagus Nerve Stimulation (PDF) (CP.MP.12)
- Ventricular Assist Devices (PDF) (CP.MP.46) - effective through 9/30/23
- Ventricular Assist Devices (PDF) (CP.MP.46) - effective 10/1/23
- Vitamin D Testing (PDF) (WA.CP.MP.527)
- Wheelchair seating (PDF) (CP.MP.99)
- Wireless Motility Capsule (PDF) (CP.MP.143)
Ambetter Pharmacy Policies Listing
- Abaloparatide (Tymlos) (PDF) (CP.PHAR.345)
- Abametapir (Xeglyze) (PDF) (CP.PMN.253)
- Abemaciclib (Verzenio) (PDF) (CP.PHAR.355)
- Abrocitinib (Cibinqo) (PDF) (CP.PHAR.578)
- Acalabrutinib (Calquence) (PDF) (CP.PHAR.366)
- Acyclovir Buccal Tablet (Sitavig), Ophthalmic Ointment (Avaclyr) (PDF) (CP.PMN.210)
- Afamelanotide (Scenesse) (PDF) (CP.PHAR.444)
- Abiraterone (PDF) (CP.PHAR.84)
- AbobotulinumtoxinA (Dysport) (PDF) (CP.PHAR.230)
- Adagrasib (Krazati) (PDF) (CP.PHAR.605)
- Adefovir (Hepsera) (PDF) (CP.PHAR.142)
- Ado-Trastuzumab (Kadcyla) (PDF) (CP.PHAR.229)
- Aducanumab (PDF) (CP.PHAR.468)
- Afatinib (Gilotrif) (PDF) (CP.PHAR.298)
- Afinitor (everolimus) (PDF) (CP.PHAR.63)
- Aflibercept (Eylea®) (PDF) (CP.PHAR.184)
- Agalsidase Beta (Fabrazyme) (PDF) (CP.PHAR.158)
- Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) (CP.PMN.138)
- Alectinib (Alecensa) (PDF) (CP.PHAR.369)
- Alemtuzumab (Lemtrada) (PDF) (CP.PHAR.243)
- Alendronate (Binosto, Fosamax plus D) (PDF) (CP.PMN.88)
- Alglucosidase (Lumizyme) (PDF) (CP.PHAR.160)
- Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) (PDF) (CP.PHAR.562)
- Allogenic Processed Thymus Tissue-agdc (Rethymic) (PDF) (CP.PHAR.563)
- Alpelisib (Piqray) (PDF) (CP.PHAR.430)
- Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF) (CP.PHAR.94)
- Amantadine ER (Gocovri, Osmolex ER) (PDF) (CP.PMN.89)
- Ambrisentan (Letairis®) (PDF) (CP.PHAR.190)
- Amifampridine (Firdapse) (PDF) (CP.PHAR.411)
- Amikacin (Arikayce) (PDF) (CP.PHAR.401)
- Amisulpride (Barhemsys) (PDF) (CP.PMN.236)
- Amivantamab-vmjw (Rybrevant) (PDF) (CP.PHAR.544)
- Anifrolumab-fnia (Saphnelo) (PDF) (CP.PHAR.551)
- Anti-Inhibitor Coagulant Complex (Feiba®) (PDF) (CP.PHAR.217)
- Antithrombin III (ATryn, Thrombate III) (PDF) (CP.PHAR.564)
- Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) (CP.PHAR.506)
- Apalutamide (Erleada) (PDF) (CP.PCH.45)
- Apalutamide (Erleada) (PDF) (CP.PHAR.376)
- Apomorphine (Apokyn, Kynmobi) (PDF) (CP.PHAR.488)
- aprepitant (PDF) (CP.PMN.19)
- Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF) (CP.PHAR.290)
- Aripiprazole Orally Disintegrating Tablet (PDF) (CP.PCH.37)
- Armodafinil (Nuvigil) (PDF) (CP.PMN.35)
- Asciminib (Scemblix) (PDF) (CP.PHAR.565)
- Asenapine (Saphris) (PDF) (CP.PMN.15)
- Asfotase Alfa (Strensiq) (PDF) (CP.PHAR.328)
- Aspirin-dipyridamole (Aggrenox) (PDF) (CP.PMN.20)
- Atezolizumab (Tecentriq®) (PDF) (CP.PHAR.235)
- Atogepant (Qulipta) (PDF) (CP.PHAR.566)
- Avacopan (Tavneos) (PDF) (CP.PHAR.515)
- Avalglucosidase Alfa-ngpt (Nexviazyme) (PDF) (CP.PHAR.521)
- Avapritinib (Ayvakit) (PDF) (CP.PHAR.454)
- Avatrombopag (Doptelet) (PDF) (CP.PHAR.130)
- Avelumab (Bavencio®) (PDF) (CP.PHAR.333)
- Axicabtagene Ciloleucel (Yescarta®) (PDF) (CP.PHAR.362)
- Axitinib (Inlyta®) (PDF) (CP.PHAR.100)
- Azacitidine (Vidaza) (PDF) (CP.PHAR.387)
- Azelaic Acid (Finacea) (PDF) (HIM.PA.119)
- Aztreonam (Cayston®) (PDF) (CP.PHAR.209)
- Baloxavir Marboxil (Xofluza) (PDF) (CP.PMN.185)
- Bedaquiline (Sirturo) (PDF) (CP.PMN.212)
- Belantamab Mafodotin (Blenrep) (PDF) (CP.PHAR.469)
- belatacept (Nulojix®) (PDF) (CP.PHAR.201)
- Belimumab (Benlysta) (PDF) (CP.PHAR.88)
- belinostat (Beleodaq®) (PDF) (CP.PHAR.311)
- Belumosudil (Rezurock) (PDF) (CP.PHAR.552)
- Belzutifan (Welireg) (PDF) (CP.PHAR.553)
- Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet) (PDF) (CP.PMN.237)
- bendamustine (Bendeka®, Treanda®) (PDF) (CP.PHAR.307)
- Benralizumab (Fasenra) (PDF) (CP.PHAR.373)
- Benznidazole (PDF) (CP.PMN.90)
- Beremagene geperpavec-svdt (Vyjuvek) (PDF) (CP.PHAR.592)
- Berotralstat (Orladeyo) (PDF) (CP.PHAR.485)
- Betaine (Cystadane) (PDF) (CP.PHAR.143)
- Betamethasone Dipropionate Spray (Sernivo) (PDF) (CP.PMN.182)
- Betibeglogene Autotemcel (Zynteglo) (PDF) (CP.PHAR.545)
- Bevacizumab (Avastin) (PDF) (CP.PHAR.93)
- Bexarotene (Targretin Capsules, Gel) (PDF) (CP.PHAR.75)
- Bezlotoxumab (Zinplava) (PDF) (CP.PHAR.300)
- Bimatoprost Implant (Durysta) (PDF) (CP.PHAR.486)
- Binimetinib (PDF) (CP.PHAR.50)
- Biologic DMARDs (PDF) (HIM.PA.SP60)
- Blinatumomab (PDF) (CP.PHAR.312)
- Bortezomib (Velcade) (PDF) (CP.PHAR.410)
- Bosentan (Tracleer®) (PDF) (CP.PHAR.191)
- Bosutinib (Bosulif) (PDF) (CP.PHAR.105)
- Brand Name Override and Non-Formulary Medications (PDF) (HIM.PA.103)
- Brentuximab (PDF) (CP.PHAR.303)
- Brexanolone (Zulresso) (PDF) (CP.PHAR.417)
- Brexpiprazole (Rexulti) (PDF) (CP.PMN.68)
- Brexucabtagene Autoleucel (Tecartus) (PDF) (CP.PHAR.472)
- Brigatinib (Alunbrig) (PDF) (CP.PHAR.342)
- Brimonidine Tartrate (Mirvaso) (PDF) (CP.PMN.192)
- Brinzolamide/Brimonidine (Simbrinza) (PDF) (HIM.PA.15)
- Brivaracetam (Briviact) (PDF) (CP.PCH.26)
- Brodalumab (Siliq) (PDF) (CP.PHAR.375)
- Brolucizumab-dbll (Beovu) (PDF) (CP.PHAR.445)
- Budesonide (Tarpeyo) (PDF) (CP.PHAR.572)
- Budesonide (Uceris) (PDF) (CP.PCH.11)
- Buprenorphine (Subutex) (PDF) (CP.PMN.82)
- buprenorphine implant (Probuphine) (PDF) (CP.PHAR.289)
- Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF) (CP.PMN.81)
- Bupropion/Naltrexone (Contrave) (PDF) (CP.PCH.12)
- Burosumab-twza (Crysvita) (PDF) (CP.PHAR.11)
- Butorphanol Nasal Spray (PDF) (HIM.PA.46)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF) (CP.PHAR.202)
- Cabazitaxel (Jevtana) (PDF) (CP.PHAR.316)
- Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) (PDF) (CP.PHAR.573)
- Cabozantinib (Cometriq®, Cabometyx®) (PDF) (CP.PHAR.111)
- Calcifediol (Rayaldee) (PDF) (CP.PMN.76)
- Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) (PDF) (CP.PMN.181)
- Canakinumab (Ilaris) (PDF) (CP.PHAR.246)
- Cannabidiol (Epidiolex) (PDF) (CP.PMN.164)
- Capecitabine (Xeloda) (PDF) (CP.PHAR.60)
- Caplacizumab-yhdp (Cablivi) (PDF) (CP.PHAR.416)
- Capmatinib (Tabrecta) (PDF) (CP.PHAR.494)
- Carbidopa/Levodopa ER Capsules (Rytary) (PDF) (CP.PMN.238)
- carfilzomib (Kyprolis®) (PDF) (CP.PHAR.309)
- Carglumic Acid (Carbaglu) (PDF) (CP.PHAR.206)
- Cariprazine (Vraylar) (PDF) (CP.PMN.91)
- Casimersen (Amondys 45) (PDF) (CP.PHAR.470)
- Casirivimab and Imdevimab (REGEN-COV) (PDF) (CP.PHAR.520)
- Celecoxib (Celebrex) (PDF) (CP.PMN.122)
- Cemiplimab-rwlc (Libtayo) (PDF) (CP.PHAR.397)
- Cenegermin-bkbj (Oxervate) (PDF) (CP.PMN.186)
- Cenobamate (Xcopri) (PDF) (CP.PMN.231)
- Ceritinib (Zykadia) (PDF) (CP.PHAR.349)
- Cerliponase alfa (PDF) (CP.PHAR.338)
- cetuximab (Erbitux®) (PDF) (CP.PHAR.317)
- Chenodiol (Chenodal) (PDF) (CP.PMN.239)
- Chlorambucil (Leukeran) (PDF) (CP.PHAR.554)
- Chloramphenicol Sodium Succinate (PDF) (CP.PHAR.388)
- Cholic Acid (Cholbam) (PDF) (CP.PHAR.390)
- Ciclopirox (Penlac) (PDF) (CP.PMN.24)
- Ciltacabtagene Autoleucel (Carvykti) (PDF) (CP.PHAR.533)
- Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) (CP.PMN.248)
- Ciprofloxacin/Fluocinolone (Otovel) (PDF) (CP.PMN.249)
- Cladribine (Mavenclad) (PDF) (CP.PHAR.422)
- Clascoterone (Winlevi) (PDF) (CP.PMN.257)
- Clobazam (PDF) (CP.PMN.54)
- CNS Stimulants (PDF) (CP.PMN.92)
- Cobimetinib (Cotellic) (PDF) (CP.PHAR.380)
- Colesevelam (Welchol) (PDF) (CP.PMN.250)
- Collagenase (PDF) (CP.PHAR.82)
- Colonoscopy Preparation Products (PDF) (CP.PCH.43)
- Compounded Medications (PDF) (CP.PMN.280)
- Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) (CP.PMN.258)
- Continuous Glucose Monitors (PDF) (CP.PMN.214)
- copanlisib (Aliqopa®) (PDF) (CP.PHAR.357)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert) (PDF) (CP.PHAR.385)
- Cosyntropin (Cortrosyn®) (PDF) (CP.PHAR.203)
- Crisaborole (Eucrisa) (PDF) (CP.PMN.110)
- Crizanlizumab-tmca (Adakveo) (PDF) (CP.PHAR.449)
- Crizotinib (Xalkori) (PDF) (CP.PHAR.90)
- Cyclosporine ophthalmic emulsion (Cequa, Restasis) (PDF) (CP.PMN.48)
- Cyramza® (PDF) (CP.PHAR.119)
- Cysteamine ophthalmic (Cystaran, Cystadrops) (PDF) (CP.PMN.130)
- Cysteamine oral (Cystagon, Procysbi) (PDF) (CP.PHAR.155)
- Cytomegalovirus Immune Globulin (Cytogam) (PDF) (CP.PHAR.277)
- Dabrafenib (Tafinlar) (PDF) (CP.PHAR.239)
- Dacomitinib (Vizimpro) (PDF) (CP.PHAR.399)
- Dalfampridine (Ampyra) (PDF) (CP.PHAR.248)
- Dalteparin (Fragmin) (PDF) (CP.PHAR.225)
- Daptomycin (Cubicin, Cubicin RF) (PDF) (CP.PHAR.351)
- Daratumumab (PDF) (CP.PHAR.310)
- Darbepoetin alfa (Aranesp) (PDF) (CP.PHAR.236)
- Darolutamide (Nubeqa) (PDF) (CP.PHAR.435)
- Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) (PDF) (HIM.PA.SP61)
- Dasatinib (Sprycel) (PDF) (CP.PHAR.72)
- Daprodustat (Jesduvroq) (PDF) (CP.PHAR.628)
- Dapsone (Aczone Gel) (PDF) (CP.PCH.32)
- daunorubicin/cytarabine (Vyxeos®) (PDF) (CP.PHAR.352)
- Decitabine-Cedazuridine (Inqovi) (PDF) (CP.PHAR.479)
- deferasirox (PDF) (CP.PHAR.145)
- Deferoxamine (Desferal) (PDF) (CP.PHAR.146)
- Deflazacort (Emflaza) (PDF) (CP.PHAR.331)
- degarelix acetate (Firmagon®) (PDF) (CP.PHAR.170)
- Delafloxacin (Baxdela) (PDF) (CP.PMN.115)
- Delandistrogene moxeparvovec-rokl (Elevidys) (PDF) (CP.PHAR.593)
- Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (PDF) (CP.PHAR.214)
- Deutetrabenazine (Austedo) (PDF) (CP.PCH.42)
- Dexrazoxane (Zinecard Totect) (PDF) (CP.PHAR.418)
- Dextromethorphan/Bupropion (Auvelity) (PDF) (CP.PMN.284)
- Dextromethorphan-Quinidine (Nuedexta) (PDF) (CP.PMN.93)
- Diazepam Nasal Spray (Valtoco) (PDF) (CP.PMN.216)
- Dichlorphenamide (Keveyis) (PDF) (CP.PMN.261)
- Diclofenac (Cambia, Flector, Licart, Pennsaid, Solaraze, Zipsor, Zorvolex) (PDF) (CP.PCH.28)
- Dimethyl Fumarate (Tecfidera) (PDF) (CP.PCH.41)
- Dipeptidyl Peptidase-4 Inhibitors (PDF) (HIM.PA.58)
- Dolasetron (Anzemet) (PDF) (CP.PMN.141)
- Dornase alfa (Pulmozyme) (PDF) (CP.PHAR.212)
- Dostarlimab-gxly (Jemperli) (PDF) (CP.PHAR.540)
- Doxepin Hydrochloride Cream (Prudoxin, Zonalon) (PDF) (HIM.PA.147)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF) (CP.PMN.79)
- Dupilumab (Dupixent) (PDF) (CP.PHAR.336)
- Durvalumab (Imfinzi) (PDF) (CP.PHAR.339)
- Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn) (PDF) (CP.PMN.128)
- Duvelisib (Copiktra) (PDF) (CP.PHAR.400)
- Ecallantide (Kalbitor®) (PDF) (CP.PHAR.177)
- Eculizumab (Soliris®) (CP.PHAR.97)
- Edaravone (Radicava) (PDF) (CP.PHAR.343)
- Efgartigimod Alfa-fcab (Vyvgart) (PDF) (CP.PHAR.555)
- Efinaconazole (Jublia) (PDF) (CP.PMN.25)
- Elacestrant (Orserdu) (PDF) (CP.PHAR.623)
- Elagolix (Orilissa) (PDF) (CP.PHAR.136)
- Elapegademase-lvlr (Revcovi) (PDF) (CP.PHAR.419)
- Elbasvir/Grazoprevir (Zepatier) (PDF) (HIM.PA.SP62)
- Electromyography and Nerve Conduction Studies (PDF) (CP.MP.211) Effective 9/1/21
- Elexacaftor, tezacaftor (Trikafta) (PDF) (CP.PHAR.440)
- Eliglustat (Cerdelga) (PDF) (CP.PHAR.153)
- Elivaldogene Autotemcel (Skysona) (PDF) (CP.PHAR.556)
- Elotuzumab (Empliciti®) (PDF) (CP.PHAR.308)
- Elosulfase alfa (Vimizim) (PDF) (CP.PHAR.162)
- Eltrombopag (Promacta®) (PDF) (CP.PHAR.180)
- Eluxadoline (Viberzi) (PDF) (CP.PMN.170)
- Emapalumab-lzsg (Gamifant) (PDF) (CP.PHAR.402)
- Emicizumab-kxwh (Hemlibra) (PDF) (CP.PHAR.370)
- Emtricitabine/Tenofovir Alafenamide (Descovy) (PDF) (CP.PMN.235)
- Enasidenib (Idhifa) (PDF) (CP.PHAR.363)
- Encorafenib (PDF) (CP.PHAR.127)
- Enfortumab Vedotin-ejfv (Padcev) (PDF) (CP.PHAR.455)
- Enfuvirtide (PDF) (CP.PHAR.41)
- Enoxaparin (Lovenox) (PDF) (CP.PHAR.224)
- Entecavir (Baraclude) (PDF) (HIM.PA.08)
- Entrectinib (Rozlytrek) (PDF) (CP.PHAR.441)
- Enzalutamide (Xtandi) (PDF) (CP.PHAR.106)
- Epcoritamab-bysp (Epkinly) (PDF) (CP.PHAR.634)
- Epoetin alfa (Epogen, Procrit), Epoetin alfa-epbx (Retacrit) (PDF) (CP.PHAR.237)
- Epoprostenol (Flolan®, Veletri®) (PDF) (CP.PHAR.192)
- Eptinezumab-jjmr (Vyepti) (PDF) (HIM.PA.SP64)
- Erdafitinib (Balversa) (PDF) (CP.PHAR.423)
- Eribulin Mesylate (Halaven®) (PDF) (CP.PHAR.318)
- Erlotinib (Tarceva) (PDF) (CP.PHAR.74)
- Erenumab-aaoe (Aimovig) (PDF) (HIM.PA.SP65)
- erwina asparaginase (Erwinaze®) (PDF) (CP.PHAR.301)
- Esketamine (Spravato) (PDF) (CP.PMN.199)
- Estradiol Vaginal Ring (Femring) (PDF) (CP.PMN.263)
- Etelcalcetide (Parsabiv) (PDF) (CP.PHAR.379)
- Eteplirsen (Exondys 51) (PDF) (CP.PHAR.288)
- Etranacogene Dezaparvovec-drlb (Hemgenix) (PDF) (CP.PHAR.580)
- Evinacumab-dgnb (Evkeeza) (PDF) (HIM.PA.166)
- Evolocumab (Repatha) (PDF) (HIM.PA.156)
- Factor IX (Human, Recombinant) (PDF) (CP.PHAR.218)
- Factor IX Complex Human (Bebulin®, Profilnine®) (PDF) (CP.PHAR.219)
- Factor VIIa, Recombinant (NovoSeven® RT) (PDF) (CP.PHAR.220)
- Factor VIII (Human Recombinant) (PDF) (CP.PHAR.215)
- Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF) (CP.PHAR.216)
- Factor XIII A-Subunit, Recombinant (Tretten®) (PDF) (CP.PHAR.222)
- Factor XIII, Human (Corifact®) (PDF) (CP.PHAR.221)
- Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) (CP.PHAR.456)
- Faricimab-svoa (Vabysmo) (PDF) (CP.PHAR.581)
- Febuxostat (Uloric) (PDF) (CP.PMN.57)
- Fecal Microbiota, Live-jslm (Rebyota) (PDF) (CP.PHAR.613)
- Fecal Microbiota Spores, Live-brpk (Vowst) (PDF) (CP.PHAR.632)
- Fedratinib (Inrebic) (PDF) (CP.PHAR.442)
- Fenfluramine (Fintepla) (PDF) (CP.PMN.246)
- Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF) (CP.PMN.127)
- Ferric Carboxymaltose (Injectafer) (PDF) (CP.PHAR.234)
- Ferric Derisomaltose (Monoferric) (PDF) (CP.PHAR.480)
- Ferric gluconate (Ferrlecit®) (PDF) (CP.PHAR.166)
- Ferric Maltol (Accrufer) (PDF) (CP.PMN.213)
- Ferric Pyrophosphate (Triferic, Triferic Avnu) (PDF) (CP.PHAR.624)
- Ferumoxytol (Feraheme®) (PDF) (CP.PHAR.165)
- Fezolinetant (Veozah) (PDF) (CP.PMN.289)
- Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP) (PDF) (CP.PHAR.526)
- Filgrastim (PDF) (CP.PHAR.297)
- Finerenone (Kerendia) (PDF) (CP.PMN.266)
- Fingolimod (Gilenya) (PDF) (CP.PCH.38)
- Flibanserin (Addyi) (PDF) (CP.PHAR.446)
- Fluorouracil Cream (Tolak) (PDF) (CP.PMN.165)
- Fluticasone Propionate (Xhance) (PDF) (CP.PMN.95)
- Fondaparinux (Arixtra) (PDF) (CP.PHAR.226)
- Formulary Medications Without Specific Guidelines (PDF) (HIM.PA.33)
- Fosdenopterin (Nulibry) (PDF) (CP.PHAR.471)
- Fostamatinib (Tavalisse) (PDF) (CP.PHAR.24)
- Fremanezumab-vfrm (Ajovy) (PDF) (HIM.PA.SP66)
- Fulvestrant (Faslodex Injection) (PDF) (CP.PHAR.424)
- Furosemide (Furoscix) (PDF) (CP.PHAR.608)
- Futibatinib (Lytgobi) (PDF) (CP.PHAR.604)
- Gabapentin ER (Gralise, Horizant) (PDF) (CP.PMN.240)
- Galcanezumab-gnlm (Emgality) (PDF) (HIM.PA.SP67)
- Galsulfase (Naglazyme) (PDF) (CP.PHAR.161)
- Ganaxolone (Ztalmy) (PDF) (CP.PMN.278)
- Gefitinib (Iressa) (PDF) (CP.PHAR.68)
- gemtuzumab ozogamicin (Mylotarg®) (PDF) (CP.PHAR.358)
- Gilteritinib (Xospata) (PDF) (CP.PHAR.412)
- Givosiran (Givlaari) (PDF) (CP.PHAR.457)
- Glasdegib (Daurismo) (PDF) (CP.PHAR.413)
- Glatiramer (Copaxone, Glatopa) (PDF) (HIM.PA.SP68)
- Glaucoma Agents (PDF) (CP.PMN.286)
- Glecaprevir/Pibrentasvir (Mavyret) (PDF) (HIM.PA.SP36)
- Glofitamab-gxbm (Columvi) (PDF) (CP.PHAR.636)
- Glucagon-Like Peptide-1 Receptor Agonists (PDF) (HIM.PA.53)
- Glycerol phenylbutyrate (Ravicti®) (PDF) (CP.PHAR.207)
- Golodirsen (Vyondys 53) (PDF) (CP.PHAR.453)
- goserelin acetate (Zoladex®) (PDF) (CP.PHAR.171)
- Granisetron (Sancuso, Sustol) (PDF) (CP.PMN.74)
- Halcinonide (Halog) (PDF) (HIM.PA.20)
- Halobetasol Propionate (Bryhali, Lexette, Ultravate) (PDF) (CP.PMN.180)
- Halobetasol Propionate/Tazarotene (Duobrii) (PDF) (CP.PMN.208)
- Hemin (Panhematin®) (PDF) (CP.PHAR.181)
- histrelin acetate (Vantas®, Supprelin LA®) (PDF) (CP.PHAR.172)
- House Dust Mite Allergen Extract (Odactra) (PDF) (CP.PMN.111)
- Human Growth Hormone (Somapacitan, Somatropin) (PDF) (HIM.PA.161)
- Hyaluronate Derivatives (PDF) (CP.PHAR.05)
- Hydroxyprogesterone Caproate (Makena/compound) (PDF) (CP.PHAR.14)
- Hydroxyurea (Siklos) (PDF) (CP.PMN.193)
- Ibalizumab-uiyk (Trogarzo) (PDF) (CP.PHAR.378)
- Ibandronate Injection (Boniva) (PDF) (CP.PHAR.189)
- Ibrutinib (PDF) (CP.PHAR.126)
- Ibuprofen/Famotidine (Duexis) (PDF) (CP.PMN.120)
- Icatibant (Firazyr®) (PDF) (CP.PHAR.178)
- Icosapent ethyl (Vascepa) (PDF) (CP.PMN.187)
- Idecabtagene Vicleucel (Abecma) (PDF) (CP.PHAR.481)
- Idelalisib (Zydelig) (PDF) (CP.PHAR.133)
- Idursulfase (PDF) (CP.PHAR.156)
- Iloperidone (Fanapt) (PDF) (CP.PMN.32)
- Iloprost (Ventavis®) (PDF) (CP.PHAR.193)
- Imatinib (Gleevec) (CP.PHAR.65) (PDF)
- Imiglucerase (Cerezyme) (PDF) (CP.PHAR.154)
- Immune Globulins (PDF) (CP.PHAR.103)
- Inclisiran (Leqvio) (PDF) (CP.PHAR.568)
- IncobotulinumtoxinA (Xeomin) (PDF) (CP.PHAR.231)
- Inebilizumab-cdon (Uplizna) (PDF) (CP.PHAR.458)
- Inhaled Agents for Asthma and COPD (PDF) (HIM.PA.153)
- Infertility and Fertility Preservation (PDF) (CP.PHAR.131)
- Infigratinib (Truseltiq) (PDF) (CP.PHAR.547)
- Inotersen (Tegsedi) (PDF) (CP.PHAR.405)
- inotuzumab ozogamicin (Besponsa®) (PDF) (CP.PHAR.359)
- Insulin degludec (Tresiba) (PDF) (CP.PMN.285)
- Insulin Degludec (Tresiba) (PDF) (HIM.PA.09)
- Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF) (CP.PHAR.534)
- Interferon beta-1a (Avonex, Rebif) (PDF) (CP.PHAR.255)
- Interferon Beta-1b (Betaseron, Extavia) (PDF) (CP.PCH.46)
- Interferon Gamma- 1b (Actimmune) (PDF) (CP.PHAR.52)
- Intrathecal Baclofen (Gablofen, Lioresal) (PDF) (CP.PHAR.149)
- Iobenguane I-131 (Azedra) (PDF) (CP.PHAR.459)
- Ipilimumab (Yervoy) (PDF) (CP.PHAR.319)
- irinotecan Liposome (Onivyde®) (PDF) (CP.PHAR.304)
- Iron sucrose (Venofer®) (PDF) (CP.PHAR.167)
- Isatuximab-irfc (Sarclisa) (PDF) (CP.PHAR.482)
- Isavuconazonium (Cresemba®) (PDF) (CP.PMN.154)
- Isotretinoin (PDF) (CP.PMN.143)
- Istradefylline (Nourianz) (PDF) (CP.PMN.217)
- Itraconazole (Sporanox, Onmel) (PDF) (CP.PMN.124)
- Ivabradine (Corlanor) (PDF) (CP.PMN.70)
- Ivacaftor (Kalydeco) (PDF) (CP.PHAR.210)
- ivermectin (Sklice®) (PDF) (HIM.PA.124)
- Ivermectin (Stromectol, Sklice) (PDF) (CP.PMN.269)
- Ivosidenib (Tibsovo) (PDF) (CP.PHAR.137)
- Ixazomib (PDF) (CP.PHAR.302)
- Ketorolac Nasal Spray (Sprix) (PDF) (CP.PMN.282)
- Korlym (mifepristone) (PDF) (CP.PHAR.101)
- Lanadelumab-fylo (Takhzyro) (PDF) (CP.PHAR.396)
- Lanreotide (Somatuline Depot) (PDF) (CP.PHAR.391)
- lapatinib (Tykerb®) (PDF) (CP.PHAR.79)
- Laronidase (Aldurazyme) (PDF) (CP.PHAR.152)
- Larotrectinib (Vitrakvi) (PDF) (CP.PHAR.414)
- Lasmiditan (Reyvow) (PDF) (CP.PMN.218)
- Lecanemab-irmb (Leqembi) (PDF) (CP.PHAR.596)
- Ledipasvir/Sofosbuvir (Harvoni) (PDF) (HIM.PA.SP3)
- Lefamulin (Xenleta) (PDF) (CP.PMN.219)
- Lenacapavir (Sunlenca) (PDF) (CP.PHAR.622)
- Lenalidomide (Revlimid) (PDF) (CP.PHAR.71)
- Leniolisib (Joenja) (PDF) (CP.PHAR.597)
- Lenvatinib (Lenvima) (PDF) (CP.PHAR.138)
- Letermovir (Prevymis) (PDF) (CP.PHAR.367)
- Levodopa Inhalation Powder (Inbrija) (PDF) (CP.PMN.267)
- Levoketoconazole (Recorlev) (PDF) (CP.PMN.275)
- levoleucovorin (Fusilev) (PDF) (CP.PHAR.151)
- Levomilnacipran (Fetzima) (PDF) (HIM.PA.125)
- Leucovorin Injection (PDF) (CP.PHAR.393)
- Leuprolide Acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi) (PDF) (CP.PHAR.173)
- L-glutamine (Endari) (PDF) (CP.PMN.116)
- lidocaine transdermal (Lidoderm, ZTlido) (PDF) (CP.PMN.08)
- Lifitegrast (Xiidra®) (PDF) (CP.PMN.73)
- Linaclotide (Linzess) (PDF) (CP.PMN.71)
- Linezolid (Zyvox) (PDF) (CP.PMN.27)
- Lisocabtagene Maraleucel (Breyanzi) (PDF) (CP.PHAR.483)
- Lofexidine (Lucemyra) (PDF) (CP.PMN.152)
- Lomustine (Gleostine) (PDF) (CP.PHAR.507)
- Lonafarnib (Zokinvy) (PDF) (CP.PHAR.499)
- Loncastuximab Tesirine-lpyl (Zynlonta) (PDF) (CP.PHAR.539)
- Lorlatinib (Lorbrena) (PDF) (CP.PHAR.406)
- Loteprednol etabonate (Eysuvis) (PDF) (CP.PMN.260)
- Lubiprostone (Amitiza) (PDF) (CP.PMN.142)
- Luliconazole Cream (Luzu) (PDF) (CP.PMN.166)
- Lumacaftor-ivacaftor (PDF) (CP.PHAR.213)
- Lumasiran (Oxlumo) (PDF) (CP.PHAR.473)
- Lumateperone (Caplyta) (PDF) (CP.PMN.232)
- Lurasidone (Latuda) (PDF) (CP.PMN.50)
- Lurbinectedin (Zepzelca) (PDF) (CP.PHAR.500)
- Luspatercept-aamt (Reblozyl) (PDF) (CP.PHAR.450)
- Lusutrombopag (Mulpleta) (PDF) (CP.PHAR.407)
- Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) (PDF) (CP.PHAR.582)
- Lutetium Lu 177 Dotatate (Lutathera) (PDF) (CP.PHAR.384)
- Macitentan (Opsumit) (PDF) (CP.PHAR.194)
- Mannitol (Bronchitol) (PDF) (CP.PHAR.518)
- Maralixibat (LUM001) (PDF) (CP.PHAR.543)
- Margetuximab-cmkb (Margenza) (PDF) (CP.PHAR.522)
- Maribavir (Livtencity) (PDF) (CP.PMN.271)
- Mavacamten (Camzyos) (PDF) (CP.PMN.272)
- Mecamylamine (Vecamyl) (PDF) (CP.PMN.136)
- Mecaserim (PDF) (CP.PHAR.150)
- Mechlorethamine Gel (Valchlor) (PDF) (CP.PHAR.381)
- Megestrol Acetate (Megace ES) (PDF) (CP.PMN.179)
- Melphalan flufenamide (Pepaxto) (PDF) (CP.PHAR.535)
- Memantine ER (Namenda XR), Memantine/Donepezil (Namzaric) (PDF) (CP.PCH.30)
- Mepolizumab (Nucala) (PDF) (CP.PHAR.200)
- Mercaptopurine (Purixan) (PDF) (CP.PHAR.447)
- Metformin ER (Fortamet, Glumetza) (PDF) (CP.PMN.72)
- Methotrexate (Otrexup, Rasuvo, Xatmep) (PDF) (CP.PHAR.134)
- Methoxsalen (Uvadex) (PDF) (HIM.PA.17)
- Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) (CP.PHAR.238)
- Methylnaltrexone Bromide (Relistor) (PDF) (CP.PMN.169)
- Metoclopramide (Gimoti) (PDF) (CP.PMN.252)
- Metreleptin (Myalept) (PDF) (CP.PHAR.425)
- Midazolam (Nayzilam) (PDF) (CP.PMN.211)
- Midostaurin (Rydapt) (PDF) (CP.PHAR.344)
- Migalastat (Galafold) (PDF) (CP.PHAR.394)
- Miglustat (Zavesca) (PDF) (CP.PHAR.164)
- Milnacipran (Savella) (PDF) (CP.PMN.125)
- Minocycline ER (Solodyn, Ximino, Minolira) and Microspheres (Arestin), Foam (Zilxi) (PDF) (CP.PMN.80)
- Mirvetuximab soravatansine-gynx (Elahere) (PDF) (CP.PHAR.617)
- Mitapivat (Pyrukynd) (PDF) (CP.PHAR.558)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF) (CP.PHAR.495)
- Mitoxantrone (Novantrone) (PDF) (CP.PHAR.258)
- Mobocertinib (Exkivity) (PDF) (CP.PHAR.559)
- Modafinil (Provigil) (PDF) (CP.PMN.39)
- Mogamulizumab-kpkc (Poteligeo) (PDF) (CP.PHAR.139)
- Mometasone (Nasonex) (PDF) (HIM.PA.93)
- Mometasone Furoate (Sinuva) (PDF) (CP.PHAR.448)
- Mosunetuzumab-axgb (Lunsumio) (PDF) (CP.PHAR.618)
- Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) (CP.PHAR.398)
- Nabumetone Double-Strength (Relafen DS) (PDF) (CP.PMN.287)
- Nadofaragene Firadenovec-vncg (Adstiladrin) (PDF) (CP.PHAR.461)
- nafarelin acetate (Synarel®) (PDF) (CP.PHAR.174)
- Naldemedine (Symproic) (PDF) (CP.PMN.112)
- Nalmefene (Opvee) (PDF) (CP.PHAR.638)
- Naloxegol (Movantik) (PDF) (HIM.PA.167)
- Naltrexone (Vivitrol®) (PDF) (CP.PHAR.96)
- Naproxen/Esomeprazole (Vimovo) (PDF) (CP.PMN.117)
- Naproxen oral suspension (Naprosyn) (PDF) (HIM.PA.130)
- Natalizumab (Tysabri) (PDF) (CP.PHAR.259)
- Naxitamab-gqgk (Danyelza) (PDF) (CP.PHAR.523)
- necitumumab (Portrazza®) (PDF) (CP.PHAR.320)
- Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF) (CP.PMN.167)
- Neratinib (Nerlynx) (PDF) (CP.PHAR.365)
- Netupitant and Palonosetron (Akynzeo) (PDF) (CP.PMN.158)
- Nifurtimox (Lampit) (PDF) (CP.PMN.256)
- Nilotinib (Tasigna) (PDF) (CP.PHAR.76)
- Nintedanib (Ofev) (PDF) (CP.PHAR.285)
- Niraparib (Zejula) (PDF) (CP.PHAR.408)
- Nirmatrelvir and Ritonavir (Paxlovid) (PDF) (CP.PMN.288)
- Nitazoxanide (Alinia) (PDF) (HIM.PA.152)
- Nitisinone (Nityr, Orfadin) (PDF) (CP.PHAR.132)
- Nivolumab (PDF) (CP.PHAR.121)
- Nivolumab and Relatlimab-rmbw (Opdualag) (PDF) (CP.PHAR.588)
- Non-Calcium Phosphate Binders (PDF) (CP.PMN.04)
- Non-Formulary and Formulary Contraceptives (PDF) (HIM.PA.100)
- Non-Formulary Test Strips (PDF) (HIM.PA.34)
- Nusinersen (PDF) (CP.PHAR.327)
- Obeticholic Aacid (Ocaliva) (PDF) (CP.PHAR.287)
- obinutuzumab (Gazyva®) (PDF) (CP.PHAR.305)
- Ocrelizumab (Ocrevus) (PDF) (CP.PHAR.335)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot) (PDF) (CP.PHAR.40)
- Odevixibat (Bylvay) (PDF) (CP.PHAR.528)
- Ofatumumab (Arzerra, Kesimpta) (PDF) (CP.PHAR.306)
- Off-Label Drug Use (PDF) (HIM.PA.154)
- Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) (CP.PHAR.292)
- Olanzapine/Samidorphan (Lybalvi) (PDF) (CP.PMN.265)
- Olaparib (Lynparza) (PDF) (CP.PHAR.360)
- olaratumab (Lartruvo®) (PDF) (CP.PHAR.326)
- Olipudase Alfa-rpcp (Xenpozyme) (PDF) (CP.PHAR.586)
- Olutasidenib (Rezlidhia) (PDF) (CP.PHAR.615)
- Omaveloxolone (Skyclarys) (PDF) (CP.PHAR.590)
- Omecetaxine (Synribo) (PDF) (CP.PHAR.108)
- Omadacycline (Nuzyra) (PDF) (CP.PMN.188)
- Omalizumab (Xolair) (PDF) (CP.PCH.49)
- OnabotulinumtoxinA (Botox) (PDF) (CP.PHAR.232)
- Onasemnogene abeparvovec (Zolgensma) (PDF) (CP.PHAR.421)
- Ondansetron (Zuplenz) (PDF) (CP.PMN.45)
- Opicapone (Ongentys) (PDF) (CP.PMN.245)
- Opioid Analgesics (PDF) (HIM.PA.139)
- Ophthalmic Corticosteroids (PDF) (HIM.PA.03)
- Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF) (CP.PHAR.536)
- Osilodrostat (Isturisa) (PDF) (CP.PHAR.487)
- Osimertinib (Tagrisso) (PDF) (CP.PHAR.294)
- Ospemifene (Osphena) (PDF) (CP.PMN.168)
- Overactive Bladder Agents (PDF) (CP.PMN.198)
- Oxymetazoline (Rhofade, Upneeq) (PDF) (CP.PMN.86)
- Ozanimod (Zeposia) (PDF) (CP.PHAR.462)
- Ozenoxacin (Xepi) (PDF) (CP.PMN.119)
- Paclitaxel protein-bound (Abraxane) (PDF) (CP.PHAR.176)
- Pacritinib (Vonjo) (PDF) (CP.PHAR.583)
- Palbociclib (Ibrance) (PDF) (CP.PHAR.125)
- Paliperidone Long-Acting Injections (Invega Sustenna, Invega Trinza) (PDF) (CP.PHAR.291)
- Palivizumab (Synagis) (PDF) (CP.PHAR.16)
- Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep) (PDF) (CP.PCH.44)
- panitumumab (Vectibix®) (PDF) (CP.PHAR.321)
- Panobinostat (Farydak) (PDF) (CP.PHAR.382)
- Parathyroid Hormone (Natpara) (PDF) (CP.PHAR.282)
- Paricalcitrol Injection (PDF) (CP.PHAR.270)
- pasireotide (Signifor LAR®) (PDF) (CP.PHAR.332)
- Patiromer (Veltassa) (PDF) (CP.PMN.205)
- Patisiran (Onpattro) (PDF) (CP.PHAR.395)
- Pazopanib (PDF) (CP.PHAR.81)
- Peanut Allergen Powder-dnfp (Palforzia) (PDF) (CP.PMN.220)
- pegaspargase (Oncaspar®) (PDF) (CP.PHAR.353)
- Pegcetacoplan (Empaveli) (PDF) (CP.PHAR.524)
- Pegfilgrastim (PDF) (CP.PHAR.296)
- Peginterferon beta-1a (Plegridy) (PDF) (CP.PHAR.271)
- Pegloticase (Krystexxa®) (PDF) (CP.PHAR.115)
- Pegunigalsidase Alfa-iwxj (Elfabrio) (PDF) (CP.PHAR.512)
- Pegvaliase-pqpz (Palynziq) (PDF) (CP.PHAR.140)
- Pegvisomant (Somavert) (PDF) (CP.PHAR.389)
- Pembrolizumab (Keytruda®) (PDF) (CP.PHAR.322)
- Pemetrexed (Alimta®) (PDF) (CP.PHAR.368)
- Pemigatinib (Pemazyre) (PDF) (CP.PHAR.496)
- Penicillamine (Cuprimine) (PDF) (CP.PCH.09)
- Perampanel (Fycompa) (PDF) (CP.PMN.156)
- Perfluorohexyloctane (Miebo) (PDF) (CP.PMN.290)
- Pertuzumab (Perjeta) (PDF) (CP.PHAR.227)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (PDF) (CP.PHAR.501)
- Pexidartinib (Turalio) (PDF) (CP.PHAR.436)
- Phendimetrazine (PDF) (CP.PCH.47)
- Phentermine (Adipex-P, Lomaira) (PDF) (CP.PCH.13)
- Pilocarpine (Vuity) (PDF) (CP.PMN.270)
- Pimavanserin (Nuplazid) (PDF) (CP.PMN.140)
- Pirfenidone (Esbriet) (PDF) (CP.PHAR.286)
- Pirtobrutinib (Jaypirca) (PDF) (CP.PHAR.620)
- Pitolisant (Wakix) (PDF) (CP.PMN.221)
- Plasminogen, human-tvmh (Ryplazim) (PDF) (CP.PHAR.513)
- Plecanatide (Trulance) (PDF) (HIM.PA.158)
- Plerixafor (PDF) (CP.PHAR.323)
- Polatuzumab Vedotin-piiq (Polivy) (PDF) (CP.PHAR.433)
- Pomalidomide (Pomalyst) (PDF) (CP.PHAR.116)
- Ponatinib (Iclusig) (PDF) (CP.PHAR.112)
- Ponesimod (Ponvory) (PDF) (CP.PHAR.537)
- Potassium (Klor-Con) (PDF) (HIM.PA.143)
- pralatrexate (Folotyn®) (PDF) (CP.PHAR.313)
- Pramlintide (Symlin) (PDF) (CP.PMN.129)
- Prasterone (Intrarosa) (PDF) (CP.PMN.99)
- Pregabalin (Lyrica, Lyrica CR) (PDF) (CP.PMN.33)
- Pretomanid (PDF) (CP.PMN.222)
- Progesterone (Crinone, Endometrin, Milprosa) (PDF) (CP.PMN.243)
- Propranolol HCl Oral Solution (Hemangeol) (PDF) (CP.PMN.58)
- protein c concentrate, human (Ceprotin®) (PDF) (CP.PHAR.330)
- Prucalopride (Motegrity) (PDF) (HIM.PA.159)
- pyrimethamine (Daraprim®) (PDF) (CP.PMN.44)
- Quetiapine ER (Seroquel XR) (PDF) (CP.PMN.64)
- Quinine Sulfate (Qualaquin) (PDF) (CP.PNM.262)
- Tivozanib (Fotivda) (PDF) (CP.PHAR.538)
- Ranibizumab (Lucentis®) (PDF) (CP.PHAR.186)
- rasagiline (Azilect®) (PDF) (HIM.PA.89)
- Ravulizumab-cwvz (Ultomiris) (PDF) (CP.PHAR.415)
- Regorafenib (Stivarga) (PDF) (CP.PHAR.107)
- Relugolix (Orgovyx) (PDF) (CP.PHAR.529)
- Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel) (PDF) (HIM.PA.168)
- Reslizumab (Cinqair) (PDF) (CP.PHAR.223)
- Retifanlimab-dlwr (Zynyz) (PDF) (CP.PHAR.629)
- Revlimid (PDF) (CP.PHAR.71)
- Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF) (CP.PHAR.141)
- Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara) (PDF) (CP.PHAR.334)
- Rifabutin (Mycobutin) (PDF) (CP.PMN.223)
- Rifamycin (Aemcolo) (PDF) (CP.PMN.196)
- Rilonacept (Arcalyst) (PDF) (CP.PHAR.266)
- RimabotulinumtoxinB (Myobloc) (PDF) (CP.PHAR.233)
- Rimegepant (Nurtec ODT) (PDF) (CP.PHAR.490)
- Riociguat (Adempas®) (PDF) (CP.PHAR.195)
- Ripretinib (Qinlock) (PDF) (CP.PHAR.502)
- Risdiplam (Evrysdi) (PDF) (CP.PHAR.477)
- Risedronate (Actonel, Atelvia) (PDF) (CP.PMN.100)
- Risperidone LA Inj (PDF) (CP.PHAR.293)
- rifaximin (PDF) (CP.PMN.47)
- Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela) (PDF) (CP.PHAR.260)
- Roflumilast (Daliresp, Zoryve) (PDF) (CP.PMN.46)
- Rolapitant (Varubi) (PDF) (CP.PMN.102)
- romidepsin (Istodax®) (PDF) (CP.PHAR.314)
- Romiplostim (Nplate®) (PDF) (CP.PHAR.179)
- Romosozumab-aqqg (Evenity) (PDF) (CP.PHAR.428)
- Ropeginterferon Alfa-2b-njft (BESREMi) (PDF) (CP.PHAR.570)
- Rucaparib (Rubraca®) (PDF) (CP.PHAR.350)
- Rufinamide (Banzel) (PDF) (CP.PMN.157)
- Rukobia (fostemsavir) (PDF) (CP.PHAR.516)
- Ruxolitinib (Jakafi) (PDF) (CP.PHAR.98)
- Sacituzumab Govitecan-hziy (Trodelvy) (PDF) (CP.PHAR.475)
- Sacubitril/Valsartan (Entresto) (PDF) (CP.PMN.67)
- Safinamide (Xadago) (PDF) (CP.PMN.113)
- Sapropterin (Kuvan) (PDF) (CP.PHAR.43)
- Sarecycline (Seysara) (PDF) (CP.PMN.189)
- Sargramostim (PDF) (CP.PHAR.295)
- Satralizumab (PDF) (CP.PHAR.463)
- Sebelipase Alfa (Kanuma) (PDF) (CP.PHAR.159)
- Secnidazole (Solosec) (PDF) (CP.PMN.103)
- Selexipag (Uptravi®) (PDF) (CP.PHAR.196)
- Selinexor (Xpovio) (PDF) (CP.PHAR.431)
- Selpercatinib (Retevmo) (PDF) (CP.PHAR.478)
- Selumetinib (PDF) (CP.PHAR.464)
- Sensipar (PDF) (CP.PHAR.61)
- Setmelanotide (Imcivree) (PDF) (CP.PHAR.491)
- Short Ragweed Pollen Allergen Extract (Ragwitek) (PDF) (CP.PMN.83)
- Sildenafil (Revatio®) (PDF) (CP.PHAR.197)
- Sildenafil (Viagra) (PDF) (CP.PCH.07)
- Siltuximab (Sylvant®) (PDF) (CP.PHAR.329)
- Siponimod (Mayzent) (PDF) (CP.PHAR.427)
- Sirolimus Protein-Bound Particles (Fyarro) (PDF) (CP.PHAR.574)
- Sodium-Glucose Co-Transporter 2 Inhibitors (PDF) (HIM.PA.91)
- Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, Sodium Oxybate (Xywav) (PDF) (CP.PMN.42)
- Sodium Phenylbutyrate (Buphenyl) (PDF) (CP.PHAR.208)
- Sodium Phenylbutyrate/Taurursodiol (Relyvrio) (PDF) (CP.PHAR.584)
- Sodium thiosulfate (Pedmark) (PDF) (CP.PHAR.610)
- Sodium Zirconium Cyclosilicate (Lokelma) (PDF) (CP.PMN.163)
- Sofosbuvir (Sovaldi) (PDF) (HIM.PA.SP2)
- Sofosbuvir/Vepatasvir/Voxilaprevir (Vosevi) (PDF) (HIM.PA.SP63)
- Sofosbuvir-Velpatasvir (Epclusa) (PDF) (HIM.PA.SP1)
- Solriamfetol (Sunosi) (PDF) (CP.PMN.209)
- Sonidegib (Odomzo) (PDF) (CP.PHAR.272)
- Sorafenib (Nexavar) (PDF) (CP.PHAR.69)
- Sotorasib (Lumakras) (PDF) (CP.PHAR.549)
- Sparsentan (Filspari) (PDF) (CP.PHAR.631)
- Spesolimab-sbzo (Spevigo) (PDF) (CP.PHAR.606)
- Spinosad (Natroba) (PDF) (HIM.PA.134)
- Step Therapy Criteria (PDF) (HIM.PA.109)
- Stiripentol (Diacomit) (PDF) (CP.PMN.184)
- Sunitinib (Sutent) (PDF) (CP.PHAR.73)
- Sutimlimab-jome (Enjaymo) (PDF) (CP.PHAR.503)
- Suvorexant (Belsomra®) (PDF) (CP.PMN.109)
- Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair) (PDF) (CP.PMN.85)
- Sylatron (peginterferon alfa-2b) (PDF) (CP.PHAR.89)
- Tadalafil (Adcirca®) (PDF) (CP.PHAR.198)
- Tadafil BHP - ED (Cialis) (PDF) (CP.PMN.132)
- Tafamidis (Vyndaqel, Vyndamax) (PDF) (CP.PHAR.432)
- Tafasitamab-cxix (Monjuvi) (PDF) (CP.PHAR.508)
- Talazoparib (Talzenna) (PDF) (CP.PHAR.409)
- Taliglucerase Alfa (Elelyso) (PDF) (CP.PHAR.157)
- Taliglucerase Alfa (Elelyso) (PDF) (HIM.PA.162)
- Talimogene laherepvec (Imlygic) (PDF) (CP.PHAR.542)
- Tapinarof (Vtama) (PDF) (CP.PMN.283)
- Tasimelteon (Hetlioz) (PDF) (CP.PMN.104)
- Tavaborole (Kerydin®) (PDF) (CP.PMN.105)
- Tazemetostat (PDF) (CP.PHAR.452)
- Tazarotene (Arazlo, Fabior, Tazorac) (PDF) (CP.PMN.244)
- Tebentafusp-tebn (Kimmtrak) (PDF) (CP.PHAR.575)
- Teclistamab-cqyv (Tecvayli) (PDF) (CP.PHAR.611)
- Tedizolid (Sivextro) (PDF) (CP.PMN.62)
- Teduglutide (Gattex) (PDF) (CP.PHAR.114)
- Tegaserod (Zelnorm) (PDF) (HIM.PA.160)
- Telotristat ethyl (Xermelo) (PDF) (CP.PHAR.337)
- Temozolomide (Temodar) (PDF) (CP.PHAR.77)
- temsirolimus (Torisel®) (PDF) (CP.PHAR.324)
- Tetrabenazine (Xenazine) (PDF) (CP.PHAR.92)
- Tenapanor (Ibsrela) (PDF) (CP.PMN.224)
- Tenofovir Alafenamide Fumarate (Vemlidy) (PDF) (CP.PMN.268)
- Teplizumab-mzwv (Tzield) (PDF) (CP.PHAR.492)
- Tepotinib (Tepmetko) (PDF) (CP.PHAR.530)
- Teprotumumab (Tepezza) (PDF) (CP.PHAR.465)
- Teriflunomide (Aubagio) (PDF) (CP.PCH.40)
- Teriparatide (Forteo®) (PDF) (CP.PHAR.188)
- Tesamorelin (PDF) (CP.PHAR.109)
- Testosterone (Testopel, Jatenzo) (PDF) (CP.PHAR.354)
- Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF) (CP.PHAR.377)
- Tezepelumab-ekko (Tezspire) (PDF) (CP.PHAR.576)
- Thalidomide (Thalomid) (PDF) (CP.PHAR.78)
- Thioguanine (Tabloid) (PDF) (CP.PHAR.437)
- Thyrotropin alfa (PDF) (CP.PHAR.95)
- Timothy Grass Pollen Allergen Extract (Grastek) (PDF) (CP.PMN.84)
- Tiopronin Delayed-Release (Thiola EC) (PDF) (CP.PCH.50)
- Tisagenlecleucel (PDF) (CP.PHAR.361)
- Tisotumab vedotin-tftv (Tivdak) (PDF) (CP.PHAR.561)
- Tobramycin (Bethkis®, Kitabis Pak®, TOBI®, TOBI Podhaler®) (PDF) (CP.PHAR.211)
- Tofersen (Qalsody) (PDF) (CP.PHAR.591)
- Tolvaptan (Jynarque) (PDF) (CP.PHAR.27)
- Topical Acne Treatment (PDF) (HIM.PA.71)
- Topical Immunomodulators (PDF) (CP.PMN.107)
- topical testosterone (PDF) (HIM.PA.87)
- Topiramate Extended-Release (Qudexy XR, Trokendi XR) (PDF) (CP.PMN.281)
- Topotecan (Hycamtin) (PDF) (CP.PHAR.64)
- Trabectedin (Yondelis®) (PDF) (CP.PHAR.204)
- Tralokinumab-ldrm (Adbry) (PDF) (CP.PHAR.577)
- Trametinib (Mekinist) (PDF) (CP.PHAR.240)
- Trastuzumab Biosimilars Trastuzumab-Hyaluronidase (PDF) (CP.PHAR.228)
- Tremelimumab-actl (Imjudo) (PDF) (CP.PHAR.612)
- Treprostinil (Orenitram®, Remodulin®, Tyvaso®) (PDF) (CP.PHAR.199)
- Triamcinolone ER Injection (Zilretta) (PDF) (CP.PHAR.371)
- Triclabendazole (Egaten) (PDF) (CP.PMN.207)
- Trientine (Syprine) (PDF) (CP.PHAR.438)
- Trifarotene (Aklief) (PDF) (CP.PMN.225)
- Trifluridine/Tipiracil (Lonsurf) (PDF) (CP.PHAR.383)
- Triheptanoin (Dojolvi) (PDF) (CP.PHAR.509)
- triptorelin pamoate (Trelstar®, Triptodur®) (PDF) (CP.PHAR.175)
- Trofinetide (Daybue) (PDF) (CP.PHAR.600)
- Tucatinib (Tukysa) (PDF) (CP.PHAR.497)
- Ublituximab-xiiy (Briumvi) (PDF) (CP.PHAR.621)
- Ubrogepant (Ubrelvy) (PDF) (CP.PHAR.476)
- Ulcer Therapy Combinations (PDF) (CP.PMN.277)
- Umbralisib (Ukoniq) (PDF) (CP.PHAR.531)
- Uridine acetate (Vistogard) (PDF) (HIM.PA.SP55)
- Valbenazine (Ingrezza) (PDF) (CP.PCH.48)
- valganciclovir (Valcyte) (PDF) (CP.PCH.06)
- Valoctocogene Roxaparvovec-rvox (Roctavian) (PDF) (CP.PHAR.466)
- Valrubicin (Valstar) (PDF) (CP.PHAR.439)
- Vandetanib (Caprelsa®) (PDF) (CP.PHAR.80)
- Varenicline (Tyrvaya) (PDF) (CP.PMN.273)
- Velaglucerase Alfa (VPRIV) (PDF) (CP.PHAR.163)
- Velaglucerase Alfa (VPRIV) (PDF) (HIM.PA.163)
- Velmanase Alfa-tycv (Lamzede) (PDF) (CP.PHAR.601)
- Vemurafenib (Zelboraf®) (PDF) (CP.PHAR.91)
- Venetoclax (Venclexta) (PDF) (CP.PHAR.129)
- Verteporfin (Visudyne) (PDF) (CP.PHAR.187)
- Vestronidase alfa-vjbk (Mepsevii) (PDF) (CP.PHAR.374)
- Vigabatrin (PDF) (CP.PHAR.169)
- Vilazodone (Viibryd) (PDF) (CP.PMN.145)
- Viloxazine (Qelbree) (PDF) (CP.PMN.264)
- Viltolarsen (Viltepso) (PDF) (CP.PHAR.484)
- vincristine sulfate liposome injection (Marqibo®) (PDF) (CP.PHAR.315)
- Vismodegib (Erivedge) (PDF) (CP.PHAR.273)
- Voclosporin (Lupkynis) (PDF) (CP.PHAR.504)
- Vorapaxar (Zontivity) (PDF) (HIM.PA.146)
- Voretigene neparvovec-rzyl (Luxturna) (PDF) (CP.PHAR.372)
- Vorinostat (Zolinza) (PDF) (CP.PHAR.83)
- Vortioxetine (Trintellix®) (PDF) (CP.PMN.65)
- Vosoritide (Voxzogo) (PDF) (CP.PHAR.525)
- Voxelotor (Oxbryta) (PDF) (CP.PHAR.451)
- Vutrisiran (Amvuttra) (PDF) (CP.PHAR.550)
- Xgeva (PDF) (CP.PHAR.58)
- Xiaflex™ (PDF) (CP.PHAR.82)
- Zanubrutinib (Brukinsa) (PDF) (CP.PHAR.467)
- Zavegepant (Zavzpret) (PDF) (CP.PHAR.630)
- ziv-aflibercept (Zaltrap®) (PDF) (CP.PHAR.325)
- Zometa (PDF) (CP.PHAR.59)
Medicaid Clinical Policies Listing
- ADHD Assessment and Treatment (PDF) (CP.MP.124)
- Administrative Days (PDF) (WA.CP.MP.519)
- Allergy Testing and Therapy (PDF) (CP.MP.100) - effective through 6/30/23
- Allergy Testing and Therapy (PDF) (CP.MP.100) - effective 7/1/23
- Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF) (CP.MP.108) - effective through 6/30/23
- Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF) (CP.MP.108) - effective 7/1/23
- Alpha1-Proteinase Inhibitors (PDF) (CP.PHAR.94)
- Applied Behavior Analysis (PDF) (CP.BH.104)
- Bariatric Surgery (PDF) (WA.CP.MP.37)
- Behavioral Health Personal Care Services (PDF) (WA.CP.MP.521)
- BH Treatment Documentation Requirements (PDF) (CP.BH.500)
- Bone-anchored Hearing Aid (PDF) (CP.MP.93)
- Burn Surgery (PDF) (CP.MP.186)
- Cardiac Biomarker Testing (PDF) (CP.MP.156)
- Cardiac Stents (PDF) (WA.CP.MP.513)
- Carotid Artery Stenting (PDF) (WA.CP.MP.516)
- Catheter Ablation for SVTA (PDF) (WA.CP.MP.525)
- Clinical Trials (PDF) (CP.MP.94)
- Cochlear Implant Replacements (PDF) (CP.MP.14)
- Cochlear Implants: Bilateral vs. Unilateral (PDF) (WA.CP.MP.502)
- Continuous Glucose Monitoring (PDF) (WA.CP.MP.501)
- Cosmetic and Reconstructive Surgery (PDF) (CP.MP.31)
- Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (PDF) (CP.BH.201)
- Diaphragmatic/Phrenic Nerve Stimulation (PDF) (CP.MP.203)
- Digital Analysis of EEG (PDF) (CP.MP.105)
- Discography (PDF) (CP.MP.115)
- Donor lymphocyte infusion (PDF) (CP.MP.101) - effective through 6/30/23
- Donor lymphocyte infusion (PDF) (CP.MP.101) - effective 7/1/23
- Drugs of Abuse: Definitive Testing (PDF) (WA.CP.MP.50) - effective through 11/30/23
- Drugs of Abuse: Definitive Testing (PDF) (WA.CP.MP.50) - effective 12/1/23
- Durable Medical Equipment (DME) (PDF) (CP.MP.107) - effective through 4/30/23
- Durable Medical Equipment (DME) (PDF) (CP.MP.107) - effective 5/1/23
- Electroencephalography in the evaluation of headache (PDF) (CP.MP.155)
- Elective Delivery Prior to 39 Weeks (PDF) (WA.CP.MP.504)
- Endometrial ablation (PDF) (CP.MP.106)
- Evoked Potential Testing (PDF) (CP.MP.134)
- Experimental Technologies (PDF) (WA.CP.MP.36) - effective through 6/30/23
- Experimental Technologies (PDF) (WA.CP.MP.36) - effective 7/1/23
- Extra-Corporeal Membrane Oxygenation Therapy (PDF) (WA.CP.MP.514)
- Facet Joint Interventions (PDF) (WA.CP.MP.171) - policy effective through 5/31/23
- Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF) (CP.MP.248)
- Fecal Incontinence Treatments (PDF) (CP.MP.137)
- Fecal Microbiota Transplantation (PDF) (WA.CP.MP.515)
- Fertility Preservation (PDF) (WA.CP.MP.130)
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) (CP.MP.129) - effective through 11/30/23
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) (CP.MP.129) - effective 12/1/23
- Gastric Electrical Stimulation (PDF) (CP.MP.40) - effective through 6/30/23
- Gastric Electrical Stimulation (PDF) (CP.MP.40) - effective 7/1/23
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) (CP.MP.209)
- Concert Genetic Testing Aortopathies & Connective Tissue Disorders (PDF) (V2.2023)
- Concert Genetic Testing Cardiac Disorders (PDF) (V2.2023)
- Concert Genetic Testing Dermatologic Conditions (PDF) (V2.2023)
- Concert Genetic Testing Epilepsy Neurodegenerative and Neuromuscular Conditions (PDF) (V2.2023)
- Genetic Testing Exome and Genome Sequecing (PDF) (WA.CP.MP.219) - effective through 8/31/23
- Concert Genetic Testing Exome and Genome Sequencing for DX of Genetic Disorders (PDF) (V2.2023)
- Concert Genetic Testing Eye Disorders (PDF) (V2.2023)
- Concert Genetic Testing Gastroenterologic Disorders Non-cancerous (PDF) (V2.2023)
- Concert Genetic Testing General Approach to Genetic Testing (PDF) (V2.2023)
- Concert Genetic Testing Hearing Loss (PDF) (V2.2023)
- Concert Genetic Testing Hematologic Conditions Non-cancerous (PDF) (V2.2023)
- Concert Genetic Testing Hereditary Cancer Susceptibility (PDF) (V2.2023)
- Concert Genetic Testing Immune Autoimmune and Rheumatoid Disorders (PDF) (V2.2023)
- Concert Genetic Testing Kidney Disorders (PDF) (V2.2023)
- Concert Genetic Testing Lung Disorders (PDF) (V2.2023)
- Concert Genetic Testing Metabolic Endocrine Mitochondrial Disorders (PDF) (V2.2023)
- Genetic Testing Multisystem Inherited Disorders ID and DD (PDF) (WA.CP.MP.230) - effective through 8/31/23
- CG Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay (PDF) (WA.CP.MP.230) - effective 9/1/23
- Genetic Testing Non-Invasive Prenatal Screening (PDF) (WA.CP.MP.231) - effective through 8/31/23
- CG Non-Invasive Prenatal Screening (PDF) (WA.CP.MP.231) - effective 9/1/23
- Concert Genetic Testing Pharmacogenetics (PDF) (V2.2023)
- Concert Genetic Testing Preimplantation Genetic Testing (PDF) (V2.2023)
- Concert Genetic Testing Prenatal and Preconception Carrier Screening (PDF) (V2.2023)
- Concert Genetic Testing Prenatal Diagnosis Pregnancy Loss (PDF) (V2.2023)
- Concert Genetic Testing Skeletal Dysplasia Rare Bone Disorders (PDF) (V2.2023)
- Concert Genetics Oncology Algorithmic Testing (PDF) (V2.2023)
- Concert Genetics Oncology Cancer Screening (PDF) (V2.2023)
- Concert Genetics Oncology Circulating Tumor DNA Tumor Cells Liquid Biopsy (PDF) (V2.2023)
- Concert Genetics Oncology Cytogenetic Testing (PDF) (V2.2023)
- Concert Genetics Oncology Molecular Analysis Solid Tumors & Hematolgic Malignancies (PDF) (V2.2023)
- H. Pylori serology testing (PDF) (CP.MP.153)
- Heart-Lung Transplant (PDF) (CP.MP.132) - effective through 6/30/23
- Heart-Lung Transplant (PDF) (CP.MP.132) - effective 7/1/23
- Holter Monitors (PDF) (CP.MP.113)
- Home Birth (PDF) (CP.MP.136)
- Home Prothrombin Time Monitoring (PDF) (WA.CP.MP.207)
- Home Ventilators (PDF) (CP.MP.184)
- Homocysteine testing (PDF) (CP.MP.121)
- Hospice Services (PDF) (WA.CP.MP.54)
- Hyperbaric Oxygen Therapy (PDF) (WA.CP.MP.27)
- Hyperhidrosis Treatments (PDF) (CP.MP.62)
- Implantable Hypoglossal Nerve Stimulation (PDF) (CP.MP.180)
- Implantable Intrathecal or Epidural Pain Pump (PDF) (CP.MP.173)
- Implantable Loop Recorder (CP.MP.243)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) (CP.MP.160)
- Inhaled Nitric Oxide (PDF) (CP.MP.87)
- Intensity-Modulated Radiotherapy (IMRT) (PDF) (WA.CP.MP.69)
- Intestinal and Multivisceral Transplant (PDF) (CP.MP.58)
- Intradiscal Steroid Injections for Pain Management (PDF) (CP.MP.167)
- Laser therapy for skin conditions (PDF) (CP.MP.123)
- Liposuction of Lipedema (PDF) (CP.MP.244)
- Lung Transplantation (PDF) (CP.MP.57)
- Lysis of Epidural Lesions (PDF) (CP.MP.116)
- Mandibular Advancement Devices (PDF) (WA.CP.MP.500)
- Micro-Processor Controlled Prosthetics (PDF) (WA.CP.MP.505)
- Multiple Sleep Latency Testing (PDF) (CP.MP.24)
- Negative Pressure Wound Therapy for Home Use (PDF) (WA.CP.MP.518)
- Neonatal Abstinence Syndrome Guidelines (PDF) (CP.MP.86) - effective through 6/30/23
- Neonatal Abstinence Syndrome Guidelines (PDF) (CP.MP.86) - effective 7/1/23
- Neonatal Sepsis Management Guidelines (PDF) (CP.MP.85)
- Nerve Blocks for Pain Management (PDF) (CP.MP.170)
- NICU Apnea Bradycardia Guidelines (PDF) (CP.MP.82)
- NICU Discharge Guidelines (PDF) (CP.MP.81)
- Nonmyeloablative allogeneic SCT (PDF) (CP.MP.141)
- Omisirge (Omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF) (CP.MP.249)
- Oral Enteral Nutrition (PDF) (WA.CP.MP.507)
- Orthognathic Surgery (PDF) (CP.MP.202)
- Osteogenic Stimulation (PDF) (CP.MP.194)
- Pancreas Transplantation (PDF) (CP.MP.102) - effective through 6/30/23
- Pancreas Transplantation (PDF) (CP.MP.102) - effective 7/1/23
- Panniculectomy (PDF) (CP.MP.109)
- Pediatric Heart Transplant (PDF) (CP.MP.138)
Pediatric Liver Transplant (PDF) (CP.MP.120) - effective through 6/30/23 - Pediatric Liver Transplant (PDF) (CP.MP.120) - effective 7/1/23
- Pediatric Kidney Transplant (PDF) (CP.MP.246) - effective 2/1/2023
- Pediatric Oral Function Therapy (PDF) (CP.MP.188)
- Peripheral and Percutaneous Nerve Stimulation (PDF) (WA.CP.MP.117)
- Photherapy for Neonatal Hyperbilirubinemia (PDF) (CP.MP.150)
- Physical, Occupational and Speech Therapy Services (PDF) (CP.MP.49)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) (CP.MP.181)
- Private Duty Nursing Services (PDF) (WA.CP.MP.503)
- Proton and Neutron Beam Therapies (PDF) (WA.CP.MP.70)
- Psychological Testing (PDF) (WA.CP.BH.506)
- Pulmonary Function Testing (PDF) (CP.MP.242)
- Reduction Mammoplasty and Gynecomastia Surgery (PDF) (CP.MP.51)
- Repair of Nasal Valve Compromise (PDF) (CP.MP.210)
- Sacroiliac Joint Interventions for Pain Management (PDF) (CP.MP.166) - policy effective through 5/31/23
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF) (CP.MP.146) - effective 9/1/23
- Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF) (CP.MP.165) - policy effective through 5/31/23
- Short Inpatient Hospital Stay (PDF) (CP.MP.182) - effective through 9/30/23
- Short Inpatient Hospital Stay (PDF) (CP.MP.182) - effective 10/1/23
- Skilled Nursing Facility Leveling (PDF) (CP.MP.206)
- Skin and Soft Tissue Substitutes for Chronic Wounds (PDF) (WA.CP.MP.185)
- Stem Cell Therapy for Musculoskeletal Conditions (PDF) (WA.CP.MP.526)
- Stereotactic Body Radiation Therapy (PDF) (CP.MP.22)
- Substance Use Treatment and Services (PDF) (CP.BH.100)
- Tandem Transplant (PDF) (CP.MP.162) - effective through 6/30/23
- Tandem Transplant (PDF) (CP.MP.162) - effective 7/1/23
- Testosterone Testing (PDF) (WA.CP.MP.517)
- Thyroid hormones and insulin testing in pediatrics (PDF) (CP.MP.154)
- Tinnitus Treatment (PDF) (WA.CP.MP.510)
- Total Artificial Heart (PDF) (CP.MP.127)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) (CP.MP.163)
- Transcatheter Closure of Patent Foramen Ovale (PDF) (CP.MP.151)
- Transcranial Magnetic Stimulation (PDF) (WA.CP.BH.200)
- Transplant Service Documentation Requirements (PDF) (CP.MP.247) - effective 5/1/23
- Trigger Point Injections for Pain Management (PDF) (CP.MP.169)
- Tympanostomy Tubes (PDF) (WA.CP.MP.520)
- Ultrasound in Pregnancy (PDF) (CP.MP.38)
- Upper GI Endoscopy for GERD (PDF) (WA.CP.MP.509)
- Urinary Incontinence Devices and Treatments (PDF) (CP.MP.142)
- Urodynamic testing (PDF) (CP.MP.98)
- Vagus Nerve Stimulation (PDF) (CP.MP.12)
- Varicose Vein Treatment (PDF) (WA.CP.MP.522) - effective through 8/31/23
- Varicose Vein Treatment (PDF) (WA.CP.MP.522) - effective 9/1/23
- Ventricular Assist Devices (PDF) (WA.CP.MP.46)
- Vitamin D Testing (PDF) (WA.CP.MP.527)
Medicaid Pharmacy Policies Listing
- 72-Hour Emergency Supply of Medication (PDF) (CC.PHAR.01)
- Abametapir (Xeglyze) (PDF) (CP.PMN.253)
- Abemaciclib (PDF) (CP.PHAR.355)
- AbobotulinumtoxinA (Dysport) (PDF) (CP.PHAR.230)
- Abiraterone (Zytiga) (PDF) (CP.PHAR.84)
- Abrocitinib (Cibinqo) (PDF) (CP.PHAR.578)
- ACEI and ARB Duplicate Therapy (PDF) (CP.PMN.61)
- Acitretin (Soriatane) (PDF) (CP.PMN.40)
- Acyclovir Buccal Tablet (Sitavig), Ophthalmic Ointment (Avaclyr) (PDF) (CP.PMN.210)
- Acute Migraine Treatment Calcitonin Gene Related Peptide (CGRP) Receptor Antagonist (PDF) (WA.PHAR.106)
- Adagrasib (Krazati) (PDF) (CP.PHAR.605)
- Adefovir (Hepsera) (PDF) (CP.PHAR.142)
- ADHD Anti-Narcolepsy Stimulants Misc Armodafinil Modafinil (PDF) (WA.PHAR.124)
- ADHD Anti-Narcolepsy Non-Stimulants Viloxazine (Qelbree) (PDF) (WA.PHAR.131)
- Ado-Trastuzumab (Kadcyla) (PDF) (CP.PHAR.229)
- Aflibercept (Eylea) (PDF) (CP.PHAR.184)
- Age Limit for Topical Tretinoin (PDF) (CP.PMN.191)
- Agents for Sickle Cell Anemia L-glutamine (ENDARI) (PDF) (WA.PHAR.59)
- Alemtuzumab (Lemtrada) (PDF) (CP.PHAR.243)
- Allergenic Extracts (Oral) (PDF) (WA.PHAR.27)
- Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) (PDF) (CP.PHAR.562)
- Alpelisib (Piqray, Vijoice) (PDF) (CP.PHAR.430)
- Amantadine ER (PDF) (CP.PMN.89)
- Amifampridine (Firdapse) (PDF) (CP.PHAR.411)
- Amikacin (Arikayce) (PDF) (CP.PHAR.401)
- Amisulpride (Barhemsys) (PDF) (CP.PMN.236)
- Amivantamab-vmjw (Rybrevant) (PDF) (CP.PHAR.544)
- Amlodipine/Atorvastatin (Caduet) (PDF) (CP.PMN.176)
- Analgesics Opioid Agonists (PDF) (WA.PHAR.23)
- Androgenic Agents-Testosterone Replacement Therapy (TRT) (PDF) (WA.PHAR.28)
- Anifrolumab-fnia (Saphnelo) (PDF) (CP.PHAR.551)
- Antiasthmatic Monoclonal Antibodies Anti IgE Antibodies (PDF) (WA.PHAR.29)
- Antiasthmatic Monoclonal Antibodies IL-5 Antagonists (PDF) (WA.PHAR.30)
- Antibiotics Anti-Infective Agents- Oral rifaximin (XIFAXAN) (PDF) (WA.PHAR.66)
- Antibiotics-Inhaled-aminoglycosides (PDF) (WA.PHAR.79)
- Antibiotics Inhaled aztreonam (CAYSTON) (PDF) (WA.PHAR.31)
- Anticonvulsants-Rescue Agents (PDF) (WA.PHAR.32)
- Antidepressants- Serotonin Modulators (PDF) (WA.PHAR.123)
- Antidiabetics-Amylin Analogs (PDF) (WA.PHAR.33)
- Antidiabetics- GLP-1 Agonists (PDF) (WA.PHAR.122)
- Antidiabetics-Inhaled Insulin (Afrezza) (PDF) (WA.PHAR.34)
- Antihyperlipidemics-Apolipoprotein B Synthesis Inhibitors lomitapide mesylate (PDF) (WA.PHAR.38)
- Antihyperlipidemics-PCSK9 Inhibitors (PDF) (WA.PHAR.39)
- Antineoplastics and Adjunctive Therapies - Imidazotetrazines– Oral (PDF) (WA.PHAR.117)
- Antimemetic-Antivertigo Agents (Dronabinol) (PDF) (WA.PHAR.35)
- Antineoplastics and Adjunctive Therapies Tyrosine Kinase Inhibitors (PDF) (WA.PHAR.103)
- Antiparasitics Antiprotozoal Agents- nitazoxanide (Alinia) (PDF) (WA.PHAR.67)
- Antipsychotics 2nd Generation Vraylar (PDF) (WA.PHAR.105)
- Antithrombin III (ATryn, Thrombate III) (PDF) (CP.PHAR.564)
- Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) (CP.PHAR.506)
- Antivirals-HIV Combinations (PDF) (WA.PHAR.97)
- Antivirals HIV-emtricitabinetenofovir alafenamide (Descovy) (PDF) (WA.PHAR.98)
- Antivirals HIV- Rilpivirine (Edurant) (PDF) (WA.PHAR.120)
- Apalutamide (Erleada) (PDF) (CP.PHAR.376)
- Apomorphine (Apokyn, Kynmobi) (PDF) (CP.PHAR.488)
- Aprepitant (PDF) (CP.PMN.19)
- aripiprazole long-acting injections (PDF) (CP.PHAR.290)
- Asenapine (PDF) (CP.PMN.15)
- Aspirin-dipyridamole (PDF) (CP.PMN.20)
- Atezolizumab (Tecentriq) (PDF) (CP.PHAR.235)
- Atopic Dermatitis Agents Dupilumab (Dupixent) (PDF) (WA.PHAR.41)
- Atopic Dermatitis Agents-Topical Immunosuppressives (PDF) (WA.PHAR.42)
- Atopic Dermatitis Agents Crisaborole (Eucrisa) (PDF) (WA.PHAR.43)
- Avelumab (Bavencio) (PDF) (CP.PHAR.333)
- Azacitidine (Vidaza) (PDF) (CP.PHAR.387)
- Baloxavir Marboxil (Xofluza) (PDF) (CP.PMN.185)
- Bedaquiline (Sirturo) (PDF) (CP.PMN.212)
- Belantamab Mafodotin (Blenrep) (PDF) (CP.PHAR.469)
- Belatacept (Nulojix) (PDF) (CP.PHAR.201)
- Belimumab (Benlysta) (PDF) (CP.PHAR.88)
- belinostat (PDF) (CP.PHAR.311)
- Belumosudil (Rezurock) (PDF) (CP.PHAR.552)
- Belzutifan (Welireg) (PDF) (CP.PHAR.553)
- Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet) (PDF) (CP.PMN.237)
- bendamustine (PDF) (CP.PHAR.307)
- Benign Prostatic Hyperplasia (BPH) Agents-PDE5 Inhibitors (PDF) (WA.PHAR.44)
- Benznidazole (PDF) (CP.PMN.90)
- Benzyl Alcohol (Ulesfia) (PDF) (CP.PMN.202)
- Betaine (Cystadane) (PDF) (CP.PHAR.143)
- Betamethasone Dipropionate Spray (Sernivo) (PDF) (CP.PMN.182)
- Bevacizumab (Avastin) (PDF) (CP.PHAR.93)
- Bexarotene (Targretin Capsules, Gel) (PDF) (CP.PHAR.75)
- Bezlotoxumab (PDF) (CP.PHAR.300)
- Bimatoprost Implant (Durysta) (PDF) (CP.PHAR.486)
- Binimetinib (Mektovi) (PDF) (CP.PHAR.50)
- Blinatumomab (PDF) (CP.PHAR.312)
- Bone Density Regulators (PDF) (WA.PHAR.45)
- Bortezomib (Velcade) (PDF) (CP.PHAR.410)
- Brands with Generic Equivalents (PDF) (WA.PHAR.65)
- Bremelanotide (Vyleesi) (PDF) (CP.PHAR.434)
- Brentuximab (PDF) (CP.PHAR.303)
- Brexanolone (Zulresso) (PDF) (CP.PHAR.417)
- Brexpiprazole (PDF) (CP.PMN.68)
- Brimonidine Tartrate (Mirvaso) (PDF) (CP.PMN.192)
- Brolucizumab-dbll (Beovu) (PDF) (CP.PHAR.445)
- Budesonide (Tarpeyo) (PDF) (CP.PHAR.572)
- (MAT) Buprenorphine Products (PDF) (WA.PHAR.62)
- Cabazitaxel (Jevtana) (PDF) (CP.PHAR.316)
- Calcifediol (Rayaldee) (PDF) (CP.PMN.76)
- Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) (PDF) (CP.PMN.181)
- Cannabidiol (Epidiolex) (PDF) (CP.PMN.164)
- Capecitabine (Xeloda) (PDF) (CP.PHAR.60)
- Carbamazepine ER (Equetro) (PDF) (CP.PMN.137)
- Carbidopa/Levodopa ER Capsules (Rytary) (PDF) (CP.PMN.238)
- Cardiovascular Agents-Sinus Node Inhibitors (PDF) (WA.PHAR.46)
- carfilzomib (PDF) (CP.PHAR.309)
- Carglumic Acid (Carbaglu) (PDF) (CP.PHAR.206)
- Celecoxib (Celebrex, Elyxyb) (PDF) (CP.PMN.122)
- Cemiplimab-rwlc (Libtayo) (PDF) (CP.PHAR.397)
- Cenobamate (Xcopri) (PDF) (CP.PMN.231)
- cetuximab (PDF) (CP.PHAR.317)
- Chenodiol (Chenodal) (PDF) (CP.PMN.239)
- Chlorambucil (Leukeran) (PDF) (CP.PHAR.554)
- Chloramphenicol Sodium Succinate (PDF) (CP.PHAR.388)
- Cholic Acid (Cholbam) (PDF) (CP.PHAR.390)
- Chronic GI Motility Agents (PDF) (WA.PHAR.47)
- Ciclopirox (Penlac) (PDF) (CP.PMN.24)
- Ciprofloxacin/Dexamethasone (Ciprodex) (PDF) (CP.PMN.248)
- Ciprofloxacin/Fluocinolone (Otovel) (PDF) (CP.PMN.249)
- Cladribine (Mavenclad) (PDF) (CP.PHAR.422)
- Clascoterone (Winlevi) (PDF) (CP.PMN.257)
- Clobazam (Onfi) (PDF) (CP.PMN.54)
- Clomipramine (Anafranil) (PDF) (CP.PMN.197)
- Clozapine orally disintegrating tablet (Fazaclo) (PDF) (CP.PMN.12)
- CNS Stimulants (PDF) (CP.PMN.92)
- Cobimetinib (Cotellic) (PDF) (CP.PHAR.380)
- Colchicine (PDF) (CP.PMN.123)
- Colesevelam (WelChol) (PDF) (CP.PMN.250)
- Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) (CP.PMN.258)
- Continuous Glucose Monitors (PDF) (CP.PMN.214)
- copanlisib (PDF) (CP.PHAR.357)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert) (PDF) (CP.PHAR.385)
- Corticotropin (H.P. Acthar Gel) (PDF) (CP.PHAR.168)
- Cosyntropin (Cortrosyn) (PDF) (CP.PHAR.203)
- Cyclosporine (Cequa, Restasis, Verkazia) (PDF) (CP.PMN.48)
- Cysteamine Ophthalmic (Cystaran, Cystadrops) (PDF) (CP.PMN.130)
- Cystic Fibrosis Agents (Oral) (PDF) (WA.PHAR.48)
- Cytokine and CAM Antagonists (PDF) (WA.PHAR.49)
- Cytomegalovirus Immune Globulin (Cytogam) (PDF) (CP.PHAR.277)
- Dabigatran (Pradaxa) (PDF) (CP.PMN.49)
- Dabrafenib (Tafinlar) (PDF) (CP.PHAR.239)
- Dalteparin (PDF) (CP.PHAR.225)
- Daprodustat (Jesduvroq) (PDF) (CP.PHAR.628)
- daptomycin (PDF) (CP.PHAR.351)
- Daratumumab (PDF) (CP.PHAR.310)
- Darolutamide (Nubeqa) (PDF) (CP.PHAR.435)
- daunorubicin cytarabine (PDF) (CP.PHAR.352)
- Decitabine-Cedazuridine (Inqovi) (PDF) (CP.PHAR.479)
- deferasirox (PDF) (CP.PHAR.145)
- deferiprone (PDF) (CP.PHAR.147)
- deferoxamine (PDF) (CP.PHAR.146)
- Deflazacort (PDF) (CP.PHAR.331)
- Degarelix Acetate (Firmagon) (PDF) (CP.PHAR.170)
- Delafloxacin (Baxdela) (PDF) (CP.PMN.115)
- Denosumab (Prolia, Xgeva) (PDF) (CP.PHAR.58)
- Dermatologics Acne Products- Isotretinoin (PDF) (WA.PHAR.121)
- Desmopressin (DDAVP, Stimate) (PDF) (CP.PHAR.214)
- Deucravacitinib (Sotyktu) (PDF) (CP.PHAR.607)
- Dexrazoxane (Zinecard Totect) (PDF) (CP.PHAR.418)
- Dextromethorphan/Bupropion (Auvelity) (PDF) (CP.PMN.284)
- Dextromethorphan-Quinidine (PDF) (CP.PMN.93)
- Diabetic Test Strip Quantity Limit - Not Receiving Insulin (PDF) (CP.PMN.151)
- Diazepam Nasal Spray (Valtoco) (PDF) (CP.PMN.216)
- Dichlorphenamide (Keveyis) (PDF) (CP.PMN.261)
- Diclofenac (Pennsaid) (PDF) (CP.PMN.274)
- Dimethyl fumarate (Tecfidera), diroximel fumarate (Vumerity), monomethyl fumarate (Bafiertam) (PDF) (CP.PHAR.249)
- Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF) (CP.PMN.03)
- Dolasetron (Anzemet) (PDF) (CP.PMN.141)
- Dornase alfa (Pulmozyme) (PDF) (CP.PHAR.212)
- Dostarlimab-gxly (Jemperli) (PDF) (CP.PHAR.540)
- Doxepin (Silenor) (PDF) (CP.PMN.175)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF) (CP.PMN.79)
- Droxidopa (Northera) (PDF) (CP.PMN.17)
- Duplicate SSRI SNRI Therapy (PDF) (CP.PMN.60)
- Durvalumab (Imfinzi) (PDF) (CP.PHAR.339)
- Dutasteride (Avodart, Jalyn) (PDF) (CP.PMN.128)
- Duvelisib (Copiktra) (PDF) (CP.PHAR.400)
- Early and Periodic Screening, Diagnostic, and Treatment Benefit for Pediatric Members (PDF) (CP.PMN.234)
- Edoxaban (Savaysa) (PDF) (CP.PMN.227)
- Efinaconazole (Jublia) (PDF) (CP.PMN.25)
- Elacestrant (Orserdu) (PDF) (CP.PHAR.623)
- Elagolix (Orilissa) (PDF) (CP.PHAR.136)
- Elotuzumab (Empliciti) (PDF) (CP.PHAR.308)
- enasidenib (PDF) (CP.PHAR.363)
- Encorafenib (Braftovi) (PDF) (CP.PHAR.127)
- Enfortumab Vedotin-ejfv (Padcev) (PDF) (CP.PHAR.455)
- Enoxaparin (PDF) (CP.PHAR.224)
- Entrectinib (Rozlytrek) (PDF) (CP.PHAR.441)
- Enzalutamide (PDF) (CP.PHAR.106)
- Epcoritamab-bysp (Epkinly) (PDF) (CP.PHAR.634)
- Epinephrine (EpiPen and EpiPen Jr) Quanity Limit Override (PDF) (CP.PMN.144)
- Epoprostenol (Flolan, Veletri) (PDF) (CP.PHAR.192)
- Erdafitinib (Balversa) (PDF) (CP.PHAR.423)
- eribulin Mesylate (PDF) (CP.PHAR.318)
- Erwinia Asparaginase (Erwinaze) (PDF) (CP.PHAR.301)
- Esketamine (Spravato) (PDF) (CP.PMN.199)
- Estradiol Vaginal Ring (Femring) (PDF) (CP.PMN.263)
- Etelcalcetide (Parsabiv) (PDF) (CP.PHAR.379)
- Everolimus (PDF) (CP.PHAR.63)
- Experimental Technologies (PDF) (WA.CP.MP.36)
- Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) (CP.PHAR.456)
- Faricimab-svoa (Vabysmo) (PDF) (CP.PHAR.581)
- Fecal Microbiota, Live-jslm (Rebyota) (PDF) (CP.PHAR.613)
- Fecal Microbiota Spores, Live-brpk (Vowst) (PDF) (CP.PHAR.632)
- Fedratinib (Inrebic) (PDF) (CP.PHAR.442)
- Fenfluramine (Fintepla) (PDF) (CP.PMN.246)
- Ferric Carboxymaltose (Injectafer) (PDF) (CP.PHAR.234)
- Ferric Derisomaltose (Monoferric) (PDF) (CP.PHAR.480)
- Ferric Gluconate (Ferrlecit) (PDF) (CP.PHAR.166)
- Ferric Maltol (Accrufer) (PDF) (CP.PMN.213)
- Ferric Pyrophosphate (Triferic, Triferic Avnu) (PDF) (CP.PHAR.624)
- Ferumoxytol (Feraheme) (PDF) (CP.PHAR.165)
- Fezolinetant (Veozah) (PDF) (CP.PMN.289)
- Finerenone (Kerendia) (PDF) (CP.PMN.266)
- Fingolimod (Gilenya) (PDF) (CP.PHAR.251)
- Flibanserin (Addyi) (PDF) (CP.PHAR.446)
- Fluorouracil Cream (Tolak) (PDF) (CP.PMN.165)
- Fluticasone propionate (PDF) (CP.PMN.95)
- Fondaparinux (PDF) (CP.PHAR.226)
- Fulvestrant (Faslodex Injection) (PDF) (CP.PHAR.424)
- Furosemide (Furoscix) (PDF) (CP.PHAR.608)
- Futibatinib (Lytgobi) (PDF) (CP.PHAR.604)
- Gabapentin ER (Gralise, Horizant) (PDF) (CP.PMN.240)
- gemtuzumab ozogamicin (PDF) (CP.PHAR.358)
- Glasdegib (Daurismo) (PDF) (CP.PHAR.413)
- Glatiramer Acetate (PDF) (CP.PHAR.252)
- Glaucoma Agents (PDF) (CP.PMN.286)
- Glofitamab-gxbm (Columvi) (PDF) (CP.PHAR.636)
- Glycopyrronium (Qbrexza) (PDF) (CP.PMN.177)
- Goserelin Acetate (Zoladex) (PDF) (CP.PHAR.171)
- Gout Agents (PDF) (WA.PHAR.40)
- Granisetron (Sancuso) (PDF) (CP.PMN.74)
- Growth Hormone Agents (PDF) (WA.PHAR.50)
- Halobetasol Propionate Lotion 0.05% (Ultravate) (PDF) (CP.PMN.180)
- Halobetasol Propionate/Tazarotene (Duobrii) (PDF) (CP.PMN.208)
- Hematopoietic Agents Erythropoiesis-Stimulating Agents (ESAs) (PDF) (WA.PHAR.71)
- Hematopoietic Agents Granulocyte Colony Stimulating Factors (G-CSF) (PDF) (WA.PHAR.72)
- Hematopoietic Agents Thrombopoieses (TPO) Stimulating Proteins (PDF) (WA.PHAR.73)
- Hemin (Panhematin) (PDF) (CP.PHAR.181)
- Hormone Therapy for Gender Dysphoria (PDF) (WA.PHAR.104)
- Hyaluronate Derivatives (PDF) (CP.PHAR.05)
- Hydroxyurea (Siklos) (PDF) (CP.PMN.193)
- Ibrance (palbociclib) (PDF) (CP.PHAR.125)
- Ibuprofen/Famotidine (Duexis) (PDF) (CP.PMN.120)
- Icosapent ethyl (Vascepa) (PDF) (CP.PMN.187)
- Idelalisib (Zydelig) (PDF) (CP.PHAR.133)
- Iloperidone (Fanapt) (PDF) (CP.PMN.32)
- Immune Globulins (PDF) (CP.PHAR.103)
- Immunization coverage (PDF) (CP.PHAR.28)
- Inclisiran (Leqvio) (PDF) (CP.PHAR.568)
- IncobotulinumtoxinA (Xeomin) (PDF) (CP.PHAR.231)
- Infigratinib (Truseltiq) (PDF) (CP.PHAR.547)
- Inhaled Agents for Asthma and COPD (PDF) (CP.PMN.259)
- inotuzumab ozogamicin (PDF) (CP.PHAR.359)
- Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF) (CP.PHAR.534)
- Interferon beta-1a (Avonex, Rebif) (PDF) (CP.PHAR.255)
- Interferon beta-1b (Betaseron, Extavia) (PDF) (CP.PHAR.256)
- Intrathecal Baclofen (Gablofen, Lioresal) (PDF) (CP.PHAR.149)
- Iobenguane I-131 (Azedra) (PDF) (CP.PHAR.459)
- Ipilimumab (Yervoy) (PDF) (CP.PHAR.319)
- irinotecan Liposome (PDF) (CP.PHAR.304)
- Iron sucrose (Venofer) (Acthar Gel) (PDF) (CP.PHAR.167)
- Isatuximab-irfc (Sarclisa) (PDF) (CP.PHAR.482)
- Isavuconazonium (Cresemba) (PDF) (CP.PMN.154)
- Isotretinoin (PDF) (CP.PMN.143)
- Istradefylline (Nourianz) (PDF) (CP.PMN.217)
- Itraconazole (Sporanox, Onmel) (PDF) (CP.PMN.124)
- Ivermectin (Stromectol, Sklice) (PDF) (CP.PMN.269)
- Ivosidenib (Tibsovo) (PDF) (CP.PHAR.137)
- Ixazomib (PDF) (CP.PHAR.302)
- Jakafi™ (ruxolitinib) (PDF) (CP.PHAR.98)
- Ketorolac Nasal Spray (Sprix) (PDF) (CP.PMN.282)
- Korlym (mifepristone) (PDF) (CP.PHAR.101)
- Lacosamide (Vimpat) (PDF) (CP.PMN.155)
- Lactic Acid/Citric Acid/Potassium Bitartrate (Phexxi) (PDF) (CP.PMN.251)
- Lanreotide (Somatuline Depot) (PDF) (CP.PHAR.391)
- Larotrectinib (Vitrakvi) (PDF) (CP.PHAR.414)
- Lasmiditan (Reyvow) (PDF) (CP.PMN.218)
- Lefamulin (Xenleta) (PDF) (CP.PMN.219)
- Lenacapavir (Sunlenca) (PDF) (CP.PHAR.622)
- Lenalidomide (Revlimid) (PDF) (CP.PHAR.71)
- Letermovir (PDF) (CP.PHAR.367)
- Leucovorin Injection (PDF) (CP.PHAR.393)
- Leuprolide Acetate (Eligard, Fensolvi, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped) (PDF) (CP.PHAR.173)
- Levodopa Inhalation Powder (Inbrija) (PDF) (CP.PMN.267)
- Levoleucovorin (Fusilev) (PDF) (CP.PHAR.151)
- lidocaine transdermal (PDF) (CP.PMN.08)
- Lindane Lotion Shampoo (PDF) (CP.PMN.09)
- Linezolid (Zyvox) (PDF) (CP.PMN.27)
- Lofexidine (Lucemyra) (PDF) (CP.PMN.152)
- Lomustine (Gleostine) (PDF) (CP.PHAR.507)
- Loncastuximab Tesirine-lpyl (Zynlonta) (PDF) (CP.PHAR.539)
- Loteprednol etabonate (Eysuvis) (PDF) (CP.PMN.260)
- Luliconazole Cream (Luzu) (PDF) (CP.PMN.166)
- Lumateperone (Caplyta) (PDF) (CP.PMN.232)
- Lurasidone (Latuda) (PDF) (CP.PMN.50)
- Lurbinectedin (Zepzelca) (PDF) (CP.PHAR.500)
- Mannitol (Bronchitol) (PDF) (CP.PHAR.518)
- Margetuximab-cmkb (Margenza) (PDF) (CP.PHAR.522)
- Maribavir (Livtencity) (PDF) (CP.PMN.271)
- Mavacamten (Camzyos) (PDF) (CP.PMN.272)
- Mecamylamine (Vecamyl) (PDF) (CP.PMN.136)
- Mecasermin (PDF) (CP.PHAR.150)
- Mechlorethamine Gel (Valchlor) (PDF) (CP.PHAR.381)
- Megestrol Acetate 125 mg/mL Oral Suspension (Megace ES) (PDF) (CP.PMN.179)
- Melphalan flufenamide (Pepaxto) (PDF) (CP.PHAR.535)
- Mercaptopurine (Purixan) (PDF) (CP.PHAR.447)
- Metformin ER (Fortamet, Glumetza) (PDF) (CP.PMN.72)
- Methadone (Dolophine) (PDF) (WA.PHAR.20)
- Methotrexate (Otrexup, Rasuvo, Xatmep) (PDF) (CP.PHAR.134)
- Metoclopramide (Gimoti) (PDF) (CP.PMN.252)
- Midostaurin (Rydapt) (PDF) (CP.PHAR.344)
- Migraine Products Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist (PDF) (WA.PHAR.64)
- Milnacipran (Savella) (PDF) (CP.PMN.125)
- Minocycline ER (Solodyn, Ximino) and Microspheres (Arestin), Foam (Zilxi) (PDF) (CP.PMN.80)
- Minocycline Micronized Foam (Amzeeq) (PDF) (CP.PMN.242)
- Mirvetuximab soravatansine-gynx (Elahere) (PDF) (CP.PHAR.617)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF) (CP.PHAR.495)
- Mitoxantrone (Novantrone) (PDF) (CP.PHAR.258)
- Mogamulizumab-kpkc (Poteligeo) (PDF) (CP.PHAR.139)
- Mometasone Furoate (Sinuva) (PDF) (CP.PHAR.448)
- Mosunetuzumab-axgb (Lunsumio) (PDF) (CP.PHAR.618)
- Movement Disorder Agents (PDF) (WA.PHAR.51)
- Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) (CP.PHAR.398)
- Multiple Sclerosis Agents-Dalfampridine (Ampyra) (PDF) (WA.PHAR.52)
- Multiple Sclerosis- Ocrelizumab (Ocrevus) (PDF) (WA.PHAR.69)
- Musculoskeletal Therapy Agents - Carisoprodol (PDF) (WA.PHAR.130)
- Nabumetone Double-Strength (Relafen DS) (PDF) (CP.PMN.287)
- Nadofaragene Firadenovec-vncg (Adstiladrin) (PDF) (CP.PHAR.461)
- Nafarelin Acetate (Synarel) (PDF) (CP.PHAR.174)
- Nalmefene (Opvee) (PDF) (CP.PHAR.638)
- Naproxen/Esomeprazole (Vimovo) (PDF) (CP.PMN.117)
- (MAT) Naltrexone Products (PDF) (WA.PHAR.63)
- Natalizumab (Tysabri) (PDF) (CP.PHAR.259)
- Naxitamab-gqgk (Danyelza) (PDF) (CP.PHAR.523)
- necitumumab (PDF) (CP.PHAR.320)
- Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF) (CP.PMN.167)
- Netupitant and Palonosetron (Akynzeo) (PDF) (CP.PMN.158)
- Nifurtimox (Lampit) (PDF) (CP.PMN.256)
- Niraparib (Zejula) (PDF) (CP.PHAR.408)
- Nivolumab (PDF) (CP.PHAR.121)
- Nivolumab and Relatlimab-rmbw (Opdualag) (PDF) (CP.PHAR.588)
- No Coverage Criteria (PDF) (CP.PMN.255)
- No Coverage Criteria/Off-Label Use Policy (PDF) (CP.PMN.53)
- Non-Calcium Phosphate Binders (PDF) (CP.PMN.04)
- Non-Contracted Drugs (PDF) (WA.PHAR.126)
- Non-Formulary and Non-Preferred Drug Not Otherwise Specified (PDF) (WA.PHAR.61)
- Non-Preferred Blood Glucose Monitors/Test Strips (PDF) (CP.PMN.215)
- Obeticholic (PDF) (CP.PHAR.287)
- obinutuzumab (PDF) (CP.PHAR.305)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot) (PDF) (CP.PHAR.40)
- Ofatumumab (Arzerra, Kesimpta) (PDF) (CP.PHAR.306)
- olanzapine la inj (PDF) (CP.PHAR.292)
- Olanzapine (Zyprexa Zydis®) (PDF) (CP.PMN.29)
- Olanzapine/Samidorphan (Lybalvi) (PDF) (CP.PMN.265)
- Olaparib (PDF) (CP.PHAR.360)
- olaratumab (PDF) (CP.PHAR.326)
- Olutasidenib (Rezlidhia) (PDF) (CP.PHAR.615)
- Omadacycline (Nuzyra) (PDF) (CP.PMN.188)
- Omecetaxine (Synribo) (PDF) (CP.PHAR.108)
- Omega-3-Acid Ethyl Esters (Lovaza) (PDF) (CP.PMN.52)
- OnabotulinumtoxinA (Botox) (PDF) (CP.PHAR.232)
- Ondansetron (Zuplenz) (PDF) (CP.PMN.45)
- Ophthalmic Immunomodulators-Lifitegrast 5% Ophthalmic Solution (PDF) (WA.PHAR.58)
- Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF) (CP.PHAR.536)
- Opicapone (Ongentys) (PDF) (CP.PMN.245)
- Ospemifene (Osphena) (PDF) (CP.PMN.168)
- Overactive Bladder Agents (PDF) (CP.PMN.198)
- Oxymetazoline (Rhofade, Upneeq) (PDF) (CP.PMN.86)
- Ozanimod (Zeposia) (PDF) (CP.PHAR.462)
- Ozenoxacin (Xepi) (PDF) (CP.PMN.119)
- Paclitaxel protein-bound (Abraxane) (PDF) (CP.PHAR.176)
- Pacritinib (Vonjo) (PDF) (CP.PHAR.583)
- paliperidone inj (PDF) (CP.PHAR.291)
- Palivizumab (Synagis) (PDF) (CP.PHAR.16)
- Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep) (PDF) (CP.PMN.226)
- panitumumab (PDF) (CP.PHAR.321)
- Panobinostat (Farydak) (PDF) (CP.PHAR.382)
- Parathyroid hormone (Natpara) (PDF) (CP.PHAR.282)
- Paricalcitol Injection (PDF) (CP.PHAR.270)
- pasireotide (PDF) (CP.PHAR.332)
- Patiromer (Veltassa) (PDF) (CP.PMN.205)
- Peanut Allergen Powder-dnfp (Palforzia) (PDF) (CP.PMN.220)
- pegaspargase (PDF) (CP.PHAR.353)
- Peginterferon beta-1a (Plegridy) (PDF) (CP.PHAR.271)
- Pegvisomant (Somavert) (PDF) (CP.PHAR.389)
- pembrolizumab (PDF) (CP.PHAR.322)
- Pemetrexed (Alimta) (PDF) (CP.PHAR.368)
- Pemigatinib (Pemazyre) (PDF) (CP.PHAR.496)
- Pentosan Polysulfate Sodium (Elmiron) (PDF) (CP.PMN.276)
- Perampanel (Fycompa) (PDF) (CP.PMN.156)
- Perfluorohexyloctane (Miebo) (PDF) (CP.PMN.290)
- Perindopril/Amlodipine (Prestalia) (PDF) (CP.PMN.174)
- Pertuzumab (Perjeta) (PDF) (CP.PHAR.227)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (PDF) (CP.PHAR.501)
- Pilocarpine (Vuity) (PDF) (CP.PMN.270)
- Pimavanserin (Nuplazid) (PDF) (CP.PMN.140)
- Plerixafor (PDF) (CP.PHAR.323)
- Pitolisant (Wakix) (PDF) (CP.PMN.221)
- Polatuzumab Vedotin-piiq (Polivy) (PDF) (CP.PHAR.433)
- Pomalidomide (Pomalyst) (PDF) (CP.PHAR.116)
- Ponesimod (Ponvory) (PDF) (CP.PHAR.537)
- pralatrexate (PDF) (CP.PHAR.313)
- Prasterone (Intrarosa) (PDF) (CP.PMN.99)
- Preferred Stimulants for Adults (PDF) (WA.PHAR.132)
- Pregabalin (Lyrica, Lyrica CR) (PDF) (CP.PMN.33)
- Pretomanid (PDF) (CP.PMN.222)
- Progesterone (Crinone, Endometrin, Milprosa) (PDF) (CP.PMN.243)
- Progesterone Hydroxyprogesterone Caproate (Makena) (PDF) (WA.PHAR.54)
- Propranolol HCl Oral Solution (Hemangeol) (PDF) (CP.PMN.58)
- Protein C Concentrate, Human (Ceprotin) (PDF) (CP.PHAR.330)
- Proton Pump Inhibitors (PPI) (PDF) (WA.PHAR.81)
- Pulmonary Arterial Hypertension (PAH) Agents (Oral and Inhalation) (PDF) (WA.PHAR.55)
- Pulmonary Fibrosis Agents (PDF) (WA.PHAR.57)
- Quantity Limit Overrides (PDF) (CP.PMN.59)
- Quetiapine ER (Seroquel XR) (PDF) (CP.PMN.64)
- Quinine Sulfate (Qualaquin) (PDF) (CP.PNM.262)
- Tivozanib (Fotivda) (PDF) (CP.PHAR.538)
- Ramelteon (Rozerem) (PDF) (CP.PMN.173)
- Ramucirumab (Cyramza) (PDF) (CP.PHAR.119)
- Ranibizumab (Lucentis) (PDF) (CP.PHAR.186)
- Ranolazine (Ranexa) (PDF) (CP.PMN.34)
- Regorafenib (PDF) (CP.PHAR.107)
- Relugolix (Orgovyx) (PDF) (CP.PHAR.529)
- Respiratory Agents- Misc Alpha-Proteinase Inhibitor (Human) (PDF) (WA.PHAR.68)
- Retifanlimab-dlwr (Zynyz) (PDF) (CP.PHAR.629)
- Revlimid (PDF) (CP.PHAR.71)
- Ribavirin (Rebetol, Ribasphere) (PDF) (CP.PHAR.141)
- Ribociclib (PDF) (CP.PHAR.334)
- Rifabutin (Mycobutin) (PDF) (CP.PMN.223)
- Rifamycin (Aemcolo) (PDF) (CP.PMN.196)
- Rifapentine (Priftin) (PDF) (CP.PMN.05)
- RimabotulinumtoxinB (Myobloc) (PDF) (CP.PHAR.233)
- Risperidone LA Inj (PDF) (CP.PHAR.293)
- Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela) (PDF) (CP.PHAR.260)
- Rivaroxaban (Xarelto) (PDF) (CP.PMN.247)
- Rivastigmine (Exelon®) (PDF) (CP.PMN.101)
- roflumilast (PDF) (CP.PMN.46)
- Rolapitant (Varubi) (PDF) (CP.PMN.102)
- romidepsin (PDF) (CP.PHAR.314)
- Romosozumab-aqqg (Evenity) (PDF) (CP.PHAR.428)
- Ropeginterferon Alfa-2b-njft (BESREMi) (PDF) (CP.PHAR.570)
- Rucaparib (Rubraca) (PDF) (CP.PHAR.350)
- Rufinamide (Banzel) (PDF) (CP.PMN.157)
- Rukobia (fostemsavir) (PDF) (CP.PHAR.516)
- Sacituzumab Govitecan-hziy (Trodelvy) (PDF) (CP.PHAR.475)
- Safinamide (Xadago) (PDF) (CP.PMN.113)
- Sarecycline (Seysara) (PDF) (CP.PMN.189)
- Sargramostim (PDF) (CP.PHAR.295)
- Secnidazole (PDF) (CP.PMN.103)
- Second Opinion Network (SON) Review (PDF) (WA.PHAR.14)
- Selinexor (Xpovio) (PDF) (CP.PHAR.431)
- Selumetinib (PDF) (CP.PHAR.464)
- Sensipar (PDF) (CP.PHAR.61)
- Setmelanotide (Imcivree) (PDF) (CP.PHAR.491)
- Siltuximab (Sylvant) (PDF) (CP.PHAR.329)
- Siponimod (Mayzent) (PDF) (CP.PHAR.427)
- Sirolimus Protein-Bound Particles (Fyarro) (PDF) (CP.PHAR.574)
- Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, Sodium Oxybate (Xywav) (PDF) (CP.PMN.42)
- Sodium thiosulfate (Pedmark) (PDF) (CP.PHAR.610)
- Sodium Zirconium Cyclosilicate (Lokelma) (PDF) (CP.PMN.163)
- Solriamfetol (Sunosi) (PDF) (CP.PMN.209)
- Sonidegib (Odomzo) (PDF) (CP.PHAR.272)
- Sorafenib (Nexavar) (PDF) (CP.PHAR.69)
- Sotorasib (Lumakras) (PDF) (CP.PHAR.549)
- Spesolimab-sbzo (Spevigo) (PDF) (CP.PHAR.606)
- Sparsentan (Filspari) (PDF) (CP.PHAR.631)
- Stiripentol (Diacomit) (PDF) (CP.PMN.184)
- Substance Use Disorders (SUDs)- Buprenorphine extended-release injection (Sublocade) (PDF) (WA.PHAR.108)
- Sunitinib (Sutent) (PDF) (CP.PHAR.73)
- Suvorexant (Belsomra®) (PDF) (CP.PMN.109)
- Sylatron (peginterferon alfa-2b) (PDF) (CP.PHAR.89)
- Tafasitamab-cxix (Monjuvi) (PDF) (CP.PHAR.508)
- Talazoparib (Talzenna) (PDF) (CP.PHAR.409)
- Talimogene laherepvec (Imlygic) (PDF) (CP.PHAR.542)
- Tapinarof (Vtama) (PDF) (CP.PMN.283)
- Tazarotene (Arazlo, Fabior, Tazorac) (PDF) (CP.PMN.244)
- Tasimelteon (Hetlioz) (PDF) (CP.PMN.104)
- Tavaborole (Kerydin) (PDF) (CP.PMN.105)
- Tazemetostat (PDF) (CP.PHAR.452)
- Tebentafusp-tebn (Kimmtrak) (PDF) (CP.PHAR.575)
- Teclistamab-cqyv (Tecvayli) (PDF) (CP.PHAR.611)
- Tedizolid (Sivextro) (PDF) (CP.PMN.62)
- Telotristat ethyl (Xermelo) (PDF) (CP.PHAR.337)
- Tesamorelin (PDF) (CP.PHAR.109)
- temsirolimus (PDF) (CP.PHAR.324)
- Tenapanor (Ibsrela) (PDF) (CP.PMN.224)
- Tenofovir Alafenamide Fumarate (Vemlidy) (PDF) (CP.PMN.268)
- Tepotinib (Tepmetko) (PDF) (CP.PHAR.530)
- Teriflunomide (PDF) (CP.PHAR.262)
- Tezepelumab-ekko (Tezspire) (PDF) (CP.PHAR.576)
- Thalidomide (Thalomid) (PDF) (CP.PHAR.78)
- Therapies for COVID-19 (PDF) (WA.PHAR.127)
- Thioguanine (Tabloid) (PDF) (CP.PHAR.437)
- Thyrotropin alfa (PDF) (CP.PHAR.95)
- Tisotumab vedotin-tftv (Tivdak) (PDF) (CP.PHAR.561)
- Tolvaptan (Jynarque) (PDF) (CP.PHAR.27)
- Topiramate Extended-Release (Qudexy XR, Trokendi XR) (PDF) (CP.PMN.281)
- Topotecan (Hycamtin) (PDF) (CP.PHAR.64)
- Toremifene (Fareston) (PDF) (CP.PMN.126)
- Trabectedin (Yondelis) (PDF) (CP.PHAR.204)
- Tralokinumab-ldrm (Adbry) (PDF) (CP.PHAR.577)
- Trametinib (Mekinist) (PDF) (CP.PHAR.240)
- Transmucosal Fentanyl Products (PDF) (WA.PHAR.80)
- Trastuzumab Biosimilars Trastuzumab-Hyaluronidase (PDF) (CP.PHAR.228)
- Tremelimumab-actl (Imjudo) (PDF) (CP.PHAR.612)
- Triamcinolone ER Injection (PDF) (CP.PHAR.371)
- Triclabendazole (Egaten) (PDF) (CP.PMN.207)
- Trientine (Syprine) (PDF) (CP.PHAR.438)
- Trifarotene (Aklief) (PDF) (CP.PMN.225)
- Trifluridine, Tipiracil (Lonsurf) (PDF) (CP.PHAR.383)
- Triptorelin Pamoate (Trelstar, Triptodur) (PDF) (CP.PHAR.175)
- Ublituximab-xiiy (Briumvi) (PDF) (CP.PHAR.621)
- Ulcer Therapy Combinations (PDF) (CP.PMN.277)
- Umbralisib (Ukoniq) (PDF) (CP.PHAR.531)
- Valrubicin (Valstar) (PDF) (CP.PHAR.439)
- Varenicline (Tyrvaya) (PDF) (CP.PMN.273)
- Vemurafenib (Zelboraf®) (PDF) (CP.PHAR.91)
- Venetoclax (Venclexta) (PDF) (CP.PHAR.129)
- Verteporfin (Visudyne) (PDF) (CP.PHAR.187)
- Vigabatrin (PDF) (CP.PHAR.169)
- vincristine sulfate liposome injection (PDF) (CP.PHAR.315)
- Vismodegib (Erivedge) (PDF) (CP.PHAR.273)
- Voclosporin (Lupkynis) (PDF) (CP.PHAR.504)
- Vorinostat (PDF) (CP.PHAR.83)
- Voxelotor (Oxbryta) (PDF) (CP.PHAR.451)
- Xiaflex™ (PDF) (CP.PHAR.82)
- Zavegepant (Zavzpret) (PDF) (CP.PHAR.630)
- ziv-aflibercept (PDF) (CP.PHAR.325)
- Zoledronic Acid (Reclast, Zometa) (PDF) (CP.PHAR.59)
- Zolpidem Tartrate (Edluar, Intermezzo, Zolpimist) (PDF) (CP.PMN.172)
Payment Policies
Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.
All policies found in the Coordinated Care Payment Policy Manual apply with respect to Coordinated Care members. Policies in the Coordinated Care Payment Policy Manual may have either a Coordinated Care or a “Centene” heading. In addition, Coordinated Care may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Coordinated Care.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Ambetter Payment Policies
- 3-Day Payment Window (PDF) (CC.PP.500)
- 30-Day Readmission (PDF) (CC.PP.501)
- Add on Code Billed Without Primary Code (PDF) (CC.PP.030)
- Assistant Surgeon (PDF) (CC.PP.029)
- Bilateral Procedures (PDF) (CC.PP.037)
- Cerumen Removal (PDF) (CC.PP.008)
- Clean Claims (PDF) (CC.PP.021)
- Coding Overview (PDF) (CC.PP.011)
- Cosmetic Procedures (PDF) (CC.PP.024)
- Distinct Procedural Modifiers (PDF) (CC.PP.020)
- DRG Technical Denials (PDF) (CC.PP.801)
- Duplicate Primary Code Billing (PDF) (CC.PP.044)
- E&M Medical Decision-Making (PDF) (CC.PP.051)
- EM Bundling Edits (PDF) (CC.PP.010)
- Global Maternity Billing (PDF) (CC.PP.016)
- Hospital Visit Codes Billed with Labs (PDF) (CC.PP.023)
- Inpatient Consultation (PDF) (CC.PP.038)
- Inpatient Only Procedures (PDF) (CC.PP.018)
- IV Hydration (PDF) (CC.PP.012)
- Leveling of Emergency Room Services (PDF) (CC.PP.053)
- Maximum Units (PDF) (CC.PP.007)
- Moderate Conscious Sedation (PDF) (CC.PP.015)
- Modifier -25 clinical validation (PDF) (CC.PP.013)
- Modifier -59 clinical validation (PDF) (CC.PP.014)
- Modifier DOS Validation (PDF) (CC.PP.034)
- Modifier to Procedure Code Validation (PDF) (CC.PP.028)
- Multiple CPT Code Replacement (PDF) (CC.PP.033)
- Multiple Diagnostic Cardiovascular Procedure (MDCP) (PDF) (CC.PP.065)
- Payment Reduction (MDCR)NCCI Unbundling (PDF) (CC.PP.031)
- Never Paid Events (PDF) (CC.PP.017)
- New Patient (PDF) (CC.PP.036)
- Outpatient Consultation (PDF) (CC.PP.039)
- Pelvic and Transabdominal US (PDF) (CC.PP.061)
- Physician's Consultation Services (PDF) (CC.PP.054)
- Physician Visit Codes Billed with Labs (PDF) (CC.PP.019)
- Place of Service Mismatch (PDF) (CC.PP.063)
- Post-Operative Visits (PDF) (CC.PP.042)
- Pre-Operative Visits (PDF) (CC.PP.041)
- Professional Component (PDF) (CC.PP.027)
- Pulse Oximetry (PDF) (CC.PP.025)
- Renal Hemodialysis (PDF) (CC.PP.067)
- Robotic Surgery (PDF) (CC.PP.050)
- Same Day Visits (PDF) (CC.PP.040)
- Sleep Studies Place of Services (PDF) (CC.PP.035)
- Status "B" Bundled Services (PDF) (CC.PP.046)
- Status P Bundled Services (PDF) (CC.PP.049)
- Supplies Billed on Same Day As Surgery (PDF) (CC.PP.032)
- Transgender Related Services (PDF) (CC.PP.047)
- Unbundled Surgical Procedures (PDF) (CC.PP.045)
- Unbundled Professional Services (PDF) (CC.PP.043)
- Unlisted Procedure Codes (PDF) (CC.PP.009)
- Wheelchair Accessories (PDF) (CC.PP.502)
Medicaid Payment Policies
- 1-Day Payment Window (PDF) (WA.PP.500)
- Add on Code Billed Without Primary Code (PDF) (CC.PP.030)
- Assistant Surgeon (PDF) (CC.PP.029)
- Bilateral Procedures (PDF) (CC.PP.037)
- Cerumen Removal (PDF) (CC.PP.008)
- Clean Claims (PDF) (CC.PP.021)
- Coding Overview (PDF) (CC.PP.011)
- Cosmetic Procedures (PDF) (CC.PP.024)
- Distinct Procedural Modifiers (PDF) (CC.PP.020)
- DRG Technical Denials (PDF) (CC.PP.801)
- Duplicate Primary Code Billing (PDF) (CC.PP.044)
- E&M Medical Decision-Making (PDF) (CC.PP.051)
- EM Bundling Edits (PDF) (CC.PP.010)
- Global Maternity Billing (PDF) (CC.PP.016)
- Hospital Visit Codes Billed with Labs (PDF) (CC.PP.023)
- Inpatient Consultation (PDF) (CC.PP.038)
- Inpatient Only Procedures (PDF) (CC.PP.018)
- IV Hydration (PDF) (CC.PP.012)
- Leveling of Emergency Room Services (PDF) (CC.PP.053)
- Maximum Units (PDF) (CC.PP.007)
- Moderate Conscious Sedation (PDF) (CC.PP.015)
- Modifier -25 clinical validation (PDF) (CC.PP.013)
- Modifier -59 clinical validation (PDF) (CC.PP.014)
- Modifier DOS Validation (PDF) (CC.PP.034)
- Modifier to Procedure Code Validation (PDF) (CC.PP.028)
- Multiple CPT Code Replacement (PDF) (CC.PP.033)
- Multiple Diagnostic Cardiovascular Procedure (MDCP) (PDF) (CC.PP.065)
- NCCI Unbundling (PDF) (CC.PP.031)
- Never Paid Events (PDF) (CC.PP.017)
- New Patient (PDF) (CC.PP.036)
- Outpatient Consultation (PDF) (CC.PP.039)
- Pelvic and Transabdominal US (PDF) (CC.PP.061)
- Physician Visit Codes Billed with Labs (PDF) (CC.PP.019)
- Place of Service Mismatch (PDF) (CC.PP.063)
- Post-Operative Visits (PDF) (CC.PP.042)
- Pre-Operative Visits (PDF) (CC.PP.041)
- Professional Component (PDF) (CC.PP.027)
- Provider Preventable Readmissions (PDF) (WA.PP.501)
- Pulse Oximetry (PDF) (CC.PP.025)
- Renal Hemodialysis (PDF) (CC.PP.067)
- Same Day Visits (PDF) (CC.PP.040)
- Sepsis Diagnosis (PDF) (CP.PP.073)
- Sleep Studies Place of Services (PDF) (CC.PP.035)
- Status "B" Bundled Services (PDF) (CC.PP.046)
- Status P Bundled Services (PDF) (CC.PP.049)
- Supplies Billed on Same Day As Surgery (PDF) (CC.PP.032)
- Transgender Related Services (PDF) (CC.PP.047)
- Unbundled Surgical Procedures (PDF) (CC.PP.045)
- Unbundled Professional Services (PDF) (CC.PP.043)
- Unlisted Procedure Codes (PDF) (CC.PP.009)
- Wheelchair Accessories (PDF) (CC.PP.502)
Policy Revision Summary
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.129 | Fetal Surgery in Utero for Prenatally Diagnosed Malformations | Annual review. Criteria I.F.3. updated to include confirmation on fetal MRI. Added clarifying language to Criteria I.F.4. Background updated with no impact on criteria. Added CPT code 59072. ICD-10 codes removed. References reviewed and updated. Reviewed by external specialist.
|
Policy Number | Policy Title | Revision Notes |
---|---|---|
WA.CP.MP.50 | Drugs of Abuse: Definitive Testing | Annual Review. Added an example of synthetic cannabinoids to I.A.1., drugs for which presumptive testing is not reliable. Coding reviewed. Replaced all instances of dashes (-) with the word “to” within the CPT and HCPCS codes. Added 0082U to the CPT codes that do not support coverage criteria list. Removed table of ICD-10 CM codes. Updated background information to include information regarding American Society of Addiction Medicine (ASAM). Other minor wording changes made to background with no clinical significance. References reviewed and updated. Policy reviewed by an internal specialist.
|
CP.MP.181 | Polymerase Chain Reaction Respiratory Viral Panel Testing | Removed note after the policy description referring to CP.CPC.03 Preventive Health and Clinical Practice Guidelines for PCR testing for COVID-19. Added 0202U, 0223U and 0225U to CPT table 2. |
WA.CP.MP.50 | Drugs of Abuse: Definitive Testing | Annual Review. Added an example of synthetic cannabinoids to I.A.1., drugs for which presumptive testing is not reliable. Coding reviewed. Replaced all instances of dashes (-) with the word “to” within the CPT and HCPCS codes. Added 0082U to the CPT codes that do not support coverage criteria list. Removed table of ICD-10 CM codes. Updated background information to include information regarding American Society of Addiction Medicine (ASAM). Other minor wording changes made to background with no clinical significance. References reviewed and updated. Policy reviewed by an internal specialist. Removed deleted codes 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, 0150U from table of CPT codes that do not support coverage criteria. |
CP.MP.38 | Ultrasound in Pregnancy | Annual review. Minor rewording in Description, in Table 1 under Criteria IV., and in Criteria V. Verbiage added to indicate list is not all inclusive under Classifications of fetal ultrasounds Section I. and Section II. Background updated with no impact on criteria. Updated Table 4 Coding description. The following retired code ranges were removed: O35.0XX0 through O35.0XX9 and O35.1XX0 through O35.1XX9. The following code ranges were added: O35.00X0 through O35.00X9, O35.01X0 through O35.01X9, O35.02X0 through O35.02X9, O35.03X0 through O35.03X9, O35.04X0 through O35.04X9, O35.05X0 through O35.05X9, O35.06X0 through O35.06X9, O35.07X0 through O35.07X9, O35.08X0 through O35.08X9, O35.09X0 through O35.09X9, O35.10X0 through O35.10X9, O35.11X0 through O35.11X9, O35.12X0 through O35.12X9, O35.13X0 through O35.13X9, O35.14X0 through O35.14X9, O35.15X0 through O35.15X9, O35.19X0 through O35.19X9, O35.AXX0 through O35.AXX9, O35.BXX0 through O35.BXX9, O35.CXX0 through O35.CXX9, O35.DXX0 through O35.DXX9, O35.EXX0 through O35.EXX9, O35.FXX0 through O35.FXX9, O35.GXX0 through O35.GXX9, O35.HXX0 through O35.HXX9. References reviewed and updated. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.182 | Short Inpatient Hospital Stay | Annual review completed. Updated hyperlink to CMS inpatient only list in Criteria I.A. Added option in I.A. for procedure to be listed as an inpatient-only procedure in InterQual for those under 18 years of age, and noted that the CMS inpatient only list applies to those 18 years of age and older. Minor rewording with no clinical significance. References reviewed and updated. Internal specialist reviewed. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.14 | Cochlear Implant Replacements | Annual review completed. Changed verbiage in I.C. from “A sound processor replacement if the current processor is at least five years old” to “C. The existing component has reached the limit of its reasonable useful life. The reasonable useful life of a sound processor is not less than five years”. Minor rewording with no clinical significance. Background updated with no impact to criteria. ICD-10-CM Diagnosis Code table removed. References reviewed and updated. External specialist reviewed. |
WA.CP.MP.514 | Extra-Corporeal Membrane Oxygenation Therapy (ECMO) | Annual review. References updated. |
CP.MP.137 | Fecal Incontinence Treatments | Annual review. Removed “≥ 4 years age” criteria and added “in a member/enrollee that has previously achieved bowel control” to I.A. Also removed “more than twelve months after vaginal childbirth” from definition of severe, chronic fecal incontinence in I.A. Description and background section updated with no clinical significance. References reviewed and updated. External specialist reviewed. |
WA.CP.MP.54 | Hospice Services | References updated. Background information updated. Removed statement regarding previous investigational treatment from Initial Request paragraph. Updated Initial Request Section I. language to correspond to HCA billing guidelines. Updated Initial and Subsequent Request sections II. Continuous Homecare and General Inpatient descriptions to correspond to HCA billing guidelines. Removed debility and failure to thrive exclusion from section III. Updated section III. D. language re: hospice discharge per HCA billing guidelines. Covered and non-covered services sections updated to correspond to HCA billing guidelines. |
CP.MP.127 | Total Artificial Heart | Annual review. Removed criteria III. Updated background with no clinical significance. Removed ICD-10 code table. References reviewed and updated. |
WA.CP.BH.200 | Transcranial Magnetic Stimulation for Treatment Resistant Major Depression | New policy. |
WA.CP.MP.522 | Varicose Vein Treatment | Annual review. References reviewed and updated. Section I. medical necessity criteria revised to align with HTA/HCA billing guidelines. Removed ligation/stripping procedures from policy description and criteria. Added note below section II. regarding use of InterQual criteria for review of ligation/stripping procedures. Removed ligation procedure codes 37780 and 37785 from CPT code table. Updated section B. contraindications to correspond to HTA/billing guidelines and current corporate sclerotherapy/EVLA policy CP.MP.146. Updated section C. Venaseal requirements per CP.MP.146. Background updated with no impact on criteria. . Removed table of codes that do not support medical necessity. |
V2.2023 | CG Aortopathies and Connective Tissue Disorders | Annual review. Policy number change from CP.MP.215 |
V2.2023 | CG Cardiac Disorders | Annual review. Policy number change from CP.MP.216 |
V2.2023 | CG Dermatologic Conditions | Annual review. Policy number change from CP.MP.217 |
V2.2023 | CG Epilepsy Neurodegenerative and Neuromuscular Conditions | Annual review. Policy number change from CP.MP.218 |
V2.2023 | CG Exome and Genome Sequencing for DX of Genetic Disorders | Annual review. Policy number change from CP.MP.219 |
V2.2023 | CG Eye Disorders | Annual review. Policy number change from CP.MP.220 |
V2.2023 | CG Gastroenterologic Disorders Non-cancerous | Annual review. Policy number change from CP.MP.221 |
V2.2023 | CG General Approach to Genetic Testing | Annual review. Policy number change from CP.MP.222 |
V2.2023 | CG Hearing Loss | Annual review. Policy number change from CP.MP.223 |
V2.2023 | CG Hematologic Conditions Non-cancerous | Annual review. Policy number change from CP.MP.224 |
V2.2023 | CG Hereditary Cancer Susceptibility | Annual review. Policy number change from CP.MP.225 |
V2.2023 | CG Immune Autoimmune and Rheumatoid Disorders | Annual review. Policy number change from CP.MP.226 |
V2.2023 | CG Kidney Disorders | Annual review. Policy number change from CC.MP.227 |
V2.2023 | CG Lung Disorders | Annual review. Policy number change from CC.MP.228 |
V2.2023 | CG Metabolic Endocrine Mitochondrial Disorders | Annual review. Policy number change from CP.MP.229 |
WA.CP.MP.230 | CG Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay | Annual review. |
WA.CP.MP.231 | CG Non-Invasive Prenatal Screening | Annual review. |
V2.2023 | CG Oncology Algorithmic Testing | Annual review. Policy number change from CP.MP.237 |
V2.2023 | CG Oncology Cancer Screening | Annual review. Policy number change from CP.MP.238 |
V2.2023 | CG Oncology Circulating Tumor DNA Tumor Cells Liquid Biopsy | Annual review. Policy number change from CP.MP.239 |
V2.2023 | CG Oncology Cytogenetic Testing | Annual review. Policy number change from CP.MP.240 |
V2.2023 | CG Oncology Molecular Analysis Solid Tumors & Hematolgic Malignancies | Annual review. Policy number change from CP.MP.241 |
V2.2023 | CG Pharmacogenetics | Annual review. Policy number change from CP.MP.232 |
V2.2023 | CG Preimplantation Genetic Testing | Annual review. Policy number change from CP.MP.233 |
V2.2023 | CG Prenatal and Preconception Carrier Screening | Annual review. Policy number change from CP.MP.234 |
V2.2023 | CG Prenatal Diagnosis Pregnancy Loss | Annual review. Policy number change from CP.MP.235 |
V2.2023 | CG Skeletal Dysplasia Rare Bone Disorders | Annual review. Policy number change from CP.MP.236 |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.93 | Bone-anchored Hearing Aid | Annual review. Removed Criteria II. stating "BAHAs for any other indication are considered not medically necessary." Updated background with no clinical significance. Added new CPT codes 69728, 69729, and 69730 and removed ICD-10 codes from policy. References reviewed and updated. Reviewed by external specialist. |
CP.MP.94 | Clinical Trials | Annual review completed; policy reformatted. Minor rewording with no clinical significance. References reviewed and updated. |
CP.MP.115 | Discography | Annual review. Background updated with no impact on criteria. References reviewed and updated. |
CP.MP.248 | Facility-Based Sleep Studies for Obstructive Sleep Apnea | Revised criteria III.B. by removing requirement to meet criteria for facility-based sleep study and rewording failed APAP trial statement. |
CP.MP.184 | Home Ventilators | Annual review completed. Minor rewording with no clinical significance. Background updated with no clinical significance. References reviewed and updated. |
CP.MP.249 | Omisirge (omidubicel): Nicotinamide-modified allogeneic hematopoietic progenitor cell therapy | New Policy |
CP.MP.49 | Physical, Occupational and Speech Therapy Services | Annual review. Minor rewording throughout Criteria section with no impact on policy criteria. Removed Criteria I.F.6.a. and added as a notation. Added Criteria I.F.8. that member/enrollee agrees to participation and plan of care. Added Criteria I.H. and Criteria II.B. regarding treatment to be performed in the home. Removed Criteria V. and Criteria VI. Background updated with no impact on criteria. References reviewed and updated. Reviewed by internal specialist. |
CP.MP.142 | Urinary Incontinence Devices and Treatments | Removed continence support pessaries from criteria I.D.1. Revised order in which conservative therapies are listed in I.D.2. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.BH.104 | Applied Behavior Analysis | New Policy |
WA.CP.BH.104 | Applied Behavior Analysis | Policy archived |
CP.MP.164 | Caudal or Interlaminar Epidural Steroid Injections for Pain Management | Policy archived |
NIA_CG_300 | Epidural Spine Injections | New Policy on NIA site |
NIA_CG_301 | Facet Joint Injections | New Policy on NIA site |
NIA_CG_302 | Facet Joint Denervation | New Policy on NIA site |
WA.CP.MP.171 | Facet Joint Interventions for Pain Management | Policy archived |
WA.CP.BH.506 | Psychological Testing | Annual review. Renumbered policy from WA.CP.MP.506 to WA.CP.BH.506. Replaced “member” with “member/enrollee’ in all instances. References updated. |
CP.MP.166 | Sacroiliac Joint Interventions for Pain Management | Policy archived |
NIA_CG_305 | Sacroiliac Joint Injection | New Policy on NIA site |
CP.MP.165 | Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management | Policy archived |
WA.CP.MP.248 | Sleep Apnea Diagnosis and Treatment | Policy archived |
CP.BH.200 | Transcranial Magnetic Stimulation for Treatment Resistant Major Depression | Ad hoc Review. Policy restructured. Added additional information to the description section with no impact to the policy. Replaced all instances of the statement “It is the policy of health plans affiliated with Centene Corporation®” with “It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation”. Deleted criteria point I.D as the information was redundant to I.B. In criteria subsection I.I. (5), clarified that three months or less of remission constitutes a contraindication. Added the statement “requests for 6 tapered final sessions of TMS (over a 3-week period)” to the revised criteria point II. Added criteria point II.A to indicate that “all initial criteria must be met prior to request for additional sessions”. Deleted what was criteria III as the information was redundant to criteria II. In criteria section III, replaced “maintenance treatment with TMS is not medically necessary, as there is insufficient evidence in the published peer reviewed literature to support it” with “It is the policy of health plans affiliated with Centene Corporation that maintenance treatment with TMS is not medically necessary, as there is insufficient evidence in the published peer reviewed literature to support it”. Added criteria point IV.A to indicate that “criteria for initial TMS treatment guidelines continues to be met”. Added semicolons throughout the criteria section. References reformatted. Replaced all instances of “dashes (-) in page numbers to the word “to”. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
WA.CP.MP.37 | Bariatric Surgery | Annual review. Updated policy format. Updated policy statement in I, I.A.1, and I.A.1.a. In I.A.1.a.i updated policy statement and BMI threshold to ≥ 35 or ≥ 32.5 kg/m2 for South Asian, Southeast Asian, and East Asian adults. In I.A.1.a.ii BMI threshold was updated to "BMI ≥ 30 and < 35 kg/m², or < 27.5 kg/m2 and < 32.5 kg/m2 for South Asian, Southeast Asian, and East Asian adults and policy statements in I.A.1.a.ii, I.A.1.a.ii.a), and c). Moved Type 2 diabetes mellitus (DM) to I.A.1.a.ii.b) as an absolute co-morbidity. Added "pseudotumor cerebri" and "disqualification from other surgeries..." to I.A.1.a.ii.c). Updated policy statement in I.A.1.b.ii. Updated I.B.2 to "Glycemic control evaluation to include A1c and fasting blood glucose". Removed criteria I.B.5.c. requiring prescribed exercise program as part of nutritional counseling. Moved IV. Contraindications to I.C and added "severe cardiac disease with prohibitive anesthetic risks," "uncontrolled and untreated eating disorders (eg, bulimia)," "inability on the part of the patient or parent/guardian to comprehend the risks and benefits of the surgical procedure," and "a medical, psychiatric, psychosocial, or cognitive condition that prevents adherence to postoperative dietary and medication regimens or impairs decisional capacity." Background updated with no clinical impact. Removed deleted CPT codes 0312T- 0317T and added CPT codes 43290, 43291, and 43632 to not medically necessary table. Removed ICD-10 codes and table. References reviewed and updated. Reviewed by internal and external specialists. Section III: updated abbreviations in III.3 with no clinical significance; added indication for SG to RYGB or BPD-DS DS as a bridging procedure for BMI ≥ 50 kg/m² in III.4. |
CP.MP.107 | Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines | Annual review. Updated policy statement in I. and added general criteria I.A.1. and I.A.2. Removed ambulatory assist products and updated I.B. policy table. Retired gait trainers and standing frame criteria, defer to standard IQ criteria. Updated pneumatic compression device criteria and added non-pneumatic compression device criteria. Added "one month’s rental for a standard manual wheelchair is considered medically necessary if a member/enrollee owned wheelchair is being repaired" to wheelchair repair. Added foot orthotics, custom criteria and codes. Removed "male" from male vacuum erection device. Added criteria section for walkers. Minor verbiage and formatting updates with no impact on criteria. References reviewed, updated, and reformatted. Internal specialist review. |
CP.MP.106 | Endometrial ablation | Annual review completed. Added requirement in I.F. that thyroid disorders have been treated or ruled out. Removed contraindication “previous classic cesarean or other transmural surgery” from I.G. Background and Table 1 updated. Minor rewording with no clinical significance. References reviewed and updated. Internal specialist reviewed. |
CP.MP.121 | Homocysteine Testing | Annual review. References reviewed and updated. |
WA.CP.MP.505 | Microprocessor Controlled Lower Limb Prosthetics | Annual review. References updated. Removed HCPCS L2006 and L5973 as these services are not covered by HCA. |
CP.MP.242 | Pulmonary Function Testing | Annual review. Updated Criteria I.B.1. to include type and degree of pulmonary dysfunction. Minor rewording to Criteria I.B.2. and I.B.4. without clinical significance. Minor rewording to Criteria C. Background updated with no impact on criteria. References reviewed and updated. |
WA.CP.MP.517 | Testosterone Testing | Annual review. Reference updated. Grammatical changes to mirror billing guideline. |
CP.MP.247 | Transplant Service Documentation Requirements | New policy |
WA.CP.MP.520 | Tympanostomy Tubes in Children | Annual review. References updated. Criteria updated to mirror billing guideline. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
WA.CP.MP.519 | Administrative Days | Added section III for Newborn Subsequent Days. References updated. |
WA.CP.BH.521 | Behavioral Health Personal Care Services | Annual review. Changed policy number from WA.CP.MP.521 to WA.CP.BH.521. References updated. |
WA.CP.MP.502 | Cochlear Implants: Bilateral vs. Unilateral | Annual review. references updated. Removed L8614. |
WA.CP.MP.501 | Continuous Glucose Monitoring | Annual review. References updated. Updated all HCPCS |
CP.MP.34 | Hyperemesis Gravidarum Treatment | Policy archived |
CP.MP.180 | Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea | Annual review completed. I.C. Changed BMI to 35 kg/m2; I.E. Adjusted AHI to ≥15 to ≤ 65 events per hour; I.F.1. Adjusted 20 to 15. Added criteria I.I.5. and I.I.8. through 14. Background updated and minor rewording with no clinical significance. Added CPT codes 64582, 64583, and 64584. Removed CPT codes 0466T, 0467T, 0468T, 61886, 61888, 64568, 64569, 64570, and 64585. |
CP.MP.57 | Lung Transplantation | Annual review. Criteria I.C.14. updated to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. Added pediatric indication for end-stage emphysema due to alpha-1 trypsin deficiency. ICD-10 codes removed. References reviewed and updated. Reviewed by external specialist |
CP.MP.85 | Neonatal Sepsis Management | Annual review completed. Description and background updated. Minor rewording with no clinical significance. References reviewed and updated. |
CP.MP.81 | NICU Discharge Guidelines | Annual review. Updated the note in section II. from "1800 grams” to “1600 to 1800 grams.” References reviewed and updated. Reviewed by external specialist. |
CP.MP.141 | Non-Myeloablative Allogenic Stem Cell Transplants | Annual review completed. Criteria I.C.4. updated to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. Background updated; minor rewording with no clinical significance. ICD-10 diagnosis code table removed. References reviewed and updated. |
WA.CP.MP.503 | Private Duty Nursing Services | Annual review. Added HCA definition of Private Duty Nursting to the Description section. Added minimum hours to section I. Updated sections II.A and II.B to add clarity and examples. Reworded III.A. to add billing instructions for patient’s home in addition to the instructions for billing when in a group home. Clarified billing instructions in IV. Updated references. |
CP.MP.187 | Radiofrequency Ablation of Uterine Fibroids | Policy archived |
CP.MP.151 | Transcatheter Closure of Patent Foramen Ovale | Annual review. Updated description to include newest FDA-approved device: AmplatzerTM TalismanTM PFO Occluder. Clarfied in I.B. that age requirements are in years. Updated Criteria I.B. # 2 to state that cryptogenic stroke caused by a presumed paradoxical embolism, and a possible, probable, or definite likelihood that the stroke was causally related to PFO based on the PFO-associated stroke causal likelihood (PASCAL) classification system with a Risk of Paradoxical Embolism (RoPE) score > 6, and/or there is a large shunt or atrial septal aneurysm. Updated Criteria to include Criteria C. Device is FDA-approved for percutaneous transcatheter closure of PFO (eg AmplatzerTM PFO Occluder, AmplatzerTM TalismanTM PFO Occluder, and the Gore® Cardioform Septal Occluder). Background updated and includes information on PASCAL classification system and RoPE score. Removed ICD-10 codes. References reviewed and updated. Reviewed by internal specialist and external specialist. |
WA.CP.MP.46 | Ventricular Assist Devices | Annual review. Background and note updated with no clinical significance. Section III reworded. Removed ICD codes. References updated. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.BH.500 | Behavioral Health Treatment Document Requirements | Edited policy statement I to apply to Centene Advanced Behavioral Health as well as plans affiliated with Centene. |
NIA.CG.062 | CT Coronary Angiography | Added the following statement, "Low probability patients will be directed to exercise stress test over CCTA unless other criteria for imaging studies are met." |
WA.CP.MP.515 | Fecal Microbiota Transplantation | Annual review. Updated references |
CP.MP.136 | Home Births | Annual review completed. Removed criteria II. regarding all other indications not medically necessary. Minor rewording with no clinical significance. ICD-10 codes removed. References reviewed and updated. Internal and external specialist reviewed. |
CP.MP.62 | Hyperhidrosis Treatments | Annual review. Updated Criteria II.B. to greater than 55 beats per minute. Removed “is relatively healthy” in criteria II.F. Background updated with no impact on criteria. ICD-10 codes removed. References reviewed and updated. |
CP.MP.173 | Implantable Intrathecal or Epidural Pain Pump | Annual review. References reviewed and updated. ICD-10 code table removed. Minor rewording with no clinical significance. Reviewed by external specialist. |
CP.MP.202 | Orthognathic Surgery | Annual review completed. Reformatted criteria II. and added II.B. as additional non-medically necessary indication. Additional minor rewording with no clinical significance. Background updated. CDT codes removed from policy. References revised and updated. Reviewed by external and internal specialists. |
CP.MP.150 | Phototherapy for Neonatal Hyperbilirubinemia | Annual review. Changed title from “Home phototherapy…” to “Phototherapy…” Updated criteria I.D. from 24-48 hours to 12-24 hours. Updated criteria to include the following: I.E. ≥48 hours old; I.F. An LED-based phototherapy device will be available in the home without delay; I.G. No previous phototherapy; I.H. TSB will be measured daily. Criteria I.I. #1 updated to include example of positive direct antiglobulin test for isoimmune hemolytic disease and to include glucose-6-phosphate dehydrogenase (G6PD) and other hemolytic disease. Criteria I.I. #2 updated to include hypoxic ischemia encephalopathy (HIE). Significant lethargy removed from Criteria I.I. Criteria I.I. updated to include the following: #13 Significant clinical instability in the previous 24 hours; #14 Clinical history of a parent or sibling requiring phototherapy or exchange transfusion; #15 Exclusive breastfeeding with suboptimal intake (≥10% weight loss); #16 Down syndrome; #17 Macrosomic infant of a diabetic mother. Added note below Table 1 that explains the values are conservative TSB values based on lower age range thresholds in inpatient criteria. Added clarification to II that extenuating circumstances can include lack of expected compliance with therapy at home. Added note below policy statement II stating: that infants should be admitted for inpatient phototherapy if the TSB concentration is more than 1 mg/dL above the AAP guidelines phototherapy treatment threshold per the bili risk tool, and that table 1 is consistent with AAP guidelines allowing treatment at lower levels per provider discretion; and that clinical decision support tools provider further criteria for inpatient phototherapy treatment. Updated background to include 2022 AAP clinical practice guidelines. Removed ICD-10 codes. References reviewed and updated. Reviewed by internal specialist and external specialist. |
WA.CP.MP.248 | Sleep Apnea Diagnosis and Treatment | Updated policy to reflect new Centene policy: significant changes to section I.B. and change in policy numbering from WA.CP.MP.523 to WA.CP.MP.248. Updated section II.A. to reflect consideration of titration studies. Added coverage statement about actigraphy. Added code 95803 to code list. Minor changes to company name. Updated references. |
WA.CP.MP.526 | Stem Cell Therapy for Musculoskeletal Conditions | Annual review. Updated references. Added CPT codes 38230 and 38232 and HCPCS code S2150. |
CP.MP.22 | Stereotactic Body Radiation Therapy | Annual review completed. Added I.F. “Recurrent malignant disease requiring palliation and/or as palliative treatment for liver-related symptoms”. Added I.J. “Extracranial oligometastatic disease: 1.One to three metastatic lesions involving the lungs, liver or bone; 2.Primary tumor is breast, colorectal, melanoma, non-small cell lung, prostate, renal cell, or sarcoma; 3.Primary tumor is controlled 4.No prior history of metastatic disease”. Background updated and minor rewording with no clinical significance. ICD-10 Code table removed. References reviewed and updated. Reviewed by external specialist. |
CP.BH.100 | Substance Use Treatment and Services | Ad-hoc review. Edited policy statement I. to note that it applies to health plans affiliated with Centene Corporation as well as CABH. Replaced all instances of “dashes (-)” in the CPT codes with the word “through”. Replaced all instances of “dashes (-) in page numbers to the word “to”. |
CP.MP.162 | Tandem Transplant | Annual review. References reviewed and updated. ICD-10 codes removed. Review completed by external specialist. Minor background edits with no change to criteria. |
WA.CP.MP.510 | Tinnitus Treatment | Annual review. Replaced all instances of “members” with “members/enrollees”. Added “repetitive” to transcranial magnetic stimulation in 2.B. Updated references. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
WA.CP.MP.525 | Catheter Ablation for Supraventricular Tachyarrhythmia | Annual review. References updated. Removed CPT 93650 |
CP.MP.203 | Diaphragmatic/Phrenic Nerve Stimulation | Annual review. Criteria II.A.1.c. and Criteria II.A.2.b. updated to include “or by other radiographic techniques such as ultrasound” in addition to fluoroscopy. Background updated to include U.S. Food and Drug Administration premarket approval information regarding the Avery Spirit Diaphragm Pacing Transmitter. ICD-10 codes removed. References reviewed and updated. Reviewed by external specialist. |
WA.CP.MP.54 | Hospice Services | Annual review. References updated. Reworded description of Pediatric Palliative Care. |
WA.CP.MP.69 | Intensity-Modulated Radiotherapy | Annual review. Updated references. Removed CPT 77370. |
WA.CP.MP.500 | Mandibular Advancement Devices | Annual review. Reference updated. |
CP.MP.138 | Pediatric Heart Transplant | Annual review. Appendix A tables updated to remove dashes. Removed ICD-10 codes. References reviewed and reformatted. |
CP.MP.246 | Pediatric Kidney Transplant | New policy |
WA.CP.MP.117 | Percutaneous Electrical and Peripheral Nerve Stimulation | Policy renumbered WA.CP.MP.117. References to spinal cord stimulation removed. |
CP.MP.242 | Pulmonary Function Testing | New policy |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.186 | Burn Surgery | Annual review completed. Background updated and minor rewording with no clinical significance. References reviewed, reformatted and updated. |
CP.MP.131 | Essure Removal | Policy retired |
CP.MP.209 | Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing | Removed deleted code 0097U |
WA.CP.MP.70 | Proton and Neutron Beam Therapy | Annual review completed. Removed “treated in a hypofractionated regimen” from I. D. Background updated and minor rewording with no clinical significance. References reviewed, reformatted and updated. External specialist reviewed. |
CP.MP.182 | Short Inpatient Hospital Stay | Annual review. Added I.C. “Acute hospital care at home.” Background updated with no clinical significance. References reviewed and updated. |
CP.MP.142 | Urinary Incontinence Devices and Treatments | Annual review. Updated criteria section to clarify abbreviations. Criteria I.D. # 1 updated to include continence-support pessaries as a conservative measure. Updated background with no impact on criteria. Removed ICD-10 codes. References reviewed and updated. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.108 | Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia | Annual Review. References reviewed, updated, and reformatted. Reviewed by internal specialist. |
CP.MP.31 | Cosmetic and Reconstructive Procedures | Annual review completed. Added to I.A.4.b. “poly-L-lactic acid” and “calcium hydroxylapatite microspheres”. Minor rewording with no clinical significance. References reviewed and updated. Reviewed by external specialist. |
CP.MP.101 | Donor Lymphocyte Infusion | Annual review. Background updated with no impact on criteria. ICD-10 codes removed. References reviewed and updated. Specialist review. |
CP.MP.109 | Panniculectomy | Annual review. Removed ICD-10 codes. References reviewed and updated. |
WA.CP.MP.185 | Skin Substitutes for Chronic Wounds | Updated description for code Q4128. Added new HCPCS codes that are covered and not covered. |
CP.MP.127 | Total Artificial Heart | Annual review. Background updated with no impact on criteria. Changed “date” in the revision log header to “revision date.” References reviewed and updated. Specialist review. |
WA.CP.MP.527 | Vitamin D Testing | Returned 0038U to policy. Deleted in error |
WA.CP.MP.50 | Drugs of Abuse: Definitive Testing | Changed title of tables from “CPT Codes That Do Not Support Coverage Criteria” to “CPT Codes That Are Not Covered per the HCA”. Updated ICD-10 codes to include code ranges. References updated. Added CPT 0328U to the list of CPT codes that are not covered by HCA. Updated parenthetic in policy statement II to indicate codes are examples. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.105 | Digital EEG Spike Analysis | Annual review. References reviewed and updated. |
CP.MP.106 | Endometrial ablation | In I.A.2, reworded portion pertaining to abnormal bleeding in transgender members from “female to male transgender person” to “member/enrollee with a female reproductive system undergoing treatment for gender affirmation.” |
CP.MP.113 | Holter Monitors | Annual review completed. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Minor rewording with no clinical significance. Added the following criteria to I.M. “Evaluation of recurrent chronic heart failure, when arrhythmia is suspected” and I.N. “Evaluation of possible arrhythmias post ablation procedures”. References reviewed and updated. Specialist review. |
CP.MP.134 | Evoked Potential Testing | Annual review. References reviewed and updated. Specialist reviewed. |
CP.MP.153 | H. Pylori Serology Testing | Annual review completed. Background updated and minor rewording with no clinical significance. References reviewed and updated. |
CP.MP.154 |
Thyroid Hormones and Insulin Testing in Pediatrics |
Annual review completed. Changed “Date of Last Review” to “Date of Last Revision” in the header. Background updated and minor rewording with no clinical significance. References reviewed and updated. |
CP.MP.155 | EEG in Evaluation of Headache | Annual review. References reviewed and updated. Reviewed by specialist. |
CP.MP.156 | Cardiac Biomarker Testing for Acute MI | Annual review. Background updated with no impact on criteria. References reviewed and updated. |
CP.MP.194 | Osteogenic Stimulation | Annual review completed. Added “electrical” to I. and II. Replaced “smoking habit” with “tobacco use” in criteria I.E.7., II.E.7., and III.B.7. Removed criteria point III.6.c. “The patient has failed more than one surgery and other medical therapies (e.g. immobilization and non-weight bearing status)”. Background updated and minor rewording with no clinical significance. References reviewed and updated. Specialist reviewed. |
CP.MP.203 | Diaphragmatic Phrenic Nerve Stimulation | Updated code G83.89 to G83.9. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
WA.CP.MP.519 | Administrative Days | Added Newborn Administrative Days section and Note regarding request. |
WA.CP.BH.104 | Applied Behavioral Analysis | Addition of treatment range for focused ABA and literature review in introduction. Addition of medical necessity criteria for behavioral assessment. Addition of intensity of services for ABA. Addition of "or appropriate diagnosis as otherwise specified according to state defined ABA criteria" and removal of "clinical professional counselor, marriage and family therapist, addition counselor", addition of "strengths-specific, family-focused, community-based, multisystem, culturally-competent, and least intrusive. And where specific target behaviors are clearly defined; frequency, rate, symptom intensity or duration" in criteria. Section III.D. updated definition. Addition of H, K, L, M in initiation of services criteria. Addition of K, L, M, N in continuation of ABA services criteria. Addition of transition planning section. Updated introduction and research studies including citations to Background. Addition of Screening Recommendations for ASD. Edit of verbiage for caregiver training goals to "Caregiver training is performance based and parent drive. Identifies measurable outcomes for every goal and objective." |
CP.BH.500 | BH Treatment Documentation Requirements | New Policy |
WA.CP.MP.516 | Carotid Artery Stenting | Annual review. References updated. Removed HTA criteria from policy. |
CP.MP.167 | Intradiscal Steroid Injections for Pain Management | Annual Review. Criteria section updated to single spacing. Background updated with no impact on criteria. References reviewed and updated. Specialist reviewed. |
CP.MP.244 |
Liposuction of Lipedema |
New Policy |
CP.MP.170 | Nerve Blocks for Pain Management | Annual review completed. Added “as effectiveness has not been established” to I. C. Background updated. Reworded some extraneous language with no clinical significance. References reviewed and updated. |
CP.MP.206 | Skilled Nursing Facility Leveling | Annual review completed. Added “in the community” and “moderate/maximum/total” to Section I.A.4. and II.A.4. Updated II.C.4. from 3 hours of skilled therapy per day to “at least” 3 hours of skilled therapy per day. Additional minor rewording with no clinical significance. References reviewed and updated. Specialist reviewed. |
CP.BH.100 | Substance Use Treatment and Services | New Policy |
CP.BH.200 | Transcranial Magnetic Stimulation for Treatment Resistant Major Depression | Annual Review. Revisions made to Policy/Criteria Section I. E to reflect the elimination of point 1 completely. The former point 2 and 3, will now be combined as the new point 1. The original point 4 has now changed to become the new point 2. Replaced terminology in Policy/Criteria I: H.5, II: B.5, III: V.5 from “Substance abuse at time of treatment” to “a minimum of 3 month substantiated early remission from substance use disorder” |
CP.MP.169 | Trigger Point Injections for Pain Management | Annual review. References reviewed, updated, and reformatted. Updated criteria in I.B. from 2 additional injections to 4. In I.B.1 added pain relief with functional improvement, in I.B.2. added “≥” 6 weeks, and in I.B.4 added “from initial injection” and changed maximum of 4 total sessions to 6. Specialist review. |
CP.MP.12 | Vagus Nerve Stimulation | Adopted CP.MP.12 to replace WA.CP.MP.12. |
WA.CP.MP.12 | Vagus Nerve Stimulation | Retire |
Policy Number | Policy Title | Revision Notes |
---|---|---|
WA.CP.MP.37 | Bariatric Surgery | Section III: updated abbreviations in III.3 with no clinical significance; added indication for SG to RYGB or BPD-DS DS as a bridging procedure for BMI ≥ 50 kg/m² in III.4. Updated references. |
CP.MP.14 | Cochlear Implant Replacements | Annual review completed. Removed “or” in I.A. and I.B. Background updated with no impact to criteria. References reviewed and updated. |
WA.CP.MP.514 | Extra-Corporeal Membrane Oxygenation | Annual review. References updated. |
CP.MP.137 | Fecal Incontinence Treatments | Annual review completed. In Section I.B. changed “member” to “member/enrollee”. Added “sacral neuromodulation” to Section I.C. Background updated with minor verbiage changes with no clinical significance. Updated description for CPT codes 46760, 46761, 64581, 64590 and HCPCS Code L8683. References reviewed and updated. Specialist reviewed. |
CP.MP.129 | Fetal Surgery in Utero for Prenatally Diagnoses Malformations | Annual review. Description updated with no impact on criteria. Background updated with no impact on criteria. References reviewed and updated. |
CP.MP.243 |
Implantable Loop Recorder (Implantable Cardiac Monitor) |
New Policy |
CP.MP.85 | Neonatal Sepsis Management | Annual review. Description updated. Background updated: Minor rewording for clarity in II.C; added verbiage about procalcitonin in II.G; in III.B, changed 48 hours to 36-48 hours. References reviewed and updated. Reviewed by specialist. |
CP.MP.128 | Optic Nerve Decompression Surgery | Annual review. References reviewed and updated. Specialist review. Background updated with no clinical significance. |
CP.MP.51 | Reduction Mammoplasty and Gynecomastia Surgery | Annual review completed. Changed “women” to “members/enrollees” in I.A.5.c. Added I.B.5. to gigantomastia of pregnancy criteria. Language references in the criteria, description and background sections changed from “male” and/or “female” to “those with a male reproductive system” and/or “those with a female reproductive system.” References reviewed and updated. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
WA.CP.MP.37 |
Bariatric Surgery |
Annual review. Moved note about G9012 into section I. Description updated with no impact on criteria. Criteria I.A. procedures listed with abbreviations with no impact on criteria. Background updated with no impact on criteria. Corrected ICD10 code I10.0 to I10. References reviewed and updated. |
CP.MP.93 | Bone-anchored Hearing Aid | Annual Review. Description updated with no impact on criteria. Criteria I. updated to include abbreviation of BAHA. Criteria III.C. wording updated for clarity. Background updated with no impact on criteria. References reviewed and updated. Removed deleted codes 69715 and 69718. Added new codes 69716, 69719, 69726, and 69727. |
CP.MP.94 | Clinical Trials | Annual review. Criteria I.,II.,III.,IV. updated to remove “and” after semi-colons. Criteria IV.B. “et al” changed to “etc.” Criteria IV.E. #7 abbreviation updated for Department of Energy (DoE). References reviewed and updated. |
CP.MP.115 | Discography | Annual review completed. Description and background updated with no impact to criteria. References reviewed and updated. Specialist reviewed. |
CP.MP.107 | Durable Medical Equipment (DME), Orthotics and Prosthetics Guidelines | Removed cardiac event monitor (E0616) criteria from cardiac equipment section of policy and moved to CP.MP.243 Implantable Loop Recorders. Removed invasive home ventilator criteria (E0465) and moved to CP.MP.184 Home Ventilators. Added statement that current evidence does not support the effectiveness of intrapulmonary percussive ventilation (E1399). |
CP.MP.184 | Home Ventilators | Annual review. Changed policy title from “Noninvasive Home Ventilators” to “Home Ventilators”. Removed (-) before 60 in I.A.1.b. Changed ≥ 45 to > 45 in I.A.1.a.i. Added pediatric criteria in I.A.1.a.ii. Changed I.A.1.b.i to apply to those over age 18 and added “1.A.1.b.ii. “For those < 18 years of age, documentation of Type 1 (hypoxemic) and/or Type 2 (hypercapneic) respiratory failure or inability to maintain airflow”. Replaced “tachypnea (respirations >24)” with “including tachypnea, increased work of breathing, hypoxemia, hypercapnia and/or respiratory acidosis (e.g., pH <7.35)” in I.A.2.c.; I.B.3.c.; I.C.3.c.; and I.D.1.c. Added “Baseline” to all “FIO2 requirement > 0.40”. Moved invasive ventilator criteria from CP.MP.107 DME and placed in criteria IV. Combined invasive and nonivasive backup or second home ventilator into section V. Added HCPCS code E0465. Description and background updated to include information re: invasive ventilators. Reworded some extraneous language with no clinical significance. Changed “Review Date” in the header to “Date of Last Revision” and “Date” in the revision log header to “Revision Date.” References reviewed and updated. Specialist reviewed. |
CP.MP.82 | NICU Apnea Bradycardia Guidelines | Annual review completed. Expanded criteria I.A.3.c. into two criteria points by adding criteria I.A.3.d. Changed “child’s” to “infant’s” in criteria I.B. Removed conditional caffeine criteria I.D. Reworded criteria former criteria I.E, now I.D., for clarity. Moved criteria I.E. and I.F. to notes section. Minor rewording in description, original notes, and background with no clinical significance. References reviewed and updated. Specialist reviewed. |
CP.MP.81 | NICU Discharge Guidelines | Annual Review. Description updated with no impact on criteria. Criteria II.A. updated to include normal axillary and rectal temperature ranges and to include range for normal ambient environment temperature. References reviewed and updated. |
CP.MP.49 | Physical, Occupational and Speech Therapy Services | Annual review completed. References reviewed and updated. Specialist reviewed. |