Clinical, Payment & Pharmacy Policies
To view Superior's latest Clinical and Payment Policy news updates, please visit Superior's Provider News and Information webpage.
Please note: To see historical policy revisions to currently posted policies, please review the Revision Log included in each policy.
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 Superior HealthPlan Clinical Policy Manual apply to Superior HealthPlan members. Policies in the Superior HealthPlan Clinical Policy Manual may have either a Superior HealthPlan or a “Centene” heading. Superior HealthPlan utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Superior HealthPlan 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 Superior HealthPlan. In addition, Superior HealthPlan 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 Superior HealthPlan.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
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 Superior HealthPlan Payment Policy Manual apply with respect to Superior HealthPlan members. Policies in the Superior HealthPlan Payment Policy Manual may have either a Superior HealthPlan or a “Centene” heading. In addition, Superior HealthPlan 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 Superior HealthPlan.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Biopharmacy policies are used to help identify whether clinician administered drugs (CAD) are medically necessary. Pharmacy policies are used to help identify whether medications dispensed by pharmacies and billed through the pharmacy benefit are medically necessary. The criteria used are based on information found in generally accepted standards of medical and pharmacy 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 such as but not limited to the drug package insert. Pharmacy and biopharmacy policies are reviewed and approved by the Superior Pharmacy and Therapeutic (P&T) Committee prior to use. This webpage lists biopharmacy policies for Medicaid and biopharmacy and pharmacy policies for Ambetter.
Consistent with guidance issued by Texas Medicaid for Clinician Administered Drugs (CAD) and the regulation at 42 CFR §438.210 and 42 CFR §457.1230(d), Superior HealthPlan does not use any standard for determining medical necessity that is more restrictive than what is developed by the Vendor Drug Program. For more details on the clinical policy and prior authorization requirements, please review the Outpatient Drug Services Handbook located at: https://www.tmhp.com/resources/provider-manuals/tmppm.
Superior routinely reviews the TMPPM to ensure any of our clinical policies for medical necessity are not more restrictive than what is provided for fee-for-service with regards to amount, duration and scope of service.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Pharmacy department.If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Pharmacy department.
Effective Policies
Ambetter from Superior HealthPlan Policies
- Air Amulance (CP.MP.92) (PDF)
- Allergy Testing (TX.CP.MP.100) (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-Thalassemia (CP.MP.108) (PDF)
- Antithrombin III (Thrombate III, Atryn) (CP.MP.179) (PDF)
- Applied Behavioral Analysis for Autism (CP.BH.104) (PDF)
- Bone-anchored Hearing Aid (CP.MP.93) (PDF)
- Bronchial Thermoplasty (CP.MP.110) (PDF)
- Burn Surgery (CP.MP.186) (PDF)
- Caudal or Interlaminar Epidural Steroid Injections for Pain Management (CP.MP.164) (PDF)
- Cell-free Fetal DNA Testing (CP.MP.84) (PDF)
- Cochlear Implant Replacements (CP.MP.14) (PDF)
- Cosmetic and Reconstructive Procedures (CP.MP.31) (PDF)
- Deep Transcranial Magnetic Stimulation For OCD (CP.BH.201) (PDF)
- Dental Anesthesia (CP.MP.61) (PDF)
- Diaphragmatic/Phrenic Nerve Stimulation (CP.MP.203) (PDF)
- Donor Lymphocyte Infusion (CP.MP.101) (PDF)
- Drugs of Abuse: Presumptive Testing (CP.MP.208) (PDF)
- Durable Medical Equipment (DME) (CP.MP.107) (PDF)
- Electric Tumor Treating Fields (Optune) (CP.MP.145) (PDF)
- Essure Removal (CP.MP.131) (PDF)
- Experimental Technologies (CP.MP.36) (PDF)
- Facet Joint Interventions for Pain Management (CP.MP.171) (PDF)
- Fecal Incontinence Treatments (CP.MP.137) (PDF)
- Fertility Preservation (CP.MP.130) (PDF)
- Fetal Surgery In Utero (CP.MP.129) (PDF)
- Fixed Wing Air Transportation (CP.MP.175) (PDF)
- Functional MRI (CP.MP.43) (PDF)
- Gastric Electrical Stimulation (CP.MP.40) (PDF)
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (CP.MP.209) (PDF)
- Gender-Affirming Procedures (CP.MP.95) (PDF)
- Genetic and Pharmacogenetic Testing (CP.MP.89) (PDF)
- Heart-Lung Transplant (CP.MP.132) (PDF)
- Home Births (CP.MP.136) (PDF)
- Home Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150) (PDF)
- Hospice Services (CP.MP.54) (PDF)
- Hyperemesis Gravidarum Treatment (CP.MP.34) (PDF)
- Hyperhidrosis Treatments (CP.MP.62) (PDF)
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (CP.MP.180) (PDF)
- Implantable Intrathecal Pain Pump (CP.MP.173) (PDF)
- Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Intestinal and Multivisceral Transplant (CP.MP.58) (PDF)
- Intradiscal Steroid Injections for Pain Management (CP.MP.167) (PDF)
- Lung Transplantation (CP.MP.57) (PDF)
- Lysis of Epidural Lesions (CP.MP.116) (PDF)
- Mechanical Stretching Devices for Joint Stiffness (CP.MP.144)
- Multiple Sleep Latency Testing (CP.MP.24) (PDF)
- NICU Apnea Bradycardia Guidelines (CP.MP.82) (PDF)
- NICU Discharge Guidelines (CP.MP.81) (PDF)
- Neonatal Abstinence Syndrome Guidelines (CP.MP.86) (PDF)
- Neonatal Sepsis Management Guidelines (CP.MP.85) (PDF)
- Nerve Blocks for Pain Management (CP.MP.170) (PDF)
- Neuromuscular Electrical Stimulation (CP.MP.48)
- Non-Invasive Home Ventilator (CP.MP.184) (PDF)
- Non-myeloablative Allogeneic Stem Cell Transplants (CP.MP.141) (PDF)
- Obstetrical Home Health Care Programs (CP.MP.91) (PDF)
- Osteogenic Stimulation (CP.MP.194)
- Outpatient Cardiac Rehabilitation (CP.MP.176) (PDF)
- Outpatient Testing for Drugs of Abuse (CP.MP.50) (PDF)
- Oxygen Use and Concentrators (CP.MP.190) (PDF)
- Pancreas Transplantation (CP.MP.102) (PDF)
- Panniculectomy (CP.MP.109) (PDF)
- Pediatric Heart Transplant (CP.MP.138) (PDF)
- Pediatric Liver Transplant (CP.MP.120) (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (CP.MP.133) (PDF)
- Private Duty Nursing (TX.CP.MP.520) (PDF)
- Proton and Neutron Beam Therapies (CP.MP.70) (PDF)
- Radiofrequency Ablation of Uterine Fibroids (CP.MP.187) (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF)
- Renal Hemodialysis (CC.PP.067) (PDF)
- Sacroiliac Joint Interventions for Pain Management (CP.MP.166) (PDF)
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins (CP.MP.146) (PDF)
- Selective Dorsal Rhizotomy (CP.MP.174) (PDF)
- Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (CP.MP.165) (PDF)
- Short Inpatient Hospital Stay (CP.MP.182) (PDF)
- Sickle Cell Disease Observation (CP.MP.88) (PDF)
- Skin Substitutes for Chronic Wounds (CP.MP.185) (PDF)
- Spinal Cord Stimulation (CP.MP.117) (PDF)
- Stereotactic Body Radiation Therapy (CP.MP.22) (PDF)
- Tandem Transplant (CP.MP.162) (PDF)
- Testing for Select Genitourinary Conditions (CP.MP.97) (PDF)
- Therapy Services (PT/OT/ST) (CP.MP.49) (PDF)
- Total Artificial Heart (CP.MP.127) (PDF)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (CP.MP.163) (PDF)
- Transcatheter Closure of Patent Foramen Ovale (CP.MP.151) (PDF)
- Transcranial Magnetic Stimulation (CP.BH.200) (PDF)
- Trigger Point Injections for Pain Management (CP.MP.169) (PDF)
- Urinary Incontinence Devices and Treatments (CP.MP.142) (PDF)
- Vagus Nerve Stimulation (CP.MP.12) (PDF)
- Ventricular Assist Devices (CP.MP.46) (PDF)
- Wheelchair Seating (CP.MP.99) (PDF)
- 340B Drug Payment Reduction (CC.PP.070) (PDF)
- Add on Code Billed Without Primary Code (CC.PP.030) (PDF)
- ADHD Assessment and Treatment (TX.CP.MP.124) (PDF)
- Allergy Testing (TX.CP.MP.100) (PDF)
- Assistant Surgeon (CC.PP.029) (PDF)
- Bilateral Procedures (CC.PP.037) (PDF)
- Bronchial Thermoplasty (CP.MP.110) (PDF)
- Cardiac Biomarker Testing for Acute MI (CP.MP.156) (PDF)
- Cerumen Removal (CC.PP.008) (PDF)
- Clinical Validation of Modifier 25 (CC.PP.013) (PDF)
- Clinical Validation of Modifier 59 (CC.PP.014) (PDF)
- Code Editing Overview (CC.PP.011) (PDF)
- Cosmetic Procedures (CC.PP.024) (PDF)
- Diagnostic Testing Guidelines for 2019-Novel Coronavirus (CP.MP.183) (PDF)
- Digital Analysis of EEGs (CP.MP.105) (PDF)
- Distinct Procedural Modifiers (CC.PP.020) (PDF)
- Drugs of Abuse: Presumptive Testing (CP.MP.208) (PDF)
- Duplicate Primary Code Billing (CC.PP.044) (PDF)
- E&M Bundling with Lab-Radiology (CC.PP.010) (PDF)
- E&M Medical Decision-Making (CC.PP.051) (PDF)
- EEG in Evaluation of Headache (CP.MP.155) (PDF)
- Endometrial Ablation (EA) (CP.MP.106) (PDF)
- Enhanced Code Editing (TX.PP.011-A) (PDF)
- EpiFix Wound Treatment (CP.MP.140) (PDF)
- Evaluation and Management (E/M) Services Billed with Treatment Room Revenue Codes (CC.PP.071) (PDF)
- Evoked Potentials (CP.MP.134) (PDF)
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (CP.MP.209) (PDF)
- Genetic and Molecular Testing Services (TX.PP.551) (PDF)
- Global Maternity Billing (CC.PP.016) (PDF)
- H Pylori Testing (CP.MP.153) (PDF)
- Holter Monitors (CP.MP.113) (PDF)
- Home Births (CP.MP.136) (PDF)
- Homocysteine Testing (CP.MP.121) (PDF)
- Hospital Visit Codes Billed with Labs (CC.PP.023) (PDF)
- Inpatient Only Procedures (CC.PP.018) (PDF)
- Intravenous Hydration (CC.PP.012) (PDF)
- Laser Skin Treatment (CP.MP.123) (PDF)
- Leveling of Emergency Room Services - Professional (CC.PP.053) (PDF)
- Leveling of Emergency Room Services - Facility (CC.PP.064)
- Maximum Units of Service (CC.PP.007) (PDF)
- Measure Serum 1,25 Vitamin D (CP.MP.152) (PDF)
- Mechanical Stretch Devices (CP.MP.144) (PDF)
- Moderate Conscious Sedation (CC.PP.015) (PDF)
- Modifier DOS Validation (CC.PP.034) (PDF)
- Modifier to Procedure Code Validation (CC.PP.028) (PDF)
- Multiple CPT Code Replacement (CC.PP.033) (PDF)
- Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular Procedures (CC.PP.065) (PDF)
- NCCI Unbundling (CC.PP.031) (PDF)
- Never Paid Events (CC.PP.017) (PDF)
- New Patient (CC.PP.036) (PDF)
- Non-obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds (CC.PP.061) (PDF)
- Not Medically Necessary Inpatient Professional Services (CC.PP.060) (PDF)
- Outpatient Consultation (CC.PP.039) (PDF)
- Physician Visit Codes Billed with Labs (CC.PP.019) (PDF)
- Place of Service Mismatch (CC.PP.063) (PDF)
- Polymerase Chain Reaction (PCR) Testing (TX.PP.150) (PDF)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (CP.MP.181) (PDF)
- Post-Operative Visits (CC.PP.042) (PDF)
- Pre-Operative Visits (CC.PP.041) (PDF)
- Problem Oriented Visits Billed with Preventative Visits (CC.PP.057)
- Problem Oriented Visits Billed with Surgical Procedures (CC.PP.052)
- Professional Component Modifier (CC.PP.027) (PDF)
- PROM Testing (CP.MP.149) (PDF)
- Pulse Oximetry with Office Visits (CC.PP.025) (PDF)
- Renal Hemodialysis (CC.PP.067) (PDF)
- Robotic Surgery (CC.PP.050) (PDF)
- Same Day Visits (CC.PP.040) (PDF)
- Sleep Studies Place of Services (CC.PP.035) (PDF)
- Status "B" Bundled Services (CC.PP.046) (PDF)
- Status "P" Bundled Services (CC.PP.049) (PDF)
- Supplies Billed on Same Day As Surgery (CC.PP.032) (PDF)
- Testing for Select Genitourinary Conditions (CP.MP.97) (PDF)
- Thyroid Testing in Pediatrics (CP.MP.154) (PDF)
- Transgender Related Services (CC.PP.047) (PDF)
- Ultrasound in Pregnancy (CP.MP.38) (PDF)
- Unbundled Professional Services (CC.PP.043) (PDF)
- Unbundled Surgical Procedures (CC.PP.045) (PDF)
- Unlisted Procedure Codes (CC.PP.009) (PDF)
- Urine Specimen Validity Testing (CC.PP.056) (PDF)
- Urodynamic Testing (CP.MP.98) (PDF)
- Vitamin D Testing in Children (CP.MP.157) (PDF)
- Wheelchair and Accessories (CC.PP.502) (PDF)
- Wireless Motility Capsule (CP.MP.143) (PDF)
- Abaloparatide (Tymlos) (CP.PHAR.345) - Effective July 1, 2017 (PDF)
- Abametapir (Xeglyze) (CP.PMN.253) - Effective December 1, 2020 (PDF)
- Abemaciclib (Verzenio) (CP.PHAR.355) - Effective December 1, 2021 (PDF)
- Abiraterone (Zytiga, Yonsa) (CP.PHAR.84) - Effective November 17, 2020 (PDF)
- AbobotulinumtoxinA (Dysport) (CP.PHAR.230) - Effective November 1, 2021 (PDF)
- Aclidinium-formoterol (Duaklir Pressair) (HIM.PA.151) - Effective March 1, 2021 (PDF)
- Acyclovir Buccal Tablet (Sitavig) (CP.PMN.210) - Effective March 1, 2021 (PDF)
- Adefovir (Hepsera) (CP.PHAR.142) - Effective August 28, 2018 (PDF)
- Ado-Trastuzumab Emtansine (Kadcyla) (CP.PHAR.229) - Effective June 1, 2021 (PDF)
- Aducanumab-avwa (Aduhelm) (CP.PHAR.468) - Effective August 9, 2021 (PDF)
- Afamelanotide (Scenesse) (CP.PHAR.444) - Effective September 16, 2020 (PDF)
- Afatinib (Gilotrif) (CP.PHAR.298) - Effective January 1, 2017 (PDF)
- Aflibercept (Eylea) (CP.PHAR.184) - Effective October 4, 2021 (PDF)
- Agalsidase Beta (Fabrazyme) (CP.PHAR.158) - Effective December 1, 2021 (PDF)
- Age Limit Override (Codeine, Tramadol, Hydrocodone) (CP.PMN.138) - Effective March 13, 2018 (PDF)
- Alectinib (Alecensa) (CP.PHAR.369) - Effective November 16, 2016 (PDF)
- Alemtuzumab (Lemtrada) (CP.PHAR.243) - Effective February 1, 2021 (PDF)
- Alendronate (Binosto, Fosamax Plus D) (CP.PMN.88) - Effective March 1, 2018 (PDF)
- Alglucosidase Alfa (Lumizyme) (CP.PHAR.160) - Effective February 1, 2016 (PDF)
- Allogeneic cultured keratinocytes and dermal fibroblasts (StrataGraft) (CP.PHAR.562) - Effective March 1, 2022 (PDF)
- Allogenic processed thymus tissue-agdc (Rethymic) (CP.PHAR.563) - Effective March 1, 2022 (PDF)
- Alpelisib (Piqray) (CP.PHAR.430) - Effective 7/9/2019 (PDF)
- Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (CP.PHAR.94) - Effective March 1, 2012 (PDF)
- Amantadine ER (Gocovri,Osmolex ER) (CP.PMN.89) - Effective March 1, 2021 (PDF)
- Ambrisentan (Letairis) (CP.PHAR.190) - Effective March 1, 2016 (PDF)
- Amifampridine (Firdapse, Ruzurgi) (CP.PHAR.411) - Effective May 3, 2021 (PDF)
- Amikacin (Arikayce) (CP.PHAR.401) - Effective April 1, 2022 (PDF)
- Amisulpride (Barhemsys) (CP.PMN.236) - Effective September 1, 2021 (PDF)
- Amivantamab-vmjw (Rybrevant) (CP.PHAR.544) - Effective September 1, 2021 (PDF)
- Anifrolumab-fnia (Saphnelo) (CP.PHAR.551) - Effective December 1, 2021 (PDF)
- Anti-inhibitor Coagulant Complex (Feiba) (CP.PHAR.217) - Effective November 17, 2020 (PDF)
- Antithrombin III (ATryn, Thrombate III) (CP.PHAR.564) - Effective March 1, 2022 (PDF)
- Antithymocyte Globulin (Atgam, Thymoglobulin) (CP.PHAR.506) - Effective December 1, 2020 (PDF)
- Apalutamide (Erleada) (CP.PCH.45) - Effective August 2, 2021 (PDF)
- Apomorphine (Apokyn) (CP.PHAR.488) - Effective 11/17/2020 (PDF)
- Aprepitant (Cinvanti, Emend) (CP.PMN.19) - Effective November 1, 2006 (PDF)
- Arformoterol tartrate (Brovana) (CP.PMN.201) - Effective 9/1/2018 (PDF)
- Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada, Aristada Initio) (CP.PHAR.290) - Effective 11/17/2020 (PDF)
- Aripiprazole Orally Disintegrating Tab (CP.PCH.37) - Effective March 1, 2021 (PDF)
- Armodafinil (Nuvigil) (CP.PMN.35) - Effective December 1, 2020 (PDF)
- Asciminib (Scemblix) (CP.PHAR.565) - Effective March 1, 2022 (PDF)
- Asenapine (Saphris, Secuado) (CP.PMN.15) - Effective December 1, 2014 (PDF)
- Asfotase Alfa (Strensiq) (CP.PHAR.328) - Effective March 1, 2017 (PDF)
- Aspirin/Dipyridamole (Aggrenox) (CP.PMN.20) - Effective May 3, 2021 (PDF)
- Atezolizumab (Tecentriq®) (CP.PHAR.235) - Effective April 1, 2022 (PDF)
- Avacopan (Tavneos) (CP.PHAR.515) - Effective May 3, 2021 (PDF)
- Avalglucosidase alfa-ngpt (Nexviazyme) (CP.PHAR.521) - Effective December 1, 2021 (PDF)
- Avapritinib (Ayvakit) (CP.PHAR.454) - Effective April 1, 2022 (PDF)
- Avatrombopag (Doptelet) (CP.PHAR.130) - Effective November 17, 2020 (PDF)
- Avelumab (Bavencio) (CP.PHAR.333) - Effective April 1, 2022 (PDF)
- Axicabtagene Ciloleucel (Yescarta) (CP.PHAR.362) - Effective September 23, 2021 (PDF)
- Axitinib (Inlyta) (CP.PHAR.100) - Effective March 1, 2021 (PDF)
- Azacitidine (Onureg, Vidaza) (CP.PHAR.387) - Effective February 1, 2022 (PDF)
- Azelaic Acid (Finacea Topical Gel) (HIM.PA.119) - Effective December 1, 2021 (PDF)
- Aztreonam (Cayston) (CP.PHAR.209) - Effective May 3, 2021 (PDF)
- Baclofen (Gablofen, Lioresal, Ozobax) (CP.PHAR.149) - Effective February 1, 2022 (PDF)
- Baloxavir Marboxil (Xofluza) (CP.PMN.185) - Effective December 1, 2021 (PDF)
- Bamlanivimab-etesevimab (LY-CoV555-LY-CoV016) (CP.PHAR.532) - Effective December 1, 2021 (PDF)
- Bedaquiline (Sirturo) (CP.PMN.212) - Effective June 1, 2021 (PDF)
- Belantamab Mafodotin (Blenrep) (CP.PHAR.469) - Effective December 1, 2020 (PDF)
- Belatacept (Nulojix) (CP.PHAR.201) - Effective March 1, 2016 (PDF)
- Belimumab (Benlysta) (CP.PHAR.88) - Effective June 1, 2021 (PDF)
- Belinostat (Beleodaq) (CP.PHAR.311) - Effective December 1, 2020 (PDF)
- Belumosudil (Rezurock) (CP.PHAR.552) - Effective December 1, 2021 (PDF)
- Belzutifan (Welireg) (CP.PHAR.553) - Effective December 1, 2021 (PDF)
- Bempedoic acid (Nexletol), bempedoic acid-ezetimibe (Nexlizet) (CP.PMN.237) - Effective November 17, 2020 (PDF)
- Bendamustine (Bendeka, Treanda) (CP.PHAR.307) - Effective February 1, 2022 (PDF)
- Benralizumab (Fasenra) (CP.PHAR.373) - Effective June 1, 2018 (PDF)
- Benznidazole (CP.PMN.90) - Effective December 1, 2020 (PDF)
- Berotralstat (Orladeyo) (CP.PHAR.485) - Effective October 1, 2021 (PDF)
- Betaine (Cystadane) (CP.PHAR.143) - Effective August 28, 2018 (PDF)
- Betamethasone Dipropionate Spray (Sernivo) (CP.PMN.182) - Effective March 1, 2021 (PDF)
- Betibeglogene autotemcel (CP.PHAR.545) - Effective September 1, 2021 (PDF)
- Bevacizumab (Avastin, Mvasi, Zirabev) (CP.PHAR.93) - Effective February 1, 2022 (PDF)
- Bexarotene (Targretin Capsules, Gel) (CP.PHAR.75) - Effective June 1, 2021 (PDF)
- Bezlotoxumab (Zinplava) (CP.PHAR.300) - Effective November 16, 2016 (PDF)
- Bimatoprost Implant (Durysta) (CP.PHAR.486) - Effective June 1, 2021 (PDF)
- Binimetinib (Mektovi) (CP.PHAR.50) - Effective August 2, 2021 (PDF)
- Biologic DMARDs (HIM.PA.SP60) - Effective December 1, 2021 (PDF)
- Blinatumomab (Blincyto) (CP.PHAR.312) - Effective 9/16/2020 (PDF)
- Bortezomib (Velcade) (CP.PHAR.410) - Effective March 1, 2021 (PDF)
- Bosentan (Tracleer) (CP.PHAR.191) - Effective March 1, 2016 (PDF)
- Bosutinib (Bosulif) (CP.PHAR.105) - Effective August 2, 2021 (PDF)
- Brand Name Override and Non-Formulary Medications (HIM.PA.103) - Effective May 3, 2021 (PDF)
- Brentuximab Vedotin (Adcetris) (CP.PHAR.303) - Effective April 1, 2022 (PDF)
- Brexanolone (Zulresso) (CP.PHAR.417) - Effective June 1, 2019 (PDF)
- Brexpiprazole (Rexulti) (CP.PMN.68) - Effective September 16, 2020 (PDF)
- Brexucabtagene Autoleucel (Tecartus) (CP.PHAR.472) - Effective September 1, 2021 (PDF)
- Brigatinib (Alunbrig) (CP.PHAR.342) - Effective June 1, 2021 (PDF)
- Brimonidine Tartrate (Mirvaso) (CP.PMN.192) - Effective June 1, 2021 (PDF)
- Brinzolamide/Brimonidine (Simbrinza) (HIM.PA.15) - Effective September 4, 2018 (PDF)
- Brivaracetam (Briviact) (CP.PCH.26) - Effective November 1, 2021 (PDF)
- Brolucizumab (Beovu) (CP.PHAR.445) - Effective March 1, 2020 (PDF)
- Budesonide (Uceris) (CP.PCH.11) (PDF)
- Buprenorphine (Subutex) (CP.PMN.82) - Effective September 1, 2017 (PDF)
- Buprenorphine (Probuphine, Sublocade) (CP.PHAR.289) - Effective December 1, 2016 (PDF)
- Buprenorphine Injection (Brixadi) (CP.PHAR.498) - Effective November 17, 2020 (PDF)
- Buprenorphine-naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (CP.PMN.81) - Effective June 1, 2021 (PDF)
- Bupropion-naltrexone (Contrave) (CP.PCH.12) - Effective November 17, 2020 (PDF)
- Burosumab-twza (Crysvita) (CP.PHAR.11) - Effective December 1, 2020 (PDF)
- Butorphanol Nasal Spray (HIM.PA.46) - Effective December 1, 2014 (PDF)
- C1 Esterase Inhibitors (Berinert Cinryze Haegarda Ruconest) (CP.PHAR.202) - Effective April 1, 2022 (PDF)
- Cabazitaxel (Jevtana) (CP.PHAR.316) - Effective August 2, 2021 (PDF)
- Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) (CP.PHAR.573)- Effective May 2, 2022
- Cabozantinib (Cabometyx, Cometriq) (CP.PHAR.111) - Effective August 2, 2021 (PDF)
- Calcifediol (Rayaldee) (CP.PMN.76) - Effective 11/17/2020 (PDF)
- Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) (CP.PMN.181) - Effective March 1, 2021 (PDF)
- Canakinumab (Ilaris) (CP.PHAR.246) - Effective August 2, 2021 (PDF)
- Cannabidiol (Epidiolex) (CP.PMN.164) - Effective 12/1/2020 (PDF)
- Capecitabeine (Xeloda) (CP.PHAR.60) - Effective June 1, 2021 (PDF)
- Caplacizumab-yhdp (Cablivi) (CP.PHAR.416) - Effective March 12, 2019 (PDF)
- Capmatinib (Tabrecta) (CP.PHAR.494) - Effective 11/17/2020 (PDF)
- Carbidopa-Levodopa ER Capsules (Rytary) (CP.PMN.238) - Effective 11/17/2020 (PDF)
- Carfilzomib (Kyprolis) (CP.PHAR.309) - Effective December 1, 2020 (PDF)
- Carglumic Acid (Carbaglu) (CP.PHAR.206) - Effective June 1, 2021 (PDF)
- Casimersen (Amondys 45) (CP.PHAR.470) – Effective June 1, 2021 (PDF)
- Casirivimab and imdevimab (REGN-COV2) (CP.PHAR.520) - Effective December 22, 2020 (PDF)
- Celecoxib (Celebrex, Elyxyb) (CP.PMN.122) - Effective January 1, 2007 (PDF)
- Cemiplimab-rwlc (Libtayo) (CP.PHAR.397) - Effective June 1, 2021 (PDF)
- Cenegermin-bkbj (Oxervate) (CP.PMN.186) - Effective March 1, 2019 (PDF)
- Cenobamate (Xcopri) (CP.PMN.231) - Effective March 1, 2020 (PDF)
- Ceritinib (Zykadia) (CP.PHAR.349) - Effective July 1, 2017 (PDF)
- Cerliponase alfa (Brineura) (CP.PHAR.338) - Effective 7/1/2017 (PDF)
- Cetuximab (Erbitux) (CP.PHAR.317) - Effective December 1, 2020 (PDF)
- Chenodiol (Chenodal) (CP.PMN.239) - Effective 11/17/2020 (PDF)
- Chlorambucil (Leukeran) (CP.PHAR.554) - Effective February 1, 2022 (PDF)
- Chlorambucil (Leukeran) (HIM.PA.SP59) - Effective 8/28/2018 (PDF)
- Chloramphenicol (CP.PHAR.388) - Effective December 1, 2018 (PDF)
- Cholic Acid (Cholbam) (CP.PHAR.390) - Effective March 1, 2021 (PDF)
- Ciclopirox (Penlac) (CP.PMN.24) - Effective April 1, 2022 (PDF)
- Cinacalcet (Sensipar) (CP.PHAR.61) - Effective October 18, 2021 (PDF)
- Ciprofloxacin/Dexamethasone (Ciprodex) (CP.PMN.248) - Effective December 1, 2020 (PDF)
- Ciprofloxacin/Fluocinolone (Otovel) (CP.PMN.249) - Effective December 1, 2020 (PDF)
- Cladribine (Mavenclad) (CP.PHAR.422) - Effective February 1, 2021 (PDF)
- Clascoterone (Winlevi) (CP.PMN.257) - Effective March 1, 2021 (PDF)
- Clobazam (Onfi, Sympazan) (CP.PMN.54) - Effective December 1, 2012 (PDF)
- Colchicine (Colcrys) (CP.PMN.123) - Effective September 1, 2021 (PDF)
- Colesevelam (Welchol) (CP.PMN.250) - Effective December 1, 2020 (PDF)
- CNS Stimulants (CP.PMN.92) - Effective May 2, 2022 (PDF)
- Cobimetinib (Cotellic) (CP.PHAR.380) - Effective November 16, 2016 (PDF)
- Collagenase Clostridium Histolyticum (Xiaflex) (CP.PHAR.82) - Effective 11/17/2020 (PDF)
- Colonoscopy Preparation Products (CP.PCH.43) - Effective January 15, 2021 (PDF)
- Compounded Medications (CP.PCH.27) - Effective December 1, 2021 (PDF)
- Conjugated Estrogens/Bazedoxifene (Duavee) (CP.PMN.258) - Effective March 1, 2021 (PDF)
- Continuous Glucose Monitors (CP.PMN.214) - Effective September 3, 2019 (PDF)
- Copanlisib (Aliqopa) (CP.PHAR.357) - Effective October 17, 2017 (PDF)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (CP.PHAR.385) - Effective September 1, 2021 (PDF)
- Cosyntropin (Cortrosyn) (CP.PHAR.203) - Effective April 1, 2016 (PDF)
- Crisaborole (Eucrisa) (CP.PMN.110) - Effective February 21, 2017 (PDF)
- Crizanlizumab-tmca (Adakveo) (CP.PHAR.449) - Effective June 1, 2021 (PDF)
- Crizotinib (Xalkori) (CP.PHAR.90) - Effective June 1, 2021 (PDF)
- Cyclosprine (Cequa, Restasis) (CP.PMN.48) - Effective February 1, 2022 (PDF)
- Cysteamine ophthalmic (Cystaran, Cystadrops) (CP.PMN.130) - Effective June 1, 2021 (PDF)
- Cysteamine oral (Cystagon, Procysbi) (CP.PHAR.155) - Effective February 1, 2016 (PDF)
- Cytomegalovirus Immune Globulin (CytoGam) (CP.PHAR.277) - Effective 11/17/2020 (PDF)
- Dabrafenib (Tafinlar) (CP.PHAR.239) - Effective 11/16/2016 (PDF)
- Dacomitinib (Vizimpro) (CP.PHAR.399) - Effective October 16, 2018 (PDF)
- Daclatasvir (Daklinza) (HIM.PA.SP27) - Effective 11/17/2020 (PDF)
- Dalfampridine (Ampyra) (CP.PHAR.248) - Effective August 1, 2016 (PDF)
- Dalteparin (Fragmin) (CP.PHAR.225) - Effective May 1, 2016 (PDF)
- Dapsone (Aczone Gel) (CP.PCH.32) - Effective December 1, 2020 (PDF)
- Daptomycin (Cubicin, Cubicin RF) (CP.PHAR.351) - Effective 11/17/2020 (PDF)
- Daratumumab, Daratumumab-Hyaluronidase-fihj (Darzalex, Darzalex Faspro) (CP.PHAR.310) - Effective March 12, 2021 (PDF)
- Darbepoetin Alfa (Aranesp) (CP.PHAR.236) - Effective November 17, 2020 (PDF)
- Darolutamide (Nubeqa) (CP.PHAR.435) - Effective September 3, 2019 (PDF)
- Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) (HIM.PA.SP61) - Effective November 17, 2020 (PDF)
- Dasatinib (Sprycel) (CP.PHAR.72) - Effective June 1, 2021 (PDF)
- Daunorubicin-cytarabine (Vyxeos) (CP.PHAR.352) - Effective December 1, 2021 (PDF)
- Decitabine/Cedazuridine (Inqovi) (CP.PHAR.479) - Effective December 1, 2020 (PDF)
- Deferasirox (Exjade, Jadenu) (CP.PHAR.145) - Effective 11/17/2020 (PDF)
- Deferoxamine (Desferal) (CP.PHAR.146) - Effective 9/16/2020 (PDF)
- Deflazacort (Emflaza) (CP.PHAR.331) - Effective April 1, 2017 (PDF)
- Degarelix Acetate (Firmagon) (CP.PHAR.170) - Effective October 1, 2016 (PDF)
- Delafloxacin (Baxdela) (CP.PMN.115) - Effective December 1, 2017 (PDF)
- Denosumab (Prolia Xgeva) (CP.PHAR.58) - Effective August 9, 2021 (PDF)
- Desmopressin (DDAVP, Stimate, Nocdurna, Noctiva) (CP.PHAR.214) - Effective May 1, 2016 (PDF)
- Deutetrabenazine (Austedo) (CP.PCH.42) - Effective June 1, 2021 (PDF)
- Dexlansoprazole (Dexilant) (HIM.PA.05) - Effective February 1, 2022 (PDF)
- Dexrazoxane (Zinecard, Totect) (CP.PHAR.418) - Effective March 19, 2019 (PDF)
- Dextromethorphan-Quinidine (Nuedexta) (CP.PMN.93) - Effective December 2, 2017 (PDF)
- Diazepam Nasal Spray (Valtoco) (CP.PMN.216) - Effective December 1, 2019 (PDF)
- Dichlorphenamide (Keveyis) (CP.PMN.261) - Effective March 1, 2021 (PDF)
- Diclofenac (Cambia, Flector, Licart, Pennsaid, Solaraze, Zipsor, Zorvolex) (CP.PCH.28) - Effective August 9, 2021 (PDF)
- Dimethyl fumarate (Tecfidera), diroximel fumarate (Vumerity), monomethyl fumarate (Bafiertam) (CP.PCH.41) - Effective 2/1/2021 (PDF)
- Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (HIM.PA.58) - Effective March 1, 2021 (PDF)
- Dolasetron (Anzemet) (CP.PMN.141) - Effective September 1, 2006 (PDF)
- Donislecel (Lantidra) (CP.PHAR.569) - Effective March 1, 2022 (PDF)
- Dornase alfa (Pulmozyme) (CP.PHAR.212) - Effective May 3, 2021 (PDF)
- Dostarlimab-gxly (Jemperli) (CP.PHAR.540) - Effective November 1, 2021 (PDF)
- Doxepin (Silenor, Prudoxin, Zonalon) (HIM.PA.147) - Effective November 17, 2017 (PDF)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (CP.PMN.79) - Effective August 2, 2021 (PDF)
- Dupilumab (Dupixent) (CP.PHAR.336) - Effective April 1, 2022 (PDF)
- Durvalumab (Imfinzi) (CP.PHAR.339) - Effective August 2, 2021 (PDF)
- Duvelisib (Copiktra) (CP.PHAR.400) - Effective February 1, 2022 (PDF)
- Ecallantide (Kalbitor) (CP.PHAR.177) - Effective April 1, 2022 (PDF)
- Eculizumab (Soliris) (CP.PHAR.97) - Effective May 3, 2021 (PDF)
- Edaravone (Radicava) (CP.PHAR.343) - Effective November 1, 2021 (PDF)
- Efinaconazole (Jublia) (CP.PMN.25) - Effective April 1, 2022 (PDF)
- Elagolix (Orilissa), elagolix-estradiol-norethindrone (Oriahnn) (CP.PHAR.136) - Effective December 1, 2021 (PDF)
- Elapegademase-lvlr (Revcovi) (CP.PHAR.419) - Effective August 2, 2021 (PDF)
- Elbasvir/Grazoprevir (Zepatier) (HIM.PA.SP62) - Effective November 17, 2020 (PDF)
- Elexacaftor-ivacaftor-tezacaftor (Trikafta) (CP.PHAR.440) - Effective July 1, 2021 (PDF)
- Eliglustat (Cerdelga) (CP.PHAR.153) - Effective February 1, 2016 (PDF)
- Elosulfase Alfa (Vimizim) (CP.PHAR.162) - Effective February 1, 2016 (PDF)
- Elotuzumab (Empliciti) (CP.PHAR.308) - Effective Febraury 1, 2017 (PDF)
- Eltrombopag (Promacta) (CP.PHAR.180) - Effective April 9, 2021 (PDF)
- Eluxadoline (Viberzi) (CP.PMN.170) - Effective March 1, 2021 (PDF)
- Emapalumab-lzsg (Gamifant) (CP.PHAR.402) - Effective May 3, 2021 (PDF)
- Emicizumab-kxwh (Hemlibra) (CP.PHAR.370) - Effective November 17, 2020 (PDF)
- Emtricitabine/Tenofovir Alafenamide (Descovy) (CP.PMN.235) - Effective November 17, 2020 (PDF)
- Enasidenib (Idhifa) (CP.PHAR.363) - Effective December 1, 2021 (PDF)
- Encorafenib (Braftovi) (CP.PHAR.127) - Effective September 1, 2018 (PDF)
- Enfortumab Vedotin-ejfv (Padcev) (CP.PHAR.455) - Effective October 1, 2021 (PDF)
- Enfuvirtide (Fuzeon) (CP.PHAR.41) - Effective 6/1/2010 (PDF)
- Enoxaparin (Lovenox) (CP.PHAR.224) - Effective April 1, 2022 (PDF)
- Entecavir (Baraclude) (HIM.PA.08) - Effective June 1, 2019 (PDF)
- Entrectinib (Rozlytrek) (CP.PHAR.441) - Effective September 16, 2020 (PDF)
- Enzalutamide (Xtandi) (HIM.PA.164) - Effective October 1, 2012 (PDF)
- Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) (CP.PHAR.237) - Effective August 2, 2021 (PDF)
- Epoprostenol (Flolan, Veletri) (CP.PHAR.192) - Effective March 1, 2016 (PDF)
- Eptinezumab (Vyepti) (HIM.PA.SP64) - Effective August 9, 2021 (PDF)
- Erdafitinib (Balversa) (CP.PHAR.423) - Effective September 1, 2021 (PDF)
- Erenumab-aaoe (Aimovig) (HIM.PA.SP65) - Effective August 9, 2021 (PDF)
- Eribulin Mesylate (Halaven) (CP.PHAR.318) - Effective February 1, 2022 (PDF)
- Erlotinib (Tarceva) (CP.PHAR.74) - Effective September 16, 2020 (PDF)
- Erwinia Asparaginase (Erwinaze, Rylaze) (CP.PHAR.301) - Effective April 1, 2022 (PDF)
- Esketamine (Spravato) (CP.PMN.199) - Effective August 2, 2021 (PDF)
- Etelcalcetide (Parsabiv) (CP.PHAR.379) - Effective 11/17/2020 (PDF)
- Eteplirsen (Exondys 51) (CP.PHAR.288) - Effective January 1, 2017 (PDF)
- Everolimus (Afinitor, Afinitor Disperz, Zortress) (CP.PHAR.63) - Effective March 1, 2021 (PDF)
- Evinacumab-dgnb (Evkeeza) (CP.PHAR.511) - Effective June 1, 2021 (PDF)
- Evolocumab (Repatha) (HIM.PA.156) - Effective June 1, 2021 (PDF)
- Factor IX Human Recombinant (CP.PHAR.218) - Effective September 1, 2021 (PDF)
- Factor IX Complex, Human (Profilnine) (CP.PHAR.219) - Effective May 1, 2016 (PDF)
- Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (CP.PHAR.220) (PDF) - Effective March 1, 2021 (PDF)
- Factor VIII (Human, Recombinant) (CP.PHAR.215) - Effective October 6, 2020 (PDF)
- Factor VIII/von Willebrand Factor Complex (Human – Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi) (CP.PHAR.216) - Effective May 3, 2021 (PDF)
- Factor XIIIa_Recombinant (Tretten) (CP.PHAR.222) - Effective November 17, 2020 (PDF)
- Factor XIII Human (Corifact) (CP.PHAR.221) - Effective November 17, 2020 (PDF)
- Fam-trastuzumab Deruxtecan-nxki (Enhertu) (CP.PHAR.456) - Effective March 1, 2021 (PDF)
- Febuxostat (Uloric) (CP.PMN.57) - Effective August 1, 2013 (PDF)
- Fedratinib (Inrebic) (CP.PHAR.442) - Effective December 1, 2021 (PDF)
- Fenfluramine (Fintepla) (CP.PMN.246) - Effective 11/17/2020 (PDF)
- Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (CP.PMN.127) - Effective June 1, 2015 (PDF)
- Ferric Carboxymaltose (Injectafer) (CP.PHAR.234) - Effective June 1, 2016 (PDF)
- Ferric Derisomaltose (Monoferric) (CP.PHAR.480) - Effective August 2, 2021 (PDF)
- Ferric Gluconate (Ferrlecit) (CP.PHAR.166) - Effective May 3, 2021 (PDF)
- Ferric Maltol (Accrufer) (CP.PMN.213) - Effective September 3, 2019 (PDF)
- Ferumoxytol (Feraheme) (CP.PHAR.165) - Effective March 1, 2016 (PDF)
- Fibrinogen concentrate (human) (Fibryga, RiaSTAP) (CP.PHAR.526) - Effective August 2, 2021 (PDF)
- Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastim-aafi (Nivestym) (CP.PHAR.297) - Effective September 1, 2021 (PDF)
- Flibanserin (Addyi) (CP.PHAR.446) - Effective February 1, 2022 (PDF)
- Finerenone (Kerendia) (CP.PMN.266) - Effective December 1, 2021 (PDF)
- Fingolimod (Gilenya) (CP.PCH.38) - Effective March 1, 2021 (PDF)
- Fluorouracil Cream (Tolak) (CP.PMN.165) - Effective December 1, 2018 (PDF)
- Fluticasone Propionate (Xhance) (CP.PMN.95) - Effective September 1, 2021 (PDF)
- Fondaparinux (Arixtra) (CP.PHAR.226) - Effective May 3, 2021 (PDF)
- Formulary Medications without Specific Guidelines (HIM.PA.33) - Effective March 1, 2021 (PDF)
- Fostemsavir (Rukobia) (CP.PHAR.516) - Effective April 1, 2022 (PDF)
- Fosdenopterin (Nulibry) (CP.PHAR.471) - Effective June 1, 2021 (PDF)
- Fostamatinib (Tavalisse) (CP.PHAR.24) - Effective June 5, 2018 (PDF)
- Fremanezumab-vfrm (Ajovy) (HIM.PA.SP66) - Effective August 9, 2021 (PDF)
- Fulvestrant (Faslodex Injection) (CP.PHAR.424) - Effective 9/16/2020 (PDF)
- Gabapentin ER (Gralise, Horizant) (CP.PMN.240) - Effective 11/17/2020 (PDF)
- Galcanezumab-gnlm (Emgality) (HIM.PA.SP67) - Effective August 9, 2021 (PDF)
- Galsulfase (Naglazyme) (CP.PHAR.161) - Effective February 1, 2016 (PDF)
- Gefitinib (Iressa) (CP.PHAR.68) - Effective November 16, 2016 (PDF)
- Gemtuzumab Ozogamicin (Mylotarg) (CP.PHAR.358) - Effective February 1, 2022 (PDF)
- Gilteritinib (Xospata) (CP.PHAR.412) - Effective March 1, 2021 (PDF)
- Givosiran (Givlaari) (CP.PHAR.457) - Effective April 1, 2022 (PDF)
- Glasdegib (Daurismo) (CP.PHAR.413) - Effective January 8, 2019 (PDF)
- Glatiramer (Copaxone, Glatopa) (HIM.PA.SP68) - Effective March 1, 2021 (PDF)
- Glecaprevir/Pibrentasvir (Mavyret) (HIM.PA.SP36) - Effective 9/16/2020 (PDF)
- GLP-1 receptor agonists (HIM.PA.53) - Effective May 2, 2022 (PDF)
- Glycerol Phenylbutyrate (Ravicti) (CP.PHAR.207) - Effective May 1, 2016 (PDF)
- Golodirsen (Vyondys 53) (CP.PHAR.453) - Effective March 1, 2020 (PDF)
- Goserelin Acetate (Zoladex) (CP.PHAR.171) - Effective March 1, 2021 (PDF)
- Granisetron (Kytril, Sancuso, Sustol) (CP.PMN.74) - Effective November 11, 2016 (PDF)
- Halcinonide (Halog) (HIM.PA.20) - Effective August 28, 2018 (PDF)
- Halobetasol Propionate (Bryhali, Lexette, Ultravate)(CP.PMN.180) - Effective February 1, 2022 (PDF)
- Halobetasol-Tazarotene (Duobrii) (CP.PMN.208) - Effective 11/17/2020 (PDF)
- Hemin (Panhematin) (CP.PHAR.181) - Effective February 1, 2016 (PDF)
- Histrelin Acetate (Vantas, Supprelin LA) (CP.PHAR.172) - Effective october 1, 2016 (PDF)
- House Dust Mite Allergen Extract (Odactra) (CP.PMN.111) - Effective 11/17/2020 (PDF)
- Human Growth Hormone (Somapacitan, Somatropin)(HIM.PA.161) - Effective April 1, 2022 (PDF)
- Hyaluronate Derivatives (CP.PHAR.05) - Effective September 23, 2021 (PDF)
- Hydroxyprogesterone caproate (Makena) (CP.PHAR.14) - Effective November 17, 2020 (PDF)
- Hydroxyurea (Siklos) (CP.PMN.193) - Effective June 1, 2021 (PDF)
- Ibalizumab-uiyk (Trogarzo) (CP.PHAR.378) - Effective June 1, 2018 (PDF)
- Ibandronate Injection (Boniva) (CP.PHAR.189) - Effective November 15, 2017 (PDF)
- Ibrutinib (Imbruvica) (CP.PHAR.126) - Effective April 1, 2022 (PDF)
- Ibuprofen/Famotidine (Duexis) (CP.PMN.120) - Effective August 2, 2021 (PDF)
- Icatibant (Firazyr) (CP.PHAR.178) - Effective April 1, 2022 (PDF)
- Icosapent Ethyl (Vascepa) (CP.PMN.187) - Effective May 3, 2021 (PDF)
- Idecabtagene Vicleucel (Abecma) (CP.PHAR.481) - Effective June 1, 2021 (PDF)
- Idelalisib (Zydelig) (CP.PHAR.133) - Effective February 1, 2022 (PDF)
- Idursulfase (Elaprase) (CP.PHAR.156) - Effective February 1, 2016 (PDF)
- Iloperidone (Fanapt) (CP.PMN.32) - Effective September 1, 2015 (PDF)
- Iloprost (Ventavis) (CP.PHAR.193) - Effective March 1, 2016 (PDF)
- Imatinib (Gleevec) (CP.PHAR.65) - Effective June 1, 2021 (PDF)
- Imiglucerase (Cerezyme) (CP.PHAR.154) - Effective February 1, 2016 (PDF)
- Immune Globulins (CP.PHAR.103) - Effective October 1, 2021 (PDF)
- Inclisiran (Leqvio) (CP.PHAR.568) - Effective March 1, 2022 (PDF)
- IncobotulinumtoxinA (Xeomin) (CP.PHAR.231) - Effective June 1, 2021 (PDF)
- Indacaterol (Arcapta Neohaler) (CP.PMN.203) - Effective 1/1/2021 (PDF)
- Inebilizumab-cdon (Uplizna) (CP.PHAR.458) - Effective November 17, 2020 (PDF)
- Infertility and Fertility Preservation (CP.PHAR.131) - Effective March 1, 2021 (PDF)
- Infigratinib (Truseltiq) (CP.PHAR.547) - Effective September 1, 2021 (PDF)
- Inhaled Agents for Asthma and COPD (HIM.PA.153) - Effective May 3, 2021 (PDF)
- Inotersen (Tegsedi) (CP.PHAR.405) - Effective February 1, 2022 (PDF)
- Inotuzumab Ozogamicin (Besponsa) (CP.PHAR.359) - Effective December 1, 2021 (PDF)
- Insulin Glargine (Semglee, Toujeo) (HIM.PA.09)– Effective February 1, 2022 (PDF)
- Insulin Delivery Systems (V-Go, Omnipod, InPen) (CP.PHAR.534) - Effective June 1, 2021 (PDF)
- Interferon beta-1a (Avonex, Rebif) (CP.PHAR.255) - Effective November 17, 2020 (PDF)
- Interferon beta-1b (Betaseron, Extavia) (CP.PCH.46) - Effective April 1, 2022 (PDF)
- Interferon Gamma- 1b (Actimmune) (CP.PHAR.52) - Effective June 1, 2010 (PDF)
- Iobenguane I 131 (Azedra) (CP.PHAR.459) - Effective March 1, 2020 (PDF)
- Ipilimumab (Yervoy) (CP.PHAR.319) - Effective August 9, 2021 (PDF)
- Irinotecan Liposome (Onivyde) (CP.PHAR.304) - Effective March 1, 2021 (PDF)
- Iron Sucrose (Venofer) (CP.PHAR.167) - Effective May 3, 2021 (PDF)
- Isatuximab-irfc (Sarclisa) (CP.PHAR.482) - Effective January 3, 2022 (PDF)
- Isavuconazonium (Cresemba) (CP.PMN.154) - Effective November 16, 2016 (PDF)
- Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (CP.PMN.143) - Effective December 1, 2014 (PDF)
- Istradefylline (Nourianz) (CP.PMN.217) - Effective March 1, 2020 (PDF)
- Itraconazole (Sporanox, Tolsura) (CP.PMN.124) - Effective 11/17/2020 (PDF)
- Ivabradine (Corlanor) (CP.PMN.70) - Effective November 1, 2015 (PDF)
- Ivacaftor (Kalydeco) (CP.PHAR.210) - Effective November 10, 2020 (PDF)
- Ivermectin (Sklice) (HIM.PA.124) - Effective 12/1/2017 (PDF)
- Ivermectin (Stromectol, Sklice) (CP.PMN.269) - Effective February 1, 2022 (PDF)
- Ivosidenib (Tibsovo) (CP.PHAR.137) - Effective December 1, 2021 (PDF)
- Ixazomib (Ninlaro) (CP.PHAR.302) - Effective 9/16/2020 (PDF)
- Lactic Acid/Citric Acid/Potassium Bitartrate (Phexxi) (CP.PMN.251) - Effective December 1, 2020 (PDF)
- Lactitol (Pizensy) (CP.PMN.241) - Effective 11/17/2020 (PDF)
- Lacosamide (Vimpat) (CP.PMN.155) - Effective January 3, 2022 (PDF)
- Lanadelumab-fylo (Takhzyro) (CP.PHAR.396) - Effective April 1, 2022 (PDF)
- Lanreotide (Somatuline Depot) (CP.PHAR.391) - Effective December 1, 2020 (PDF)
- Lapatinib (Tykerb) (CP.PHAR.79) - Effective February 1, 2022 (PDF)
- Laronidase (Aldurazyme) (CP.PHAR.152) - Effective August 2, 2021 (PDF)
- Larotrectinib (Vitrakvi) (CP.PHAR.414) - Effective May 3, 2021 (PDF)
- Lasmiditan (Reyvow) (CP.PMN.218) - Effective March 1, 2020 (PDF)
- Latanoprostene Bunod (Vyzulta) (CP.PMN.108) - Effective May 3, 2021 (PDF)
- Ledipasvir/Sofosbuvir (Harvoni) (HIM.PA.SP3) - Effective 11/17/2020 (PDF)
- Lefamulin (Xenleta) (CP.PMN.219) - Effective March 1, 2020 (PDF)
- Lenalidomide (Revlimid) (CP.PHAR.71) - Effective December 1, 2021 (PDF)
- Lenvatinib (Lenvima) (CP.PHAR.138) - Effective October 1, 2021 (PDF)
- Letermovir (Prevymis) (CP.PHAR.367) - Effective March 1, 2018 (PDF)
- Leucovorin Injection (CP.PHAR.393) - Effective December 1, 2018 (PDF)
- Leuprolide Acetate (Eligard, Fensolvi, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped) (CP.PHAR.173) - Effective December 1, 2021 (PDF)
- Levalbuterol (Xopenex HFA/Inhalation Solution) (CP.PMN.07) - Effective 9/1/2006 (PDF)
- Levodopa Inhalation Powder (Inbrija) (CP.PMN.267) - Effective December 1, 2021 (PDF)
- Levoleucovorin (Fusilev, Khapzory) (CP.PHAR.151) - Effective December 1, 2020 (PDF)
- Levomilnacipran (Fetzima) (HIM.PA.125) - Effective September 1, 2021 (PDF)
- L-glutamine (Endari) (CP.PMN.116) - Effective March 1, 2021 (PDF)
- Lidocaine Transdermal (Lidoderm, ZTlido) (CP.PMN.08) - Effective 9/16/2020 (PDF)
- Lifitegrast (Xiidra) (CP.PMN.73) - Effective April 1, 2022 (PDF)
- Linaclotide (Linzess) (CP.PMN.71) - Effective October 1, 2021 (PDF)
- Linezolid (Zyvox) (CP.PMN.27) - Effective June 30, 2021 (PDF)
- Lisocabtagene maraleucel (Breyanzi) (CP.PHAR.483) - Effective September 1, 2021 (PDF)
- Lofexidine (Lucemyra) (CP.PMN.152) - Effective 7/31/2018 (PDF)
- Lomustine (Gleostine) (CP.PHAR.507) - Effective February 1, 2022 (PDF)
- Lonafarnib (Zokinvy) (CP.PHAR.499) - Effective November 17, 2020 (PDF)
- Lorcaserin (Belviq, Belviq XR) (CP.PCH.03) - Effective November 17, 2020 (PDF)
- Loncastuximab tesirine-lpyl (Zynlonta) (CP.PHAR.539) - Effective September 1, 2021 (PDF)
- Lorlatinib (Lorbrena) (CP.PHAR.406) - Effective June 1, 2021 (PDF)
- Loteprednol etabonate (Eysuvis) (CP.PMN.260) - Effective March 1, 2021 (PDF)
- Lubiprostone (Amitiza) (CP.PMN.142) - Effective September 23, 2021 (PDF)
- Luliconazole Cream (Luzu) (CP.PMN.166) - Effective August 28, 2018 (PDF)
- Lumacaftor-ivacaftor (Orkambi) (CP.PHAR.213) - Effective 11/17/2020 (PDF)
- Lumasiran (Oxlumo) (CP.PHAR.473) - Effective September 1, 2021 (PDF)
- Lumateperone (Caplyta) (CP.PMN.232) - Effective March 1, 2020 (PDF)
- Lurasidone (Latuda) (CP.PMN.50) - Effective September 1, 2015 (PDF)
- Lurbinectedin (Zepzelca) (CP.PHAR.500) - Effective 11/17/2020 (PDF)
- Luspatercept-aamt (Reblozyl) (CP.PHAR.450) - Effective September 16, 2020 (PDF)
- Lusutrombopag (Mulpleta) (CP.PHAR.407) - Effective May 3, 2021 (PDF)
- Lutetium Lu 177 dotatate (Lutathera) (CP.PHAR.384) - Effective 11/17/2020 (PDF)
- Mannitol (Bronchitol) (CP.PHAR.518) - Effective March 1, 2021 (PDF)
- Maralixibat (Livmarli) (CP.PHAR.543) - Effective December 1, 2021 (PDF)
- Maribavir (Livtencity) (CP.PMN.271) - Effective March 1, 2022 (PDF)
- Margetuximab-cmkb (Margenza) (CP.PHAR.522) - Effective March 1, 2022 (PDF)
- Mecamylamine (Vecamyl) (CP.PMN.136) - Effective June 1, 2017 (PDF)
- Mecasermin (Increlex) (CP.PHAR.150) - Effective 11/17/2020 (PDF)
- Mechlorethamine (Valchlor) (CP.PHAR.381) - Effective 11/17/2020 (PDF)
- Macitentan (Opsumit) (CP.PCH.31) - Effective March 1, 2016 (PDF)
- Megestrol Acetate (Megace ES) (CP.PMN.179) - Effective December 1, 2018 (PDF)
- Melphalan flufenamide (Pepaxto) (CP.PHAR.535) - Effective June 1, 2021 (PDF)
- Memantine (Namenda XR, Namzaric) (CP.PCH.30) - Effective October 1, 2021 (PDF)
- Mepolizumab (Nucala) (CP.PHAR.200) - Effective April 1, 2022 (PDF)
- Mercaptopurine (Purixan) (CP.PHAR.447) - Effective June 1, 2021 (PDF)
- Metformin ER (Glumetza, Fortamet) (CP.PMN.72) - Effective December 1, 2015 (PDF)
- Methotrexate (Otrexup, Rasuvo, Reditrex, Xatmep) (CP.PHAR.134) - Effective December 1, 2018 (PDF)
- Methoxsalen (Uvadex) (HIM.PA.17) - Effective September 4, 2018 (PDF)
- Methoxy polyethylene glycol-epoetin beta (Mircera) (CP.PHAR.238) - Effective November 17, 2020 (PDF)
- Methylnaltrexone Bromide (Relistor) (CP.PMN.169) - Effective December 1, 2018 (PDF)
- Metoclopramide (Gimoti) (CP.PMN.252) - Effective December 1, 2020 (PDF)
- Metreleptin (Myalept) (CP.PHAR.425) - Effective 11/16/2016 (PDF)
- Midazolam (Nayzilam) (CP.PMN.211) - Effective 6/25/2019 (PDF)
- Midostaurin (Rydapt) (CP.PHAR.344) - Effective June 1, 2021 (PDF)
- Mifepristone (Korlym) (CP.PHAR.101) - Effective March 1, 2012 (PDF)
- Migalastat (Galafold) (CP.PHAR.394) - Effective December 1, 2021 (PDF)
- Miglustat (Zavesca) (CP.PHAR.164) - Effective February 1, 2016 (PDF)
- Milnacipran (Savella) (CP.PMN.125) - Effective August 1, 2012 (PDF)
- Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) (CP.PMN.80) - Effective December 1, 2020 (PDF)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) (CP.PHAR.495) - Effective 11/17/2020 (PDF)
- Mitoxantrone (Novantrone) (CP.PHAR.258) - Effective August 2, 2021 (PDF)
- Mobocertinib (Exkivity) (CP.PHAR.559) - Effective December 1, 2021 (PDF)
- Modafinil (Provigil) (CP.PMN.39) - Effective December 1, 2020 (PDF)
- Mogamulizumab-kpkc (Poteligeo) (CP.PHAR.139) - Effective September 4, 2018 (PDF)
- Mometasone (Asmanex) (HIM.PA.01) - Effective March 1, 2021 (PDF)
- Mometasone (Nasonex) (HIM.PA.93) - Effective 11/17/2020 (PDF)
- Mometasone Furoate (Sinuva) (CP.PHAR.448) - Effective April 1, 2022 (PDF)
- Montelukast Oral Granules (Singulair) (HIM.PA.129) - Effective March 1, 2021 (PDF)
- Moxetumomab Pasudotox-tdfk (Lumoxiti) (CP.PHAR.398) - Effective October 16, 2018 (PDF)
- Nadofaragene FiradeNovec (Instiladrin) (CP.PHAR.461) - Effective March 1, 2021 (PDF)
- Nafarelin Acetate (Synarel) (CP.PHAR.174) - Effective October 1, 2016 (PDF)
- Naloxone (Evzio) (CP.PMN.139) - Effective 11/16/2016 (PDF)
- Naltrexone (Vivitrol) (CP.PHAR.96) - Effective December 1, 2021 (PDF)
- Naproxen Oral Suspension (Naprosyn) (HIM.PA.130) - Effective December 1, 2017 (PDF)
- Naproxen/Esomeprazole (Vimovo) (CP.PMN.117) - Effective August 2, 2021 (PDF)
- Natalizumab (Tysabri) (HIM.PA.SP17) - Effective June 1, 2021 (PDF)
- Naxitamab-gqgk (Danyelza) (CP.PHAR.523) - Effective March 1, 2022 (PDF)
- Nebivolol (Bystolic) (HIM.PA.131) - Effective January 15, 2021 (PDF)
- Necitumumab (Portrazza) (CP.PHAR.320) - Effective March 1, 2017 (PDF)
- Neomycin/Fluocinolone Cream (Neo-Synalar) (CP.PMN.167) - Effective August 28, 2018 (PDF)
- Neratinib (Nerlynx) (CP.PHAR.365) - Effective September 16, 2020 (PDF)
- Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan) (CP.PMN.118) - Effective February 13, 2018 (PDF)
- Netupitant and PaloNosetron (Akynzeo) (CP.PMN.158) - Effective September 16, 2020 (PDF)
- Nifurtimox (Lampit) (CP.PMN.256) - Effective December 1, 2020 (PDF)
- Nilotinib (Tasigna) (CP.PHAR.76) - Effective November 1, 2021 (PDF)
- Nintedanib (Ofev) (CP.PHAR.285) - Effective December 1, 2021 (PDF)
- Niraparib (Zejula) (CP.PHAR.408) - Effective June 9, 2021 (PDF)
- Nitazoxanide (Alinia) (HIM.PA.152) - Effective May 2, 2022 (PDF)
- Nitisinone (Nityr, Orfadin) (CP.PHAR.132) - Effective February 1, 2022 (PDF)
- Nivolumab (Opdivo) (CP.PHAR.121) - Effective April 1, 2022 (PDF)
- No Coverage Criteria (HIM.PA.33) - Effective March 1, 2022 (PDF)
- Non-Calcium Phosphate Binders (CP.PMN.04) - Effective March 1, 2022 (PDF)
- Non-Formulary and Formulary Contraceptives (HIM.PA.100) - Effective May 1, 2015 (PDF)
- Non-Formulary Test Strips (HIM.PA.34) - Effective February 1, 2016 (PDF)
- Nusinersen (Spinraza) (CP.PHAR.327) - Effective December 1, 2021 (PDF)
- Obeticholic Aacid (Ocaliva) (CP.PHAR.287) - Effective September 16, 2020 (PDF)
- Obinutuzumab (Gazyva) (CP.PHAR.305) - Effective February 1, 2022 (PDF)
- Ocrelizumab (Ocrevus) (CP.PHAR.335) - Effective February 1, 2021 (PDF)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (CP.PHAR.40) - Effective March 1, 2021 (PDF)
- Odevixibat (Bylvay) (CP.PHAR.528) - Effective September 1, 2021 (PDF)
- Ofatumumab (Arzerra, Kesimpta) (CP.PHAR.306) - Effective August 2, 2021 (PDF)
- Off-Label Use (HIM.PA.154) - Effective March 1, 2022 (PDF)
- Olanzapine Long-Acting Injection (Zyprexa Relprevv) (CP.PHAR.292) - Effective 11/17/2020 (PDF)
- Olanzapine-samidorphan (Lybalvi) (CP.PMN.265) - Effective September 1, 2021 (PDF)
- Olaparib (Lynparza) (CP.PHAR.360) - Effective April 1, 2022 (PDF)
- Olaratumab (Lartruvo) (CP.PHAR.326) - Effective May 3, 2021 (PDF)
- Omadacycline (Nuzyra) (CP.PMN.188) - Effective March 1, 2019 (PDF)
- Omalizumab (Xolair) (CP.PHAR.01) - Effective December 1, 2021 (PDF)
- Omecetaxine (Synribo) (CP.PHAR.108) - Effective August 2, 2021 (PDF)
- Omega-3-Acid Ethyl Esters (Lovaza) (CP.PMN.52) - Effective May 3, 2021 (PDF)
- OnabotulinumtoxinA (Botox) (CP.PHAR.232) - Effective November 1, 2021 (PDF)
- Onasemnogene Abeparvovec (Zolgensma) (CP.PHAR.421) - Effective November 17, 2020 (PDF)
- Ondansetron (Zuplenz) (CP.PMN.45) - Effective April 1, 2022 (PDF)
- Ophthalmic corticosteroids (Lotemax, Durezol, Alrex, Pred Mild, FML Forte, Maxidex) (HIM.PA.03) - Effective January 1, 2020 (PDF)
- Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (CP.PHAR.536) - Effective June 1, 2021 (PDF)
- Opicapone (Ongentys) (CP.PMN.245) - Effective 11/17/2020 (PDF)
- Opioid Analgesics (HIM.PA.139) - Effective January 15, 2021 (PDF)
- Osilodrostat (Isturisa) (CP.PHAR.487) - Effective 11/17/2020 (PDF)
- Osimertinib (Tagrisso) (CP.PHAR.294) - Effective January 3, 2022 (PDF)
- Ospemifene (Osphena) (CP.PMN.168) - Effective August 28, 2018 (PDF)
- Overactive Bladder Agents (CP.PMN.198) - Effective November 17, 2020 (PDF)
- Oxymetazoline (Rhofade, Upneeq) (CP.PMN.86) - Effective June 1, 2021 (PDF)
- Ozenoxacin (Xepi) (CP.PMN.119) - Effective June 1, 2018 (PDF)
- Paclitaxel, Protein-Bound (Abraxane) (CP.PHAR.176) - Effective August 2, 2021 (PDF)
- Palbociclib (Ibrance) (CP.PHAR.125) - Effective December 1, 2021 (PDF)
- Paliperidone inj (Invega Sustenna, Invega Trinza, Invega Hafyera) (CP.PHAR.291) - Effective November 1, 2021 (PDF)
- Palivizumab (Synagis) (CP.PHAR.16) - Effective December 1, 2021 (PDF)
- Pancrelipase (Creon, Pancreaze, Pertyze, Viokace, Zenpep) (CP.PCH.44) - Effective June 1, 2021 (PDF)
- Panitumumab (Vectibix) (CP.PHAR.321) - Effective December 1, 2020 (PDF)
- Panobinostat (Farydak) (CP.PHAR.382) - Effective 11/17/2020 (PDF)
- Parathyroid Hormone (Natpara) (CP.PHAR.282) - Effective November 16, 2016 (PDF)
- Paricalcitol Injection (Zemplar) (CP.PHAR.270) - Effective October 1, 2021 (PDF)
- Pasireotide (Signifor, Signifor LAR) (CP.PHAR.332) - Effective March 1, 2017 (PDF)
- Patiromer (Veltassa) (CP.PMN.205) - Effective September 1, 2021 (PDF)
- Patisiran (Onpattro) (CP.PHAR.395) - Effective February 1, 2022 (PDF)
- Pazopanib (Votrient) (CP.PHAR.81) - Effective September 1, 2021 (PDF)
- Peanut allergen powder (Palforzia) (CP.PMN.220) - Effective March 1, 2020 (PDF)
- Pegaptanib (Macugen) (CP.PHAR.185) - Effective March 1, 2021 (PDF)
- Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (CP.PHAR.353) - Effective February 1, 2022 (PDF)
- Pegcetacoplan (Empaveli) (CP.PHAR.524) - Effective September 1, 2021 (PDF)
- Pegfilgrastim (Neulasta, Neulasta Onpro), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo), Pegfilgrastin-apgf (Nyvepria) (CP.PHAR.296) - Effective September 1, 2021 (PDF)
- Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) (CP.PHAR.89) - Effective September 1, 2021 (PDF)
- Peginterferon beta-1a (Plegridy) (CP.PHAR.271) - Effective November 17, 2020 (PDF)
- Pegloticase (Krystexxa) (CP.PHAR.115) - Effective May 3, 2021 (PDF)
- Pegvaliase-pqpz (Palynziq) (CP.PHAR.140) - Effective March 1, 2021 (PDF)
- Pegvisomant (Somavert) (CP.PHAR.389) - Effective December 1, 2018 (PDF)
- Pembrolizumab (Keytruda) (CP.PHAR.322) - Effective February 1, 2022 (PDF)
- Pemetrexed (Alimta, Pemfexy) (CP.PHAR.368) - Effective April 1, 2022 (PDF)
- Pemigatinib (Pemazyre)(CP.PHAR.496) - Effective October 1, 2021 (PDF)
- Penicillamine (Cuprimine) (CP.PCH.09) - Effective December 12, 2018 (PDF)
- Perampanel (Fycompa) (CP.PMN.156) - Effective 11/16/2016 (PDF)
- Pertuzumab (Perjeta) (CP.PHAR.227) - Effective August 2, 2021 (PDF)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (CP.PHAR.501) - Effective 11/17/2020 (PDF)
- Pexidartinib (Turalio) (CP.PHAR.436) - Effective September 3, 2019 (PDF)
- Phendimetrazine (Bontril PDM) (HIM.PA.114) - Effective August 2, 2021 (PDF)
- Phentermine (Adipex-P, Lomaira) (CP.PCH.13) - Effective November 17, 2020 (PDF)
- Pilocarpine (Vuity) (CP.PMN.270) - Effective December 1, 2021 (PDF)
- Pimavanserin (Nuplazid) (CP.PMN.140) - Effective 11/17/2020 (PDF)
- Pirfenidone (Esbriet) (CP.PHAR.286) - Effective December 1, 2021 (PDF)
- Pitolisant (Wakix) (CP.PMN.221) - Effective September 23, 2021 (PDF)
- Plasminogen, human-tvmh (Ryplazim) (CP.PHAR.513) - Effective December 1, 2021 (PDF)
- Plecanatide (Trulance) (HIM.PA.158) - Effective September 23, 2021 (PDF)
- Plerixafor (Mozobil) (CP.PHAR.323) - Effective 3/1/2017 (PDF)
- Polatuzumab vedotin-piiq (Polivy) (CP.PHAR.433) - Effective 1/15/2021 (PDF)
- Pomalidomide (Pomalyst) (CP.PHAR.116) - Effective December 1, 2021 (PDF)
- Ponatinib (Iclusig) (CP.PHAR.112) - Effective August 2, 2021 (PDF)
- Ponesimod (Ponvory) (CP.PHAR.537) - Effective June 1, 2021 (PDF)
- Potassium Chloride for Oral Solution (Klor-Con Powder) (HIM.PA.143) - Effective May 3, 2021 (PDF)
- Pralatrexate (Folotyn) (CP.PHAR.313) - Effective December 1, 2021 (PDF)
- Pramlintide (Symlin) (CP.PMN.129) - Effective June 1, 2018 (PDF)
- Prasterone (Intrarosa) (CP.PMN.99) - Effective March 1, 2021 (PDF)
- Pregabalin (Lyrica, Lyrica CR) (CP.PMN.33) - Effective January 1, 2007 (PDF)
- Pretomanid (CP.PMN.222) - Effective June 1, 2021 (PDF)
- Progesterone (Crinone, Endometrin, Milprosa) (CP.PMN.243) - Effective 11/17/2020 (PDF)
- Propranolol HCl Oral Solution (Hemangeol) (CP.PMN.58) - Effective May 1, 2014 (PDF)
- Protein C Concentrate Human (Ceprotin) (CP.PHAR.330) - Effective March 1, 2017 (PDF)
- Prucalopride (Motegrity) (HIM.PA.159) - Effective June 1, 2021 (PDF)
- Pyrimethamine (Daraprim) (CP.PMN.44) - Effective April 1, 2022 (PDF)
- Quetiapine ER (Seroquel XR) (CP.PMN.64) - Effective 9/16/2020 (PDF)
- Quinine Sulfate (Qualaquin) (CP.PMN.262) - Effective December 1, 2018 (PDF)
- Ramucirumab (Cyramza) (CP.PHAR.119) - Effective April 1, 2022 (PDF)
- Ranibizumab (Byooviz, Lucentis, Susvimo) (CP.PHAR.186) - Effective April 1, 2022 (PDF)
- Rasagiline (Azilect) (HIM.PA.89) - Effective 12/1/2014 (PDF)
- Ravulizumab-cwvz (Ultomiris) (CP.PHAR.415) - Effective April 1, 2022 (PDF)
- Regorafenib (Stivarga) (CP.PHAR.107) - Effective June 1, 2021 (PDF)
- Relugolix (Orgovyx), Relugolix-Estradiol-Norethindrone (Myfembree) (CP.PHAR.529)(CP.PHAR.529) - Effective October 1, 2021 (PDF)
- Repository Corticotropin Injection (H.P. Acthar Gel) (CP.PHAR.168) - Effective April 1, 2022 (PDF)
- Reslizumab (Cinqair) (CP.PHAR.223) - Effective June 1, 2016 (PDF)
- Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (CP.PHAR.141) - Effective December 1, 2020 (PDF)
- Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara) (CP.PHAR.334) - Effective December 1, 2021 (PDF)
- Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) (CP.PMN.223) - Effective May 3, 2021 (PDF)
- Rifamycin (Aemcolo) (CP.PMN.196) - Effective June 1, 2019 (PDF)
- Rifaximin (Xifaxan) (CP.PMN.47) - Effective March 1, 2021 (PDF)
- Rilonacept (Arcalyst) (CP.PHAR.266) - Effective September 1, 2021 (PDF)
- RimabotulinumtoxinB (Myobloc) (CP.PHAR.233) - Effective June 1, 2021 (PDF)
- Rimegepant (Nurtec ODT) (CP.PHAR.490) - Effective April 1, 2022 (PDF)
- Riociguat (Adempas) (CP.PHAR.195) - Effective March 1, 2016 (PDF)
- Ripretinib (Qinlock) (CP.PHAR.502) - Effective September 1, 2021 (PDF)
- Risdiplam (Evrysdi) (CP.PHAR.477) - Effective September 1, 2021 (PDF)
- Risedronate (Actonel, Atelvia) (CP.PMN.100) - Effective March 1, 2018 (PDF)
- Risperidone LA Injection (Risperdal Consta, Perseris) (CP.PHAR.293) - Effective 12/1/2016
- Rituximab (Rituxan), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) (CP.PHAR.260) - Effective February 1, 2022 (PDF)
- Rolapitant (Varubi) (CP.PMN.102) - Effective February 1, 2017 (PDF)
- Romidepsin (Istodax) (CP.PHAR.314) - Effective February 1, 2022 (PDF)
- Romiplostim (Nplate) (CP.PHAR.179) - Effective November 17, 2020 (PDF)
- Romosozumab-aqqg (Evenity) (CP.PHAR.428) - Effective May 21, 2019 (PDF)
- Ropeginterferon alfa-2b-njft (Besremi) (CP.PHAR.570) - Effective March 1, 2022 (PDF)
- Rucaparib (Rubraca) (CP.PHAR.350) - Effective May 3, 2021 (PDF)
- Rufinamide (Banzel) (CP.PMN.157) - Effective December 1, 2014 (PDF)
- Ruxolitinib (Jakafi) (CP.PHAR.98) - Effective May 2, 2022 (PDF)
- Sacituzumab govitecan-hziy (Trodelvy) (CP.PHAR.475) - Effective November 17, (PDF)
- Sacubitril-Valsartan (Entresto) (CP.PMN.67) - Effective 11/1/2015 (PDF)
- Safinamide (Xadago) (CP.PMN.113) - Effective March 1, 2021 (PDF)
- Sapropterin (Kuvan) (CP.PHAR.43) - Effective August 2, 2021 (PDF)
- Sarecycline (Seysara) (CP.PMN.189) - Effective March 1, 2019 (PDF)
- Sargramostim (Leukine) (CP.PHAR.295) - Effective February 1, 2021 (PDF)
- Satralizumab-mwge (Enspryng) (CP.PHAR.463) - Effective March 1, 2021 (PDF)
- Sebelipase Alfa (Kanuma) (CP.PHAR.159) - Effective February 1, 2016 (PDF)
- Secnidazole (Solosec) (CP.PMN.103) - Effective April 1, 2022 (PDF)
- Selexipag (Uptravi) (CP.PHAR.196) - Effective March 1, 2016 (PDF)
- Selinexor (Xpovio) (CP.PHAR.431) - Effective March 12, 2021 (PDF)
- Selpercatinib (Retevmo) (CP.PHAR.478) - Effective November 17, 2020 (PDF)
- Selumetinib (Koselugo) (CP.PHAR.464) - Effective April 10, 2020 (PDF)
- Setmelanotide (Imcivree) (CP.PHAR.491) - Effective November 17, 2020 (PDF)
- Sildenafil (Revatio) (CP.PHAR.197) - Effective March 1, 2016 (PDF)
- Sildenafil for ED (Viagra) (CP.PCH.07) - Effective June 1, 2018 (PDF)
- Siltuximab (Sylvant) (CP.PHAR.329) - Effective March 1, 2017 (PDF)
- Siponimod (Mayzent) (CP.PHAR.427) - Effective November 1, 2021 (PDF)
- Short Ragweed Pollen Allergen Extract (Ragwitek) (CP.PMN.83) - Effective September 1, 2021 (PDF)
- Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, Sodium Oxybate (Xywav) (CP.PMN.42) - Effective April 1, 2022 (PDF)
- Sodium phenylbutyrate (Buphenyl) (CP.PHAR.208) - Effective May 1, 2016 (PDF)
- Sodium zirconium cyclosilicate (Lokelma) (CP.PMN.163) - Effective September 1, 2021 (PDF)
- SGLT2 inhibitors (HIM.PA.91) - Effective October 1, 2021 (PDF)
- Sofosbuvir (Sovaldi) (HIM.PA.SP2) - Effective 11/17/2020 (PDF)
- Sofosbuvir/Velpatasvir (Epclusa) (HIM.PA.SP1) - Effective 9/16/2020 (PDF)
- Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (HIM.PA.SP63) - Effective June 1, 2021 (PDF)
- Solriamfetol (Sunosi) (CP.PMN.209) - Effective December 1, 2020 (PDF)
- Sonidegib (Odomzo) (CP.PHAR.272) - Effective August 2, 2021 (PDF)
- Sorafenib (Nexavar) (CP.PHAR.69) - Effective August 2, 2021 (PDF)
- Sotorasib (Lumakras) (CP.PHAR.549) - Effective September 1, 2021 (PDF)
- Spinosad (Natroba) (HIM.PA.134) - Effective September 1, 2021 (PDF)
- Step Therapy (HIM.PA.109) - Effective October 1, 2021 (PDF)
- Stiripentol (Diacomit) (CP.PMN.184) - Effective September 25, 2018 (PDF)
- Sunitinib (Sutent) (CP.PHAR.73) - Effective August 2, 2021 (PDF)
- Suvorexant (Belsomra) (CP.PMN.109) - Effective February 1, 2017 (PDF)
- Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair) (CP.PMN.85) - Effective 11/16/2016 (PDF)
- Tadalafil (Adcirca, Alyq) (CP.PHAR.198) - Effective March 1, 2016 (PDF)
- Tadalafil BPH - ED (Cialis) (CP.PMN.132) - Effective 9/16/2020 (PDF)
- Tafamidis (Vyndaqel, Vyndamax) (CP.PHAR.432) - Effective 9/1/2019 (PDF)
- Tafasitamab-cxix (Monjuvi) (CP.PHAR.508) - Effective December 1, 2020 (PDF)
- Talazoparib (Talzenna) (CP.PHAR.409) - Effective March 1, 2021 (PDF)
- Taliglucerase Alfa (Elelyso) (HIM.PA.162) - Effective February 1, 2022 (PDF)
- Talimogene laherparepvec (Imlygic) (CP.PHAR.542) - Effective September 1, 2021 (PDF)
- Tazarotene (Arazlo, Fabior, Tazorac) (CP.PMN.244) - Effective December 1, 2020 (PDF)
- Tasimelteon (Hetlioz) (CP.PMN.104) - Effective May 3, 2021 (PDF)
- Tavaborole (Kerydin) (CP.PMN.105) - Effective April 1, 2022 (PDF)
- Tazemetostat (Tazverik) (CP.PHAR.452) - Effective May 3, 2021 (PDF)
- Tedizolid (Sivextro) (CP.PMN.62) - Effective 11/01/2020 (PDF)
- Teduglutide (Gattex) (CP.PHAR.114) Effective April 1, 2022 (PDF)
- Tegaserod (Zelnorm) (HIM.PA.160) - Effective June 1, 2021 (PDF)
- Telotristat Ethyl (Xermelo) (CP.PHAR.337) - Effective June 1, 2017 (PDF)
- Temozolomide (Temodar) (CP.PHAR.77) - Effective August 2, 2021 (PDF)
- Temsirolimus (Torisel) (CP.PHAR.324) - Effective December 1, 2021 (PDF)
- Tenapanor (Ibsrela) (CP.PMN.224) - Effective 3/1/2020 (PDF)
- Tenofovir Alafenamide Fumarate (Vemlidy) (CP.PMN.268) - Effective December 1, 2020 (PDF)
- Teplizumab (PRV-031) (CP.PHAR.492) - Effective 11/17/2020 (PDF)
- Tepotinib (Tepmetko) (CP.PHAR.530) - Effective June 1, 2021 (PDF)
- Teprotumumab (Tepezza) (CP.PHAR.465) - Effective Septebmer 16, 2020 (PDF)
- TerifluNomide (Aubagio) (CP.PCH.40) - Effective March 1, 2021 (PDF)
- Teriparatide (Forteo) (CP.PHAR.188) - Effective October 1, 2021 (PDF)
- Tesamorelin (Egrifta) (CP.PHAR.109) - Effective 9/16/2020 (PDF)
- Testosterone (Androderm) (HIM.PA.87) - Effective December 1, 2014 (PDF)
- Testosterone (Testopel, Jatenzo) (CP.PHAR.354) - Effective December 1, 2020 (PDF)
- Tetrabenazine (Xenazine) (CP.PHAR.92) - Effective June 1, 2021 (PDF)
- Tezacaftor-Ivacaftor (Symdeko) (CP.PHAR.377) - Effective April 3, 2018 (PDF)
- Thalidomide (Thalomid) (CP.PHAR.78) - Effective December 1, 2021 (PDF)
- Thioguanine (Tabloid) (CP.PHAR.437) - Effective February 1, 2022 (PDF)
- Thyrotropin Alfa (Thyrogen) (CP.PHAR.95) - Effective 11/17/2020 (PDF)
- Timothy Grass Pollen Allergen Extract (Grastek) (CP.PMN.84) - Effective 11/16/2016 (PDF)
- Tisagenlecleucel (Kymriah) (CP.PHAR.361) - Effective April 1, 2022 (PDF)
- Tisotumab vedotin-tftv (Tivdak) (CP.PHAR.561) - Effective December 1, 2021 (PDF)
- Tivozanib (Fotivda) (CP.PHAR.538) - Effective June 1, 2021 (PDF)
- Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (CP.PHAR.211) - Effective May 3, 2021 (PDF)
- Tolvaptan (Jynarque, Samsca) (CP.PHAR.27) - Effective 9/16/2020 (PDF)
- Topical Acne Treatment (HIM.PA.71) - Effective December 1, 2020 (PDF)
- Topical Immunomodulators (CP.PMN.107) - Effective September 1, 2006 (PDF)
- Topotecan (Hycamtin) (CP.PHAR.64) - Effective June 1, 2011 (PDF)
- Trabectedin (Yondelis) (CP.PHAR.204) - Effective May 1, 2016 (PDF)
- Trametinib (Mekinist) (CP.PHAR.240) - Effective 7/1/2016 (PDF)
- Trastuzumab, Biosimilars, Trastuzumab-Hyaluronidase (CP.PHAR.228) - Effective February 1, 2022 (PDF)
- Treprostinil (Orenitram, Remodulin, Tyvaso) (CP.PHAR.199) - Effective September 1, 2021 (PDF)
- Triamcinolone ER Injection (Zilretta) (CP.PHAR.371) - Effective April 1, 2022 (PDF)
- Triclabendazole (Egaten) (CP.PMN.207) - Effective 4/2/2019 (PDF)
- Trientine (Syprine) (CP.PHAR.438) - Effective December 1, 2018 (PDF)
- Trifarotene (Aklief) (CP.PMN.225) - Effective September 16, 2020 (PDF)
- Trifluridine-tipiracil (Lonsurf) (CP.PHAR.383) - Effective October 1, 2021 (PDF)
- Triheptanoin (Dojolvi) (CP.PHAR.509) - Effective December 1, 2020 (PDF)
- Triptorelin pamoate (Trelstar, Triptodur) (CP.PHAR.175) - Effective December 1, 2021 (PDF)
- Tucatinib (Tukysa) (CP.PHAR.497) - Effective 11/17/2020 (PDF)
- Ubrogepant (Ubrelvy) (CP.PHAR.476) - Effective September 16, 2020 (PDF)
- Umbralisib (Ukoniq) (CP.PHAR.531) - Effective June 1, 2021 (PDF)
- Unoprostone Isopropyl (Rescula) (HIM.PA.11) - Effective 9/4/2018 (PDF)
- Uridine triacetate (Vistogard) (HIM.PA.SP55) - Effective December 1, 2017 (PDF)
- Valganciclovir (Valcyte) (CP.PCH.06) - Effective 12/1/2017 (PDF)
- Valoctocogene Roxaparvovec (CP.PHAR.466) - Effective March 1, 2021 (PDF)
- Valproate (Depacon) (CP.PHAR.429) - Effective 6/4/2019 (PDF)
- Valrubicin (Valstar) (CP.PHAR.439) - Effective December 1, 2020 (PDF)
- Vandetanib (Caprelsa) (CP.PHAR.80) - Effective April 1, 2022 (PDF)
- Varenicline (Tyrvaya) (CP.PMN.273) - Effective March 1, 2022 (PDF)
- Velaglucerase Alfa (VPRIV) (HIM.PA.163) - Effective February 1, 2022 (PDF)
- Vemurafenib (Zelboraf) (CP.PHAR.91) - Effective May 3, 2021 (PDF)
- Venetoclax (Venclexta) (CP.PHAR.129) - Effective February 1, 2022 (PDF)
- Verteporfin (Visudyne) (CP.PHAR.187) - Effective June 30, 2021 (PDF)
- Vestronidase alfa-vjbk (Mepsevii) (CP.PHAR.374) - Effective January 9, 2018 (PDF)
- Vigabatrin (Sabril) (CP.PHAR.169) - Effective 9/16/2020 (PDF)
- Vilazodone (Viibryd) (CP.PMN.145) - Effective September 1, 2021 (PDF)
- Viloxazine (Qelbree) (CP.PMN.264) - Effective June 1, 2021 (PDF)
- Viltolarsen (Viltepso) (CP.PHAR.484) - Effective November 17, 2020 (PDF)
- Vincristine Sulfate Liposome Injection (Marqibo) (CP.PHAR.315) - Effective February 1, 2022 (PDF)
- Vismodegib (Erivedge) (CP.PHAR.273) - Effective August 2, 2021 (PDF)
- Voclosporin (Lupkynis) (CP.PHAR.504) - Effective July 1, 2021 (PDF)
- Vorapaxar (Zontivity) (HIM.PA.146) - Effective October 31, 2017 (PDF)
- Voretigene Neparvovec-rzyl (Luxturna) (CP.PHAR.372) - Effective March, 1 2018 (PDF)
- Vorinostat (Zolinza) (CP.PHAR.83) - Effective September 16, 2020 (PDF)
- Vortioxetine (Trintellix) (CP.PMN.65) - Effective September 1, 2021 (PDF)
- Vosoritide (Voxzogo) (CP.PHAR.525) - Effective March 1, 2022 (PDF)
- Voxelotor (Oxbryta) (CP.PHAR.451) - Effective March 1, 2020 (PDF)
- Zanubrutinib (Brukinsa) (CP.PHAR.467) - Effective June 1, 2021 (PDF)
- Ziv-aflibercept (Zaltrap) (CP.PHAR.325) - Effective March 1, 2017 (PDF)
- Zoledronic Acid (Reclast, Zometa) (CP.PHAR.59) - Effective March 1, 2021 (PDF)
Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP Policies
- Allergy Testing (TX.CP.MP.100) (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-Thalassemia (CP.MP.108) (PDF)
- Antithrombin III (Thrombate III, Atryn) (CP.MP.179) (PDF)
- Assistive Communication Device (TX.CP.MP.551) (PDF)
- Bariatric Surgery (CP.MP.37) (PDF)
- Bronchial Thermoplasty (CP.MP.110) (PDF)
- Burn Surgery (CP.MP.186) (PDF)
- Caudal or Interlaminar Epidural Steroid Injections for Pain Management (CP.MP.164) (PDF)
- Child and Adolescent Strength and Needs (CANS) 2.0 Medical Necessity (TX.CP.MP.543) (PDF)
- Cell-free Fetal DNA Testing (CP.MP.84) (PDF)
- Cochlear Implants and Bone-Anchored Hearing Aid (TX.CP.MP.522) (PDF)
- Cochlear Implant Replacement (CP.MP.14) (PDF)
- Cognitive Rehabilitation Therapy (TX.CP.MP.553) (PDF)
- Cosmetic and Reconstructive Procedures (CP.MP.31) (PDF)
- Cranial Remolding Orthosis (TX.CP.MP.516) (PDF)
- Custom Mobility Seating and Systems (TX.CP.MP.599) (PDF)
- Dental Therapy Under General Anesthesia (TX.CP.MP.518) (PDF)
- Diabetic Supplies (TX.CP.MP.526) (PDF)
- Diaphragmatic/Phrenic Nerve Stimulation (CP.MP.203) (PDF)
- Discography (CP.MP.115) (PDF)
- Donor Lymphocyte Infusion (CP.MP.101) (PDF)
- Drugs of Abuse: Presumptive Testing (CP.MP.208) (PDF)
- Durable Medical Equipment (DME) (CP.MP.107) (PDF)
- Durable Medical Equipment (TX.CP.MP.552) (PDF)
- Elective Deliveries Before 39 Weeks Gestational Age (TX.CP.MP.513) (PDF)
- Electric Tumor Treating Fields (Optune) (CP.MP.145) (PDF)
- Enteral Nutrition (TX.CP.MP.550) (PDF)
- EpiFix Wound Treatment (CP.MP.140) (PDF)
- Evinacumab-dgnb (Evkeeza) (CP.PHAR.511) (PDF)
- Excision of Lesions (TX.CP.MP.525) (PDF)
- Experimental Technologies (CP.MP.36) - for CHIP only (PDF)
- Facet Joint Interventions for Pain Management (CP.MP.171) (PDF)
- Fecal Incontinence Treatments (CP.MP.137) (PDF)
- Fertility Preservation (CP.MP.130) (PDF)
- Fetal Surgery In Utero (CP.MP.129) (PDF)
- Fixed Wing Air Transportation (CP.MP.175) (PDF)
- Fractional Exhaled Nitric Oxide (CP.MP.103) (PDF)
- Genetic and Pharmacogenetic Testing (CP.MP.89) (PDF)
- Global Maternity Billing (CC.PP.016) (PDF)
- Gastric Electrical Stimulation (CP.MP.40) (PDF)
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (CP.MP.209) (PDF)
- Gender-Affirming Procedures (CP.MP.95) (PDF)
- Genetic Testing (TX.CP.MP.531) (PDF)
- Heart-Lung Transplant (CP.MP.132) (PDF)
- Home Birth (CP.MP.136) (PDF)
- Home Cardiorespiratory Monitors (TX.CP.MP.501) (PDF)
- Home Phototherapy (TX.CP.MP.510) (PDF)
- Hyperemesis Gravidarum Treatment (CP.MP.34) (PDF)
- Hyperhidrosis Treatments (CP.MP.62) (PDF)
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (CP.MP.180) (PDF)
- Implantable Intrathecal Pain Pump (CP.MP.173) (PDF)
- Incontinence Supplies (TX.CP.MP.508) (PDF)
- Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Intestinal and Multivisceral Transplant (CP.MP.58) (PDF)
- Intradiscal Steroid Injections for Pain Management (CP.MP.167) (PDF)
- Long Term Care Placement Criteria (CP.MP.71) (PDF)
- Low-Frequency Ultrasound Wound Therapy (CP.MP.139) (PDF)
- Lung Transplantation (CP.MP.57) (PDF)
- Mastectomy for Pubertal Gynecomastia (TX.CP.MP.571) (PDF)
- Mechanical Stretch Devices (CP.MP.144) (PDF)
- Multiple Sleep Latency Testing (CP.MP.24) (PDF)
- Neonatal Abstinence Syndrome Guidelines (CP.MP.86) (PDF)
- Neonatal Sepsis Management Guidelines (CP.MP.85) (PDF)
- Nerve Blocks for Pain Management (CP.MP.170) (PDF)
- Neuromuscular Electrical Stimulation (CP.MP.48) (PDF)
- NICU Apnea Bradycardia Guidelines (CP.MP.82) (PDF)
- NICU Discharge Guidelines (CP.MP.81) (PDF)
- Non-Emergent Ambulance Transportation (TX.CP.MP.507) (PDF)
- Non-Invasive Home Ventilator (CP.MP.184) - for CHIP only (PDF)
- Non-Myeloablative Allogeneic Stem Cell Transplants (CP.MP.141) (PDF)
- Obstetrical Home Health Care Programs (CP.MP.91) (PDF)
- Osteogenic Stimulation (CP.MP.194)
- Outpatient Testing for Drugs of Abuse (CP.MP.50) (PDF)
- Oxygen Use and Concentrators (CP.MP.190) - for CHIP only (PDF)
- Pancreas Transplant (CP.MP.102) (PDF)
- Panniculectomy (CP.MP.109) (PDF)
- Pediatric Heart Transplant (CP.MP.138) (PDF)
- Pediatric Liver Transplant (CP.MP.120) (PDF)
- Pharmacogenetic Testing (TX.CP.MP.528) (PDF)
- Physical, Occupational and Speech Therapy Services (TX.CP.MP.549) (PDF)
- Podiatry Services (TX.CP.MP.527) (PDF)
- Private Duty Nursing (TX.CP.MP.520) (PDF)
- Private Duty Nursing - for CHIP only (TX.CP.MP.521) (PDF)
- Proton and Neutron Beam Therapy (CP.MP.70) (PDF)
- Reduction mammoplasty & Gynecomastia Surgery (CP.MP.51) (PDF)
- Renal Hemodialysis (CC.PP.067) (PDF)
- Sacroiliac Joint Interventions for Pain Management (CP.MP.166) (PDF)
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins (CP.MP.146) (PDF)
- Short Inpatient Hospital Stay (CP.MP.182) (PDF)
- Selective Dorsal Rhizotomy (CP.MP.174) (PDF)
- Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (CP.MP.165) (PDF)
- Sickle Cell Disease Observation (CP.MP.88) (PDF)
- Skilled Nursing Visits (TX.CP.MP.538) (PDF)
- Spinal Cord Stimulation (CP.MP.117) (PDF)
- Tandem Transplant (CP.MP.162) (PDF)
- Testing for Select Genitourinary Conditions (CP.MP.97) (PDF)
- Therapy Services (PT, OT, ST) (CP.MP.49) (PDF)
- Total Artificial Heart (CP.MP.127) (PDF)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (CP.MP.163) (PDF)
- Transcatheter Closure of Patent Foramen Ovale (CP.MP.151) (PDF)
- Urinary Incontinence Devices and Treatments (CP.MP.142) (PDF)
- Vagus Nerve Stimulation (CP.MP.12) (PDF)
- Ventricular Assist Devices (CP.MP.46) (PDF)
- Wheelchair Seating (CP.MP.99) (PDF)
- The policies listed below are used for medically billed drugs only. Also, the date in the link name is either the most recent revision date, or the effective date of the policy if no clinically significant changes have been made since September 1, 2019. Please refer to change log for the original effective date and previous revisions to the policy.
- Consistent with guidance issued by Texas Medicaid for Clinician Administered Drugs (CAD) and the regulation at 42 CFR §438.210 and 42 CFR §457.1230(d), Superior HealthPlan does not use any standard for determining medical necessity that is more restrictive than what is developed by the Vendor Drug Program. For more details on the clinical policy and prior authorization requirements, please review the Outpatient Drug Services Handbook located at: https://www.tmhp.com/resources/provider-manuals/tmppm.
Superior routinely reviews the TMPPM to ensure any of our clinical policies for medical necessity are not more restrictive than what is provided for fee-for-service with regards to amount, duration and scope of service.
- Abaloparatide (Tymlos) (CP.PHAR.345) - Effective July 1, 2017 (PDF)
- AbobotulinumtoxinA (Dysport) (CP.PHAR.230) - Effective November 1, 2021 (PDF)
- Adalimumab (Humira), Adalimumab-atto (Amjevita), Adalimumab-adbm (Cyltezo), Adalimumab-bwwd (Hadlima), Adalimumab-adaz (Hyrimoz) (CP.PHAR.242) - Effective December 1, 2021 (PDF)
- Ado-Trastuzumab Emtansine (Kadcyla) (CP.PHAR.229) - Effective June 1, 2021 (PDF)
- Aducanumab-avwa (Aduhelm) (TX.PHAR.101) - Effective January 3, 2022 (PDF)
- Aflibercept (Eylea) (CP.PHAR.184) - Effective October 4, 2021 (PDF)
- Alemtuzumab (Lemtrada) (CP.PHAR.243) - Effective Febraury 1, 2021 (PDF)
- Alirocumab (Praluent) (CP.PHAR.124)- Effective March 1, 2021 (PDF)
- Allogeneic cultured keratinocytes and dermal fibroblasts (StrataGraft) (CP.PHAR.562) - Effective March 1, 2022 (PDF)
- Allogenic processed thymus tissue-agdc (Rethymic) (CP.PHAR.563) - Effective March 1, 2022 (PDF)
- Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (CP.PHAR.94) - Effective March 1, 2012 (PDF)
- Amikacin (Arikayce) (CP.PHAR.401) - Effective April 1, 2022 (PDF)
- Amisulpride (Barhemsys) (CP.PMN.236) - Effective September 1, 2021 (PDF)
- Amivantamab-vmjw (Rybrevant) (CP.PHAR.544) - Effective September 1, 2021 (PDF)
- Anakinra (Kineret) (CP.PHAR.244) - Effective February 1, 2022 (PDF)
- Anti-Inhibitor Coagulant Complex, Human (Feiba) (CP.PHAR.217) - Effective November 17, 2020 (PDF)
- Antithrombin III (ATryn, Thrombate III) (CP.PHAR.564) - Effective March 1, 2022 (PDF)
- Antithymocyte Globulin (Atgam, Thymoglobulin) (CP.PHAR.506) - Effective December 1, 2020 (PDF)
- Apomorphine (Apokyn, Kynmobi) (CP.PHAR.488) - Effective November 17, 2020 (PDF)
- Aprepitant (Cinvanti, Emend) (CP.PMN.19) - Effective November 1, 2006 (PDF)
- Aripiprazole LA Injections (Abilify Maintena Aristada Aristada Initio) (CP.PHAR.290) - Effective November 17, 2020 (PDF)
- Asfotase Alfa (Strensiq) (CP.PHAR.328) - Effective March 1, 2017 (PDF)
- Atezolizumab (Tecentriq) (CP.PHAR.235) - Effective April 1, 2022 (PDF)
- Avelumab (Bavencio) (CP.PHAR.333) - Effective April 1, 2022 (PDF)
- Axicabtagene Ciloleucel (Yescarta®) (TX.PHAR.48) - Effective October 18, 2021 (PDF)
- Azacitidine (Onureg, Vidaza) (CP.PHAR.387) - Effective February 1, 2022 (PDF)
- Baclofen (Gablofen, Lioresal, Ozobax) (CP.PHAR.149) - Effective February 1, 2022 (PDF)
- Bamlanivimab-etesevimab (LY-CoV555-LY-CoV016) (CP.PHAR.532) - Effective December 1, 2021 (PDF)
- Belantamab Mafodotin (Blenrep) (CP.PHAR.469) - Effective 12/1/2020 (PDF)
- Belatacept (Nulojix) (CP.PHAR.201) - Effective March 1, 2016 (PDF)
- Belinostat (Beleodaq) (CP.PHAR.311) - Effective December 1, 2020 (PDF)
- Bendamustine (Belrapzo, Bendeka, Treanda) (CP.PHAR.307) - Effective February 1, 2022 (PDF)
- Benralizumab (Fasenra) (TX.PHAR.99) - Effective October 18, 2021 (PDF)
- Betibeglogene autotemcel (CP.PHAR.545) - Effective September 1, 2021 (PDF)
- Bevacizumab (Avastin, Mvasi, Zirabev) (CP.PHAR.93) - Effective February 1, 2022 (PDF)
- Bezlotoxumab (Zinplava) (CP.PHAR.300) - Effective November 16, 2016 (PDF)
- Bimatoprost Implant (Durysta) (CP.PHAR.486) - Effective June 1, 2021 (PDF)
- Blinatumomab (Blincyto) (CP.PHAR.312) - Effective September 16, 2020 (PDF)
- Bortezomib (Velcade) (CP.PHAR.410) - Effective March 1, 2021 (PDF)
- Brentuximab Vedotin (Adcetris) (CP.PHAR.303) - Effective April 1, 2022 (PDF)
- Brexanolone (Zulresso) (CP.PHAR.417) - Effective June 1, 2019 (PDF)
- Brodalumab (Siliq) (CP.PHAR.375) - Effective December 1, 2021 (PDF)
- Brolucizumab (Beovu) (CP.PHAR.445) - Effective March 1, 2020 (PDF)
- Buprenorphine (Probuphine, Sublocade) (CP.PHAR.289) - Effective December 1, 2016 (PDF)
- Buprenorphine Injection (Brixadi) (CP.PHAR.498) - Effective November 17, 2020 (PDF)
- Burosumab-Twza (Crysvita) (TX.PHAR.55) - Effective May 12, 2021 (PDF)
- C1 Esterase Inhibitors (Berinert Cinryze Haegarda Ruconest) (CP.PHAR.202) - Effective April 1, 2022 (PDF)
- Cabazitaxel (Jevtana) (CP.PHAR.316) - Effective August 2, 2021 (PDF)
- Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) (CP.PHAR.573)- Effective May 2, 2022
- Casimersen (Amondys 45) (TX.PHAR.91) - Effective June 9, 2021
- Canakinumab (Ilaris) (CP.PHAR.246) - Effective August 2, 2021 (PDF)
- Caplacizumab-yhdp (Cablivi) (CP.PHAR.416) - Effective March 12, 2019 (PDF)
- Carfilzomib (Kyprolis) (CP.PHAR.309) - Effective December 1, 2020 (PDF)
- Casirivimab and imdevimab (REGN-COV2) (CP.PHAR.520) - Effective December 22, 2020 (PDF)
- Cemiplimab-rwlc (Libtayo) (CP.PHAR.397) - Effective June 1, 2021 (PDF)
- Cenegermin-bkbj (Oxervate) (CP.PMN.186) - Effective March 1, 2019 (PDF)
- Certolizumab (Cimzia) (CP.PHAR.247) - Effective February 1, 2022 (PDF)
- Cetuximab (Erbitux) (CP.PHAR.317) - Effective December 1, 2020 (PDF)
- Chloramphenicol (CP.PHAR.388) - Effective 12/1/2018 (PDF)
- Collagenase Clostridium Histolyticum (Xiaflex) (CP.PHAR.82) - Effective November 17, 2020 (PDF)
- Copanlisib (Aliqopa) (CP.PHAR.357) - Effective October 17, 2017 (PDF)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (TX.PHAR.93) - Effective October 18, 2021 (PDF)
- Cosyntropin (Cortrosyn) (CP.PHAR.203) - Effective April 1, 2016 (PDF)
- Cytomegalovirus Immune Globulin (Cytogam) (CP.PHAR.277) - Effective November 17, 2020 (PDF)
- Dalteparin (Fragmin) (CP.PHAR.225) - Effective May 1, 2016 (PDF)
- Daptomycin (Cubicin, Cubicin RF) (CP.PHAR.351) - Effective November 17, 2020 (PDF)
- Daratumumab, Daratumumab-Hyaluronidase-fihj (Darzalex, Darzalex Faspro) (CP.PHAR.310) - Effective March 12, 2021 (PDF)
- Darbepoetin Alfa (Aranesp) (CP.PHAR.236) - Effective August 2, 2021 (PDF)
- Daunorubicin-cytarabine (Vyxeos) (CP.PHAR.352) - Effective December 1, 2021 (PDF)
- Deferoxamine (Desferal) (CP.PHAR.146) - Effective September 16, 2020 (PDF)
- Degarelix Acetate (Firmagon) (CP.PHAR.170) - Effective October 1, 2016 (PDF)
- Delafloxacin (Baxdela) (CP.PMN.115) - Effective December 1, 2017 (PDF)
- Denosumab (Prolia Xgeva) (CP.PHAR.58) - Effective August 9, 2021 (PDF)
- Desmopressin (DDAVP, Stimate, Nocdurna, Noctiva) (CP.PHAR.214) - Effective May 1, 2016 (PDF)
- Dexrazoxane (Zinecard, Totect) (CP.PHAR.418) - Effective March 19, 2019 (PDF)
- Donislecel (Lantidra) (CP.PHAR.569) - Effective March 1, 2022 (PDF)
- Dornase Alfa (Pulmozyme) (CP.PHAR.212) - Effective May 3, 2021 (PDF)
- Dostarlimab-gxly (Jemperli) (CP.PHAR.540) - Effective November 1, 2021 (PDF)
- Dupilumab (Dupixent) (CP.PHAR.336) - Effective April 1, 2022 (PDF)
- Durvalumab (Imfinzi) (CP.PHAR.339) - Effective August 2, 2021 (PDF)
- Ecallantide (Kalbitor) (CP.PHAR.177) - Effective April 1, 2022 (PDF)
- Eculizumab (Soliris) (CP.PHAR.97) - Effective May 3, 2021 (PDF)
- Edaravone (Radicava) (CP.PHAR.343) - Effective November 1, 2021 (PDF)
- Elapegademase-lvlr (Revcovi) (CP.PHAR.419) - Effective August 2, 2021 (PDF)
- Elotuzumab (Empliciti) (CP.PHAR.308) - Effective February 1, 2017 (PDF)
- Emicizumab-kxwh (Hemlibra) (CP.PHAR.370) - Effective November 17, 2020 (PDF)
- Enfuvirtide (Fuzeon) (CP.PHAR.41) - Effective June 1, 2010 (PDF)
- Enoxaparin (Lovenox) (CP.PHAR.224) - Effective May 3, 2021 (PDF)
- Enzyme Replacement Therapy (Fabrazyme, Lumizyme, Nexviazyme, Brineura, Vimizim, Naglazyme, Elaprase, Cerezyme, Aldurazyme, Ceprotin, Kanuma, Elelyso, Vpriv) (TX.PHAR.104) - Effective January 24, 2022 (PDF)
- Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) (CP.PHAR.237) - Effective August 2, 2021 (PDF)
- Epoprostenol (Flolan, Veletri) (CP.PHAR.192) - Effective March 1, 2016 (PDF)
- Eptinezumab (Vyepti) (CP.PHAR.489) - Effective October 4, 2021 (PDF)
- Eribulin Mesylate (Halaven) (CP.PHAR.318) - Effective February 1, 2022 (PDF)
- Erenumab-aaoe (Aimovig) (CP.PHAR.128) - Effective October 4, 2021 (PDF)
- Erwinia Asparaginase (Erwinaze, Rylaze) (CP.PHAR.301) - Effective April 1, 2022 (PDF)
- Esketamine (Spravato) (CP.PMN.199) - Effective August 2, 2021 (PDF)
- Etanercept (Enbrel) (CP.PHAR.250) - Effective May 3, 2021 (PDF)
- Etelcalcetide (Parsabiv) (CP.PHAR.379) - Effective November 17, 2020 (PDF)
- Eteplirsen (Exondys51) (TX.PHAR.56) - Effective April 8, 2019 (PDF)
- Evinacumab-dgnb (Evkeeza) (CP.PHAR.511) - Effective June 1, 2021 (PDF)
- Evolocumab (Repatha) (CP.PHAR.123) - Effective October 1, 2015 (PDF)
- Factor IX (Human, Recombinant) (CP.PHAR.218) - Effective September 1, 2021 (PDF)
- Factor IX Complex, Human (Profilnine) (CP.PHAR.219) - Effective May 1, 2016 (PDF)
- Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (CP.PHAR.220) - Effective March 1, 2021 (PDF)
- Factor VIII (Human, Recombinant) (CP.PHAR.215) - Effective October 6, 2020 (PDF)
- Factor VIII/von Willebrand Factor Complex (Human – Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi) (CP.PHAR.216) - Effective May 3, 2021 (PDF)
- Factor XIIIa_Recombinant (Tretten) (CP.PHAR.222) - Effective November 17, 2020 (PDF)
- Factor XIII, Human (Corifact) (CP.PHAR.221) - Effective November 17, 2020 (PDF)
- Fam-trastuzumab Deruxtecan-nxki (Enhertu) (CP.PHAR.456) - Effective March 1, 2021 (PDF)
- Ferric Carboxymaltose (Injectafer) (CP.PHAR.234) - Effective June 1, 2016 (PDF)
- Ferric Derisomaltose (Monoferric) (CP.PHAR.480) - Effective August 2, 2021 (PDF)
- Ferric Gluconate (Ferrlecit) (CP.PHAR.166) - Effective May 3, 2021 (PDF)
- Ferumoxytol (Feraheme) (CP.PHAR.165) - Effective March 1, 2016 (PDF)
- Fibrinogen concentrate (human) (Fibryga, RiaSTAP) (CP.PHAR.526) - Effective August 2, 2021 (PDF)
- Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastim-aafi (Nivestym) (CP.PHAR.297) - Effective September 1, 2021 (PDF)
- Fondaparinux (Arixtra) (CP.PHAR.226) - Effective May 3, 2021 (PDF)
- Fosdenopterin (Nulibry) (CP.PHAR.471) - Effective June 1, 2021 (PDF)
- Fremanezumab-vfrm (Ajovy) (CP.PHAR.403) - Effective October 4, 2021 (PDF)
- Fulvestrant (Faslodex Injection) (CP.PHAR.424) - Effective September 16, 2020 (PDF)
- Galcanezumab-gnlm (Emgality) (CP.PHAR.404) - Effective October 4, 2021 (PDF)
- Gemtuzumab Ozogamicin (Mylotarg) (CP.PHAR.358) - Effective February 1, 2022 (PDF)
- Givosiran (Givlaari) (CP.PHAR.457) - Effective April 1, 2022 (PDF)
- Glatiramer (Copaxone, Glatopa) (CP.PHAR.252) - Effective June 1, 2021 (PDF)
- Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (CP.PMN.183) - Effective May 2, 2022 (PDF)
- Golimumab (Simponi, Simponi Aria) (CP.PHAR.253) - Effective February 1, 2022 (PDF)
- Golodirsen (Vyondys53) (TX.PHAR.85) - Effective August 1, 2020 (PDF)
- Goserelin Acetate (Zoladex) (CP.PHAR.171) - Effective March 1, 2021 (PDF)
- Granisetron (Kytril, Sancuso, Sustol) (CP.PMN.74) - Effective November 1, 2016 (PDF)
- Guselkumab (Tremfya) (CP.PHAR.364) - Effective February 1, 2022 (PDF)
- Hemin (panhematin) (CP.PHAR.181) - Effective February 1, 2016 (PDF)
- Histrelin Acetate (Vantas, Supprelin LA) (CP.PHAR.172) - Effective October 1, 2016 (PDF)
- Human Growth Hormone (Somapacitan, Somatropin) (CP.PHAR.517) - Effective April 1, 2022 (PDF)
- Hyaluronate Derivatives (CP.PHAR.05) - Effective Septebmer 23, 2021 (PDF)
- Ibandronate Injection (Boniva) (CP.PHAR.189) - Effective November 15, 2017 (PDF)
- Icatibant (Firazyr) (CP.PHAR.178) - Effective April 1, 2022 (PDF)
- Idecabtagene Vicleucel (Abecma) (TX.PHAR.94) - Effective December 1, 2021 (PDF)
- Iloprost (Ventavis) (CP.PHAR.193) - Effective March 1, 2016 (PDF)
- Immune Globulins (CP.PHAR.103) - Effective October 1, 2021 (PDF)
- Inclisiran (Leqvio) (CP.PHAR.568) - Effective March 1, 2022 (PDF)
- IncobotulinumtoxinA (Xeomin) (CP.PHAR.231) - Effective June 1, 2021 (PDF)
- Infertility and Fertility Preservation (CP.PHAR.131) - Effective November 17, 2020 (PDF)
- Infliximab (Remicade), Infliximab-axxq (Avsola), Infliximab-dyyb (Inflectra), and Infliximab-abda (Renflexis) (CP.PHAR.254) - Effective October 1, 2021 (PDF)
- Inotersen (Tegsedi) (CP.PHAR.405) - Effective February 1, 2022 (PDF)
- Inotuzumab ozogamicin (Besponsa) (TX.PHAR.47) - Effective April 6, 2018 (PDF)
- Interferon Beta-1a (Avonex, Rebif) (CP.PHAR.255) - Effective November 17, 2020 (PDF)
- Interferon Beta-1b (Betaseron, Extavia) (CP.PHAR.256) - Effective April 1, 2022 (PDF)
- Interferon Gamma- 1b (Actimmune) (CP.PHAR.52) - Effective June 1, 2010 (PDF)
- Iobenguane I 131 (Azedra) (CP.PHAR.459) - Effective March 1, 2020 (PDF)
- Ipilimumab (Yervoy) (CP.PHAR.319) - Effective August 9, 2021 (PDF)
- Irinotecan Liposome (Onivyde) (CP.PHAR.304) - Effective March 1, 2021 (PDF)
- Iron Sucrose (Venofer) (CP.PHAR.167) - Effective May 3, 2021 (PDF)
- Isatuximab-irfc (Sarclisa) (CP.PHAR.482) - Effective January 3, 2022 (PDF)
- Isavuconazonium (Cresemba) (CP.PMN.154) - Effective November 16, 2016 (PDF)
- Ixekizumab (Taltz) (CP.PHAR.257) - Effective August 2, 2021 (PDF)
- Lacosamide (Vimpat) (CP.PMN.155) - Effective January 3, 2022 (PDF)
- Lanadelumab-fylo (Takhzyro) (CP.PHAR.396) - Effective April 1, 2022 (PDF)
- Lanreotide (Somatuline Depot) (CP.PHAR.391) - Effective December 1, 2020 (PDF)
- Lefamulin (Xenleta) (CP.PMN.219) - Effective March 1, 2020 (PDF)
- Letermovir (Prevymis) (CP.PHAR.367) - Effective March 1, 2018 (PDF)
- Leucovorin Injection (CP.PHAR.393) - Effective December 1, 2018 (PDF)
- Leuprolide Acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi) (CP.PHAR.173) - Effective December 1, 2021 (PDF)
- Levoleucovorin (Fusilev) (CP.PHAR.151) - Effective December 12, 2020 (PDF)
- Lisocabtagene maraleucel (Breyanzi) (TX.PHAR.95) - Effective December 1, 2021 (PDF)
- Linezolid (Zyvox) (CP.PMN.27) Effective June 30, 2021 (PDF)
- Loncastuximab tesirine-lpyl (Zynlonta) (CP.PHAR.539) - Effective September 1, 2021 (PDF)
- Lumasiran (Oxlumo) (CP.PHAR.473) - Effective September 1, 2021 (PDF)
- Lurbinectedin (Zepzelca) (CP.PHAR.500) - Effective November 17, 2020 (PDF)
- Makena Clinical Criteria for Authorization via Medical Benefit (TX.PHAR.15) - Effective October 18, 2021 (PDF)
- Maralixibat (Livmarli) (CP.PHAR.543) - Effective December 1, 2021 (PDF)
- Margetuximab-cmkb (Margenza) (CP.PHAR.522) - Effective March 1, 2022 (PDF)
- Melphalan flufenamide (Pepaxto) (CP.PHAR.535) - Effective June 1, 2021 (PDF)
- Mepolizumab (Nucala) (TX.PHAR.96) - Effective October 18, 2021 (PDF)
- Methotrexate (Otrexup, Rasuvo, Reditrex, Xatmep) (CP.PHAR.134) - Effective December 1, 2018 (PDF)
- Methoxy polyethylene glycol-epoetin beta (Mircera) (CP.PHAR.238) - Effective November 17, 2020 (PDF)
- Methylnaltrexone Bromide (Relistor) (CP.PMN.169) - Effective December 1, 2018 (PDF)
- Metreleptin (Myalept) (CP.PHAR.425) - Effective November 16, 2016 (PDF)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) (CP.PHAR.495) - Effective November 17, 2020 (PDF)
- Mitoxantrone (Novantrone) (CP.PHAR.258) - Effective August 2, 2021 (PDF)
- Mogamulizumab-kpkc (Poteligeo) (CP.PHAR.139) - Effective September 4, 2018 (PDF)
- Mometasone Furoate (Sinuva) (CP.PHAR.448) - Effective April 1, 2022 (PDF)
- Nadofaragene FiradeNovec (Instiladrin) (CP.PHAR.461) - Effective March 1, 2021 (PDF)
- Naloxone (Evzio) (CP.PMN.139) - Effective November 16, 2016 (PDF)
- Naltrexone (Vivitrol) (CP.PHAR.96) - Effective December 1, 2021 (PDF)
- Natalizumab (Tysabri) (CP.PHAR.259) - Effective October 1, 2021 (PDF)
- Naxitamab-gqgk (Danyelza) (CP.PHAR.523) - Effective March 1, 2022 (PDF)
- Necitumumab (Portrazza) (CP.PHAR.320) - Effective March 1, 2017 (PDF)
- Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (CP.PMN.158) - Effective September 16, 2020 (PDF)
- Nivolumab (Opdivo) (CP.PHAR.121) - Effective April 1, 2022 (PDF)
- No Coverage Criteria (CP.PMN.255) - Effective December 1, 2020 (PDF)
- Nusinersen (Spinraza) Criteria (TX.PHAR.44) - Effective February 7, 2018 (PDF)
- Obinutuzumab (Gazyva) (CP.PHAR.305) - Effective February 1, 2022 (PDF)
- Ocrelizumab (Ocrevus) (CP.PHAR.335) - Effective Febraury 1, 2021 (PDF)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (CP.PHAR.40) - Effective March 1, 2021 (PDF)
- Ofatumumab (Arzerra, Kesimpta) (CP.PHAR.306) - Effective August 2, 2021 (PDF)
- Off-Label Use (CP.PMN.53) - Effective August 2, 2021 (PDF)
- Olanzapine LA Injection (Zyprexa Relprevv) (CP.PHAR.292) - Effective November 17, 2020 (PDF)
- Olaratumab (Lartruvo) (CP.PHAR.326) - Effective May 3, 2021 (PDF)
- Omacetaxine (Synribo) (CP.PHAR.108) - Effective August 2, 2021 (PDF)
- Omadacycline (Nuzyra) (CP.PMN.188) - Effective March 1, 2019 (PDF)
- Omalizumab (Xolair) (TX.PHAR.97) - Effective October 18, 2021 (PDF)
- OnabotulinumtoxinA (Botox) (CP.PHAR.232) - Effective November 1, 2021 (PDF)
- Onasemnogene Abeparvovec-xioi (Zolgensma) (TX.PHAR.79) - Effective April 5, 2021 (PDF)
- Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (CP.PHAR.536) - Effective June 1, 2021 (PDF)
- Paclitaxel, Protein-Bound (Abraxane) (CP.PHAR.176) - Effective August 2, 2021 (PDF)
- Paliperidone inj (Invega Sustenna, Invega Trinza, Invega Hafyera) (CP.PHAR.291) - Effective November 1, 2021 (PDF)
- Panitumumab (Vectibix) (CP.PHAR.321) - Effective December 1, 2020 (PDF)
- Parathyroid Hormone (Natpara) (CP.PHAR.282) - Effective November 16, 2016 (PDF)
- Paricalcitol Injection (Zemplar) (CP.PHAR.270) - Effective October 1, 2021 (PDF)
- Patisiran (Onpattro) (CP.PHAR.395) - Effective February 1, 2022 (PDF)
- Pasireotide (Signifor, Signifor LAR) (CP.PHAR.332) - Effective February 1, 2022 (PDF)
- Pegaptanib (Macugen) (CP.PHAR.185) - Effective March 1, 2021 (PDF)
- Pegcetacoplan (Empaveli) (CP.PHAR.524) - Effective September 1, 2021 (PDF)
- Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (CP.PHAR.353) - Effective February 1, 2022 (PDF)
- Pegfilgrastim (Neulasta, Neulasta Onpro), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo), Pegfilgrastin-apgf (Nyvepria) (CP.PHAR.296) - Effective September 1, 2021 (PDF)
- Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) (CP.PHAR.89) - Effective September 1, 2021 (PDF)
- Peginterferon Beta-1a (Plegridy) (CP.PHAR.271) - Effective November 17, 2020 (PDF)
- Pegloticase (Krystexxa) (CP.PHAR.115) - Effective May 3, 2021 (PDF)
- Pegvisomant (Somavert) (CP.PHAR.389) - Effective December 1, 2018 (PDF)
- Pembrolizumab (Keytruda) (CP.PHAR.322) - Effective January 3, 2022 (PDF)
- Pemetrexed (Alimta, Pemfexy) (CP.PHAR.368) - Effective April 1, 2022 (PDF)
- Pertuzumab (Perjeta) (CP.PHAR.227) - Effective August 2, 2021 (PDF)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (CP.PHAR.501) - Effective November 17, 2020 (PDF)
- Plasminogen, human-tvmh (Ryplazim) (CP.PHAR.513) - Effective December 1, 2021 (PDF)
- Plerixafor (Mozobil) (CP.PHAR.323) - Effective March 1, 2017 (PDF)
- Polatuzumab Vedotin-piiq (Polivy) (CP.PHAR.433) - Effective January 15, 2021 (PDF)
- Pralatrexate (Folotyn) (CP.PHAR.313) - Effective December 1, 2021 (PDF)
- Pramlintide (Symlin) (CP.PMN.129) - Effective June 1, 2018 (PDF)
- Protein C Concentrate Human (Ceprotin) (CP.PHAR.330) - Effective March 1, 2022 (PDF)
- Ramucirumab (Cyramza) (CP.PHAR.119) - Effective April 1, 2022 (PDF)
- Ranibizumab (Byooviz, Lucentis, Susvimo) (CP.PHAR.186) - Effective April 1, 2022 (PDF)
- Ravulizumab-cwvz (Ultomiris) (CP.PHAR.415) - Effective April 1, 2022 (PDF)
- Repository Corticotropin Injection (H.P. Acthar Gel) (CP.PHAR.168) - Effective April 1, 2022 (PDF)
- Reslizumab (Cinqair) (TX.PHAR.98) - Effective October 18, 2021 (PDF)
- Rilonacept (Arcalyst) (CP.PHAR.266) - Effective September 1, 2021 (PDF)
- RimabotulinumtoxinB (Myobloc) (CP.PHAR.233) - Effective June 1, 2021 (PDF)
- Risankizumab-rzaa (Skyrizi) (CP.PHAR.426) - Effective August 2, 2021 (PDF)
- Risdiplam (Evrysdi) (CP.PHAR.477) - Effective September 1, 2021 (PDF)
- Risperidone LA Injection (Risperdal Consta, Perseris) (CP.PHAR.293) - Effective June 4, 2019 (PDF)
- Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), RituximabHyaluronidase (Rituxan Hycela) (CP.PHAR.260) - Effective February 1, 2022 (PDF)
- Rolapitant (Varubi) (CP.PMN.102) - Effective February 1, 2017 (PDF)
- Romidepsin (Istodax) (CP.PHAR.314) - Effective February 1, 2022 (PDF)
- Romiplostim (Nplate) (CP.PHAR.179) - Effective November 17, 2020 (PDF)
- Romosozumab-aqqg (Evenity) (CP.PHAR.428) - Effective May 21, 2019 (PDF)
- Ropeginterferon alfa-2b-njft (Besremi) (CP.PHAR.570) - Effective March 1, 2022 (PDF)
- Sacituzumab govitecan-hziy (Trodelvy) (CP.PHAR.475) - Effective November 17, 2020 (PDF)
- Sargramostim (Leukine) (CP.PHAR.295) - Effective February 1, 2021 (PDF)
- Sarilumab (Kevzara) (CP.PHAR.346) - Effective August 2, 2021 (PDF)
- Satralizumab-mwge (Enspryng) (CP.PHAR.463) - Effective March 1, 2021 (PDF)
- Secukinumab (Cosentyx) (CP.PHAR.261) - Effective February 1, 2022 (PDF)
- Selpercatinib (Retevmo) (CP.PHAR.478) - Effective November 17, 2020 (PDF)
- Setmelanotide (Imcivree) (CP.PHAR.491) - Effective November 17, 2020 (PDF)
- Sildenafil (Revatio) (CP.PHAR.197) - Effective March 1, 2016 (PDF)
- Siltuximab (Sylvant) (CP.PHAR.329) - Effective March 1, 2017 (PDF)
- Sipuleucel-T (Provenge) (CP.PHAR.120) - Effective August 2, 2021 (PDF)
- Tafasitamab-cxix (Monjuvi) (CP.PHAR.508) - Effective December 1, 2020 (PDF)
- Talimogene laherparepvec (Imlygic) (CP.PHAR.542) - Effective September 1, 2021 (PDF)
- Tedizolid (Sivextro) (CP.PMN.62) - Effective November 1, 2020 (PDF)
- Teduglutide (Gattex) (CP.PHAR.114) - Effective 5/1/2013 (PDF)
- Temozolomide (Temodar) (CP.PHAR.77) - Effective August 2, 2021 (PDF)
- Temsirolimus (Torisel) (CP.PHAR.324) - Effective December 1, 2021 (PDF)
- Teriparatide (Forteo) (CP.PHAR.188) - Effective October 1, 2021 (PDF)
- Testosterone (Testopel, Jatenzo) (CP.PHAR.354) - Effective August 1, 2017 (PDF)
- Thyrotropin alfa (Thyrogen) (CP.PHAR.95) - Effective November 17, 2020 (PDF)
- Tildrakizumab-asmn (Ilumya) (CP.PHAR.386) - Effective February 1, 2022 (PDF)
- Tisagenlecleucel (Kymriah) (TX.PHAR.58) - Effective October 18, 2021 (PDF)
- Tisotumab vedotin-tftv (Tivdak) (CP.PHAR.561) - Effective December 1, 2021 (PDF)
- Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (CP.PHAR.211) - Effective May 3, 2021 (PDF)
- Tocilizumab (Actemra) (CP.PHAR.263) - Effective December 1, 2021 (PDF)
- Topotecan (Hycamtin) (CP.PHAR.64) - Effective June 1, 2011 (PDF)
- Trabectedin (Yondelis) (CP.PHAR.204) - Effective May 1, 2016 (PDF)
- Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (CP.PHAR.228) - Effective February 1, 2022 (PDF)
- Treprostinil (Orenitram, Remodulin, Tyvaso) (CP.PHAR.199) - Effective September 1, 2021 (PDF)
- Triamcinolone ER Injection (Zilretta) (CP.PHAR.371) - Effective April 1, 2022 (PDF)
- Triptorelin pamoate (Trelstar, Triptodur) (CP.PHAR.175) - Effective 10/1/2016 (PDF)
- Ustekinumab (Stelara) (CP.PHAR.264) - Effective February 1, 2022 (PDF)
- Valoctocogene Roxaparvovec (CP.PHAR.466) - Effective March 1, 2021 (PDF)
- Valproate (Depacon) (CP.PHAR.429) - Effective June 4, 2019 (PDF)
- Valrubicin (Valstar) (CP.PHAR.439) - Effective December 1, 2020 (PDF)
- Vedolizumab (Entyvio) (CP.PHAR.265) - Effective February 1, 2022 (PDF)
- Velaglucerase Alfa (VPRIV) (CP.PHAR.163) - Effective February 1, 2022 (PDF)
- Verteporfin (Visudyne) (CP.PHAR.187) - Effective June 30, 2021 (PDF)
- Vestronidase alfa-vjbk (Mepsevii) (CP.PHAR.374) - Effective January 9, 2018 (PDF)
- Viltolarsen (Viltepso) (TX.PHAR.88) - Effective April 5, 2021 (PDF)
- Vincristine Sulfate Liposome Injection (Marqibo) (CP.PHAR.315) - Effective February 1, 2022 (PDF)
- Voretigene neparvovec-rzyl (Luxturna®) Criteria (TX.PHAR.49) - Effective August 1, 2018 (PDF)
- Vosoritide (Voxzogo) (CP.PHAR.525) - Effective March 1, 2022 (PDF)
- Ziv-aflibercept (Zaltrap) (CP.PHAR.325) - Effective March 1, 2017 (PDF)
- Zoledronic Acid (Reclast, Zometa) (CP.PHAR.59) - Effective March 1, 2021 (PDF)
- Add on Code Billed Without Primary Code (CC.PP.030) (PDF)
- ADHD Assessment and Treatment (TX.CP.MP.124) (PDF)
- Allergy Testing (TX.CP.MP.100) (PDF)
- Assistant Surgeon (CC.PP.029) (PDF)
- Bilateral Procedures (CC.PP.037) (PDF)
- Bronchial Thermoplasty (CP.MP.110) (PDF)
- Cardiac Biomarker Testing for Acute MI (CP.MP.156) (PDF)
- Cerumen Removal (CC.PP.008) (PDF)
- Clinical Validation of Modifier 25 (CC.PP.013) (PDF)
- Clinical Validation of Modifier 59 (CC.PP.014) (PDF)
- Code Editing Overview (CC.PP.011) (PDF)
- Cosmetic Procedures (CC.PP.024) (PDF)
- Diagnostic Testing Guidelines for 2019-Novel Coronavirus (CP.MP.183) (PDF)
- Digital Analysis of EEGs (CP.MP.105) (PDF)
- Distinct Procedural Modifiers (CC.PP.020) (PDF)
- Drugs of Abuse: Presumptive Testing (CP.MP.208) (PDF)
- Duplicate Primary Code Billing (CC.PP.044) (PDF)
- E&M Bundling with Lab-Radiology (CC.PP.010) (PDF)
- E&M Medical Decision-Making (CC.PP.051) (PDF)
- EEG in Evaluation of Headache (CP.MP.155) (PDF)
- Endometrial Ablation (EA) (CP.MP.106) (PDF)
- Enhanced Code Editing (TX.PP.011-A) (PDF)
- Evaluation and Management (E/M) Services Billed with Treatment Room Revenue Codes (CC.PP.071) (PDF)
- Evoked Potentials (CP.MP.134) (PDF)
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (CP.MP.209) (PDF)
- Genetic and Molecular Testing Services (TX.PP.551) (PDF)
- H Pylori Testing (CP.MP.153) (PDF)
- Holter Monitors (CP.MP.113) (PDF)
- Homocysteine Testing (CP.MP.121) (PDF)
- Hospital Visit Codes Billed with Labs (CC.PP.023) (PDF)
- Inpatient Only Procedures (CC.PP.018) (PDF)
- Intravenous Hydration (CC.PP.012) (PDF)
- Leveling of Emergency Room Services - Professional (CC.PP.053)
- Leveling of Emergency Room Services - Facility (CC.PP.064)
- Maximum Units of Service (CC.PP.007) (PDF)
- Measure Serum 1,25 Vitamin D (CP.MP.152) (PDF)
- Mechanical Stretch Devices (CP.MP.144) (PDF)
- Moderate Conscious Sedation (CC.PP.015) (PDF)
- Modifier DOS Validation (CC.PP.034) (PDF)
- Modifier to Procedure Code Validation (CC.PP.028) (PDF)
- Multiple CPT Code Replacement (CC.PP.033) (PDF)
- Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular Procedures (CC.PP.065) (PDF)
- NCCI Unbundling (CC.PP.031) (PDF)
- Never Paid Events (CC.PP.017) (PDF)
- New Patient (CC.PP.036) (PDF)
- Non-obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds (CC.PP.061) (PDF)
- Not Medically Necessary Inpatient Professional Services (CC.PP.060) (PDF)
- Outpatient Consultation (CC.PP.039) (PDF)
- Physician Visit Codes Billed with Labs (CC.PP.019) (PDF)
- Place of Service Mismatch (CC.PP.063) (PDF)
- Polymerase Chain Reaction (PCR) Testing (TX.PP.150) (PDF)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (TX.CP.MP.181) (PDF)
- Post-Operative Visits (CC.PP.042) (PDF)
- Pre-Operative Visits (CC.PP.041) (PDF)
- Professional Component Modifier (CC.PP.027) (PDF)
- PROM Testing (CP.MP.149) (PDF)
- Pulse Oximetry with Office Visits (CC.PP.025) (PDF)
- Renal Hemodialysis (CC.PP.067) (PDF)
- Robotic Surgery (CC.PP.050) (PDF)
- Same Day Visits (CC.PP.040) (PDF)
- Sleep Studies Place of Services (CC.PP.035) (PDF)
- Status "B" Bundled Services (CC.PP.046) (PDF)
- Status "P" Bundled Services (CC.PP.049) (PDF)
- Supplies Billed on Same Day As Surgery (CC.PP.032) (PDF)
- Testing for Select Genitourinary Conditions (CP.MP.97) (PDF)
- Thyroid Testing in Pediatrics (CP.MP.154) (PDF)
- Transgender Related Services (CC.PP.047) (PDF)
- Ultrasound in Pregnancy (CP.MP.38) (PDF)
- Unbundled Professional Services (CC.PP.043) (PDF)
- Unbundled Surgical Procedures (CC.PP.045) (PDF)
- Unlisted Procedure Codes (CC.PP.009) (PDF)
- Urine Specimen Validity Testing (CC.PP.056) (PDF)
- Urodynamic Testing (CP.MP.98) (PDF)
- Vitamin D Testing in Children (CP.MP.157) (PDF)
- Wheelchair and Accessories (CC.PP.502) (PDF)
- Wireless Motility Capsule (CP.MP.143) (PDF)
Wellcare By Allwell (Medicare) Policies
- 30-Day Readmission (CC.PP.501) (PDF)
- 340B Drug Payment Reduction (CC.PP.070) (PDF)
- Add on Code Billed Without Primary Code (CC.PP.030) (PDF)
- ADHD Assessment and Treatment (TX.CP.MP.124) (PDF)
- Allergy Testing (TX.CP.MP.100) (PDF)
- Ambulatory EEG (CP.MP.96) (PDF)
- Assistant Surgeon (CC.PP.029) (PDF)
- Bariatric Surgery (CP.MP.37) (PDF)
- Bevacizumab (Avastin) (CP.PHAR.93) (PDF)
- Bilateral Procedures (CC.PP.037) (PDF)
- Bronchial Thermoplasty (CP.MP.110) (PDF)
- Cardiac Biomarker Testing for Acute MI (CP.MP.156) (PDF)
- Cell-free Fetal DNA Testing (CP.MP.84) (PDF)
- Cerumen Removal (CC.PP.008) (PDF)
- Clean Claims (CC.PP.021) (PDF)
- Clinical Validation of Modifier 25 (CC.PP.013) (PDF)
- Clinical Validation of Modifier 59 (CC.PP.014) (PDF)
- Code Editing Overview (CC.PP.011) (PDF)
- Cosmetic Procedures (CC.PP.024) (PDF)
- Diagnostic Testing Guidelines for 2019-Novel Coronavirus (CP.MP.183) (PDF)
- Digital Analysis of EEGs (CP.MP.105) (PDF)
- Distinct Procedural Modifiers (CC.PP.020) (PDF)
- DNA Analysis of Stool (CP.MP.125) (PDF)
- Drugs of Abuse: Presumptive Testing (CP.MP.208) (PDF)
- Duplicate Primary Code Billing (CC.PP.044) (PDF)
- E&M Bundling (CC.PP.010) (PDF)
- E&M Medical Decision-Making (CC.PP.051) (PDF)
- EEG in Evaluation of Headache (CP.MP.155) (PDF)
- Endometrial Ablation (EA) (CP.MP.106) (PDF)
- Enhanced Code Editing (TX.PP.011-A) (PDF)
- EpiFix Wound Treatment (CP.MP.140) (PDF)
- Evaluation and Management (E/M) Services Billed with Treatment Room Revenue Codes (CC.PP.072) (PDF)
- Evoked Potentials (CP.MP.134) (PDF)
- Experimental Technologies (CP.MP.36) (PDF)
- Fecal Calprotectin Assay (CP.MP.135) (PDF)
- FeNo Testing (CP.MP.103) (PDF)
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (CP.MP.209) (PDF)
- Genetic and Molecular Testing Services (TX.PP.551) (PDF)
- Global Maternity Billing (CC.PP.016) (PDF)
- H Pylori Testing (CP.MP.153) (PDF)
- Holter Monitors (CP.MP.113) (PDF)
- Homocysteine Testing (CP.MP.121) (PDF)
- Hospital Visit Codes Billed with Labs (CC.PP.023) (PDF)
- Hyperemesis Gravidarum Treatment (CP.MP.34) (PDF)
- Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Inpatient Consultation (CC.PP.038) (PDF)
- Inpatient Only Procedures (CC.PP.018) (PDF)
- Intravenous Hydration (CC.PP.012) (PDF)
- Leveling of Emergency Room Services (CC.PP.053) (PDF)
- Laser Skin Treatment (CP.MP.123) (PDF)
- Maximum Units of Service (CC.PP.007) (PDF)
- Measure Serum 1,25 Vitamin D (CP.MP.152) (PDF)
- Mechanical Stretch Devices (CP.MP.144) (PDF)
- Moderate Conscious Sedation (CC.PP.015) (PDF)
- Modifier DOS Validation (CC.PP.034) (PDF)
- Modifier to Procedure Code Validation (CC.PP.028) (PDF)
- Monitored Anesthesia Care for Gastrointestinal Endoscopy (CP.MP.161) PDF)
- Multiple CPT Code Replacement (CC.PP.033) (PDF)
- Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular Procedures (CC.PP.065) (PDF)
- NCCI Unbundling (CC.PP.031) (PDF)
- Neonatal Sepsis Management (CP.MP.85) (PDF)
- Never Paid Events (CC.PP.017) (PDF)
- New Patient (CC.PP.036) (PDF)
- Non-obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds (CC.PP.061) (PDF)
- Obstetrical Home Care Programs (CP.MP.91) (PDF)
- Outpatient Consultation (CC.PP.039) (PDF)
- Place of Service Mismatch (CC.PP.063) (PDF)
- Physician Visit Codes Billed with Labs (CC.PP.019) (PDF)
- Polymerase Chain Reaction (PCR) Testing (TX.PP.150) (PDF)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (CP.MP.181) (PDF)
- Post-Operative Visits (CC.PP.042) (PDF)
- Pre-Operative Visits (CC.PP.041) (PDF)
- Professional Component Modifier (CC.PP.027) (PDF)
- PROM Testing (CP.MP.149) (PDF)
- Proton and Neutron Beam Therapy (CP.MP.70) (PDF)
- Pulse Oximetry with Office Visits (CC.PP.025) (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF)
- Renal Hemodialysis (CC.PP.067) (PDF)
- Same Day Visits (CC.PP.040) (PDF)
- Sleep Studies Place of Services (CC.PP.035) (PDF)
- Status "B" Bundled Services (CC.PP.046) (PDF)
- Status "P" Bundled Services (CC.PP.049) (PDF)
- Supplies Billed on Same Day As Surgery (CC.PP.032) (PDF)
- Testing for Select Genitourinary Conditions (CP.MP.97) (PDF)
- Transgender Related Services (CC.PP.047) (PDF)
- Ultrasound in Pregnancy (CP.MP.38) (PDF)
- Unbundled Professional Services (CC.PP.043) (PDF)
- Unbundled Surgical Procedures (CC.PP.045) (PDF)
- Unlisted Procedure Codes (CC.PP.009) (PDF)
- Urine Specimen Validity Testing (CC.PP.056) (PDF)
- Urodynamic Testing (CP.MP.98) (PDF)
- Wheelchair and Accessories (CC.PP.502) (PDF)
- Wheelchair Seating (CP.MP.99) (PDF)
- Wireless Motility Capsule (CP.MP.143) (PDF)
Archived Policies
- Thymus Transplantation (CP.MP.189) - RETIRED (Medicaid and Ambetter April 28, 2022)(PDF)
- Ambulatory EEG (CP.MP.96) (Medicaid and Ambetter April 28, 2022) (PDF)
- Lesinurad (Zurampic), Lesinurad-allopuriNol (Duzallo) (CP.PMN.150) - RETIRED (Ambetter March 1, 2022) (PDF)
- Cerliponase alfa (Brineura) (TX.PHAR.46) - RETIRED (Medicaid January 24, 2022)(PDF)
- Ivermectin (Sklice) (HIM.PA.124) - RETIRED (Ambetter February 1, 2022) (PDF)
- Velaglucerase Alfa (VPRIV) (CP.PHAR.163) - RETIRED (Ambetter February 1, 2022) (PDF)
- Taliglucerase Alfa (Elelyso) (CP.PHAR.157) - Effective January 15, 2021 (PDF)
- Chlorambucil (Leukeran) (HIM.PA.SP59) - RETIRED (Ambetter February 1, 2022) (PDF)
- Anifrolumab-fnia (Saphnelo) (CP.PHAR.551) - RETIRED (Medicaid February 1, 2022)
- Fractional Exhaled Nitric Oxide (CP.MP.103) (PDF) - RETIRED (Medicaid January 26, 2022)
- Pegademase Bovine (Adagen) (CP.PHAR.392) - RETIRED (Medicaid and Ambetter December 1, 2021 (PDF)
- Human Growth Hormone (Somapacitan, Somatropin) (CP.PCH.39) - RETIRED (Ambetter December 1, 2021) (PDF)
- Bremelanotide (Vyleesi) (CP.PHAR.434) - RETIRED (Ambetter December 1, 2021) (PDF)
- DNA Analysis of Stool (CP.MP.125) - RETIRED (Medicaid and Ambetter November 18, 2021) (PDF)
- Handling Authorizations for Transportation (TX.UM.10.07) - RETIRED (Medicaid November 1, 2021 (PDF)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (CP.PHAR.385) (PDF) - RETIRED (Medicaid October 18, 2021)
- Abatacept (Orencia) (CP.PHAR.241) (PDF) - RETIRED (Medicaid October 18, 2021)
- Alglucosidase Alfa (Lumizyme) (CP.PHAR.160) (PDF) - RETIRED (Medicaid October 18, 2021)
- Benralizumab (Fasenra) (CP.PHAR.373) (PDF) - RETIRED (Medicaid October 18, 2021)
- Brexucabtagene Autoleucel (Tecartus) (CP.PHAR.472) (PDF) - RETIRED (Medicaid October 18, 2021)
- Brexucabtagene Autoleucel (Tecartus) (CP.PHAR.472) (PDF) - RETIRED (Medicaid October 18, 2021)
- Crizanlizumab-tmca (Adakveo) (CP.PHAR.449) (PDF) - RETIRED (Medicaid October 18, 2021)
- Emapalumab-lzsg (Gamifant) (CP.PHAR.402) - RETIRED (Medicaid October 18, 2021) (PDF)
- Treprostinil (Orenitram, Remodulin, Tyvaso) (CP.PHAR.199) - RETIRED (Medicaid October 18, 2021) (PDF)
- Ibalizumab-uiyk (Trogarzo) (CP.PHAR.378) - RETIRED (Medicaid October 18, 2021) (PDF)
- Inebilizumab-cdon (Uplizna) (CP.PHAR.458) - RETIRED (Medicaid October 18, 2021) (PDF)
- Luspatercept-aamt (Reblozyl) (CP.PHAR.450) - RETIRED (Medicaid October 18, 2021)(PDF)
- Mepolizumab (Nucala) (CP.PHAR.200) - RETIRED (Medicaid October 18, 2021) (PDF)
- Mogamulizumab-kpkc (Poteligeo) (CP.PHAR.139) - RETIRED (Medicaid October 18, 2021) (PDF)
- Moxetumomab Pasudotox-tdfk (Lumoxiti) (CP.PHAR.398) - RETIRED (Medicaid October 18, 2021)(PDF)
- Omalizumab (Xolair) (CP.PHAR.01) - RETIRED (Medicaid October 18, 2021) (PDF)
- Patisiran (Onpattro) (CP.PHAR.395) - RETIRED (Medicaid October 18, 2021) (PDF)
- Reslizumab (Cinqair) (CP.PHAR.223) - RETIRED (Medicaid October 18, 2021) (PDF)
- Teprotumumab (Tepezza) (CP.PHAR.465) - Effective 9/16/2020 (PDF)
- Vestronidase alfa-vjbk (Mepsevii) (CP.PHAR.374) - Effective January 9, 2018 (PDF)
- Plecanatide (Trulance) (CP.PMN.87) - RETIRED (Ambetter Septebmer 23, 2021)
- Sipuleucel-T (Provenge) (CP.PHAR.120) - RETIRED (Ambetter August 2, 2021)
- Carrier Screening in Pregnancy (CP.MP.83) (PDF) - RETIRED (Medicaid July 30, 2021)
- Evolocumab (Repatha) (CP.PHAR.123) - Effective 10/1/2015 (PDF) – RETIRED (Ambetter June 1, 2021)
- Continuous Insulin Delivery Systems (V-Go, Omnipod) (CP.PHAR.505) - Effective 12/1/2020 (PDF) – RETIRED (Ambetter June 1, 2021)
- Prucalopride (Motegrity) (CP.PMN.194) - Effective January 29, 2019 (PDF) – RETIRED (Ambetter June 1, 2021)
- Pralsetinib (Gavreto) (CP.PHAR.514) - Effective 2/1/2021 (PDF) – RETIRED (Ambetter June 1, 2021)
- Lemborexant (Dayvigo) (CP.PMN.233) - Effective 6/1/2020 (PDF) – RETIRED (Ambetter June 1, 2021)
- Budesonide (Pulmicort Respules) (HIM.PA.48) - Effective 9/1/2018 (PDF) – RETIRED (Ambetter May 3, 2021)
- Budesonide/Glycopyrrolate/Formoterol Fumarate (Breztri Aerosphere) (HIM.PA.150) - Effective 12/1/2020 (PDF) – RETIRED (Ambetter May 3, 2021)
- Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone) (HIM.PA.35) - Effective 2/1/2017 (PDF) – RETIRED (Ambetter May 3, 2021)
- Ciclesonide (Alvesco) (HIM.PA.65) - Effective 11/17/2020 (PDF) – RETIRED (Ambetter May 3, 2021)
- Indacaterol/Glycopyrrolate (Utibron Neohaler) (HIM.PA.102) - Effective 1/1/2021 (PDF) – RETIRED (Ambetter May 3, 2021)
- Aclidinium/Formoterol (Duaklir Pressair) (CP.PCH.23) - Effective 9/16/2020 (PDF) – RETIRED (Ambetter 3/1/2021)
- Eptinezumab (Vyepti) (CP.PCH.29) - Effective 6/1/2011 (PDF) – RETIRED (Ambetter 1/1/2021)
- Fremanezumab-vfrm (Ajovy) (CP.PCH.17) - Effective 3/1/2020 (PDF) – RETIRED (Ambetter 1/1/2021)
- Applied Behavioral Analysis for Autism (CP.MP.104) (PDF) – RETIRED (Ambetter 12/30/2020)
- Cell-free Fetal DNA Testing (CP.MP.84) (PDF) – RETIRED (Ambetter 12/30/2020)
- Neonatal Abstinence Syndrome Guidelines (CP.MP.86) (PDF) – RETIRED (Ambetter 12/30/2020)
- Genetic Testing (TX.CP.MP.531) (PDF) – RETIRED (Medicaid and CHIP 12/30/2020)
- Enteral Nutrition (TX.CP.MP.550) (PDF) – RETIRED (Medicaid and CHIP 12/30/2020)
- Magnetoencephalography (TX.CP.MP.570) – RETIRED (Medicaid and CHIP 12/30/2020)
- Antithymocyte Globulin (Thymoglobulin, Atgam) (HIM.PA.16) - RETIRED (Ambetter - 12/1/2020)
- Ciprofloxacin/Dexamethasone (Ciprodex) (HIM.PA.120) - Effective 12/1/2017 (PDF) - RETIRED (Ambetter - 12/1/2020)
- Ciprofloxacin/Fluocinolone (Otovel) (HIM.PA.14) - Effective 9/4/2018 (PDF) - RETIRED (Ambetter - 12/1/2020)
- Clindamycin (Evoclin) (HIM.PA.21) - Effective 8/28/2018 (PDF) - RETIRED (Ambetter - 12/1/2020)
- Clindamycin Phosphate/Benzoyl Peroxide (BenzaClin) (HIM.PA.31) - Effective 12/1/2018 (PDF) - RETIRED (Ambetter - 12/1/2020)
- Colesevelam (WelChol) (HIM.PA.121) - Effective 12/1/2017 (PDF) - RETIRED (Ambetter - 12/1/2020)
- Insulin Infusion Pump (Omnipod, Omnipod DASH) (CP.PHAR.420) - Effective 4/23/2019 (PDF) - RETIRED (Ambetter - 12/1/2020)
- Lomustine (Gleostine) (HIM.PA.19) - Effective 8/28/2018 (PDF) - RETIRED (Ambetter - 12/1/2020)
- Mesalamine (Apriso) (HIM.PA.42) - Effective 9/4/2018 (PDF) - RETIRED (Ambetter - 12/1/2020)
- Topical Diclofenac (Solaraze, Flector) (HIM.PA.123) (PDF) - RETIRED (Ambetter - 12/1/2020)
- Apomorphine (Apokyn) (CP.PCH.14) (PDF) - RETIRED (Ambetter - 11/17/2020)
- Brivaracetam (Briviact) (HIM.PA.07) (PDF) - RETIRED (Ambetter - 11/17/2020)
- Daclatasvir (Daklinza) (CP.PCH.15) (PDF) - RETIRED (Ambetter - 11/17/2020)
- Elbasvir/Grazoprevir (Zepatier) (CP.PCH.16) (PDF) - RETIRED (Ambetter - 11/17/2020)
- Ledipasvir/Sofosbuvir (Harvoni) (CP.PCH.19) (PDF) - RETIRED (Ambetter - 11/17/2020)
- Sofosbuvir (Sovaldi) (CP.PCH.20) (PDF) - RETIRED (Ambetter - 11/17/2020)
- Topical Diclofenac (Solaraze, Flector) (HIM.PA.123) (PDF) - RETIRED (Ambetter - 11/17/2020)
- Trigger Point Injections for Pain Management (CP.MP.169) (PDF) - RETIRED (Ambetter - 10/30/2020)
- Vagus Nerve Stimulation (CP.MP.12) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 10/30/2020)
- Facet Joint Interventions for Pain Management (CP.MP.171) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 10/1/2020)
- Fecal Incontinence Treatments (CP.MP.137) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 10/1/2020)
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 10/1/2020)
- Neonatal Sepsis Management Guidelines (CP.MP.85) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 10/1/2020)
- Physician’s Office Lab Testing (CC.PP.055) (PDF) – IMPLEMENTATION CANCELLED
- Monitored Anesthesia Care for Gastrointestinal Endoscopy - Effective 1/15/19 (CP.MP.161) PDF) - RETIRED (Medicaid and CHIP - 7/18/2019, Medicare - 7/22/2019, MarketPlace - 7/22/2019)
- Rituximab - Effective 11/1/2017 (CP.PHAR.260) (PDF) - RETIRED (Medicaid and CHIP, Medicare, Ambetter - 1/1/ 2019)
- Alpelisib (Piqray) (CP.PHAR.430) (PDF) - RETIRED
- Rivastigmine (Exelon) (CP.PMN.101) (PDF) - RETIRED
- Segesterone-Ethinyl Estradiol (Annovera) (CP.PMN.190) (PDF - RETIRED)
- Siponimod (Mayzent) (HIM.PA.SP37) (PDF) - RETIRED
- Somatropin (Human Growth Hormone) (HIM.PA.SP39) (PDF) - RETIRED
- Tafenoquine (Arakoda, Krintafel) (CP.PMN.178) (PDF) - RETIRED
- Enoxaparin (Lovenox) (CP.PHAR.224) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Halobetasol-Tazarotene (Duobrii) (CP.PMN.208) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Isavuconazonium (Cresemba) (HIM.PA.108) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Ixekizumab (Taltz) (CP.PHAR.257) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Naloxone (Evzio) (CP.PMN.139) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Olodaterol (Striverdi Respimat) (CP.PMN.204) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Peginterferon Beta-1a (Plegridy) (HIM.PA.SP18) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Revefenacin (Yupelri) (CP.PMN.195) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Sodium Zirconium Cyclosilicate (Lokelma) (CP.PMN.163) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Tegaserod (Zelnorm) (CP.PMN.206) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Teriflunomide (Aubagio) (CP.PCH.02) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Umeclidinium-vilanterol (Anoro Ellipta) (HIM.PA.106) (PDF) - RETIRED (Ambetter - 3/24/2021)
- Digital Breast Tomosynthesis (DBT) (CP.MP.90) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 10/5/2018)
- Fecal Calprotectin Assay (CP.MP.135) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 12/14/2018)
- Assertive Community Treatment (TX.CP.MP.548) (PDF) - RETIRED (Medicaid and CHIP - 3/20/2020)
- Home Telemonitoring Services (TX.CP.MP.547) (PDF) - RETIRED (Medicaid and CHIP - 3/18/2020)
- Standard Manual Wheelchair or Standard Power Wheeled Mobility Systems (TX.CP.MP.519) (PDF) - RETIRED (Medicaid and CHIP - 4/15/2020)
- Emtricitabine-Tenofovir (Truvada) (HIM.PA.78) - RETIRED (Ambetter - 9/16/2020)
- Glecaprevir/Pibrentasvir (Mavyret) (CP.PCH.18) - RETIRED (Ambetter - 9/16/2020)
- Sofosbuvir/Velpatasvir (Epclusa) (CP.PCH.21) - RETIRED (Ambetter - 9/16/2020)
- Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (CP.PCH.22) - RETIRED (Ambetter - 9/16/2020)
- Erenumab-aaoe (Aimovig) (CP.PHAR.128) - Effective 7/10/2018 (PDF) - RETIRED (Ambetter - 10/6/2020)
- Galcanezumab-gnlm (Emgality) (CP.PCH.24) - Effective 1/1/2020 (PDF) - RETIRED (Ambetter - 10/6/2020)