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 and Therapy (PDF) (CP.MP.100)
- Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF) (CP.MP.108)
- BH Treatment Documentation Requirements (PDF) (CP.BH.500)
- Biofeedback (PDF) (CP.MP.168)
- Bone-anchored Hearing Aid (PDF) (CP.MP.93)
- Bronchial Thermoplasty (PDF) (CP.MP.110)
- Burn Surgery (PDF) (CP.MP.186)
- Cardiac Biomarker Testing for Acute MI (PDF) (CP.MP.156)
- Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF) (CP.MP.164)
- Clinical Trials (PDF) (CP.MP.94)
- Cochlear Implant Replacement (PDF) (CP.MP.14)
- Cosmetic and Reconstructive Surgery (PDF) (CP.MP.31)
- Deep TMS for OCD (PDF) (CP.BH.201)
- Diaphragmatic/Phrenic Nerve Stimulation (PDF) (CP.MP.203)
- Digital Analysis of EEG (PDF) (CP.MP.105)
- Discography (PDF) (CP.MP.115)
- Donor lymphocyte infusion (PDF) (CP.MP.101)
- Drugs of Abuse: Definitive Testing (PDF) (CP.MP.50)
- Durable Medical Equipment (DME) (PDF) (CP.MP.107)
- Electric Tumor Treating Fields (PDF) (CP.MP.145) - effective through 3/31/23
- Electric Tumor Treating Fields (PDF) (CP.MP.145) - effective 4/1/23
- Electroencephalography in the evaluation of headache (PDF) (CP.MP.155)
- Endometrial ablation (PDF) (CP.MP.106)
- Evoked Potential Testing (PDF) (CP.MP.134)
- Experimental Technologies (PDF) (CP.MP.36)
- 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)
- Gender Affirming Procedures (PDF) (WA.CP.MP.95)
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) (CP.MP.209)
- Genetic Testing Aortopathies & Connective Tissue Disorder (PDF) (CP.MP.215)
- Genetic Testing Cardiac Disorders (PDF) (CP.MP.216)
- Genetic Testing Dermatologic Conditions (PDF) (CP.MP.217)
- Genetic Testing Epilepsy Neurodegenerative Neuromuscular Disorder (PDF) (CP.MP.218)
- Genetic Testing Exome and Genome Sequencing (PDF) (CP.MP.219)
- Genetic Testing Eye Disorders (PDF) (CP.MP.220)
- Genetic Testing Gastroenterologic Disorders (Non-Cancerous) (PDF) (CP.MP.221)
- Genetic Testing General Approach to Genetic Testing (PDF) (CP.MP.222)
- Genetic Testing Hearing Loss (PDF) (CP.MP.223)
- Genetic Testing Hematologic Conditions (non-cancerous) (PDF) (CP.MP.224)
- Genetic Testing Hereditary Cancer Susceptibility (PDF) (CP.MP.225)
- Genetic Testing Immune Autoimmune and Rheumatoid Disorders (PDF) (CP.MP.226)
- Genetic Testing Kidney Disorders (PDF) (CP.MP.227)
- Genetic Testing Lung Disorders (PDF) (CP.MP.228)
- Genetic Testing Metabolic Endocrine and Mitochondrial Disorders (PDF) (CP.MP.229)
- Genetic Testing for Multisystem Inherited Disorders, ID & DD (PDF) (CP.MP.230)
- Genetic Testing Non-Invasive Prenatal Screening (NIPS) (PDF) (CP.MP.231)
- Genetic Testing Pharmacogenetics (PDF) (CP.MP.232)
- Genetic Testing Preimplantation Genetic Testing (PDF) (CP.MP.233)
- Genetic Testing Prenatal and Precon Carrier Screening (PDF) (CP.MP.234)
- Genetic Testing Prenatal Diagnosis (Via Amniocentesis CVS or PUBS) & Pregnancy Loss (PDF) (CP.MP.235)
- Genetic Testing Skeletal Dysplasia and Rare Bone Disorders (PDF) (CP.MP.236)
- Oncology Algorithmic Testing (PDF) (CP.MP.237)
- Oncology Cancer Screening (PDF) (CP.MP.238)
- Oncology Circulating Tumor DNA & Circulating Tumor Cells (Lqd Biopsy) (PDF) (CP.MP.239)
- Oncology Cytogenetic Testing (PDF) (CP.MP.240)
- Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF) (CP.MP.241)
- H. Pylori serology testing (PDF) (CP.MP.153)
- Heart-Lung Transplant (PDF) (CP.MP.132)
- Holter Monitors (PDF) (CP.MP.113)
- Home Birth (PDF) (CP.MP.136)
- Home Ventilators (PDF) (CP.MP.184)
- Homocysteine testing (PDF) (CP.MP.121)
- Hospice Services (PDF) (CP.MP.54)
- Hyperemesis Gravidarum Treatment (PDF) (CP.MP.34)
- Hyperhidrosis Treatments (PDF) (CP.MP.62)
- Implantable Hypoglossal Nerve Stimulation (PDF) (CP.MP.180) - effective through 3/31/23
- Implantable Hypoglossal Nerve Stimulation (PDF) (CP.MP.180) - effective 4/1/23
- Implantable Intrathecal or Epidural Pain Pump (PDF) (CP.MP.173)
- Implantable Loop Recorder (CP.MP.243)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) (CP.MP.160)
- Inhaled Nitric Oxide (PDF) (CP.MP.87)
- Intensity-Modulated Radiotherapy (PDF) (CP.MP.69)
- Intestinal and Multivisceral Transplant (PDF) (CP.MP.58)
- Intradiscal Steroid Injections for Pain Management (PDF) (CP.MP.167)
- IV Moderate Sedation, IV Deep Sedation and General Anesthesia for Dental Procedures (PDF) (CP.MP.61) - effective through 2/28/23
- IV Moderate Sedation, IV Deep Sedation and General Anesthesia for Dental Procedures (PDF) (CP.MP.61) - effective 3/1/23
- Laser therapy for skin conditions (PDF) (CP.MP.123)
- Liposuction of Lipedema (PDF) (CP.MP.244)
- Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF) (CP.MP.139)
- Lung Transplantation (PDF) (CP.MP.57)
- Lysis of Epidural Lesions (PDF) (CP.MP.116)
- Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) (CP.MP.144)
- 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)
- Neuromuscular Electrical Stimulation (NMES) (PDF) (CP.MP.48)
- NICU Apnea Bradycardia Guidelines (PDF) (CP.MP.82)
- NICU Discharge Guidelines (PDF) (CP.MP.81)
- Nonmyeloablative allogeneic SCT (PDF) (CP.MP.141)
- Obstetrical Home Health Care Programs (PDF) (CP.MP.91)
- Optic nerve decompression surgery (PDF) (CP.MP.128)
- Orthognathic Surgery (PDF) (CP.MP.202) - effective through 2/28/23
- Orthognathic Surgery (PDF) (CP.MP.202) - effective 3/1/23
- Osteogenic Stimulation (PDF) (CP.MP.194)
- Outpatient Cardiac Rehabilitation (PDF) (CP.MP.176)
- Oxygen Use and Concentrators (PDF) (CP.MP.190)
- 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 Kidney Transplant (PDF) (CP.MP.246) - effective 2/1/2023
- Pediatric Oral Function Therapy (PDF) (CP.MP.188)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) (CP.MP.147)
- Peripheral and Percutaneous Nerve Stimulation (PDF) (WA.CP.MP.117) - effective 2/1/2023
- Photherapy for Neonatal Hyperbilirubinemia (PDF) (CP.MP.150) - effective through 2/28/23
- Photherapy for Neonatal Hyperbilirubinemia (PDF) (CP.MP.150) - effective 3/1/23
- Physical, Occupational and Speech Therapy Services (PDF) (CP.MP.49)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) (CP.MP.181)
- Posterior tibial nerve stimulation for voiding dysfunction (PDF) (CP.MP.133)
- Proton and Neutron Beam Therapy (PDF) (CP.MP.70)
- Pulmonary Function Testing (PDF) (CP.MP.242) - effective 2/1/23
- Radiofrequency Ablation of Uterine Fibroids (PDF) (CP.MP.187)
- Reduction Mammoplasty and Gynecomastia Surgery (PDF) (CP.MP.51)
- Repair of Nasal Valve Compromise (PDF) (CP.MP.210)
- Sacroiliac Joint Interventions for Pain Management (PDF) (CP.MP.166)
- 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)
- Skilled Nursing Facility Leveling (PDF) (CP.MP.206)
- Skin Substitutes for Chronic Wounds (PDF) (CP.MP.185)
- Sleep Apnea Diagnosis and Treatment (PDF) (WA.CP.MP.523)
- Stereotactic Body Radiation Therapy (PDF) (CP.MP.22)
- Substance Use Treatment and Services (PDF) (CP.BH.100)
- Tandem Transplant (PDF) (CP.MP.162)
- Thyroid hormones and insulin testing in pediatrics (PDF) (CP.MP.154)
- Total artificial heart (PDF) (CP.MP.127)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) (CP.MP.163)
- Transcatheter Closure of Patent Foramen Ovale (PDF) (CP.MP.151) - effective through 3/31/23
- Transcatheter Closure of Patent Foramen Ovale (PDF) (CP.MP.151) - effective 4/1/23
- Transcranial Magnetic Stimulation (PDF) (CP.BH.200)
- Trigger Point Injections for Pain Management (PDF) (CP.MP.169)
- Ultrasound in Pregnancy (PDF) (WA.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)
- Vitamin D Testing (PDF) (WA.CP.MP.527)
- Wheelchair seating (PDF) (CP.MP.99)
- Wireless Motility Capsule (PDF) (CP.MP.143)
Ambetter Pharmacy Policies Listing
- Abaloparatide (Tymlos) (PDF) (CP.PHAR.345)
- Abametapir (Xeglyze) (PDF) (CP.PMN.253)
- Abemaciclib (Verzenio) (PDF) (CP.PHAR.355)
- Abrocitinib (Cibinqo) (PDF) (CP.PHAR.578)
- Acalabrutinib (Calquence) (PDF) (CP.PHAR.366)
- Acyclovir Buccal Tablet (Sitavig), Ophthalmic Ointment (Avaclyr) (PDF) (CP.PMN.210)
- Afamelanotide (Scenesse) (PDF) (CP.PHAR.444)
- Abiraterone (PDF) (CP.PHAR.84)
- AbobotulinumtoxinA (Dysport) (PDF) (CP.PHAR.230)
- Adefovir (Hepsera) (PDF) (CP.PHAR.142)
- Ado-Trastuzumab (Kadcyla) (PDF) (CP.PHAR.229)
- Aducanumab (PDF) (CP.PHAR.468)
- Afatinib (Gilotrif) (PDF) (CP.PHAR.298)
- Afinitor (everolimus) (PDF) (CP.PHAR.63)
- Aflibercept (Eylea®) (PDF) (CP.PHAR.184)
- Agalsidase Beta (Fabrazyme) (PDF) (CP.PHAR.158)
- Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) (CP.PMN.138)
- Alectinib (Alecensa) (PDF) (CP.PHAR.369)
- Alemtuzumab (Lemtrada) (PDF) (CP.PHAR.243)
- Alendronate (Binosto, Fosamax plus D) (PDF) (CP.PMN.88)
- Alglucosidase (Lumizyme) (PDF) (CP.PHAR.160)
- Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) (PDF) (CP.PHAR.562)
- Allogenic Processed Thymus Tissue-agdc (Rethymic) (PDF) (CP.PHAR.563)
- Alpelisib (Piqray) (PDF) (CP.PHAR.430)
- Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF) (CP.PHAR.94)
- Amantadine ER (Gocovri, Osmolex ER) (PDF) (CP.PMN.89)
- Ambrisentan (Letairis®) (PDF) (CP.PHAR.190)
- Amifampridine (Firdapse) (PDF) (CP.PHAR.411)
- Amikacin (Arikayce) (PDF) (CP.PHAR.401)
- Amisulpride (Barhemsys) (PDF) (CP.PMN.236)
- Amivantamab-vmjw (Rybrevant) (PDF) (CP.PHAR.544)
- Anifrolumab-fnia (Saphnelo) (PDF) (CP.PHAR.551)
- Anti-Inhibitor Coagulant Complex (Feiba®) (PDF) (CP.PHAR.217)
- Antithrombin III (ATryn, Thrombate III) (PDF) (CP.PHAR.564)
- Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) (CP.PHAR.506)
- Apalutamide (Erleada) (PDF) (CP.PCH.45)
- Apomorphine (Apokyn, Kynmobi) (PDF) (CP.PHAR.488)
- aprepitant (PDF) (CP.PMN.19)
- Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF) (CP.PHAR.290)
- Aripiprazole Orally Disintegrating Tablet (PDF) (CP.PCH.37)
- Armodafinil (Nuvigil) (PDF) (CP.PMN.35)
- Asciminib (Scemblix) (PDF) (CP.PHAR.565)
- Asenapine (Saphris) (PDF) (CP.PMN.15)
- Asfotase Alfa (Strensiq) (PDF) (CP.PHAR.328)
- Aspirin-dipyridamole (Aggrenox) (PDF) (CP.PMN.20)
- Atezolizumab (Tecentriq®) (PDF) (CP.PHAR.235)
- Atogepant (Qulipta) (PDF) (CP.PHAR.566)
- Avacopan (Tavneos) (PDF) (CP.PHAR.515)
- Avalglucosidase Alfa-ngpt (Nexviazyme) (PDF) (CP.PHAR.521)
- Avapritinib (Ayvakit) (PDF) (CP.PHAR.454)
- Avatrombopag (Doptelet) (PDF) (CP.PHAR.130)
- Avelumab (Bavencio®) (PDF) (CP.PHAR.333)
- Axicabtagene Ciloleucel (Yescarta®) (PDF) (CP.PHAR.362)
- Axitinib (Inlyta®) (PDF) (CP.PHAR.100)
- Azacitidine (Vidaza) (PDF) (CP.PHAR.387)
- Azelaic Acid (Finacea) (PDF) (HIM.PA.119)
- Aztreonam (Cayston®) (PDF) (CP.PHAR.209)
- Baloxavir Marboxil (Xofluza) (PDF) (CP.PMN.185)
- Bedaquiline (Sirturo) (PDF) (CP.PMN.212)
- Belantamab Mafodotin (Blenrep) (PDF) (CP.PHAR.469)
- belatacept (Nulojix®) (PDF) (CP.PHAR.201)
- Belimumab (Benlysta) (PDF) (CP.PHAR.88)
- belinostat (Beleodaq®) (PDF) (CP.PHAR.311)
- Belumosudil (Rezurock) (PDF) (CP.PHAR.552)
- Belzutifan (Welireg) (PDF) (CP.PHAR.553)
- Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet) (PDF) (CP.PMN.237)
- bendamustine (Bendeka®, Treanda®) (PDF) (CP.PHAR.307)
- Benralizumab (Fasenra) (PDF) (CP.PHAR.373)
- Benznidazole (PDF) (CP.PMN.90)
- Betaine (Cystadane) (PDF) (CP.PHAR.143)
- Betamethasone Dipropionate Spray (Sernivo) (PDF) (CP.PMN.182)
- Betibeglogene Autotemcel (Zynteglo) (PDF) (CP.PHAR.545)
- Bevacizumab (Avastin) (PDF) (CP.PHAR.93)
- Bexarotene (Targretin Capsules, Gel) (PDF) (CP.PHAR.75)
- Bezlotoxumab (Zinplava) (PDF) (CP.PHAR.300)
- Bimatoprost Implant (Durysta) (PDF) (CP.PHAR.486)
- Binimetinib (PDF) (CP.PHAR.50)
- Biologic DMARDs (PDF) (HIM.PA.SP60)
- Blinatumomab (PDF) (CP.PHAR.312)
- Bortezomib (Velcade) (PDF) (CP.PHAR.410)
- Bosentan (Tracleer®) (PDF) (CP.PHAR.191)
- Bosutinib (Bosulif) (PDF) (CP.PHAR.105)
- Brand Name Override and Non-Formulary Medications (PDF) (HIM.PA.103)
- Brentuximab (PDF) (CP.PHAR.303)
- Brexanolone (Zulresso) (PDF) (CP.PHAR.417)
- Brexpiprazole (Rexulti) (PDF) (CP.PMN.68)
- Brexucabtagene Autoleucel (Tecartus) (PDF) (CP.PHAR.472)
- Brigatinib (Alunbrig) (PDF) (CP.PHAR.342)
- Brimonidine Tartrate (Mirvaso) (PDF) (CP.PMN.192)
- Brinzolamide/Brimonidine (Simbrinza) (PDF) (HIM.PA.15)
- Brivaracetam (Briviact) (PDF) (CP.PCH.26)
- Brolucizumab-dbll (Beovu) (PDF) (CP.PHAR.445)
- Budesonide (Tarpeyo) (PDF) (CP.PHAR.572)
- Budesonide (Uceris) (PDF) (CP.PCH.11)
- Buprenorphine (Subutex) (PDF) (CP.PMN.82)
- buprenorphine implant (Probuphine) (PDF) (CP.PHAR.289)
- Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF) (CP.PMN.81)
- Bupropion/Naltrexone (Contrave) (PDF) (CP.PCH.12)
- Burosumab-twza (Crysvita) (PDF) (CP.PHAR.11)
- Butorphanol Nasal Spray (PDF) (HIM.PA.46)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF) (CP.PHAR.202)
- Cabazitaxel (Jevtana) (PDF) (CP.PHAR.316)
- Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) (PDF) (CP.PHAR.573)
- Cabozantinib (Cometriq®, Cabometyx®) (PDF) (CP.PHAR.111)
- Calcifediol (Rayaldee) (PDF) (CP.PMN.76)
- Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) (PDF) (CP.PMN.181)
- Canakinumab (Ilaris) (PDF) (CP.PHAR.246)
- Cannabidiol (Epidiolex) (PDF) (CP.PMN.164)
- Capecitabine (Xeloda) (PDF) (CP.PHAR.60)
- Caplacizumab-yhdp (Cablivi) (PDF) (CP.PHAR.416)
- Capmatinib (Tabrecta) (PDF) (CP.PHAR.494)
- Carbidopa/Levodopa ER Capsules (Rytary) (PDF) (CP.PMN.238)
- carfilzomib (Kyprolis®) (PDF) (CP.PHAR.309)
- Carglumic Acid (Carbaglu) (PDF) (CP.PHAR.206)
- Cariprazine (Vraylar) (PDF) (CP.PMN.91)
- Casimersen (Amondys 45) (PDF) (CP.PHAR.470)
- Casirivimab and Imdevimab (REGEN-COV) (PDF) (CP.PHAR.520)
- Celecoxib (Celebrex) (PDF) (CP.PMN.122)
- Cemiplimab-rwlc (Libtayo) (PDF) (CP.PHAR.397)
- Cenegermin-bkbj (Oxervate) (PDF) (CP.PMN.186)
- Cenobamate (Xcopri) (PDF) (CP.PMN.231)
- Ceritinib (Zykadia) (PDF) (CP.PHAR.349)
- Cerliponase alfa (PDF) (CP.PHAR.338)
- cetuximab (Erbitux®) (PDF) (CP.PHAR.317)
- Chenodiol (Chenodal) (PDF) (CP.PMN.239)
- Chlorambucil (Leukeran) (PDF) (CP.PHAR.554)
- Chloramphenicol Sodium Succinate (PDF) (CP.PHAR.388)
- Cholic Acid (Cholbam) (PDF) (CP.PHAR.390)
- Ciclopirox (Penlac) (PDF) (CP.PMN.24)
- Ciltacabtagene Autoleucel (Carvykti) (PDF) (CP.PHAR.533)
- Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) (CP.PMN.248)
- Ciprofloxacin/Fluocinolone (Otovel) (PDF) (CP.PMN.249)
- Cladribine (Mavenclad) (PDF) (CP.PHAR.422)
- Clascoterone (Winlevi) (PDF) (CP.PMN.257)
- Clobazam (PDF) (CP.PMN.54)
- CNS Stimulants (PDF) (CP.PMN.92)
- Cobimetinib (Cotellic) (PDF) (CP.PHAR.380)
- Colesevelam (Welchol) (PDF) (CP.PMN.250)
- Collagenase (PDF) (CP.PHAR.82)
- Colonoscopy Preparation Products (PDF) (CP.PCH.43)
- Compounded Medications (PDF) (CP.PMN.280)
- Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) (CP.PMN.258)
- Continuous Glucose Monitors (PDF) (CP.PMN.214)
- copanlisib (Aliqopa®) (PDF) (CP.PHAR.357)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert) (PDF) (CP.PHAR.385)
- Cosyntropin (Cortrosyn®) (PDF) (CP.PHAR.203)
- Crisaborole (Eucrisa) (PDF) (CP.PMN.110)
- Crizanlizumab-tmca (Adakveo) (PDF) (CP.PHAR.449)
- Crizotinib (Xalkori) (PDF) (CP.PHAR.90)
- Cyclosporine ophthalmic emulsion (Cequa, Restasis) (PDF) (CP.PMN.48)
- Cyramza® (PDF) (CP.PHAR.119)
- Cysteamine ophthalmic (Cystaran, Cystadrops) (PDF) (CP.PMN.130)
- Cysteamine oral (Cystagon, Procysbi) (PDF) (CP.PHAR.155)
- Cytomegalovirus Immune Globulin (Cytogam) (PDF) (CP.PHAR.277)
- Dabrafenib (Tafinlar) (PDF) (CP.PHAR.239)
- Dacomitinib (Vizimpro) (PDF) (CP.PHAR.399)
- Dalfampridine (Ampyra) (PDF) (CP.PHAR.248)
- Dalteparin (Fragmin) (PDF) (CP.PHAR.225)
- Daptomycin (Cubicin, Cubicin RF) (PDF) (CP.PHAR.351)
- Daratumumab (PDF) (CP.PHAR.310)
- Darbepoetin alfa (Aranesp) (PDF) (CP.PHAR.236)
- Darolutamide (Nubeqa) (PDF) (CP.PHAR.435)
- Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) (PDF) (HIM.PA.SP61)
- Dasatinib (Sprycel) (PDF) (CP.PHAR.72)
- Dapsone (Aczone Gel) (PDF) (CP.PCH.32)
- daunorubicin/cytarabine (Vyxeos®) (PDF) (CP.PHAR.352)
- Decitabine-Cedazuridine (Inqovi) (PDF) (CP.PHAR.479)
- deferasirox (PDF) (CP.PHAR.145)
- Deferoxamine (Desferal) (PDF) (CP.PHAR.146)
- Deflazacort (Emflaza) (PDF) (CP.PHAR.331)
- degarelix acetate (Firmagon®) (PDF) (CP.PHAR.170)
- Delafloxacin (Baxdela) (PDF) (CP.PMN.115)
- Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (PDF) (CP.PHAR.214)
- Deutetrabenazine (Austedo) (PDF) (CP.PCH.42)
- Dexlansoprazole (Dexilant) (PDF) (HIM.PA.05)
- Dexrazoxane (Zinecard Totect) (PDF) (CP.PHAR.418)
- Dextromethorphan/Bupropion (Auvelity) (PDF) (CP.PMN.284)
- Dextromethorphan-Quinidine (Nuedexta) (PDF) (CP.PMN.93)
- Diazepam Nasal Spray (Valtoco) (PDF) (CP.PMN.216)
- Dichlorphenamide (Keveyis) (PDF) (CP.PMN.261)
- Diclofenac (Cambia, Flector, Licart, Pennsaid, Solaraze, Zipsor, Zorvolex) (PDF) (CP.PCH.28)
- Dimethyl Fumarate (Tecfidera) (PDF) (CP.PCH.41)
- Dipeptidyl Peptidase-4 Inhibitors (PDF) (HIM.PA.58)
- Dolasetron (Anzemet) (PDF) (CP.PMN.141)
- Dornase alfa (Pulmozyme) (PDF) (CP.PHAR.212)
- Dostarlimab-gxly (Jemperli) (PDF) (CP.PHAR.540)
- Doxepin Hydrochloride Cream (Prudoxin, Zonalon) (PDF) (HIM.PA.147)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF) (CP.PMN.79)
- Dupilumab (Dupixent) (PDF) (CP.PHAR.336)
- Durvalumab (Imfinzi) (PDF) (CP.PHAR.339)
- Duvelisib (Copiktra) (PDF) (CP.PHAR.400)
- Ecallantide (Kalbitor®) (PDF) (CP.PHAR.177)
- Eculizumab (Soliris®) (CP.PHAR.97)
- Edaravone (Radicava) (PDF) (CP.PHAR.343)
- Efgartigimod Alfa-fcab (Vyvgart) (PDF) (CP.PHAR.555)
- Efinaconazole (Jublia) (PDF) (CP.PMN.25)
- Elagolix (Orilissa) (PDF) (CP.PHAR.136)
- Elapegademase-lvlr (Revcovi) (PDF) (CP.PHAR.419)
- Elbasvir/Grazoprevir (Zepatier) (PDF) (HIM.PA.SP62)
- Electromyography and Nerve Conduction Studies (PDF) (CP.MP.211) Effective 9/1/21
- Elexacaftor, tezacaftor (Trikafta) (PDF) (CP.PHAR.440)
- Eliglustat (Cerdelga) (PDF) (CP.PHAR.153)
- Elivaldogene Autotemcel (Skysona) (PDF) (CP.PHAR.556)
- Elotuzumab (Empliciti®) (PDF) (CP.PHAR.308)
- Elosulfase alfa (Vimizim) (PDF) (CP.PHAR.162)
- Eltrombopag (Promacta®) (PDF) (CP.PHAR.180)
- Eluxadoline (Viberzi) (PDF) (CP.PMN.170)
- Emapalumab-lzsg (Gamifant) (PDF) (CP.PHAR.402)
- Emicizumab-kxwh (Hemlibra) (PDF) (CP.PHAR.370)
- Emtricitabine/Tenofovir Alafenamide (Descovy) (PDF) (CP.PMN.235)
- Enasidenib (Idhifa) (PDF) (CP.PHAR.363)
- Encorafenib (PDF) (CP.PHAR.127)
- Enfortumab Vedotin-ejfv (Padcev) (PDF) (CP.PHAR.455)
- Enfuvirtide (PDF) (CP.PHAR.41)
- Enoxaparin (Lovenox) (PDF) (CP.PHAR.224)
- Entecavir (Baraclude) (PDF) (HIM.PA.08)
- Entrectinib (Rozlytrek) (PDF) (CP.PHAR.441)
- Enzalutamide (Xtandi) (PDF) (HIM.PA.164)
- Epoetin alfa (Epogen, Procrit), Epoetin alfa-epbx (Retacrit) (PDF) (CP.PHAR.237)
- Epoprostenol (Flolan®, Veletri®) (PDF) (CP.PHAR.192)
- Eptinezumab-jjmr (Vyepti) (PDF) (HIM.PA.SP64)
- Erdafitinib (Balversa) (PDF) (CP.PHAR.423)
- Eribulin Mesylate (Halaven®) (PDF) (CP.PHAR.318)
- Erlotinib (Tarceva) (PDF) (CP.PHAR.74)
- Erenumab-aaoe (Aimovig) (PDF) (HIM.PA.SP65)
- erwina asparaginase (Erwinaze®) (PDF) (CP.PHAR.301)
- Esketamine (Spravato) (PDF) (CP.PMN.199)
- Estradiol Vaginal Ring (Femring) (PDF) (CP.PMN.263)
- Etelcalcetide (Parsabiv) (PDF) (CP.PHAR.379)
- Eteplirsen (Exondys 51) (PDF) (CP.PHAR.288)
- Evinacumab-dgnb (Evkeeza) (PDF) (CP.PHAR.511)
- Evolocumab (Repatha) (PDF) (HIM.PA.156)
- Factor IX (Human, Recombinant) (PDF) (CP.PHAR.218)
- Factor IX Complex Human (Bebulin®, Profilnine®) (PDF) (CP.PHAR.219)
- Factor VIIa, Recombinant (NovoSeven® RT) (PDF) (CP.PHAR.220)
- Factor VIII (Human Recombinant) (PDF) (CP.PHAR.215)
- Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF) (CP.PHAR.216)
- Factor XIII A-Subunit, Recombinant (Tretten®) (PDF) (CP.PHAR.222)
- Factor XIII, Human (Corifact®) (PDF) (CP.PHAR.221)
- Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) (CP.PHAR.456)
- Faricimab-svoa (Vabysmo) (PDF) (CP.PHAR.581)
- Febuxostat (Uloric) (PDF) (CP.PMN.57)
- 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)
- Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP) (PDF) (CP.PHAR.526)
- Filgrastim (PDF) (CP.PHAR.297)
- Finerenone (Kerendia) (PDF) (CP.PMN.266)
- Fingolimod (Gilenya) (PDF) (CP.PCH.38)
- Flibanserin (Addyi) (PDF) (CP.PHAR.446)
- Fluorouracil Cream (Tolak) (PDF) (CP.PMN.165)
- Fluticasone Propionate (Xhance) (PDF) (CP.PMN.95)
- Fondaparinux (Arixtra) (PDF) (CP.PHAR.226)
- Formulary Medications Without Specific Guidelines (PDF) (HIM.PA.33)
- Fosdenopterin (Nulibry) (PDF) (CP.PHAR.471)
- Fostamatinib (Tavalisse) (PDF) (CP.PHAR.24)
- Fremanezumab-vfrm (Ajovy) (PDF) (HIM.PA.SP66)
- Fulvestrant (Faslodex Injection) (PDF) (CP.PHAR.424)
- Gabapentin ER (Gralise, Horizant) (PDF) (CP.PMN.240)
- Galcanezumab-gnlm (Emgality) (PDF) (HIM.PA.SP67)
- Galsulfase (Naglazyme) (PDF) (CP.PHAR.161)
- Ganaxolone (Ztalmy) (PDF) (CP.PMN.278)
- Gefitinib (Iressa) (PDF) (CP.PHAR.68)
- gemtuzumab ozogamicin (Mylotarg®) (PDF) (CP.PHAR.358)
- Gilteritinib (Xospata) (PDF) (CP.PHAR.412)
- Givosiran (Givlaari) (PDF) (CP.PHAR.457)
- Glasdegib (Daurismo) (PDF) (CP.PHAR.413)
- Glatiramer (Copaxone, Glatopa) (PDF) (HIM.PA.SP68)
- Glecaprevir/Pibrentasvir (Mavyret) (PDF) (HIM.PA.SP36)
- Glucagon-Like Peptide-1 Receptor Agonists (PDF) (HIM.PA.53)
- Glycerol phenylbutyrate (Ravicti®) (PDF) (CP.PHAR.207)
- Golodirsen (Vyondys 53) (PDF) (CP.PHAR.453)
- goserelin acetate (Zoladex®) (PDF) (CP.PHAR.171)
- Granisetron (Sancuso, Sustol) (PDF) (CP.PMN.74)
- Halcinonide (Halog) (PDF) (HIM.PA.20)
- Halobetasol Propionate (Bryhali, Lexette, Ultravate) (PDF) (CP.PMN.180)
- Halobetasol Propionate/Tazarotene (Duobrii) (PDF) (CP.PMN.208)
- Hemin (Panhematin®) (PDF) (CP.PHAR.181)
- histrelin acetate (Vantas®, Supprelin LA®) (PDF) (CP.PHAR.172)
- House Dust Mite Allergen Extract (Odactra) (PDF) (CP.PMN.111)
- Human Growth Hormone (Somapacitan, Somatropin) (PDF) (HIM.PA.161)
- Hyaluronate Derivatives (PDF) (CP.PHAR.05)
- Hydroxyprogesterone Caproate (Makena/compound) (PDF) (CP.PHAR.14)
- Hydroxyurea (Siklos) (PDF) (CP.PMN.193)
- Ibalizumab-uiyk (Trogarzo) (PDF) (CP.PHAR.378)
- Ibandronate Injection (Boniva) (PDF) (CP.PHAR.189)
- Ibrutinib (PDF) (CP.PHAR.126)
- Ibuprofen/Famotidine (Duexis) (PDF) (CP.PMN.120)
- Icatibant (Firazyr®) (PDF) (CP.PHAR.178)
- Icosapent ethyl (Vascepa) (PDF) (CP.PMN.187)
- Idecabtagene Vicleucel (Abecma) (PDF) (CP.PHAR.481)
- Idelalisib (Zydelig) (PDF) (CP.PHAR.133)
- Idursulfase (PDF) (CP.PHAR.156)
- Iloperidone (Fanapt) (PDF) (CP.PMN.32)
- Iloprost (Ventavis®) (PDF) (CP.PHAR.193)
- Imatinib (Gleevec) (CP.PHAR.65) (PDF)
- Imiglucerase (Cerezyme) (PDF) (CP.PHAR.154)
- Immune Globulins (PDF) (CP.PHAR.103)
- Inclisiran (Leqvio) (PDF) (CP.PHAR.568)
- IncobotulinumtoxinA (Xeomin) (PDF) (CP.PHAR.231)
- Inebilizumab-cdon (Uplizna) (PDF) (CP.PHAR.458)
- Inhaled Agents for Asthma and COPD (PDF) (HIM.PA.153)
- Infertility and Fertility Preservation (PDF) (CP.PHAR.131)
- Infigratinib (Truseltiq) (PDF) (CP.PHAR.547)
- Inotersen (Tegsedi) (PDF) (CP.PHAR.405)
- inotuzumab ozogamicin (Besponsa®) (PDF) (CP.PHAR.359)
- Insulin Degludec (Tresiba) (PDF) (HIM.PA.09)
- Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF) (CP.PHAR.534)
- Interferon beta-1a (Avonex, Rebif) (PDF) (CP.PHAR.255)
- Interferon Beta-1b (Betaseron, Extavia) (PDF) (CP.PCH.46)
- Interferon Gamma- 1b (Actimmune) (PDF) (CP.PHAR.52)
- Intrathecal Baclofen (Gablofen, Lioresal) (PDF) (CP.PHAR.149)
- Iobenguane I-131 (Azedra) (PDF) (CP.PHAR.459)
- Ipilimumab (Yervoy) (PDF) (CP.PHAR.319)
- irinotecan Liposome (Onivyde®) (PDF) (CP.PHAR.304)
- Iron sucrose (Venofer®) (PDF) (CP.PHAR.167)
- Isatuximab-irfc (Sarclisa) (PDF) (CP.PHAR.482)
- Isavuconazonium (Cresemba®) (PDF) (CP.PMN.154)
- Isotretinoin (PDF) (CP.PMN.143)
- Istradefylline (Nourianz) (PDF) (CP.PMN.217)
- Itraconazole (Sporanox, Onmel) (PDF) (CP.PMN.124)
- Ivabradine (Corlanor) (PDF) (CP.PMN.70)
- Ivacaftor (Kalydeco) (PDF) (CP.PHAR.210)
- ivermectin (Sklice®) (PDF) (HIM.PA.124)
- Ivermectin (Stromectol, Sklice) (PDF) (CP.PMN.269)
- Ivosidenib (Tibsovo) (PDF) (CP.PHAR.137)
- Ixazomib (PDF) (CP.PHAR.302)
- Ketorolac Nasal Spray (Sprix) (PDF) (CP.PMN.282)
- Korlym (mifepristone) (PDF) (CP.PHAR.101)
- Lanadelumab-fylo (Takhzyro) (PDF) (CP.PHAR.396)
- Lanreotide (Somatuline Depot) (PDF) (CP.PHAR.391)
- lapatinib (Tykerb®) (PDF) (CP.PHAR.79)
- Laronidase (Aldurazyme) (PDF) (CP.PHAR.152)
- Larotrectinib (Vitrakvi) (PDF) (CP.PHAR.414)
- Lasmiditan (Reyvow) (PDF) (CP.PMN.218)
- Latanoprostene Bunod (Vyzulta) (PDF) (CP.PMN.108)
- Ledipasvir/Sofosbuvir (Harvoni) (PDF) (HIM.PA.SP3)
- Lefamulin (Xenleta) (PDF) (CP.PMN.219)
- Lenalidomide (Revlimid) (PDF) (CP.PHAR.71)
- Lenvatinib (Lenvima) (PDF) (CP.PHAR.138)
- Letermovir (Prevymis) (PDF) (CP.PHAR.367)
- Levodopa Inhalation Powder (Inbrija) (PDF) (CP.PMN.267)
- Levoketoconazole (Recorlev) (PDF) (CP.PMN.275)
- levoleucovorin (Fusilev) (PDF) (CP.PHAR.151)
- Levomilnacipran (Fetzima) (PDF) (HIM.PA.125)
- Leucovorin Injection (PDF) (CP.PHAR.393)
- Leuprolide Acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi) (PDF) (CP.PHAR.173)
- L-glutamine (Endari) (PDF) (CP.PMN.116)
- lidocaine transdermal (Lidoderm, ZTlido) (PDF) (CP.PMN.08)
- Lifitegrast (Xiidra®) (PDF) (CP.PMN.73)
- Linaclotide (Linzess) (PDF) (CP.PMN.71)
- Linezolid (Zyvox) (PDF) (CP.PMN.27)
- Lisocabtagene Maraleucel (Breyanzi) (PDF) (CP.PHAR.483)
- Lofexidine (Lucemyra) (PDF) (CP.PMN.152)
- Lomustine (Gleostine) (PDF) (CP.PHAR.507)
- Lonafarnib (Zokinvy) (PDF) (CP.PHAR.499)
- Loncastuximab Tesirine-lpyl (Zynlonta) (PDF) (CP.PHAR.539)
- Lorlatinib (Lorbrena) (PDF) (CP.PHAR.406)
- Loteprednol etabonate (Eysuvis) (PDF) (CP.PMN.260)
- Lubiprostone (Amitiza) (PDF) (CP.PMN.142)
- Luliconazole Cream (Luzu) (PDF) (CP.PMN.166)
- Lumacaftor-ivacaftor (PDF) (CP.PHAR.213)
- Lumasiran (Oxlumo) (PDF) (CP.PHAR.473)
- Lumateperone (Caplyta) (PDF) (CP.PMN.232)
- Lurasidone (Latuda) (PDF) (CP.PMN.50)
- Lurbinectedin (Zepzelca) (PDF) (CP.PHAR.500)
- Luspatercept-aamt (Reblozyl) (PDF) (CP.PHAR.450)
- Lusutrombopag (Mulpleta) (PDF) (CP.PHAR.407)
- Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) (PDF) (CP.PHAR.582)
- Lutetium Lu 177 Dotatate (Lutathera) (PDF) (CP.PHAR.384)
- Macitentan (Opsumit) (PDF) (CP.PHAR.194)
- Mannitol (Bronchitol) (PDF) (CP.PHAR.518)
- Maralixibat (LUM001) (PDF) (CP.PHAR.543)
- Margetuximab-cmkb (Margenza) (PDF) (CP.PHAR.522)
- Maribavir (Livtencity) (PDF) (CP.PMN.271)
- Mavacamten (Camzyos) (PDF) (CP.PMN.272)
- Mecamylamine (Vecamyl) (PDF) (CP.PMN.136)
- Mecaserim (PDF) (CP.PHAR.150)
- Mechlorethamine Gel (Valchlor) (PDF) (CP.PHAR.381)
- Megestrol Acetate (Megace ES) (PDF) (CP.PMN.179)
- Melphalan flufenamide (Pepaxto) (PDF) (CP.PHAR.535)
- Memantine ER (Namenda XR), Memantine/Donepezil (Namzaric) (PDF) (CP.PCH.30)
- Mepolizumab (Nucala) (PDF) (CP.PHAR.200)
- Mercaptopurine (Purixan) (PDF) (CP.PHAR.447)
- Metformin ER (Fortamet, Glumetza) (PDF) (CP.PMN.72)
- Methotrexate (Otrexup, Rasuvo, Xatmep) (PDF) (CP.PHAR.134)
- Methoxsalen (Uvadex) (PDF) (HIM.PA.17)
- Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) (CP.PHAR.238)
- Methylnaltrexone Bromide (Relistor) (PDF) (CP.PMN.169)
- Metoclopramide (Gimoti) (PDF) (CP.PMN.252)
- Metreleptin (Myalept) (PDF) (CP.PHAR.425)
- Midazolam (Nayzilam) (PDF) (CP.PMN.211)
- Midostaurin (Rydapt) (PDF) (CP.PHAR.344)
- Migalastat (Galafold) (PDF) (CP.PHAR.394)
- Miglustat (Zavesca) (PDF) (CP.PHAR.164)
- Milnacipran (Savella) (PDF) (CP.PMN.125)
- Minocycline ER (Solodyn, Ximino, Minolira) and Microspheres (Arestin), Foam (Zilxi) (PDF) (CP.PMN.80)
- Mitapivat (Pyrukynd) (PDF) (CP.PHAR.558)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF) (CP.PHAR.495)
- Mitoxantrone (Novantrone) (PDF) (CP.PHAR.258)
- Mobocertinib (Exkivity) (PDF) (CP.PHAR.559)
- Modafinil (Provigil) (PDF) (CP.PMN.39)
- Mogamulizumab-kpkc (Poteligeo) (PDF) (CP.PHAR.139)
- Mometasone (Nasonex) (PDF) (HIM.PA.93)
- Mometasone Furoate (Sinuva) (PDF) (CP.PHAR.448)
- Montelukast oral granules (Singulair) (PDF) (HIM.PA.129)
- Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) (CP.PHAR.398)
- 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) (CP.PHAR.259)
- Naxitamab-gqgk (Danyelza) (PDF) (CP.PHAR.523)
- necitumumab (Portrazza®) (PDF) (CP.PHAR.320)
- Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF) (CP.PMN.167)
- Neratinib (Nerlynx) (PDF) (CP.PHAR.365)
- 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)
- Niraparib (Zejula) (PDF) (CP.PHAR.408)
- Nitazoxanide (Alinia) (PDF) (HIM.PA.152)
- Nitisinone (Nityr, Orfadin) (PDF) (CP.PHAR.132)
- Nivolumab (PDF) (CP.PHAR.121)
- Nivolumab and Relatlimab-rmbw (Opdualag) (PDF) (CP.PHAR.588)
- No Coverage Criteria/Off-Label Use Policy (PDF) (CP.PMN.53)
- Non-Calcium Phosphate Binders (PDF) (CP.PMN.04)
- Non-Formulary and Formulary Contraceptives (PDF) (HIM.PA.100)
- Non-Formulary Test Strips (PDF) (HIM.PA.34)
- Nusinersen (PDF) (CP.PHAR.327)
- Obeticholic Aacid (Ocaliva) (PDF) (CP.PHAR.287)
- obinutuzumab (Gazyva®) (PDF) (CP.PHAR.305)
- Ocrelizumab (Ocrevus) (PDF) (CP.PHAR.335)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot) (PDF) (CP.PHAR.40)
- Odevixibat (Bylvay) (PDF) (CP.PHAR.528)
- Ofatumumab (Arzerra, Kesimpta) (PDF) (CP.PHAR.306)
- Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) (CP.PHAR.292)
- Olanzapine/Samidorphan (Lybalvi) (PDF) (CP.PMN.265)
- Olaparib (Lynparza) (PDF) (CP.PHAR.360)
- olaratumab (Lartruvo®) (PDF) (CP.PHAR.326)
- Olipudase Alfa-rpcp (Xenpozyme) (PDF) (CP.PHAR.586)
- Omecetaxine (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)
- Opicapone (Ongentys) (PDF) (CP.PMN.245)
- Opioid Analgesics (PDF) (HIM.PA.139)
- Ophthalmic Corticosteroids (PDF) (HIM.PA.03)
- Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF) (CP.PHAR.536)
- Osilodrostat (Isturisa) (PDF) (CP.PHAR.487)
- Osimertinib (Tagrisso) (PDF) (CP.PHAR.294)
- Ospemifene (Osphena) (PDF) (CP.PMN.168)
- Overactive Bladder Agents (PDF) (CP.PMN.198)
- Oxymetazoline (Rhofade, Upneeq) (PDF) (CP.PMN.86)
- Ozanimod (Zeposia) (PDF) (CP.PHAR.462)
- Ozenoxacin (Xepi) (PDF) (CP.PMN.119)
- Paclitaxel protein-bound (Abraxane) (PDF) (CP.PHAR.176)
- Pacritinib (Vonjo) (PDF) (CP.PHAR.583)
- Palbociclib (Ibrance) (PDF) (CP.PHAR.125)
- Paliperidone Long-Acting Injections (Invega Sustenna, Invega Trinza) (PDF) (CP.PHAR.291)
- Palivizumab (Synagis) (PDF) (CP.PHAR.16)
- Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep) (PDF) (CP.PCH.44)
- panitumumab (Vectibix®) (PDF) (CP.PHAR.321)
- Panobinostat (Farydak) (PDF) (CP.PHAR.382)
- Parathyroid Hormone (Natpara) (PDF) (CP.PHAR.282)
- Paricalcitrol Injection (PDF) (CP.PHAR.270)
- pasireotide (Signifor LAR®) (PDF) (CP.PHAR.332)
- Patiromer (Veltassa) (PDF) (CP.PMN.205)
- Patisiran (Onpattro) (PDF) (CP.PHAR.395)
- Pazopanib (PDF) (CP.PHAR.81)
- Peanut Allergen Powder-dnfp (Palforzia) (PDF) (CP.PMN.220)
- Pegaptanib (Macugen) (PDF) (CP.PHAR.185)
- pegaspargase (Oncaspar®) (PDF) (CP.PHAR.353)
- Pegcetacoplan (Empaveli) (PDF) (CP.PHAR.524)
- Pegfilgrastim (PDF) (CP.PHAR.296)
- Peginterferon beta-1a (Plegridy) (PDF) (CP.PHAR.271)
- Pegloticase (Krystexxa®) (PDF) (CP.PHAR.115)
- 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 (PDF) (CP.PCH.47)
- Phentermine (Adipex-P, Lomaira) (PDF) (CP.PCH.13)
- Pilocarpine (Vuity) (PDF) (CP.PMN.270)
- Pimavanserin (Nuplazid) (PDF) (CP.PMN.140)
- Pirfenidone (Esbriet) (PDF) (CP.PHAR.286)
- Pitolisant (Wakix) (PDF) (CP.PMN.221)
- Plasminogen, human-tvmh (Ryplazim) (PDF) (CP.PHAR.513)
- Plecanatide (Trulance) (PDF) (HIM.PA.158)
- Plerixafor (PDF) (CP.PHAR.323)
- Polatuzumab Vedotin-piiq (Polivy) (PDF) (CP.PHAR.433)
- Pomalidomide (Pomalyst) (PDF) (CP.PHAR.116)
- Ponatinib (Iclusig) (PDF) (CP.PHAR.112)
- Ponesimod (Ponvory) (PDF) (CP.PHAR.537)
- Potassium (Klor-Con) (PDF) (HIM.PA.143)
- pralatrexate (Folotyn®) (PDF) (CP.PHAR.313)
- Pramlintide (Symlin) (PDF) (CP.PMN.129)
- Prasterone (Intrarosa) (PDF) (CP.PMN.99)
- Pregabalin (Lyrica, Lyrica CR) (PDF) (CP.PMN.33)
- Pretomanid (PDF) (CP.PMN.222)
- Progesterone (Crinone, Endometrin, Milprosa) (PDF) (CP.PMN.243)
- Propranolol HCl Oral Solution (Hemangeol) (PDF) (CP.PMN.58)
- protein c concentrate, human (Ceprotin®) (PDF) (CP.PHAR.330)
- Prucalopride (Motegrity) (PDF) (HIM.PA.159)
- pyrimethamine (Daraprim®) (PDF) (CP.PMN.44)
- Quetiapine ER (Seroquel XR) (PDF) (CP.PMN.64)
- Quinine Sulfate (Qualaquin) (PDF) (CP.PNM.262)
- Tivozanib (Fotivda) (PDF) (CP.PHAR.538)
- Ranibizumab (Lucentis®) (PDF) (CP.PHAR.186)
- rasagiline (Azilect®) (PDF) (HIM.PA.89)
- Ravulizumab-cwvz (Ultomiris) (PDF) (CP.PHAR.415)
- Regorafenib (Stivarga) (PDF) (CP.PHAR.107)
- Relugolix (Orgovyx) (PDF) (CP.PHAR.529)
- Repository Corticotropin Injection (H.P. Acthar Gel) (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) (PDF) (CP.PMN.223)
- Rifamycin (Aemcolo) (PDF) (CP.PMN.196)
- Rilonacept (Arcalyst) (PDF) (CP.PHAR.266)
- RimabotulinumtoxinB (Myobloc) (PDF) (CP.PHAR.233)
- Rimegepant (Nurtec ODT) (PDF) (CP.PHAR.490)
- Riociguat (Adempas®) (PDF) (CP.PHAR.195)
- Ripretinib (Qinlock) (PDF) (CP.PHAR.502)
- Risdiplam (Evrysdi) (PDF) (CP.PHAR.477)
- Risedronate (Actonel, Atelvia) (PDF) (CP.PMN.100)
- Risperidone LA Inj (PDF) (CP.PHAR.293)
- rifaximin (PDF) (CP.PMN.47)
- Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela) (PDF) (CP.PHAR.260)
- Rolapitant (Varubi) (PDF) (CP.PMN.102)
- romidepsin (Istodax®) (PDF) (CP.PHAR.314)
- Romiplostim (Nplate®) (PDF) (CP.PHAR.179)
- Romosozumab-aqqg (Evenity) (PDF) (CP.PHAR.428)
- Ropeginterferon Alfa-2b-njft (BESREMi) (PDF) (CP.PHAR.570)
- Rucaparib (Rubraca®) (PDF) (CP.PHAR.350)
- Rufinamide (Banzel) (PDF) (CP.PMN.157)
- Rukobia (fostemsavir) (PDF) (CP.PHAR.516)
- Ruxolitinib (Jakafi) (PDF) (CP.PHAR.98)
- Sacituzumab Govitecan-hziy (Trodelvy) (PDF) (CP.PHAR.475)
- Sacubitril/Valsartan (Entresto) (PDF) (CP.PMN.67)
- Safinamide (Xadago) (PDF) (CP.PMN.113)
- Sapropterin (Kuvan) (PDF) (CP.PHAR.43)
- Sarecycline (Seysara) (PDF) (CP.PMN.189)
- Sargramostim (PDF) (CP.PHAR.295)
- Satralizumab (PDF) (CP.PHAR.463)
- Sebelipase Alfa (Kanuma) (PDF) (CP.PHAR.159)
- Secnidazole (Solosec) (PDF) (CP.PMN.103)
- Selexipag (Uptravi®) (PDF) (CP.PHAR.196)
- Selinexor (Xpovio) (PDF) (CP.PHAR.431)
- Selpercatinib (Retevmo) (PDF) (CP.PHAR.478)
- Selumetinib (PDF) (CP.PHAR.464)
- Sensipar (PDF) (CP.PHAR.61)
- Setmelanotide (Imcivree) (PDF) (CP.PHAR.491)
- Short Ragweed Pollen Allergen Extract (Ragwitek) (PDF) (CP.PMN.83)
- Sildenafil (Revatio®) (PDF) (CP.PHAR.197)
- Sildenafil (Viagra) (PDF) (CP.PCH.07)
- Siltuximab (Sylvant®) (PDF) (CP.PHAR.329)
- Siponimod (Mayzent) (PDF) (CP.PHAR.427)
- Sirolimus Protein-Bound Particles (Fyarro) (PDF) (CP.PHAR.574)
- Sodium-Glucose Co-Transporter 2 Inhibitors (PDF) (HIM.PA.91)
- Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, Sodium Oxybate (Xywav) (PDF) (CP.PMN.42)
- Sodium Phenylbutyrate (Buphenyl) (PDF) (CP.PHAR.208)
- Sodium Phenylbutyrate/Taurursodiol (Relyvrio) (PDF) (CP.PHAR.584)
- Sodium Zirconium Cyclosilicate (Lokelma) (PDF) (CP.PMN.163)
- Sofosbuvir (Sovaldi) (PDF) (HIM.PA.SP2)
- Sofosbuvir/Vepatasvir/Voxilaprevir (Vosevi) (PDF) (HIM.PA.SP63)
- Sofosbuvir-Velpatasvir (Epclusa) (PDF) (HIM.PA.SP1)
- Soliris (eculizumab) (PDF) (CP.PHAR.97)
- Solriamfetol (Sunosi) (PDF) (CP.PMN.209)
- Sonidegib (Odomzo) (PDF) (CP.PHAR.272)
- Sorafenib (Nexavar) (PDF) (CP.PHAR.69)
- Sotorasib (Lumakras) (PDF) (CP.PHAR.549)
- Spinosad (Natroba) (PDF) (HIM.PA.134)
- Step Therapy Criteria (PDF) (HIM.PA.109)
- Stiripentol (Diacomit) (PDF) (CP.PMN.184)
- Sunitinib (Sutent) (PDF) (CP.PHAR.73)
- Sutimlimab-jome (Enjaymo) (PDF) (CP.PHAR.503)
- Suvorexant (Belsomra®) (PDF) (CP.PMN.109)
- Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair) (PDF) (CP.PMN.85)
- Sylatron (peginterferon alfa-2b) (PDF) (CP.PHAR.89)
- Tadalafil (Adcirca®) (PDF) (CP.PHAR.198)
- Tadafil BHP - ED (Cialis) (PDF) (CP.PMN.132)
- Tafamidis (Vyndaqel, Vyndamax) (PDF) (CP.PHAR.432)
- Tafasitamab-cxix (Monjuvi) (PDF) (CP.PHAR.508)
- Talazoparib (Talzenna) (PDF) (CP.PHAR.409)
- Taliglucerase Alfa (Elelyso) (PDF) (HIM.PA.162)
- Talimogene laherepvec (Imlygic) (PDF) (CP.PHAR.542)
- Tapinarof (Vtama) (PDF) (CP.PMN.283)
- Tasimelteon (Hetlioz) (PDF) (CP.PMN.104)
- Tavaborole (Kerydin®) (PDF) (CP.PMN.105)
- Tazemetostat (PDF) (CP.PHAR.452)
- Tazarotene (Arazlo, Fabior, Tazorac) (PDF) (CP.PMN.244)
- Tebentafusp-tebn (Kimmtrak) (PDF) (CP.PHAR.575)
- Tedizolid (Sivextro) (PDF) (CP.PMN.62)
- Teduglutide (Gattex) (PDF) (CP.PHAR.114)
- Tegaserod (Zelnorm) (PDF) (HIM.PA.160)
- Telotristat ethyl (Xermelo) (PDF) (CP.PHAR.337)
- Temozolomide (Temodar) (PDF) (CP.PHAR.77)
- temsirolimus (Torisel®) (PDF) (CP.PHAR.324)
- Tetrabenazine (Xenazine) (PDF) (CP.PHAR.92)
- Tenapanor (Ibsrela) (PDF) (CP.PMN.224)
- Tenofovir Alafenamide Fumarate (Vemlidy) (PDF) (CP.PMN.268)
- Tepotinib (Tepmetko) (PDF) (CP.PHAR.530)
- Teprotumumab (Tepezza) (PDF) (CP.PHAR.465)
- Teriflunomide (Aubagio) (PDF) (CP.PCH.40)
- Teriparatide (Forteo®) (PDF) (CP.PHAR.188)
- Tesamorelin (PDF) (CP.PHAR.109)
- Testosterone (Testopel, Jatenzo) (PDF) (CP.PHAR.354)
- Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF) (CP.PHAR.377)
- Tezepelumab-ekko (Tezspire) (PDF) (CP.PHAR.576)
- Thalidomide (Thalomid) (PDF) (CP.PHAR.78)
- Thioguanine (Tabloid) (PDF) (CP.PHAR.437)
- Thyrotropin alfa (PDF) (CP.PHAR.95)
- Timothy Grass Pollen Allergen Extract (Grastek) (PDF) (CP.PMN.84)
- Tisagenlecleucel (PDF) (CP.PHAR.361)
- Tisotumab vedotin-tftv (Tivdak) (PDF) (CP.PHAR.561)
- 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)
- Topiramate Extended-Release (Qudexy XR, Trokendi XR) (PDF) (CP.PMN.281)
- Topotecan (Hycamtin) (PDF) (CP.PHAR.64)
- Trabectedin (Yondelis®) (PDF) (CP.PHAR.204)
- Tralokinumab-ldrm (Adbry) (PDF) (CP.PHAR.577)
- Trametinib (Mekinist) (PDF) (CP.PHAR.240)
- Trastuzumab Biosimilars Trastuzumab-Hyaluronidase (PDF) (CP.PHAR.228)
- 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)
- Ulcer Therapy Combinations (PDF) (CP.PMN.277)
- Umbralisib (Ukoniq) (PDF) (CP.PHAR.531)
- Uridine acetate (Vistogard) (PDF) (HIM.PA.SP55)
- Valbenazine (Ingrezza) (PDF) (CP.PCH.48)
- valganciclovir (Valcyte) (PDF) (CP.PCH.06)
- Valrubicin (Valstar) (PDF) (CP.PHAR.439)
- Vandetanib (Caprelsa®) (PDF) (CP.PHAR.80)
- Varenicline (Tyrvaya) (PDF) (CP.PMN.273)
- Velaglucerase Alfa (VPRIV) (PDF) (HIM.PA.163)
- Vemurafenib (Zelboraf®) (PDF) (CP.PHAR.91)
- Venetoclax (Venclexta) (PDF) (CP.PHAR.129)
- Verteporfin (Visudyne) (PDF) (CP.PHAR.187)
- Vestronidase alfa-vjbk (Mepsevii) (PDF) (CP.PHAR.374)
- Vigabatrin (PDF) (CP.PHAR.169)
- Vilazodone (Viibryd) (PDF) (CP.PMN.145)
- Viloxazine (Qelbree) (PDF) (CP.PMN.264)
- Viltolarsen (Viltepso) (PDF) (CP.PHAR.484)
- vincristine sulfate liposome injection (Marqibo®) (PDF) (CP.PHAR.315)
- Vismodegib (Erivedge) (PDF) (CP.PHAR.273)
- Voclosporin (Lupkynis) (PDF) (CP.PHAR.504)
- Vorapaxar (Zontivity) (PDF) (HIM.PA.146)
- Voretigene neparvovec-rzyl (Luxturna) (PDF) (CP.PHAR.372)
- Vorinostat (Zolinza) (PDF) (CP.PHAR.83)
- Vortioxetine (Trintellix®) (PDF) (CP.PMN.65)
- Vosoritide (Voxzogo) (PDF) (CP.PHAR.525)
- Voxelotor (Oxbryta) (PDF) (CP.PHAR.451)
- Vutrisiran (Amvuttra) (PDF) (CP.PHAR.550)
- Xgeva (PDF) (CP.PHAR.58)
- Xiaflex™ (PDF) (CP.PHAR.82)
- Zanubrutinib (Brukinsa) (PDF) (CP.PHAR.467)
- ziv-aflibercept (Zaltrap®) (PDF) (CP.PHAR.325)
- Zometa (PDF) (CP.PHAR.59)
Medicaid Clinical Policies Listing
- ADHD Assessment and Treatment (PDF) (CP.MP.124)
- Administrative Days (PDF) (WA.CP.MP.519)
- Allergy Testing and Therapy (PDF) (CP.MP.100)
- Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF) (CP.MP.108)
- Alpha1-Proteinase Inhibitors (PDF) (CP.PHAR.94)
- Applied Behavior Analysis (PDF) (WA.CP.BH.104)
- Bariatric Surgery (PDF) (WA.CP.MP.37)
- Behavioral Health Personal Care Services (PDF) (WA.CP.MP.521)
- BH Treatment Documentation Requirements (PDF) (CP.BH.500)
- Bone-anchored Hearing Aid (PDF) (CP.MP.93)
- Burn Surgery (PDF) (CP.MP.186)
- Cardiac Biomarker Testing (PDF) (CP.MP.156)
- Cardiac Stents (PDF) (WA.CP.MP.513)
- Carotid Artery Stenting (PDF) (WA.CP.MP.516)
- Catheter Ablation for SVTA (PDF) (WA.CP.MP.525)
- Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF) (CP.MP.164)
- Clinical Trials (PDF) (CP.MP.94)
- Cochlear Implant Replacement (PDF) (CP.MP.14)
- Cochlear Implants: Bilateral vs. Unilateral (PDF) (WA.CP.MP.502)
- Continuous Glucose Monitoring (PDF) (WA.CP.MP.501)
- Cosmetic and Reconstructive Surgery (PDF) (CP.MP.31)
- Diaphragmatic/Phrenic Nerve Stimulation (PDF) (CP.MP.203)
- Digital Analysis of EEG (PDF) (CP.MP.105)
- Discography (PDF) (CP.MP.115)
- Donor Lymphocyte Infusion (PDF) (CP.MP.101)
- Drugs of Abuse: Definitive Testing (PDF) (WA.CP.MP.50)
- 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 Interventions (PDF) (WA.CP.MP.171)
- Fecal incontinence treatments (PDF) (CP.MP.137)
- Fecal Microbiota Transplantation (PDF) (WA.CP.MP.515)
- Fertility Preservation (PDF) (WA.CP.MP.130)
- Fetal surgery in utero for prenatally diagnosed malformations (PDF) (CP.MP.129)
- Gastric Electrical Stimulation (PDF) (CP.MP.40)
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) (CP.MP.209)
- Genetic Testing Aortopathies & Connective Tissue Disorder (PDF) (CP.MP.215)
- Genetic Testing Cardiac Disorders (PDF) (CP.MP.216)
- Genetic Testing Dermatologic Conditions (PDF) (CP.MP.217)
- Genetic Testing Epilepsy Neurodegenerative Neuromuscular Disorder (PDF) (CP.MP.218)
- Genetic Testing Exome and Genome Sequecing (PDF) (WA.CP.MP.219)
- Genetic Testing Eye Disorders (PDF) (CP.MP.220)
- Genetic Testing Gastroenterologic Disorders (Non-Cancerous) (PDF) (CP.MP.221)
- Genetic Testing General Approach to Genetic Testing (PDF) (CP.MP.222)
- Genetic Testing Hearing Loss (PDF) (CP.MP.223)
- Genetic Testing Hematologic Conditions (non-cancerous) (PDF) (CP.MP.224)
- Genetic Testing Hereditary Cancer Susceptibility (PDF) (CP.MP.225)
- Genetic Testing Immune Autoimmune and Rheumatoid Disorders (PDF) (CP.MP.226)
- Genetic Testing Kidney Disorders (PDF) (CP.MP.227)
- Genetic Testing Lung Disorders (PDF) (CP.MP.228)
- Genetic Testing Metabolic Endocrine and Mitochondrial Disorders (PDF) (CP.MP.229)
- Genetic Testing Multisystem Inherited Disorders ID and DD (PDF) (WA.CP.MP.230)
- Genetic Testing Non-Invasive Prenatal Screening (PDF) (WA.CP.MP.231)
- Genetic Testing Pharmacogenetics (PDF) (CP.MP.232)
- Genetic Testing Preimplantation Genetic Testing (PDF) (CP.MP.233)
- Genetic Testing Prenatal and Precon Carrier Screening (PDF) (CP.MP.234)
- Genetic Testing Prenatal Diagnosis (Via Amniocentesis CVS or PUBS) & Pregnancy Loss (PDF) (CP.MP.235)
- Genetic Testing Skeletal Dysplasia and Rare Bone Disorders (PDF) (CP.MP.236)
- Oncology Algorithmic Testing (PDF) (CP.MP.237)
- Oncology Cancer Screening (PDF) (CP.MP.238)
- Oncology Circulating Tumor DNA & Circulating Tumor Cells (Lqd Biopsy) (PDF) (CP.MP.239)
- Oncology Cytogenetic Testing (PDF) (CP.MP.240)
- Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF) (CP.MP.241)
- 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 Prothrombin Time Monitoring (PDF) (WA.CP.MP.207)
- Home Ventilators (PDF) (CP.MP.184)
- Homocysteine testing (PDF) (CP.MP.121)
- Hospice Services (PDF) (WA.CP.MP.54)
- Hyperbaric Oxygen Therapy (PDF) (WA.CP.MP.27)
- Hyperemesis Gravidarum Treatment (PDF) (CP.MP.34)
- Hyperhidrosis Treatments (PDF) (CP.MP.62)
- Implantable Hypoglossal Nerve Stimulation (PDF) (CP.MP.180) - effective through 3/31/23
- Implantable Hypoglossal Nerve Stimulation (PDF) (CP.MP.180) - effective 4/1/23
- Implantable Intrathecal or Epidural Pain Pump (PDF) (CP.MP.173)
- Implantable Loop Recorder (CP.MP.243)
- Inhaled Nitric Oxide (PDF) (CP.MP.87)
- Intensity-Modulated Radiotherapy (IMRT) (PDF) (WA.CP.MP.69)
- Intestinal and Multivisceral Transplant (PDF) (CP.MP.58)
- Intradiscal Steroid Injections for Pain Management (PDF) (CP.MP.167)
- Laser therapy for skin conditions (PDF) (CP.MP.123)
- Liposuction of Lipedema (PDF) (CP.MP.244)
- Lung Transplantation (PDF) (CP.MP.57)
- Lysis of Epidural Lesions (PDF) (CP.MP.116)
- Mandibular Advancement Devices (PDF) (WA.CP.MP.500)
- Medical Necessity Review (PDF) (WA.UM.02.01)
- Micro-Processor Controlled Prosthetics (PDF) (WA.CP.MP.505)
- Multiple Sleep Latency Testing (PDF) (CP.MP.24)
- Negative Pressure Wound Therapy for Home Use (PDF) (WA.CP.MP.518)
- Neonatal Abstinence Syndrome Guidelines (PDF) (CP.MP.86)
- Neonatal Sepsis Management Guidelines (PDF) (CP.MP.85)
- Nerve Blocks for Pain Management (PDF) (CP.MP.170)
- NICU Apnea Bradycardia Guidelines (PDF) (CP.MP.82)
- NICU Discharge Guidelines (PDF) (CP.MP.81)
- Nonmyeloablative allogeneic SCT (PDF) (CP.MP.141)
- Optic nerve decompression surgery (PDF) (CP.MP.128)
- Oral Enteral Nutrition (PDF) (WA.CP.MP.507)
- Orthognathic Surgery (PDF) (CP.MP.202) - effective through 2/28/23
- Orthognathic Surgery (PDF) (CP.MP.202) - effective 3/1/23
- Osteogenic Stimulation (PDF) (CP.MP.194)
- 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 Kidney Transplant (PDF) (CP.MP.246) - effective 2/1/2023
- Pediatric Oral Function Therapy (PDF) (CP.MP.188)
- Peripheral and Percutaneous Nerve Stimulation (PDF) (WA.CP.MP.117) - effective 2/1/2023
- Photherapy for Neonatal Hyperbilirubinemia (PDF) (CP.MP.150) - effective through 2/28/23
- Photherapy for Neonatal Hyperbilirubinemia (PDF) (CP.MP.150) - effective 3/1/23
- Physical, Occupational and Speech Therapy Services (PDF) (CP.MP.49)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) (CP.MP.181)
- Private Duty Nursing Services (PDF) (WA.CP.MP.503)
- Proton and Neutron Beam Therapies (PDF) (WA.CP.MP.70)
- Psychological Testing (PDF) (WA.CP.MP.506)
- Pulmonary Function Testing (PDF) (CP.MP.242) - effective 2/1/23
- Reduction Mammoplasty and Gynecomastia Surgery (PDF) (CP.MP.51)
- Repair of Nasal Valve Compromise (PDF) (CP.MP.210)
- Sacroiliac Joint Interventions for Pain Management (PDF) (CP.MP.166)
- Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF) (CP.MP.165)
- Short Inpatient Hospital Stay (PDF) (CP.MP.182)
- Skilled Nursing Facility Leveling (PDF) (CP.MP.206)
- Skin Substitutes for Chronic Wounds (PDF) (WA.CP.MP.185)
- Sleep Apnea Diagnosis and Treatment (PDF) (WA.CP.MP.523)
- Stem Cell Therapy for Musculoskeletal Conditions (PDF) (WA.CP.MP.526)
- Stereotactic Body Radiation Therapy (PDF) (CP.MP.22)
- Substance Use Treatment and Services (PDF) (CP.BH.100)
- Tandem Transplant (PDF) (CP.MP.162)
- Testosterone Testing (PDF) (WA.CP.MP.517)
- Thyroid hormones and insulin testing in pediatrics (PDF) (CP.MP.154)
- Tinnitus Treatment (PDF) (WA.CP.MP.510)
- Total artificial heart (PDF) (CP.MP.127)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) (CP.MP.163)
- Transcatheter Closure of Patent Foramen Ovale (PDF) (CP.MP.151) - effective through 3/31/23
- Transcatheter Closure of Patent Foramen Ovale (PDF) (CP.MP.151) - effective 4/1/23
- Transcranial Magnetic Stimulation (PDF) (CP.BH.200)
- Trigger Point Injections for Pain Management (PDF) (CP.MP.169)
- Tympanostomy Tubes (PDF) (WA.CP.MP.520)
- Ultrasound in Pregnancy (PDF) (CP.MP.38)
- Upper GI Endoscopy for GERD (PDF) (WA.CP.MP.509)
- Urinary Incontinence Devices and Treatments (PDF) (CP.MP.142)
- Urodynamic testing (PDF) (CP.MP.98)
- Vagus Nerve Stimulation (PDF) (CP.MP.12)
- Varicose Vein Treatment (PDF) (WA.CP.MP.522)
- Ventricular Assist Devices (PDF) (WA.CP.MP.46)
- Vitamin D Testing (PDF) (WA.CP.MP.527)
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 (Dysport) (PDF) (CP.PHAR.230)
- Abiraterone (Zytiga) (PDF) (CP.PHAR.84)
- Abrocitinib (Cibinqo) (PDF) (CP.PHAR.578)
- ACEI and ARB Duplicate Therapy (PDF) (CP.PMN.61)
- Acitretin (Soriatane) (PDF) (CP.PMN.40)
- Acyclovir Buccal Tablet (Sitavig), Ophthalmic Ointment (Avaclyr) (PDF) (CP.PMN.210)
- Acute Migraine Treatment Calcitonin Gene Related Peptide (CGRP) Receptor Antagonist (PDF) (WA.PHAR.106)
- Adefovir (Hepsera) (PDF) (CP.PHAR.142)
- ADHD Anti-Narcolepsy Stimulants-Misc- Armodafinil Modafinil (PDF) (WA.PHAR.124)
- Ado-Trastuzumab (Kadcyla) (PDF) (CP.PHAR.229)
- Aflibercept (Eylea) (PDF) (CP.PHAR.184)
- Age Limit for Topical Tretinoin (PDF) (CP.PMN.191)
- Agents for Sickle Cell Anemia L-glutamine (ENDARI) (PDF) (WA.PHAR.59)
- Alemtuzumab (Lemtrada) (PDF) (CP.PHAR.243)
- Allergenic Extracts (Oral) (PDF) (WA.PHAR.27)
- Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) (PDF) (CP.PHAR.562)
- Alpelisib (Piqray, Vijoice) (PDF) (CP.PHAR.430)
- Amantadine ER (PDF) (CP.PMN.89)
- Amifampridine (Firdapse) (PDF) (CP.PHAR.411)
- Amikacin (Arikayce) (PDF) (CP.PHAR.401)
- Amisulpride (Barhemsys) (PDF) (CP.PMN.236)
- Amivantamab-vmjw (Rybrevant) (PDF) (CP.PHAR.544)
- Amlodipine/Atorvastatin (Caduet) (PDF) (CP.PMN.176)
- Analgesics Opioid Agonists (PDF) (WA.PHAR.23)
- Androgenic Agents-Testosterone Replacement Therapy (TRT) (PDF) (WA.PHAR.28)
- Anifrolumab-fnia (Saphnelo) (PDF) (CP.PHAR.551)
- Antiasthmatic Monoclonal Antibodies Anti IgE Antibodies (PDF) (WA.PHAR.29)
- Antiasthmatic Monoclonal Antibodies IL-5 Antagonists (PDF) (WA.PHAR.30)
- Antibiotics Anti-Infective Agents- Oral rifaximin (XIFAXAN) (PDF) (WA.PHAR.66)
- Antibiotics-Inhaled-aminoglycosides (PDF) (WA.PHAR.79)
- Antibiotics Inhaled aztreonam (CAYSTON) (PDF) (WA.PHAR.31)
- Anticonvulsants-Rescue Agents (PDF) (WA.PHAR.32)
- Antidepressants- Serotonin Modulators (PDF) (WA.PHAR.123)
- Antidiabetics-Amylin Analogs (PDF) (WA.PHAR.33)
- Antidiabetics- GLP-1 Agonists (PDF) (WA.PHAR.122)
- Antidiabetics-Inhaled Insulin (Afrezza) (PDF) (WA.PHAR.34)
- Antihyperlipidemics-APOB Synthesis Inhibitors (Kynamro) (PDF) (WA.PHAR.37)
- Antihyperlipidemics-Apolipoprotein B Synthesis Inhibitors lomitapide mesylate (PDF) (WA.PHAR.38)
- Antihyperlipidemics-PCSK9 Inhibitors (PDF) (WA.PHAR.39)
- Antineoplastics and Adjunctive Therapies - Imidazotetrazines– Oral (PDF) (WA.PHAR.117)
- Antimemetic-Antivertigo Agents (Dronabinol) (PDF) (WA.PHAR.35)
- Antineoplastics and Adjunctive Therapies Tyrosine Kinase Inhibitors (PDF) (WA.PHAR.103)
- Antiparasitics Antiprotozoal Agents- nitazoxanide (Alinia) (PDF) (WA.PHAR.67)
- Antipsychotics 2nd Generation Vraylar (PDF) (WA.PHAR.105)
- Antithrombin III (ATryn, Thrombate III) (PDF) (CP.PHAR.564)
- Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) (CP.PHAR.506)
- Antivirals-HIV Combinations (PDF) (WA.PHAR.97)
- Antivirals HIV-emtricitabinetenofovir alafenamide (Descovy) (PDF) (WA.PHAR.98)
- Antivirals HIV- Rilpivirine (Edurant) (PDF) (WA.PHAR.120)
- Apalutamide (Erleada) (PDF) (CP.PHAR.376)
- Apomorphine (Apokyn, Kynmobi) (PDF) (CP.PHAR.488)
- Apple Health (Medicaid) COVID-19 testing clinical policy (PDF) (WA.PHAR.128)
- Aprepitant (PDF) (CP.PMN.19)
- aripiprazole long-acting injections (PDF) (CP.PHAR.290)
- Asciminib (Scemblix) (PDF) (CP.PHAR.565)
- Asenapine (PDF) (CP.PMN.15)
- Aspirin-dipyridamole (PDF) (CP.PMN.20)
- Atezolizumab (Tecentriq) (PDF) (CP.PHAR.235)
- Atogepant (Qulipta) (PDF) (CP.PHAR.566)
- Atopic Dermatitis Agents Dupilumab (Dupixent) (PDF) (WA.PHAR.41)
- Atopic Dermatitis Agents-Topical Immunosuppressives (PDF) (WA.PHAR.42)
- Atopic Dermatitis Agents Crisaborole (Eucrisa) (PDF) (WA.PHAR.43)
- Avelumab (Bavencio) (PDF) (CP.PHAR.333)
- Azacitidine (Vidaza) (PDF) (CP.PHAR.387)
- Baloxavir Marboxil (Xofluza) (PDF) (CP.PMN.185)
- Bedaquiline (Sirturo) (PDF) (CP.PMN.212)
- Belantamab Mafodotin (Blenrep) (PDF) (CP.PHAR.469)
- Belatacept (Nulojix) (PDF) (CP.PHAR.201)
- Belimumab (Benlysta) (PDF) (CP.PHAR.88)
- belinostat (PDF) (CP.PHAR.311)
- Belumosudil (Rezurock) (PDF) (CP.PHAR.552)
- Belzutifan (Welireg) (PDF) (CP.PHAR.553)
- Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet) (PDF) (CP.PMN.237)
- bendamustine (PDF) (CP.PHAR.307)
- Benign Prostatic Hyperplasia (BPH) Agents-PDE5 Inhibitors (PDF) (WA.PHAR.44)
- Benznidazole (PDF) (CP.PMN.90)
- Benzyl Alcohol (Ulesfia) (PDF) (CP.PMN.202)
- Betaine (Cystadane) (PDF) (CP.PHAR.143)
- Betamethasone Dipropionate Spray (Sernivo) (PDF) (CP.PMN.182)
- Bevacizumab (Avastin) (PDF) (CP.PHAR.93)
- Bexarotene (Targretin Capsules, Gel) (PDF) (CP.PHAR.75)
- Bezlotoxumab (PDF) (CP.PHAR.300)
- Bimatoprost Implant (Durysta) (PDF) (CP.PHAR.486)
- Binimetinib (Mektovi) (PDF) (CP.PHAR.50)
- Blinatumomab (PDF) (CP.PHAR.312)
- Bone Density Regulators (PDF) (WA.PHAR.45)
- Bortezomib (Velcade) (PDF) (CP.PHAR.410)
- Brands with Generic Equivalents (PDF) (WA.PHAR.65)
- Bremelanotide (Vyleesi) (PDF) (CP.PHAR.434)
- Brentuximab (PDF) (CP.PHAR.303)
- Brexanolone (Zulresso) (PDF) (CP.PHAR.417)
- Brexpiprazole (PDF) (CP.PMN.68)
- Brimonidine Tartrate (Mirvaso) (PDF) (CP.PMN.192)
- Brolucizumab-dbll (Beovu) (PDF) (CP.PHAR.445)
- Budesonide (Tarpeyo) (PDF) (CP.PHAR.572)
- (MAT) Buprenorphine Products (PDF) (WA.PHAR.62)
- Cabazitaxel (Jevtana) (PDF) (CP.PHAR.316)
- Calcifediol (Rayaldee) (PDF) (CP.PMN.76)
- Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) (PDF) (CP.PMN.181)
- Cannabidiol (Epidiolex) (PDF) (CP.PMN.164)
- Capecitabine (Xeloda) (PDF) (CP.PHAR.60)
- Caplacizumab-yhdp (Cablivi) (PDF) (CP.PHAR.416)
- Carbamazepine ER (Equetro) (PDF) (CP.PMN.137)
- Carbidopa/Levodopa ER Capsules (Rytary) (PDF) (CP.PMN.238)
- Cardiovascular Agents-Sinus Node Inhibitors (PDF) (WA.PHAR.46)
- carfilzomib (PDF) (CP.PHAR.309)
- Carglumic Acid (Carbaglu) (PDF) (CP.PHAR.206)
- Celecoxib (Celebrex, Elyxyb) (PDF) (CP.PMN.122)
- Cemiplimab-rwlc (Libtayo) (PDF) (CP.PHAR.397)
- Cenobamate (Xcopri) (PDF) (CP.PMN.231)
- cetuximab (PDF) (CP.PHAR.317)
- Chenodiol (Chenodal) (PDF) (CP.PMN.239)
- Chlorambucil (Leukeran) (PDF) (CP.PHAR.554)
- Chloramphenicol Sodium Succinate (PDF) (CP.PHAR.388)
- Cholic Acid (Cholbam) (PDF) (CP.PHAR.390)
- Chronic GI Motility Agents (PDF) (WA.PHAR.47)
- Ciclopirox (Penlac) (PDF) (CP.PMN.24)
- Ciprofloxacin/Dexamethasone (Ciprodex) (PDF) (CP.PMN.248)
- Ciprofloxacin/Fluocinolone (Otovel) (PDF) (CP.PMN.249)
- Cladribine (Mavenclad) (PDF) (CP.PHAR.422)
- Clascoterone (Winlevi) (PDF) (CP.PMN.257)
- Clobazam (Onfi) (PDF) (CP.PMN.54)
- Clomipramine (Anafranil) (PDF) (CP.PMN.197)
- Clozapine orally disintegrating tablet (Fazaclo) (PDF) (CP.PMN.12)
- CNS Stimulants (PDF) (CP.PMN.92)
- Cobimetinib (Cotellic) (PDF) (CP.PHAR.380)
- Colchicine (PDF) (CP.PMN.123)
- Colesevelam (WelChol) (PDF) (CP.PMN.250)
- Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) (CP.PMN.258)
- Continuous Glucose Monitors (PDF) (CP.PMN.214)
- copanlisib (PDF) (CP.PHAR.357)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert) (PDF) (CP.PHAR.385)
- Corticotropin (H.P. Acthar Gel) (PDF) (CP.PHAR.168)
- Cosyntropin (Cortrosyn) (PDF) (CP.PHAR.203)
- Cyclosporine (Cequa, Restasis, Verkazia) (PDF) (CP.PMN.48)
- Cysteamine Ophthalmic (Cystaran, Cystadrops) (PDF) (CP.PMN.130)
- Cystic Fibrosis Agents (Oral) (PDF) (WA.PHAR.48)
- Cytokine and CAM Antagonists (PDF) (WA.PHAR.49)
- Cytomegalovirus Immune Globulin (Cytogam) (PDF) (CP.PHAR.277)
- Dabigatran (Pradaxa) (PDF) (CP.PMN.49)
- Dabrafenib (Tafinlar) (PDF) (CP.PHAR.239)
- Dalteparin (PDF) (CP.PHAR.225)
- daptomycin (PDF) (CP.PHAR.351)
- Daratumumab (PDF) (CP.PHAR.310)
- Darolutamide (Nubeqa) (PDF) (CP.PHAR.435)
- daunorubicin cytarabine (PDF) (CP.PHAR.352)
- Decitabine-Cedazuridine (Inqovi) (PDF) (CP.PHAR.479)
- deferasirox (PDF) (CP.PHAR.145)
- deferiprone (PDF) (CP.PHAR.147)
- deferoxamine (PDF) (CP.PHAR.146)
- Deflazacort (PDF) (CP.PHAR.331)
- Degarelix Acetate (Firmagon) (PDF) (CP.PHAR.170)
- Delafloxacin (Baxdela) (PDF) (CP.PMN.115)
- Denosumab (Prolia, Xgeva) (PDF) (CP.PHAR.58)
- Dermatologics Acne Products- Isotretinoin (PDF) (WA.PHAR.121)
- Desmopressin (DDAVP, Stimate) (PDF) (CP.PHAR.214)
- Dexrazoxane (Zinecard Totect) (PDF) (CP.PHAR.418)
- Dextromethorphan/Bupropion (Auvelity) (PDF) (CP.PMN.284)
- Dextromethorphan-Quinidine (PDF) (CP.PMN.93)
- Diabetic Test Strip Quantity Limit - Not Receiving Insulin (PDF) (CP.PMN.151)
- Diazepam Nasal Spray (Valtoco) (PDF) (CP.PMN.216)
- Dichlorphenamide (Keveyis) (PDF) (CP.PMN.261)
- Diclofenac (Pennsaid) (PDF) (CP.PMN.274)
- Dimethyl fumarate (Tecfidera), diroximel fumarate (Vumerity), monomethyl fumarate (Bafiertam) (PDF) (CP.PHAR.249)
- Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF) (CP.PMN.03)
- Dolasetron (Anzemet) (PDF) (CP.PMN.141)
- Dornase alfa (Pulmozyme) (PDF) (CP.PHAR.212)
- Dostarlimab-gxly (Jemperli) (PDF) (CP.PHAR.540)
- Doxepin (Silenor) (PDF) (CP.PMN.175)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF) (CP.PMN.79)
- Droxidopa (Northera) (PDF) (CP.PMN.17)
- Duplicate SSRI SNRI Therapy (PDF) (CP.PMN.60)
- Durvalumab (Imfinzi) (PDF) (CP.PHAR.339)
- Dutasteride (Avodart, Jalyn) (PDF) (CP.PMN.128)
- Duvelisib (Copiktra) (PDF) (CP.PHAR.400)
- Early and Periodic Screening, Diagnostic, and Treatment Benefit for Pediatric Members (PDF) (CP.PMN.234)
- Edoxaban (Savaysa) (PDF) (CP.PMN.227)
- Efinaconazole (Jublia) (PDF) (CP.PMN.25)
- Elagolix (Orilissa) (PDF) (CP.PHAR.136)
- Elotuzumab (Empliciti) (PDF) (CP.PHAR.308)
- enasidenib (PDF) (CP.PHAR.363)
- Encorafenib (Braftovi) (PDF) (CP.PHAR.127)
- Enfortumab Vedotin-ejfv (Padcev) (PDF) (CP.PHAR.455)
- Enoxaparin (PDF) (CP.PHAR.224)
- Entrectinib (Rozlytrek) (PDF) (CP.PHAR.441)
- Enzalutamide (PDF) (CP.PHAR.106)
- Epinephrine (EpiPen and EpiPen Jr) Quanity Limit Override (PDF) (CP.PMN.144)
- Epoprostenol (Flolan, Veletri) (PDF) (CP.PHAR.192)
- Eptinezumab-jjmr (Vyepti) (PDF) (CP.PHAR.489)
- Erdafitinib (Balversa) (PDF) (CP.PHAR.423)
- eribulin Mesylate (PDF) (CP.PHAR.318)
- Erwinia Asparaginase (Erwinaze) (PDF) (CP.PHAR.301)
- Esketamine (Spravato) (PDF) (CP.PMN.199)
- Estradiol Vaginal Ring (Femring) (PDF) (CP.PMN.263)
- Etelcalcetide (Parsabiv) (PDF) (CP.PHAR.379)
- Everolimus (PDF) (CP.PHAR.63)
- Experimental Technologies (PDF) (WA.CP.MP.36)
- Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) (CP.PHAR.456)
- Faricimab-svoa (Vabysmo) (PDF) (CP.PHAR.581)
- Fedratinib (Inrebic) (PDF) (CP.PHAR.442)
- Fenfluramine (Fintepla) (PDF) (CP.PMN.246)
- Ferric Carboxymaltose (Injectafer) (PDF) (CP.PHAR.234)
- Ferric Derisomaltose (Monoferric) (PDF) (CP.PHAR.480)
- Ferric Gluconate (Ferrlecit) (PDF) (CP.PHAR.166)
- Ferric Maltol (Accrufer) (PDF) (CP.PMN.213)
- Ferumoxytol (Feraheme) (PDF) (CP.PHAR.165)
- Finerenone (Kerendia) (PDF) (CP.PMN.266)
- Fingolimod (Gilenya) (PDF) (CP.PHAR.251)
- Flibanserin (Addyi) (PDF) (CP.PHAR.446)
- Fluorouracil Cream (Tolak) (PDF) (CP.PMN.165)
- Fluticasone propionate (PDF) (CP.PMN.95)
- Fondaparinux (PDF) (CP.PHAR.226)
- Fulvestrant (Faslodex Injection) (PDF) (CP.PHAR.424)
- Gabapentin ER (Gralise, Horizant) (PDF) (CP.PMN.240)
- Ganaxolone (Ztalmy) (PDF) (CP.PMN.278)
- gemtuzumab ozogamicin (PDF) (CP.PHAR.358)
- Glasdegib (Daurismo) (PDF) (CP.PHAR.413)
- Glatiramer Acetate (PDF) (CP.PHAR.252)
- Glycopyrronium (Qbrexza) (PDF) (CP.PMN.177)
- Goserelin Acetate (Zoladex) (PDF) (CP.PHAR.171)
- Gout Agents (PDF) (WA.PHAR.40)
- Granisetron (Sancuso) (PDF) (CP.PMN.74)
- Growth Hormone Agents (PDF) (WA.PHAR.50)
- Halobetasol Propionate Lotion 0.05% (Ultravate) (PDF) (CP.PMN.180)
- Halobetasol Propionate/Tazarotene (Duobrii) (PDF) (CP.PMN.208)
- Hematopoietic Agents Erythropoiesis-Stimulating Agents (ESAs) (PDF) (WA.PHAR.71)
- Hematopoietic Agents Granulocyte Colony Stimulating Factors (G-CSF) (PDF) (WA.PHAR.72)
- Hematopoietic Agents Thrombopoieses (TPO) Stimulating Proteins (PDF) (WA.PHAR.73)
- Hemin (Panhematin) (PDF) (CP.PHAR.181)
- Hormone Therapy for Gender Dysphoria (PDF) (WA.PHAR.104)
- Hyaluronate Derivatives (PDF) (CP.PHAR.05)
- Hydroxyurea (Siklos) (PDF) (CP.PMN.193)
- Ibrance (palbociclib) (PDF) (CP.PHAR.125)
- Ibuprofen/Famotidine (Duexis) (PDF) (CP.PMN.120)
- Icosapent ethyl (Vascepa) (PDF) (CP.PMN.187)
- Idelalisib (Zydelig) (PDF) (CP.PHAR.133)
- Iloperidone (Fanapt) (PDF) (CP.PMN.32)
- Immune Globulins (PDF) (CP.PHAR.103)
- Immunization coverage (PDF) (CP.PHAR.28)
- Inclisiran (Leqvio) (PDF) (CP.PHAR.568)
- IncobotulinumtoxinA (Xeomin) (PDF) (CP.PHAR.231)
- Infigratinib (Truseltiq) (PDF) (CP.PHAR.547)
- Inhaled Agents for Asthma and COPD (PDF) (CP.PMN.259)
- inotuzumab ozogamicin (PDF) (CP.PHAR.359)
- Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF) (CP.PHAR.534)
- Interferon beta-1a (Avonex, Rebif) (PDF) (CP.PHAR.255)
- Interferon beta-1b (Betaseron, Extavia) (PDF) (CP.PHAR.256)
- Intrathecal Baclofen (Gablofen, Lioresal) (PDF) (CP.PHAR.149)
- Iobenguane I-131 (Azedra) (PDF) (CP.PHAR.459)
- Ipilimumab (Yervoy) (PDF) (CP.PHAR.319)
- irinotecan Liposome (PDF) (CP.PHAR.304)
- Iron sucrose (Venofer) (Acthar Gel) (PDF) (CP.PHAR.167)
- Isatuximab-irfc (Sarclisa) (PDF) (CP.PHAR.482)
- Isavuconazonium (Cresemba) (PDF) (CP.PMN.154)
- Isotretinoin (PDF) (CP.PMN.143)
- Istradefylline (Nourianz) (PDF) (CP.PMN.217)
- Itraconazole (Sporanox, Onmel) (PDF) (CP.PMN.124)
- Ivermectin (Stromectol, Sklice) (PDF) (CP.PMN.269)
- Ivosidenib (Tibsovo) (PDF) (CP.PHAR.137)
- Ixazomib (PDF) (CP.PHAR.302)
- Jakafi™ (ruxolitinib) (PDF) (CP.PHAR.98)
- Ketorolac Nasal Spray (Sprix) (PDF) (CP.PMN.282)
- Korlym (mifepristone) (PDF) (CP.PHAR.101)
- Lacosamide (Vimpat) (PDF) (CP.PMN.155)
- Lactic Acid/Citric Acid/Potassium Bitartrate (Phexxi) (PDF) (CP.PMN.251)
- Lanreotide (Somatuline Depot) (PDF) (CP.PHAR.391)
- Larotrectinib (Vitrakvi) (PDF) (CP.PHAR.414)
- Lasmiditan (Reyvow) (PDF) (CP.PMN.218)
- Latanoprostene Bunod (Vyzulta) (PDF) (CP.PMN.108)
- Lefamulin (Xenleta) (PDF) (CP.PMN.219)
- Lenalidomide (Revlimid) (PDF) (CP.PHAR.71)
- Letermovir (PDF) (CP.PHAR.367)
- Leucovorin Injection (PDF) (CP.PHAR.393)
- Leuprolide Acetate (Eligard, Fensolvi, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped) (PDF) (CP.PHAR.173)
- Levodopa Inhalation Powder (Inbrija) (PDF) (CP.PMN.267)
- Levoleucovorin (Fusilev) (PDF) (CP.PHAR.151)
- lidocaine transdermal (PDF) (CP.PMN.08)
- Lindane Lotion Shampoo (PDF) (CP.PMN.09)
- Linezolid (Zyvox) (PDF) (CP.PMN.27)
- Lisdexamfetamine (Vyvanse) (PDF) (CP.PMN.121)
- Lofexidine (Lucemyra) (PDF) (CP.PMN.152)
- Lomustine (Gleostine) (PDF) (CP.PHAR.507)
- Loncastuximab Tesirine-lpyl (Zynlonta) (PDF) (CP.PHAR.539)
- Loteprednol etabonate (Eysuvis) (PDF) (CP.PMN.260)
- Luliconazole Cream (Luzu) (PDF) (CP.PMN.166)
- Lumateperone (Caplyta) (PDF) (CP.PMN.232)
- Lurasidone (Latuda) (PDF) (CP.PMN.50)
- Lurbinectedin (Zepzelca) (PDF) (CP.PHAR.500)
- Mannitol (Bronchitol) (PDF) (CP.PHAR.518)
- Margetuximab-cmkb (Margenza) (PDF) (CP.PHAR.522)
- Maribavir (Livtencity) (PDF) (CP.PMN.271)
- Mavacamten (Camzyos) (PDF) (CP.PMN.272)
- Mecamylamine (Vecamyl) (PDF) (CP.PMN.136)
- Mecasermin (PDF) (CP.PHAR.150)
- Mechlorethamine Gel (Valchlor) (PDF) (CP.PHAR.381)
- Megestrol Acetate 125 mg/mL Oral Suspension (Megace ES) (PDF) (CP.PMN.179)
- Melphalan flufenamide (Pepaxto) (PDF) (CP.PHAR.535)
- Mercaptopurine (Purixan) (PDF) (CP.PHAR.447)
- Metformin ER (Fortamet, Glumetza) (PDF) (CP.PMN.72)
- Methadone (Dolophine) (PDF) (WA.PHAR.20)
- Methotrexate (Otrexup, Rasuvo, Xatmep) (PDF) (CP.PHAR.134)
- Metoclopramide (Gimoti) (PDF) (CP.PMN.252)
- Midostaurin (Rydapt) (PDF) (CP.PHAR.344)
- Migraine Products Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist (PDF) (WA.PHAR.64)
- Milnacipran (Savella) (PDF) (CP.PMN.125)
- Minocycline ER (Solodyn, Ximino) and Microspheres (Arestin), Foam (Zilxi) (PDF) (CP.PMN.80)
- Minocycline Micronized Foam (Amzeeq) (PDF) (CP.PMN.242)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF) (CP.PHAR.495)
- Mitoxantrone (Novantrone) (PDF) (CP.PHAR.258)
- Mobocertinib (Exkivity) (PDF) (CP.PHAR.559)
- Mogamulizumab-kpkc (Poteligeo) (PDF) (CP.PHAR.139)
- Mometasone Furoate (Sinuva) (PDF) (CP.PHAR.448)
- Movement Disorder Agents (PDF) (WA.PHAR.51)
- Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) (CP.PHAR.398)
- Multiple Sclerosis Agents-Dalfampridine (Ampyra) (PDF) (WA.PHAR.52)
- Multiple Sclerosis- Ocrelizumab (Ocrevus) (PDF) (WA.PHAR.69)
- Musculoskeletal Therapy Agents - Carisoprodol (PDF) (WA.PHAR.130)
- Nafarelin Acetate (Synarel) (PDF) (CP.PHAR.174)
- Naloxone (Evzio) (PDF) (CP.PMN.139)
- Naproxen/Esomeprazole (Vimovo) (PDF) (CP.PMN.117)
- (MAT) Naltrexone Products (PDF) (WA.PHAR.63)
- Natalizumab (Tysabri) (PDF) (CP.PHAR.259)
- Naxitamab-gqgk (Danyelza) (PDF) (CP.PHAR.523)
- necitumumab (PDF) (CP.PHAR.320)
- Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF) (CP.PMN.167)
- Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan) (PDF) (CP.PMN.118)
- Netupitant and Palonosetron (Akynzeo) (PDF) (CP.PMN.158)
- Nifurtimox (Lampit) (PDF) (CP.PMN.256)
- Niraparib (Zejula) (PDF) (CP.PHAR.408)
- Nivolumab (PDF) (CP.PHAR.121)
- Nivolumab and Relatlimab-rmbw (Opdualag) (PDF) (CP.PHAR.588)
- No Coverage Criteria (PDF) (CP.PMN.255)
- No Coverage Criteria/Off-Label Use Policy (PDF) (CP.PMN.53)
- Non-Calcium Phosphate Binders (PDF) (CP.PMN.04)
- Non-Contracted Drugs (PDF) (WA.PHAR.126)
- Non-Formulary and Non-Preferred Drug Not Otherwise Specified (PDF) (WA.PHAR.61)
- Non-Preferred Blood Glucose Monitors/Test Strips (PDF) (CP.PMN.215)
- Obeticholic (PDF) (CP.PHAR.287)
- obinutuzumab (PDF) (CP.PHAR.305)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot) (PDF) (CP.PHAR.40)
- Ofatumumab (Arzerra, Kesimpta) (PDF) (CP.PHAR.306)
- olanzapine la inj (PDF) (CP.PHAR.292)
- Olanzapine (Zyprexa Zydis®) (PDF) (CP.PMN.29)
- Olanzapine/Samidorphan (Lybalvi) (PDF) (CP.PMN.265)
- Olaparib (PDF) (CP.PHAR.360)
- olaratumab (PDF) (CP.PHAR.326)
- Omadacycline (Nuzyra) (PDF) (CP.PMN.188)
- Omecetaxine (Synribo) (PDF) (CP.PHAR.108)
- Omega-3-Acid Ethyl Esters (Lovaza) (PDF) (CP.PMN.52)
- OnabotulinumtoxinA (Botox) (PDF) (CP.PHAR.232)
- Ondansetron (Zuplenz) (PDF) (CP.PMN.45)
- Ophthalmic Immunomodulators-Lifitegrast 5% Ophthalmic Solution (PDF) (WA.PHAR.58)
- Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF) (CP.PHAR.536)
- Opicapone (Ongentys) (PDF) (CP.PMN.245)
- Ospemifene (Osphena) (PDF) (CP.PMN.168)
- Overactive Bladder Agents (PDF) (CP.PMN.198)
- Oxymetazoline (Rhofade, Upneeq) (PDF) (CP.PMN.86)
- Ozanimod (Zeposia) (PDF) (CP.PHAR.462)
- Ozenoxacin (Xepi) (PDF) (CP.PMN.119)
- Paclitaxel protein-bound (Abraxane) (PDF) (CP.PHAR.176)
- Pacritinib (Vonjo) (PDF) (CP.PHAR.583)
- paliperidone inj (PDF) (CP.PHAR.291)
- Palivizumab (Synagis) (PDF) (CP.PHAR.16)
- Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep) (PDF) (CP.PMN.226)
- panitumumab (PDF) (CP.PHAR.321)
- Panobinostat (Farydak) (PDF) (CP.PHAR.382)
- Parathyroid hormone (Natpara) (PDF) (CP.PHAR.282)
- Paricalcitol Injection (PDF) (CP.PHAR.270)
- pasireotide (PDF) (CP.PHAR.332)
- Patiromer (Veltassa) (PDF) (CP.PMN.205)
- Peanut Allergen Powder-dnfp (Palforzia) (PDF) (CP.PMN.220)
- Pegaptanib (Macugen) (PDF) (CP.PHAR.185)
- pegaspargase (PDF) (CP.PHAR.353)
- Peginterferon beta-1a (Plegridy) (PDF) (CP.PHAR.271)
- Pegvisomant (Somavert) (PDF) (CP.PHAR.389)
- pembrolizumab (PDF) (CP.PHAR.322)
- Pemetrexed (Alimta) (PDF) (CP.PHAR.368)
- Pemigatinib (Pemazyre) (PDF) (CP.PHAR.496)
- Pentosan Polysulfate Sodium (Elmiron) (PDF) (CP.PMN.276)
- Perampanel (Fycompa) (PDF) (CP.PMN.156)
- Perindopril/Amlodipine (Prestalia) (PDF) (CP.PMN.174)
- Pertuzumab (Perjeta) (PDF) (CP.PHAR.227)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (PDF) (CP.PHAR.501)
- Pilocarpine (Vuity) (PDF) (CP.PMN.270)
- Pimavanserin (Nuplazid) (PDF) (CP.PMN.140)
- Plerixafor (PDF) (CP.PHAR.323)
- Pitolisant (Wakix) (PDF) (CP.PMN.221)
- Polatuzumab Vedotin-piiq (Polivy) (PDF) (CP.PHAR.433)
- Pomalidomide (Pomalyst) (PDF) (CP.PHAR.116)
- Ponesimod (Ponvory) (PDF) (CP.PHAR.537)
- pralatrexate (PDF) (CP.PHAR.313)
- Prasterone (Intrarosa) (PDF) (CP.PMN.99)
- Pregabalin (Lyrica, Lyrica CR) (PDF) (CP.PMN.33)
- Pretomanid (PDF) (CP.PMN.222)
- Progesterone (Crinone, Endometrin, Milprosa) (PDF) (CP.PMN.243)
- Progesterone Hydroxyprogesterone Caproate (Makena) (PDF) (WA.PHAR.54)
- Propranolol HCl Oral Solution (Hemangeol) (PDF) (CP.PMN.58)
- Protein C Concentrate, Human (Ceprotin) (PDF) (CP.PHAR.330)
- Proton Pump Inhibitors (PPI) (PDF) (WA.PHAR.81)
- Pulmonary Arterial Hypertension (PAH) Agents (Oral and Inhalation) (PDF) (WA.PHAR.55)
- Pulmonary Fibrosis Agents (PDF) (WA.PHAR.57)
- Quantity Limit Overrides (PDF) (CP.PMN.59)
- Quetiapine ER (Seroquel XR) (PDF) (CP.PMN.64)
- Quinine Sulfate (Qualaquin) (PDF) (CP.PNM.262)
- Tivozanib (Fotivda) (PDF) (CP.PHAR.538)
- Ramelteon (Rozerem) (PDF) (CP.PMN.173)
- Ramucirumab (Cyramza) (PDF) (CP.PHAR.119)
- Ranibizumab (Lucentis) (PDF) (CP.PHAR.186)
- Ranolazine (Ranexa) (PDF) (CP.PMN.34)
- Regorafenib (PDF) (CP.PHAR.107)
- Relugolix (Orgovyx) (PDF) (CP.PHAR.529)
- Respiratory Agents- Misc Alpha-Proteinase Inhibitor (Human) (PDF) (WA.PHAR.68)
- Revlimid (PDF) (CP.PHAR.71)
- Ribavirin (Rebetol, Ribasphere) (PDF) (CP.PHAR.141)
- Ribociclib (PDF) (CP.PHAR.334)
- Rifabutin (Mycobutin) (PDF) (CP.PMN.223)
- Rifamycin (Aemcolo) (PDF) (CP.PMN.196)
- Rifapentine (Priftin) (PDF) (CP.PMN.05)
- RimabotulinumtoxinB (Myobloc) (PDF) (CP.PHAR.233)
- Risperidone LA Inj (PDF) (CP.PHAR.293)
- Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela) (PDF) (CP.PHAR.260)
- Rivaroxaban (Xarelto) (PDF) (CP.PMN.247)
- Rivastigmine (Exelon®) (PDF) (CP.PMN.101)
- roflumilast (PDF) (CP.PMN.46)
- Rolapitant (Varubi) (PDF) (CP.PMN.102)
- romidepsin (PDF) (CP.PHAR.314)
- Romosozumab-aqqg (Evenity) (PDF) (CP.PHAR.428)
- Ropeginterferon Alfa-2b-njft (BESREMi) (PDF) (CP.PHAR.570)
- Rucaparib (Rubraca) (PDF) (CP.PHAR.350)
- Rufinamide (Banzel) (PDF) (CP.PMN.157)
- Rukobia (fostemsavir) (PDF) (CP.PHAR.516)
- Sacituzumab Govitecan-hziy (Trodelvy) (PDF) (CP.PHAR.475)
- Safinamide (Xadago) (PDF) (CP.PMN.113)
- Sarecycline (Seysara) (PDF) (CP.PMN.189)
- Sargramostim (PDF) (CP.PHAR.295)
- Secnidazole (PDF) (CP.PMN.103)
- Second Opinion Network (SON) Review (PDF) (WA.PHAR.14)
- Selinexor (Xpovio) (PDF) (CP.PHAR.431)
- Selumetinib (PDF) (CP.PHAR.464)
- Sensipar (PDF) (CP.PHAR.61)
- Setmelanotide (Imcivree) (PDF) (CP.PHAR.491)
- Siltuximab (Sylvant) (PDF) (CP.PHAR.329)
- Siponimod (Mayzent) (PDF) (CP.PHAR.427)
- Sirolimus Protein-Bound Particles (Fyarro) (PDF) (CP.PHAR.574)
- Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF) (CP.PMN.14)
- Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, Sodium Oxybate (Xywav) (PDF) (CP.PMN.42)
- Sodium Zirconium Cyclosilicate (Lokelma) (PDF) (CP.PMN.163)
- Solriamfetol (Sunosi) (PDF) (CP.PMN.209)
- Sonidegib (Odomzo) (PDF) (CP.PHAR.272)
- Sorafenib (Nexavar) (PDF) (CP.PHAR.69)
- Sotorasib (Lumakras) (PDF) (CP.PHAR.549)
- Stiripentol (Diacomit) (PDF) (CP.PMN.184)
- Substance Use Disorders (SUDs)- Buprenorphine extended-release injection (Sublocade) (PDF) (WA.PHAR.108)
- Sunitinib (Sutent) (PDF) (CP.PHAR.73)
- Suvorexant (Belsomra®) (PDF) (CP.PMN.109)
- Sylatron (peginterferon alfa-2b) (PDF) (CP.PHAR.89)
- Tafasitamab-cxix (Monjuvi) (PDF) (CP.PHAR.508)
- Talazoparib (Talzenna) (PDF) (CP.PHAR.409)
- Talimogene laherepvec (Imlygic) (PDF) (CP.PHAR.542)
- Tapinarof (Vtama) (PDF) (CP.PMN.283)
- Tazarotene (Arazlo, Fabior, Tazorac) (PDF) (CP.PMN.244)
- Tasimelteon (Hetlioz) (PDF) (CP.PMN.104)
- Tavaborole (Kerydin) (PDF) (CP.PMN.105)
- Tazemetostat (PDF) (CP.PHAR.452)
- Tebentafusp-tebn (Kimmtrak) (PDF) (CP.PHAR.575)
- Tedizolid (Sivextro) (PDF) (CP.PMN.62)
- Telotristat ethyl (Xermelo) (PDF) (CP.PHAR.337)
- Tesamorelin (PDF) (CP.PHAR.109)
- temsirolimus (PDF) (CP.PHAR.324)
- Tenapanor (Ibsrela) (PDF) (CP.PMN.224)
- Tenofovir Alafenamide Fumarate (Vemlidy) (PDF) (CP.PMN.268)
- Tepotinib (Tepmetko) (PDF) (CP.PHAR.530)
- Teriflunomide (PDF) (CP.PHAR.262)
- Tezepelumab-ekko (Tezspire) (PDF) (CP.PHAR.576)
- Thalidomide (Thalomid) (PDF) (CP.PHAR.78)
- Therapies for COVID-19 (PDF) (WA.PHAR.127)
- Thioguanine (Tabloid) (PDF) (CP.PHAR.437)
- Thyrotropin alfa (PDF) (CP.PHAR.95)
- Tisotumab vedotin-tftv (Tivdak) (PDF) (CP.PHAR.561)
- Tolvaptan (Jynarque) (PDF) (CP.PHAR.27)
- Topiramate Extended-Release (Qudexy XR, Trokendi XR) (PDF) (CP.PMN.281)
- Topotecan (Hycamtin) (PDF) (CP.PHAR.64)
- Toremifene (Fareston) (PDF) (CP.PMN.126)
- Trabectedin (Yondelis) (PDF) (CP.PHAR.204)
- Tralokinumab-ldrm (Adbry) (PDF) (CP.PHAR.577)
- Trametinib (Mekinist) (PDF) (CP.PHAR.240)
- Transmucosal Fentanyl Products (PDF) (WA.PHAR.80)
- Trastuzumab Biosimilars Trastuzumab-Hyaluronidase (PDF) (CP.PHAR.228)
- Triamcinolone ER Injection (PDF) (CP.PHAR.371)
- Triclabendazole (Egaten) (PDF) (CP.PMN.207)
- Trientine (Syprine) (PDF) (CP.PHAR.438)
- Trifarotene (Aklief) (PDF) (CP.PMN.225)
- Trifluridine, Tipiracil (Lonsurf) (PDF) (CP.PHAR.383)
- Triptorelin Pamoate (Trelstar, Triptodur) (PDF) (CP.PHAR.175)
- Ulcer Therapy Combinations (PDF) (CP.PMN.277)
- Umbralisib (Ukoniq) (PDF) (CP.PHAR.531)
- Valrubicin (Valstar) (PDF) (CP.PHAR.439)
- Varenicline (Tyrvaya) (PDF) (CP.PMN.273)
- Vemurafenib (Zelboraf®) (PDF) (CP.PHAR.91)
- Venetoclax (Venclexta) (PDF) (CP.PHAR.129)
- Verteporfin (Visudyne) (PDF) (CP.PHAR.187)
- Vigabatrin (PDF) (CP.PHAR.169)
- Viloxazine (Qelbree) (PDF) (CP.PMN.264)
- vincristine sulfate liposome injection (PDF) (CP.PHAR.315)
- Vismodegib (Erivedge) (PDF) (CP.PHAR.273)
- Voclosporin (Lupkynis) (PDF) (CP.PHAR.504)
- Vorinostat (PDF) (CP.PHAR.83)
- Voxelotor (Oxbryta) (PDF) (CP.PHAR.451)
- Xiaflex™ (PDF) (CP.PHAR.82)
- ziv-aflibercept (PDF) (CP.PHAR.325)
- Zoledronic Acid (Reclast, Zometa) (PDF) (CP.PHAR.59)
- Zolpidem Tartrate (Edluar, Intermezzo, Zolpimist) (PDF) (CP.PMN.172)
Payment Policies
Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.
All policies found in the Coordinated Care Payment Policy Manual apply with respect to Coordinated Care members. Policies in the Coordinated Care Payment Policy Manual may have either a Coordinated Care or a “Centene” heading. In addition, Coordinated Care may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Coordinated Care.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Ambetter Payment Policies
- 3-Day Payment Window (PDF) (CC.PP.500)
- 30-Day Readmission (PDF) (CC.PP.501)
- Add on Code Billed Without Primary Code (PDF) (CC.PP.030)
- Assistant Surgeon (PDF) (CC.PP.029)
- Bilateral Procedures (PDF) (CC.PP.037)
- Cerumen Removal (PDF) (CC.PP.008)
- Clean Claims (PDF) (CC.PP.021)
- Coding Overview (PDF) (CC.PP.011)
- Cosmetic Procedures (PDF) (CC.PP.024)
- Distinct Procedural Modifiers (PDF) (CC.PP.020)
- DRG Technical Denials (PDF) (CC.PP.801)
- Duplicate Primary Code Billing (PDF) (CC.PP.044)
- E&M Medical Decision-Making (PDF) (CC.PP.051)
- EM Bundling Edits (PDF) (CC.PP.010)
- Global Maternity Billing (PDF) (CC.PP.016)
- Hospital Visit Codes Billed with Labs (PDF) (CC.PP.023)
- Inpatient Consultation (PDF) (CC.PP.038)
- Inpatient Only Procedures (PDF) (CC.PP.018)
- IV Hydration (PDF) (CC.PP.012)
- Leveling of Emergency Room Services (PDF) (CC.PP.053)
- Maximum Units (PDF) (CC.PP.007)
- Moderate Conscious Sedation (PDF) (CC.PP.015)
- Modifier -25 clinical validation (PDF) (CC.PP.013)
- Modifier -59 clinical validation (PDF) (CC.PP.014)
- Modifier DOS Validation (PDF) (CC.PP.034)
- Modifier to Procedure Code Validation (PDF) (CC.PP.028)
- Multiple CPT Code Replacement (PDF) (CC.PP.033)
- Multiple Diagnostic Cardiovascular Procedure (MDCP) (PDF) (CC.PP.065)
- Payment Reduction (MDCR)NCCI Unbundling (PDF) (CC.PP.031)
- Never Paid Events (PDF) (CC.PP.017)
- New Patient (PDF) (CC.PP.036)
- Outpatient Consultation (PDF) (CC.PP.039)
- Pelvic and Transabdominal US (PDF) (CC.PP.061)
- Physician's Consultation Services (PDF) (CC.PP.054)
- Physician Visit Codes Billed with Labs (PDF) (CC.PP.019)
- Place of Service Mismatch (PDF) (CC.PP.063)
- Post-Operative Visits (PDF) (CC.PP.042)
- Pre-Operative Visits (PDF) (CC.PP.041)
- Professional Component (PDF) (CC.PP.027)
- Pulse Oximetry (PDF) (CC.PP.025)
- Renal Hemodialysis (PDF) (CC.PP.067)
- Robotic Surgery (PDF) (CC.PP.050)
- Same Day Visits (PDF) (CC.PP.040)
- Sleep Studies Place of Services (PDF) (CC.PP.035)
- Status "B" Bundled Services (PDF) (CC.PP.046)
- Status P Bundled Services (PDF) (CC.PP.049)
- Supplies Billed on Same Day As Surgery (PDF) (CC.PP.032)
- Transgender Related Services (PDF) (CC.PP.047)
- Unbundled Surgical Procedures (PDF) (CC.PP.045)
- Unbundled Professional Services (PDF) (CC.PP.043)
- Unlisted Procedure Codes (PDF) (CC.PP.009)
- Wheelchair Accessories (PDF) (CC.PP.502)
Medicaid Payment Policies
- 1-Day Payment Window (PDF) (WA.PP.500)
- Add on Code Billed Without Primary Code (PDF) (CC.PP.030)
- Assistant Surgeon (PDF) (CC.PP.029)
- Bilateral Procedures (PDF) (CC.PP.037)
- Cerumen Removal (PDF) (CC.PP.008)
- Clean Claims (PDF) (CC.PP.021)
- Coding Overview (PDF) (CC.PP.011)
- Cosmetic Procedures (PDF) (CC.PP.024)
- Distinct Procedural Modifiers (PDF) (CC.PP.020)
- DRG Technical Denials (PDF) (CC.PP.801)
- Duplicate Primary Code Billing (PDF) (CC.PP.044)
- E&M Medical Decision-Making (PDF) (CC.PP.051)
- EM Bundling Edits (PDF) (CC.PP.010)
- Global Maternity Billing (PDF) (CC.PP.016)
- Hospital Visit Codes Billed with Labs (PDF) (CC.PP.023)
- Inpatient Consultation (PDF) (CC.PP.038)
- Inpatient Only Procedures (PDF) (CC.PP.018)
- IV Hydration (PDF) (CC.PP.012)
- Leveling of Emergency Room Services (PDF) (CC.PP.053)
- Maximum Units (PDF) (CC.PP.007)
- Moderate Conscious Sedation (PDF) (CC.PP.015)
- Modifier -25 clinical validation (PDF) (CC.PP.013)
- Modifier -59 clinical validation (PDF) (CC.PP.014)
- Modifier DOS Validation (PDF) (CC.PP.034)
- Modifier to Procedure Code Validation (PDF) (CC.PP.028)
- Multiple CPT Code Replacement (PDF) (CC.PP.033)
- Multiple Diagnostic Cardiovascular Procedure (MDCP) (PDF) (CC.PP.065)
- NCCI Unbundling (PDF) (CC.PP.031)
- Never Paid Events (PDF) (CC.PP.017)
- New Patient (PDF) (CC.PP.036)
- Outpatient Consultation (PDF) (CC.PP.039)
- Pelvic and Transabdominal US (PDF) (CC.PP.061)
- Physician Visit Codes Billed with Labs (PDF) (CC.PP.019)
- Place of Service Mismatch (PDF) (CC.PP.063)
- Post-Operative Visits (PDF) (CC.PP.042)
- Pre-Operative Visits (PDF) (CC.PP.041)
- Professional Component (PDF) (CC.PP.027)
- Provider Preventable Readmissions (PDF) (WA.PP.501)
- Pulse Oximetry (PDF) (CC.PP.025)
- Renal Hemodialysis (PDF) (CC.PP.067)
- Same Day Visits (PDF) (CC.PP.040)
- Sepsis Diagnosis (PDF) (CP.PP.073)
- Sleep Studies Place of Services (PDF) (CC.PP.035)
- Status "B" Bundled Services (PDF) (CC.PP.046)
- Status P Bundled Services (PDF) (CC.PP.049)
- Supplies Billed on Same Day As Surgery (PDF) (CC.PP.032)
- Transgender Related Services (PDF) (CC.PP.047)
- Unbundled Surgical Procedures (PDF) (CC.PP.045)
- Unbundled Professional Services (PDF) (CC.PP.043)
- Unlisted Procedure Codes (PDF) (CC.PP.009)
- Wheelchair Accessories (PDF) (CC.PP.502)
Policy Revision Summary
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.151 | Transcatheter Closure of Patent Foramen Ovale | Annual review. Updated description to include newest FDA-approved device: AmplatzerTM TalismanTM PFO Occluder. Clarfied in I.B. that age requirements are in years. Updated Criteria I.B. # 2 to state that cryptogenic stroke caused by a presumed paradoxical embolism, and a possible, probable, or definite likelihood that the stroke was causally related to PFO based on the PFO-associated stroke causal likelihood (PASCAL) classification system with a Risk of Paradoxical Embolism (RoPE) score > 6, and/or there is a large shunt or atrial septal aneurysm. Updated Criteria to include Criteria C. Device is FDA-approved for percutaneous transcatheter closure of PFO (eg AmplatzerTM PFO Occluder, AmplatzerTM TalismanTM PFO Occluder, and the Gore® Cardioform Septal Occluder). Background updated and includes information on PASCAL classification system and RoPE score. Removed ICD-10 codes. References reviewed and updated. Reviewed by internal specialist and external specialist. |
CP.MP.180 | Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea | Annual review completed. I.C. Changed BMI to 35 kg/m2; I.E. Adjusted AHI to ≥15 to ≤ 65 events per hour; I.F.1. Adjusted 20 to 15. Added criteria I.I.5. and I.I.8. through 14. Background updated and minor rewording with no clinical significance. Added CPT codes 64582, 64583, and 64584. Removed CPT codes 0466T, 0467T, 0468T, 61886, 61888, 64568, 64569, 64570, and 64585. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.202 | Orthognathic Surgery | Annual review completed. Reformatted criteria II. and added II.B. as additional non-medically necessary indication. Additional minor rewording with no clinical significance. Background updated. CDT codes removed from policy. References revised and updated. Reviewed by external and internal specialists. |
CP.MP.150 | Phototherapy for Neonatal Hyperbilirubinemia | Annual review. Changed title from “Home phototherapy…” to “Phototherapy…” Updated criteria I.D. from 24-48 hours to 12-24 hours. Updated criteria to include the following: I.E. ≥48 hours old; I.F. An LED-based phototherapy device will be available in the home without delay; I.G. No previous phototherapy; I.H. TSB will be measured daily. Criteria I.I. #1 updated to include example of positive direct antiglobulin test for isoimmune hemolytic disease and to include glucose-6-phosphate dehydrogenase (G6PD) and other hemolytic disease. Criteria I.I. #2 updated to include hypoxic ischemia encephalopathy (HIE). Significant lethargy removed from Criteria I.I. Criteria I.I. updated to include the following: #13 Significant clinical instability in the previous 24 hours; #14 Clinical history of a parent or sibling requiring phototherapy or exchange transfusion; #15 Exclusive breastfeeding with suboptimal intake (≥10% weight loss); #16 Down syndrome; #17 Macrosomic infant of a diabetic mother. Added note below Table 1 that explains the values are conservative TSB values based on lower age range thresholds in inpatient criteria. Added clarification to II that extenuating circumstances can include lack of expected compliance with therapy at home. Added note below policy statement II stating: that infants should be admitted for inpatient phototherapy if the TSB concentration is more than 1 mg/dL above the AAP guidelines phototherapy treatment threshold per the bili risk tool, and that table 1 is consistent with AAP guidelines allowing treatment at lower levels per provider discretion; and that clinical decision support tools provider further criteria for inpatient phototherapy treatment. Updated background to include 2022 AAP clinical practice guidelines. Removed ICD-10 codes. References reviewed and updated. Reviewed by internal specialist and external specialist. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.246 | Pediatric Kidney Transplant | New policy |
WA.CP.MP.117 | Percutaneous Electrical and Peripheral Nerve Stimulation | Policy renumbered WA.CP.MP.117. References to spinal cord stimulation removed. |
CP.MP.242 | Pulmonary Function Testing | New policy |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.186 | Burn Surgery | Annual review completed. Background updated and minor rewording with no clinical significance. References reviewed, reformatted and updated. |
CP.MP.131 | Essure Removal | Policy retired |
CP.MP.209 | Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing | Removed deleted code 0097U |
WA.CP.MP.70 | Proton and Neutron Beam Therapy | Annual review completed. Removed “treated in a hypofractionated regimen” from I. D. Background updated and minor rewording with no clinical significance. References reviewed, reformatted and updated. External specialist reviewed. |
CP.MP.182 | Short Inpatient Hospital Stay | Annual review. Added I.C. “Acute hospital care at home.” Background updated with no clinical significance. References reviewed and updated. |
CP.MP.142 | Urinary Incontinence Devices and Treatments | Annual review. Updated criteria section to clarify abbreviations. Criteria I.D. # 1 updated to include continence-support pessaries as a conservative measure. Updated background with no impact on criteria. Removed ICD-10 codes. References reviewed and updated. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.108 | Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia | Annual Review. References reviewed, updated, and reformatted. Reviewed by internal specialist. |
CP.MP.31 | Cosmetic and Reconstructive Procedures | Annual review completed. Added to I.A.4.b. “poly-L-lactic acid” and “calcium hydroxylapatite microspheres”. Minor rewording with no clinical significance. References reviewed and updated. Reviewed by external specialist. |
CP.MP.101 | Donor Lymphocyte Infusion | Annual review. Background updated with no impact on criteria. ICD-10 codes removed. References reviewed and updated. Specialist review. |
CP.MP.109 | Panniculectomy | Annual review. Removed ICD-10 codes. References reviewed and updated. |
WA.CP.MP.185 | Skin Substitutes for Chronic Wounds | Updated description for code Q4128. Added new HCPCS codes that are covered and not covered. |
CP.MP.127 | Total Artificial Heart | Annual review. Background updated with no impact on criteria. Changed “date” in the revision log header to “revision date.” References reviewed and updated. Specialist review. |
WA.CP.MP.527 | Vitamin D Testing | Returned 0038U to policy. Deleted in error |
WA.CP.MP.50 | Drugs of Abuse: Definitive Testing | Changed title of tables from “CPT Codes That Do Not Support Coverage Criteria” to “CPT Codes That Are Not Covered per the HCA”. Updated ICD-10 codes to include code ranges. References updated. Added CPT 0328U to the list of CPT codes that are not covered by HCA. Updated parenthetic in policy statement II to indicate codes are examples. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.105 | Digital EEG Spike Analysis | Annual review. References reviewed and updated. |
CP.MP.106 | Endometrial ablation | In I.A.2, reworded portion pertaining to abnormal bleeding in transgender members from “female to male transgender person” to “member/enrollee with a female reproductive system undergoing treatment for gender affirmation.” |
CP.MP.113 | Holter Monitors | Annual review completed. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Minor rewording with no clinical significance. Added the following criteria to I.M. “Evaluation of recurrent chronic heart failure, when arrhythmia is suspected” and I.N. “Evaluation of possible arrhythmias post ablation procedures”. References reviewed and updated. Specialist review. |
CP.MP.134 | Evoked Potential Testing | Annual review. References reviewed and updated. Specialist reviewed. |
CP.MP.153 | H. Pylori Serology Testing | Annual review completed. Background updated and minor rewording with no clinical significance. References reviewed and updated. |
CP.MP.154 |
Thyroid Hormones and Insulin Testing in Pediatrics |
Annual review completed. Changed “Date of Last Review” to “Date of Last Revision” in the header. Background updated and minor rewording with no clinical significance. References reviewed and updated. |
CP.MP.155 | EEG in Evaluation of Headache | Annual review. References reviewed and updated. Reviewed by specialist. |
CP.MP.156 | Cardiac Biomarker Testing for Acute MI | Annual review. Background updated with no impact on criteria. References reviewed and updated. |
CP.MP.194 | Osteogenic Stimulation | Annual review completed. Added “electrical” to I. and II. Replaced “smoking habit” with “tobacco use” in criteria I.E.7., II.E.7., and III.B.7. Removed criteria point III.6.c. “The patient has failed more than one surgery and other medical therapies (e.g. immobilization and non-weight bearing status)”. Background updated and minor rewording with no clinical significance. References reviewed and updated. Specialist reviewed. |
CP.MP.203 | Diaphragmatic Phrenic Nerve Stimulation | Updated code G83.89 to G83.9. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
WA.CP.MP.519 | Administrative Days | Added Newborn Administrative Days section and Note regarding request. |
WA.CP.BH.104 | Applied Behavioral Analysis | Addition of treatment range for focused ABA and literature review in introduction. Addition of medical necessity criteria for behavioral assessment. Addition of intensity of services for ABA. Addition of "or appropriate diagnosis as otherwise specified according to state defined ABA criteria" and removal of "clinical professional counselor, marriage and family therapist, addition counselor", addition of "strengths-specific, family-focused, community-based, multisystem, culturally-competent, and least intrusive. And where specific target behaviors are clearly defined; frequency, rate, symptom intensity or duration" in criteria. Section III.D. updated definition. Addition of H, K, L, M in initiation of services criteria. Addition of K, L, M, N in continuation of ABA services criteria. Addition of transition planning section. Updated introduction and research studies including citations to Background. Addition of Screening Recommendations for ASD. Edit of verbiage for caregiver training goals to "Caregiver training is performance based and parent drive. Identifies measurable outcomes for every goal and objective." |
CP.BH.500 | BH Treatment Documentation Requirements | New Policy |
WA.CP.MP.516 | Carotid Artery Stenting | Annual review. References updated. Removed HTA criteria from policy. |
CP.MP.167 | Intradiscal Steroid Injections for Pain Management | Annual Review. Criteria section updated to single spacing. Background updated with no impact on criteria. References reviewed and updated. Specialist reviewed. |
CP.MP.244 |
Liposuction of Lipedema |
New Policy |
CP.MP.170 | Nerve Blocks for Pain Management | Annual review completed. Added “as effectiveness has not been established” to I. C. Background updated. Reworded some extraneous language with no clinical significance. References reviewed and updated. |
CP.MP.206 | Skilled Nursing Facility Leveling | Annual review completed. Added “in the community” and “moderate/maximum/total” to Section I.A.4. and II.A.4. Updated II.C.4. from 3 hours of skilled therapy per day to “at least” 3 hours of skilled therapy per day. Additional minor rewording with no clinical significance. References reviewed and updated. Specialist reviewed. |
CP.BH.100 | Substance Use Treatment and Services | New Policy |
CP.BH.200 | Transcranial Magnetic Stimulation for Treatment Resistant Major Depression | Annual Review. Revisions made to Policy/Criteria Section I. E to reflect the elimination of point 1 completely. The former point 2 and 3, will now be combined as the new point 1. The original point 4 has now changed to become the new point 2. Replaced terminology in Policy/Criteria I: H.5, II: B.5, III: V.5 from “Substance abuse at time of treatment” to “a minimum of 3 month substantiated early remission from substance use disorder” |
CP.MP.169 | Trigger Point Injections for Pain Management | Annual review. References reviewed, updated, and reformatted. Updated criteria in I.B. from 2 additional injections to 4. In I.B.1 added pain relief with functional improvement, in I.B.2. added “≥” 6 weeks, and in I.B.4 added “from initial injection” and changed maximum of 4 total sessions to 6. Specialist review. |
CP.MP.12 | Vagus Nerve Stimulation | Adopted CP.MP.12 to replace WA.CP.MP.12. |
WA.CP.MP.12 | Vagus Nerve Stimulation | Retire |
Policy Number | Policy Title | Revision Notes |
---|---|---|
WA.CP.MP.37 | Bariatric Surgery | Section III: updated abbreviations in III.3 with no clinical significance; added indication for SG to RYGB or BPD-DS DS as a bridging procedure for BMI ≥ 50 kg/m² in III.4. Updated references. |
CP.MP.14 | Cochlear Implant Replacements | Annual review completed. Removed “or” in I.A. and I.B. Background updated with no impact to criteria. References reviewed and updated. |
WA.CP.MP.514 | Extra-Corporeal Membrane Oxygenation | Annual review. References updated. |
CP.MP.137 | Fecal Incontinence Treatments | Annual review completed. In Section I.B. changed “member” to “member/enrollee”. Added “sacral neuromodulation” to Section I.C. Background updated with minor verbiage changes with no clinical significance. Updated description for CPT codes 46760, 46761, 64581, 64590 and HCPCS Code L8683. References reviewed and updated. Specialist reviewed. |
CP.MP.129 | Fetal Surgery in Utero for Prenatally Diagnoses Malformations | Annual review. Description updated with no impact on criteria. Background updated with no impact on criteria. References reviewed and updated. |
CP.MP.243 |
Implantable Loop Recorder (Implantable Cardiac Monitor) |
New Policy |
CP.MP.85 | Neonatal Sepsis Management | Annual review. Description updated. Background updated: Minor rewording for clarity in II.C; added verbiage about procalcitonin in II.G; in III.B, changed 48 hours to 36-48 hours. References reviewed and updated. Reviewed by specialist. |
CP.MP.128 | Optic Nerve Decompression Surgery | Annual review. References reviewed and updated. Specialist review. Background updated with no clinical significance. |
CP.MP.51 | Reduction Mammoplasty and Gynecomastia Surgery | Annual review completed. Changed “women” to “members/enrollees” in I.A.5.c. Added I.B.5. to gigantomastia of pregnancy criteria. Language references in the criteria, description and background sections changed from “male” and/or “female” to “those with a male reproductive system” and/or “those with a female reproductive system.” References reviewed and updated. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
WA.CP.MP.37 |
Bariatric Surgery |
Annual review. Moved note about G9012 into section I. Description updated with no impact on criteria. Criteria I.A. procedures listed with abbreviations with no impact on criteria. Background updated with no impact on criteria. Corrected ICD10 code I10.0 to I10. References reviewed and updated. |
CP.MP.93 | Bone-anchored Hearing Aid | Annual Review. Description updated with no impact on criteria. Criteria I. updated to include abbreviation of BAHA. Criteria III.C. wording updated for clarity. Background updated with no impact on criteria. References reviewed and updated. Removed deleted codes 69715 and 69718. Added new codes 69716, 69719, 69726, and 69727. |
CP.MP.94 | Clinical Trials | Annual review. Criteria I.,II.,III.,IV. updated to remove “and” after semi-colons. Criteria IV.B. “et al” changed to “etc.” Criteria IV.E. #7 abbreviation updated for Department of Energy (DoE). References reviewed and updated. |
CP.MP.115 | Discography | Annual review completed. Description and background updated with no impact to criteria. References reviewed and updated. Specialist reviewed. |
CP.MP.107 | Durable Medical Equipment (DME), Orthotics and Prosthetics Guidelines | Removed cardiac event monitor (E0616) criteria from cardiac equipment section of policy and moved to CP.MP.243 Implantable Loop Recorders. Removed invasive home ventilator criteria (E0465) and moved to CP.MP.184 Home Ventilators. Added statement that current evidence does not support the effectiveness of intrapulmonary percussive ventilation (E1399). |
CP.MP.184 | Home Ventilators | Annual review. Changed policy title from “Noninvasive Home Ventilators” to “Home Ventilators”. Removed (-) before 60 in I.A.1.b. Changed ≥ 45 to > 45 in I.A.1.a.i. Added pediatric criteria in I.A.1.a.ii. Changed I.A.1.b.i to apply to those over age 18 and added “1.A.1.b.ii. “For those < 18 years of age, documentation of Type 1 (hypoxemic) and/or Type 2 (hypercapneic) respiratory failure or inability to maintain airflow”. Replaced “tachypnea (respirations >24)” with “including tachypnea, increased work of breathing, hypoxemia, hypercapnia and/or respiratory acidosis (e.g., pH <7.35)” in I.A.2.c.; I.B.3.c.; I.C.3.c.; and I.D.1.c. Added “Baseline” to all “FIO2 requirement > 0.40”. Moved invasive ventilator criteria from CP.MP.107 DME and placed in criteria IV. Combined invasive and nonivasive backup or second home ventilator into section V. Added HCPCS code E0465. Description and background updated to include information re: invasive ventilators. Reworded some extraneous language with no clinical significance. Changed “Review Date” in the header to “Date of Last Revision” and “Date” in the revision log header to “Revision Date.” References reviewed and updated. Specialist reviewed. |
CP.MP.82 | NICU Apnea Bradycardia Guidelines | Annual review completed. Expanded criteria I.A.3.c. into two criteria points by adding criteria I.A.3.d. Changed “child’s” to “infant’s” in criteria I.B. Removed conditional caffeine criteria I.D. Reworded criteria former criteria I.E, now I.D., for clarity. Moved criteria I.E. and I.F. to notes section. Minor rewording in description, original notes, and background with no clinical significance. References reviewed and updated. Specialist reviewed. |
CP.MP.81 | NICU Discharge Guidelines | Annual Review. Description updated with no impact on criteria. Criteria II.A. updated to include normal axillary and rectal temperature ranges and to include range for normal ambient environment temperature. References reviewed and updated. |
CP.MP.49 | Physical, Occupational and Speech Therapy Services | Annual review completed. References reviewed and updated. Specialist reviewed. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.100 | Allergy Testing and Therapy | Added the following ICD-10 codes as medically necessary in ICD-10 code table 1: L20.0, L20.81-L20.83 (within code range L20-L20.9), L24.9, L30.2. |
WA.CP.MP.84 |
Cell-free Fetal DNA Testing |
Policy retired |
WA.CP.MP.511 | Gene Expression Profile Testing for Cancer Tissue | Policy retired |
CP.MP.89 | Genetic and Pharmacogenetic Testing | Policy retired |
CP.MP.215 | Genetic Testing Aortopathies & Connective Tissue Disorder | New Policy |
CP.MP.216 | Genetic Testing Cardiac Disorder | New Policy |
CP.MP.217 | Genetic Testing Dermatologic Conditions | New Policy |
CP.MP.218 | Genetic Testing Epilepsy, Neurodegenerative and Neuromuscular Disorders | New Policy |
WA.CP.MP.219 | Genetic Testing Exome and Genome Sequencing | New Policy - replaces WA.CP.MP.524 - Whole Exome Sequencing |
CP.MP.220 | Genetic Testing Eye Disorders | New Policy |
CP.MP.221 | Genetic Testing Gastroenterologic Disorders (non-cancerous) | New Policy |
CP.MP.222 | Genetic Testing General Approach to Genetic Testing | New Policy |
CP.MP.223 | Genetic Testing Hearing Loss | New Policy |
CP.MP.224 | Genetic Testing Hematologic Conditions (non-cancerous) | New Policy |
CP.MP.225 | Genetic Testing Hereditary Cancer Susceptibility | New Policy |
CP.MP.226 | Genetic Testing Immune, Autoimmune and Rheumatoid Disorders | New Policy |
CP.MP.227 | Genetic Testing Kidney Disorders | New Policy |
CP.MP.228 | Genetic Testing Lung Disorders | New Policy |
CP.MP.229 | Genetic Testing Metabolic, Endocrine and Mitochondrial Disorders | New Policy |
WA.CP.MP.230 | Genetic Testing Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay | New Policy – incorporates WA.CP.MP.512 - Genomic Microarray Testing. Revised section on Chromosomal Microarray Analysis to mirror Washington State Health Technology Assessment criteria. Updated reference. |
WA.CP.MP.231 | Genetic Testing Non-Invasive Prenatal Screening (NIPS) | New Policy - replaces WA.CP.MP.84 – Cell-free Fetal DNA Testing |
CP.MP.232 | Genetic Testing Pharmacogenetics | New Policy |
CP.MP.233 | Genetic Testing Pre-Implantation | New Policy |
CP.MP.234 | Genetic Testing Prenatal and Preconception Carrier Screening | New Policy |
CP.MP.235 | Genetic Testing Prenatal Diagnosis (via Amniocenteses, CVS or PUBS) and Pregnancy Loss | New Policy |
CP.MP.236 | Genetic Testing Skeletal Dysplasia and Rare Bone Disorders | New Policy |
WA.CP.MP.512 | Genomic Microarray Testing | Policy retired |
CP.MP.132 | Heart-Lung Transplant | Added specific congenital heart disease criteria to 2.i. Removed contraindication regarding specific congenital heart disease lesion. |
CP.MP.58 | Intestinal and Multivisceral Transplant | Annual review. References reviewed, updated, and reformatted. Specialist reviewed. |
CP.MP.116 | Lysis of Epidural Lesions | Annual review. References reviewed, updated, and reformatted. Background updated with no clinical significance. Specialist reviewed. |
WA.CP.MP.518 | Negative Pressure Wound Therapy for Home Use | Annual review. References updated. Added emphasis that coverage is for a maximum of four months of treatment. |
CP.MP.86 | Neonatal Abstinence Syndrome Guidelines | Annual review. Description updated. Added cocaine, SSRIs, and caffeine to the NAS symptom onset table. In I.B, replaced portion of note reflecting a 6 hour dosing interval with a 4 hour morphine dosing interval. Added requirement in I.C.2 discharge criteria that infant is consolable with appropriate measures 24-48 hours after the last dose of morphine prior to discharge, based on gestational age, with note about morphine half-lives applicable to a range of gestational ages. Noted in background section A.3.b regarding screening that meconium and umbilical blood reflect drug use for 20 weeks of gestation and later. Background: Changed background heading “Observation/Assessment” to “ B. Observation location//Assessment tool/Level of Care,” and in that section: expanded information regarding LOC for Finnegan scoring, and added section for LOC for ESC scoring; in 3.c, added that polysubstance use should correspond to observation for 5-7 days, and added note that when more than 1 scoring system is used, LOC should be determined according to the scoring system driving the care decisions. In nonpharmacologic treatment section, changed recommendation from frequent feedings of calorie dense formular or fortified breastmilk to “breastfeeding or formula feeding as indicated.” Added c under pharmacologic treatment regarding ESC assessment categories. Added details regarding morphine, clonidine, and phenobarbital weaning. Added additional background to “ESC Assessment Approach.” References reviewed and updated. |
CP.MP.237 | Oncology Algorithmic Testing | New Policy. Incorporates WA.CP.MP.511 - Gene Expression Profile Testing for Cancer Tissue. |
CP.MP.238 | Oncology Cancer Screening | New Policy |
CP.MP.239 | Oncology Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) | New Policy |
CP.MP.240 | Oncology Cytogenetic Testing | New Policy |
CP.MP.241 | Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies | New Policy |
CP.MP.188 | Pediatric Oral Function Therapy | Annual review completed. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Expanded criteria I.D. to I.D.1.-3. and included parenteral nutrition and/or gastrostomy feedings as options for nutritional support. Background updated with no impact to criteria. References reviewed and updated. Specialist reviewed. |
CP.MP.210 | Repair of Nasal Valve Compromise | Annual Review. Updated Criteria I.B. to include nasal dilators such as Max-Air Nose Cones® and Sinus Cones®. Background updated with no impact on criteria. References reviewed and updated. Changed “Last Review Date” in policy header to “Date of Last Revision,” and “Date” in the revision log header to “Revision Date.” |
WA.CP.MP.509 | Upper GI Endoscopy for GERD | Annual review. Detailed Alarm Symptoms. Updated reference. |
WA.CP.MP.524 | Whole Exome Sequencing | Policy retired |
Policy Number | Policy Title | Revision Notes |
---|---|---|
WA.CP.MP.519 |
Administrative Days |
Criteria for Physical Health (Section I.) re-ordered and discharge planning criteria restated. Section II on non-approval removed. Criteria for Behavioral Health, previously Section III, renumbered and re-ordered. References reviewed and updated. All occurrences of “member” replaced with “member/enrollee”. |
WA.CP.MP.504 |
Elective Delivery Prior to 39 Weeks |
Annual review. Changed “Review Date” in the header to “Date of Last Revision” and “Date” in the revision log header to “Revision Date.” Updated diagnosis code list. |
CP.MP.106 | Endometrial ablation | Changed criteria I.D. from “no structural anomalies, such as fibroids or polyps that require transmural surgery or represent a contraindication to an ablation procedure” to “no structural anomalies, such as fibroids or polyps that require transmural surgery or represent a contraindication to an ablation procedure.” Added contraindication criteria I.F.6. “Previous classical cesarean or other transmural surgery.” |
WA.CP.MP.207 |
Home Prothrombin Time Monitoring | Policy retired. |
WA.CP.MP.27 | Hyperbaric Oxygen Therapy | Policy reviewed and verified variances from InterQual justify maintenance. References reviewed and updated. Changed “date” in the revision log header to “revision date”. |
CP.MP.173 |
Implantable Intrathecal or Epidural Pain Pump |
Annual review. Reference reviewed, updated, and reformatted. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Updated “Refer to” note. In I. added “epidural or” intrathecal administration. In I.A.1. added Inadequate response “to or intolerable side effects from.” II.A added when “the above criteria for” the preliminary trial is met “and the following: Body size is sufficient to support the weight and bulk of the device; No other implanted programmable devices for which the interaction between devices may inadvertently change the prescription; No known allergy or hypersensitivity to the drug being used.” II.A. added “Note: The trial requirement for a percutaneous intrathecal or epidural drug delivery system for pain of malignant origin may be reviewed on a case-by-case basis for instances of advanced disease, when survival time is limited, or considered high risk for procedures.” II.B added “when the above criteria for the preliminary trial is met and all of the following.” Removed duplicate criteria from II.B “no active infection.” Updated policy title from "Implantable Intrathecal Pain Pump" to “Implantable Intrathecal or Epidural Pain Pump." |
CP.MP.87 | Inhaled nitric oxide | Annual Review. Spelled out “partial pressure of oxygen” in I.B.1.e. and “inhaled nitric oxide” in IV. Updated description and background with no impact on criteria. References reviewed and updated. Specialist reviewed. |
CP.MP.24 | Multiple Sleep Latency Testing | Annual review. Added criteria for repeat MSLT in section II. Updated additional background information with no further impact to criteria. References reviewed and updated. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Specialist reviewed. |
WA.CP.MP.507 | Oral Enteral Nutrition | Annual Review. Changed “Review Date” in the header to “Date of Last Revision” and “Date” in the revision log header to “Revision Date.” Replaced "members" with "members/enrollees". |
WA.CP.MP.506 |
Psychological Testing | Annual review. Policy updated to more closely mirror HCA Billing Guidelines. |
WA.CP.MP.185 | Skin Substitutes | Annual review. References reviewed and updated. Changed “Review Date” in the header to “Date of Last Revision” and “Date” in the revision log header to “Revision Date.” Reworded some extraneous language with no clinical significance. Added to I.F.2. “unless Integra® is used per FDA guidelines”. Removed I.J.3. “Concurrent treatment with hyperbaric oxygen therapy”. Background section updated with no additional impact to criteria. Update code listing of covered and non-covered codes to mirror HCA Billing Guidelines. Added reference CMS A56696. Specialist reviewed. |
CP.MP.163 | Total Parenteral Nutrition and Intradialytic Parenteral Nutrition | Annual review. References reviewed and updated to AMA format. Spelling correction in criteria I.A.2.c. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Background updated with no impact to criteria. Specialist reviewed. |
CP.BH.200 | Transcranial Magnetic Stimulation for Treatment Resistant Major Depression | Revised Policy/Criteria Section I.B. to reflect that oversight of treatment is provided by a licensed psychiatrist except where state scope of practice acts allow otherwise. |
WA.CP.MP.522 | Varicose Vein Treatment | Annual review. Added I.C, that if cyanoacrylate adhesive (VenaSeal) is requested, it is for the smaller saphenous vein only. Removed section III stating that cyanoacrylate adhesive is not medically necessary. References reviewed and updated. Background updated with no impact on criteria. Specialist reviewed. Moved codes 36482 and 36483. |
WA.CP.MP.527 | Vitamin D Testing | Annual review. Added reference to coding guidelines. References updated. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.124 |
ADHD Assessment and Treatment | Annual review. “Experimental/investigational” verbiage replaced in policy statement with “there is insufficient evidence to support”. References reviewed, updated, and reformatted. Duplicate reference removed. Changed “review date” in the header to “Date of Last Revision” and “Date” in the revision log header to “Revision date”. Added “Findings from clinical trials studying adults with noncomorbid ADHD suggest amphetamines as first-line treatment when compared to other medications or cognitive-behavioral therapy (CBT). Methylphenidate is also the first option of treatment for adults with moderate or severe ADHD; however, the evidence on the effects of immediate-release (IR) methylphenidate is limited and controversial in the treatment of the adult population” and “Suggested first line treatment for adults with ADHD is medication rather than cognitive-behavioral therapy (CBT)” to the Background section with no impact to criteria. Revised description of CPT-81229, 92065, 96366, 96367 and 97814. |
CP.MP.100 | Allergy Testing and Therapy | Removed codes 86160, 86161 and 86162 from the not medically necessary table. Added ICD-10 Table 7 with codes that do not support medical necessity for 86160-86162. |
CP.MP.96 | Ambulatory EEG | Policy retired |
WA.CP.MP.513 | Cardiac Stents | Annual review. Reference updated. Removed codes to mirror HCA Billing Guideline. Replaced all occurrences of “member” with “member/enrollee”. |
CP.BH.201 | Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder | Annual review of policy. Changed “Review Date” in header to “Date of Last Revision” and “Date” in revision log header to “Revision Date.” Confirmed current CPT codes for TMS and ICD-10 codes for OCD, and updated policy with grammar and format revisions. |
WA.CP.MP.50 | Drugs of Abuse: Definitive Testing | References reviewed and updated. Added “It is the policy of Coordinated Care…” to criteria III. Updated background with no impact to criteria. Description updated for CPT code 80370. Reviewed by specialist. |
CP.MP.106 | Endometrial Ablation | Annual review completed. Added “or HPV testing” to I.B. References reviewed and updated. Background updated with no impact to criteria. |
CP.MP.209 | GI Pathogen Nucleic Acid Detection Panel Testing | Annual review. References reviewed, updated, and reformatted. |
CP.MP.121 | Homocysteine Testing | Annual review. References reviewed and updated. Updated description and background with no impact on criteria. Reviewed by specialist. |
CP.MP.123 | Laser Therapy for Skin Conditions | Annual review. Background updated with no impact to policy statement. Specialist reviewed. References reviewed and updated. |
WA.CP.MP.505 | Microprocessor-Controlled Lower Limb Prosthetics | Annual review. No changes made. |
CP.MP.181 | Polymerase Chain Reaction Respiratory Viral Panel Testing | Annual review. References reviewed and updated. Updated background with no clinical significance. Specialist reviewed. |
CP.MP.149 | Testing for Rupture of Fetal Membrane | Policy retired |
WA.CP.MP.517 | Testosterone Testing | Annual review. Reference updated. Added coverage criteria for gender dysphoria. Updated language regarding services outside of the scope of this policy. Added a note about gender dysphoria benefits. |
CP.MP.189 | Thymus Transplantation | Policy retired |
CP.BH.200 | Transcranial Magnetic Stimulation for Treatment Resistant Major Depression | Review of recent research and annual review of policy by the CABH CPSC. Revisions included Policy/Criteria, initial sessions revised from 30 to 20; Section II, additional sessions revised from 20 to 10; and a statement was added to the background section in reference to a randomized clinical trial published by J.A. Yesavage et al (2018), Effect of Repetitive Transcranial Magnetic Stimulation on Treatment-Resistant Major Depression in US Veterans to reflect the reference supports CABH exclusion criteria related to treatment of ongoing SUD, PTSD, and comorbidity disorders. Changed “Review Date” in header to “Date of Last Revision” and “Date” in revision log header to “Revision Date.” References updated. |
WA.CP.MP.520 | Tympanostomy Tubes | Annual review. Updates to section II to mirror HCA Billing Guideline. References updated. |
CP.MP.38 | Ultrasound in Pregnancy | Annual review. Removed table 5, diagnosis codes supporting medical necessity for TVU, which was included in the previous version in error. Added “detailed “ to criteria statement, section III: “Further detailed anatomic ultrasounds…..” for clarification. References reviewed and updated. Specialist review. |
CP.MP.98 | Urodynamic Testing | References reviewed and updated. In 1.D.1, changed “incontinence associated with recurrent UTI” to “Urinary incontinence.” Codes checked. Updated background with no impact to policy statement. |
CP.MP.177 | Video Electroencephalography (V-EEG) | Policy retired |
Policy Number | Policy Title | Revision Notes |
---|---|---|
WA.CP.MP.521 |
Behavioral Health Personal Care Services |
Annual review. Reference updated. |
WA.CP.MP.502 | Cochlear Implants: Bilateral vs. Unilateral | Annual review. Reference updated. |
WA.CP.MP.501 | Continuous Glucose Monitoring System | Annual review. References updated. |
CP.MP.211 | Electromyography and Nerve Conduction Studies | Policy retired in favor of InterQual criteria. |
WA.CP.MP.36 | Experimental Technologies | Annual review. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References updated. Corrected logo. |
WA.CP.MP.130 |
Fertility Preservation | Annual review. Reference updated. |
WA.CP.MP.46 | Ventricular Assist Devices | Annual review. Updated Description. Added age for pediatric services. Updated Background. Reviewed and updated References. |
CP.MP.132 | Heart-Lung Transplant | Annual review. References reviewed, updated, and reformatted. Updated 1.C. with some contraindications from ISHLT 2021 guidelines. Background updated with no clinical significance. |
CP.MP.34 | Hyperemesis Gravidarum Treatment | Annual review. References reviewed, updated with AMA format. Updated background with no impact to criteria. Changed “Last Review Date” in the header to “Date of Last Revision” and “Date” in the revision log header to “Revision Date." Specialist reviewed. |
CP.MP.58 | Intestinal and Multivisceral Transplant | Edited contraindications: Replaced “non-hepatic malignancy…” with malignancy with high risk of recurrence or death…”; added GFR restriction, added HIV infection with detectable viral load, added stroke, acute coronary syndrome, or MI; added acute renal failure…; added septic shock; added progressive cognitive impairment; replaced “untreatable significant dysfunction of another major organ system…” with “Other severe uncontrolled medical condition expected to limit survival after transplant;” slightly reworded substance use contraindication; removed “acute medical instability…”; removed “uncorrectable bleeding diathesis.” |
CP.MP.57 | Lung Transplantation | Annual review. Added “or surgical therapy” to I and noted that maximal medical therapy includes pulmonary rehab when applicable. Updated the following based on ISHLT 2021 guidelines; removed criteria “High (> 80%) likelihood of surviving at least 90 days after lung transplantation.”, updated I.C., I.D.1.a, I.D.1.b., I.D.1.c., I.D.1.d., I.D.1.f., I.D.2.a, I.D.2.b. Clarified nicotine and tobacco abstinence contraindication. Added CPT codes 32850, 32855, and 32856. References reviewed, updated, and reformatted. Reviewed by specialist. |
CP.MP.141 | Non-Myeloablative Allogenic Stem Cell Transplants | Annual review. Rephrased criteria I.A.3. from “aplastic anemia” to “acquired bone marrow failure such as severe aplastic anemia.” Added new indication I.A.4., “Familial bone marrow syndromes such as….” Removed “molecular remissions induced by Gleevec” from I.A.8.” Added criteria points 13. and 14. to criteria I.A. “Experimental/investigational” verbiage in criteria II. replaced with descriptive language. Sorted list of non-supported indications in criteria II. into 3 subcategories, solid tumors, autoimmune disorders and hemoglobinopathies. In criteria I.C., combined and rephrased contraindications 2. and 3. and updated verbiage regarding substance abuse and dependence in 4. Minor rewording in description and background with no impact on criteria. Removed ICD-10 codes D57.00-D57.819 for sickle-cell disorders from ICD-10 table of codes to support coverage. References reviewed and updated. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Reviewed by specialist. |
CP.MP.102 | Pancreas Transplantation | Annual review. References reviewed and updated. Updated description and background with no clinical significance. Updated all contraindications in criteria I.C. “Experimental/investigational” verbiage replaced in criteria IV. statement with descriptive language. Specialist reviewed. |
CP.MP.138 | Pediatric Heart Transplant | Moved criterion “all reversible causes of heart failure have been ruled out…” to I.C, and moved contraindications to I.D. Edited contraindications: added GFR rate; added “Acute liver failure or cirrhosis…”, added acute renal failure; added HIV infection with detectable viral load; added septic shock; added progressive cognitive impairment; replaced “untreatable significant dysfunction of another major organ system..” with “Other severe uncontrolled medical condition expected to limit survival after transplant”; slightly reworded substance use contraindication; removed “acute medical instability…” and “uncorrectable bleeding diathesis;” replaced “malignancy, except for non-melanoma…” with “Malignancy with high risk of recurrence or death related to cancer.” |
CP.MP.120 | Pediatric Liver Transplant | Edited contraindications: Replaced “non-hepatic malignancy…” with malignancy with high risk of recurrence or death…”; added GFR restriction, added HIV infection with detectable viral load, added stroke, acute coronary syndrome, or MI; added acute renal failure…; added septic shock; added progressive cognitive impairment; replaced “untreatable significant dysfunction of another major organ system…” with “Other severe uncontrolled medical condition expected to limit survival after transplant;” slightly reworded substance use contraindication. |
WA.CP.MP.503 | Private Duty Nursing Services | Updated to reflect the decision to move to Interqual criteria vs. current policy. Removal of all MATLOC criteria, insertion of Social Factors assessment for additional hours. Updated references. Replaced “member” with “member/enrollee” in all instances. |
WA.CP.MP.523 | Sleep Apnea Diagnosis and Treatment | Corrected I.B. to indicate “HFrEF of 40% or less” |
CP.MP.162 | Tandem Transplant | Replaced contraindications “Inadequate cardiac, renal, pulmonary, or hepatic function and significant, uncorrectable, life-limiting medical condition” with those concerning GFR, acute liver failure…, acute renal failure…, septic shock, active extrapulmonary or disseminated infection, active tuberculosis infection, HIV infection with detectable viral load, progressive cognitive impairment, other severe uncontrolled medical condition…Updated references. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.179 |
Antithrombin III (Atryn, Thomate) |
Policy is retired. |
WA.CP.MP.525 |
Catheter Ablation for SVTA |
Annual review. References updated. |
WA.CP.MP.515 |
Fecal Microbiota Transplantation |
Annual review. Changed “not covered” to “not medically necessary”. Changed “members” to “members/enrollees”. Updated references. |
CP.MP.62 |
Hyperhidrosis Treatments |
Annual review. References reviewed and updated. Reviewed by specialist. Changed "Last Review Date" in the header to "Date of Last Revision" and "Date" in revision log to "Revision Date". “Experimental/investigational” verbiage replaced in policy statement and background with descriptive language. Updated reference to CP.PHAR.09 to CP.PHAR.230 and CP.PHAR.232 as well as CP.PMN.117 to CP.PMN.177. |
WA.CP.MP.500 |
Mandibular Advancement Devices |
Annual review. Reference reviewed. |
CP.MP.202 |
Orthognathic Surgery |
New policy |
CP.MP.206 |
Skilled Nursing Facility Leveling |
Added corresponding revenue codes to each level’s “care requirements” section in I.C and II.C. |
WA.CP.MP.523 |
Sleep Apnea Diagnosis and Treatment |
Added reference to new policy CP.MP.202 – Orthognathic Surgery |
WA.CP.MP.526 |
Stem Cell Therapy for Musculoskeletal Conditions |
Annual review. Changed headings to “Date of Last Revision” and added “Effective Date”. Replaced “not covered” with “not medically necessary”. Updated references. |
CP.MP.22 |
Stereotactic Body Radiation Therapy |
Annual Review. In II.A., clarified that “one of the following” must be met. Removed “SBRT” from the note about proximity to cranial nerves in II.F. “Experimental/investigational” verbiage replaced in criteria III. with descriptive language. Changed "Last Review Date" in the header to "Date of Last Revision" and "Date" in revision log to "Revision Date". Reviewed by specialist. |
WA.CP.MP.510 |
Tinnitus Treatment |
Annual review. Replaced "not covered" with "not medically necessary". References updated. |
CP.MP.177 |
Video Electroencephalography (V-EEG) |
Annual review. References reviewed and updated. Minor wording changes in background with no clinical significance. |
WA.CP.MP.177 |
Video Electroencephalography (V-EEG) |
Policy archived and replaced with CP.MP.177 |
WA.CP.MP.524 |
Whole Exome Sequencing |
Annual review. Expanded Description. Added Effective Date. Added 0036U, 0214U, 0215U, 81417. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
WA.CP.MP.508 |
Bone Growth Stimulator |
Policy retired and replaced with CP.MP.194 – Osteogenic Stimulation |
CP.MP.186 | Burn Surgery | Annual review. References reviewed and updated. Changed, “review date,” in the header to, “date of last revision,” and, “date,” in the revision log header to, “revision date." Removed criteria III. Stating burn surgery was, “not medically necessary when duplicating another provider’s procedure, product, or service.” Reviewed by specialist. |
CP.MP.203 | Diaphragmatic/Phrenic Nerve Stimulation | Annual review. References reviewed, updated, and reformatted. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Replaced investigational verbiage with “evidence is limited in supporting safety and efficacy.” Added CPT 64580 and 64590 and HCPCS L8680, L8682, L8683, L8695, and L8696 |
CP.MP.107 | Durable Medical Equipment (DME) | Annual review. References reviewed and updated. Added burn garment HCPCS codes A6502, A6503, A6504, A6505, A6506, A6508, A6509, A6510, A6512 and A6513 to policy. Made note for HCPCS code K0108 to refer to CP.MP.99 for wheelchair seating in Specialized supply or Equipment section. |
CP.MP.89 | Genetic and Pharmacogenetic Testing | Annual review. Updated verbiage in Description section. Under Notes: added “clinical policies” to bullet point 1 and updated bullet point 3 to state “Requests for genetic panels will be reviewed to determine if all included gene analyses are medically necessary.” In I.A. added “having inherited” and “or genetic disorder.” Updated verbiage in I.C from “consistent with community standards” to “when available”. In I.E., removed requirement for technical performance verification in the literature. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed, updated, and reformatted. Specialist reviewed. |
CP.MP.209 | GI Pathogen Panel Testing | In the note below table 3, replaced “PCR” with “GI pathogen panel testing.” |
CP.MP.113 | Holter Monitor | Added note: "This policy provides medical necessity guidelines for Holter monitoring up to 48 hours. For Holter monitoring beyond 48 hours, see clinical decision support criteria." |
WA.CP.MP.54 | Hospice Services | Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed. |
WA.CP.MP.69 |
Intensity-Modulated Radiotherapy | Annual review. Revised criteria to more closely mirror the HCA Billing Guideline. References updated. |
CP.MP.170 | Nerve Blocks for Pain Management | Revised policy title from “Nerve Blocks for Pain Management” to “Nerve Blocks and Neurolysis for Pain Management.” Added VII. Insufficient evidence to determine the safety and effectiveness of intraosseous radiofrequency nerve ablation of basivertebral nerve. Updated background and references accordingly. |
CP.MP.194 |
Osteogenic Stimulation |
New policy |
CP.MP.138 | Pediatric Heart Transplant | Annual review. References reviewed and updated. Reviewed by specialist. |
CP.MP.182 |
Short Inpatient Hospital Stay | Replaced 2020 inpatient only list with 2022 inpatient only list in I.A. and updated references accordingly. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.108 |
Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia |
Annual review. References reviewed, updated, and reformatted. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” “Experimental/investigational” verbiage replaced in policy statement with, “there is insufficient evidence regarding the safety and efficacy." Reviewed by specialist. |
CP.MP.31 |
Cosmetic and Reconstructive Procedures |
Clarified in I.A.1. failure of conservative therapy “(unless conservative therapy is not standard of care for the condition, or is contraindicated).” Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Added the following codes from the retired Craniofacial Surgery policy; 21120, 21121, 21122, 21123, 21137, 21138, 21139, 21159, 21160, 21172, 21175, 21179, 21180, 21181, 21182, 21183, 21184, 21230, 21235, 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21270, 21275, 21280, 21282, 21295, 21296, and craniectomy/craniotomy codes for craniosynostosis. Clarified in I.A.4.a. “Post-mastectomy,* medically necessary lumpectomy, or other medically necessary breast surgery.” Updated II.R. “Mastopexy (except for breast reconstruction post-mastectomy, medically necessary lumpectomy, other medically necessary breast surgery resulting in significant asymmetry). In II.E., changed “InterQual” to “Decision Support Criteria.” Added II.U. “Breast reconstruction for fibroadenomas or other benign lesions, unless medically necessary per clinical decision support criteria” to not medically necessary procedures. Added codes 19330 and 19499. Annual review. References reviewed, updated, and reformatted. |
WA.CP.MP.208 |
Drugs of Abuse: Presumptive Testing |
Policy retired |
WA.CP.MP.50 |
Drugs of Abuse: Definitive Testing |
Annual review. Deleted note referring to WA.CP.MP.208 Drugs of Abuse, Presumptive Testing. References updated and coding reviewed. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” |
CP.MP.103 |
Fractional Exhaled Nitric Oxide |
Policy retired |
CP.MP.180 |
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea |
Annual review. References reviewed and updated. Changed "Last Review Date" in the header to "Date of Last Review" and "Date" in revision log to "Revision Date." Added CPT code 64585. Reviewed by specialist. |
CP.MP.170 |
Nerve Blocks for Pain Management |
Annual review. Added refractory chronic pancreatitis as an indication for celiac plexus block to section III and updated background accordingly. Added ICD -10 codes K86.0 & K86.1 to support coverage criteria. Changed “Experimental/investigational” language in section V. and VI.E. to “insufficient evidence to support…”.Under section VI, moved “Note” for visibility. Added insufficient evidence to support peripheral nerve block for treatment of trigeminal neuralgia to VI.D, removed G50.0 from list of ICD 10 codes that support coverage criteria and updated background accordingly. References reviewed, reformatted and updated. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Reviewed by specialist. |
CP.MP.109 |
Panniculectomy |
Annual review. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed, updated, and reformatted. Minor verbiage changes with no clinical significance. Reviewed by specialist. |
WA.CP.MP.70 |
Proton and Neutron Beam Therapy |
Annual review. References reviewed and updated. Updated background. Changed "Last Review Date" in the header to "Date of Last Review" and "Date" in revision log to "Revision Date". Replaced “not covered” in III with “not medically necessary”. |
CP.MP.165 |
Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management |
Annual review. References reviewed and updated. In policy statement, removed option for procedures “without radiographic guidance.” Reviewed by specialist. Changed “Last Review Date” in header to “Date of Last Revision” and changed “Date” in Revision log to “Revision Date”. |
CP.MP.151 |
Transcatheter Closure of Patent Foramen Ovale |
Annual review. Reworded policy statement, adding “when used according to FDA labeled indications, contraindications, warnings and precautions. Removed contraindications (I.B.4) since they are specific to the Amplatzer PFO device. Updated background with 2021 AHA/ASA recommendations. Added AAN recommendation for patients who opt to receive medical therapy alone without PFO closure. “Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed, updated and reformatted. Reviewed by specialist. |
CP.MP.127 |
Total Artificial Heart |
Annual review. Replaced investigational/experimental language in II & III with, “insufficient evidence to support the use of …” Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed, updated and reformatted. |
CP.MP.142 |
Urinary Incontinence Devices and Treatments |
Annual review. Replaced investigational language in IV, to “insufficient evidence in the published peer-reviewed literature to support the use of UBA injection of autologous fat, non- FDA approved procedures, and any other circumstances than those specified above.” Added HCPCS code A4290. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed, updated and reformatted. Reviewed by specialist. |