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
- ABA Therapy (PDF) (CP.BH.104)
- Acupuncture (PDF) (CP.MP.92)
- ADHD Assessment and Treatment (PDF) (CP.MP.124)
- Air Ambulance (PDF) (CP.MP.175)
- Allergy Testing (PDF) (CP.MP.100) Effective Through 2/28/21
- Allergy Testing and Therapy (PDF) (CP.MP.100) Revision Effective 3/1/21
- Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF) (CP.MP.108)
- Ambulatory EEG (PDF) (CP.MP.96)
- Antithrombin III (PDF) (CP.MP.179)
- Applied Behavioral Analysis (PDF) (CP.MP.104)
- Balloon sinus ostial dilation (PDF) (CP.MP.119)
- 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)
- Carrier Screening in Pregnancy (PDF) (CP.MP.83)
- Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF)(CP.MP.164)
- Cell-free Fetal DNA Testing (PDF) (CP.MP.84)
- Clinical Trials (PDF) (CP.MP.94)
- Cochlear Implant Replacement (PDF) (CP.MP.14)
- Cosmetic and Reconstructive Surgery (PDF) (CP.MP.31)
- Dental Anesthesia (PDF) (CP.MP.61)
- Diaphragmatic/Phrenic Nerve Stimulation (PDF) (CP.MP.203) New policy. Effective 5/1/21
- Digital Analysis of EEG (PDF) (CP.MP.105)
- Discography (PDF) (CP.MP.115)
- DNA analysis of stool to screen for colorectal cancer (PDF) (CP.MP.125)
- Donor lymphocyte infusion (PDF) (CP.MP.101)
- Drugs of Abuse: Definitive Testing (PDF) (CP.MP.50)
- Drugs of Abuse: Presumptive Testing (PDF) (CP.MP.208)
- 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)
- Essure Removal (PDF) (CP.MP.131)
- Evoked Potential Testing (PDF) (CP.MP.134)
- Experimental Technologies (PDF) (CP.MP.36)
- Facet Joint Intervention for Pain Management (PDF) (CP.MP.171)
- Fecal incontinence treatments (PDF) (CP.MP.137)
- Fetal surgery in utero for prenatally diagnosed malformations (PDF) (CP.MP.129)
- Fractional exhaled nitric oxide (PDF) (CP.MP.103)
- Gender-Affirming Procedures (PDF) (CP.MP.95)
- Genetic Testing (PDF) (CP.MP.89)
- 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 Phototherapy for Neonatal Hyperbilirubinemia (PDF) (CP.MP.150)
- Home Ventilators (PDF) (CP.MP.184)
- Homocysteine testing (PDF) (CP.MP.121) Effective through 9/30/20
- Hospice Services (PDF) (CP.MP.54)
- Hyperemesis Gravidarum Treatment (PDF) (CP.MP.34)
- Hyperhidrosis Treatments (PDF) (CP.MP.62)
- Implantable Hypoglossal Nerve Stimulation (PDF) (CP.MP.180)
- Implantable Intrathecal Pain Pump (PDF) (CP.MP.173)
- 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)
- Laser therapy for skin conditions (PDF) (CP.MP.123)
- 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)
- Medical Necessity Review (PDF) (WA.UM.02.01)
- 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)
- NICU Apnea Bradycardia Guidelines (PDF) (CP.MP.82)
- NICU Discharge Guidelines (PDF) (CP.MP.81)
- Non-invasive Home Ventilators (PDF) (CP.MP.184)
- Nonmyeloablative allogeneic SCT (PDF) (CP.MP.141)
- Obstetrical Home Health Care Programs (PDF) (CP.MP.91)
- Optic nerve decompression surgery (PDF) (CP.MP.128)
- Outpatient Cardiac Rehabilitation (PDF) (CP.MP.176)
- Outpatient Testing for Drugs of Abuse (PDF) (CP.MP.50)
- Oxygen Use and Concentrators (PDF) (CP.MP.190) Revision Effective 3/1/21
- Pancreas Transplant (PDF) (CP.MP.102)
- Panniculectomy (PDF) (CP.MP.109)
- Pediatric Heart Transplant (PDF) (CP.MP.138)
- Pediatric Liver Transplant (PDF) (CP.MP.120)
- Pediatric Oral Function Therapy (PDF) (CP.MP.188)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) (CP.MP.147)
- PT, OT, ST Services (PDF) (CP.MP.49) Effective through 03/31/21
- Physical, Occupational and Speech Therapy Services (PDF) (CP.MP.49) Revision Effective 04/01/2021
- Posterior tibial nerve stimulation for voiding dysfunction (PDF) (CP.MP.133)
- Proton and Neutron Beam Therapy (PDF) (CP.MP.70)
- Radiofrequency Ablation of Uterine Fibroids (PDF) (CP.MP.187)
- Reduction Mammoplasty and Gynecomastia Surgery (PDF) (CP.MP.51)
- Sacroiliac Joint Interventions for Pain Management (PDF) (CP.MP.166)
- Sclerotherapy for Varicose Veins (PDF) (CP.MP.146)
- Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF) (CP.MP.165)
- Short Inpatient Hospital Stay (PDF) (CP.MP.182)
- Sickle Cell Observation (PDF) (CP.MP.88)
- Skilled Nursing Facility Leveling (PDF) (CP.MP.206)
- Skin Substitutes for Chronic Wounds (PDF) (CP.MP.185)
- SNF Leveling (PDF) (CP.MP.206)
- Stereotactic Body Radiation Therapy (PDF) (CP.MP.22)
- Tandem Transplant (PDF) (CP.MP.162)
- Testing for rupture of fetal membranes (PDF) (CP.MP.149)
- Thymus Transplantation (PDF) (CP.MP.189)
- 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)
- Trigger Point Injections for Pain Management (PDF) (CP.MP.169) Effective Through 12/31/20
- Trigger Point Injections for Pain Management (PDF) (CP.MP.169) Revision Effective 1/1/21
- Ultrasound in Pregnancy (PDF) (CP.MP.38)
- 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)
- Ventriculectomy and Cardiomyoplasty (PDF) (CP.MP.56)
- Video Electroencephalography (V-EEG) (PDF) (WA.CP.MP.177)
- Vitamin D Testing (PDF) (CP.MP.152) Effective through 6/30/21
- Vitamin D Testing (PDF) (WA.CP.MP.527) Effective 7/1/21
- Vitamin D Testing in Children (PDF) (CP.MP.157) Effective through 6/30/21
- 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)
- 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)
- Adefovir (Hepsera) (PDF) (CP.PHAR.142)
- Ado-Trastuzumab Emtansine (Kadcyla) (PDF) (CP.PHAR.229)
- 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 Alfa (Lumizyme) (PDF) (CP.PHAR.160)
- 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)
- Anti-Inhibitor Coagulant Complex (Feiba®) (PDF) (CP.PHAR.217)
- Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) (CP.PHAR.506)
- Apalutamide (Erleada) (PDF) (CP.PHAR.376)
- Apomorphine (Apokyn, Kynmobi) (PDF) (CP.PHAR.488)
- Apremilast (Otezla) (PDF) (CP.PHAR.245)
- 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)
- 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)
- 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 (PDF) (CP.PHAR.88)
- belinostat (Beleodaq®) (PDF) (CP.PHAR.311)
- 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)
- Berotralstat (Orladeyo) (PDF) (CP.PHAR.485)
- Betaine (Cystadane) (PDF) (CP.PHAR.143)
- Betamethasone Dipropionate Spray (Sernivo) (PDF) (CP.PMN.182)
- Bevacizumab (Avastin) (PDF) (CP.PHAR.93)
- Bexarotene (Targretin) (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)
- Brolucizumab-dbll (Beovu) (PDF) (CP.PHAR.445)
- 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)
- 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)
- 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) (HIM.PA.SP59)
- Chloramphenicol Sodium Succinate (PDF) (CP.PHAR.388)
- Cholic Acid (Cholbam) (PDF) (CP.PHAR.390)
- 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 (PDF) (CP.PMN.54)
- CNS Stimulants (PDF) (CP.PMN.92)
- Cobimetinib (Cotellic) (PDF) (CP.PHAR.380)
- Colchicine (Colcrys) (PDF) (CP.PMN.123)
- Colesevelam (Welchol) (PDF) (CP.PMN.250)
- Collagenase (PDF) (CP.PHAR.82)
- Colonoscopy Preparation Products (PDF) (HIM.PA.04)
- Compounded Medications (PDF) (CP.PCH.27)
- Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) (CP.PMN.258)
- Continuous Glucose Monitors (PDF) (CP.PMN.214)
- Continuous Insulin Delivery Systems (V-Go, Omnipod) (PDF) (CP.PHAR.505)
- 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 (Restasis) (PDF) (CP.PMN.48)
- Cyramza® (PDF) (CP.PHAR.119)
- Cysteamine ophthalmic (Cystaran) (PDF) (CP.PMN.130)
- Cysteamine oral (Cystagon, Procysbi) (PDF) (CP.PHAR.155)
- Cytomegalovirus Immune Globulin (Cytogam) (PDF) (CP.PHAR.277)
- Dabrafenib (PDF) (CP.PHAR.239)
- Daclatasvir (Daklinza) (PDF) (HIM.PA.SP27)
- 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)
- 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)
- deferiprone (PDF) (CP.PHAR.147)
- 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)
- Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (PDF) (CP.PHAR.214)
- Deutetrabenazine (Austedo) (PDF) (CP.PHAR.341)
- Dexlansoprazole (Dexilant) (PDF) (HIM.PA.05)
- Dexrazoxane (Zinecard, Totect) (PDF) (CP.PHAR.418)
- 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)
- diclofenac sodium topical gel (Solaraze, Voltaren®) (PDF) (HIM.PA.123)
- 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)
- 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)
- Duvelisib (Copiktra) (PDF) (CP.PHAR.400)
- Ecallantide (Kalbitor®) (PDF) (CP.PHAR.177)
- Eculizumab (Soliris®) (CP.PHAR.97)
- Edaravone (Radicava) (PDF) (CP.PHAR.343)
- Efinaconazole (Jublia) (PDF) (CP.PMN.25)
- Egrifta® (PDF) (CP.PHAR.109)
- Elagolix (Orilissa) (PDF) (CP.PHAR.136)
- Elapegademase-lvlr (Revcovi) (PDF) (CP.PHAR.419)
- Elbasvir/Grazoprevir (Zepatier) (PDF) (HIM.PA.SP62)
- Elexacaftor, tezacaftor (Trikafta) (PDF) (CP.PHAR.440)
- Eliglustat (Cerdelga) (PDF) (CP.PHAR.153)
- Elotuzumab (Empliciti®) (PDF) (CP.PHAR.308)
- Elosulfase alfa (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 (PDF) (CP.PHAR.106)
- Epoetin alfa (Epogen, Procrit), Epoetin alfa-epbx (Retacrit) (PDF) (CP.PHAR.237)
- Epoprostenol (Flolan®, Veletri®) (PDF) (CP.PHAR.192)
- Eptinezumab-jjmr (Vyepti) (PDF) (CP.PCH.29)
- 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)
- Etelcalcetide (Parsabiv) (PDF) (CP.PHAR.379)
- Eteplirsen (Exondys 51) (PDF) (CP.PHAR.288)
- Evolocumab (PDF) (CP.PHAR.123)
- 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)
- Febuxostat (Uloric) (PDF) (CP.PMN.57)
- 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)
- Ferumoxytol (Feraheme®) (PDF) (CP.PHAR.165)
- Filgrastim (PDF) (CP.PHAR.297)
- 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)
- Fostamatinib (Tavalisse) (PDF) (CP.PHAR.24)
- Fremanezumab-vfrm (Ajovy) (PDF) (HIM.PA.SP66)
- Fulvestrant (Faslodex Injection) (PDF) (CP.PHAR.424)
- Gabapentin ER (Gralise, Horizant) (PDF) (CP.PMN.240)
- Galcanezumab-gnlm (Emgality) (PDF) (HIM.PA.SP67)
- Galsulfase (Naglazyme) (PDF) (CP.PHAR.161)
- 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)
- Glecaprevir/Pibrentasvir (Mavyret) (PDF) (HIM.PA.SP36)
- Gleevec (imatinib mesylate) (PDF) (CP.PHAR.65)
- Glucagon-Like Peptide-1 Receptor Agonists (PDF) (HIM.PA.53)
- Glycerol phenylbutyrate (Ravicti®) (PDF) (CP.PHAR.207)
- Glycopyrronium (Qbrexza) (PDF) (CP.PMN.177)
- Golodirsen (Vyondys 53) (PDF) (CP.PHAR.453)
- goserelin acetate (Zoladex®) (PDF) (CP.PHAR.171)
- Granisetron (Kytril, Sancuso, Sustol) (PDF) (CP.PMN.74)
- Halcinonide (Halog) (PDF) (HIM.PA.20)
- Halobetasol Propionate/Tazarotene (Duobrii) (PDF) (CP.PMN.208)
- Hemin (Panhematin®) (PDF) (CP.PHAR.181)
- histrelin acetate (Vantas®, Supprelin LA®) (PDF) (CP.PHAR.172)
- Human Growth Hormone (Somapacitan, Somatropin) (PDF) (CP.PCH.39)
- Hyaluronate Derivatives (PDF) (CP.PHAR.05)
- Hydroxyprogesterone Caproate (Makena/compound) (PDF) (CP.PHAR.14)
- Ibalizumab-uiyk (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)
- Idelalisib (Zydelig) (PDF) (CP.PHAR.133)
- Idursulfase (PDF) (CP.PHAR.156)
- Iloperidone (Fanapt) (PDF) (CP.PMN.32)
- Iloprost (Ventavis®) (PDF) (CP.PHAR.193)
- Imiglucerase (Cerezyme) (PDF) (CP.PHAR.154)
- Immune Globulins (PDF) (CP.PHAR.103)
- 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)
- Inotersen (Tegsedi) (PDF) (CP.PHAR.405)
- inotuzumab ozogamicin (Besponsa®) (PDF) (CP.PHAR.359)
- Insulin Degludec (Tresiba) (PDF) (HIM.PA.09)
- Interferon beta-1a (Avonex, Rebif) (PDF) (CP.PHAR.256)
- Interferon Beta-1a (Avonex, Rebif) (PDF) (CP.PHAR.255)
- 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)
- Ivosidenib (Tibsovo) (PDF) (CP.PHAR.137)
- Ixazomib (PDF) (CP.PHAR.302)
- Korlym (mifepristone) (PDF) (CP.PHAR.101)
- Kuvan (PDF) (CP.PHAR.43)
- Lacosamide (Vimpat) (PDF) (CP.PMN.155)
- Lactic Acid/Citric Acid/Potassium Bitartrate (Phexxi) (PDF) (CP.PMN.251)
- Lactitol (Pizensy) (PDF) (CP.PMN.241)
- 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)
- Latanoprostene Bunod (Vyzulta) (PDF) (CP.PMN.108)
- Ledipasvir/Sofosbuvir (Harvoni) (PDF) (HIM.PA.SP3)
- Lefamulin (Xenleta) (PDF) (CP.PMN.219)
- Lemborexant (Dayvigo) (PDF) (CP.PMN.233)
- Lenvatinib (Lenvima) (PDF) (CP.PHAR.138)
- Lesinurad (Zurampic), Lesinurad/Allopurinol (Duzallo) (PDF) (CP.PMN.150)
- Letermovir (Prevymis) (PDF) (CP.PHAR.367)
- levoleucovorin (Fusilev) (PDF) (CP.PHAR.151)
- Levomilnacipran (Fetzima) (PDF) (HIM.PA.125)
- Leucovorin Injection (PDF) (CP.PHAR.393)
- leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (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)
- Lofexidine (Lucemyra) (PDF) (CP.PMN.152)
- Lomustine (Gleostine) (PDF) (CP.PHAR.507)
- Lonafarnib (Zokinvy) (PDF) (CP.PHAR.499)
- Lorcaserin (Belviq®, Belviq XR) (PDF) (CP.PCH.03)
- 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 Dotatate (Lutathera) (PDF) (CP.PHAR.384)
- Macitentan (Opsumit®) (PDF) (CP.PCH.31)
- Mannitol (Bronchitol) (PDF) (CP.PHAR.518)
- Margetuximab-cmkb (Margenza) (PDF) (CP.PHAR.522)
- 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)
- Memantine ER (Namenda XR), Memantine/Donepezil (Namzaric) (PDF) (CP.PCH.30)
- Mepolizumab (Nucala) (PDF) (CP.PHAR.200)
- 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) (PDF) (CP.PMN.80)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF) (CP.PHAR.495)
- Mitoxantrone (Novantrone) (PDF) (CP.PHAR.258)
- 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)
- Monomethyl Fumarate (Bafiertam) (PDF) (CP.PHAR.460)
- Montelukast oral granules (Singulair) (PDF) (HIM.PA.129)
- Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) (CP.PHAR.398)
- Nadofaragene Firadenovec (Instiladrin) (PDF) (CP.PHAR.461)
- nafarelin acetate (Synarel®) (PDF) (CP.PHAR.174)
- Naltrexone (Vivitrol®) (PDF) (CP.PHAR.96)
- Naproxen/Esomeprazole (Vimovo) (PDF) (CP.PMN.117)
- Naproxen oral suspension (Naprosyn) (PDF) (HIM.PA.130)
- Natalizumab (Tysabri) (PDF) (HIM.PA.SP17)
- Naxitamab-gqgk (Danyelza) (PDF) (CP.PHAR.523)
- Nebivolol (Bystolic) (PDF) (HIM.PA.131)
- necitumumab (Portrazza®) (PDF) (CP.PHAR.320)
- Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF) (CP.PMN.167)
- Neratinib (Nerlynx) (PDF) (CP.PHAR.365)
- Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan) (PDF) (CP.PMN.118)
- 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)
- Nitisinone (Nityr, Orfadin) (PDF) (CP.PHAR.132)
- Nivolumab (PDF) (CP.PHAR.121)
- No Coverage Criteria (PDF) (CP.PMN.255)
- No Coverage Criteria/Off-Label Use Policy (PDF) (CP.PMN.53)
- 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)
- ofatumumab (Arzerra®) (PDF) (CP.PHAR.306)
- Off-Label Drug Use (PDF) (HIM.PA.154)
- Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) (CP.PHAR.292)
- Olaparib (Lynparza) (PDF) (CP.PHAR.360)
- olaratumab (Lartruvo®) (PDF) (CP.PHAR.326)
- Omacetaxine (Synribo) (PDF) (CP.PHAR.108)
- Omadacycline (Nuzyra) (PDF) (CP.PMN.188)
- omalizumab (PDF) (CP.PHAR.01)
- Omega-3-Acid Ethyl Esters (Lovaza) (PDF) (CP.PMN.52)
- OnabotulinumtoxinA (Botox) (PDF) (CP.PHAR.232)
- Onasemnogene abeparvovec (Zolgensma) (PDF) (CP.PHAR.421)
- Ondansetron (Zuplenz) (PDF) (CP.PMN.45)
- Opioid Analgesics (PDF) (HIM.PA.139)
- Ophthalmic Corticosteroids (PDF) (HIM.PA.03)
- 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)
- Palbociclib (Ibrance) (PDF) (CP.PHAR.125)
- Paliperidone Long-Acting Injections (Invega Sustenna, Invega Trinza) (PDF) (CP.PHAR.291)
- 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)
- Patisiran (Onpattro) (PDF) (CP.PHAR.395)
- Pazopanib (PDF) (CP.PHAR.81)
- Peanut Allergen Powder-dnfp (Palforzia) (PDF) (CP.PMN.220)
- Pegademase Bovine (Adagen) (PDF) (CP.PHAR.392)
- Pegaptanib (Macugen) (PDF) (CP.PHAR.185)
- pegaspargase (Oncaspar®) (PDF) (CP.PHAR.353)
- Pegfilgrastim (PDF) (CP.PHAR.296)
- peginterferon beta-1a (Plegridy) (PDF) (CP.PHAR.271)
- Pegloticase (Krystexxa®) (PDF) (CP.PHAR.115)
- 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)
- Pertuzumab (Perjeta) (PDF) (CP.PHAR.227)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (PDF) (CP.PHAR.501)
- Pexidartinib (Turalio) (PDF) (CP.PHAR.436)
- Phendimetrazine IR (Bontril PDM) (PDF) (HIM.PA.114)
- Phentermine (Adipex-P, Lomaira) (PDF) (CP.PCH.13)
- Pimavanserin (Nuplazid) (PDF) (CP.PMN.140)
- Pirfenidone (Esbriet) (PDF) (CP.PHAR.286)
- Pitolisant (Wakix) (PDF) (CP.PMN.221)
- Plecanatide (Trulance) (PDF) (CP.PMN.87)
- Plerixafor (PDF) (CP.PHAR.323)
- Polatuzumab Vedotin-piiq (Polivy) (PDF) (CP.PHAR.433)
- Pomalyst (PDF) (CP.PHAR.116)
- Ponatinib (Iclusig) (PDF) (CP.PHAR.112)
- Potassium (Klor-Con) (PDF) (HIM.PA.143)
- pralatrexate (Folotyn®) (PDF) (CP.PHAR.313)
- Pralsetinib (Gavreto) (PDF) (CP.PHAR.514)
- 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) (CP.PMN.194)
- pyrimethamine (Daraprim®) (PDF) (CP.PMN.44)
- Quetiapine ER (Seroquel XR) (PDF) (CP.PMN.64)
- Quinine Sulfate (Qualaquin) (PDF) (CP.PCH.10)
- 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)
- Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) (CP.PHAR.168)
- Reslizumab (Cinqair) (PDF) (CP.PHAR.223)
- 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), Rifabutin/Omeprazole/Amoxicillin (Talicia) (PDF) (CP.PMN.223)
- Rifamycin (Aemcolo) (PDF) (CP.PMN.196)
- Rilonacept (Arcalyst) (PDF) (CP.PHAR.266)
- RimabotulinumtoxinB (Myobloc) (PDF) (CP.PHAR.233)
- 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), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) (PDF) (CP.PHAR.260)
- 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)
- 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)
- 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 (LOXO-292) (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)
- Siponimod (Mayzent) (PDF) (CP.PHAR.427)
- Sipuleucel-T (Provenge) (PDF) (CP.PHAR.120)
- Siltuximab (Sylvant®) (PDF) (CP.PHAR.329)
- Sodium-Glucose Co-Transporter 2 Inhibitors (PDF) (HIM.PA.91)
- Sodium Oxybate (Xyrem) (PDF) (CP.PMN.42)
- Sodium Phenylbutyrate (Buphenyl) (PDF) (CP.PHAR.208)
- 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)
- Soliris (eculizumab) (PDF) (CP.PHAR.97)
- Solriamfetol (Sunosi) (PDF) (CP.PMN.209)
- Sonidegib (Odomzo) (PDF) (CP.PHAR.272)
- Sorafenib (Nexavar) (PDF) (CP.PHAR.69)
- Spinosad (Natroba) (PDF) (HIM.PA.134)
- Step Therapy (PDF) (HIM.PA.109)
- Stiripentol (Diacomit) (PDF) (CP.PMN.184)
- sucroferric oxyhydoxide (Velphoro) (PDF) (HIM.PA.SP30)
- sunitinib (Sutent) (PDF) (CP.PHAR.73)
- Suvorexant (Belsomra®) (PDF) (CP.PMN.109)
- Sylatron (peginterferon alfa-2b) (PDF) (CP.PHAR.89)
- Synagis_palivizumab (PDF) (CP.PHAR.16)
- 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)
- 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)
- Tedizolid (Sivextro) (PDF) (CP.PMN.62)
- Teduglutide (Gattex) (PDF) (CP.PHAR.114)
- Telotristat Ethyl (Xermelo) (PDF) (CP.PHAR.337)
- Temodar (PDF) (CP.PHAR.77)
- temsirolimus (Torisel®) (PDF) (CP.PHAR.324)
- Tenofovir Alafenamide Fumarate (Vemlidy) (PDF) (CP.PCH.33)
- Tenapanor (Ibsrela) (PDF) (CP.PMN.224)
- Teprotumumab (Tepezza) (PDF) (CP.PHAR.465)
- Teriparatide (Forteo®) (PDF) (CP.PHAR.188)
- Tesamorelin (PDF) (CP.PHAR.109)
- Testosterone (Testopel, Jatenzo) (PDF) (CP.PHAR.354)
- Thalomid (PDF) (CP.PHAR.78)
- Thioguanine (Tabloid) (PDF) (CP.PHAR.437)
- Thyrotropin alfa (PDF) (CP.PHAR.95)
- Teriflunomide (Aubagio) (PDF) (CP.PCH.40)
- Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF) (CP.PHAR.377)
- Timothy Grass Pollen Allergen Extract (Grastek) (PDF) (CP.PMN.84)
- Tisagenlecleucel (PDF) (CP.PHAR.361)
- Tobramycin (Bethkis®, Kitabis Pak®, TOBI®, TOBI Podhaler®) (PDF) (CP.PHAR.211)
- 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)
- Topotecan (Hycamtin) (PDF) (CP.PHAR.64)
- Trabectedin (Yondelis®) (PDF) (CP.PHAR.204)
- Trametinib (PDF) (CP.PHAR.240)
- Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF) (CP.PHAR.228)
- 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)
- Tucatinib (Tukysa) (PDF) (CP.PHAR.497)
- Ubrogepant (Ubrelvy) (PDF) (CP.PHAR.476)
- Uridine acetate (Vistogard) (PDF) (HIM.PA.SP55)
- Valbenazine (Ingrezza) (PDF) (CP.PHAR.340)
- valganciclovir (Valcyte) (PDF) (CP.PCH.06)
- Valproate Sodium for Intravenous Injection (Depacon) (PDF) (CP.PHAR.429)
- Valrubicin (Valstar) (PDF) (CP.PHAR.439)
- Vandetanib (Caprelsa®) (PDF) (CP.PHAR.80)
- Velaglucerase Alfa (VPRIV) (PDF) (CP.PHAR.163)
- 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)
- Viltolarsen (Viltepso) (PDF) (CP.PHAR.484)
- vincristine sulfate liposome injection (Marqibo®) (PDF) (CP.PHAR.315)
- Vismodegib (Erivedge) (PDF) (CP.PHAR.273)
- 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)
- Voxelotor (Oxbryta) (PDF) (CP.PHAR.451)
- Xenazine (tetrabenazine) (PDF) (CP.PHAR.92)
- Xgeva (PDF) (CP.PHAR.58)
- Xiaflex™ (PDF) (CP.PHAR.82)
- Xolair® (PDF) (CP.PHAR.01)
- Zanubrutinib (Brukinsa) (PDF) (CP.PHAR.467)
- ziv-aflibercept (Zaltrap®) (PDF) (CP.PHAR.325)
- Zometa (PDF) (CP.PHAR.59)
Medicaid Clinical Policies Listing
- ABA Therapy (PDF) (WA.CP.BH.104)
- ADHD Assessment and Treatment (PDF) (CP.MP.124)
- Administrative Days (PDF) (WA.CP.MP.519)
- Allergy Testing (PDF) (CP.MP.100) Effective Through 2/28/21
- Allergy Testing and Therapy (PDF) (CP.MP.100) Revision Effective 3/1/21
- Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF) (CP.MP.108)
- Alpha1-Proteinase Inhibitors (PDF) (CP.PHAR.94)
- Antithrombin III (PDF) (CP.MP.179)
- Applied Behavioral Analysis (PDF) (WA.CP.MP.104)
- Balloon Sinus Ostial Dilation (PDF) (WA.CP.MP.119)
- Bariatric Surgery (PDF) (WA.CP.MP.37)
- Behavioral Health Personal Care Services (PDF) (WA.CP.MP.521)
- Bone-anchored Hearing Aid (PDF) (CP.MP.93)
- Bone Growth Stimulator (PDF) (WA.CP.MP.508)
- 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)
- Carrier Screening in Pregnancy (PDF) (CP.MP.83)
- Catheter Ablation for SVTA (PDF) (WA.CP.MP.525)
- Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF) (CP.MP.164)
- Cell-free Fetal DNA Testing (PDF) (WA.CP.MP.84)
- Clinical Trials (PDF) (CP.MP.94)
- Cochlear Implant Replacement (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)
- Dental Anesthesia (PDF) (CP.MP.61)
- Diaphragmatic/Phrenic Nerve Stimulation (PDF) (CP.MP.203) New policy. Effective 5/1/21
- Digital Analysis of EEG (PDF) (CP.MP.105)
- Discography (PDF) (WA.CP.MP.115)
- Donor Lymphocyte Infusion (PDF) (CP.MP.101)
- Drugs of Abuse: Definitive Testing (PDF) (WA.CP.MP.50)
- Drugs of Abuse: Presumptive Testing (PDF) (WA.CP.MP.208)
- Durable Medical Equipment (DME) (PDF) (CP.MP.107)
- 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)
- Extra-Corporeal Membrane Oxygenation Therapy (PDF) (WA.CP.MP.514)
- Facet Joint Intervention for Pain Management (PDF) (WA.CP.MP.171)
- Fecal Microbiota Transplantation (PDF) (WA.CP.MP.515)
- FeNo Testing (PDF) (CP.MP.103)
- Fertility Preservation (PDF) (WA.CP.MP.130)
- Gastric Electrical Stimulation (PDF) (CP.MP.40)
- Gene Expression Profile Testing (PDF) (WA.CP.MP.511)
- Genetic Testing (PDF) (CP.MP.89)
- Genomic Microarray Testing (PDF) (WA.CP.MP.512)
- H. Pylori serology testing (PDF) (CP.MP.153)
- Heart-Lung Transplant (PDF) (CP.MP.132)
- Holter Monitors (PDF) (CP.MP.113)
- Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) (CP.MP.150)
- Home Ventilators (PDF) (CP.MP.184)
- Homocysteine testing (PDF) (CP.MP.121)
- Homocysteine testing (PDF) (CP.MP.121) Effective 10/1/20
- Hospice Services (PDF) (WA.CP.MP.54)
- Hyperbaric Oxygen Therapy (PDF) (WA.CP.MP.27)
- Hyperemesis Gravidarum Treatment (PDF) (CP.MP.34)
- Hyperhidrosis Treatments (PDF) (CP.MP.62)
- Implantable Hypoglossal Nerve Stimulation (PDF) (CP.MP.180)
- Implantable Intrathecal Pain Pump (PDF) (CP.MP.173)
- Inhaled Nitric Oxide (PDF) (CP.MP.87)
- Intensity-Modulated Radiotherapy (IMRT) (PDF) (WA.CP.MP.69)
- Intestinal and Multivisceral Transplant (PDF) (CP.MP.58)
- Laser therapy for skin conditions (PDF) (CP.MP.123)
- Lung Transplantation (PDF) (CP.MP.57)
- Lysis of Epidural Lesions (PDF) (CP.MP.116)
- Mandibular Advancement Devices (PDF) (WA.CP.MP.500)
- Medical Necessity Review (PDF) (WA.UM.02.01)
- Micro-Processor Controlled Prosthetics (PDF) (WA.CP.MP.505)
- Monitored Anesthesia Care for Gastroinestinal Endoscopy (PDF) (CP.MP.161)
- 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)
- Neonatal Sepsis Management Guidelines (PDF) (CP.MP.85)
- NICU Apnea Bradycardia Guidelines (PDF) (CP.MP.82)
- NICU Discharge Guidelines (PDF) (CP.MP.81)
- Non-invasive Home Ventilators (PDF) (CP.MP.184)
- Nonmyeloablative allogeneic SCT (PDF) (CP.MP.141)
- Obstructive Sleep Apnea Diagnosis and Treatment (PDF) (WA.CP.MP.523)
- Oral Enteral Nutrition (PDF) (WA.CP.MP.507)
- Output Testing for Drugs of Abuse (PDF) (WA.CP.MP.50)
- Pancreas Transplant (PDF) (CP.MP.102)
- Panniculectomy (PDF) (CP.MP.109)
- Pediatric Heart Transplant (PDF) (CP.MP.138)
- Pediatric Liver Transplant (PDF) (CP.MP.120)
- Pediatric Oral Function Therapy (PDF) (CP.MP.188)
- Personal Care Services (PDF) (WA.CP.MP.521)
- Physical, Occupational and Speech Therapy Services (PDF) (CP.MP.49) Effective Through 3/31/21
- Physical, Occupational and Speech Therapy Services (PDF) (CP.MP.49) Revision Effective 4/01/21
- Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) (CP.MP.181) Effective 1/1/21
- PT, OT, ST Services (PDF) (CP.MP.49)
- Private Duty Nursing Services (PDF) (WA.CP.MP.503)
- Proton and Neutron Beam Therapies (PDF) (WA.CP.MP.70)
- Psychological Testing (PDF) (WA.CP.MP.506)
- Reduction Mammoplasty and Gynecomastia Surgery (PDF) (CP.MP.51)
- Sacroiliac Joint Interventions for Pain Management (PDF) (CP.MP.166)
- Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF) (CP.MP.165)
- Short Inpatient Hospital Stay (PDF) (CP.MP.182)
- Sickle Cell Observation (PDF) (CP.MP.88)
- Skilled Nursing Facility Leveling (PDF) (CP.MP.206)
- Skin Substitutes for Chronic Wounds (PDF) (WA.CP.MP.185)
- Sleep Apnea Diagnosis and Treatment (PDF) (WA.CP.MP.523)
- SNF Leveling (PDF) (CP.MP.206)
- Stem Cell Therapy for Musculoskeletal Conditions (PDF) (WA.CP.MP.526)
- Stereotactic Body Radiation Therapy (PDF) (CP.MP.22)
- Tandem Transplant (PDF) (CP.MP.162)
- Testosterone Testing (PDF) (WA.CP.MP.517)
- Thymus Transplantation (PDF) (CP.MP.189) Effective 11/1/20
- Thyroid hormones and insulin testing in pediatrics (PDF) (CP.MP.154)
- Tinnitus Treatment (PDF) (WA.CP.MP.510)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) (CP.MP.163)
- Transcranial Magnetic Stimulation (PDF) (CP.MP.172)
- Trigger Point Injections for Pain Management (PDF) (CP.MP.169) Revision Effective 1/1/21
- 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) (WA.CP.MP.12)
- Varicose Vein Treatment (PDF) (WA.CP.MP.522)
- Ventricular Assist Devices (PDF) (WA.CP.MP.46)
- Ventriculectomy and Cardiomyoplasty (PDF) (CP.MP.56)
- Video Electroencephalography (V-EEG) (PDF) (WA.CP.MP.177)
- Vitamin D Testing (PDF) (CP.MP.152) Effective through 6/30/21
- Vitamin D Testing (PDF) (WA.CP.MP.527) Effective 7/1/21
- Vitamin D Testing in Children (PDF) (CP.MP.157) Effective through 6/30/21
- Whole Exome Sequencing (PDF) (WA.CP.MP.524) Revision Effective 3/1/21
Medicaid Pharmacy Policies Listing
- 30 Day Emergency Supply of Medication (PDF) (WA.PHAR.01)
- Abametapir (Xeglyze) (PDF) (CP.PMN.253)
- Abemaciclib (PDF) (CP.PHAR.355)
- AbobotulinumtoxinA (PDF) (CP.PHAR.230)
- Abiraterone (Zytiga) (PDF) (CP.PHAR.84)
- 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)
- Adalimumab (Humira), Adalimumab-atto (Amjevita) (PDF) (CP.PHAR.242)
- Adefovir (Hepsera) (PDF) (CP.PHAR.142)
- Ado-Trastuzumab Emtansine (PDF) (CP.PHAR.229)
- Afamelanotide (Scenesse) (PDF) (CP.PHAR.444)
- Aflibercept (Eylea) (PDF) (CP.PHAR.184)
- Agalsidase Beta (PDF) (CP.PHAR.158)
- Age Limit for Topical Tretinoin (PDF) (CP.PMN.191)
- Agents For Gauchers Disease (PDF) (WA.PHAR.26)
- Agents for Sickle Cell Anemia L-glutamine (ENDARI) (PDF) (WA.PHAR.59)
- Alemtuzumab (PDF) (CP.PHAR.243)
- Alglucosidase Alfa (PDF) (CP.PHAR.160)
- Allergenic Extracts (Oral) (PDF) (WA.PHAR.27)
- Alpelisib (Piqray) (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)
- Amlodipine/Atorvastatin (Caduet) (PDF) (CP.PMN.176)
- Amondys 45 (casimersen) (PDF) (WA.PHAR.110)
- Analgesics Opioid Agonists (PDF) (WA.PHAR.23)
- Androgenic Agents-Testosterone Replacement Therapy (TRT) (PDF) (WA.PHAR.28)
- 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)
- Anticonvulsants-Pregabalin (Lyrica) (PDF) (WA.PHAR.56)
- Antidiabetics-Amylin Analogs (PDF) (WA.PHAR.33)
- Antidiabetics-Inhaled Insulin (Afrezza) (PDF) (WA.PHAR.34)
- Antihyperlipidemics-APOB Synthesis Inhibitors (Kynamro) (PDF) (WA.PHAR.37)
- Antihyperlipidemics-Apolipoprotein B Synthesis Inhibitors lomitapide mesylate (PDF) (WA.PHAR.38)
- Antihyperlipidemics-PCSK9 Inhibitors (PDF) (WA.PHAR.39)
- Antihyperuricemic Agents (PDF) (WA.PHAR.40)
- Antifungal Topical Solutions (PDF) (WA.PHAR.36)
- 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)
- Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) (CP.PHAR.506)
- Antivirals Hepatitis C Agents (PDF) (WA.PHAR.95)
- Antivirals-HIV Combinations (PDF) (WA.PHAR.97)
- Antivirals HIV-emtricitabinetenofovir alafenamide (Descovy) (PDF) (WA.PHAR.98)
- Apalutamide (PDF) (CP.PHAR.376)
- Apomorphine (Apokyn, Kynmobi) (PDF) (CP.PHAR.488)
- Aprepitant (PDF) (CP.PMN.19)
- aripiprazole long-acting injections (PDF) (CP.PHAR.290)
- Armodafinil (PDF) (CP.PMN.35)
- Asenapine (PDF) (CP.PMN.15)
- asfotase alfa (PDF) (CP.PHAR.328)
- Aspirin-dipyridamole (PDF) (CP.PMN.20)
- Atezolizumab (Tecentriq) (PDF) (CP.PHAR.235)
- Atopic Dermatitis Agents-Monoclonal Antibodies (PDF) (WA.PHAR.41)
- Atopic Dermatitis Agents-Topical Immunosuppressives (PDF) (WA.PHAR.42)
- Atopic Dermatitis Agents-Topical Phosphodiesterase-4 (PDE4) Inhibitors (PDF) (WA.PHAR.43)
- Avelumab (Bavencio) (PDF) (CP.PHAR.333)
- Azacitidine (Vidaza) (PDF) (CP.PHAR.387)
- Baloxavir Marboxil (Xofluza) (PDF) (CP.PMN.185)
- Becaplermin (Regranex) (PDF) (CP.PMN.21)
- Bedaquiline (Sirturo) (PDF) (CP.PMN.212)
- Belantamab Mafodotin (Blenrep) (PDF) (CP.PHAR.469)
- Belatacept (Nulojix) (PDF) (CP.PHAR.201)
- Belimumab (PDF) (CP.PHAR.88)
- belinostat (PDF) (CP.PHAR.311)
- 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)
- Berotralstat (Orladeyo) (PDF) (CP.PHAR.485)
- Betaine (Cystadane) (PDF) (CP.PHAR.143)
- Betamethasone Dipropionate Spray (Sernivo) (PDF) (CP.PMN.182)
- Bevacizumab (Avastin) (PDF) (CP.PHAR.93)
- Bexarotene (Targretin) (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)
- Brigatinib (PDF) (CP.PHAR.342)
- Brimonidine Tartrate (Mirvaso) (PDF) (CP.PMN.192)
- Brolucizumab-dbll (Beovu) (PDF) (CP.PHAR.445)
- Budesonide/Glycopyrrolate/Formoterol Fumarate (Breztri Aerosphere) (PDF) (CP.PMN.254)
- Buprenorphine Implant/Injection (Probuphine, Sublocade) (PDF) (CP.PHAR.289)
- (MAT) Buprenorphine Products (PDF) (WA.PHAR.62)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda) (PDF) (CP.PHAR.202)
- cabazitaxel (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)
- Caplacizumab-yhdp (Cablivi) (PDF) (CP.PHAR.416)
- Carbamazepine ER (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 (PDF) (CP.PMN.122)
- Cemiplimab-rwlc (Libtayo) (PDF) (CP.PHAR.397)
- Cenegermin-bkbj (Oxervate) (PDF) (CP.PMN.186)
- Cenobamate (Xcopri) (PDF) (CP.PMN.231)
- cetuximab (PDF) (CP.PHAR.317)
- Chenodiol (Chenodal) (PDF) (CP.PMN.239)
- 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)
- Continuous Insulin Delivery Systems (V-Go, Omnipod) (PDF) (CP.PHAR.505)
- 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 ophthalmic emulsion (PDF) (CP.PMN.48)
- Cysteamine (Cystagon-Procysbi) Policy (PDF) (WA.PHAR.21)
- Cysteamine Ophthalmic (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 (PDF) (CP.PMN.49)
- Dabrafenib (PDF) (CP.PHAR.239)
- Dalteparin (PDF) (CP.PHAR.225)
- 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)
- Desmopressin (DDAVP, Stimate) (PDF) (CP.PHAR.214)
- Dexrazoxane (Zinecard, Totect) (PDF) (CP.PHAR.418)
- 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)
- Dimethyl fumarate (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)
- Dose optimization (PDF) (CP.PMN.13)
- Doxepin (Silenor) (PDF) (CP.PMN.175)
- Doxycycline Hyclate (PDF) (CP.PMN.79)
- Droxidopa (Northera) (PDF) (CP.PMN.17)
- Duplicate SSRI SNRI Therapy (PDF) (CP.PMN.60)
- Durvalumab (PDF) (CP.PHAR.339)
- Dutasteride (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)
- Ecallantide (Kalbitor) (PDF) (CP.PHAR.177)
- Eculizumab (Soliris) (PDF) (CP.PHAR.97)
- Edoxaban (Savaysa) (PDF) (CP.PMN.227)
- Elagolix (Orilissa) (PDF) (CP.PHAR.136)
- Elexacaftor, tezacaftor (Trikafta) (PDF) (CP.PHAR.440)
- Elosulfase Alfa (PDF) (CP.PHAR.162)
- Elotuzumab (Empliciti) (PDF) (CP.PHAR.308)
- Emtricitabine/Tenofovir Alafenamide (Descovy) (PDF) (CP.PMN.235)
- enasidenib (PDF) (CP.PHAR.363)
- Encorafenib (Braftovi) (PDF) (CP.PHAR.127)
- Endocrine and Metabolic Agents (Revcovi) (PDF) (WA.PHAR.75)
- Endocrine and Metabolic Agents Metabolic Modifiers- Phenylketonuria (PKU) Agents (PDF) (WA.PHAR.78)
- Endocrine and Metabolic Agents PKU Agents (Palynziq) (PDF) (WA.PHAR.77)
- Endocrine and Metabolic Agents X-Linked Hypophosphatemia Agents (Crysvita) (PDF) (WA.PHAR.107)
- Enfortumab Vedotin-ejfv (Padcev) (PDF) (CP.PHAR.455)
- Endocrine And Metabolic Agents Tripeptidyl Peptidase 1 Deficiency Agents (Brineura) (PDF) (WA.PHAR.84)
- Enfuvirtide (PDF) (CP.PHAR.41)
- Enoxaparin (PDF) (CP.PHAR.224)
- Entrectinib (Rozlytrek) (PDF) (CP.PHAR.441)
- Enzalutamide (PDF) (CP.PHAR.106)
- Epinephrine (EpiPen and EpiPen Jr) Quanity Limit Override (PDF) (CP.PMN.144)
- Epoprostenol (Flolan, Veletri) (PDF) (CP.PHAR.192)
- Eptinezumab-jjmr (Vyepti) (PDF) (CP.PHAR.489)
- 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)
- 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)
- Fedratinib (Inrebic) (PDF) (CP.PHAR.442)
- Fenfluramine (Fintepla) (PDF) (CP.PMN.246)
- Fentanyl IR (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)
- Ferumoxytol (Feraheme) (PDF) (CP.PHAR.165)
- Fingolimod (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)
- Gabapentin ER (Gralise, Horizant) (PDF) (CP.PMN.240)
- Galsulfase (PDF) (CP.PHAR.161)
- gemtuzumab ozogamicin (PDF) (CP.PHAR.358)
- Glasdegib (Daurismo) (PDF) (CP.PHAR.413)
- Glatiramer Acetate (PDF) (CP.PHAR.252)
- Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF) (CP.PMN.183)
- Glycerol phenylbutyrate (Ravicti) (PDF) (CP.PHAR.207)
- Glycopyrronium (Qbrexza) (PDF) (CP.PMN.177)
- goserelin acetate (PDF) (CP.PHAR.171)
- 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)
- Hematological Agents - Misc Aminolevulinate Synthase 1-Directed Sirna (Givlaari) (PDF)(WA.PHAR.87)
- Hematological Agents - Misc Antihemophilic Products (PDF) (WA.PHAR.94)
- Hematopoietic Agents Erythroid Maturation Agents (Reblozyl) (PDF) (WA.PHAR.90)
- Hematopoietic Agents Erythropoiesis-Stimulating Agents (ESAs) (PDF) (WA.PHAR.71)
- Hematopoietic Agents Granulocyte Colony Stimulating Factors (G-CSF) (PDF) (WA.PHAR.72)
- Hematopoietic Agents- Sickle Cell Anemia (Adakveo) (PDF) (WA.PHAR.82)
- Hematopoietic Agents Thrombopoieses (TPO) Stimulating Proteins (PDF) (WA.PHAR.73)
- Hemin (Panhematin) (PDF) (CP.PHAR.181)
- Histrelin Acetate (PDF) (CP.PHAR.172)
- Hormone Therapy for Gender Dysphoria (PDF) (WA.PHAR.104)
- Hyaluronate Derivatives (PDF) (CP.PHAR.05)
- Hydroxyurea (Siklos) (PDF) (CP.PMN.193)
- Ibalizumab-uiyk (PDF) (CP.PHAR.378)
- Ibrance (palbociclib) (PDF) (CP.PHAR.125)
- Ibuprofen and Famotidine (Duexis) (PDF) (CP.PMN.120)
- Icatibant (Firazyr) (PDF) (CP.PHAR.178)
- Icosapent ethyl (Vascepa) (PDF) (CP.PMN.187)
- Idelalisib (Zydelig) (PDF) (CP.PHAR.133)
- Idursulfase (PDF) (CP.PHAR.156)
- Iloperidone (Fanapt) (PDF) (CP.PMN.32)
- Immune Globulins (PDF) (CP.PHAR.103)
- Immunization coverage (PDF) (CP.PHAR.28)
- Immunosuppressive Agents (Gamifant) (PDF) (WA.PHAR.76)
- IncobotulinumtoxinA (PDF) (CP.PHAR.231)
- Inebilizumab-cdon (Uplizna) (PDF) (CP.PHAR.458)
- Inhaled Agents for Asthma and COPD (PDF) (CP.PMN.259)
- inotuzumab ozogamicin (PDF) (CP.PHAR.359)
- Interferon Beta-1a (PDF) (CP.PHAR.255)
- Interferon Beta-1b (PDF) (CP.PHAR.256)
- 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 (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)
- Ivosidenib (Tibsovo) (PDF) (CP.PHAR.137)
- Ixazomib (PDF) (CP.PHAR.302)
- Jakafi™ (ruxolitinib) (PDF) (CP.PHAR.98)
- Korlym (mifepristone) (PDF) (CP.PHAR.101)
- Lacosamide (Vimpat) (PDF) (CP.PMN.155)
- Lactic Acid/Citric Acid/Potassium Bitartrate (Phexxi) (PDF) (CP.PMN.251)
- Lactitol (Pizensy) (PDF) (CP.PMN.241)
- Lanadelumab-fylo (Takhzyro) (PDF) (CP.PHAR.396)
- Lanreotide (Somatuline Depot) (PDF) (CP.PHAR.391)
- Laronidase (PDF) (CP.PHAR.152)
- Larotrectinib (Vitrakvi) (PDF) (CP.PHAR.414)
- Lasmiditan (Reyvow) (PDF) (CP.PMN.218)
- Latanoprostene Bunod (Vyzulta) (PDF) (CP.PMN.108)
- Lefamulin (Xenleta) (PDF) (CP.PMN.219)
- Lemborexant (Dayvigo) (PDF) (CP.PMN.233)
- Letermovir (PDF) (CP.PHAR.367)
- Leucovorin Injection (PDF) (CP.PHAR.393)
- Leuprolide Acetate (PDF) (CP.PHAR.173)
- 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)
- Lisdexamfetamine (Vyvanse) (PDF) (CP.PMN.121)
- Lofexidine (Lucemyra) (PDF) (CP.PMN.152)
- Lomustine (Gleostine) (PDF) (CP.PHAR.507)
- Lonafarnib (Zokinvy) (PDF) (CP.PHAR.499)
- Loteprednol etabonate (Eysuvis) (PDF) (CP.PMN.260)
- Luliconazole Cream (Luzu) (PDF) (CP.PMN.166)
- Lumasiran (Oxlumo) (PDF) (CP.PHAR.473)
- 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)
- 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)
- 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)
- Metreleptin (Myalept) (PDF) (CP.PHAR.425)
- Midostaurin (PDF) (CP.PHAR.344)
- Migalastat (Galafold) (PDF) (CP.PHAR.394)
- 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) (PDF) (CP.PMN.80)
- Minocycline Micronized Foam (Amzeeq) (PDF) (CP.PMN.242)
- Mitoxantrone (PDF) (CP.PHAR.258)
- Modafinil (Provigil) (PDF) (CP.PMN.39)
- Mogamulizumab-kpkc (Poteligeo) (PDF) (CP.PHAR.139)
- Mometasone Furoate (Sinuva) (PDF) (CP.PHAR.448)
- Monomethyl Fumarate (Bafiertam) (PDF) (CP.PHAR.460)
- 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)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF) (CP.PHAR.495)
- Nabilone (Cesamet) (PDF) (CP.PMN.160)
- Nadofaragene Firadenovec (Instiladrin) (PDF) (CP.PHAR.461)
- Nafarelin Acetate (Synarel) (PDF) (CP.PHAR.174)
- Naloxone (Evzio) (PDF) (CP.PMN.139)
- Naproxen and Esomeprazole (Vimovo) (PDF) (CP.PMN.117)
- (MAT) Naltrexone Products (PDF) (WA.PHAR.63)
- Natalizumab (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)
- Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan) (PDF) (CP.PMN.118)
- Netupitant and Palonosetron (Akynzeo) (PDF) (CP.PMN.158)
- Neuromuscular Agents Als Agents Misc (Radicava) (PDF) (WA.PHAR.85)
- Neuromuscular Agents Muscular Dystrophy Agents (Exondys51) (PDF) (WA.PHAR.86)
- Neuromuscular Agents Muscular Dystrophy Agents- Viltolarsen (Viltepso) (PDF) (WA.PHAR.102)
- Neuromuscular Agents Muscular Dystrophy Agents (Vyondys 53) (PDF) (WA.PHAR.93)
- Neuromuscular Agents Spinal Muscular Atrophy Agents - Antisense Oligonucleotides (Spinraza) (PDF) (WA.PHAR.89)
- Nifurtimox (Lampit) (PDF) (CP.PMN.256)
- Niraparib (Zejula) (PDF) (CP.PHAR.408)
- Nitisinone (Nityr, Orfadin) (PDF) (CP.PHAR.132)
- Nivolumab (PDF) (CP.PHAR.121)
- 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-Preferred Blood Glucose Monitors/Test Strips (PDF) (CP.PMN.215)
- Obeticholic (PDF) (CP.PHAR.287)
- obinutuzumab (PDF) (CP.PHAR.305)
- Ocrelizumab (Ocrevus) (PDF) (CP.PHAR.335)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot) (PDF) (CP.PHAR.40)
- ofatumumab (PDF) (CP.PHAR.306)
- olanzapine la inj (PDF) (CP.PHAR.292)
- Olanzapine (Zyprexa Zydis®) (PDF) (CP.PMN.29)
- Olaparib (PDF) (CP.PHAR.360)
- olaratumab (PDF) (CP.PHAR.326)
- Omadacycline (Nuzyra) (PDF) (CP.PMN.188)
- Omecetaxine (Synribo) (PDF) (CP.PHAR.108)
- Omega-3-Acid Ethyl Esters (Lovaza) (PDF) (CP.PMN.52)
- OnabotulinumtoxinA (PDF) (CP.PHAR.232)
- Oncology Agents Autologous Cellular Immunotherapy (Car-T) (Breyanzi) (PDF) (WA.PHAR.109)
- Oncology Agents Autologous Cellular Immunotherapy (Car-T) (Kymriah) (PDF) (WA.PHAR.91)
- Oncology Agents- Autologous Cellular Immunotherapy (Car-T) (Yescarta) (PDF) (WA.PHAR.83)
- Oncology Agents Radiopharmaceuticals (Lutathera) (PDF) (WA.PHAR.88)
- Ondansetron (Zuplenz) (PDF) (CP.PMN.45)
- Ophthalmic Agents Gene Therapy (Luxturna) (PDF) (WA.PHAR.92)
- Ophthalmic Immunomodulators-Lifitegrast 5% Ophthalmic Solution (PDF) (WA.PHAR.58)
- Opicapone (Ongentys) (PDF) (CP.PMN.245)
- Osilodrostat (Isturisa) (PDF) (CP.PHAR.487)
- Ospemifene (Osphena) (PDF) (CP.PMN.168)
- Overactive Bladder Agents (PDF) (CP.PMN.198)
- Oxymetazoline (Rhofade) (PDF) (CP.PMN.86)
- Ozanimod (Zeposia) (PDF) (CP.PHAR.462)
- Ozenoxacin (Xepi) (PDF) (CP.PMN.119)
- Paclitaxel Protein-Bound (PDF) (CP.PHAR.176)
- paliperidone inj (PDF) (CP.PHAR.291)
- Palivizumab (PDF) (CP.PHAR.16)
- Pancrelipase (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)
- Pegademase Bovine (Adagen) (PDF) (CP.PHAR.392)
- Pegaptanib (Macugen) (PDF) (CP.PHAR.185)
- pegaspargase (PDF) (CP.PHAR.353)
- Peginterferon beta-1a (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)
- Perampanel (Fycompa) (PDF) (CP.PMN.156)
- Perindopril/Amlodipine (Prestalia) (PDF) (CP.PMN.174)
- Pertuzumab (PDF) (CP.PHAR.227)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (PDF) (CP.PHAR.501)
- Pimavanserin (Nuplazid) (PDF) (CP.PMN.140)
- Pirfenidone (PDF) (CP.PHAR.286)
- 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)
- pralatrexate (PDF) (CP.PHAR.313)
- Prasterone (Intrarosa) (PDF) (CP.PMN.99)
- 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)
- Prucalopride (Motegrity) (PDF) (CP.PMN.194)
- Psychotherapeutic and Neurological Agents MISC - Transthyretin (PDF) (WA.PHAR.70)
- Pulmonary Arterial Hypertension (PAH) Agents (Oral and Inhalation) (PDF) (WA.PHAR.55)
- Pulmonary Fibrosis Agents (PDF) (WA.PHAR.57)
- Pyrimethamine (PDF) (CP.PMN.44)
- Quantity Limit Overrides (PDF) (CP.PMN.59)
- Quetiapine ER (Seroquel XR) (PDF) (CP.PMN.64)
- Ramelteon (Rozerem) (PDF) (CP.PMN.173)
- Ramucirumab (Cyramza) (PDF) (CP.PHAR.119)
- Ranibizumab (Lucentis) (PDF) (CP.PHAR.186)
- Ranolazine (Ranexa) (PDF) (CP.PMN.34)
- Ravulizumab-cwvz (Ultomiris) (PDF) (CP.PHAR.415)
- Regorafenib (PDF) (CP.PHAR.107)
- Request for Medically Necessary Drug Not on the PDL (PDF) (WA.PHAR.61)
- Respiratory Agents- Misc Alpha-Proteinase Inhibitor (Human) (PDF) (WA.PHAR.68)
- Revlimid (PDF) (CP.PHAR.71)
- Ribociclib (PDF) (CP.PHAR.334)
- Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) (PDF) (CP.PMN.223)
- Rifamycin (Aemcolo) (PDF) (CP.PMN.196)
- Rifapentine (Priftin) (PDF) (CP.PMN.05)
- RimabotulinumtoxinB (PDF) (CP.PHAR.233)
- Risankizumab-rzaa (Skyrizi) (PDF) (CP.PHAR.426)
- Risperidone LA Inj (PDF) (CP.PHAR.293)
- Rituximab (Rituxan), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (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)
- 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)
- Satralizumab (PDF) (CP.PHAR.463)
- Sebelipase Alfa (PDF) (CP.PHAR.159)
- 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)
- Sipuleucel-T (Provenge) (PDF) (CP.PHAR.120)
- Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF) (CP.PMN.14)
- Sodium Oxybate (Xyrem) (PDF) (CP.PMN.42)
- Sodium Phenylbutyrate (Buphenyl) (PDF) (CP.PHAR.208)
- Sodium Zirconium Cyclosilicate (Lokelma) (PDF) (CP.PMN.163)
- Solriamfetol (Sunosi) (PDF) (CP.PMN.209)
- Sonidegib (PDF) (CP.PHAR.272)
- Sorafenib (Nexavar) (PDF) (CP.PHAR.69)
- Spinal Muscular Atrophy (Zolgensma) (PDF) (WA.PHAR.74)
- Step Therapy (PDF) (CP.PST.01)
- Stiripentol (Diacomit) (PDF) (CP.PMN.184)
- Sunitinib (Sutent) (PDF) (CP.PHAR.73)
- Suvorexant (Belsomra®) (PDF) (CP.PMN.109)
- Sylatron (peginterferon alfa-2b) (PDF) (CP.PHAR.89)
- Tafamidis (Vyndaqel, Vyndamax) (PDF) (CP.PHAR.432)
- Tafasitamab-cxix (Monjuvi) (PDF) (CP.PHAR.508)
- Talazoparib (Talzenna) (PDF) (CP.PHAR.409)
- Tazarotene (Arazlo, Fabior, Tazorac) (PDF) (CP.PMN.244)
- Tasimelteon (Hetlioz) (PDF) (CP.PMN.104)
- Tazemetostat (PDF) (CP.PHAR.452)
- Tecartus (Brexucabtagene Autoleucel Suspension for IV Infusion) (PDF) (WA.PHAR.100)
- Tedizolid (Sivextro) (PDF) (CP.PMN.62)
- Teduglutide (Gattex) (PDF) (CP.PHAR.114)
- Tegaserod (Zelnorm) (PDF) (CP.PMN.206)
- Telotristat ethyl (PDF) (CP.PHAR.337)
- Tesamorelin (PDF) (CP.PHAR.109)
- Temozolomide (Temodar) (PDF) (CP.PHAR.77)
- temsirolimus (PDF) (CP.PHAR.324)
- Tenapanor (Ibsrela) (PDF) (CP.PMN.224)
- Teprotumumab (Tepezza) (PDF) (CP.PHAR.465)
- Teriflunomide (PDF) (CP.PHAR.262)
- testosterone pellet (PDF) (CP.PHAR.354)
- Thalidomide (Thalomid) (PDF) (CP.PHAR.78)
- Thioguanine (Tabloid) (PDF) (CP.PHAR.437)
- Thyrotropin alfa (PDF) (CP.PHAR.95)
- Tildrakizumab-asmn (Ilumya) (PDF) (CP.PHAR.386)
- Tolvaptan (Jynarque) (PDF) (CP.PHAR.27)
- Topotecan (Hycamtin) (PDF) (CP.PHAR.64)
- Toremifene (Fareston) (PDF) (CP.PMN.126)
- Trabectedin (Yondelis) (PDF) (CP.PHAR.204)
- Trametinib (PDF) (CP.PHAR.240)
- Transmucosal Fentanyl Products (PDF) (WA.PHAR.80)
- Trastuzumab, Trastuzumab-dkst (PDF) (CP.PHAR.228)
- 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 (PDF) (CP.PHAR.175)
- Umeclidinium-vilanterol (Anoro Ellipta) (PDF) (CP.PMN.149)
- Upadacitinib (Rinvoq) (PDF) (CP.PHAR.443)
- Valproate Sodium for Intravenous Injection (Depacon) (PDF) (CP.PHAR.429)
- Valrubicin (Valstar) (PDF) (CP.PHAR.439)
- Vemurafenib (Zelboraf®) (PDF) (CP.PHAR.91)
- Venetoclax (Venclexta) (PDF) (CP.PHAR.129)
- Verteporfin (Visudyne) (PDF) (CP.PHAR.187)
- Vestronidase alfa-vjbk (PDF) (CP.PHAR.374)
- Vigabatrin (PDF) (CP.PHAR.169)
- Vilazodone (Viibryd) (PDF) (CP.PMN.145)
- vincristine sulfate liposome injection (PDF) (CP.PHAR.315)
- Vismodegib (PDF) (CP.PHAR.273)
- Vorinostat (PDF) (CP.PHAR.83)
- Vortioxetine (PDF) (CP.PMN.65)
- Voxelotor (Oxbryta) (PDF) (CP.PHAR.451)
- Xgeva (PDF) (CP.PHAR.58)
- Xiaflex™ (PDF) (CP.PHAR.82)
- 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)
- Not Medically Necessary IP Serv (PDF) (CC.PP.060)
- 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)
- Physician's Office Lab Testing (PDF) (CC.PP.055)
- 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'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)
- 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)
- 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 |
---|---|---|
WA.CP.MP.527 |
Vitamin D Testing | New policy. |
Effective Date |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|---|
|
Effective Date |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|---|
5/1/21 |
CP.MP.203 |
Diaphragmatic/Phrenic Nerve Stimulation |
New policy. |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|
WA.CP.MP.52 |
Behavioral Health Personal Care Services |
Annual review. Reference updated. |
WA.CP.MP.502 |
Cochlear Implants: Bilateral vs. Unilateral |
Annual review. Added “Bilateral vs. Unilateral” to policy title. Reference updated. |
WA.CP.MP.501 |
Continuous Glucose Monitoring |
Annual review. Clarified policy is regarding long-term use of CGM. Removed criteria for pregnant woman who are not insulin-dependent to be consistent with state billing guideline. Removed CPT codes 95249-95251. Updated references. |
WA.CP.MP.50 |
Drugs of Abuse: Definitive Testing |
Changed name of policy from Outpatient Testing for Drugs of Abuse to Drugs of Abuse: Definitive Testing. Removed presumptive drug testing criteria from policy and created new policy, WA.CP.MP.208 Drugs of Abuse: Presumptive Testing. Removed codes for presumptive drug testing: 80305, 80306, 80307. Added CPT-0054U to list of codes that do not support coverage criteria. Removed CPT-0006U, as code is deleted in 2021. |
WA.CP.MP.208 |
Drugs of Abuse: Presumptive Testing |
New policy. |
WA.CP.MP.130 |
Fertility Preservation |
New policy. |
CP.MP.34 |
Hyperemesis Gravidarum Treatment |
Annual review. Removed criteria for TPN and codes S9364, S9365, S9365, S9366, S9367 and S9368. References checked and updated. Replaced “member” with “members/enrollees.” |
CP.MP.141 |
Non-Myeloablative Allogeneic Stem Cell Transplants |
Annual review completed. References reviewed. Codes checked. Changed “member” to member/enrollee”. Specialty review completed with no updates. |
CP.MP.102 |
Pancreas Transplantation |
Background updated to reflect current data. References reviewed and updated. Replaced “member” with “member/enrollee” in all instances. Under contraindication I.C. removed “malignancy metastasized to or extending beyond the margins of the kidney and/or pancreas” as this is inclusive to contraindication #1. |
CP.MP.49 |
Physical, Occupational and Speech Therapy Services |
Added criteria to section IV. for a formal reevaluation, requiring that there must be documentation of new clinical findings or a significant change in condition, or a failure to respond to therapeutic interventions outlined in the POC. Replaced "member" with "member/enrollee." |
CP.MP.206 |
Skilled Nursing Facility Leveling |
Added negative pressure wound therapy to I.B., “Examples of treatments appropriate to Level 2” |
WA.CP.MP.46 |
Ventricular Assist Devices |
Annual review. Added information regarding pediatric VADs. References reviewed and updated. Removed ICD-10 code Z94.1 and added Z76.82. Replaced all instances of “member” with members/enrollees. Revised description of CPT 33990, 33991 and 33992. |
CP.MP.56 |
Ventriculectomy and Cardiomyoplasty |
Policy is retired. |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|
CP.MP.100 |
Allergy Testing and Therapy |
Added “(scratch, puncture, prick)” to description in I.C.1. Updated IIIB. adding several not medically necessary tests. Updated background, adding section on sublingual immunotherapy. CPT codes added to not medically necessary CPT Table 2: 86160, 86161, 86162, 86332, 86343, 86485, 86628, 0165U, 0178U. Revised description of ICD-10 codes Z88.0-Z88.9 in ICD-10 Tables 4 & 5. References reviewed and updated. Replaced member with member/enrollee in all instances. |
CP.MP.156 |
Cardiac Biomarker Testing for Acute MI |
Added “or myocardial injury due to other mechanisms” in addition to acute myocardial infarction for approval in criteria I. References reviewed and updated. Coding reviewed. Replaced “member” with “member/enrollee” in all instances. |
WA.CP.MP.525 |
Catheter Ablatiofor Supraventricular Tachyarrhythmia |
Annual review. References updated. |
WA.CP.MP.84 |
Cell-Free Fetal DNA Testing |
New Policy |
CP.MP.31 |
Cosmetic and Reconstructive Procedures |
Added applicable CPT codes: 15771, 15772 |
CP.MP.105 |
Digital EEG Spike Analysis |
Replaced “members” with “members/enrollees’ in all instances. References reviewed and updated. |
WA.CP.MP.515 |
Fecal Microbiota Transplantation |
Annual review. References updated. |
CP.MP.62 |
Hyperhidrosis Treatments |
Combined criteria points in II. H. and III. C to read “failed one of the following: 1. Iontophoresis or 2. Trial of botulinum toxin.” References reviewed and updated. Replaced “members” with “members/enrollees” in all instances. |
WA.CP.MP.500 |
Mandibular Advancement Devices |
Annual review. References updated. |
CP.MP.120 |
Pediatric Liver Transplant |
Clarified in I.B.5.e, neonatal hemochromatosis is now referred to as Gestational alloimmune liver disease. References reviewed and updated. Revised description of ICD-10 code E72.53. |
WA.CP.MP.523 |
Sleep Apnea Diagnosis and Treatment |
Added III. D. indicating titration can be requested after the testing is completed. |
WA.CP.MP.526 |
Stem Cell Therapy for Musculoskeletal Conditions |
New Policy |
CP.MP.22 |
Stereotactic Body Radiation Therapy |
Annual review of policy. References reviewed and updated. Added CPT- 61800. Replaced “member” with "member/enrollee” in all instances. |
WA.CP.MP.510 |
Tinnitus Treatment |
New Policy |
WA.CP.MP.524 |
Whole Exome Sequencing |
New policy |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|
WA.CP.MP.69 |
Intensity-Modulated Radiation Therapy |
Added indications by cancer site and associated ICD-10-CM diagnosis codes. Removed references to Health Technology Assessment (HTA). Added Background. References reviewed and updated. Replaced “members” with “members/enrollees’ in all instances. |
CP.MP.139 |
Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy |
Renamed policy to Low Frequency Ultrasound Therapy and Noncontact Normothermic Wound Therapy for Wound Management. Added criteria and background for noncontact normothermic wound therapy. References reviewed and updated. Replaced “members’ with “members/enrollees” in all instances. |
CP.MP.91 |
OB Home Health Programs |
Archived policy |
WA.CP.MP.507 |
Oral Entral Nutrition |
Annual review. Updated reference. Added E1399 and K0739. |
CP.MP.206 |
SNF Leveling |
New policy |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|
CP.MP.183 |
Diagnostic Testing Guidelines for 2019-Novel Coronavirus |
Policy being retired. |
CP.MP.180 |
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea |
Added codes 61886 and 61888. Replaced “member” with “member/enrollee” in all instances. References reviewed and updated. |
CP.MP.87 |
Inhaled Nitric Oxide |
Corrected calculation of Oxygen Index in I.A.2.IV. Updated background with no impact on criteria. References added. Replaced “member” with “member/enrollee.” |
CP.MP.181 |
Polymerase Chain Reaction Respiratory Viral Panel Testing |
New Policy |
WA.CP.MP.70 |
Proton and Neutron Beam Therapies |
Replaced all instances of “member” with “member/enrollee”. References reviewed and updated. Changed title to Proton and Neutron Beam Therapies |
CP.MP.182 |
Short Inpatient Hospital Stay |
Added to the description that “medical necessity criteria for day one and day two of an inpatient hospital stay, excluding behavioral health and obstetrical delivery admissions.” Clarified that the medical necessity statement in I. applies to the first and second days of an inpatient stay. Added section II., stating that days 3 and beyond are medically necessary per nationally-recognized clinical decision support tools. Replaced all instances of member with member/enrollee. |
CP.MP.127 |
Total Artificial Heart |
In I.G, removed specifications about chest size related to the device, and added that the requested device is FDA approved and will be used according to FDA indications, which include chest measurements. Background updated. Specialist review. Replaced “member” with “member/enrollee” in all instances. |
CP.MP.169 |
Trigger Point Injections for Pain Management |
I.B.4: Changed maximum of 6 injections/year to 4. Added ICD-10 code M79.18 and changed M79.1 to M79.12. References reviewed and updated. |
WA.CP.MP.177 |
Video Electroencephalography (V-EEG) |
New Policy |
WA.UM.23 |
Video Electroencephalography (V-EEG) |
Policy is archived and replaced with WA.CP.MP.177 |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|
WA.CP.MP.37 |
Bariatric Surgery |
Specified that H. Pylori screening should be conducted using a urea breath test or stool antigen test. Added the following ICD-10 code ranges: M17.0-M17.9, M19.171-M19.179 and M19.271-M19.279. 10/1/20 ICD 10 updates: Replaced category K21.0-K21.9 with K21.00- K21.9. Removed “member” from II.C.4. and II.G. Reworded II.G with no impact on criteria. Replaced “member” with “member/ enrollee” in all other instances. Add guidance around case management. Updated references. |
CP.MP.98 |
Urodynamic Testing |
Code update: ICD-10 N40.1 and R35.1, no longer specific to 51798 and moved to list of codes that support medical necessity. Added ICD-10 codes that support medical necessity: A18.13, G82.21, G82.22, 539.11, S14.0XXA-S14.9XXS, S24.0XXA-S24.9XXS. |
CP.MP.101 |
Donor Lymphocyte Infusion |
Description updated. Specified in I.A. that DLI is indicated to reduce the risk of relapse. Added to I.B. that DLI is intended to convert recipient cells from mixed to full chimerism, if there is a risk of relapse. Added to II. “higher than grade 2 acute graft-versus-host-disease (GvHD)” and “total host chimerism.” Removed not medically necessary indication from section II. of a second DLI when benefits were not noted from the first. References reviewed and updated. Specialist review. Replaced “member” with “member/enrollee” in all instances. |
CP.MP.150 |
Home Phototherapy for Neonatal Hyperbilirubinemia |
Added criterion that “if the mother is breastfeeding, she has been offered lactation support from a qualified professional.” References reviewed and updated. Specialist review. Replaced “member” with “member/enrollee in all instances. |
CP.MP.154 |
Thyroid Hormones and Insulin Testing in Pediatrics |
References reviewed and updated. 10/1/20 ICD-10 code updates: Revised ICD-10 codes Z68.52, Z68.53, and Z68.54: code set revised changing parenthesis around BMI to brackets with no change in code descriptor. Replaced “member” with “member/enrollees” in all instances in the disclaimer. |
CP.MP.184 |
Non-invasive Home Ventilator |
Removed code E0467. Replaced all instances of “member” with “member/enrollee,” or removed them where possible. |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|
CP.MP.108 |
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia |
Revised ICD-10 code range for sickle cell disorders to codes that expand sickle cell categorization. Removed “member” from policy statement in I. and replaced “member” with “member/enrollee” in all other instances. |
WA.CP.MP.119 |
Balloon Sinus Ostial Dilation |
In I.B.2, gave an option for when corticosteroids are contraindicated. References reviewed and updated. |
CP.MP.31 |
Cosmetic and Reconstructive Procedures |
Clarified in II.N. that hair transplant is not medically necessary, when not performed to correct permanent hair loss caused by disease or injury. Added the following applicable CPT codes: 15220,15221, 15775, 15776. Supporting references added. |
CP.MP.107 |
Durable Medical Equipment (DME) |
Under Wound Care, removed HCPCS code Q4111, GammaGraft, as code is included in CP.MP.185 Skin Substitutes for Chronic Wounds |
CP.MP.134 |
Evoked Potential Testing |
Reorganized section IV and added indications when visual evoked potentials are not medically necessary. Revised IV.C, “Treatment of all other conditions than those specified above” to “evaluation/assessment of all other conditions…” Added additional ICD 10 codes A39.82, H35.54, R44.1 and R48.3 as supporting medical necessity. Removed code H54.7 from list of medically necessary codes. References reviewed and updated. |
CP.MP.136 |
Home Birth |
Added to I.A.1.a., “and practicing within an integrated and regulated health system”; Added to I.E that singleton pregnancy “is estimated to be appropriate for gestational age.” Revised criteria in I.G: Changed “Spontaneous labor in a pregnancy that has lasted at least 38 weeks” to specify 37 0/7 weeks clarified that no more than 41 weeks is no more than 41 6/7 weeks. Added separate criteria for home birth in a pregnancy induced as an outpatient. Updated section in background, American Academy of Pediatrics (AAP), with most current recommendations. References reviewed and updated. |
WA.CP.MP.27 |
Hyperbaric Oxygen Therapy |
Policy reactivated to meet HTA requirements. Previously archived 3/1/2020. Criteria-using InterQual-remain the same. |
CP.MP.116 |
Lysis of Epidural Lesions |
Revised ICD-10 code G96.19 to G96.198 per 10/1/20 ICD-10 code updates. Replaced “member” with “member/enrollee” in all instances. |
CP.MP.86 |
Neonatal Abstinence Syndrome Guidelines |
In asymptomatic infants section: specified that transitional care or newborn level 1 is appropriate if being assessed with modified Finnegan’s scoring; added an alternative option for Level 2 nursery if being assessed and treated using ESC. Updated background relating to ESC. References review and updated. Reviewed by neonatologists. |
CP.MP.120 |
Pediatric Liver Transplant |
10/1/20 ICD-10 code update: replaced code range K74.0-K74.69 with K74.00- K74.69 to include new codes included in this range. Replaced “member” with “member/enrollee” in all instances |
WA.CP.MP.523 |
Sleep Apnea Diagnosis and Treatment |
Highlighted definitions of hypopnea and apnea. Added comments and criteria on CPAP titration. Clarified guidelines when home study fails. |
CP.MP.189 |
Thymus Transplantation |
New Policy |
WA.CP.MP.38 |
Ultrasound in Pregnancy |
Policy is archived and replaced with CP.MP.38. |
CP.MP.38 |
Ultrasound in Pregnancy |
New Policy Per 10/1/20 ICD-10 code updates, code set Z68.35 – Z68.45 was revised changing parenthesis around BMI to brackets with no change to code descriptor. Removed “member” from I.A and replaced “member” with “member/enrollee” in all instances. |
CP.MP.98 |
Urodynamic Testing |
References reviewed and updated. Added ICD-10 codes: C70.1, C72.0, C72.1, D33.4. |
CP.MP.99 |
Wheelchair Seating |
Typo corrected in II.B- Should be K0860-K0864, rather than K0860, K0864. For clarity, added the codes included in this range. References reviewed and updated. |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|
CP.MP.124 |
ADHD Assessment & Treatment |
Policy reviewed. References reviewed and updated. Updated Section I.A. to include “collection of collateral information” and “toxicology screen.” Updated Section I.B. to include “ongoing assessment and application of standardized scales to assess treatment benefit.” Updated Section II. “investigational or unproven” assessments and treatments with the following: pharmacogenetic tools; Cannabidiol oil; cognitive training; external trigeminal nerve stimulation (eTNS); mindfulness; and supportive counseling, to reflect the 2019 version of American Academy of Pediatrics (AAP) Clinical Practice Guidelines. Edited Section II.A.19. to read “Neuro Biofeedback/EEG Biofeedback.” Updated AAP recommended treatment modalities. Added information regarding The Society for Developmental and Behavioral Pediatrics (SDBP) Clinical Practice Guidelines and Process of Care Algorithms for Assessment and Treatment of Children and Adolescents with Complex ADHD. Updated Background section to include most recent prevalent statistics and the necessity of treatment by Primary Care Providers. CPT Code Updates: Removed 78607, 95827, 97127. Added 78803, 81171, 81172, 92547, 95705, 95706, 95707, 95708, 95709, 95710, 95711, 95712, 95713, 95714, 95715, 95716, 95717, 95718, 95719, 95720, 95721, 95722, 95723, 95724, 95725, 95726, 96121, 97129, 97130. HCPCS Code Updates: Added G0176. (All code changes relate to non-covered services) |
CP.MP.93 |
Bone-anchored Hearing Aid |
References reviewed and updated. Removed HCPCS code L8613, added L8692. Added ICD-10 code H61.111-H61.119 |
CP.MP.186 |
Burn Surgery |
New policy |
CP.MP.184 |
Home Ventilators |
New policy |
CP.MP.121 |
Homocysteine Testing |
References reviewed and updated. Revised I.A from “Borderline vitamin B12 deficiency” to “Borderline low or inconclusive Vitamin B12 deficiency, or discordant with the clinical picture.” Changed borderline B12 deficiency and idiopathic VTE/thromboembolism indications from medically necessary to investigational. Added supporting background information and references. Removed from the list of ICD-10 codes supporting coverage criteria: D51.0-D51.9, E53.8, I26.01-I26.99, I81, I82.0-I82.91, Z86.711, Z86.718. |
CP.MP.170 |
Nerve Blocks for Pain Management |
For occipital nerve block, added “trigger point at the emergence of the greater occipital nerve or in the distribution of C2” as an alternative to tenderness at the affected nerve branch. References reviewed and updated. |
WA.PP.800 |
Observation Status |
Archived policy |
CP.MP.188 |
Pediatric Oral Function Therapy |
New policy |
CP.MP.166 |
Sacroiliac Joint Interventions for Pain Management |
Added Patrick’s test/FABER test as an acceptable pain provocation test in I.A3. References reviewed and updated. |
CP.MP.165 |
Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management |
Clarified criteria in II.B, C, and D.1 that a request for TFESI is for one level bilaterally or up to two levels unilaterally. References reviewed and updated. |
CP.MP.182 |
Short Inpatient Hospital Stay |
Renumbered from WA.PP.800 and renamed. Observation status will be approved for stays of 48 hours or less, unless one of the policy exceptions is noted. Intermediate/step down level of care is now part of the observation exclusion list. |
WA.CP.MP.12 |
Vagus Nerve Stimulation |
Lowered minimum age to 4 years. Called out non-covered services. Added additional investigational indications for VNS to section II. Removed ICD-10 Codes: G40.001, G40.009, G40.201, G40.209, G40.309, G40.A09, G40.409, G40.509, G40.802, G40.909, G40.911 and G40.919. Added ICD-10: G40.813, G40.814. References reviewed and updated. |
WA.CP.MP.522 |
Varicose Vein Treatment |
Revised policy statement adding Varithena as an example of a foam irritant. Added 36468 to code list not medically necessary. In I.A.2., added tributary and accessory vein treatment as indications when meeting the established criteria. |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|
WA.CP.BH.104 |
ABA Therapy |
Annual Review. Renumbered policy, was WA.CP.MP.104. Moved to standard corporate policy, with state-specific requirements for Center of Excellence, DSM Checklist and use of HCPCS H2020. |
CP.MP.96 |
Ambulatory EEG |
Annual review completed. References reviewed and updated. Added the following ICD-10 codes: R40.4, R55 |
CP.MP.107 |
Durable Medical Equipment |
Code E0780 added to criteria for ambulatory infusion pump. Moved ambulatory and implantable infusion pump criteria into pumps section. Updated table of contents. |
CP.MP.137 |
Fecal Incontinence Treatment |
Additional criteria added for sacral nerve stimulators from local coverage article (A53017). Clarified definition of chronic fecal incontinence as greater than two incontinent episodes on average per week and duration of incontinence greater than six months or for more than twelve months after vaginal childbirth. Added additional criteria requiring a successful percutaneous test stimulation, condition not be related to anorectal malformation and/or chronic inflammatory bowel disease, incontinence not be related to another neurologic condition and contraindications for device. Added sacral nerve stimulation for the treatment of chronic constipation or chronic pelvic pain to the not medically necessary section II. |
CP.MP.85 |
Neonatal Sepsis Management Guidelines |
Under section III. Discharge criteria, added E. Follow-up planned with provider within 48 hours of discharge. In background section I.G., changed ≥ 10^5 CFU to ≤ 10^5 CFU. References reviewed and updated. |
WA.CP.MP.523 |
Obstructive Sleep Apnea Diagnosis and Treatment |
Clarified Attended Sleep Study criteria. Updated references. |
WA.CP.MP.50 |
Outpatient Testing for Drugs of Abuse |
In II.B, added that “Tests are only for the specific drug(s) or number of drug classes for which the presumptive test is expected to be positive.” Added CPT 80366. Reinstated notes regarding PA not being required for children < 6 years of age, and a 10 day post-test window for PA. |
CP.MP.51 |
Reduction Mammoplasty and Gynecomastia Surgery |
Added note to reference CP.MP.95 for breast surgeries pertaining to gender affirming procedures. Added criteria for breast reduction for females that cup size has not changed in 6 months. Added criteria for adolescent males requiring that adult testicular size has been attained. References reviewed and updated. |
CP.MP.162 |
Tandem Transplant |
Changed contraindication of significant systemic or multisystem disease to “significant, uncorrectable, life-limiting medical condition. Removed substance abuse or dependence contraindication. Background updated with no impact on criteria. References reviewed and updated. |
CP.BH.200 |
Transcranial Magnetic Stimulation |
Renumbered policy, was WA.CP.MP.172. Policy/Criteria section updated to clarify that Section I. refers to initial approval of TMS sessions. Updated item I.B. to reflect “Oversight of treatment is provided by a licensed psychiatrist.” Updated I.C. to include “Other standardized scale indicating moderately severe to severe depression.” Added Section I.I., “The initial request can be reviewed for up to 20 TMS sessions.” Added Section II. to include criteria for authorization of additional TMS sessions. |
CP.MP.183 |
2019 Novel Coronavirus Testing |
Modified criteria to reflect CDC testing guidelines as of 7/20/20. Added criteria for neonatal testing. Added criteria for discontinuation of transmission-based precautions, home isolation, and for return to work for healthcare providers. Changed antibody/serology testing medical necessity statement to medically necessary for those presenting late in illness, in conjunction with viral testing, and when post-acute infection syndrome is suspected. Removed background statement about antibody testing not being appropriate for diagnosis of acute infection. Added antibody testing code 86328 to the table supporting medical necessity, as well as codes 0202U, 0223U, 0224U. References updated. |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|
WA.CP.MP.37 |
Bariatric Surgery |
Added Coronary artery disease as a comorbidity under A.1.b.ii. Edits made to ICD-10 codes; M54-M54.9 now M54.00-M54.9; T81.1X+-T81.9X now T81.10X+ - T81.9XX+; and T85.59 – T85.59 now T85.590+ - T85.598+. References reviewed and updated. Updated coverage statement to reflect WAC that allows only laparoscopic gastric band procedures for adults 18-21 years of age. |
CP.MP.94 |
Clinical Trials |
Added reference to CP.MP.36 Experimental Technologies. References reviewed and updated. |
WA.CP.MP.115 |
Discography |
Revised I. to “not a covered benefit” and II. to indicate all other conditions are “not medically necessary”. References reviewed and updated. |
WA.CP.MP.36 |
Experimental Technologies |
References reviewed and updated. Added note regarding Clinical Trials policy. Clarified Humanitarian Use Device and Institutional Review Board exceptions. |
CP.MP.123 |
Laser Therapy for Skin Conditions |
Revised indication from “Mild, moderate, or severe psoriasis with < 10% body surface area (BSA) involvement” to “Localized plaque psoriasis <10% body surface area (BSA) involvement, individual lesions, or with more extensive disease.” Background updated with recent guidelines from AAD. References reviewed and updated. |
CP.MP.81 |
NICU Discharge Guidelines |
Revised II.A “from normal ambient temperature (23.9 to 25º C)” to "(20 – 25 º C.)” References reviewed and updated. Specialist review. |
WA.CP.MP.523 |
Obstructive Sleep Apnea Diagnosis and Treatment |
Attended sleep study criteria added. Title changed to include “Obstructive”. References reviewed and updated. |
WA.CP.MP.50 |
Outpatient Testing for Drugs of Abuse |
Clarified Not Medically Necessary vs. Not Covered items in code tables. |
CP.MP.49 |
Physical, Occupational and Speech Therapies |
Removed section on school based services from I.E.1. References reviewed and updated. |
WA.CP.MP.503 |
Private Duty Nurse |
Annual review. References updated. Removed statement about SNF placement with no SNF bed available. |
WA.CP.MP.185 |
Skin Substitutes |
New policy |
WA.CP.MP.509 |
Upper GI Endoscopy for GERD |
Annual review. References updated. CPT 43200, 43202 and 43239 added. |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|
WA.CP.MP.508 |
Bone Growth Stimulator |
Annual review. References updated. Added “separated by a minimum of 90 days” to section III.A.1. |
WA.CP.MP.513 |
Cardiac Stents |
Annual review. References updated. Clarified that policy applies to both bare metal and drug eluting stents. Added C1874 through C1877 |
CP.MP.31 |
Cosmetic and Reconstructive Procedures |
Added criteria for dermal injections and autologous fat injections for HIV-associated FLS. Changed policy title and medical necessity statements to state “cosmetic procedures” or “reconstructive procedures” instead of “cosmetic surgery” or “reconstructive surgery.” Added CPT and HCPCS codes for specified medically necessary indications. Added note to refer to CP.MP.95 Gender Affirming procedures for procedures related to treatment of gender dysphoria |
CP.MP.87 |
Inhaled nitric oxide |
Annual review completed. Codes and references checked and updated. P29.3 changed to P29.30-P29.38 and I27.2 changed to I27.20 - I27.29. Added iNO as medically necessary for adults with COVID-19, severe ARDS, and hypoxemia despite optimized ventilation and other rescue strategies. Updated background. Added the following ICD-10 codes: J80, J96.01, U07.1 and U07.2 |
CP.MP.58 |
Intestinal and Multivisceral Transplant |
Edited malignancy contraindication to not specify within 2 years, and added exceptions early stage prostate cancer, cancer that has been completely resected, or that has been treated and poses acceptable future risk. References reviewed and updated. |
CP.MP.57 |
Lung Transplantation |
Edited malignancy contraindication to not specify within 2 years, and added exceptions of early stage prostate cancer, cancer that has been completely resected, or that has been treated and poses acceptable future risk. |
CP.MP.82 |
NICU Apnea Bradycardia Guidelines |
Restructured guidelines and specified that these are “guidelines.” In discharge criteria for significant events and on home respiratory monitoring, added that the infant has no other conditions requiring inpatient care. Reworded sections headings and organized information accordingly. Changed all instances of “parents” to “parents or caregivers.” Combined caffeine criteria section into the “discharge for significant cardiorespiratory events” section. |
WA.CP.MP.50 |
Outpatient Testing for Drugs of Abuse |
Revised policy to state that HCPCS codes G0482 & G0483 are not medically necessary. Updated references. |
CP.MP.102 |
Pancreas Transplantation |
Edited malignancy contraindication to not specify within 2 years, or low Gleason score, and added exceptions early stage prostate cancer, cancer that has been completely resected, or that has been treated and poses acceptable future risk. |
CP.MP.138 |
Pediatric Heart Transplant |
Edited malignancy contraindication to not specify within 2 years, and added exceptions of cancer that has been completely resected, or that has been treated and poses acceptable future risk. |
CP.MP.120 |
Pediatric Liver Transplant |
Edited malignancy contraindication adding exceptions: cancer that has been completely resected, or that has been treated and poses acceptable future risk. |
CP.MP.183 |
2019 Novel Coronavirus Testing |
Updated description. Changed medical necessity statement to replace persons under investigation language with evaluation and laboratory testing for COVID-19. Modified criteria to reflect priorities for testing per 3/24/20 CDC update. Added that state and local health departments may adapt |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|
WA.CP.MP.519 |
Administrative Days |
Removed exclusion for custodial care days. |
CP.MP.96 |
Ambulatory Electroencephalography |
Removed CPT codes 95950, 95953-codes deleted 1/1/2020. Added the following 2020 CPT codes: 95700, 95705, 95708, 95717, 95719, 95721, 95723, and 95725. Removed CPT codes from criteria note specifying which CPT codes should precede which ambulatory EEG codes. |
CP.MP.183 |
2019 Novel Coronavirus Testing |
Added CPT codes 86328 and 86769. |
CP.MP.155 |
EEG in the Evaluation of Headache |
Revised CPT 95813 description |
WA.CP.MP.504 |
Elective Delivery Prior to 39 Weeks |
Annual review. Added WAC reference to background. Updated references. Added ICD-10 codes K83.5 and O26. |
CP.MP.140 |
EpiFix |
Archived policy |
CP.MP.113 |
Holter Monitors |
Annual review completed. References and codes reviewed/updated. ICD-10 codes I42.3-7 were added; R06.00-R06.09 description changes to Dyspnea |
WA.CP.MP.54 |
Hospice Services |
Annual review, references updated. Inclusion of transportation services added. Associated revenue code added to HCPCS table. |
WA.CP.MP.505 |
Microprocessor-Controlled Lower Limb Prosthetics |
Annual review. Added L2006. |
WA.CP.MP.517 |
Testosterone Testing |
Annual review. Reference updated. Grammatical changes. 84410 added. |
CP.MP.169 |
Trigger Point Injections for Pain Management |
CPT 20560 and 20561 added as not supporting coverage criteria. |
CP.MP.56 |
Ventriculectomy and Cardiomyoplasty |
CPT codes added: 33426, 33542, and 33548. |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|
CP.MP.31 |
Cosmetic and Reconstructive Surgery |
Removed “significant” in I.A.4.a. In II. N.changed “hair replacement” to “hair transplantation.” Added additional not medically necessary indications i.e.,(mastopexy except for breast reconstruction post-mastectomy or lumpectomy resulting in significant asymmetry, correction of inverted nipples, and repair of diastasis recti. Specialist reviewed. References reviewed and updated. |
CP.MP.89 |
Genetic Testing |
Added general criteria for pharmacogenetic testing. Updated background on pharmacogenetic testing. References reviewed and updated. |
CP.MP.109 |
Panniculectomy |
ICD -10 codes added. References reviewed and updated. Specialist reviewed. |
CP.MP.142 |
Urinary Incontinence Devices and Treatments |
References reviewed and updated. Added ICD-10: R35.0. |
CP.MP.183 |
Novel Coronavirus Testing |
Modified medical necessity statement to state that testing following CDC guidelines is medically necessary. Changed criteria to reflect CDC guidelines as of 3/4/20 |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|
CP.MP.103 |
Fractional Exhaled Nitric Oxide |
Added that testing FeNO is investigational for all other conditions, in addition to asthma, with supporting sources. |
CP.MP.107 |
DME |
Under Ambulatory Assist Products: Added criteria for standers under codes E0637, E0638, E0639, E0641, and E0642; Under Heat, Cold & Light Therapy Equipment: Changed coverage recommendation for Cold Pad Pump to “Not medically necessary” based on current research; Under Orthopedic Care Equipment: Added criteria for traction equipment for codes E0849 and E0855 that target Temporomandibular Joint Dysfunction; Moved Fracture Frames with codes E0974 and E0984 to the section with Halo Procedure Equipment as criteria and indications are the same; Changed male vacuum erection devices from not medically necessary to medically necessary; Added hip labral tears as an indication for a Hip Orthotic; Added clarification to prosthetics an additions section to avoid inappropriate application; Under Other Equipment: Added criteria for E1399, K0108 and K0739 when they are used for wheelchair repairs; Added criteria for E2300 Seat Elevators; Under Stimulator Equipment: Added E0770 when the diagnosis is spinal cord injury to the coverage criteria detailed under Neuromuscular stimulator |