Clinical & Payment Policies
Clinical Policies
Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information.
All policies found in the Coordinated Care Clinical Policy Manual apply to Coordinated Care members. Policies in the Coordinated Care Clinical Policy Manual may have either a Coordinated Care or a “Centene” heading. Coordinated Care utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Coordinated Care clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Coordinated Care. In addition, Coordinated Care may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or InterQual®criteria is payable by Coordinated Care.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Ambetter Clinical Policies Listing
- Acupuncture (PDF) (CP.MP.92)
- Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF) (CP.BH.124)
- Air Ambulance (PDF) (CP.MP.175)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-Thalassemia (PDF) (CP.MP.108)
- Applied Behavior Analysis (PDF) (CP.BH.104)
- Applied Behavioral Analysis Documentation Requirements (PDF) (CP.BH.105)
- Bariatric Surgery (PDF) (CP.MP.37)
- Behavioral Health 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 (PDF) (CP.MP.156)
- Clinical Trials (PDF) (CP.MP.94)
- Cochlear Implant Replacements (PDF) (CP.MP.14)
- Cosmetic and Reconstructive Procedures (PDF) (CP.MP.31)
- Deep TMS for OCD (PDF) (CP.BH.201)
- Diaphragmatic/Phrenic Nerve Stimulation (PDF) (CP.MP.203)
- Digital EEG Spike Analysis (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 and Orthotics and Prosthetics Guidelines (DME) (PDF) (CP.MP.107)
- Electric Tumor Treating Fields (Optune) (PDF) (CP.MP.145)
- Electroencephalography in the Evaluation of Headache (PDF) (CP.MP.155)
- Endometrial Ablation (PDF) (CP.MP.106)
- Evoked Potential Testing (PDF) (CP.MP.134)
- Experimental Technologies (PDF) (CP.MP.36)
- Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF) (CP.MP.248)
- Fecal Incontinence Treatments (PDF) (CP.MP.137)
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) (CP.MP.129)
- Gastric Electrical Stimulation (PDF) (CP.MP.40)
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) (CP.MP.209)
- Gender Affirming Procedures (PDF) (WA.CP.MP.95)
- Helicobacter Pylori Serology Testing (PDF) (CP.MP.153)
- Heart-Lung Transplant (PDF) (CP.MP.132)
- Holter Monitors (PDF) (CP.MP.113)
- Home Birth (PDF) (CP.MP.136)
- Home Ventilators (PDF) (CP.MP.184)
- Homocysteine testing (PDF) (CP.MP.121)
- Hospice Services (PDF) (CP.MP.54)
- Hyperhidrosis Treatments (PDF) (CP.MP.62)
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) (CP.MP.180)
- Implantable Intrathecal or Epidural Pain Pump (PDF) (CP.MP.173)
- Implantable Loop Recorder (CP.MP.243)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) (CP.MP.160)
- Inhaled Nitric Oxide (PDF) (CP.MP.87)
- Intensity-Modulated Radiotherapy (PDF) (CP.MP.69)
- Intestinal and Multivisceral Transplant (PDF) (CP.MP.58)
- Intradiscal Steroid Injections for Pain Management (PDF) (CP.MP.167)
- IV Moderate Sedation, IV Deep Sedation and General Anesthesia for Dental Procedures (PDF) (CP.MP.61)
- Lantidra (Donislecel): Allogeneic Pancreatic Islet Cellular Therapy (PDF) (CP.MP.250)
- Laser Therapy for Skin Conditions (PDF) (CP.MP.123)
- Liposuction of Lipedema (PDF) (CP.MP.244)
- Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF) (CP.MP.139)
- Lung Transplantation (PDF) (CP.MP.57)
- Lysis of Epidural Lesions (PDF) (CP.MP.116)
- Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) (CP.MP.144)
- Multiple Sleep Latency Testing (PDF) (CP.MP.24)
- Neonatal Abstinence Syndrome Guidelines (PDF) (CP.MP.86)
- Neonatal Sepsis Management Guidelines (PDF) (CP.MP.85)
- Nerve Blocks and Neurolysis for Pain Management (PDF) (CP.MP.170)
- Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF) (CP.MP.48)
- NICU Apnea Bradycardia Guidelines (PDF) (CP.MP.82)
- NICU Discharge Guidelines (PDF) (CP.MP.81)
- Nonmyeloablative allogeneic SCT (PDF) (CP.MP.141)
- Obstetrical Home Care Programs (PDF) (CP.MP.91)
- Omisirge (Omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF) (CP.MP.249)
- Orthognathic Surgery (PDF) (CP.MP.202)
- Osteogenic Stimulation (PDF) (CP.MP.194)
- Outpatient Cardiac Rehabilitation (PDF) (CP.MP.176)
- Outpatient Oxygen Use (PDF) (CP.MP.190)
- Pancreas Transplantation (PDF) (CP.MP.102)
- Panniculectomy (PDF) (CP.MP.109)
- Pediatric Heart Transplant (PDF) (CP.MP.138)
- Pediatric Kidney Transplant (PDF) (CP.MP.246)
- Pediatric Liver Transplant (PDF) (CP.MP.120)
- Pediatric Oral Function Therapy (PDF) (CP.MP.188)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) (CP.MP.147)
- Peripheral and Percutaneous Nerve Stimulation (PDF) (WA.CP.MP.117)
- Photherapy for Neonatal Hyperbilirubinemia (PDF) (CP.MP.150)
- Physical, Occupational and Speech Therapy Services (PDF) (CP.MP.49)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) (CP.MP.181)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) (CP.MP.133)
- Proton and Neutron Beam Therapies (PDF) (CP.MP.70)
- Pulmonary Function Testing (PDF) (CP.MP.242)
- Reduction Mammoplasty and Gynecomastia Surgery (PDF) (CP.MP.51)
- Repair of Nasal Valve Compromise (PDF) (CP.MP.210)
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF) (CP.MP.146)
- Short Inpatient Hospital Stay (PDF) (CP.MP.182)
- Skin Substitutes for Chronic Wounds (PDF) (CP.MP.185)
- Stereotactic Body Radiation Therapy (PDF) (CP.MP.22)
- Tandem Transplant (PDF) (CP.MP.162)
- Thyroid Hormones and Insulin Testing in Pediatrics (PDF) (CP.MP.154)
- Total Artificial Heart (PDF) (CP.MP.127)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) (CP.MP.163)
- Transcatheter Closure of Patent Foramen Ovale (PDF) (CP.MP.151)
- Transcranial Magnetic Stimulation (PDF) (CP.BH.200)
- Transplant Service Documentation Requirements (PDF) (CP.MP.247)
- Trigger Point Injections for Pain Management (PDF) (CP.MP.169)
- Ultrasound in Pregnancy (PDF) (WA.CP.MP.38)
- 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)
- Concert Genetics Genetic Testing Aortopathies & Connective Tissue Disorders (PDF) (V1.2024)
- Concert Genetics Genetic Testing Cardiac Disorders (PDF) (V1.2024)
- Concert Genetics Genetic Testing Dermatologic Conditions (PDF) (V1.2024)
- Concert Genetics Genetic Testing Epilepsy Neurodegenerative and Neuromuscular Conditions (PDF) (V1.2024)
- Concert Genetics Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF) (V1.2024)
- Concert Genetics Genetic Testing Eye Disorders (PDF) (V1.2024)
- Concert Genetics Genetic Testing Gastroenterologic Disorders Non-cancerous (PDF) (V1.2024)
- Concert Genetics Genetic Testing General Approach to Genetic Testing (PDF) (V1.2024)
- Concert Genetics Genetic Testing Hearing Loss (PDF) (V1.2024)
- Concert Genetics Genetic Testing Hematologic Conditions Non-cancerous (PDF) (V1.2024)
- Concert Genetics Genetic Testing Hereditary Cancer Susceptibility (PDF) (V1.2024)
- Concert Genetics Genetic Testing Immune Autoimmune and Rheumatoid Disorders (PDF) (V1.2024)
- Concert Genetics Genetic Testing Kidney Disorders (PDF) (V1.2024)
- Concert Genetics Genetic Testing Lung Disorders (PDF) (V1.2024)
- Concert Genetics Genetic Testing Metabolic Endocrine Mitochondrial Disorders (PDF) (V1.2024)
- Concert Genetics Genetic Testing Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay (PDF) (V1.2024)
- Concert Genetics Genetic Testing Non-Invasive Prenatal Screening (PDF) (V1.2024)
- Concert Genetics Genetic Testing Pharmacogenetics (PDF) (V1.2024)
- Concert Genetics Genetic Testing Preimplantation Genetic Testing (PDF) (V1.2024)
- Concert Genetics Genetic Testing Prenatal and Preconception Carrier Screening (PDF) (V1.2024)
- Concert Genetics Genetic Testing Prenatal Diagnosis Pregnancy Loss (PDF) (V1.2024)
- Concert Genetics Genetic Testing Skeletal Dysplasia Rare Bone Disorders (PDF) (V1.2024)
- Concert Genetics Oncology Algorithmic Testing (PDF) (V1.2024) -
- Concert Genetics Oncology Cancer Screening (PDF) (V1.2024)
- Concert Genetics Oncology Circulating Tumor DNA Tumor Cells Liquid Biopsy (PDF) (V1.2024)
- Concert Genetics Oncology Cytogenetic Testing (PDF) (V1.2024)
- Concert Genetics Oncology Molecular Analysis Solid Tumors & Hematolgic Malignancies (PDF) (V1.2024)
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)
- Adzynma (ADAMTS13, Recombinant-krhn) (PDF) (CP.PHAR.635)
- Afamelanotide (Scenesse) (PDF) (CP.PHAR.444)
- Abiraterone (PDF) (CP.PHAR.84)
- AbobotulinumtoxinA (Dysport) (PDF) (CP.PHAR.230)
- Adagrasib (Krazati) (PDF) (CP.PHAR.605)
- Adefovir (Hepsera) (PDF) (CP.PHAR.142)
- Ado-Trastuzumab (Kadcyla) (PDF) (CP.PHAR.229)
- Aducanumab (PDF) (CP.PHAR.468)
- Afatinib (Gilotrif) (PDF) (CP.PHAR.298)
- Afinitor (everolimus) (PDF) (CP.PHAR.63)
- Aflibercept (Eylea®) (PDF) (CP.PHAR.184)
- Agalsidase Beta (Fabrazyme) (PDF) (CP.PHAR.158)
- Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) (CP.PMN.138)
- Alectinib (Alecensa) (PDF) (CP.PHAR.369)
- Alemtuzumab (Lemtrada) (PDF) (CP.PHAR.243)
- Alendronate (Binosto, Fosamax plus D) (PDF) (CP.PMN.88)
- Alglucosidase (Lumizyme) (PDF) (CP.PHAR.160)
- Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) (PDF) (CP.PHAR.562)
- Allogenic Processed Thymus Tissue-agdc (Rethymic) (PDF) (CP.PHAR.563)
- Alpelisib (Piqray) (PDF) (CP.PHAR.430)
- Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF) (CP.PHAR.94)
- Amantadine ER (Gocovri, Osmolex ER) (PDF) (CP.PMN.89)
- Ambrisentan (Letairis®) (PDF) (CP.PHAR.190)
- Amifampridine (Firdapse) (PDF) (CP.PHAR.411)
- Amikacin (Arikayce) (PDF) (CP.PHAR.401)
- Amisulpride (Barhemsys) (PDF) (CP.PMN.236)
- Amivantamab-vmjw (Rybrevant) (PDF) (CP.PHAR.544)
- Anifrolumab-fnia (Saphnelo) (PDF) (CP.PHAR.551)
- Anti-Inhibitor Coagulant Complex (Feiba®) (PDF) (CP.PHAR.217)
- Antithrombin III (ATryn, Thrombate III) (PDF) (CP.PHAR.564)
- Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) (CP.PHAR.506)
- Apalutamide (Erleada) (PDF) (CP.PCH.45)
- Apalutamide (Erleada) (PDF) (CP.PHAR.376)
- Apomorphine (Apokyn, Kynmobi) (PDF) (CP.PHAR.488)
- aprepitant (PDF) (CP.PMN.19)
- Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF) (CP.PHAR.290)
- Aripiprazole Orally Disintegrating Tablet (PDF) (CP.PCH.37)
- Armodafinil (Nuvigil) (PDF) (CP.PMN.35)
- Asciminib (Scemblix) (PDF) (CP.PHAR.565)
- Asenapine (Saphris) (PDF) (CP.PMN.15)
- Asfotase Alfa (Strensiq) (PDF) (CP.PHAR.328)
- Aspirin-dipyridamole (Aggrenox) (PDF) (CP.PMN.20)
- Atezolizumab (Tecentriq®) (PDF) (CP.PHAR.235)
- Atogepant (Qulipta) (PDF) (CP.PHAR.566)
- Avacincaptad pegol (Izervay) (PDF) (CP.PHAR.641)
- Avacopan (Tavneos) (PDF) (CP.PHAR.515)
- Avalglucosidase Alfa-ngpt (Nexviazyme) (PDF) (CP.PHAR.521)
- Avapritinib (Ayvakit) (PDF) (CP.PHAR.454)
- Avatrombopag (Doptelet) (PDF) (CP.PHAR.130)
- Avelumab (Bavencio®) (PDF) (CP.PHAR.333)
- Axicabtagene Ciloleucel (Yescarta®) (PDF) (CP.PHAR.362)
- Axitinib (Inlyta®) (PDF) (CP.PHAR.100)
- Azacitidine (Vidaza) (PDF) (CP.PHAR.387)
- Azelaic Acid (Finacea) (PDF) (HIM.PA.119)
- Aztreonam (Cayston®) (PDF) (CP.PHAR.209)
- Baloxavir Marboxil (Xofluza) (PDF) (CP.PMN.185)
- Bedaquiline (Sirturo) (PDF) (CP.PMN.212)
- Belantamab Mafodotin (Blenrep) (PDF) (CP.PHAR.469)
- belatacept (Nulojix®) (PDF) (CP.PHAR.201)
- Belimumab (Benlysta) (PDF) (CP.PHAR.88)
- belinostat (Beleodaq®) (PDF) (CP.PHAR.311)
- Belumosudil (Rezurock) (PDF) (CP.PHAR.552)
- Belzutifan (Welireg) (PDF) (CP.PHAR.553)
- Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet) (PDF) (CP.PMN.237)
- bendamustine (Bendeka®, Treanda®) (PDF) (CP.PHAR.307)
- Benralizumab (Fasenra) (PDF) (CP.PHAR.373)
- Benznidazole (PDF) (CP.PMN.90)
- Beremagene geperpavec-svdt (Vyjuvek) (PDF) (CP.PHAR.592)
- Berotralstat (Orladeyo) (PDF) (HIM.PA.169)
- 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)
- Birch Triterpenes (Filsuvez) (PDF) (CP.PHAR.669)
- Blinatumomab (PDF) (CP.PHAR.312)
- Bortezomib (Velcade) (PDF) (CP.PHAR.410)
- Bosentan (Tracleer®) (PDF) (CP.PHAR.191)
- Bosutinib (Bosulif) (PDF) (CP.PHAR.105)
- Brand Name Override and Non-Formulary Medications (PDF) (HIM.PA.103)
- Brentuximab (PDF) (CP.PHAR.303)
- Brexanolone (Zulresso) (PDF) (CP.PHAR.417)
- Brexpiprazole (Rexulti) (PDF) (CP.PMN.68)
- Brexucabtagene Autoleucel (Tecartus) (PDF) (CP.PHAR.472)
- Brigatinib (Alunbrig) (PDF) (CP.PHAR.342)
- Brimonidine Tartrate (Mirvaso) (PDF) (CP.PMN.192)
- Brinzolamide/Brimonidine (Simbrinza) (PDF) (HIM.PA.15)
- Brivaracetam (Briviact) (PDF) (CP.PCH.26)
- Brodalumab (Siliq) (PDF) (CP.PHAR.375)
- Brolucizumab-dbll (Beovu) (PDF) (CP.PHAR.445)
- Budesonide (Tarpeyo) (PDF) (CP.PHAR.572)
- Budesonide (Uceris) (PDF) (CP.PCH.11)
- Buprenorphine (Subutex) (PDF) (CP.PMN.82)
- buprenorphine implant (Probuphine) (PDF) (CP.PHAR.289)
- Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF) (CP.PMN.81)
- Bupropion/Naltrexone (Contrave) (PDF) (CP.PCH.12)
- Burosumab-twza (Crysvita) (PDF) (CP.PHAR.11)
- Butorphanol Nasal Spray (PDF) (HIM.PA.46)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF) (HIM.PA.170)
- 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)
- Capivasertib (Truqap) (PDF) (CP.PHAR.663)
- 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)
- Cipaglucosidase Alfa-atga + Miglustat (Pombiliti + Opfolda) (PDF) (CP.PHAR.567)
- Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) (CP.PMN.248)
- Ciprofloxacin/Fluocinolone (Otovel) (PDF) (CP.PMN.249)
- Cladribine (Mavenclad) (PDF) (CP.PHAR.422)
- Clascoterone (Winlevi) (PDF) (CP.PMN.257)
- Clobazam (PDF) (CP.PMN.54)
- CNS Stimulants (PDF) (CP.PMN.92)
- Cobimetinib (Cotellic) (PDF) (CP.PHAR.380)
- Colchicine (Colcrys, Lodoco) (PDF) (CP.PMN.123)
- 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)
- copanlisib (Aliqopa®) (PDF) (CP.PHAR.357)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert) (PDF) (CP.PHAR.385)
- Cosyntropin (Cortrosyn®) (PDF) (CP.PHAR.203)
- Crisaborole (Eucrisa) (PDF) (CP.PMN.110)
- Crizanlizumab-tmca (Adakveo) (PDF) (CP.PHAR.449)
- Crizotinib (Xalkori) (PDF) (CP.PHAR.90)
- Cyclosporine ophthalmic emulsion (Cequa, Restasis) (PDF) (CP.PMN.48)
- Cyramza® (PDF) (CP.PHAR.119)
- Cysteamine ophthalmic (Cystaran, Cystadrops) (PDF) (CP.PMN.130)
- Cysteamine oral (Cystagon, Procysbi) (PDF) (CP.PHAR.155)
- Cytomegalovirus Immune Globulin (Cytogam) (PDF) (CP.PHAR.277)
- Dabrafenib (Tafinlar) (PDF) (CP.PHAR.239)
- Dacomitinib (Vizimpro) (PDF) (CP.PHAR.399)
- Dalfampridine (Ampyra) (PDF) (CP.PHAR.248)
- Dalteparin (Fragmin) (PDF) (CP.PHAR.225)
- Daptomycin (Cubicin, Cubicin RF) (PDF) (CP.PHAR.351)
- Daratumumab (PDF) (CP.PHAR.310)
- Darbepoetin alfa (Aranesp) (PDF) (CP.PHAR.236)
- Darolutamide (Nubeqa) (PDF) (CP.PHAR.435)
- Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) (PDF) (HIM.PA.SP61)
- Dasatinib (Sprycel) (PDF) (CP.PHAR.72)
- Daprodustat (Jesduvroq) (PDF) (CP.PHAR.628)
- Dapsone (Aczone Gel) (PDF) (CP.PCH.32)
- daunorubicin/cytarabine (Vyxeos®) (PDF) (CP.PHAR.352)
- DaxibotulinumtoxinA-lanm (Daxxify) (PDF) (CP.PHAR.651)
- Decitabine-Cedazuridine (Inqovi) (PDF) (CP.PHAR.479)
- deferasirox (PDF) (CP.PHAR.145)
- Deferoxamine (Desferal) (PDF) (CP.PHAR.146)
- Deflazacort (Emflaza) (PDF) (CP.PHAR.331)
- degarelix acetate (Firmagon®) (PDF) (CP.PHAR.170)
- Delafloxacin (Baxdela) (PDF) (CP.PMN.115)
- Delandistrogene moxeparvovec-rokl (Elevidys) (PDF) (CP.PHAR.593)
- Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (PDF) (CP.PHAR.214)
- Deutetrabenazine (Austedo) (PDF) (CP.PCH.42)
- Dexrazoxane (Zinecard Totect) (PDF) (CP.PHAR.418)
- Dextromethorphan/Bupropion (Auvelity) (PDF) (CP.PMN.284)
- Dextromethorphan-Quinidine (Nuedexta) (PDF) (CP.PMN.93)
- Diazepam Nasal Spray (Valtoco) (PDF) (CP.PMN.216)
- Dichlorphenamide (Keveyis) (PDF) (CP.PMN.261)
- Diclofenac (Cambia, Flector, Licart, Pennsaid, Solaraze, Zipsor, Zorvolex) (PDF) (CP.PCH.28)
- Dipeptidyl Peptidase-4 Inhibitors (PDF) (HIM.PA.58)
- Dolasetron (Anzemet) (PDF) (CP.PMN.141)
- Dornase alfa (Pulmozyme) (PDF) (CP.PHAR.212)
- Dostarlimab-gxly (Jemperli) (PDF) (CP.PHAR.540)
- Doxepin Hydrochloride Cream (Prudoxin, Zonalon) (PDF) (HIM.PA.147)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF) (CP.PMN.79)
- Dupilumab (Dupixent) (PDF) (CP.PHAR.336)
- Durvalumab (Imfinzi) (PDF) (CP.PHAR.339)
- Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn) (PDF) (CP.PMN.128)
- Duvelisib (Copiktra) (PDF) (CP.PHAR.400)
- Ecallantide (Kalbitor®) (PDF) (CP.PHAR.177)
- Eculizumab (Soliris®) (CP.PHAR.97)
- Edaravone (Radicava) (PDF) (CP.PHAR.343)
- Efgartigimod Alfa-fcab (Vyvgart) (PDF) (CP.PHAR.555)
- Efinaconazole (Jublia) (PDF) (CP.PMN.25)
- Eflornithine (Iwilfin) (PDF) (CP.PHAR.670)
- Elacestrant (Orserdu) (PDF) (CP.PHAR.623)
- Elagolix (Orilissa) (PDF) (CP.PHAR.136)
- Elapegademase-lvlr (Revcovi) (PDF) (CP.PHAR.419)
- Elbasvir/Grazoprevir (Zepatier) (PDF) (HIM.PA.SP62)
- Electromyography and Nerve Conduction Studies (PDF) (CP.MP.211) Effective 9/1/21
- Elexacaftor, tezacaftor (Trikafta) (PDF) (CP.PHAR.440)
- Eliglustat (Cerdelga) (PDF) (CP.PHAR.153)
- Elivaldogene Autotemcel (Skysona) (PDF) (CP.PHAR.556)
- Elotuzumab (Empliciti®) (PDF) (CP.PHAR.308)
- Elosulfase alfa (Vimizim) (PDF) (CP.PHAR.162)
- Elranatamab-bcmm (Elrexfio) (PDF) (CP.PHAR.652)
- Eltrombopag (Promacta®) (PDF) (CP.PHAR.180)
- Eluxadoline (Viberzi) (PDF) (CP.PMN.170)
- Emapalumab-lzsg (Gamifant) (PDF) (CP.PHAR.402)
- Emicizumab-kxwh (Hemlibra) (PDF) (CP.PHAR.370)
- Emtricitabine/Tenofovir Alafenamide (Descovy) (PDF) (CP.PMN.235)
- Enasidenib (Idhifa) (PDF) (CP.PHAR.363)
- Encorafenib (PDF) (CP.PHAR.127)
- Enfortumab Vedotin-ejfv (Padcev) (PDF) (CP.PHAR.455)
- Enfuvirtide (PDF) (CP.PHAR.41)
- Enoxaparin (Lovenox) (PDF) (CP.PHAR.224)
- Entecavir (Baraclude) (PDF) (HIM.PA.08)
- Entrectinib (Rozlytrek) (PDF) (CP.PHAR.441)
- Enzalutamide (Xtandi) (PDF) (CP.PHAR.106)
- Epcoritamab-bysp (Epkinly) (PDF) (CP.PHAR.634)
- Epoetin alfa (Epogen, Procrit), Epoetin alfa-epbx (Retacrit) (PDF) (CP.PHAR.237)
- Epoprostenol (Flolan®, Veletri®) (PDF) (CP.PHAR.192)
- Eptinezumab-jjmr (Vyepti) (PDF) (HIM.PA.SP64)
- Erdafitinib (Balversa) (PDF) (CP.PHAR.423)
- Eribulin Mesylate (Halaven®) (PDF) (CP.PHAR.318)
- Erlotinib (Tarceva) (PDF) (CP.PHAR.74)
- Erenumab-aaoe (Aimovig) (PDF) (HIM.PA.SP65)
- erwina asparaginase (Erwinaze®) (PDF) (CP.PHAR.301)
- Esketamine (Spravato) (PDF) (CP.PMN.199)
- Estradiol Vaginal Ring (Femring) (PDF) (CP.PMN.263)
- Etelcalcetide (Parsabiv) (PDF) (CP.PHAR.379)
- Eteplirsen (Exondys 51) (PDF) (CP.PHAR.288)
- Etranacogene Dezaparvovec-drlb (Hemgenix) (PDF) (CP.PHAR.580)
- Evinacumab-dgnb (Evkeeza) (PDF) (HIM.PA.166)
- Evolocumab (Repatha) (PDF) (HIM.PA.156)
- Exagamglogene Autotemcel (Casgevy) (PDF) (CP.PHAR.603)
- Factor IX (Human, Recombinant) (PDF) (CP.PHAR.218)
- Factor IX Complex Human (Bebulin®, Profilnine®) (PDF) (CP.PHAR.219)
- Factor VIIa, Recombinant (NovoSeven® RT) (PDF) (CP.PHAR.220)
- Factor VIII (Human Recombinant) (PDF) (CP.PHAR.215)
- Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF) (CP.PHAR.216)
- Factor XIII A-Subunit, Recombinant (Tretten®) (PDF) (CP.PHAR.222)
- Factor XIII, Human (Corifact®) (PDF) (CP.PHAR.221)
- Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) (CP.PHAR.456)
- Faricimab-svoa (Vabysmo) (PDF) (CP.PHAR.581)
- Febuxostat (Uloric) (PDF) (CP.PMN.57)
- Fecal Microbiota, Live-jslm (Rebyota) (PDF) (CP.PHAR.613)
- Fecal Microbiota Spores, Live-brpk (Vowst) (PDF) (CP.PHAR.632)
- Fedratinib (Inrebic) (PDF) (CP.PHAR.442)
- Fenfluramine (Fintepla) (PDF) (CP.PMN.246)
- Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF) (CP.PMN.127)
- Ferric Carboxymaltose (Injectafer) (PDF) (CP.PHAR.234)
- Ferric Derisomaltose (Monoferric) (PDF) (CP.PHAR.480)
- Ferric gluconate (Ferrlecit®) (PDF) (CP.PHAR.166)
- Ferric Maltol (Accrufer) (PDF) (CP.PMN.213)
- Ferric Pyrophosphate (Triferic, Triferic Avnu) (PDF) (CP.PHAR.624)
- Ferumoxytol (Feraheme®) (PDF) (CP.PHAR.165)
- Fezolinetant (Veozah) (PDF) (CP.PMN.289)
- Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP) (PDF) (CP.PHAR.526)
- Filgrastim (PDF) (CP.PHAR.297)
- Finerenone (Kerendia) (PDF) (CP.PMN.266)
- Fingolimod (Gilenya) (PDF) (CP.PCH.38)
- Flibanserin (Addyi) (PDF) (CP.PHAR.446)
- Fluorouracil Cream (Tolak) (PDF) (CP.PMN.165)
- Fluticasone Propionate (Xhance) (PDF) (CP.PMN.95)
- Fondaparinux (Arixtra) (PDF) (CP.PHAR.226)
- Formulary Medications Without Specific Guidelines (PDF) (HIM.PA.33)
- Fosdenopterin (Nulibry) (PDF) (CP.PHAR.471)
- Fostamatinib (Tavalisse) (PDF) (CP.PHAR.24)
- Fremanezumab-vfrm (Ajovy) (PDF) (HIM.PA.SP66)
- Fruquintinib (Fruzaqla) (PDF) (CP.PHAR.666)
- Fulvestrant (Faslodex Injection) (PDF) (CP.PHAR.424)
- Furosemide (Furoscix) (PDF) (CP.PHAR.608)
- Futibatinib (Lytgobi) (PDF) (CP.PHAR.604)
- Gabapentin ER (Gralise, Horizant) (PDF) (CP.PMN.240)
- Galcanezumab-gnlm (Emgality) (PDF) (HIM.PA.SP67)
- Galsulfase (Naglazyme) (PDF) (CP.PHAR.161)
- Ganaxolone (Ztalmy) (PDF) (CP.PMN.278)
- Gefitinib (Iressa) (PDF) (CP.PHAR.68)
- gemtuzumab ozogamicin (Mylotarg®) (PDF) (CP.PHAR.358)
- Gepirone (Exxua) (PDF) (CP.PMN.292)
- Gilteritinib (Xospata) (PDF) (CP.PHAR.412)
- Givosiran (Givlaari) (PDF) (CP.PHAR.457)
- Glasdegib (Daurismo) (PDF) (CP.PHAR.413)
- Glaucoma Agents (PDF) (CP.PMN.286)
- Glecaprevir/Pibrentasvir (Mavyret) (PDF) (HIM.PA.SP36)
- Glofitamab-gxbm (Columvi) (PDF) (CP.PHAR.636)
- Glucagon-Like Peptide-1 Receptor Agonists (PDF) (HIM.PA.53)
- Glycerol phenylbutyrate (Ravicti®) (PDF) (CP.PHAR.207)
- Golodirsen (Vyondys 53) (PDF) (CP.PHAR.453)
- goserelin acetate (Zoladex®) (PDF) (CP.PHAR.171)
- Granisetron (Sancuso, Sustol) (PDF) (CP.PMN.74)
- Halcinonide (Halog) (PDF) (HIM.PA.20)
- Halobetasol Propionate (Bryhali, Lexette, Ultravate) (PDF) (CP.PMN.180)
- Halobetasol Propionate/Tazarotene (Duobrii) (PDF) (CP.PMN.208)
- Hemin (Panhematin®) (PDF) (CP.PHAR.181)
- histrelin acetate (Vantas®, Supprelin LA®) (PDF) (CP.PHAR.172)
- House Dust Mite Allergen Extract (Odactra) (PDF) (CP.PMN.111)
- Human Growth Hormone (Somapacitan, Somatropin) (PDF) (HIM.PA.161)
- Hyaluronate Derivatives (PDF) (CP.PHAR.05)
- Hydroxyprogesterone Caproate (Makena/compound) (PDF) (CP.PHAR.14)
- Hydroxyurea (Siklos) (PDF) (CP.PMN.193)
- Ibalizumab-uiyk (Trogarzo) (PDF) (CP.PHAR.378)
- Ibandronate Injection (Boniva) (PDF) (CP.PHAR.189)
- Ibrutinib (PDF) (CP.PHAR.126)
- Ibuprofen/Famotidine (Duexis) (PDF) (CP.PMN.120)
- Icatibant (Firazyr®) (PDF) (CP.PHAR.178)
- Icosapent ethyl (Vascepa) (PDF) (CP.PMN.187)
- Idecabtagene Vicleucel (Abecma) (PDF) (CP.PHAR.481)
- Idelalisib (Zydelig) (PDF) (CP.PHAR.133)
- Idursulfase (PDF) (CP.PHAR.156)
- Iloperidone (Fanapt) (PDF) (CP.PMN.32)
- Iloprost (Ventavis®) (PDF) (CP.PHAR.193)
- Imatinib (Gleevec) (CP.PHAR.65) (PDF)
- Imiglucerase (Cerezyme) (PDF) (CP.PHAR.154)
- Immune Globulins (PDF) (CP.PHAR.103)
- Inclisiran (Leqvio) (PDF) (CP.PHAR.568)
- IncobotulinumtoxinA (Xeomin) (PDF) (CP.PHAR.231)
- Inebilizumab-cdon (Uplizna) (PDF) (CP.PHAR.458)
- Inhaled Agents for Asthma and COPD (PDF) (HIM.PA.153)
- Infertility and Fertility Preservation (PDF) (CP.PHAR.131)
- Infigratinib (Truseltiq) (PDF) (CP.PHAR.547)
- Inotersen (Tegsedi) (PDF) (CP.PHAR.405)
- inotuzumab ozogamicin (Besponsa®) (PDF) (CP.PHAR.359)
- Insulin degludec (Tresiba) (PDF) (CP.PMN.285)
- Insulin Degludec (Tresiba) (PDF) (HIM.PA.09)
- Insulin detemir (Levemir) (PDF) (HIM.PA.171)
- 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)
- Iptacopan (Fabhalta) (PDF) (CP.PHAR.656)
- 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) (HIM.PA.172)
- Lanreotide (Somatuline Depot) (PDF) (CP.PHAR.391)
- lapatinib (Tykerb®) (PDF) (CP.PHAR.79)
- Laronidase (Aldurazyme) (PDF) (CP.PHAR.152)
- Larotrectinib (Vitrakvi) (PDF) (CP.PHAR.414)
- Lasmiditan (Reyvow) (PDF) (CP.PMN.218)
- Lecanemab-irmb (Leqembi) (PDF) (CP.PHAR.596)
- Ledipasvir/Sofosbuvir (Harvoni) (PDF) (HIM.PA.SP3)
- Lefamulin (Xenleta) (PDF) (CP.PMN.219)
- Lenacapavir (Sunlenca) (PDF) (CP.PHAR.622)
- Lenalidomide (Revlimid) (PDF) (CP.PHAR.71)
- Leniolisib (Joenja) (PDF) (CP.PHAR.597)
- Lenvatinib (Lenvima) (PDF) (CP.PHAR.138)
- Letermovir (Prevymis) (PDF) (CP.PHAR.367)
- Levodopa Inhalation Powder (Inbrija) (PDF) (CP.PMN.267)
- Levoketoconazole (Recorlev) (PDF) (CP.PMN.275)
- levoleucovorin (Fusilev) (PDF) (CP.PHAR.151)
- Levomilnacipran (Fetzima) (PDF) (HIM.PA.125)
- Leucovorin Injection (PDF) (CP.PHAR.393)
- Leuprolide Acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi) (PDF) (CP.PHAR.173)
- L-glutamine (Endari) (PDF) (CP.PMN.116)
- lidocaine transdermal (Lidoderm, ZTlido) (PDF) (CP.PMN.08)
- Lifitegrast (Xiidra®) (PDF) (CP.PMN.73)
- 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)
- Lotilaner (Xdemvy) (PDF) (CP.PMN.291)
- 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)
- Melphalan (Hepzato) (PDF) (CP.PHAR.653)
- Memantine ER (Namenda XR), Memantine/Donepezil (Namzaric) (PDF) (CP.PCH.30)
- Mepolizumab (Nucala) (PDF) (CP.PHAR.200)
- Mercaptopurine (Purixan) (PDF) (CP.PHAR.447)
- Metformin ER (Fortamet, Glumetza) (PDF) (CP.PMN.72)
- Methotrexate (Otrexup, Rasuvo, Xatmep) (PDF) (CP.PHAR.134)
- Methoxsalen (Uvadex) (PDF) (HIM.PA.17)
- Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) (CP.PHAR.238)
- Methylnaltrexone Bromide (Relistor) (PDF) (CP.PMN.169)
- Metoclopramide (Gimoti) (PDF) (CP.PMN.252)
- Metreleptin (Myalept) (PDF) (CP.PHAR.425)
- Midazolam (Nayzilam) (PDF) (CP.PMN.211)
- Midostaurin (Rydapt) (PDF) (CP.PHAR.344)
- Migalastat (Galafold) (PDF) (CP.PHAR.394)
- Miglustat (Zavesca) (PDF) (CP.PHAR.164)
- Milnacipran (Savella) (PDF) (CP.PMN.125)
- Minocycline ER (Solodyn, Ximino, Minolira) and Microspheres (Arestin), Foam (Zilxi) (PDF) (CP.PMN.80)
- Mirvetuximab soravatansine-gynx (Elahere) (PDF) (CP.PHAR.617)
- Mitapivat (Pyrukynd) (PDF) (CP.PHAR.558)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF) (CP.PHAR.495)
- Mitoxantrone (Novantrone) (PDF) (CP.PHAR.258)
- Mobocertinib (Exkivity) (PDF) (CP.PHAR.559)
- Modafinil (Provigil) (PDF) (CP.PMN.39)
- Mogamulizumab-kpkc (Poteligeo) (PDF) (CP.PHAR.139)
- Momelotinib (Ojjaara) (PDF) (CP.PHAR.654)
- Mometasone (Nasonex) (PDF) (HIM.PA.93)
- Mometasone Furoate (Sinuva) (PDF) (CP.PHAR.448)
- Mosunetuzumab-axgb (Lunsumio) (PDF) (CP.PHAR.618)
- Motixafortide (Aphexda) (PDF) (CP.PHAR.655)
- Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) (CP.PHAR.398)
- Nabumetone Double-Strength (Relafen DS) (PDF) (CP.PMN.287)
- Nadofaragene Firadenovec-vncg (Adstiladrin) (PDF) (CP.PHAR.461)
- nafarelin acetate (Synarel®) (PDF) (CP.PHAR.174)
- Naldemedine (Symproic) (PDF) (CP.PMN.112)
- Nalmefene (Opvee) (PDF) (CP.PHAR.638)
- Naloxegol (Movantik) (PDF) (HIM.PA.167)
- Naltrexone (Vivitrol®) (PDF) (CP.PHAR.96)
- Naproxen/Esomeprazole (Vimovo) (PDF) (CP.PMN.117)
- Naproxen oral suspension (Naprosyn) (PDF) (HIM.PA.130)
- Natalizumab (Tysabri) (PDF) (CP.PHAR.259)
- Naxitamab-gqgk (Danyelza) (PDF) (CP.PHAR.523)
- necitumumab (Portrazza®) (PDF) (CP.PHAR.320)
- Nedosiran (Rivfloza) (PDF) (CP.PHAR.619)
- Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF) (CP.PMN.167)
- Neratinib (Nerlynx) (PDF) (CP.PHAR.365)
- Netupitant and Palonosetron (Akynzeo) (PDF) (CP.PMN.158)
- Nifurtimox (Lampit) (PDF) (CP.PMN.256)
- Nilotinib (Tasigna) (PDF) (CP.PHAR.76)
- Nintedanib (Ofev) (PDF) (CP.PHAR.285)
- Niraparib (Zejula) (PDF) (CP.PHAR.408)
- Niraparib and Abiraterone Acetate (Akeega) (PDF) (CP.PHAR.645)
- Nirmatrelvir and Ritonavir (Paxlovid) (PDF) (CP.PMN.288)
- Nirogacestat (Ogsiveo) (PDF) (CP.PHAR.671)
- Nirsevimab-alip (Beyfortus) (PDF) (CP.PHAR.614)
- Nitazoxanide (Alinia) (PDF) (HIM.PA.152)
- Nitisinone (Nityr, Orfadin) (PDF) (CP.PHAR.132)
- Nivolumab (PDF) (CP.PHAR.121)
- Nivolumab and Relatlimab-rmbw (Opdualag) (PDF) (CP.PHAR.588)
- Non-Calcium Phosphate Binders (PDF) (CP.PMN.04)
- Non-Formulary and Formulary Contraceptives (PDF) (HIM.PA.100)
- Non-Formulary Test Strips (PDF) (HIM.PA.34)
- Nusinersen (PDF) (CP.PHAR.327)
- Obeticholic Aacid (Ocaliva) (PDF) (CP.PHAR.287)
- obinutuzumab (Gazyva®) (PDF) (CP.PHAR.305)
- Ocrelizumab (Ocrevus) (PDF) (CP.PHAR.335)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot) (PDF) (CP.PHAR.40)
- Odevixibat (Bylvay) (PDF) (CP.PHAR.528)
- Ofatumumab (Arzerra, Kesimpta) (PDF) (CP.PHAR.306)
- Off-Label Drug Use (PDF) (HIM.PA.154)
- Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) (CP.PHAR.292)
- Olanzapine/Samidorphan (Lybalvi) (PDF) (CP.PMN.265)
- Olaparib (Lynparza) (PDF) (CP.PHAR.360)
- Olipudase Alfa-rpcp (Xenpozyme) (PDF) (CP.PHAR.586)
- Olutasidenib (Rezlidhia) (PDF) (CP.PHAR.615)
- Omaveloxolone (Skyclarys) (PDF) (CP.PHAR.590)
- Omecetaxine (Synribo) (PDF) (CP.PHAR.108)
- Omadacycline (Nuzyra) (PDF) (CP.PMN.188)
- Omalizumab (Xolair) (PDF) (CP.PCH.49)
- OnabotulinumtoxinA (Botox) (PDF) (CP.PHAR.232)
- Onasemnogene abeparvovec (Zolgensma) (PDF) (CP.PHAR.421)
- Ondansetron (Zuplenz) (PDF) (CP.PMN.45)
- Opicapone (Ongentys) (PDF) (CP.PMN.245)
- Opioid Analgesics (PDF) (HIM.PA.139)
- Ophthalmic Corticosteroids (PDF) (HIM.PA.03)
- Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF) (CP.PHAR.536)
- Osilodrostat (Isturisa) (PDF) (CP.PHAR.487)
- Osimertinib (Tagrisso) (PDF) (CP.PHAR.294)
- Ospemifene (Osphena) (PDF) (CP.PMN.168)
- Overactive Bladder Agents (PDF) (CP.PMN.198)
- Oxymetazoline (Rhofade, Upneeq) (PDF) (CP.PMN.86)
- Ozanimod (Zeposia) (PDF) (CP.PHAR.462)
- Ozenoxacin (Xepi) (PDF) (CP.PMN.119)
- Paclitaxel protein-bound (Abraxane) (PDF) (CP.PHAR.176)
- Pacritinib (Vonjo) (PDF) (CP.PHAR.583)
- Palbociclib (Ibrance) (PDF) (HIM.PA.173)
- Paliperidone Long-Acting Injections (Invega Sustenna, Invega Trinza) (PDF) (CP.PHAR.291)
- Palivizumab (Synagis) (PDF) (CP.PHAR.16)
- Palovarotene (Sohonos) (PDF) (CP.PHAR.548)
- Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep) (PDF) (CP.PCH.44)
- panitumumab (Vectibix®) (PDF) (CP.PHAR.321)
- Panobinostat (Farydak) (PDF) (CP.PHAR.382)
- Parathyroid Hormone (Natpara) (PDF) (CP.PHAR.282)
- Paricalcitrol Injection (PDF) (CP.PHAR.270)
- pasireotide (Signifor LAR®) (PDF) (CP.PHAR.332)
- Patiromer (Veltassa) (PDF) (CP.PMN.205)
- Patisiran (Onpattro) (PDF) (CP.PHAR.395)
- Pazopanib (PDF) (CP.PHAR.81)
- Peanut Allergen Powder-dnfp (Palforzia) (PDF) (CP.PMN.220)
- pegaspargase (Oncaspar®) (PDF) (CP.PHAR.353)
- Pegcetacoplan (Empaveli) (PDF) (CP.PHAR.524)
- Pegfilgrastim (PDF) (CP.PHAR.296)
- Peginterferon beta-1a (Plegridy) (PDF) (CP.PHAR.271)
- Pegloticase (Krystexxa®) (PDF) (CP.PHAR.115)
- Pegunigalsidase Alfa-iwxj (Elfabrio) (PDF) (CP.PHAR.512)
- Pegvaliase-pqpz (Palynziq) (PDF) (CP.PHAR.140)
- Pegvisomant (Somavert) (PDF) (CP.PHAR.389)
- Pembrolizumab (Keytruda®) (PDF) (CP.PHAR.322)
- Pemetrexed (Alimta®) (PDF) (CP.PHAR.368)
- Pemigatinib (Pemazyre) (PDF) (CP.PHAR.496)
- Penicillamine (Cuprimine) (PDF) (CP.PCH.09)
- Perampanel (Fycompa) (PDF) (CP.PMN.156)
- Perfluorohexyloctane (Miebo) (PDF) (CP.PMN.290)
- Pertuzumab (Perjeta) (PDF) (CP.PHAR.227)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (PDF) (CP.PHAR.501)
- Pexidartinib (Turalio) (PDF) (CP.PHAR.436)
- Phendimetrazine (PDF) (CP.PCH.47)
- Phentermine (Adipex-P, Lomaira) (PDF) (CP.PCH.13)
- Pilocarpine (Vuity) (PDF) (CP.PMN.270)
- Pimavanserin (Nuplazid) (PDF) (CP.PMN.140)
- Pirfenidone (Esbriet) (PDF) (CP.PHAR.286)
- Pirtobrutinib (Jaypirca) (PDF) (CP.PHAR.620)
- Pitolisant (Wakix) (PDF) (CP.PMN.221)
- Plasminogen, human-tvmh (Ryplazim) (PDF) (CP.PHAR.513)
- Plecanatide (Trulance) (PDF) (CP.PMN.87)
- 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)
- Pozelimab-bbfg (Veopoz) (PDF) (CP.PHAR.626)
- 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)
- protein c concentrate, human (Ceprotin®) (PDF) (CP.PHAR.330)
- Prucalopride (Motegrity) (PDF) (HIM.PA.159)
- pyrimethamine (Daraprim®) (PDF) (CP.PMN.44)
- Quantity Limit Override and Dose Optimization (PDF) (CP.PMN.59)
- Quetiapine ER (Seroquel XR) (PDF) (CP.PMN.64)
- Quinine Sulfate (Qualaquin) (PDF) (CP.PNM.262)
- Quizartinib (Vanflyta) (PDF) (CP.PHAR.646)
- Tivozanib (Fotivda) (PDF) (CP.PHAR.538)
- Ranibizumab (Lucentis®) (PDF) (CP.PHAR.186)
- rasagiline (Azilect®) (PDF) (HIM.PA.89)
- Ravulizumab-cwvz (Ultomiris) (PDF) (CP.PHAR.415)
- Regorafenib (Stivarga) (PDF) (CP.PHAR.107)
- Relugolix (Orgovyx) (PDF) (CP.PHAR.529)
- Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel) (PDF) (HIM.PA.168)
- Repotrectinib (Augtyro) (PDF) (CP.PHAR.667)
- Reslizumab (Cinqair) (PDF) (CP.PHAR.223)
- Respiratory syncytial virus vaccine (Abrysvo) (PDF) (CP.PHAR.658)
- Retifanlimab-dlwr (Zynyz) (PDF) (CP.PHAR.629)
- Revlimid (PDF) (CP.PHAR.71)
- Ribavirin (Rebetol, Ribasphere) (PDF) (CP.PHAR.141)
- Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara) (PDF) (CP.PHAR.334)
- Rifabutin (Mycobutin) (PDF) (CP.PMN.223)
- Rifamycin (Aemcolo) (PDF) (CP.PMN.196)
- Rilonacept (Arcalyst) (PDF) (CP.PHAR.266)
- RimabotulinumtoxinB (Myobloc) (PDF) (CP.PHAR.233)
- Rimegepant (Nurtec ODT) (PDF) (CP.PHAR.490)
- Riociguat (Adempas®) (PDF) (CP.PHAR.195)
- Ripretinib (Qinlock) (PDF) (CP.PHAR.502)
- Risdiplam (Evrysdi) (PDF) (CP.PHAR.477)
- Risedronate (Actonel, Atelvia) (PDF) (CP.PMN.100)
- Risperidone LA Inj (PDF) (CP.PHAR.293)
- rifaximin (PDF) (CP.PMN.47)
- Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela) (PDF) (CP.PHAR.260)
- Roflumilast (Daliresp, Zoryve) (PDF) (CP.PMN.46)
- Rolapitant (Varubi) (PDF) (CP.PMN.102)
- Romidepsin (Istodax) (PDF) (CP.PHAR.314)
- Romiplostim (Nplate®) (PDF) (CP.PHAR.179)
- Romosozumab-aqqg (Evenity) (PDF) (CP.PHAR.428)
- Ropeginterferon Alfa-2b-njft (BESREMi) (PDF) (CP.PHAR.570)
- Rozanolixizumab-noli (Rystiggo) (PDF) (CP.PHAR.648)
- Rucaparib (Rubraca®) (PDF) (CP.PHAR.350)
- Rufinamide (Banzel) (PDF) (CP.PMN.157)
- Rukobia (fostemsavir) (PDF) (CP.PHAR.516)
- Ruxolitinib (Jakafi) (PDF) (CP.PHAR.98)
- Sacituzumab Govitecan-hziy (Trodelvy) (PDF) (CP.PHAR.475)
- Sacubitril/Valsartan (Entresto) (PDF) (CP.PMN.67)
- Safinamide (Xadago) (PDF) (CP.PMN.113)
- Sapropterin (Kuvan) (PDF) (CP.PHAR.43)
- Sarecycline (Seysara) (PDF) (CP.PMN.189)
- Sargramostim (PDF) (CP.PHAR.295)
- Satralizumab (PDF) (CP.PHAR.463)
- Sebelipase Alfa (Kanuma) (PDF) (CP.PHAR.159)
- Secnidazole (Solosec) (PDF) (CP.PMN.103)
- Selexipag (Uptravi®) (PDF) (CP.PHAR.196)
- Selinexor (Xpovio) (PDF) (CP.PHAR.431)
- Selpercatinib (Retevmo) (PDF) (CP.PHAR.478)
- Selumetinib (PDF) (CP.PHAR.464)
- Sensipar (PDF) (CP.PHAR.61)
- Setmelanotide (Imcivree) (PDF) (CP.PHAR.491)
- Short Ragweed Pollen Allergen Extract (Ragwitek) (PDF) (CP.PMN.83)
- Sildenafil (Revatio®) (PDF) (CP.PHAR.197)
- Sildenafil (Viagra) (PDF) (CP.PCH.07)
- Siltuximab (Sylvant®) (PDF) (CP.PHAR.329)
- Siponimod (Mayzent) (PDF) (CP.PHAR.427)
- Sirolimus Protein-Bound Particles (Fyarro) (PDF) (CP.PHAR.574)
- Sodium-Glucose Co-Transporter 2 Inhibitors (PDF) (HIM.PA.91)
- Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, Sodium Oxybate (Xywav) (PDF) (CP.PMN.42)
- Sodium Phenylbutyrate (Buphenyl) (PDF) (CP.PHAR.208)
- Sodium Phenylbutyrate/Taurursodiol (Relyvrio) (PDF) (CP.PHAR.584)
- Sodium thiosulfate (Pedmark) (PDF) (CP.PHAR.610)
- Sodium Zirconium Cyclosilicate (Lokelma) (PDF) (CP.PMN.163)
- Sofosbuvir (Sovaldi) (PDF) (HIM.PA.SP2)
- Sofosbuvir/Vepatasvir/Voxilaprevir (Vosevi) (PDF) (HIM.PA.SP63)
- Sofosbuvir-Velpatasvir (Epclusa) (PDF) (HIM.PA.SP1)
- Solriamfetol (Sunosi) (PDF) (CP.PMN.209)
- Sonidegib (Odomzo) (PDF) (CP.PHAR.272)
- Sorafenib (Nexavar) (PDF) (CP.PHAR.69)
- Sotorasib (Lumakras) (PDF) (CP.PHAR.549)
- Sparsentan (Filspari) (PDF) (CP.PHAR.631)
- Spesolimab-sbzo (Spevigo) (PDF) (CP.PHAR.606)
- Spinosad (Natroba) (PDF) (HIM.PA.134)
- Step Therapy Criteria (PDF) (HIM.PA.109)
- Stiripentol (Diacomit) (PDF) (CP.PMN.184)
- Sunitinib (Sutent) (PDF) (CP.PHAR.73)
- Sutimlimab-jome (Enjaymo) (PDF) (CP.PHAR.503)
- Suvorexant (Belsomra) (PDF) (CP.PMN.109)
- Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair) (PDF) (CP.PMN.85)
- Sylatron (peginterferon alfa-2b) (PDF) (CP.PHAR.89)
- Tadalafil (Adcirca®) (PDF) (CP.PHAR.198)
- Tadafil BHP - ED (Cialis) (PDF) (CP.PMN.132)
- Tafamidis (Vyndaqel, Vyndamax) (PDF) (CP.PHAR.432)
- Tafasitamab-cxix (Monjuvi) (PDF) (CP.PHAR.508)
- Talazoparib (Talzenna) (PDF) (CP.PHAR.409)
- Taliglucerase Alfa (Elelyso) (PDF) (CP.PHAR.157)
- Taliglucerase Alfa (Elelyso) (PDF) (HIM.PA.162)
- Talimogene laherepvec (Imlygic) (PDF) (CP.PHAR.542)
- Talquetamab-tgvs (Talvey) (PDF) (CP.PHAR.649)
- Tapinarof (Vtama) (PDF) (CP.PMN.283)
- Tasimelteon (Hetlioz) (PDF) (CP.PMN.104)
- Tavaborole (Kerydin®) (PDF) (CP.PMN.105)
- Tazemetostat (PDF) (CP.PHAR.452)
- Tazarotene (Arazlo, Fabior, Tazorac) (PDF) (CP.PMN.244)
- Tebentafusp-tebn (Kimmtrak) (PDF) (CP.PHAR.575)
- Teclistamab-cqyv (Tecvayli) (PDF) (CP.PHAR.611)
- Tedizolid (Sivextro) (PDF) (CP.PMN.62)
- Teduglutide (Gattex) (PDF) (CP.PHAR.114)
- Tegaserod (Zelnorm) (PDF) (HIM.PA.160)
- Telotristat ethyl (Xermelo) (PDF) (CP.PHAR.337)
- Temozolomide (Temodar) (PDF) (CP.PHAR.77)
- Temsirolimus (Torisel) (PDF) (CP.PHAR.324)
- Tetrabenazine (Xenazine) (PDF) (CP.PHAR.92)
- Tenapanor (Ibsrela, Xphozah) (PDF) (HIM.PA.174)
- Tenofovir Alafenamide Fumarate (Vemlidy) (PDF) (CP.PMN.268)
- Teplizumab-mzwv (Tzield) (PDF) (CP.PHAR.492)
- Tepotinib (Tepmetko) (PDF) (CP.PHAR.530)
- Teprotumumab (Tepezza) (PDF) (CP.PHAR.465)
- Teriflunomide (Aubagio) (PDF) (CP.PCH.40)
- Teriparatide (Forteo®) (PDF) (CP.PHAR.188)
- Tesamorelin (PDF) (CP.PHAR.109)
- Testosterone (Testopel, Jatenzo) (PDF) (CP.PHAR.354)
- Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF) (CP.PHAR.377)
- Tezepelumab-ekko (Tezspire) (PDF) (CP.PHAR.576)
- Thalidomide (Thalomid) (PDF) (CP.PHAR.78)
- Thioguanine (Tabloid) (PDF) (CP.PHAR.437)
- Thyrotropin alfa (PDF) (CP.PHAR.95)
- Timothy Grass Pollen Allergen Extract (Grastek) (PDF) (CP.PMN.84)
- Tiopronin Delayed-Release (Thiola EC) (PDF) (CP.PCH.50)
- Tisagenlecleucel (PDF) (CP.PHAR.361)
- Tisotumab Vedotin-tftv (Tivdak) (PDF) (CP.PHAR.561)
- Tobramycin (Bethkis®, Kitabis Pak®, TOBI®, TOBI Podhaler®) (PDF) (CP.PHAR.211)
- Tofersen (Qalsody) (PDF) (CP.PHAR.591)
- Tolvaptan (Jynarque) (PDF) (CP.PHAR.27)
- Topical Acne Treatment (PDF) (HIM.PA.71)
- Topical Immunomodulators (PDF) (CP.PMN.107)
- topical testosterone (PDF) (HIM.PA.87)
- Topiramate Extended-Release (Qudexy XR, Trokendi XR) (PDF) (CP.PMN.281)
- Topotecan (Hycamtin) (PDF) (CP.PHAR.64)
- Toripalimab-tpzi (Loqtorzi) (PDF) (CP.PHAR.668)
- 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)
- Travoprost Implant (iDose TR) (PDF) (CP.PHAR.672)
- Tremelimumab-actl (Imjudo) (PDF) (CP.PHAR.612)
- Treprostinil (Orenitram®, Remodulin®, Tyvaso®) (PDF) (CP.PHAR.199)
- Triamcinolone ER Injection (Zilretta) (PDF) (CP.PHAR.371)
- Triclabendazole (Egaten) (PDF) (CP.PMN.207)
- Trientine (Cuvrior, Syprine) (PDF) (CP.PHAR.438)
- Trifarotene (Aklief) (PDF) (CP.PMN.225)
- Trifluridine/Tipiracil (Lonsurf) (PDF) (CP.PHAR.383)
- Triheptanoin (Dojolvi) (PDF) (CP.PHAR.509)
- triptorelin pamoate (Trelstar®, Triptodur®) (PDF) (CP.PHAR.175)
- Trofinetide (Daybue) (PDF) (CP.PHAR.600)
- Tucatinib (Tukysa) (PDF) (CP.PHAR.497)
- Ublituximab-xiiy (Briumvi) (PDF) (CP.PHAR.621)
- Ulcer Therapy Combinations (PDF) (CP.PMN.277)
- Umbralisib (Ukoniq) (PDF) (CP.PHAR.531)
- Uridine acetate (Vistogard) (PDF) (HIM.PA.SP55)
- Valbenazine (Ingrezza) (PDF) (CP.PCH.48)
- valganciclovir (Valcyte) (PDF) (CP.PCH.06)
- Valoctocogene Roxaparvovec-rvox (Roctavian) (PDF) (CP.PHAR.466)
- Valrubicin (Valstar) (PDF) (CP.PHAR.439)
- Vamorolone (Agamree) (PDF) (CP.PHAR.659)
- Vandetanib (Caprelsa®) (PDF) (CP.PHAR.80)
- Varenicline (Tyrvaya) (PDF) (CP.PMN.273)
- Velaglucerase Alfa (VPRIV) (PDF) (CP.PHAR.163)
- Velaglucerase Alfa (VPRIV) (PDF) (HIM.PA.163)
- Velmanase Alfa-tycv (Lamzede) (PDF) (CP.PHAR.601)
- Vemurafenib (Zelboraf®) (PDF) (CP.PHAR.91)
- Venetoclax (Venclexta) (PDF) (CP.PHAR.129)
- Verteporfin (Visudyne) (PDF) (CP.PHAR.187)
- Vestronidase alfa-vjbk (Mepsevii) (PDF) (CP.PHAR.374)
- Vigabatrin (PDF) (CP.PHAR.169)
- Vilazodone (Viibryd) (PDF) (CP.PMN.145)
- Viloxazine (Qelbree) (PDF) (CP.PMN.264)
- Viltolarsen (Viltepso) (PDF) (CP.PHAR.484)
- Vincristine Sulfate Liposome Injection (Marqibo) (PDF) (CP.PHAR.315)
- Vismodegib (Erivedge) (PDF) (CP.PHAR.273)
- Voclosporin (Lupkynis) (PDF) (CP.PHAR.504)
- Vorapaxar (Zontivity) (PDF) (HIM.PA.146)
- Voretigene neparvovec-rzyl (Luxturna) (PDF) (CP.PHAR.372)
- Vorinostat (Zolinza) (PDF) (CP.PHAR.83)
- Vortioxetine (Trintellix®) (PDF) (CP.PMN.65)
- Vosoritide (Voxzogo) (PDF) (CP.PHAR.525)
- Voxelotor (Oxbryta) (PDF) (CP.PHAR.451)
- Vutrisiran (Amvuttra) (PDF) (CP.PHAR.550)
- Xgeva (PDF) (CP.PHAR.58)
- Xiaflex™ (PDF) (CP.PHAR.82)
- Zanubrutinib (Brukinsa) (PDF) (CP.PHAR.467)
- Zavegepant (Zavzpret) (PDF) (CP.PHAR.630)
- Zilucoplan (Zilbrysq) (PDF) (CP.PHAR.616)
- Ziv-aflibercept (Zaltrap) (PDF) (CP.PHAR.325)
- Zometa (PDF) (CP.PHAR.59)
- Zuranolone (Zurzuvae) (PDF) (CP.PHAR.650)
Medicaid Clinical Policies Listing
- Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF) (CP.BH.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) (CP.BH.104)
- Applied Behavioral Analysis Documentation Requirements (PDF) (CP.BH.105)
- Bariatric Surgery (PDF) (WA.CP.MP.37)
- Behavioral Health Personal Care Services (PDF) (WA.CP.MP.521)
- Behavioral Health Treatment Documentation Requirements (PDF) (CP.BH.500)
- Bone-anchored Hearing Aid (PDF) (CP.MP.93)
- Burn Surgery (PDF) (CP.MP.186)
- Cardiac Biomarker Testing (PDF) (CP.MP.156)
- Cardiac Stents (PDF) (WA.CP.MP.513)
- Carotid Artery Stenting (PDF) (WA.CP.MP.516)
- Catheter Ablation for SVTA (PDF) (WA.CP.MP.525)
- Clinical Trials (PDF) (CP.MP.94)
- Cochlear Implant Replacements (PDF) (CP.MP.14)
- Cochlear Implants (PDF) (WA.CP.MP.502)
- Continuous Glucose Monitoring (PDF) (WA.CP.MP.501)
- Cosmetic and Reconstructive Procedures (PDF) (CP.MP.31)
- Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (PDF) (CP.BH.201)
- Diaphragmatic/Phrenic Nerve Stimulation (PDF) (CP.MP.203)
- Digital EEG Spike Analysis (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 and Orthotics and Prosthetics Guidelines (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)
- Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF) (CP.MP.248)
- Fecal Incontinence Treatments (PDF) (CP.MP.137)
- Fecal Microbiota Transplantation (PDF) (WA.CP.MP.515)
- Fertility Preservation (PDF) (WA.CP.MP.130)
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) (CP.MP.129)
- Gastric Electrical Stimulation (PDF) (CP.MP.40)
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) (CP.MP.209)
- Helicobacter 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)
- Hyperhidrosis Treatments (PDF) (CP.MP.62)
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) (CP.MP.180)
- Implantable Intrathecal or Epidural Pain Pump (PDF) (CP.MP.173)
- Implantable Loop Recorder (CP.MP.243)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) (CP.MP.160)
- Inhaled Nitric Oxide (PDF) (CP.MP.87)
- Intensity-Modulated Radiotherapy (IMRT) (PDF) (WA.CP.MP.69)
- Intestinal and Multivisceral Transplant (PDF) (CP.MP.58)
- Intradiscal Steroid Injections for Pain Management (PDF) (CP.MP.167)
- Laser Therapy for Skin Conditions (PDF) (CP.MP.123)
- Liposuction of Lipedema (PDF) (CP.MP.244)
- Lung Transplantation (PDF) (CP.MP.57)
- Lysis of Epidural Lesions (PDF) (CP.MP.116)
- Mandibular Advancement Devices (PDF) (WA.CP.MP.500)
- Micro-Processor Controlled Prosthetics (PDF) (WA.CP.MP.505)
- Multiple Sleep Latency Testing (PDF) (CP.MP.24)
- Negative Pressure Wound Therapy for Home Use (PDF) (WA.CP.MP.518)
- Neonatal Abstinence Syndrome Guidelines (PDF) (CP.MP.86)
- Neonatal Sepsis Management Guidelines (PDF) (CP.MP.85)
- Nerve Blocks and Neurolysis for Pain Management (PDF) (CP.MP.170)
- NICU Apnea Bradycardia Guidelines (PDF) (CP.MP.82)
- NICU Discharge Guidelines (PDF) (CP.MP.81)
- Nonmyeloablative allogeneic SCT (PDF) (CP.MP.141)
- Omisirge (Omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF) (CP.MP.249)
- Oral Enteral Nutrition (PDF) (WA.CP.MP.507)
- Orthognathic Surgery (PDF) (CP.MP.202)
- Osteogenic Stimulation (PDF) (CP.MP.194)
- Pancreas Transplantation (PDF) (CP.MP.102)
- Panniculectomy (PDF) (CP.MP.109)
- Pediatric Heart Transplant (PDF) (CP.MP.138)
- Pediatric Liver Transplant (PDF) (CP.MP.120)
- Pediatric Kidney Transplant (PDF) (CP.MP.246)
- Pediatric Oral Function Therapy (PDF) (CP.MP.188)
- Peripheral and Percutaneous Nerve Stimulation (PDF) (WA.CP.MP.117)
- Photherapy for Neonatal Hyperbilirubinemia (PDF) (CP.MP.150)
- Physical, Occupational and Speech Therapy Services (PDF) (CP.MP.49)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) (CP.MP.181)
- Private Duty Nursing Services (PDF) (WA.CP.MP.503)
- Proton and Neutron Beam Therapies (PDF) (WA.CP.MP.70)
- Psychological Testing (PDF) (WA.CP.BH.506)
- Pulmonary Function Testing (PDF) (CP.MP.242)
- Reduction Mammoplasty and Gynecomastia Surgery (PDF) (CP.MP.51)
- Repair of Nasal Valve Compromise (PDF) (CP.MP.210)
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF) (CP.MP.146)
- Short Inpatient Hospital Stay (PDF) (CP.MP.182)
- Skin and Soft Tissue Substitutes for Chronic Wounds (PDF) (WA.CP.MP.185)
- Stem Cell Therapy for Musculoskeletal Conditions (PDF) (WA.CP.MP.526)
- Stereotactic Body Radiation Therapy (PDF) (CP.MP.22)
- 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)
- Transcranial Magnetic Stimulation (PDF) (WA.CP.BH.200)
- Transplant Service Documentation Requirements (PDF) (CP.MP.247)
- 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)
- Concert Genetic Testing Aortopathies & Connective Tissue Disorders (PDF) (V1.2024)
- Concert Genetic Testing Cardiac Disorders (PDF) (V1.2024)
- Concert Genetic Testing Dermatologic Conditions (PDF) (V1.2024)
- Concert Genetic Testing Epilepsy Neurodegenerative and Neuromuscular Conditions (PDF) (V1.2024)
- Concert Genetic Testing Exome and Genome Sequencing for DX of Genetic Disorders (PDF) (V1.2024)
- Concert Genetic Testing Eye Disorders (PDF) (V1.2024)
- Concert Genetic Testing Gastroenterologic Disorders Non-cancerous (PDF) (V1.2024)
- Concert Genetic Testing General Approach to Genetic Testing (PDF) (V1.2024)
- Concert Genetic Testing Hearing Loss (PDF) (V1.2024)
- Concert Genetic Testing Hematologic Conditions Non-cancerous (PDF) (V1.2024)
- Concert Genetic Testing Hereditary Cancer Susceptibility (PDF) (V1.2024)
- Concert Genetic Testing Immune Autoimmune and Rheumatoid Disorders (PDF) (V1.2024)
- Concert Genetic Testing Kidney Disorders (PDF) (V1.2024)
- Concert Genetic Testing Lung Disorders (PDF) (V1.2024)
- Concert Genetic Testing Metabolic Endocrine Mitochondrial Disorders (PDF) (V1.2024)
- Concert Genetic Testing Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay (PDF) (WA.CP.MP.230)
- Concert Genetic Testing Non-Invasive Prenatal Screening (PDF) (WA.CP.MP.231)
- Concert Genetic Testing Pharmacogenetics (PDF) (V1.2024)
- Concert Genetic Testing Preimplantation Genetic Testing (PDF) (V1.2024)
- Concert Genetic Testing Prenatal and Preconception Carrier Screening (PDF) (V1.2024)
- Concert Genetic Testing Prenatal Diagnosis Pregnancy Loss (PDF) (V1.2024)
- Concert Genetic Testing Skeletal Dysplasia Rare Bone Disorders (PDF) (V1.2024)
- Concert Genetics Oncology Algorithmic Testing (PDF) (V1.2024)
- Concert Genetics Oncology Cancer Screening (PDF) (V1.2024)
- Concert Genetics Oncology Circulating Tumor DNA Tumor Cells Liquid Biopsy (PDF) (V1.2024)
- Concert Genetics Oncology Cytogenetic Testing (PDF) (V1.2024)
- Concert Genetics Oncology Molecular Analysis Solid Tumors & Hematolgic Malignancies (PDF) (V1.2024)
Medicaid Pharmacy Policies Listing
- 72-Hour Emergency Supply of Medication (PDF) (CC.PHAR.01)
- Abametapir (Xeglyze) (PDF) (CP.PMN.253)
- Abemaciclib (PDF) (CP.PHAR.355)
- AbobotulinumtoxinA (Dysport) (PDF) (CP.PHAR.230)
- Abiraterone (Zytiga) (PDF) (CP.PHAR.84)
- Abrocitinib (Cibinqo) (PDF) (CP.PHAR.578)
- ACEI and ARB Duplicate Therapy (PDF) (CP.PMN.61)
- Acitretin (Soriatane) (PDF) (CP.PMN.40)
- Acyclovir Buccal Tablet (Sitavig), Ophthalmic Ointment (Avaclyr) (PDF) (CP.PMN.210)
- Acute Migraine Treatment Calcitonin Gene Related Peptide (CGRP) Receptor Antagonist (PDF) (WA.PHAR.106)
- Adagrasib (Krazati) (PDF) (CP.PHAR.605)
- Adefovir (Hepsera) (PDF) (CP.PHAR.142)
- ADHD Anti Narcolepsy Agents Armodafinil modafinil Sunosi Wakix (PDF) (WA.PHAR.124)
- ADHD Anti-Narcolepsy Non-Stimulants Viloxazine (Qelbree) (PDF) (WA.PHAR.131)
- Ado-Trastuzumab (Kadcyla) (PDF) (CP.PHAR.229)
- Adzynma (ADAMTS13, Recombinant-krhn) (PDF) (CP.PHAR.635)
- 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)
- Amikacin (Arikayce) (PDF) (CP.PHAR.401)
- Amisulpride (Barhemsys) (PDF) (CP.PMN.236)
- Amivantamab-vmjw (Rybrevant) (PDF) (CP.PHAR.544)
- Amlodipine/Atorvastatin (Caduet) (PDF) (CP.PMN.176)
- Analgesics Opioid Agonists (PDF) (WA.PHAR.23)
- Androgenic Agents-Testosterone Replacement Therapy (TRT) (PDF) (WA.PHAR.28)
- Anifrolumab-fnia (Saphnelo) (PDF) (CP.PHAR.551)
- Antiasthmatic Monoclonal Antibodies Anti IgE Antibodies (PDF) (WA.PHAR.29)
- Antiasthmatic Monoclonal Antibodies IL-5 Antagonists (PDF) (WA.PHAR.30)
- Antibiotics Anti-Infective Agents- Oral rifaximin (XIFAXAN) (PDF) (WA.PHAR.66)
- Antibiotics-Inhaled-aminoglycosides (PDF) (WA.PHAR.79)
- Antibiotics Inhaled aztreonam (CAYSTON) (PDF) (WA.PHAR.31)
- Anticonvulsants-Rescue Agents (PDF) (WA.PHAR.32)
- Antidepressants- Serotonin Modulators (PDF) (WA.PHAR.123)
- Antidiabetics-Amylin Analogs (PDF) (WA.PHAR.33)
- Antidiabetics- GLP-1 Agonists (PDF) (WA.PHAR.122)
- Antidiabetics-Inhaled Insulin (Afrezza) (PDF) (WA.PHAR.34)
- Antihyperlipidemics-Apolipoprotein B Synthesis Inhibitors lomitapide mesylate (PDF) (WA.PHAR.38)
- Antihyperlipidemics - icosapent ethyl (Vascepa) (PDF) (WA.PHAR.134)
- Antihyperlipidemics-PCSK9 Inhibitors (PDF) (WA.PHAR.39)
- Antineoplastics and Adjunctive Therapies - Imidazotetrazines– Oral (PDF) (WA.PHAR.117)
- Antimemetic-Antivertigo Agents (Dronabinol) (PDF) (WA.PHAR.35)
- Antineoplastics and Adjunctive Therapies Tyrosine Kinase Inhibitors (PDF) (WA.PHAR.103)
- Antiparasitics Antiprotozoal Agents- nitazoxanide (Alinia) (PDF) (WA.PHAR.67)
- Antipsychotics 2nd Generation Vraylar (PDF) (WA.PHAR.105)
- Antithrombin III (ATryn, Thrombate III) (PDF) (CP.PHAR.564)
- Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) (CP.PHAR.506)
- Antivirals-HIV Combinations (PDF) (WA.PHAR.97)
- Antivirals HIV-emtricitabinetenofovir alafenamide (Descovy) (PDF) (WA.PHAR.98)
- Antivirals HIV- Rilpivirine (Edurant) (PDF) (WA.PHAR.120)
- Apalutamide (Erleada) (PDF) (CP.PHAR.376)
- Apomorphine (Apokyn, Kynmobi) (PDF) (CP.PHAR.488)
- Aprepitant (PDF) (CP.PMN.19)
- aripiprazole long-acting injections (PDF) (CP.PHAR.290)
- Asenapine (PDF) (CP.PMN.15)
- Aspirin-dipyridamole (PDF) (CP.PMN.20)
- Atezolizumab (Tecentriq) (PDF) (CP.PHAR.235)
- Atopic Dermatitis Agents Dupilumab (Dupixent) (PDF) (WA.PHAR.41)
- Atopic Dermatitis Agents-Topical Immunosuppressives (PDF) (WA.PHAR.42)
- Atopic Dermatitis Agents Crisaborole (Eucrisa) (PDF) (WA.PHAR.43)
- Avacincaptad pegol (Izervay) (PDF) (CP.PHAR.641)
- 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)
- Bimekizumab-bkzx (Bimzelx) (PDF) (CP.PHAR.660)
- Binimetinib (Mektovi) (PDF) (CP.PHAR.50)
- Blinatumomab (PDF) (CP.PHAR.312)
- Bone Density Regulators (PDF) (WA.PHAR.45)
- Bortezomib (Velcade) (PDF) (CP.PHAR.410)
- Brands with Generic Equivalents (PDF) (WA.PHAR.65)
- Bremelanotide (Vyleesi) (PDF) (CP.PHAR.434)
- Brentuximab (PDF) (CP.PHAR.303)
- Brexanolone (Zulresso) (PDF) (CP.PHAR.417)
- Brexpiprazole (PDF) (CP.PMN.68)
- Brimonidine Tartrate (Mirvaso) (PDF) (CP.PMN.192)
- Brolucizumab-dbll (Beovu) (PDF) (CP.PHAR.445)
- Budesonide (Tarpeyo) (PDF) (CP.PHAR.572)
- (MAT) Buprenorphine Products (PDF) (WA.PHAR.62)
- Cabazitaxel (Jevtana) (PDF) (CP.PHAR.316)
- Calcifediol (Rayaldee) (PDF) (CP.PMN.76)
- Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) (PDF) (CP.PMN.181)
- Cannabidiol (Epidiolex) (PDF) (CP.PMN.164)
- Capecitabine (Xeloda) (PDF) (CP.PHAR.60)
- Carbamazepine ER (Equetro) (PDF) (CP.PMN.137)
- Carbidopa/Levodopa ER Capsules (Rytary) (PDF) (CP.PMN.238)
- Cardiovascular Agents-Sinus Node Inhibitors (PDF) (WA.PHAR.46)
- carfilzomib (PDF) (CP.PHAR.309)
- 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)
- Cipaglucosidase Alfa-atga + Miglustat (Pombiliti + Opfolda) (PDF) (CP.PHAR.567)
- 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 Monitoring (PDF) (WA.PHAR.133)
- copanlisib (PDF) (CP.PHAR.357)
- Corticosteroids - Deflazacort (Emflaza) (PDF) (WA.PHAR.135)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert) (PDF) (CP.PHAR.385)
- Corticotropin (H.P. Acthar Gel) (PDF) (CP.PHAR.168)
- Cosyntropin (Cortrosyn) (PDF) (CP.PHAR.203)
- Cyclosporine (Cequa, Restasis, Verkazia) (PDF) (CP.PMN.48)
- Cysteamine Ophthalmic (Cystaran, Cystadrops) (PDF) (CP.PMN.130)
- Cystic Fibrosis Agents (Oral) (PDF) (WA.PHAR.48)
- Cytokine and CAM Antagonists (PDF) (WA.PHAR.49)
- Cytomegalovirus Immune Globulin (Cytogam) (PDF) (CP.PHAR.277)
- Dabigatran (Pradaxa) (PDF) (CP.PMN.49)
- Dabrafenib (Tafinlar) (PDF) (CP.PHAR.239)
- Dalteparin (PDF) (CP.PHAR.225)
- Daprodustat (Jesduvroq) (PDF) (CP.PHAR.628)
- daptomycin (PDF) (CP.PHAR.351)
- Daratumumab (PDF) (CP.PHAR.310)
- Darolutamide (Nubeqa) (PDF) (CP.PHAR.435)
- daunorubicin cytarabine (PDF) (CP.PHAR.352)
- DaxibotulinumtoxinA-lanm (Daxxify) (PDF) (CP.PHAR.651)
- Decitabine-Cedazuridine (Inqovi) (PDF) (CP.PHAR.479)
- deferasirox (PDF) (CP.PHAR.145)
- deferiprone (PDF) (CP.PHAR.147)
- deferoxamine (PDF) (CP.PHAR.146)
- 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)
- Eflornithine (Iwilfin) (PDF) (CP.PHAR.670)
- Elacestrant (Orserdu) (PDF) (CP.PHAR.623)
- Elagolix (Orilissa) (PDF) (CP.PHAR.136)
- Elotuzumab (Empliciti) (PDF) (CP.PHAR.308)
- Elranatamab-bcmm (Elrexfio) (PDF) (CP.PHAR.652)
- enasidenib (PDF) (CP.PHAR.363)
- Encorafenib (Braftovi) (PDF) (CP.PHAR.127)
- Enfortumab Vedotin-ejfv (Padcev) (PDF) (CP.PHAR.455)
- Enoxaparin (PDF) (CP.PHAR.224)
- Entrectinib (Rozlytrek) (PDF) (CP.PHAR.441)
- Enzalutamide (PDF) (CP.PHAR.106)
- Epcoritamab-bysp (Epkinly) (PDF) (CP.PHAR.634)
- Epinephrine (EpiPen and EpiPen Jr) Quanity Limit Override (PDF) (CP.PMN.144)
- Epoprostenol (Flolan, Veletri) (PDF) (CP.PHAR.192)
- Erdafitinib (Balversa) (PDF) (CP.PHAR.423)
- eribulin Mesylate (PDF) (CP.PHAR.318)
- Erwinia Asparaginase (Erwinaze) (PDF) (CP.PHAR.301)
- Esketamine (Spravato) (PDF) (CP.PMN.199)
- Estradiol Vaginal Ring (Femring) (PDF) (CP.PMN.263)
- Etelcalcetide (Parsabiv) (PDF) (CP.PHAR.379)
- Etrasimod (Velsipity) (PDF) (CP.PHAR.661)
- Everolimus (PDF) (CP.PHAR.63)
- Experimental Technologies (PDF) (WA.CP.MP.36)
- Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) (CP.PHAR.456)
- Faricimab-svoa (Vabysmo) (PDF) (CP.PHAR.581)
- Fecal Microbiota, Live-jslm (Rebyota) (PDF) (CP.PHAR.613)
- Fecal Microbiota Spores, Live-brpk (Vowst) (PDF) (CP.PHAR.632)
- Fedratinib (Inrebic) (PDF) (CP.PHAR.442)
- Fenfluramine (Fintepla) (PDF) (CP.PMN.246)
- Ferric Carboxymaltose (Injectafer) (PDF) (CP.PHAR.234)
- Ferric Derisomaltose (Monoferric) (PDF) (CP.PHAR.480)
- Ferric Gluconate (Ferrlecit) (PDF) (CP.PHAR.166)
- Ferric Maltol (Accrufer) (PDF) (CP.PMN.213)
- Ferric Pyrophosphate (Triferic, Triferic Avnu) (PDF) (CP.PHAR.624)
- Ferumoxytol (Feraheme) (PDF) (CP.PHAR.165)
- Fezolinetant (Veozah) (PDF) (CP.PMN.289)
- Finerenone (Kerendia) (PDF) (CP.PMN.266)
- Fingolimod (Gilenya) (PDF) (CP.PHAR.251)
- Flibanserin (Addyi) (PDF) (CP.PHAR.446)
- Fluorouracil Cream (Tolak) (PDF) (CP.PMN.165)
- Fluticasone propionate (PDF) (CP.PMN.95)
- Fondaparinux (PDF) (CP.PHAR.226)
- Fruquintinib (Fruzaqla) (PDF) (CP.PHAR.666)
- Fulvestrant (Faslodex Injection) (PDF) (CP.PHAR.424)
- Furosemide (Furoscix) (PDF) (CP.PHAR.608)
- Futibatinib (Lytgobi) (PDF) (CP.PHAR.604)
- Gabapentin ER (Gralise, Horizant) (PDF) (CP.PMN.240)
- gemtuzumab ozogamicin (PDF) (CP.PHAR.358)
- Gepirone (Exxua) (PDF) (CP.PMN.292)
- Glasdegib (Daurismo) (PDF) (CP.PHAR.413)
- Glatiramer Acetate (Copaxone, Glatopa) (PDF) (CP.PHAR.252)
- Glaucoma Agents (PDF) (CP.PMN.286)
- Glofitamab-gxbm (Columvi) (PDF) (CP.PHAR.636)
- Glycopyrronium (Qbrexza) (PDF) (CP.PMN.177)
- Goserelin Acetate (Zoladex) (PDF) (CP.PHAR.171)
- Gout Agents (PDF) (WA.PHAR.40)
- Granisetron (Sancuso) (PDF) (CP.PMN.74)
- Growth Hormone Agents (PDF) (WA.PHAR.50)
- Halobetasol Propionate Lotion 0.05% (Ultravate) (PDF) (CP.PMN.180)
- Halobetasol Propionate/Tazarotene (Duobrii) (PDF) (CP.PMN.208)
- Hematopoietic Agents Erythropoiesis-Stimulating Agents (ESAs) (PDF) (WA.PHAR.71)
- Hematopoietic Agents Granulocyte Colony Stimulating Factors (G-CSF) (PDF) (WA.PHAR.72)
- Hematopoietic Agents Thrombopoieses (TPO) Stimulating Proteins (PDF) (WA.PHAR.73)
- Hemin (Panhematin) (PDF) (CP.PHAR.181)
- Hormone Therapy for Gender Dysphoria (PDF) (WA.PHAR.104)
- Hyaluronate Derivatives (PDF) (CP.PHAR.05)
- Hydroxyurea (Siklos) (PDF) (CP.PMN.193)
- Ibrance (palbociclib) (PDF) (CP.PHAR.125)
- Ibuprofen/Famotidine (Duexis) (PDF) (CP.PMN.120)
- Idelalisib (Zydelig) (PDF) (CP.PHAR.133)
- Iloperidone (Fanapt) (PDF) (CP.PMN.32)
- Immune Globulins (PDF) (CP.PHAR.103)
- Immunization coverage (PDF) (CP.PHAR.28)
- Inclisiran (Leqvio) (PDF) (CP.PHAR.568)
- IncobotulinumtoxinA (Xeomin) (PDF) (CP.PHAR.231)
- Infigratinib (Truseltiq) (PDF) (CP.PHAR.547)
- Inhaled Agents for Asthma and COPD (PDF) (CP.PMN.259)
- inotuzumab ozogamicin (PDF) (CP.PHAR.359)
- Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF) (CP.PHAR.534)
- Interferon beta-1a (Avonex, Rebif) (PDF) (CP.PHAR.255)
- Interferon beta-1b (Betaseron, Extavia) (PDF) (CP.PHAR.256)
- Intrathecal Baclofen (Gablofen, Lioresal) (PDF) (CP.PHAR.149)
- Iobenguane I-131 (Azedra) (PDF) (CP.PHAR.459)
- Ipilimumab (Yervoy) (PDF) (CP.PHAR.319)
- irinotecan Liposome (PDF) (CP.PHAR.304)
- Iron sucrose (Venofer) (Acthar Gel) (PDF) (CP.PHAR.167)
- Isatuximab-irfc (Sarclisa) (PDF) (CP.PHAR.482)
- Isavuconazonium (Cresemba) (PDF) (CP.PMN.154)
- Isotretinoin (PDF) (CP.PMN.143)
- Istradefylline (Nourianz) (PDF) (CP.PMN.217)
- Itraconazole (Sporanox, Onmel) (PDF) (CP.PMN.124)
- Ivermectin (Stromectol, Sklice) (PDF) (CP.PMN.269)
- Ivosidenib (Tibsovo) (PDF) (CP.PHAR.137)
- Ixazomib (PDF) (CP.PHAR.302)
- Jakafi™ (ruxolitinib) (PDF) (CP.PHAR.98)
- Ketorolac Nasal Spray (Sprix) (PDF) (CP.PMN.282)
- Korlym (mifepristone) (PDF) (CP.PHAR.101)
- Lacosamide (Vimpat) (PDF) (CP.PMN.155)
- Lactic Acid/Citric Acid/Potassium Bitartrate (Phexxi) (PDF) (CP.PMN.251)
- Lanreotide (Somatuline Depot) (PDF) (CP.PHAR.391)
- Larotrectinib (Vitrakvi) (PDF) (CP.PHAR.414)
- Lasmiditan (Reyvow) (PDF) (CP.PMN.218)
- Lefamulin (Xenleta) (PDF) (CP.PMN.219)
- Lenacapavir (Sunlenca) (PDF) (CP.PHAR.622)
- Lenalidomide (Revlimid) (PDF) (CP.PHAR.71)
- Letermovir (PDF) (CP.PHAR.367)
- Leucovorin Injection (PDF) (CP.PHAR.393)
- Leuprolide Acetate (Eligard, Fensolvi, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped) (PDF) (CP.PHAR.173)
- Levodopa Inhalation Powder (Inbrija) (PDF) (CP.PMN.267)
- Levoleucovorin (Fusilev) (PDF) (CP.PHAR.151)
- lidocaine transdermal (PDF) (CP.PMN.08)
- Lindane Lotion Shampoo (PDF) (CP.PMN.09)
- Linezolid (Zyvox) (PDF) (CP.PMN.27)
- Lofexidine (Lucemyra) (PDF) (CP.PMN.152)
- Lomustine (Gleostine) (PDF) (CP.PHAR.507)
- Loncastuximab Tesirine-lpyl (Zynlonta) (PDF) (CP.PHAR.539)
- Loteprednol etabonate (Eysuvis) (PDF) (CP.PMN.260)
- Lotilaner (Xdemvy) (PDF) (CP.PMN.291)
- 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)
- Melphalan (Hepzato) (PDF) (CP.PHAR.653)
- Mercaptopurine (Purixan) (PDF) (CP.PHAR.447)
- Metformin ER (Fortamet, Glumetza) (PDF) (CP.PMN.72)
- Methadone (Dolophine) (PDF) (WA.PHAR.20)
- Methotrexate (Otrexup, Rasuvo, Xatmep) (PDF) (CP.PHAR.134)
- Metoclopramide (Gimoti) (PDF) (CP.PMN.252)
- Midostaurin (Rydapt) (PDF) (CP.PHAR.344)
- Migraine Products Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist (PDF) (WA.PHAR.64)
- Milnacipran (Savella) (PDF) (CP.PMN.125)
- Minocycline ER (Solodyn, Ximino) and Microspheres (Arestin), Foam (Zilxi) (PDF) (CP.PMN.80)
- Minocycline Micronized Foam (Amzeeq) (PDF) (CP.PMN.242)
- Mirvetuximab soravatansine-gynx (Elahere) (PDF) (CP.PHAR.617)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF) (CP.PHAR.495)
- Mitoxantrone (Novantrone) (PDF) (CP.PHAR.258)
- Mogamulizumab-kpkc (Poteligeo) (PDF) (CP.PHAR.139)
- Momelotinib (Ojjaara) (PDF) (CP.PHAR.654)
- Mometasone Furoate (Sinuva) (PDF) (CP.PHAR.448)
- Mosunetuzumab-axgb (Lunsumio) (PDF) (CP.PHAR.618)
- Motixafortide (Aphexda) (PDF) (CP.PHAR.655)
- Movement Disorder Agents (PDF) (WA.PHAR.51)
- Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) (CP.PHAR.398)
- Multiple Sclerosis Agents-Dalfampridine (Ampyra) (PDF) (WA.PHAR.52)
- Multiple Sclerosis- Ocrelizumab (Ocrevus) (PDF) (WA.PHAR.69)
- Musculoskeletal Therapy Agents - Carisoprodol (PDF) (WA.PHAR.130)
- Nabumetone Double-Strength (Relafen DS) (PDF) (CP.PMN.287)
- Nadofaragene Firadenovec-vncg (Adstiladrin) (PDF) (CP.PHAR.461)
- Nafarelin Acetate (Synarel) (PDF) (CP.PHAR.174)
- Nalmefene (Opvee) (PDF) (CP.PHAR.638)
- Naproxen/Esomeprazole (Vimovo) (PDF) (CP.PMN.117)
- (MAT) Naltrexone Products (PDF) (WA.PHAR.63)
- Natalizumab (Tysabri) (PDF) (CP.PHAR.259)
- Naxitamab-gqgk (Danyelza) (PDF) (CP.PHAR.523)
- necitumumab (PDF) (CP.PHAR.320)
- Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF) (CP.PMN.167)
- Netupitant and Palonosetron (Akynzeo) (PDF) (CP.PMN.158)
- Nifurtimox (Lampit) (PDF) (CP.PMN.256)
- Niraparib (Zejula) (PDF) (CP.PHAR.408)
- Niraparib and Abiraterone Acetate (Akeega) (PDF) (CP.PHAR.645)
- Nirsevimab-alip (Beyfortus) (PDF) (CP.PHAR.614)
- 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)
- Olutasidenib (Rezlidhia) (PDF) (CP.PHAR.615)
- Omadacycline (Nuzyra) (PDF) (CP.PMN.188)
- Omecetaxine (Synribo) (PDF) (CP.PHAR.108)
- Omega-3-Acid Ethyl Esters (Lovaza) (PDF) (CP.PMN.52)
- OnabotulinumtoxinA (Botox) (PDF) (CP.PHAR.232)
- Ondansetron (Zuplenz) (PDF) (CP.PMN.45)
- Ophthalmic Immunomodulators-Lifitegrast 5% Ophthalmic Solution (PDF) (WA.PHAR.58)
- Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF) (CP.PHAR.536)
- Opicapone (Ongentys) (PDF) (CP.PMN.245)
- Ospemifene (Osphena) (PDF) (CP.PMN.168)
- Overactive Bladder Agents (PDF) (CP.PMN.198)
- Oxymetazoline (Rhofade, Upneeq) (PDF) (CP.PMN.86)
- Ozanimod (Zeposia) (PDF) (CP.PHAR.462)
- Ozenoxacin (Xepi) (PDF) (CP.PMN.119)
- Paclitaxel protein-bound (Abraxane) (PDF) (CP.PHAR.176)
- Pacritinib (Vonjo) (PDF) (CP.PHAR.583)
- paliperidone inj (PDF) (CP.PHAR.291)
- Palivizumab (Synagis) (PDF) (CP.PHAR.16)
- Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep) (PDF) (CP.PMN.226)
- panitumumab (PDF) (CP.PHAR.321)
- Panobinostat (Farydak) (PDF) (CP.PHAR.382)
- Parathyroid hormone (Natpara) (PDF) (CP.PHAR.282)
- Paricalcitol Injection (PDF) (CP.PHAR.270)
- pasireotide (PDF) (CP.PHAR.332)
- Patiromer (Veltassa) (PDF) (CP.PMN.205)
- Peanut Allergen Powder-dnfp (Palforzia) (PDF) (CP.PMN.220)
- pegaspargase (PDF) (CP.PHAR.353)
- Peginterferon beta-1a (Plegridy) (PDF) (CP.PHAR.271)
- Pegvisomant (Somavert) (PDF) (CP.PHAR.389)
- pembrolizumab (PDF) (CP.PHAR.322)
- Pemetrexed (Alimta) (PDF) (CP.PHAR.368)
- Pemigatinib (Pemazyre) (PDF) (CP.PHAR.496)
- Pentosan Polysulfate Sodium (Elmiron) (PDF) (CP.PMN.276)
- Perampanel (Fycompa) (PDF) (CP.PMN.156)
- Perfluorohexyloctane (Miebo) (PDF) (CP.PMN.290)
- Perindopril/Amlodipine (Prestalia) (PDF) (CP.PMN.174)
- Pertuzumab (Perjeta) (PDF) (CP.PHAR.227)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (PDF) (CP.PHAR.501)
- Pilocarpine (Vuity) (PDF) (CP.PMN.270)
- Pimavanserin (Nuplazid) (PDF) (CP.PMN.140)
- Plerixafor (PDF) (CP.PHAR.323)
- Polatuzumab Vedotin-piiq (Polivy) (PDF) (CP.PHAR.433)
- Pomalidomide (Pomalyst) (PDF) (CP.PHAR.116)
- Ponesimod (Ponvory) (PDF) (CP.PHAR.537)
- pralatrexate (PDF) (CP.PHAR.313)
- Prasterone (Intrarosa) (PDF) (CP.PMN.99)
- Preferred Stimulants for Adults (PDF) (WA.PHAR.132)
- Pregabalin (Lyrica, Lyrica CR) (PDF) (CP.PMN.33)
- Pretomanid (PDF) (CP.PMN.222)
- Progesterone (Crinone, Endometrin, Milprosa) (PDF) (CP.PMN.243)
- 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)
- Quizartinib (Vanflyta) (PDF) (CP.PHAR.646)
- 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)
- Repotrectinib (Augtyro) (PDF) (CP.PHAR.667)
- Respiratory Agents- Misc Alpha-Proteinase Inhibitor (Human) (PDF) (WA.PHAR.68)
- Respiratory syncytial virus vaccine (Abrysvo) (PDF) (CP.PHAR.658)
- Retifanlimab-dlwr (Zynyz) (PDF) (CP.PHAR.629)
- Revlimid (PDF) (CP.PHAR.71)
- Ribavirin (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)
- 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 (Istodax) (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 thiosulfate (Pedmark) (PDF) (CP.PHAR.610)
- Sodium Zirconium Cyclosilicate (Lokelma) (PDF) (CP.PMN.163)
- Sonidegib (Odomzo) (PDF) (CP.PHAR.272)
- Sorafenib (Nexavar) (PDF) (CP.PHAR.69)
- Sotorasib (Lumakras) (PDF) (CP.PHAR.549)
- Spesolimab-sbzo (Spevigo) (PDF) (CP.PHAR.606)
- 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)
- Talquetamab-tgvs (Talvey) (PDF) (CP.PHAR.649)
- Tapinarof (Vtama) (PDF) (CP.PMN.283)
- Tazarotene (Arazlo, Fabior, Tazorac) (PDF) (CP.PMN.244)
- Tasimelteon (Hetlioz) (PDF) (CP.PMN.104)
- Tavaborole (Kerydin) (PDF) (CP.PMN.105)
- Tazemetostat (PDF) (CP.PHAR.452)
- Tebentafusp-tebn (Kimmtrak) (PDF) (CP.PHAR.575)
- Teclistamab-cqyv (Tecvayli) (PDF) (CP.PHAR.611)
- Tedizolid (Sivextro) (PDF) (CP.PMN.62)
- Telotristat ethyl (Xermelo) (PDF) (CP.PHAR.337)
- Tesamorelin (PDF) (CP.PHAR.109)
- Temsirolimus (Torisel) (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)
- Tivozanib (Fotivda) (PDF) (CP.PHAR.538)
- 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)
- Toripalimab-tpzi (Loqtorzi) (PDF) (CP.PHAR.668)
- 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)
- Travoprost Implant (iDose TR) (PDF) (CP.PHAR.672)
- Tremelimumab-actl (Imjudo) (PDF) (CP.PHAR.612)
- Triamcinolone ER Injection (PDF) (CP.PHAR.371)
- Triclabendazole (Egaten) (PDF) (CP.PMN.207)
- Trientine (Cuvrior, Syprine) (PDF) (CP.PHAR.438)
- Trifarotene (Aklief) (PDF) (CP.PMN.225)
- Trifluridine, Tipiracil (Lonsurf) (PDF) (CP.PHAR.383)
- Triptorelin Pamoate (Trelstar, Triptodur) (PDF) (CP.PHAR.175)
- Ublituximab-xiiy (Briumvi) (PDF) (CP.PHAR.621)
- Ulcer Therapy Combinations (PDF) (CP.PMN.277)
- Umbralisib (Ukoniq) (PDF) (CP.PHAR.531)
- Valrubicin (Valstar) (PDF) (CP.PHAR.439)
- Varenicline (Tyrvaya) (PDF) (CP.PMN.273)
- Vemurafenib (Zelboraf®) (PDF) (CP.PHAR.91)
- Venetoclax (Venclexta) (PDF) (CP.PHAR.129)
- Verteporfin (Visudyne) (PDF) (CP.PHAR.187)
- Vigabatrin (PDF) (CP.PHAR.169)
- Vincristine Sulfate Liposome Injection (Marqibo) (PDF) (CP.PHAR.315)
- Vismodegib (Erivedge) (PDF) (CP.PHAR.273)
- Voclosporin (Lupkynis) (PDF) (CP.PHAR.504)
- Vorinostat (PDF) (CP.PHAR.83)
- Voxelotor (Oxbryta) (PDF) (CP.PHAR.451)
- Xiaflex™ (PDF) (CP.PHAR.82)
- Zavegepant (Zavzpret) (PDF) (CP.PHAR.630)
- Ziv-aflibercept (Zaltrap) (PDF) (CP.PHAR.325)
- Zoledronic Acid (Reclast, Zometa) (PDF) (CP.PHAR.59)
- Zolpidem Tartrate (Edluar, Zolpimist) (PDF) (CP.PMN.172)
- Zuranolone (Zurzuvae) (PDF) (CP.PHAR.650)
Payment Policies
Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.
All policies found in the Coordinated Care Payment Policy Manual apply with respect to Coordinated Care members. Policies in the Coordinated Care Payment Policy Manual may have either a Coordinated Care or a “Centene” heading. In addition, Coordinated Care may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Coordinated Care.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Ambetter Payment Policies
- 3-Day Payment Window (PDF) (CC.PP.500)
- 30-Day Readmission (PDF) (CC.PP.501)
- Add on Code Billed Without Primary Code (PDF) (CC.PP.030)
- Assistant Surgeon (PDF) (CC.PP.029)
- Bilateral Procedures (PDF) (CC.PP.037)
- Cerumen Removal (PDF) (CC.PP.008)
- Clean Claims (PDF) (CC.PP.021)
- Coding Overview (PDF) (CC.PP.011)
- Cosmetic Procedures (PDF) (CC.PP.024)
- Distinct Procedural Modifiers (PDF) (CC.PP.020)
- Duplicate Primary Code Billing (PDF) (CC.PP.044)
- E&M Medical Decision-Making (PDF) (CC.PP.051)
- EM Bundling Edits (PDF) (CC.PP.010)
- Global Maternity Billing (PDF) (CC.PP.016)
- Hospital Visit Codes Billed with Labs (PDF) (CC.PP.023)
- Inpatient Consultation (PDF) (CC.PP.038)
- Inpatient Only Procedures (PDF) (CC.PP.018)
- IV Hydration (PDF) (CC.PP.012)
- Leveling of Emergency Room Services (PDF) (CC.PP.053)
- Maximum Units (PDF) (CC.PP.007)
- Moderate Conscious Sedation (PDF) (CC.PP.015)
- Modifier -25 clinical validation (PDF) (CC.PP.013)
- Modifier -59 clinical validation (PDF) (CC.PP.014)
- Modifier DOS Validation (PDF) (CC.PP.034)
- Modifier to Procedure Code Validation (PDF) (CC.PP.028)
- Multiple CPT Code Replacement (PDF) (CC.PP.033)
- Multiple Diagnostic Cardiovascular Procedure (MDCP) (PDF) (CC.PP.065)
- Payment Reduction (MDCR)NCCI Unbundling (PDF) (CC.PP.031)
- Never Paid Events (PDF) (CC.PP.017)
- New Patient (PDF) (CC.PP.036)
- 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)
- Skilled Nursing Facility Leveling (PDF) (CC.PP.206)
- Sleep Studies Place of Services (PDF) (CC.PP.035)
- Status "B" Bundled Services (PDF) (CC.PP.046)
- Status P Bundled Services (PDF) (CC.PP.049)
- Supplies Billed on Same Day As Surgery (PDF) (CC.PP.032)
- Transgender Related Services (PDF) (CC.PP.047)
- Unbundled Surgical Procedures (PDF) (CC.PP.045)
- Unbundled Professional Services (PDF) (CC.PP.043)
- Unlisted Procedure Codes (PDF) (CC.PP.009)
- Wheelchair Accessories (PDF) (CC.PP.502)
Medicaid Payment Policies
- 1-Day Payment Window (PDF) (WA.PP.500)
- Add on Code Billed Without Primary Code (PDF) (CC.PP.030)
- Assistant Surgeon (PDF) (CC.PP.029)
- Bilateral Procedures (PDF) (CC.PP.037)
- Cerumen Removal (PDF) (CC.PP.008)
- Clean Claims (PDF) (CC.PP.021)
- Coding Overview (PDF) (CC.PP.011)
- Cosmetic Procedures (PDF) (CC.PP.024)
- Distinct Procedural Modifiers (PDF) (CC.PP.020)
- Duplicate Primary Code Billing (PDF) (CC.PP.044)
- E&M Medical Decision-Making (PDF) (CC.PP.051)
- EM Bundling Edits (PDF) (CC.PP.010)
- Global Maternity Billing (PDF) (CC.PP.016)
- Hospital Visit Codes Billed with Labs (PDF) (CC.PP.023)
- Inpatient Consultation (PDF) (CC.PP.038)
- Inpatient Only Procedures (PDF) (CC.PP.018)
- IV Hydration (PDF) (CC.PP.012)
- Leveling of Emergency Room Services (PDF) (CC.PP.053)
- Maximum Units (PDF) (CC.PP.007)
- Moderate Conscious Sedation (PDF) (CC.PP.015)
- Modifier -25 clinical validation (PDF) (CC.PP.013)
- Modifier -59 clinical validation (PDF) (CC.PP.014)
- Modifier DOS Validation (PDF) (CC.PP.034)
- Modifier to Procedure Code Validation (PDF) (CC.PP.028)
- Multiple CPT Code Replacement (PDF) (CC.PP.033)
- Multiple Diagnostic Cardiovascular Procedure (MDCP) (PDF) (CC.PP.065)
- NCCI Unbundling (PDF) (CC.PP.031)
- Never Paid Events (PDF) (CC.PP.017)
- New Patient (PDF) (CC.PP.036)
- Outpatient Consultation (PDF) (CC.PP.039)
- Pelvic and Transabdominal US (PDF) (CC.PP.061)
- Physician 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)
- Skilled Nursing Facility Leveling (PDF) (CC.PP.206)
- 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 (Clinical)
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.186 | Burn Surgery | Annual review. Added criteria II.C. that burn must be deep partial-thickness or full-thickness. Added used according to FDA indications to II.D.3. References reviewed and updated. Reviewed by internal specialist |
No revisions this month.
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.107 | Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines | Annual review. Updated description with no impact on criteria. Changed Orthopedic Care Equipment to Prosthetics and Orthotics Equipment. Table of contents updated. Retired pneumatic compression device criteria (E0675) for IQ. Updated "Cabinet style..." note under Ultraviolet panel lights. Under “Other Equipment” added code E0240 to “Specialized supply or equipment” section and added section, criteria, and coding (E1399, A9900) for “ROMTech device”. Reformatted Foot orthotics, custom criteria in “Prosthetics and Orthotics Equipment” section. Added criteria for Prosthetics and additions: Upper Extremity and Myoelectric in “Prosthetics and Orthotics Equipment” section. Added section, criteria, and coding (L8701, L8702) for “MyoPro Orthosis” under “Prosthetics and Orthotics Equipment”. Removed code L8035 from "other surgical supplies" and added section and criteria for "Breast Prosthetics" (L8030, L8035). Removed pediatric wheelchair codes (E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1037) from manual wheelchair section. References reviewed, updated, and reformatted. Internal specialist review. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
WA.CP.MP.525 | Catheter Ablation for Supraventricular Tachyarrhythmia | Annual review. References updated. Use of InterQual guidelines removed and policy updated to align with current HCA billing guidelines. CPT 93654 removed per billing guidelines. |
WA.CP.MP.500 | Mandibular Advancement Devices | Annual review. Reference reviewed |
CP.MP.38 | Ultrasound in Pregnancy | Updated Table 4 (Diagnosis Codes that Support Medical Necessity for First Detailed Fetal Ultrasound) to include the following codes and code ranges: A92.5, D56.0 through D56.9, D57.00 through D57.819, M32.0 through M32.9, M33.00 through M33.99, M34.0 through M34.9, M35.00 through M35.09, M35.1, M35.5, M35.8 through M35.9, M36.0, M36.8, N18.9, O00.01, O00.111 through O00.119, O00.211 through O00.219, O00.81, O00.91, O09.892 through O09.93, O10.012 through O10.019, O10.112 through O10.119, O10.212 through O10.219, O10.312 through O10.319, O10.412 through O10.419, O10.912 through O10.919, O11.2 through O11.3, O12.00, O12.02 through O12.03, O12.10, O12.12 through O12.13, O12.20, O12.22 through O12.23, O13.2 through O13.3, O13.5 through O13.9, O14.00, O14.02 through O14.03, O14.10, O14.12 through O14.13, O14.20, O14.22 through O14.23, O14.90, O14.92 through O14.93, O15.00, O15.02 through O15.03, O15.9, O16.2 through O16.3, O16.9, O22.50, O22.52 through O22.53, O23.00, O23.02 through O23.03, O24.414 through O24.415, O26.20, O26.22 through O26.23, O26.30, O26.32 through O26.33, O26.40, O26.42 through O26.43, O26.612 through O26.619, O26.832 through O26.839, O26.843 through O26.849, O26.852 through O26.859, O26.872 through O26.879, O28.5, O28.8 through O28.9, O29.012 through O29.019, O29.022 through O29.029, O29.112 through O29.119, O29.122 through O29.129, O29.212 through O29.219, O29.292 through O29.299, O30.90, O30.92 through O30.93, O31.30X1 through O31.30X9, O31.32X0 through O31.32X9, O31.33X0 through O31.33X9, O31.8X20 through O31.8X29, O31.8X30 through O31.8X39, O31.8X90 through O31.8X99, O32.0XX3 through O32.0XX9, O32.1XX1, O32.2XX1, O32.3XX1, O32.6XX1, O32.8XX1, O32.9XX1, O34.02 through O34.03, O34.30, O34.32 through O34.33, O36.20X0 through O36.20X9, O36.22X0 through O36.22X9, O36.23X0 through O36.23X9, O36.4XX0 through O36.4XX9, O36.60X0 through O36.60X9, O36.62X0 through O36.62X9, O36.63X0 through O36.63X9, O36.70X0 through O36.70X9, O36.72X0 through O36.72X9, O36.73X0 through O36.73X9, O36.80X0 through O36.80X9, O36.8130 through O36.8139, O36.8190 through O36.8199, O36.8220 through O36.8229, O36.8230 through O36.8239, O36.8290 through O36.8299, O36.8320 through O36.8329, O36.8330 through O36.8339, O36.8390 through O36.8399, O41.8X20 through O41.8X29, O41.8X30 through O41.8X39, O42.00, O42.012 through O42.02, O42.10, O42.112 through O42.119, O42.912 through O42.919, O43.012 through O43.019, O43.022 through O43.029, O43.112 through O43.119, O43.122 through O43.129, O43.212 through O43.219, O43.222 through O43.229, O43.232 through O43.239, O43.812 through O43.819, O44.00, O44.02 through O44.03, O44.10, O44.12 through O44.13, O44.20, O44.22 through O44.23, O44.30, O44.32 through O44.33, O44.40, O44.42 through O44.43, O44.50, O44.52 through O44.53, O45.002 through O45.009, O45.012 through O45.019, O45.022 through O45.029, O45.092 through O45.099, O46.002 through O46.009, O46.012 through O46.019, O46.022 through O46.029, O46.092 through O46.099, O46.8X2 through O46.8X9, O46.90, O46.92 through O46.93, O48.0 through O48.1, O60.00, O60.02 through O60.03, O60.10X0 through O60.10X9, O60.12X0 through O60.12X9, O60.13X0 through O60.13X9, O60.14X0 through O60.14X9, O98.012 through O98.019, O98.112 through O98.119, O98.919, O99.280, O99.282 through O99.283, O99.330, O99.332 through O99.333, O99.512 through O99.519, O9A.112 through O9A.119, U07.1, Z20.821, Z20.822, and Z21. References reviewed and updated. Internal specialist reviewed. |
WA.CP.MP.70 | Proton and Neutron Beam Therapies | Annual Review. Updated criteria I.G. to, unresectable benign or malignant central nervous system tumors to include but not limited to primary and variant forms of astrocytoma, glioblastoma, medulloblastoma, acoustic neuroma, craniopharyngioma, benign and atypical meningiomas, pineal gland tumors, and arteriovenous malformations. Added criteria I.H., Pituitary neoplasms. Restructured and added section A. and B. to criteria II. References reviewed and updated. |
CP.MP.142 | Urinary Incontinence Devices and Treatments | Annual review. Added note under Description to refer to CP.MP.133 Posterior Tibial Nerve Stimulation for Voiding Dysfunction for posterior tibial nerve stimulation treatment for urinary incontinence. Updated criteria I.B. from, urinary retention have been present for at least 12 months, to, urinary retention have been present for at least 6 months. Minor rewording in Criteria with no clinical significance. Background updated with no impact on criteria. References reviewed and updated. Reviewed by external specialist. |
CP.MP.151 | Transcatheter Closure of Patent Foramen Ovale | Annual review. Minor rewording in Background section with no impact on criteria. References reviewed and updated. |
CP.MP.180 | Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea | Annual review. Edits were made to criteria to align with the FDA updates issued June 8, 2023, for the Inspire Upper Airway Stimulation System. Updated criteria B. from "Age > 22 years" to "BMI ≤ 40 kg/m2"; changed C. from "BMI < 35 kg/m2" to "One of the following:" adding C.1 to C.3, indicating the updated age ranges and associated criteria. Contraindications were updated to I.D.a to I.D.g. The original criteria points I.E to I.I were removed. Background updated with no clinical significance. References reviewed and updated. Reviewed by external specialist. |
CP.MP.181 | Polymerase Chain Reaction Respiratory Viral Panel Testing | Updated description of Table 2 as Table 6 was removed. Added ICD-10 codes J15.61 and J15.69 to Table 4. Added ICD-10 codes J44.81 and J44.89 to Table 5. Deleted Table 6 from policy. |
CP.MP.206 | Skilled Nursing Facility Leveling | Retire |
CP.MP.247 | Transplant Service Documentation Requirements | Annual review. Minor rewording throughout Criteria with no impact on criteria. Criteria I.B.2. and Criteria I.B.3. updated to say “provider” instead of “physician.” Criteria I.B.5. updated to include documentation. C-peptide removed from Criteria I.B.5.e. Criteria I.B.5.f. updated to remove “no specific additional testing” and added documentation of failed total parenteral nutrition. Criteria I.B.10.g. updated to say rapid plasma reagin. Background updated with no impact on criteria. References reviewed and updated. Reviewed by internal specialist. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.BH.124 | ADHD Assessment and Treatment | Annual Review. Changed reference number for the policy from “CP.MP.124” to “CP.BH.124”. Added the following statement to section I and II: “It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation”. In criteria point II. A. 1. replaced “Actometer” with “Actigraphy”. In criteria point I.A. 2. added “Acoustic reflex testing”. In criteria point I.A.12: removed Magnetic resonance imaging, brain functional MRI as it is already captured in I.A.16: under MRI. Removed I.A.14. “Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping”. In criteria point I.A.16. added “brain mapping” to the brain imaging section. In Criteria point I.A. 24 removed “Triiodothyronine T3 levels in the blood” and reworded as “Measures of thyroid hormones”. Removed II.A.18 “neuropsychological testing from the insufficient evidence list”, with corresponding codes also removed. In criteria point II. B.2., added “Application of modality (e.g. hot or cold packs, traction, mechanical, electrical stimulation (unattended), vasopneumatic devices, paraffin bath, whirlpool, diathermy (eg, microwave), infrared, ultraviolet, electrical stimulation (manual), iontophoresis, contrast baths, ultrasound, hubbard tank)”. Removed education interventions from criteria point II.B.19. and added policy statement III. “It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation that interventions that are strictly educational in nature (e.g., classroom environmental manipulation, academic skills training training) are not medically necessary as they are not considered medical interventions”. Added criteria point II.B.19. “EndeavorRx®”. Replaced instances of dashes (-) with the word “to” within the CPT description code list. Coding reviewed. Added the following codes and related indications as not medically necessary when billed with a sole diagnosis of ADHD: 70496, 70554, 70555, 78610, 84436, 84437, 84439, 84442, 84443, 84445, 84478, 84479, 84481, 92568, 92569, 92570, 95954, 96020, 96902, 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036. References reviewed and updated. Policy reviewed by internal specialist. Policy reviewed by an external specialist. |
CP.MP.108 | Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia | Annual review. Added note at end of Description regarding criteria related to Zynteglo. Criterion I.C.3. removed related to lack of adequate support system. Expanded Criteria II.A. and Criteria II.B. to specify not in the context of gene therapy. Background updated with no impact on criteria. References reviewed and updated. Reviewed by internal and external specialist. |
CP.MP.31 | Cosmetic and Reconstructive Procedures | Annual review. Minor edits to I.A.4.b with no clinical significance. Updated pharmacy policies for Serostim (somatropin) in note. Removed CPT code 11310. References reviewed and updated. Reviewed by internal specialist. |
CP.MP.101 | Donor lymphocyte infusion | Annual review. Minor rewording in Description with no impact on criteria. Criteria II.B. updated to state grade 2 or higher acute graft versus host disease (GvHD). Background updated with no impact on criteria. References reviewed and updated. Reviewed by internal specialist. Updated policy description. Updated all criteria in statements I. and II. |
CP.MP.209 | GI Pathogen Nucleic Acid Detection Panel Testing | Annual review completed. Replaced previous criteria with current in sections I. and II. and removed section III. Background updated with no impact to criteria. Reworded some extraneous language with no clinical significance. Moved code 87506 from Table 1 to Table 2. Added Place of Service Code 19 in Table 3. Added Table 4, Table 5, and Table 6 to include ICD-10 diagnosis codes which support medical necessity. References reviewed and updated. |
CP.MP.250 | Lantidra (donislecel): Allogeneic pancreatic islet cellular therapy | New policy |
CP.MP.123 | Laser Therapy for Skin Conditions | Annual review. Added medically necessary indications I.C. atopic dermatitis and I.D. cutaneous T-cell lymphoma. Removed II.B. atopic dermatitis from insufficient evidence section. Added codes L20.81, L20.82, L20.89, C84.00 through C84.09, and C84.10 through C84.19 to table of ICD-10-CM diagnosis codes that support coverage criteria. References reviewed and updated. |
CP.MP.57 | Lung Transplantation | Revised adult and pediatric criteria to align with ISHLT 2021 consensus document. References reviewed and updated. |
CP.MP.202 | Orthognathic Surgery | Annual review. Added CPT codes 21248 and 21249. References reviewed and updated. |
CP.MP.109 | Panniculectomy | Annual Review. Combined criteria I.D. and E. into criteria I.D.1. and 2. Removed CPT code 00802 from policy. References reviewed and updated. Reviewed by external specialist. |
CP.MP.138 | Pediatric Heart Transplant | Annual review. Added additional criteria I.A.1.b.vi.a., pulmonary hypertension and a potential risk of developing fixed, irreversible elevation of pulmonary vascular resistance that could preclude orthotopic heart transplantation in the future. Updated I.D.1. from GFR < 40 mL/min/1.73m2 to GFR < 30 mL/min/1.73m2. Expanded I.D.2. with qualifying criteria for members who are HIV positive. Updated I.D.21. to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. Background reviewed and updated. References reviewed and updated. Reviewed by external specialist. |
CP.MP.246 | Pediatric Kidney Transplant | Annual review. Description updated to include source information for policy criteria. Updated Criteria I.A.1. from glomerular filtration rate (GFR) ≤ 15 mL/min/1.73m2 to GFR < 15 mL/min/1.73m2 to align with Kidney Disease: Improving Global Outcomes (KDIGO) guidance and Organ Procurement Transplant Network (OPTN) guidance. Updated Criteria I.A.2. to include members/enrollees with CKD stage 4 with GFR < 30 mL/min/1.73m2 who are expected to reach end stage renal disease (ESRD) to align with KDIGO guidance and OPTN guidance. Updated contraindications in I.B. consistent with KDIGO guidelines. References reviewed and updated. |
CP.MP.150 | Phototherapy for Neonatal Hyperbilirubinemia | Annual review. Reworded criteria I.C. for inclusive language. References reviewed and updated. |
CP.MP.181 | Polymerase Chain Reaction Respiratory Viral Panel Testing | Annual review. Replaced prior criteria in sections I. and II. with current criteria. Removed policy statement III. Background updated with no impact on criteria. Updated verbiage in Table 2 description to include new diagnosis code requirements. Added Place of Service Code 19 in Table 3. Added Table 4, Table 5, and Table 6 which include ICD-10 diagnosis codes. References reviewed and updated. |
CP.MP.98 | Urodynamic Testing | Annual review. Added criteria I.D.5. for 4.5. Prostate nodule, asymmetry or other suspicion of prostate cancer. Moved N40.3 from ICD-10 Table 2 to ICD-10 Table 1. References reviewed and updated. |
WA.CP.MP.527 | Vitamin D Testing | Annual review. Updated references. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.129 | Fetal Surgery in Utero for Prenatally Diagnosed Malformations | Annual review. Criteria I.F.3. updated to include confirmation on fetal MRI. Added clarifying language to Criteria I.F.4. Background updated with no impact on criteria. Added CPT code 59072. ICD-10 codes removed. References reviewed and updated. Reviewed by external specialist.
|
WA.CP.MP.50 | Drugs of Abuse: Definitive Testing | Annual Review. Added an example of synthetic cannabinoids to I.A.1., drugs for which presumptive testing is not reliable. Coding reviewed. Replaced all instances of dashes (-) with the word “to” within the CPT and HCPCS codes. Added 0082U to the CPT codes that do not support coverage criteria list. Removed table of ICD-10 CM codes. Updated background information to include information regarding American Society of Addiction Medicine (ASAM). Other minor wording changes made to background with no clinical significance. References reviewed and updated. Policy reviewed by an internal specialist. Removed deleted codes 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, 0150U from table of CPT codes that do not support coverage criteria. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
WA.CP.MP.519 | Administrative Days | Changed “denial” to “discharge” in Note.
|
CP.MP.100 | Allergy Testing and Therapy | Annual review. Updated description and background with no clinical significance. References reviewed and updated. Coding reviewed. Reviewed by external specialist. |
WA.CP.MP.37 | Bariatric Surgery | Modified section II.B. to allow family practice in addition to internal medicine physicians conduct pre-operative assessments. |
CP.MP.156 | Cardiac Biomarker Testing | Annual review. Background updated with no impact on criteria. Coding reviewed. References reviewed and updated. Reviewed by external specialist. |
CP.MP.105 | Digital EEG Spike Analysis | Annual review. Minor rewording in Criteria I. Background updated with no impact on criteria. References reviewed and updated. Reviewed by external specialist |
CP.MP.155 | EEG in the Evaluation of Headache | Annual review. Edits to policy name in header. Background updated with no clinical significance. References reviewed and updated. |
CP.MP.134 | Evoked Potential Testing | Annual review. References reviewed and updated. Reviewed by external specialist. |
CP.MP.153 | Helicobacter Pylori Serology Testing | Annual review. References reviewed and updated. Reviewed by external specialist. |
CP.MP.113 | Holter Monitors | Annual review. Criteria I. updated to specify a Food and Drug Administration (FDA) approved Holter monitor device, and age in Criteria I. changed from > 18 years old to ≥ 18 years old. Criteria I.D. updated to include arrhythmogenic right ventricular cardiomyopathy (ARVC), hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy, or a first degree relative with HCM. Added Criteria I.O. for baseline or periodic screening for those with adult congenital heart disease. Criteria II. updated to specify an FDA approved Holter monitor device, and age in Criteria II. changed from ≤ 18 years old to < 18 years old. Minor rewording in background with no impact on criteria. References reviewed and updated. Reviewed by internal specialist. |
CP.MP.102 | Pancreas Transplantation | Added note to policy to see CP.MP.250 Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy for criteria related to Lantidra. |
CP.MP.181 | Polymerase Chain Reaction Respiratory Viral Panel Testing | Removed note after the policy description referring to CP.CPC.03 Preventive Health and Clinical Practice Guidelines for PCR testing for COVID-19. Added 0202U, 0223U and 0225U to CPT table 2. |
CP.MP.154 | Thyroid Hormones and Insulin Testing in Pediatrics | Annual review. Edits to title in header. References reviewed and updated. Reviewed by external specialist. |
CP.MP.38 | Ultrasound in Pregnancy | Annual review. Minor rewording in Description, in Table 1 under Criteria IV., and in Criteria V. Verbiage added to indicate list is not all inclusive under Classifications of fetal ultrasounds Section I. and Section II. Background updated with no impact on criteria. Updated Table 4 Coding description. The following retired code ranges were removed: O35.0XX0 through O35.0XX9 and O35.1XX0 through O35.1XX9. The following code ranges were added: O35.00X0 through O35.00X9, O35.01X0 through O35.01X9, O35.02X0 through O35.02X9, O35.03X0 through O35.03X9, O35.04X0 through O35.04X9, O35.05X0 through O35.05X9, O35.06X0 through O35.06X9, O35.07X0 through O35.07X9, O35.08X0 through O35.08X9, O35.09X0 through O35.09X9, O35.10X0 through O35.10X9, O35.11X0 through O35.11X9, O35.12X0 through O35.12X9, O35.13X0 through O35.13X9, O35.14X0 through O35.14X9, O35.15X0 through O35.15X9, O35.19X0 through O35.19X9, O35.AXX0 through O35.AXX9, O35.BXX0 through O35.BXX9, O35.CXX0 through O35.CXX9, O35.DXX0 through O35.DXX9, O35.EXX0 through O35.EXX9, O35.FXX0 through O35.FXX9, O35.GXX0 through O35.GXX9, O35.HXX0 through O35.HXX9. References reviewed and updated. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.BH.500 | Behavioral Health Treatment Documentation Requirements | Annual Review. No changes made to criteria. References reviewed and updated. |
WA.CP.MP.516 | Carotid Artery Stending | Annual review. References updated. Removed InterQual guidelines and edited section I. to reflect current HTA criteria. |
CP.MP.203 | Diaphragmatic/Phrenic Nerve Stimulation | Annual review. Product name updates in criteria II. and in background with no clinical significance. References reviewed and updated. |
CP.MP.248 | Facility Based Sleep Studies for Obstructive Sleep Apnea | Corrected I.B.8.a.i. to require either continuous, chronic nocturnal oxygen use or moderate to severe pulmonary function impairment instead of both. |
WA.CP.MP.69 | Intensity Modulated Radiation Therapy | Annual review. References updated. |
CP.MP.167 | Intradiscal Steroid Injections for Pain Management | Annual review. References reviewed and updated. |
CP.MP.170 | Nerve Blocks for Pain Management | Annual review completed. Examples added to I.B.1. and III.B.2. Minor rewording with no clinical significance. Background updated. Added CPT codes 64628. ICD-10 Diagnosis code table removed. References reviewed and updated. External specialist reviewed. |
WA.CP.MP.507 | Oral Enteral Nutrition | Added Exception to the Rule comment for adults requesting PKU formula |
CP.MP.194 | Osteogenic Stimulation | Annual review completed. Background and references reviewed and updated. |
CP.MP.51 | Reduction Mammoplasty and Gynecomastia Surgery | Annual review. Criteria I.A.1. updated for criteria for members/enrollees ≥ 18 years of age and members/enrollees < 18 years of age. Criteria I.A.2. updated to include note regarding medical director review on case-by-case basis when weight of tissue to be resected is less than the 22nd percentile minimum based on the Schnur Sliding Scale. Criteria I.A.3.b. updated to include pain in arm. Criteria II.A.1. updated to align with ASPS guidance regarding length of time gynecomastia persists in adolescents < 18 years. Criteria II.B.3. updated to align with ASPS guidance for length of time gynecomastia persists in adults ≥ 18 years. Removed Criteria II.B.6. regarding malignancy being ruled out. Minor rewording in background with no impact on criteria. ICD-10 codes removed. References reviewed and updated. Reviewed by internal specialist and external specialist. |
CP.MP.182 | Short Inpatient Hospital Stay | Annual review completed. Updated hyperlink to CMS inpatient only list in Criteria I.A. Added option in I.A. for procedure to be listed as an inpatient-only procedure in InterQual for those under 18 years of age, and noted that the CMS inpatient only list applies to those 18 years of age and older. Minor rewording with no clinical significance. References reviewed and updated. Internal specialist reviewed. |
CP.BH.100 | Substance Use Disorder Treatment and Services | Policy Retired |
WA.CP.BH.200 | Transcranial Magnetic Stimulation for Treatment Resistant Major Depression | Typos corrected |
CP.MP.169 | Trigger Point Injections for Pain Management | Annual review completed. Minor rewording with no clinical significance. Background updated. ICD-10 Diagnosis code table removed. References reviewed and updated. |
CP.MP.12 | Vagus Nerve Stimulation | Annual review completed. Removed II.B. “Obesity”. Additional minor rewording with no clinical significance. Background updated; moved “Removal of implant” section to background. ICD-10 Diagnosis code table removed. References reviewed and updated. External specialist reviewed. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.14 | Cochlear Implant Replacements | Annual review completed. Changed verbiage in I.C. from “A sound processor replacement if the current processor is at least five years old” to “C. The existing component has reached the limit of its reasonable useful life. The reasonable useful life of a sound processor is not less than five years”. Minor rewording with no clinical significance. Background updated with no impact to criteria. ICD-10-CM Diagnosis Code table removed. References reviewed and updated. External specialist reviewed. |
WA.CP.MP.514 | Extra-Corporeal Membrane Oxygenation Therapy (ECMO) | Annual review. References updated. |
CP.MP.137 | Fecal Incontinence Treatments | Annual review. Removed “≥ 4 years age” criteria and added “in a member/enrollee that has previously achieved bowel control” to I.A. Also removed “more than twelve months after vaginal childbirth” from definition of severe, chronic fecal incontinence in I.A. Description and background section updated with no clinical significance. References reviewed and updated. External specialist reviewed. |
WA.CP.MP.54 | Hospice Services | References updated. Background information updated. Removed statement regarding previous investigational treatment from Initial Request paragraph. Updated Initial Request Section I. language to correspond to HCA billing guidelines. Updated Initial and Subsequent Request sections II. Continuous Homecare and General Inpatient descriptions to correspond to HCA billing guidelines. Removed debility and failure to thrive exclusion from section III. Updated section III. D. language re: hospice discharge per HCA billing guidelines. Covered and non-covered services sections updated to correspond to HCA billing guidelines. |
CP.MP.127 | Total Artificial Heart | Annual review. Removed criteria III. Updated background with no clinical significance. Removed ICD-10 code table. References reviewed and updated. |
WA.CP.BH.200 | Transcranial Magnetic Stimulation for Treatment Resistant Major Depression | New policy. |
WA.CP.MP.522 | Varicose Vein Treatment | Annual review. References reviewed and updated. Section I. medical necessity criteria revised to align with HTA/HCA billing guidelines. Removed ligation/stripping procedures from policy description and criteria. Added note below section II. regarding use of InterQual criteria for review of ligation/stripping procedures. Removed ligation procedure codes 37780 and 37785 from CPT code table. Updated section B. contraindications to correspond to HTA/billing guidelines and current corporate sclerotherapy/EVLA policy CP.MP.146. Updated section C. Venaseal requirements per CP.MP.146. Background updated with no impact on criteria. . Removed table of codes that do not support medical necessity. |
V2.2023 | CG Aortopathies and Connective Tissue Disorders | Annual review. Policy number change from CP.MP.215 |
V2.2023 | CG Cardiac Disorders | Annual review. Policy number change from CP.MP.216 |
V2.2023 | CG Dermatologic Conditions | Annual review. Policy number change from CP.MP.217 |
V2.2023 | CG Epilepsy Neurodegenerative and Neuromuscular Conditions | Annual review. Policy number change from CP.MP.218 |
V2.2023 | CG Exome and Genome Sequencing for DX of Genetic Disorders | Annual review. Policy number change from CP.MP.219 |
V2.2023 | CG Eye Disorders | Annual review. Policy number change from CP.MP.220 |
V2.2023 | CG Gastroenterologic Disorders Non-cancerous | Annual review. Policy number change from CP.MP.221 |
V2.2023 | CG General Approach to Genetic Testing | Annual review. Policy number change from CP.MP.222 |
V2.2023 | CG Hearing Loss | Annual review. Policy number change from CP.MP.223 |
V2.2023 | CG Hematologic Conditions Non-cancerous | Annual review. Policy number change from CP.MP.224 |
V2.2023 | CG Hereditary Cancer Susceptibility | Annual review. Policy number change from CP.MP.225 |
V2.2023 | CG Immune Autoimmune and Rheumatoid Disorders | Annual review. Policy number change from CP.MP.226 |
V2.2023 | CG Kidney Disorders | Annual review. Policy number change from CC.MP.227 |
V2.2023 | CG Lung Disorders | Annual review. Policy number change from CC.MP.228 |
V2.2023 | CG Metabolic Endocrine Mitochondrial Disorders | Annual review. Policy number change from CP.MP.229 |
WA.CP.MP.230 | CG Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay | Annual review. |
WA.CP.MP.231 | CG Non-Invasive Prenatal Screening | Annual review. |
V2.2023 | CG Oncology Algorithmic Testing | Annual review. Policy number change from CP.MP.237 |
V2.2023 | CG Oncology Cancer Screening | Annual review. Policy number change from CP.MP.238 |
V2.2023 | CG Oncology Circulating Tumor DNA Tumor Cells Liquid Biopsy | Annual review. Policy number change from CP.MP.239 |
V2.2023 | CG Oncology Cytogenetic Testing | Annual review. Policy number change from CP.MP.240 |
V2.2023 | CG Oncology Molecular Analysis Solid Tumors & Hematolgic Malignancies | Annual review. Policy number change from CP.MP.241 |
V2.2023 | CG Pharmacogenetics | Annual review. Policy number change from CP.MP.232 |
V2.2023 | CG Preimplantation Genetic Testing | Annual review. Policy number change from CP.MP.233 |
V2.2023 | CG Prenatal and Preconception Carrier Screening | Annual review. Policy number change from CP.MP.234 |
V2.2023 | CG Prenatal Diagnosis Pregnancy Loss | Annual review. Policy number change from CP.MP.235 |
V2.2023 | CG Skeletal Dysplasia Rare Bone Disorders | Annual review. Policy number change from CP.MP.236 |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.93 | Bone-anchored Hearing Aid | Annual review. Removed Criteria II. stating "BAHAs for any other indication are considered not medically necessary." Updated background with no clinical significance. Added new CPT codes 69728, 69729, and 69730 and removed ICD-10 codes from policy. References reviewed and updated. Reviewed by external specialist. |
CP.MP.94 | Clinical Trials | Annual review completed; policy reformatted. Minor rewording with no clinical significance. References reviewed and updated. |
CP.MP.115 | Discography | Annual review. Background updated with no impact on criteria. References reviewed and updated. |
CP.MP.248 | Facility-Based Sleep Studies for Obstructive Sleep Apnea | Revised criteria III.B. by removing requirement to meet criteria for facility-based sleep study and rewording failed APAP trial statement. |
CP.MP.184 | Home Ventilators | Annual review completed. Minor rewording with no clinical significance. Background updated with no clinical significance. References reviewed and updated. |
CP.MP.249 | Omisirge (omidubicel): Nicotinamide-modified allogeneic hematopoietic progenitor cell therapy | New Policy |
CP.MP.49 | Physical, Occupational and Speech Therapy Services | Annual review. Minor rewording throughout Criteria section with no impact on policy criteria. Removed Criteria I.F.6.a. and added as a notation. Added Criteria I.F.8. that member/enrollee agrees to participation and plan of care. Added Criteria I.H. and Criteria II.B. regarding treatment to be performed in the home. Removed Criteria V. and Criteria VI. Background updated with no impact on criteria. References reviewed and updated. Reviewed by internal specialist. |
CP.MP.142 | Urinary Incontinence Devices and Treatments | Removed continence support pessaries from criteria I.D.1. Revised order in which conservative therapies are listed in I.D.2. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.BH.104 | Applied Behavior Analysis | New Policy |
WA.CP.BH.104 | Applied Behavior Analysis | Policy archived |
CP.MP.164 | Caudal or Interlaminar Epidural Steroid Injections for Pain Management | Policy archived |
NIA_CG_300 | Epidural Spine Injections | New Policy on NIA site |
NIA_CG_301 | Facet Joint Injections | New Policy on NIA site |
NIA_CG_302 | Facet Joint Denervation | New Policy on NIA site |
WA.CP.MP.171 | Facet Joint Interventions for Pain Management | Policy archived |
WA.CP.BH.506 | Psychological Testing | Annual review. Renumbered policy from WA.CP.MP.506 to WA.CP.BH.506. Replaced “member” with “member/enrollee’ in all instances. References updated. |
CP.MP.166 | Sacroiliac Joint Interventions for Pain Management | Policy archived |
NIA_CG_305 | Sacroiliac Joint Injection | New Policy on NIA site |
CP.MP.165 | Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management | Policy archived |
WA.CP.MP.248 | Sleep Apnea Diagnosis and Treatment | Policy archived |
CP.BH.200 | Transcranial Magnetic Stimulation for Treatment Resistant Major Depression | Ad hoc Review. Policy restructured. Added additional information to the description section with no impact to the policy. Replaced all instances of the statement “It is the policy of health plans affiliated with Centene Corporation®” with “It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation”. Deleted criteria point I.D as the information was redundant to I.B. In criteria subsection I.I. (5), clarified that three months or less of remission constitutes a contraindication. Added the statement “requests for 6 tapered final sessions of TMS (over a 3-week period)” to the revised criteria point II. Added criteria point II.A to indicate that “all initial criteria must be met prior to request for additional sessions”. Deleted what was criteria III as the information was redundant to criteria II. In criteria section III, replaced “maintenance treatment with TMS is not medically necessary, as there is insufficient evidence in the published peer reviewed literature to support it” with “It is the policy of health plans affiliated with Centene Corporation that maintenance treatment with TMS is not medically necessary, as there is insufficient evidence in the published peer reviewed literature to support it”. Added criteria point IV.A to indicate that “criteria for initial TMS treatment guidelines continues to be met”. Added semicolons throughout the criteria section. References reformatted. Replaced all instances of “dashes (-) in page numbers to the word “to”. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
WA.CP.MP.37 | Bariatric Surgery | Annual review. Updated policy format. Updated policy statement in I, I.A.1, and I.A.1.a. In I.A.1.a.i updated policy statement and BMI threshold to ≥ 35 or ≥ 32.5 kg/m2 for South Asian, Southeast Asian, and East Asian adults. In I.A.1.a.ii BMI threshold was updated to "BMI ≥ 30 and < 35 kg/m², or < 27.5 kg/m2 and < 32.5 kg/m2 for South Asian, Southeast Asian, and East Asian adults and policy statements in I.A.1.a.ii, I.A.1.a.ii.a), and c). Moved Type 2 diabetes mellitus (DM) to I.A.1.a.ii.b) as an absolute co-morbidity. Added "pseudotumor cerebri" and "disqualification from other surgeries..." to I.A.1.a.ii.c). Updated policy statement in I.A.1.b.ii. Updated I.B.2 to "Glycemic control evaluation to include A1c and fasting blood glucose". Removed criteria I.B.5.c. requiring prescribed exercise program as part of nutritional counseling. Moved IV. Contraindications to I.C and added "severe cardiac disease with prohibitive anesthetic risks," "uncontrolled and untreated eating disorders (eg, bulimia)," "inability on the part of the patient or parent/guardian to comprehend the risks and benefits of the surgical procedure," and "a medical, psychiatric, psychosocial, or cognitive condition that prevents adherence to postoperative dietary and medication regimens or impairs decisional capacity." Background updated with no clinical impact. Removed deleted CPT codes 0312T- 0317T and added CPT codes 43290, 43291, and 43632 to not medically necessary table. Removed ICD-10 codes and table. References reviewed and updated. Reviewed by internal and external specialists. Section III: updated abbreviations in III.3 with no clinical significance; added indication for SG to RYGB or BPD-DS DS as a bridging procedure for BMI ≥ 50 kg/m² in III.4. |
CP.MP.107 | Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines | Annual review. Updated policy statement in I. and added general criteria I.A.1. and I.A.2. Removed ambulatory assist products and updated I.B. policy table. Retired gait trainers and standing frame criteria, defer to standard IQ criteria. Updated pneumatic compression device criteria and added non-pneumatic compression device criteria. Added "one month’s rental for a standard manual wheelchair is considered medically necessary if a member/enrollee owned wheelchair is being repaired" to wheelchair repair. Added foot orthotics, custom criteria and codes. Removed "male" from male vacuum erection device. Added criteria section for walkers. Minor verbiage and formatting updates with no impact on criteria. References reviewed, updated, and reformatted. Internal specialist review. |
CP.MP.106 | Endometrial ablation | Annual review completed. Added requirement in I.F. that thyroid disorders have been treated or ruled out. Removed contraindication “previous classic cesarean or other transmural surgery” from I.G. Background and Table 1 updated. Minor rewording with no clinical significance. References reviewed and updated. Internal specialist reviewed. |
CP.MP.121 | Homocysteine Testing | Annual review. References reviewed and updated. |
WA.CP.MP.505 | Microprocessor Controlled Lower Limb Prosthetics | Annual review. References updated. Removed HCPCS L2006 and L5973 as these services are not covered by HCA. |
CP.MP.242 | Pulmonary Function Testing | Annual review. Updated Criteria I.B.1. to include type and degree of pulmonary dysfunction. Minor rewording to Criteria I.B.2. and I.B.4. without clinical significance. Minor rewording to Criteria C. Background updated with no impact on criteria. References reviewed and updated. |
WA.CP.MP.517 | Testosterone Testing | Annual review. Reference updated. Grammatical changes to mirror billing guideline. |
CP.MP.247 | Transplant Service Documentation Requirements | New policy |
WA.CP.MP.520 | Tympanostomy Tubes in Children | Annual review. References updated. Criteria updated to mirror billing guideline. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
WA.CP.MP.519 | Administrative Days | Added section III for Newborn Subsequent Days. References updated. |
WA.CP.BH.521 | Behavioral Health Personal Care Services | Annual review. Changed policy number from WA.CP.MP.521 to WA.CP.BH.521. References updated. |
WA.CP.MP.502 | Cochlear Implants: Bilateral vs. Unilateral | Annual review. references updated. Removed L8614. |
WA.CP.MP.501 | Continuous Glucose Monitoring | Annual review. References updated. Updated all HCPCS |
CP.MP.34 | Hyperemesis Gravidarum Treatment | Policy archived |
CP.MP.180 | Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea | Annual review completed. I.C. Changed BMI to 35 kg/m2; I.E. Adjusted AHI to ≥15 to ≤ 65 events per hour; I.F.1. Adjusted 20 to 15. Added criteria I.I.5. and I.I.8. through 14. Background updated and minor rewording with no clinical significance. Added CPT codes 64582, 64583, and 64584. Removed CPT codes 0466T, 0467T, 0468T, 61886, 61888, 64568, 64569, 64570, and 64585. |
CP.MP.57 | Lung Transplantation | Annual review. Criteria I.C.14. updated to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. Added pediatric indication for end-stage emphysema due to alpha-1 trypsin deficiency. ICD-10 codes removed. References reviewed and updated. Reviewed by external specialist |
CP.MP.85 | Neonatal Sepsis Management | Annual review completed. Description and background updated. Minor rewording with no clinical significance. References reviewed and updated. |
CP.MP.81 | NICU Discharge Guidelines | Annual review. Updated the note in section II. from "1800 grams” to “1600 to 1800 grams.” References reviewed and updated. Reviewed by external specialist. |
CP.MP.141 | Non-Myeloablative Allogenic Stem Cell Transplants | Annual review completed. Criteria I.C.4. updated to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. Background updated; minor rewording with no clinical significance. ICD-10 diagnosis code table removed. References reviewed and updated. |
WA.CP.MP.503 | Private Duty Nursing Services | Annual review. Added HCA definition of Private Duty Nursting to the Description section. Added minimum hours to section I. Updated sections II.A and II.B to add clarity and examples. Reworded III.A. to add billing instructions for patient’s home in addition to the instructions for billing when in a group home. Clarified billing instructions in IV. Updated references. |
CP.MP.187 | Radiofrequency Ablation of Uterine Fibroids | Policy archived |
CP.MP.151 | Transcatheter Closure of Patent Foramen Ovale | Annual review. Updated description to include newest FDA-approved device: AmplatzerTM TalismanTM PFO Occluder. Clarfied in I.B. that age requirements are in years. Updated Criteria I.B. # 2 to state that cryptogenic stroke caused by a presumed paradoxical embolism, and a possible, probable, or definite likelihood that the stroke was causally related to PFO based on the PFO-associated stroke causal likelihood (PASCAL) classification system with a Risk of Paradoxical Embolism (RoPE) score > 6, and/or there is a large shunt or atrial septal aneurysm. Updated Criteria to include Criteria C. Device is FDA-approved for percutaneous transcatheter closure of PFO (eg AmplatzerTM PFO Occluder, AmplatzerTM TalismanTM PFO Occluder, and the Gore® Cardioform Septal Occluder). Background updated and includes information on PASCAL classification system and RoPE score. Removed ICD-10 codes. References reviewed and updated. Reviewed by internal specialist and external specialist. |
WA.CP.MP.46 | Ventricular Assist Devices | Annual review. Background and note updated with no clinical significance. Section III reworded. Removed ICD codes. References updated. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.BH.500 | Behavioral Health Treatment Document Requirements | Edited policy statement I to apply to Centene Advanced Behavioral Health as well as plans affiliated with Centene. |
NIA.CG.062 | CT Coronary Angiography | Added the following statement, "Low probability patients will be directed to exercise stress test over CCTA unless other criteria for imaging studies are met." |
WA.CP.MP.515 | Fecal Microbiota Transplantation | Annual review. Updated references |
CP.MP.136 | Home Births | Annual review completed. Removed criteria II. regarding all other indications not medically necessary. Minor rewording with no clinical significance. ICD-10 codes removed. References reviewed and updated. Internal and external specialist reviewed. |
CP.MP.62 | Hyperhidrosis Treatments | Annual review. Updated Criteria II.B. to greater than 55 beats per minute. Removed “is relatively healthy” in criteria II.F. Background updated with no impact on criteria. ICD-10 codes removed. References reviewed and updated. |
CP.MP.173 | Implantable Intrathecal or Epidural Pain Pump | Annual review. References reviewed and updated. ICD-10 code table removed. Minor rewording with no clinical significance. Reviewed by external specialist. |
CP.MP.202 | Orthognathic Surgery | Annual review completed. Reformatted criteria II. and added II.B. as additional non-medically necessary indication. Additional minor rewording with no clinical significance. Background updated. CDT codes removed from policy. References revised and updated. Reviewed by external and internal specialists. |
CP.MP.150 | Phototherapy for Neonatal Hyperbilirubinemia | Annual review. Changed title from “Home phototherapy…” to “Phototherapy…” Updated criteria I.D. from 24-48 hours to 12-24 hours. Updated criteria to include the following: I.E. ≥48 hours old; I.F. An LED-based phototherapy device will be available in the home without delay; I.G. No previous phototherapy; I.H. TSB will be measured daily. Criteria I.I. #1 updated to include example of positive direct antiglobulin test for isoimmune hemolytic disease and to include glucose-6-phosphate dehydrogenase (G6PD) and other hemolytic disease. Criteria I.I. #2 updated to include hypoxic ischemia encephalopathy (HIE). Significant lethargy removed from Criteria I.I. Criteria I.I. updated to include the following: #13 Significant clinical instability in the previous 24 hours; #14 Clinical history of a parent or sibling requiring phototherapy or exchange transfusion; #15 Exclusive breastfeeding with suboptimal intake (≥10% weight loss); #16 Down syndrome; #17 Macrosomic infant of a diabetic mother. Added note below Table 1 that explains the values are conservative TSB values based on lower age range thresholds in inpatient criteria. Added clarification to II that extenuating circumstances can include lack of expected compliance with therapy at home. Added note below policy statement II stating: that infants should be admitted for inpatient phototherapy if the TSB concentration is more than 1 mg/dL above the AAP guidelines phototherapy treatment threshold per the bili risk tool, and that table 1 is consistent with AAP guidelines allowing treatment at lower levels per provider discretion; and that clinical decision support tools provider further criteria for inpatient phototherapy treatment. Updated background to include 2022 AAP clinical practice guidelines. Removed ICD-10 codes. References reviewed and updated. Reviewed by internal specialist and external specialist. |
WA.CP.MP.248 | Sleep Apnea Diagnosis and Treatment | Updated policy to reflect new Centene policy: significant changes to section I.B. and change in policy numbering from WA.CP.MP.523 to WA.CP.MP.248. Updated section II.A. to reflect consideration of titration studies. Added coverage statement about actigraphy. Added code 95803 to code list. Minor changes to company name. Updated references. |
WA.CP.MP.526 | Stem Cell Therapy for Musculoskeletal Conditions | Annual review. Updated references. Added CPT codes 38230 and 38232 and HCPCS code S2150. |
CP.MP.22 | Stereotactic Body Radiation Therapy | Annual review completed. Added I.F. “Recurrent malignant disease requiring palliation and/or as palliative treatment for liver-related symptoms”. Added I.J. “Extracranial oligometastatic disease: 1.One to three metastatic lesions involving the lungs, liver or bone; 2.Primary tumor is breast, colorectal, melanoma, non-small cell lung, prostate, renal cell, or sarcoma; 3.Primary tumor is controlled 4.No prior history of metastatic disease”. Background updated and minor rewording with no clinical significance. ICD-10 Code table removed. References reviewed and updated. Reviewed by external specialist. |
CP.BH.100 | Substance Use Treatment and Services | Ad-hoc review. Edited policy statement I. to note that it applies to health plans affiliated with Centene Corporation as well as CABH. Replaced all instances of “dashes (-)” in the CPT codes with the word “through”. Replaced all instances of “dashes (-) in page numbers to the word “to”. |
CP.MP.162 | Tandem Transplant | Annual review. References reviewed and updated. ICD-10 codes removed. Review completed by external specialist. Minor background edits with no change to criteria. |
WA.CP.MP.510 | Tinnitus Treatment | Annual review. Replaced all instances of “members” with “members/enrollees”. Added “repetitive” to transcranial magnetic stimulation in 2.B. Updated references. |
Policy Number | Policy Title | Revision Notes |
---|---|---|
WA.CP.MP.525 | Catheter Ablation for Supraventricular Tachyarrhythmia | Annual review. References updated. Removed CPT 93650 |
CP.MP.203 | Diaphragmatic/Phrenic Nerve Stimulation | Annual review. Criteria II.A.1.c. and Criteria II.A.2.b. updated to include “or by other radiographic techniques such as ultrasound” in addition to fluoroscopy. Background updated to include U.S. Food and Drug Administration premarket approval information regarding the Avery Spirit Diaphragm Pacing Transmitter. ICD-10 codes removed. References reviewed and updated. Reviewed by external specialist. |
WA.CP.MP.54 | Hospice Services | Annual review. References updated. Reworded description of Pediatric Palliative Care. |
WA.CP.MP.69 | Intensity-Modulated Radiotherapy | Annual review. Updated references. Removed CPT 77370. |
WA.CP.MP.500 | Mandibular Advancement Devices | Annual review. Reference updated. |
CP.MP.138 | Pediatric Heart Transplant | Annual review. Appendix A tables updated to remove dashes. Removed ICD-10 codes. References reviewed and reformatted. |
CP.MP.246 | Pediatric Kidney Transplant | New policy |
WA.CP.MP.117 | Percutaneous Electrical and Peripheral Nerve Stimulation | Policy renumbered WA.CP.MP.117. References to spinal cord stimulation removed. |
CP.MP.242 | Pulmonary Function Testing | New policy |
Policy Number | Policy Title | Revision Notes |
---|---|---|
CP.MP.186 | Burn Surgery | Annual review completed. Background updated and minor rewording with no clinical significance. References reviewed, reformatted and updated. |
CP.MP.131 | Essure Removal | Policy retired |
CP.MP.209 | Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing | Removed deleted code 0097U |
WA.CP.MP.70 | Proton and Neutron Beam Therapy | Annual review completed. Removed “treated in a hypofractionated regimen” from I. D. Background updated and minor rewording with no clinical significance. References reviewed, reformatted and updated. External specialist reviewed. |
CP.MP.182 | Short Inpatient Hospital Stay | Annual review. Added I.C. “Acute hospital care at home.” Background updated with no clinical significance. References reviewed and updated. |
CP.MP.142 | Urinary Incontinence Devices and Treatments | Annual review. Updated criteria section to clarify abbreviations. Criteria I.D. # 1 updated to include continence-support pessaries as a conservative measure. Updated background with no impact on criteria. Removed ICD-10 codes. References reviewed and updated. |