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)
- Diagnostic Testing Guidelines for 2019-Novel Coronavirus (PDF) (CP.MP.183)
- 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)
- 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 therapy for wound management (PDF) (CP.MP.139) Effective through 1/31/21
- Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (CP.MP.139) Revision Effective 2/1/21
- 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)
- Skin Substitutes for Chronic Wounds (PDF) (CP.MP.185)
- 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)
- Vitamin D Testing in Children (PDF) (CP.MP.157)
- 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)
- Aclidinium/Formoterol (Duaklir Pressair) (PDF) (HIM.PA.151)
- Acyclovir Buccal Tablet (Sitavig), Ophthalmic Ointment (Avaclyr) (PDF) (CP.PMN.210)
- Afamelanotide (Scenesse) (PDF) (CP.PHAR.444)
- Abatacept (Orencia) (PDF) (CP.PHAR.241)
- 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)
- Ambrisentan (Letairis®) (PDF) (CP.PHAR.190)
- Amifampridine (Firdapse) (PDF) (CP.PHAR.411)
- Amikacin (Arikayce) (PDF) (CP.PHAR.401)
- Amisulpride (Barhemsys) (PDF) (CP.PMN.236)
- Anakinra (Kineret) (PDF) (CP.PHAR.244)
- 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)
- Arformoterol Tartrate (Brovana) (PDF) (CP.PMN.201)
- Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF) (CP.PHAR.290)
- 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)
- 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)
- 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/Glycopyrrolate/Formoterol Fumarate (Breztri Aerosphere) (PDF) (HIM.PA.150)
- Budesonide (Uceris) (PDF) (CP.PCH.11)
- Budesonide Suspension (Pulmicort Respules) (PDF) (HIM.PA.48)
- buprenorphine and naloxone (Bunavail®, Suboxone®) (PDF) (HIM.PA.35)
- Buprenorphine (Subutex) (PDF) (CP.PMN.82)
- buprenorphine implant (Probuphine) (PDF) (CP.PHAR.289)
- 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)
- Ciclesonide (Alvesco) (PDF) (CP.PCH.35)
- Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) (CP.PMN.248)
- Ciprofloxacin/Fluocinolone (Otovel) (PDF) (CP.PMN.249)
- Cladribine (Mavenclad) (PDF) (CP.PHAR.422)
- Clobazam (PDF) (CP.PMN.54)
- CNS Stimulants (PDF) (CP.PMN.92)
- Cobimetinib (Cotellic) (PDF) (CP.PHAR.380)
- Colesevelam (Welchol) (PDF) (CP.PMN.250)
- Collagenase (PDF) (CP.PHAR.82)
- Colonoscopy Preparation Products (PDF) (HIM.PA.04)
- Compounded Medications (PDF) (CP.PCH.27)
- Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) (HIM.PA.140)
- 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.PCH.04)
- 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.PHAR.249)
- 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)
- 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)
- Etanercept (Enbrel) (PDF) (CP.PHAR.250)
- 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.PHAR.251)
- 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) (CP.PCH.17)
- 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) (CP.PCH.24)
- 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) (CP.PHAR.252)
- 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)
- 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)
- Indacaterol/Glycopyrrolate (Utibron Neohaler) (PDF) (HIM.PA.102)
- Inebilizumab-cdon (Uplizna) (PDF) (CP.PHAR.458)
- Infertility and Fertility Preservation (PDF) (CP.PHAR.131)
- Infusion Therapy Site of Care Optimization (PDF) (CP.PHAR.493)
- 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)
- 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)
- Levalbuterol (Xopenex) (PDF) (CP.PMN.07)
- 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)
- Lorcaserin (Belviq®, Belviq XR) (PDF) (CP.PCH.03)
- Lorlatinib (Lorbrena) (PDF) (CP.PHAR.406)
- Lubiprostone (Amitiza) (PDF) (CP.PMN.142)
- Luliconazole Cream (Luzu) (PDF) (CP.PMN.166)
- Lumacaftor-ivacaftor (PDF) (CP.PHAR.213)
- 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)
- 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 (Asmanex) (PDF) (HIM.PA.01)
- Mometasone (Asmanex) (PDF) (CP.PCH.36)
- 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)
- 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)
- 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)
- 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)
- 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)
- 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)
- Rivastigmine (Exelon®) (PDF) (CP.PMN.101)
- 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)
- 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)
- Sarilumab (Kevzara) (PDF) (CP.PHAR.346)
- 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)
- Semaglutide (Rybelsus) (PDF) (HIM.PA.02)
- Sensipar (PDF) (CP.PHAR.61)
- 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)
- Somatropin (Human Growth Hormone) (PDF) (CP.PCH.25)
- 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)
- 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)
- Upadacitinib (Rinvoq) (PDF) (CP.PHAR.443)
- 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)
- 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)
- 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) (CP.MP.84)
- Clinical Trials (PDF) (CP.MP.94)
- Cochlear Implant Replacement (PDF) (CP.MP.14)
- Cochlear Implants (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)
- Diagnostic Testing Guidelines for 2019-Novel Coronavirus (PDF) (CP.MP.183)
- Digital Analysis of EEG (PDF) (CP.MP.105)
- Discography (PDF) (WA.CP.MP.115)
- Donor Lymphocyte Infusion (PDF) (CP.MP.101)
- 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)
- 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 (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)
- Obstetrical Home Health Care Programs (PDF) (CP.MP.91)
- 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)
- Skin Substitutes for Chronic Wounds (PDF) (WA.CP.MP.185)
- Sleep Apnea Diagnosis and Treatment (PDF) (WA.CP.MP.523)
- 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)
- 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) Effective Through 12/31/20
- 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) (WA.CP.MP.38) Effective until 10/31/20
- Ultrasound in Pregnancy (PDF) (CP.MP.38) Effective 11/1/20
- 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.UM.23) Effective Through 12/31/20
- Video Electroencephalography (V-EEG) (PDF) (WA.CP.MP.177) Revision Effective 1/1/21
- Vitamin D Testing (PDF) (CP.MP.152)
- Vitamin D Testing in Children (PDF) (CP.MP.157)
- Wheelchair seating (PDF) (CP.MP.99)
- 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)
- Acalabrutinib (PDF) (CP.PHAR.366)
- ACEI and ARB Duplicate Therapy (PDF) (CP.PMN.61)
- Acitretin (Soriatane) (PDF) (CP.PMN.40)
- Aclidinium/Formoterol (Duaklir Pressair) (PDF) (CP.PMN.200)
- Acyclovir Buccal Tablet (Sitavig), Ophthalmic Ointment (Avaclyr) (PDF) (CP.PMN.210)
- 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)
- Afatinib (PDF) (CP.PHAR.298)
- 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)
- Alectinib (PDF) (CP.PHAR.369)
- 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)
- 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-APOB Synthesis Inhibitors (Juxtapid) (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)
- Antiparasitics Antiprotozoal Agents- nitazoxanide (Alinia) (PDF) (WA.PHAR.67)
- 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)
- Arformoterol Tartrate (Brovana) (PDF) (CP.PMN.201)
- 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)
- Atomoxetine (Strattera) (PDF) (CP.PST.17)
- 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)
- Avapritinib (Ayvakit) (PDF) (CP.PHAR.454)
- Avelumab (Bavencio) (PDF) (CP.PHAR.333)
- Axitinib (Inlyta) (PDF) (CP.PHAR.100)
- 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)
- 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)
- Bosutinib (PDF) (CP.PHAR.105)
- Brand Name Override (PDF) (CP.PMN.22)
- 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)
- Cabozantinib (Cometriq®, Cabometyx®) (PDF) (CP.PHAR.111)
- 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)
- Capmatinib (Tabrecta) (PDF) (CP.PHAR.494)
- 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)
- Cariprazine (PDF) (CP.PMN.91)
- 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)
- Ceritinib (PDF) (CP.PHAR.349)
- 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)
- 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)
- 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)
- Crizotinib (PDF) (CP.PHAR.90)
- 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)
- Dacomitinib (Vizimpro) (PDF) (CP.PHAR.399)
- Dalteparin (PDF) (CP.PHAR.225)
- daptomycin (PDF) (CP.PHAR.351)
- Daratumumab (PDF) (CP.PHAR.310)
- Darolutamide (Nubeqa) (PDF) (CP.PHAR.435)
- Dasatinib (Sprycel) (PDF) (CP.PHAR.72)
- 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)
- 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)
- 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)
- Erlotinib (Tarceva) (PDF) (CP.PHAR.74)
- 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)
- Fluticasone Salmeterol (Advair Diskus, Advair HFA) (PDF) (CP.PMN.31)
- Fluticasone/Umeclidinium/Vilanterol (Trelegy Ellipta) (PDF) (CP.PMN.146)
- Fluticasone/Vilanterol (Breo Ellipta) (PDF) (CP.PMN.229)
- 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)
- Gefitinib (PDF) (CP.PHAR.68)
- gemtuzumab ozogamicin (PDF) (CP.PHAR.358)
- Gilteritinib (Xospata) (PDF) (CP.PHAR.412)
- 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)
- Hyaluronate Derivatives (PDF) (CP.PHAR.05)
- Hydroxyurea (Siklos) (PDF) (CP.PMN.193)
- Ibalizumab-uiyk (PDF) (CP.PHAR.378)
- Ibrance (palbociclib) (PDF) (CP.PHAR.125)
- Ibrutinib (Imbruvica) (PDF) (CP.PHAR.126)
- 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)
- Imatinib (Gleevec) (PDF) (CP.PHAR.65)
- Immune Globulins (PDF) (CP.PHAR.103)
- Immunization coverage (PDF) (CP.PHAR.28)
- Immunosuppressive Agents (Gamifant) (PDF) (WA.PHAR.76)
- IncobotulinumtoxinA (PDF) (CP.PHAR.231)
- Indacaterol (Arcapta Neohaler) (PDF) (CP.PMN.203)
- Indacaterol-glycopyrrolate (Utibron Neohaler) (PDF) (CP.PMN.147)
- Inebilizumab-cdon (Uplizna) (PDF) (CP.PHAR.458)
- Infusion Therapy Site of Care Optimization (PDF) (CP.PHAR.493)
- 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)
- 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)
- lapatinib (Tykerb®) (PDF) (CP.PHAR.79)
- Laronidase (PDF) (CP.PHAR.152)
- Larotrectinib (Vitrakvi) (PDF) (CP.PHAR.414)
- Lasmiditan (Reyvow) (PDF) (CP.PMN.218)
- Latanoprostene Bunod (Vyzulta) (PDF) (CP.PMN.108)
- Lemborexant (Dayvigo) (PDF) (CP.PMN.233)
- Lenvatinib (Lenvima) (PDF) (CP.PHAR.138)
- Letermovir (PDF) (CP.PHAR.367)
- Leucovorin Injection (PDF) (CP.PHAR.393)
- Leuprolide Acetate (PDF) (CP.PHAR.173)
- Levalbuterol (Xopenex) (PDF) (CP.PMN.07)
- 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)
- Lorlatinib (Lorbrena) (PDF) (CP.PHAR.406)
- Luliconazole Cream (Luzu) (PDF) (CP.PMN.166)
- Lumateperone (Caplyta) (PDF) (CP.PMN.232)
- Lurasidone (Latuda) (PDF) (CP.PMN.50)
- Lurbinectedin (Zepzelca) (PDF) (CP.PHAR.500)
- 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/Formoterol (Dulera) (PDF) (CP.PMN.230)
- 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)
- necitumumab (PDF) (CP.PHAR.320)
- Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF) (CP.PMN.167)
- neratinib (PDF) (CP.PHAR.365)
- 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)
- Nilotinib (Tasigna) (PDF) (CP.PHAR.76)
- 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)
- Olodaterol (Striverdi Respimat) (PDF) (CP.PMN.204)
- 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) (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)
- Osimertinib (PDF) (CP.PHAR.294)
- 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)
- 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 (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)
- Pexidartinib (Turalio) (PDF) (CP.PHAR.436)
- 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)
- Ponatinib (Iclusig) (PDF) (CP.PHAR.112)
- 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)
- Ripretinib (Qinlock) (PDF) (CP.PHAR.502)
- 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)
- 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)
- 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)
- Selpercatinib (LOXO-292) (PDF) (CP.PHAR.478)
- Selumetinib (PDF) (CP.PHAR.464)
- Sensipar (PDF) (CP.PHAR.61)
- 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)
- 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)
- Tiotropium/Olodaterol (Stiolto Respimat) (PDF) (CP.PMN.148)
- 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)
- Tucatinib (Tukysa) (PDF) (CP.PHAR.497)
- Ubrogepant (Ubrelvy) (PDF) (CP.PHAR.476)
- 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)
- Vandetanib (Caprelsa) (PDF) (CP.PHAR.80)
- 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)
- Zanubrutinib (Brukinsa) (PDF) (CP.PHAR.467)
- 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)
- 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)
- 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
Effective Date |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|---|
4/1/21 |
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." |
Effective Date |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|---|
3/1/21 |
WA.CP.MP.524 |
Whole Exome Sequencing |
New policy |
3/1/21 |
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. |
Effective Date |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|---|
2/1/21 |
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. |
Effective Date |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|---|
1/1/21 |
WA.CP.MP.177 |
Video Electroencephalography (V-EEG) |
New Policy |
1/1/21 |
WA.UM.23 |
Video Electroencephalography (V-EEG) |
Policy is archived and replaced with WA.CP.MP.177 |
1/1/21 |
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. |
1/1/21 |
CP.MP.181 |
Polymerase Chain Reaction Respiratory Viral Panel Testing |
New Policy |
Effective Date |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|---|
|
|
|
|
Effective Date |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|---|
11/1/20 |
CP.MP.189 |
Thymus Transplantation |
New Policy |
11/1/20 |
WA.CP.MP.38 |
Ultrasound in Pregnancy |
Policy is archived and replaced with CP.MP.38 |
11/1/20 |
CP.MP.38 |
Ultrasound in Pregnancy |
New Policy |
Effective Date |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|---|
10/1/20 |
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) |
10/1/20 |
CP.MP.186 |
Burn Surgery |
New policy |
10/1/20 |
CP.MP.184 |
Home Ventilators |
New policy |
10/1/20 |
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. |
10/1/20 |
WA.PP.800 |
Observation Status |
Archived policy |
10/1/20 |
CP.MP.188 |
Pediatric Oral Function Therapy |
New policy |
10/1/20 |
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. |
Effective Date |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|---|
9/1/20 |
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. |
9/1/20 |
CP.MP.96 |
Ambulatory EEG |
Annual review completed. References reviewed and updated. Added the following ICD-10 codes: R40.4, R55 |
9/1/20 |
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. |
9/1/20 |
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. |
9/1/20 |
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. |
9/1/20 |
WA.CP.MP.523 |
Obstructive Sleep Apnea Diagnosis and Treatment |
Clarified Attended Sleep Study criteria. Updated references. |
9/1/20 |
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. |
9/1/20 |
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. |
9/1/20 |
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. |
9/1/20 |
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. |
9/1/20 |
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. |
Effective Date |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|---|
8/1/20 |
WA.CP.MP.185 |
Skin Substitutes for Chronic Wounds |
New Policy |
Effective Date |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|---|
7/1/20 |
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. |
Effective Date |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|---|
6/1/20 |
WA.CP.MP.519 |
Administrative Days |
Removed exclusion for custodial care days. |
6/1/20 |
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. |
6/1/20 |
CP.MP.183 |
2019 Novel Coronavirus Testing |
Added CPT codes 86328 and 86769. |
6/1/20 |
CP.MP.155 |
EEG in the Evaluation of Headache |
Revised CPT 95813 description |
6/1/20 |
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. |
6/1/20 |
CP.MP.140 |
EpiFix |
Archive policy |
6/1/20 |
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 |
6/1/20 |
WA.CP.MP.54 |
Hospice Services |
Annual review, references updated. Inclusion of transportation services added. Associated revenue code added to HCPCS table. |
6/1/20 |
WA.CP.MP.505 |
Microprocessor-Controlled Lower Limb Prosthetics |
Annual review. Added L2006. |
6/1/20 |
WA.CP.MP.517 |
Testosterone Testing |
Annual review. Reference updated. Grammatical changes. 84410 added. |
6/1/20 |
CP.MP.169 |
Trigger Point Injections for Pain Management |
CPT 20560 and 20561 added as not supporting coverage criteria. |
6/1/20 |
CP.MP.56 |
Ventriculectomy and Cardiomyoplasty |
CPT codes added: 33426, 33542, and 33548. |
Effective Date |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|---|
5/1/20 |
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. |
5/1/20 |
CP.MP.89 |
Genetic Testing |
Added general criteria for pharmacogenetic testing. Updated background on pharmacogenetic testing. References reviewed and updated. |
5/1/20 |
CP.MP.109 |
Panniculectomy |
ICD -10 codes added. References reviewed and updated. Specialist reviewed. |
5/1/20 |
CP.MP.142 |
Urinary Incontinence Devices and Treatments |
References reviewed and updated. Added ICD-10: R35.0. |
5/1/20 |
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 |
Effective Date |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|---|
4/1/20
|
CP.MP.103 |
Fractional Exhaled Nitric Oxide |
Added that testing FeNO is investigational for all other conditions, in addition to asthma, with supporting sources. |
4/1/20 |
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 |
Effective Date |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|---|
3/1/20 |
CP.MP.27 |
Hyperbaric Oxygen Therapy |
Policy archived |
3/1/20 |
CP.MP.91 |
OB Home Health Program |
Pre-eclampsia program: I.H changed dipstick reading from 1+ to 2+. Updated background with ACOG’s statement on administration of Hydroxyprogesterone Caproate. Specialist review. |
3/1/20 |
CP.MP.165 |
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections |
Removed restriction of TFESI to lumbar region. Added the statement to all TFESI indications that for cervical TFESI, non-particulate steroid must be used and the procedure must be conducted with real-time imaging, such as fluoroscopy. Revised the not medically necessary statement regarding TFESI for all other indications and locations to only note all other indications. |
3/1/20 |
WA.CP.MP.171 |
Facet Joint Interventions |
Revised wording of section I.A. to match corporate policy. No change to criteria. Updated reference. |
Effective Date |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|---|
2/1/20 |
CP.MP.179 |
Antithrombin III (Atryn, Thromate) |
New policy |
2/1/20 |
CP.MP.180 |
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea |
New policy |
Effective Date |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|---|
1/1/20 |
CP.MP.106 |
Endometrial Ablation |
Added codes F64.0, F64.8 and F64.9 for transgender indication. Expanded the menorrhagia indication to instead say “abnormal uterine bleeding” and added the following corresponding codes: N92.5, N92.6, N93.8, N93.9. |
1/1/20 |
CP.MP.134 |
Evoked Potentials |
Removed age limit in I.B.6 and replaced with “infants and preverbal children or children with developmental delay or intellectual disability.” References reviewed and updated. ICD-10 codes deleted in 2019: H81.41, H81.42, H81.43, H81.49. Specialist review. |
1/1/20 |
CP.MP.137 |
Fecal Incontinence Treatments |
Added recommendation from ACOG to background. References reviewed and updated. CPT code 46762 deleted. Added CPT code 64566 and HPCPS code L8605 as codes that do not support medical necessity. Revised description of CPT codes 95970, 95971 and 95972. Reviewed by specialist. |
1/1/20 |
CP.MP.85 |
Neonatal Sepsis Management Guidelines |
Edits to background information regarding identification and treatment of the newborn per new AAP guidelines. |
1/1/20 |
CP.MP.170 |
Nerve Blocks |
Peripheral/Ganglion Nerve Blocks: Section A indication added for peripheral nerve blocks for malignant pain; section B.1. and 2. added indication for diagnosis or treatment of post-herniorrhaphy pain and therapeutic post-herniorrhapy pain; section C added peripheral nerve blocks for prevention or treatment of headaches, including migraines, refractory migraines in pregnancy, and short-lasting unilateral neuralgiform headaches as not medically necessary. Background and references updated accordingly. |
1/1/20 |
WA.PP.800 |
Observation Stay |
New Policy |
1/1/20 |
CP.MP.49 |
PT, OT, ST Services |
New Policy |
1/1/20 |
CP.MP.146 |
Sclerotherapy for Varicose Veins |
Added perforating veins under a current or healed ulcer as an indication; Edited previous criteria for saphenous veins to apply to saphenous veins or perforating veins. |
1/1/20 |
CP.MP.151 |
Transcatheter Closure of Patent Foramen Ovale |
Annual review. Added Gore Cardioform as an FDA-approved device appropriate for medically necessary closure of PFO. Reviewed by specialist. |
1/1/20 |
CP.MP.142 |
Urinary Incontinence Devices and Treatment |
Separated out criteria for trial and placement of SNM, with trial criteria being the same as permanent placement, excluding the permanent placement requirement for a positive response to the trial. |
1/1/20 |
CP.MP.98 |
Urodynamic Testing |
Added ICD-10-CM code R39.14 to support medical necessity of all procedure codes. Added ICD-10-CM code R35.1 to support medical necessity for CPT 51798. |
Effective Date |
Policy Number |
Policy Title |
Revision Notes |
---|---|---|---|
12/1/19 |
WA.CP.MP.12 |
Vagus Nerve Stimulation |
Moved to state-specific policy. Updated language to reflect Health Technology Assessment. |