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 Texas Medicaid Provider Procedures Manual (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. TMPPM is regularly updated to reflect the most recent policy and procedure changes. Advanced notification of upcoming changes appear as banner messages located at the TMHP Banner Messages.
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 and Therapy (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)
- 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)
- Fixed Wing Air Transportation (CP.MP.175) (PDF)
- Functional MRI (CP.MP.43) (PDF)
- Gastric Electrical Stimulation (CP.MP.40) (PDF)
- Gender-Affirming Procedures (CP.MP.95) (PDF)
- Heart-Lung Transplant (CP.MP.132) (PDF)
- Home Births (CP.MP.136) (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)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (CP.MP.160) (PDF)
- Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Intensity-Modulated Radiotherapy (CP.MP.69) (PDF)
- Intestinal and Multivisceral Transplant (CP.MP.58) (PDF)
- Intradiscal Steroid Injections for Pain Management (CP.MP.167) (PDF)
- Kidney Disorders (CP.MP.227)
- Liposuction for Lipedema (CP.MP.244)
- 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)
- Oncology Algorithmic Testing (CP.MP.237)
- Oncology Cancer Screening (CP.MP.238)
- Oncology Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (CP.MP.239)
- Oncology Cytogenetic Testing (CP.MP.240)
- Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (CP.MP.241)
- Orthognathic Surgery (CP.MP.202) (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 Kidney Transplant (CP.MP.246) (PDF)
- Pediatric Liver Transplant (CP.MP.120) (PDF)
- Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150) (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 (TX.CP.MP.582) (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)
- 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)
- Transplant Service Documentation Requirements (CP.MP.247) (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)
- Acute Care Inpatient Hospital Claims - Sepsis Diagnosis (CC.PP.073) (PDF)
- ADHD Assessment and Treatment (CP.MP.124) (PDF)
- Allergy Testing and Therapy (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 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)
- 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) (PDF)
- Abametapir (Xeglyze) (CP.PMN.253) (PDF)
- Abemaciclib (Verzenio) (CP.PHAR.355) (PDF)
- Abiraterone (Zytiga, Yonsa) (CP.PHAR.84) (PDF)
- AbobotulinumtoxinA (Dysport) (CP.PHAR.230) (PDF)
- Abrocitinib (Cibinqo) (CP.PHAR.578) (PDF)
- Acalabrutinib (Calquence) (CP.PHAR.366) (PDF)
- Aclidinium-formoterol (Duaklir Pressair) (HIM.PA.151) (PDF)
- Acyclovir Buccal Tablet (Sitavig) (CP.PMN.210) (PDF)
- Adefovir (Hepsera) (CP.PHAR.142) (PDF)
- Ado-Trastuzumab Emtansine (Kadcyla) (CP.PHAR.229) (PDF)
- Aducanumab-avwa (Aduhelm) (CP.PHAR.468) (PDF)
- Afamelanotide (Scenesse) (CP.PHAR.444) (PDF)
- Afatinib (Gilotrif) (CP.PHAR.298) (PDF)
- Aflibercept (Eylea) (CP.PHAR.184) (PDF)
- Agalsidase Beta (Fabrazyme) (CP.PHAR.158) (PDF)
- Age Limit Override (Codeine, Tramadol, Hydrocodone) (CP.PMN.138) (PDF)
- Alectinib (Alecensa) (CP.PHAR.369) (PDF)
- Alemtuzumab (Lemtrada) (CP.PHAR.243) (PDF)
- Alendronate (Binosto, Fosamax Plus D) (CP.PMN.88) (PDF)
- Alglucosidase Alfa (Lumizyme) (CP.PHAR.160) (PDF)
- Allogeneic cultured keratinocytes and dermal fibroblasts (StrataGraft) (CP.PHAR.562) (PDF)
- Allogenic processed thymus tissue-agdc (Rethymic) (CP.PHAR.563) (PDF)
- Alpelisib (Piqray, Vijoice) (CP.PHAR.430) (PDF)
- Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (CP.PHAR.94) (PDF)
- Amantadine ER (Gocovri,Osmolex ER) (CP.PMN.89) (PDF)
- Ambrisentan (Letairis) (CP.PHAR.190) (PDF)
- Amifampridine (Firdapse, Ruzurgi) (CP.PHAR.411) (PDF)
- Amikacin (Arikayce) (CP.PHAR.401) (PDF)
- Amisulpride (Barhemsys) (CP.PMN.236) (PDF)
- Amivantamab-vmjw (Rybrevant) (CP.PHAR.544) (PDF)
- Anifrolumab-fnia (Saphnelo) (CP.PHAR.551) (PDF)
- Anti-inhibitor Coagulant Complex (Feiba) (CP.PHAR.217) (PDF)
- Antithrombin III (ATryn, Thrombate III) (CP.PHAR.564) (PDF)
- Antithymocyte Globulin (Atgam, Thymoglobulin) (CP.PHAR.506) (PDF)
- Apalutamide (Erleada) (CP.PCH.45) (PDF)
- Apomorphine (Apokyn, Kynmobi) (CP.PHAR.488) (PDF)
- Aprepitant (Aponvie, Cinvanti, Emend) (CP.PMN.19) (PDF)
- Arformoterol tartrate (Brovana) (CP.PMN.201) (PDF)
- Arimoclomol (Brand Name) (CP.PHAR. 510) (PDF)
- Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada, Aristada Initio) (CP.PHAR.290) (PDF)
- Aripiprazole Orally Disintegrating Tab (Abilify) (CP.PCH.37) (PDF)
- Armodafinil (Nuvigil) (CP.PMN.35) (PDF)
- Asciminib (Scemblix) (CP.PHAR.565) (PDF)
- Asenapine (Saphris, Secuado) (CP.PMN.15) (PDF)
- Asfotase Alfa (Strensiq) (CP.PHAR.328) (PDF)
- Aspirin/Dipyridamole (Aggrenox) (CP.PMN.20) (PDF)
- Atezolizumab (Tecentriq®) (CP.PHAR.235) (PDF)
- Atidarsagene autotemcel (OTL-200) (CP.PHAR.602) (PDF)
- Atogepant (Qulipta) (CP.PHAR.566) (PDF)
- Avacopan (Tavneos) (CP.PHAR.515) (PDF)
- Avalglucosidase alfa-ngpt (Nexviazyme) (CP.PHAR.521) (PDF)
- Avapritinib (Ayvakit) (CP.PHAR.454) (PDF)
- Avatrombopag (Doptelet) (CP.PHAR.130) (PDF)
- Avelumab (Bavencio) (CP.PHAR.333) (PDF)
- Axicabtagene Ciloleucel (Yescarta) (CP.PHAR.362) (PDF)
- Axitinib (Inlyta) (CP.PHAR.100) (PDF)
- Azacitidine (Onureg, Vidaza) (CP.PHAR.387) (PDF)
- Azelaic Acid (Finacea Topical Gel) (HIM.PA.119) (PDF)
- Aztreonam (Cayston) (CP.PHAR.209) (PDF)
- Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispah, Ozobax) (CP.PHAR.149) (PDF)
- Baloxavir Marboxil (Xofluza) (CP.PMN.185) (PDF)
- Bamlanivimab-etesevimab (LY-CoV555-LY-CoV016) (CP.PHAR.532) (PDF)
- Bardoxolone Methyl (RTA 402) (CP.PHAR.560) (PDF)
- Bebtelovimab (LY-CoV1404) (CP.PHAR.579) (PDF)
- Bedaquiline (Sirturo) (CP.PMN.212) (PDF)
- Belantamab Mafodotin (Blenrep) (CP.PHAR.469) (PDF)
- Belatacept (Nulojix) (CP.PHAR.201) (PDF)
- Belimumab (Benlysta) (CP.PHAR.88) (PDF)
- Belinostat (Beleodaq) (CP.PHAR.311) (PDF)
- Belumosudil (Rezurock) (CP.PHAR.552) (PDF)
- Belzutifan (Welireg) (CP.PHAR.553) (PDF)
- Bempedoic acid (Nexletol), bempedoic acid-ezetimibe (Nexlizet) (CP.PMN.237) (PDF)
- Bendamustine (Belrapzo, Bendeka, Treanda) (CP.PHAR.307) (CP.PHAR.307)(PDF)
- Benralizumab (Fasenra) (CP.PHAR.373) (PDF)
- Benznidazole (CP.PMN.90) (PDF)
- Beremagene Geperpavec (Vyjuvek) (CP.PHAR.592) (PDF)
- Berotralstat (Orladeyo) (CP.PHAR.485) (PDF)
- Betaine (Cystadane) (CP.PHAR.143) (PDF)
- Betamethasone Dipropionate Spray (Sernivo) (CP.PMN.182) (PDF)
- Betibeglogene autotemcel (CP.PHAR.545) (PDF)
- Bevacizumab (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev) (CP.PHAR.93) (PDF)
- Bexarotene (Targretin Capsules, Gel) (CP.PHAR.75) (PDF)
- Bezlotoxumab (Zinplava) (CP.PHAR.300) (PDF)
- Bimatoprost Implant (Durysta) (CP.PHAR.486) (PDF)
- Binimetinib (Mektovi) (CP.PHAR.50) (PDF)
- Biologic and Non-biologic DMARDs (HIM.PA.SP60) (PDF)
- Blinatumomab (Blincyto) (CP.PHAR.312) (PDF)
- Bortezomib (Velcade) (CP.PHAR.410) (PDF)
- Bosentan (Tracleer) (CP.PHAR.191) (PDF)
- Bosutinib (Bosulif) (CP.PHAR.105) (PDF)
- Brand Name Override and Non-Formulary Medications (HIM.PA.103) (PDF)
- Brentuximab Vedotin (Adcetris) (CP.PHAR.303) (PDF)
- Brexanolone (Zulresso) (CP.PHAR.417) (PDF)
- Brexpiprazole (Rexulti) (CP.PMN.68) (PDF)
- Brexucabtagene Autoleucel (Tecartus) (CP.PHAR.472) (PDF)
- Brigatinib (Alunbrig) (CP.PHAR.342) (PDF)
- Brimonidine Tartrate (Mirvaso) (CP.PMN.192) (PDF)
- Brinzolamide/Brimonidine (Simbrinza) (HIM.PA.15) (PDF)
- Brivaracetam (Briviact) (CP.PCH.26) (PDF)
- Brolucizumab (Beovu) (CP.PHAR.445) (PDF)
- Budesonide (Tarpeyo) (CP.PHAR.572) (PDF)
- Budesonide (Uceris) (CP.PCH.11) (PDF)
- Bulevirtide (Hepcludex) (CP.PHAR.589) (PDF)
- Buprenorphine (Subutex) (CP.PMN.82) (PDF)
- Buprenorphine (Probuphine, Sublocade) (CP.PHAR.289) (PDF)
- Buprenorphine Injection (Brixadi) (CP.PHAR.498) (PDF)
- Buprenorphine-naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (CP.PMN.81) (PDF)
- Bupropion-naltrexone (Contrave) (CP.PCH.12) (PDF)
- Burosumab-twza (Crysvita) (CP.PHAR.11) (PDF)
- Butorphanol Nasal Spray (HIM.PA.46) (PDF)
- C1 Esterase Inhibitors (Berinert Cinryze Haegarda Ruconest) (CP.PHAR.202) (PDF)
- Cabazitaxel (Jevtana) (CP.PHAR.316) (PDF)
- Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) (CP.PHAR.573) (PDF)
- Cabozantinib (Cabometyx, Cometriq) (CP.PHAR.111) (PDF)
- Calcifediol (Rayaldee) (CP.PMN.76) (PDF)
- Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) (CP.PMN.181) (PDF)
- Canakinumab (Ilaris) (CP.PHAR.246) (PDF)
- Cannabidiol (Epidiolex) (CP.PMN.164) (PDF)
- Capecitabeine (Xeloda) (CP.PHAR.60) (PDF)
- Caplacizumab-yhdp (Cablivi) (CP.PHAR.416) (PDF)
- Capmatinib (Tabrecta) (CP.PHAR.494) (PDF)
- Carbetocin (CP.PHAR.546) (PDF)
- Carbidopa-Levodopa ER Capsules (Rytary) (CP.PMN.238) (PDF)
- Carfilzomib (Kyprolis) (CP.PHAR.309) (PDF)
- Carglumic Acid (Carbaglu) (CP.PHAR.206) (PDF)
- Cariprazine (Vraylar) (CP.PMN.91) (PDF)
- Casimersen (Amondys 45) (CP.PHAR.470) (PDF)
- Casirivimab and imdevimab (REGN-COV2) (CP.PHAR.520) (PDF)
- Celecoxib (Celebrex, Elyxyb) (CP.PMN.122) (PDF)
- Cemiplimab-rwlc (Libtayo) (CP.PHAR.397) (PDF)
- Cenegermin-bkbj (Oxervate) (CP.PMN.186) (PDF)
- Cenobamate (Xcopri) (CP.PMN.231) (PDF)
- Ceritinib (Zykadia) (CP.PHAR.349) (PDF)
- Cerliponase alfa (Brineura) (CP.PHAR.338) (PDF)
- Cetuximab (Erbitux) (CP.PHAR.317) (PDF)
- Chenodiol (Chenodal) (CP.PMN.239) (PDF)
- Chlorambucil (Leukeran) (CP.PHAR.554) (PDF)
- Chloramphenicol (CP.PHAR.388) (PDF)
- Cholic Acid (Cholbam) (CP.PHAR.390) (PDF)
- Ciclopirox (Penlac) (CP.PMN.24) (PDF)
- Ciltacabtagene Autoleucel (Carvykti) (CP.PHAR.533) (PDF)
- Cinacalcet (Sensipar) (CP.PHAR.61) (PDF)
- Cipaglucosidase alfa-miglustat (AT-GAA) (CP.PHAR.567) (PDF)
- Ciprofloxacin/Dexamethasone (Ciprodex) (CP.PMN.248) (PDF)
- Ciprofloxacin/Fluocinolone (Otovel) (CP.PMN.249) (PDF)
- Cladribine (Mavenclad) (CP.PHAR.422) (PDF)
- Clascoterone (Winlevi) (CP.PMN.257) (PDF)
- Clobazam (Onfi, Sympazan) (CP.PMN.54) (PDF)
- Colchicine (Colcrys) (CP.PMN.123) (PDF)
- Colesevelam (Welchol) (CP.PMN.250) (PDF)
- CNS Stimulants (CP.PMN.92) (PDF)
- Cobimetinib (Cotellic) (CP.PHAR.380) (PDF)
- Collagenase Clostridium Histolyticum (Xiaflex) (CP.PHAR.82) (PDF)
- Colonoscopy Preparation Products (CP.PCH.43) (PDF)
- Compounded Medications (CP.PMN.280) (PDF)
- Conjugated Estrogens/Bazedoxifene (Duavee) (CP.PMN.258) (PDF)
- Continuous Glucose Monitors (CP.PMN.214) (PDF)
- Copanlisib (Aliqopa) (CP.PHAR.357) (PDF)
- Corticosteroids for Ophthalmic Injection (Iluvien, Ozurdex, Retisert, Xipere, Yutiq) (CP.PHAR.385) (PDF)
- Cosyntropin (Cortrosyn) (CP.PHAR.203) (PDF)
- Crisaborole (Eucrisa) (CP.PMN.110) (PDF)
- Crizanlizumab-tmca (Adakveo) (CP.PHAR.449) (PDF)
- Crizotinib (Xalkori) (CP.PHAR.90) (PDF)
- Cyclosprine (Cequa, Restasis) (CP.PMN.48) (PDF)
- Cysteamine ophthalmic (Cystaran, Cystadrops) (CP.PMN.130) (PDF)
- Cysteamine oral (Cystagon, Procysbi) (CP.PHAR.155) (PDF)
- Cytomegalovirus Immune Globulin (CytoGam) (CP.PHAR.277) (PDF)
- Dabrafenib (Tafinlar) (CP.PHAR.239) (PDF)
- Dacomitinib (Vizimpro) (CP.PHAR.399) (PDF)
- Daclatasvir (Daklinza) (HIM.PA.SP27) (PDF)
- Dalfampridine (Ampyra) (CP.PHAR.248) (PDF)
- Dalteparin (Fragmin) (CP.PHAR.225) (PDF)
- Dapsone (Aczone Gel) (CP.PCH.32) (PDF)
- Daptomycin (Cubicin, Cubicin RF) (CP.PHAR.351) (PDF)
- Daratumumab, Daratumumab-Hyaluronidase-fihj (Darzalex, Darzalex Faspro) (CP.PHAR.310) (PDF)
- Darbepoetin Alfa (Aranesp) (CP.PHAR.236) (PDF)
- Darolutamide (Nubeqa) (CP.PHAR.435) (PDF)
- Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) (HIM.PA.SP61) (PDF)
- Dasatinib (Sprycel) (CP.PHAR.72) (PDF)
- Daunorubicin-cytarabine (Vyxeos) (CP.PHAR.352) (PDF)
- Decitabine/Cedazuridine (Inqovi) (CP.PHAR.479) (PDF)
- Deferasirox (Exjade, Jadenu) (CP.PHAR.145) (PDF)
- Deferoxamine (Desferal) (CP.PHAR.146) (PDF)
- Deflazacort (Emflaza) (CP.PHAR.331) (PDF)
- Degarelix Acetate (Firmagon) (CP.PHAR.170) (PDF)
- Delafloxacin (Baxdela) (CP.PMN.115) (PDF)
- Denosumab (Prolia Xgeva) (CP.PHAR.58) (PDF)
- Desmopressin (DDAVP, Stimate, Nocdurna, Noctiva) (CP.PHAR.214) (PDF)
- Deutetrabenazine (Austedo) (CP.PCH.42) (PDF)
- Dexlansoprazole (Dexilant) (HIM.PA.05) (PDF)
- Dexrazoxane (Zinecard, Totect) (CP.PHAR.418) (PDF)
- Dextromethorphan-bupropion (Auvelity) (CP.PMN.284) (PDF)
- Dextromethorphan-Quinidine (Nuedexta) (CP.PMN.93) (PDF)
- Diazepam Nasal Spray (Valtoco) (CP.PMN.216) (PDF)
- Dichlorphenamide (Keveyis) (CP.PMN.261) (PDF)
- Diclofenac (Cambia, Flector, Licart, Pennsaid, Solaraze, Zipsor, Zorvolex) (CP.PCH.28) (PDF)
- Dimethyl fumarate (Tecfidera), diroximel fumarate (Vumerity), monomethyl fumarate (Bafiertam) (CP.PCH.41) (PDF)
- Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (HIM.PA.58) (PDF)
- Dolasetron (Anzemet) (CP.PMN.141) (PDF)
- Donislecel (Lantidra) (CP.PHAR.569) (PDF)
- Dornase alfa (Pulmozyme) (CP.PHAR.212) (PDF)
- Dostarlimab-gxly (Jemperli) (CP.PHAR.540) (PDF)
- Doxepin (Silenor, Prudoxin, Zonalon) (HIM.PA.147) (PDF)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (CP.PMN.79) (PDF)
- Dupilumab (Dupixent) (CP.PHAR.336) (PDF)
- Durvalumab (Imfinzi) (CP.PHAR.339) (PDF)
- Dutasteride (Avodart) and Dutasteride/Tamsulosin (Jalyn) (CP.PMN.128) (PDF)
- Duvelisib (Copiktra) (CP.PHAR.400) (PDF)
- Ecallantide (Kalbitor) (CP.PHAR.177) (PDF)
- Eculizumab (Soliris) (CP.PHAR.97) (PDF)
- Edaravone (Radicava) (CP.PHAR.343) (PDF)
- Efinaconazole (Jublia) (CP.PMN.25) (PDF)
- Efgartigimod Alfa-fcab (Vyvgart) (CP.PHAR.555) (PDF)
- Elagolix (Orilissa), elagolix-estradiol-norethindrone (Oriahnn) (CP.PHAR.136) (PDF)
- Elapegademase-lvlr (Revcovi) (CP.PHAR.419) (PDF)
- Elbasvir/Grazoprevir (Zepatier) (HIM.PA.SP62) (PDF)
- Elexacaftor-ivacaftor-tezacaftor (Trikafta) (CP.PHAR.440) (PDF)
- Eliglustat (Cerdelga) (CP.PHAR.153) (PDF)
- Elivaldogene Autotemcel (Skysona) (CP.PHAR.556) (PDF)
- Elosulfase Alfa (Vimizim) (CP.PHAR.162) (PDF)
- Elotuzumab (Empliciti) (CP.PHAR.308) (PDF)
- Eltrombopag (Promacta) (CP.PHAR.180) (PDF)
- Eluxadoline (Viberzi) (CP.PMN.170) (PDF)
- Emapalumab-lzsg (Gamifant) (CP.PHAR.402) (PDF)
- Emicizumab-kxwh (Hemlibra) (CP.PHAR.370) (PDF)
- Emtricitabine/Tenofovir Alafenamide (Descovy) (CP.PMN.235) (PDF)
- Enasidenib (Idhifa) (CP.PHAR.363) (PDF)
- Encorafenib (Braftovi) (CP.PHAR.127) (PDF)
- Enfortumab Vedotin-ejfv (Padcev) (CP.PHAR.455) (PDF)
- Enfuvirtide (Fuzeon) (CP.PHAR.41) (PDF)
- Enoxaparin (Lovenox) (CP.PHAR.224) (PDF)
- Entecavir (Baraclude) (HIM.PA.08) (PDF)
- Entrectinib (Rozlytrek) (CP.PHAR.441) (PDF)
- Enzalutamide (Xtandi) (CP.PHAR.106) (PDF)
- Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) (CP.PHAR.237) (PDF)
- Epoprostenol (Flolan, Veletri) (CP.PHAR.192) (PDF)
- Eptinezumab (Vyepti) (HIM.PA.SP64) (PDF)
- Erdafitinib (Balversa) (CP.PHAR.423) (PDF)
- Erenumab-aaoe (Aimovig) (HIM.PA.SP65) (PDF)
- Eribulin Mesylate (Halaven) (CP.PHAR.318) (PDF)
- Erlotinib (Tarceva) (CP.PHAR.74) (PDF)
- Erwinia Asparaginase (Erwinaze, Rylaze) (CP.PHAR.301) (PDF)
- Esketamine (Spravato) (CP.PMN.199) (PDF)
- Estradiol (Femring) (CP.PMN.263) (PDF)
- Etelcalcetide (Parsabiv) (CP.PHAR.379) (PDF)
- Eteplirsen (Exondys 51) (CP.PHAR.288) (PDF)
- Everolimus (Afinitor, Afinitor Disperz, Zortress) (CP.PHAR.63) (PDF)
- Evinacumab-dgnb (Evkeeza) (HIM.PA.166) (PDF)
- Evolocumab (Repatha) (HIM.PA.156) (PDF)
- Exagamglogene autotemcel (Exa-Cel) (CP.PHAR.603) (PDF)
- Factor IX Human Recombinant (CP.PHAR.218) (PDF)
- Factor IX Complex, Human (Profilnine) (CP.PHAR.219) (PDF)
- Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (CP.PHAR.220) (PDF)
- Factor VIII (Human, Recombinant) (CP.PHAR.215) (PDF)
- Factor VIII/von Willebrand Factor Complex (Human – Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi) (CP.PHAR.216) (PDF)
- Factor XIIIa_Recombinant (Tretten) (CP.PHAR.222) (PDF)
- Factor XIII Human (Corifact) (CP.PHAR.221) (PDF)
- Fam-trastuzumab Deruxtecan-nxki (Enhertu) (CP.PHAR.456) (PDF)
- Febuxostat (Uloric) (CP.PMN.57) (PDF)
- Fedratinib (Inrebic) (CP.PHAR.442) (PDF)
- Faricimab-svoa (Vabysmo) (CP.PHAR.581) (PDF)
- Fenfluramine (Fintepla) (CP.PMN.246) (PDF)
- Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (CP.PMN.127) (PDF)
- Ferric Carboxymaltose (Injectafer) (CP.PHAR.234) (PDF)
- Ferric Derisomaltose (Monoferric) (CP.PHAR.480) (PDF)
- Ferric Gluconate (Ferrlecit) (CP.PHAR.166) (PDF)
- Ferric Maltol (Accrufer) (CP.PMN.213) (PDF)
- Ferumoxytol (Feraheme) (CP.PHAR.165) (PDF)
- Fibrinogen concentrate (human) (Fibryga, RiaSTAP) (CP.PHAR.526) (PDF)
- Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastim-aafi (Nivestym) (CP.PHAR.297) (PDF)
- Flibanserin (Addyi) (CP.PHAR.446) (PDF)
- Finerenone (Kerendia) (CP.PMN.266) (PDF)
- Fingolimod (Gilenya) (CP.PCH.38) (PDF)
- Fluorouracil Cream (Tolak) (CP.PMN.165) (PDF)
- Fluticasone Propionate (Xhance) (CP.PMN.95) (PDF)
- Fondaparinux (Arixtra) (CP.PHAR.226) (PDF)
- Fostemsavir (Rukobia) (CP.PHAR.516) (PDF)
- Fosdenopterin (Nulibry) (CP.PHAR.471) (PDF)
- Fostamatinib (Tavalisse) (CP.PHAR.24) (PDF)
- Fremanezumab-vfrm (Ajovy) (HIM.PA.SP66) (PDF)
- Fulvestrant (Faslodex Injection) (CP.PHAR.424) (PDF)
- Furosemide (Furoscix) (CP.PHAR.608) (PDF)
- Futibatinib (Lytgobi) (CP.PHAR.604) (PDF)
- Gabapentin ER (Gralise, Horizant) (CP.PMN.240) (PDF)
- Galcanezumab-gnlm (Emgality) (HIM.PA.SP67) (PDF)
- Galsulfase (Naglazyme) (CP.PHAR.161) (PDF)
- Ganaxolone (Ztalmy) (CP.PMN.278) (PDF)
- Gefitinib (Iressa) (CP.PHAR.68) (PDF)
- Gemtuzumab Ozogamicin (Mylotarg) (CP.PHAR.358) (PDF)
- Gilteritinib (Xospata) (CP.PHAR.412) (PDF)
- Givosiran (Givlaari) (CP.PHAR.457) (PDF)
- Glaucoma Agents (Omlonti, Rhopressa, Rocklatan, Vyzulta) (CP.PMN.286) (PDF)
- Glasdegib (Daurismo) (CP.PHAR.413) (PDF)
- Glatiramer (Copaxone, Glatopa) (HIM.PA.SP68) (PDF)
- Glecaprevir/Pibrentasvir (Mavyret) (HIM.PA.SP36) (PDF)
- GLP-1 receptor agonists (HIM.PA.53) (PDF)
- Glycerol Phenylbutyrate (Ravicti) (CP.PHAR.207) (PDF)
- Golodirsen (Vyondys 53) (CP.PHAR.453) (PDF)
- Goserelin Acetate (Zoladex) (CP.PHAR.171) (PDF)
- Granisetron (Sancuso, Sustol) (CP.PMN.74) (PDF)
- Halcinonide (Halog) (HIM.PA.20) (PDF)
- Halobetasol Propionate (Bryhali, Lexette, Ultravate)(CP.PMN.180) (PDF)
- Halobetasol-Tazarotene (Duobrii) (CP.PMN.208) (PDF)
- Hemin (Panhematin) (CP.PHAR.181) (PDF)
- Histrelin Acetate (Vantas, Supprelin LA) (CP.PHAR.172) (PDF)
- House Dust Mite Allergen Extract (Odactra) (CP.PMN.111) (PDF)
- Human Growth Hormone (Somapacitan, Somatropin)(HIM.PA.161) (PDF)
- Hyaluronate Derivatives (CP.PHAR.05) (PDF)
- Hydroxyurea (Siklos) (CP.PMN.193) (PDF)
- Ibalizumab-uiyk (Trogarzo) (CP.PHAR.378) (PDF)
- Ibandronate Injection (Boniva) (CP.PHAR.189) (PDF)
- Ibrutinib (Imbruvica) (CP.PHAR.126) (PDF)
- Ibuprofen/Famotidine (Duexis) (CP.PMN.120) (PDF)
- Icatibant (Firazyr) (CP.PHAR.178) (PDF)
- Icosapent Ethyl (Vascepa) (CP.PMN.187) (PDF)
- Idecabtagene Vicleucel (Abecma) (CP.PHAR.481) (PDF)
- Idelalisib (Zydelig) (CP.PHAR.133) (PDF)
- Idursulfase (Elaprase) (CP.PHAR.156) (PDF)
- Iloperidone (Fanapt) (CP.PMN.32) (PDF)
- Iloprost (Ventavis) (CP.PHAR.193) (PDF)
- Imatinib (Gleevec) (CP.PHAR.65) (PDF)
- Imiglucerase (Cerezyme) (CP.PHAR.154) (PDF)
- Immune Globulins (CP.PHAR.103) (PDF)
- Inclisiran (Leqvio) (CP.PHAR.568) (PDF)
- IncobotulinumtoxinA (Xeomin) (CP.PHAR.231) (PDF)
- Indacaterol (Arcapta Neohaler) (CP.PMN.203) (PDF)
- Inebilizumab-cdon (Uplizna) (CP.PHAR.458) (PDF)
- Infertility and Fertility Preservation (CP.PHAR.131) (PDF)
- Infigratinib (Truseltiq) (CP.PHAR.547) (PDF)
- Inhaled Agents for Asthma and COPD (HIM.PA.153) (PDF)
- Inotersen (Tegsedi) (CP.PHAR.405) (PDF)
- Inotuzumab Ozogamicin (Besponsa) (CP.PHAR.359) (PDF)
- Insulin Glargine (Rezvoglar, Semglee, Toujeo) (HIM.PA.09) (PDF)
- Insulin Delivery Systems (V-Go, Omnipod, InPen) (CP.PHAR.534) (PDF)
- Interferon beta-1a (Avonex, Rebif) (CP.PHAR.255) (PDF)
- Interferon Beta-1b (Betaseron, Extavia) (CP.PCH.46) (PDF)
- Interferon Gamma- 1b (Actimmune) (CP.PHAR.52) (PDF)
- Iobenguane I 131 (Azedra) (CP.PHAR.459) (PDF)
- Ipilimumab (Yervoy) (CP.PHAR.319) (PDF)
- Irinotecan Liposome (Onivyde) (CP.PHAR.304) (PDF)
- Iron Sucrose (Venofer) (CP.PHAR.167) (PDF)
- Isatuximab-irfc (Sarclisa) (CP.PHAR.482) (PDF)
- Isavuconazonium (Cresemba) (CP.PMN.154) (PDF)
- Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (CP.PMN.143) (PDF)
- Istradefylline (Nourianz) (CP.PMN.217) (PDF)
- Itraconazole (Sporanox, Tolsura) (CP.PMN.124) (PDF)
- Ivabradine (Corlanor) (CP.PMN.70) (PDF)
- Ivacaftor (Kalydeco) (CP.PHAR.210) (PDF)
- Ivermectin (Sklice) (HIM.PA.124) (PDF)
- Ivermectin (Stromectol, Sklice) (CP.PMN.269) (PDF)
- Ivosidenib (Tibsovo) (CP.PHAR.137) (PDF)
- Ixazomib (Ninlaro) (CP.PHAR.302) (PDF)
- Ketorolac Nasal Spray (Sprix) (CP.PMN.282) (PDF)
- Lactic Acid/Citric Acid/Potassium Bitartrate (Phexxi) (CP.PMN.251) (PDF)
- Lacosamide (Vimpat) (CP.PMN.155) (PDF)
- Lanadelumab-fylo (Takhzyro) (CP.PHAR.396) (PDF)
- Lanreotide (Somatuline Depot) (CP.PHAR.391) (PDF)
- Lapatinib (Tykerb) (CP.PHAR.79) (PDF)
- Laronidase (Aldurazyme) (CP.PHAR.152) (PDF)
- Larotrectinib (Vitrakvi) (CP.PHAR.414) (PDF)
- Lasmiditan (Reyvow) (CP.PMN.218) (PDF)
- Ledipasvir/Sofosbuvir (Harvoni) (HIM.PA.SP3) (PDF)
- Lefamulin (Xenleta) (CP.PMN.219) (PDF)
- Lenalidomide (Revlimid) (CP.PHAR.71) (PDF)
- Lenvatinib (Lenvima) (CP.PHAR.138) (PDF)
- Leniolisib (Joenja) (CP.PHAR.597) (PDF)
- Letermovir (Prevymis) (CP.PHAR.367) (PDF)
- Leucovorin Injection (CP.PHAR.393) (PDF)
- Leuprolide Acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi, Camcevi) (CP.PHAR.173) (PDF)
- Levodopa Inhalation Powder (Inbrija) (CP.PMN.267) (PDF)
- Levoketoconazole (Recorlev) (CP.PMN.275) (PDF)
- Levoleucovorin (Fusilev, Khapzory) (CP.PHAR.151) (PDF)
- Levomilnacipran (Fetzima) (HIM.PA.125) (PDF)
- L-glutamine (Endari) (CP.PMN.116) (PDF)
- Lidocaine Transdermal (Lidoderm, ZTlido) (CP.PMN.08) (PDF)
- Lifitegrast (Xiidra) (CP.PMN.73) (PDF)
- Linaclotide (Linzess) (CP.PMN.71) (PDF)
- Linezolid (Zyvox) (CP.PMN.27) (PDF)
- Lisocabtagene maraleucel (Breyanzi) (CP.PHAR.483) (PDF)
- Lofexidine (Lucemyra) (CP.PMN.152) (PDF)
- Lomustine (Gleostine) (CP.PHAR.507) (PDF)
- Lonafarnib (Zokinvy) (CP.PHAR.499) (PDF)
- Loncastuximab tesirine-lpyl (Zynlonta) (CP.PHAR.539) (PDF)
- Lorlatinib (Lorbrena) (CP.PHAR.406) (PDF)
- Loteprednol etabonate (Eysuvis) (CP.PMN.260) (PDF)
- Lubiprostone (Amitiza) (CP.PMN.142) (PDF)
- Luliconazole Cream (Luzu) (CP.PMN.166) (PDF)
- Lumacaftor-ivacaftor (Orkambi) (CP.PHAR.213) (PDF)
- Lumasiran (Oxlumo) (CP.PHAR.473) (PDF)
- Lumateperone (Caplyta) (CP.PMN.232) (PDF)
- Lurasidone (Latuda) (CP.PMN.50) (PDF)
- Lurbinectedin (Zepzelca) (CP.PHAR.500) (PDF)
- Luspatercept-aamt (Reblozyl) (CP.PHAR.450) (PDF)
- Lusutrombopag (Mulpleta) (CP.PHAR.407)(PDF)
- Lutetium Lu 177 dotatate (Lutathera) (CP.PHAR.384) (PDF)
- Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) (CP.PHAR.582) (PDF)
- Mannitol (Bronchitol) (CP.PHAR.518) (PDF)
- Maralixibat (Livmarli) (CP.PHAR.543) (PDF)
- Maribavir (Livtencity) (CP.PMN.271) (PDF)
- Margetuximab-cmkb (Margenza) (CP.PHAR.522) (PDF)
- Mavacamten (Camzyos) (CP.PMN.272) (PDF)
- Mecamylamine (Vecamyl) (CP.PMN.136) (PDF)
- Mecasermin (Increlex) (CP.PHAR.150) (PDF)
- Mechlorethamine (Valchlor) (CP.PHAR.381) (PDF)
- Macitentan (Opsumit) (CP.PHAR.194) (PDF)
- Megestrol Acetate (Megace ES) (CP.PMN.179) (PDF)
- Melphalan flufenamide (Pepaxto) (CP.PHAR.535) (PDF)
- Memantine (Namenda XR, Namzaric) (CP.PCH.30) (PDF)
- Mepolizumab (Nucala) (CP.PHAR.200) (PDF)
- Mercaptopurine (Purixan) (CP.PHAR.447) (PDF)
- Metformin ER (Glumetza, Fortamet) (CP.PMN.72) (PDF)
- Methotrexate (Otrexup, Rasuvo, Reditrex, Xatmep) (CP.PHAR.134) (PDF)
- Methoxsalen (Uvadex) (HIM.PA.17) (PDF)
- Methoxy polyethylene glycol-epoetin beta (Mircera) (CP.PHAR.238) (PDF)
- Methylnaltrexone Bromide (Relistor) (CP.PMN.169) (PDF)
- Metoclopramide (Gimoti) (CP.PMN.252) (PDF)
- Metreleptin (Myalept) (CP.PHAR.425)(PDF)
- Midazolam (Nayzilam) (CP.PMN.211) (PDF)
- Midostaurin (Rydapt) (CP.PHAR.344) (PDF)
- Mifepristone (Korlym) (CP.PHAR.101) (PDF)
- Migalastat (Galafold) (CP.PHAR.394) (PDF)
- Miglustat (Zavesca) (CP.PHAR.164) (PDF)
- Milnacipran (Savella) (CP.PMN.125) (PDF)
- Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) (CP.PMN.80) (PDF)
- Minocycline micronized foam (Amzeeq) (CP.PMN.242) (PDF)
- Mirvetuximab soravtansine-gynx (Elahere) (CP.PHAR.617) (PDF)
- Mitapivat (Pyrukynd) (CP.PHAR.558) (PDF)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) (CP.PHAR.495) (PDF)
- Mitoxantrone (Novantrone) (CP.PHAR.258) (PDF)
- Mobocertinib (Exkivity) (CP.PHAR.559) (PDF)
- Modafinil (Provigil) (CP.PMN.39) (PDF)
- Mogamulizumab-kpkc (Poteligeo) (CP.PHAR.139) (PDF)
- Mometasone (Asmanex) (HIM.PA.01) (PDF)
- Mometasone (Nasonex) (HIM.PA.93) (PDF)
- Mometasone Furoate (Sinuva) (CP.PHAR.448) (PDF)
- Montelukast Oral Granules (Singulair) (HIM.PA.129) (PDF)
- Moxetumomab Pasudotox-tdfk (Lumoxiti) (CP.PHAR.398) (PDF)
- Nadofaragene FiradeNovec (Instiladrin) (CP.PHAR.461) (PDF)
- Nafarelin Acetate (Synarel) (CP.PHAR.174) (PDF)
- Naltrexone (Vivitrol) (CP.PHAR.96) (PDF)
- Naproxen Oral Suspension (Naprosyn) (HIM.PA.130) (PDF)
- Naproxen/Esomeprazole (Vimovo) (CP.PMN.117) (PDF)
- Natalizumab (Tysabri) (CP.PHAR.259) (PDF)
- Naxitamab-gqgk (Danyelza) (CP.PHAR.523) (PDF)
- Necitumumab (Portrazza) (CP.PHAR.320) (PDF)
- Neomycin/Fluocinolone Cream (Neo-Synalar) (CP.PMN.167) (PDF)
- Neratinib (Nerlynx) (CP.PHAR.365) (PDF)
- Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (CP.PMN.158) (PDF)
- Nifurtimox (Lampit) (CP.PMN.256) (PDF)
- Nilotinib (Tasigna) (CP.PHAR.76) (PDF)
- Nintedanib (Ofev) (CP.PHAR.285) (PDF)
- Niraparib (Zejula) (CP.PHAR.408) (PDF)
- Nitazoxanide (Alinia) (HIM.PA.152) (PDF)
- Nitisinone (Nityr, Orfadin) (CP.PHAR.132) (PDF)
- Nivolumab and Relatlimab (Opdualag) (CP.PHAR.588) (PDF)
- Nivolumab (Opdivo) (CP.PHAR.121) (PDF)
- No Coverage Criteria, Recent Label Changes Pending Clinical Policy Update (HIM.PA.33) (PDF)
- Non-Calcium Phosphate Binders (Auryxia, Fosrenol, Renagel, Renvela, Velphoro) (CP.PMN.04) (PDF)
- Non-Formulary and Formulary Contraceptives (HIM.PA.100) (PDF)
- Non-Formulary Test Strips (HIM.PA.34) (PDF)
- Nusinersen (Spinraza) (CP.PHAR.327) (PDF)
- Obeticholic Aacid (Ocaliva) (CP.PHAR.287) (PDF)
- Obinutuzumab (Gazyva) (CP.PHAR.305) (PDF)
- Ocrelizumab (Ocrevus) (CP.PHAR.335) (PDF)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (CP.PHAR.40) (PDF)
- Odevixibat (Bylvay) (CP.PHAR.528) (PDF)
- Ofatumumab (Arzerra, Kesimpta) (CP.PHAR.306) (PDF)
- Off-Label Use (HIM.PA.154) (PDF)
- Olanzapine Long-Acting Injection (Zyprexa Relprevv) (CP.PHAR.292) (PDF)
- Olanzapine-samidorphan (Lybalvi) (CP.PMN.265) (PDF)
- Olaparib (Lynparza) (CP.PHAR.360) (PDF)
- Olaratumab (Lartruvo) (CP.PHAR.326) (PDF)
- Olipudase alfa-rpcp (Xenpozyme) (CP.PHAR.586)
- Omadacycline (Nuzyra) (CP.PMN.188) (PDF)
- Omalizumab (Xolair) (CP.PCH.49) (PDF)
- Omaveloxolone (RTA-408) (CP.PHAR.590) (PDF)
- Omburtamab (Omblastys) (CP.PHAR.585) (PDF)
- Omecetaxine (Synribo) (CP.PHAR.108) (PDF)
- Omega-3-Acid Ethyl Esters (Lovaza) (CP.PMN.52) (PDF)
- OnabotulinumtoxinA (Botox) (CP.PHAR.232) (PDF)
- Onasemnogene Abeparvovec (Zolgensma) (CP.PHAR.421) (PDF)
- Ondansetron (Zuplenz) (CP.PMN.45) (PDF)
- Ophthalmic corticosteroids (Lotemax, Durezol, Alrex, Pred Mild, FML Forte, Maxidex) (HIM.PA.03) (PDF)
- Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (CP.PHAR.536) (PDF)
- Opicapone (Ongentys) (CP.PMN.245) (PDF)
- Opioid Analgesics (HIM.PA.139) (PDF)
- Osilodrostat (Isturisa) (CP.PHAR.487) (PDF)
- Osimertinib (Tagrisso) (CP.PHAR.294) (PDF)
- Ospemifene (Osphena) (CP.PMN.168) (PDF)
- Overactive Bladder Agents (CP.PMN.198) (PDF)
- Oxymetazoline (Rhofade, Upneeq) (CP.PMN.86) (PDF)
- Ozanimod (Zeposia) (CP.PHAR.462) (PDF)
- Ozenoxacin (Xepi) (CP.PMN.119) (PDF)
- Paclitaxel, Protein-Bound (Abraxane) (CP.PHAR.176) (PDF)
- Pacritinib (Vonjo) (CP.PHAR.583) (PDF)
- Palbociclib (Ibrance) (CP.PHAR.125) (PDF)
- Paliperidone inj (Invega Sustenna, Invega Trinza, Invega Hafyera) (CP.PHAR.291) (PDF)
- Palivizumab (Synagis) (CP.PHAR.16) (PDF)
- Palovarotene (CP.PHAR.548) (PDF)
- Pancrelipase (Creon, Pancreze, Pertyze, Viokace, Zenpep) (CP.PCH.44) (PDF)
- Panitumumab (Vectibix) (CP.PHAR.321) (PDF)
- Panobinostat (Farydak) (CP.PHAR.382) (PDF)
- Parathyroid Hormone (Natpara) (CP.PHAR.282) (PDF)
- Paricalcitol Injection (Zemplar) (CP.PHAR.270) (PDF)
- Pasireotide (Signifor, Signifor LAR) (CP.PHAR.332) (PDF)
- Patiromer (Veltassa) (CP.PMN.205) (PDF)
- Patisiran (Onpattro) (CP.PHAR.395) (PDF)
- Pazopanib (Votrient) (CP.PHAR.81) (PDF)
- Peanut allergen powder (Palforzia) (CP.PMN.220) (PDF)
- Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (CP.PHAR.353) (PDF)
- Pegcetacoplan (Empaveli, APL-2) (CP.PHAR.524) (PDF)
- Pegfilgrastim (Neulasta, Neulasta Onpro), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-pbbk (Fylnetra), Pegfilgrastim-apgf (Nyvepria), Eflapegrastim-xnst (Rolvedon), Pegfilgrastim-fpgk (Stimufend), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo) (CP.PHAR.296) (PDF)
- Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) (CP.PHAR.89) (PDF)
- Pegunigalsidase Alfa (PRX-102) (CP.PHAR.512) (PDF)
- Peginterferon beta-1a (Plegridy) (CP.PHAR.271) (PDF)
- Pegloticase (Krystexxa) (CP.PHAR.115) (PDF)
- Pegvaliase-pqpz (Palynziq) (CP.PHAR.140) (PDF)
- Pegvisomant (Somavert) (CP.PHAR.389) (PDF)
- Pegzilarginase (AEB1102) (CP.PHAR.587) (PDF)
- Pembrolizumab (Keytruda) (CP.PHAR.322) (PDF)
- Pemetrexed (Alimta, Pemfexy) (CP.PHAR.368) (PDF)
- Pemigatinib (Pemazyre)(CP.PHAR.496) (PDF)
- Penicillamine (Cuprimine) (CP.PCH.09) (PDF)
- Perampanel (Fycompa) (CP.PMN.156) (PDF)
- Pertuzumab (Perjeta) (CP.PHAR.227) (PDF)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (CP.PHAR.501) (PDF)
- Pexidartinib (Turalio) (CP.PHAR.436) (PDF)
- Phendimetrazine (CP.PCH.47) (PDF)
- Phentermine (Adipex-P, Lomaira) (CP.PCH.13) (PDF)
- Pilocarpine (Vuity) (CP.PMN.270) (PDF)
- Pimavanserin (Nuplazid) (CP.PMN.140) (PDF)
- Pirfenidone (Esbriet) (CP.PHAR.286) (PDF)
- Pitolisant (Wakix) (CP.PMN.221) (PDF)
- Plasminogen, human-tvmh (Ryplazim) (CP.PHAR.513) (PDF)
- Plecanatide (Trulance) (HIM.PA.158) (PDF)
- Plerixafor (Mozobil) (CP.PHAR.323) (PDF)
- Polatuzumab vedotin-piiq (Polivy) (CP.PHAR.433) (PDF)
- Pomalidomide (Pomalyst) (CP.PHAR.116) (PDF)
- Ponatinib (Iclusig) (CP.PHAR.112) (PDF)
- Ponesimod (Ponvory) (CP.PHAR.537) (PDF)
- Potassium Chloride for Oral Solution (Klor-Con Powder) (HIM.PA.143) (PDF)
- Prademagene Zamikeracel (EB-101) (CP.PHAR.609) (PDF)
- Pralatrexate (Folotyn) (CP.PHAR.313) (PDF)
- Pramlintide (Symlin) (CP.PMN.129) (PDF)
- Prasterone (Intrarosa) (CP.PMN.99) (PDF)
- Pregabalin (Lyrica, Lyrica CR) (CP.PMN.33) (PDF)
- Pretomanid (CP.PMN.222) (PDF)
- Progesterone (Crinone, Endometrin, Milprosa) (CP.PMN.243) (PDF)
- Propranolol HCl Oral Solution (Hemangeol) (CP.PMN.58) (PDF)
- Protein C Concentrate Human (Ceprotin) (CP.PHAR.330) (PDF)
- Prucalopride (Motegrity) (HIM.PA.159) (PDF)
- Pyrimethamine (Daraprim) (CP.PMN.44) (PDF)
- Quetiapine ER (Seroquel XR) (CP.PMN.64) (PDF)
- Quinine Sulfate (Qualaquin) (CP.PMN.262) (PDF)
- Ramucirumab (Cyramza) (CP.PHAR.119) (PDF)
- Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo) (CP.PHAR.186) (PDF)
- Rasagiline (Azilect) (HIM.PA.89) (PDF)
- Ravulizumab-cwvz (Ultomiris) (CP.PHAR.415) (PDF)
- Regorafenib (Stivarga) (CP.PHAR.107) (PDF)
- Relugolix (Orgovyx), Relugolix-Estradiol-Norethindrone (Myfembree) (CP.PHAR.529) (PDF)
- Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel) (CP.PHAR.168) (PDF)
- Reslizumab (Cinqair) (CP.PHAR.223) (PDF)
- Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (CP.PHAR.141) (PDF)
- Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara) (CP.PHAR.334) (PDF)
- Rifabutin (Mycobutin) (CP.PMN.223) (PDF)
- Rifamycin (Aemcolo) (CP.PMN.196) (PDF)
- Rifaximin (Xifaxan) (CP.PMN.47) (PDF)
- Rilonacept (Arcalyst) (CP.PHAR.266) (PDF)
- RimabotulinumtoxinB (Myobloc) (CP.PHAR.233) (PDF)
- Rimegepant (Nurtec ODT) (CP.PHAR.490) (PDF)
- Riociguat (Adempas) (CP.PHAR.195) (PDF)
- Ripretinib (Qinlock) (CP.PHAR.502) (PDF)
- Risdiplam (Evrysdi) (CP.PHAR.477) (PDF)
- Risedronate (Actonel, Atelvia) (CP.PMN.100) (PDF)
- Risperidone LA Injection (Risperdal Consta, Perseris, Rykindo) (CP.PHAR.293) (PDF)
- Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), RituximabHyaluronidase (Rituxan Hycela) (CP.PHAR.260) (PDF)
- Rolapitant (Varubi) (CP.PMN.102) (PDF)
- Romidepsin (Istodax) (CP.PHAR.314) (PDF)
- Romiplostim (Nplate) (CP.PHAR.179) (PDF)
- Romosozumab-aqqg (Evenity) (CP.PHAR.428) (PDF)
- Ropeginterferon alfa-2b-njft (Besremi) (CP.PHAR.570) (PDF)
- RP-L201 (CP.PHAR.599) (PDF)
- Rucaparib (Rubraca) (CP.PHAR.350) (PDF)
- Rufinamide (Banzel) (CP.PMN.157) (PDF)
- Ruxolitinib (Jakafi, Opzelura) (CP.PHAR.98) (PDF)
- Sacituzumab govitecan-hziy (Trodelvy) (CP.PHAR.475) (PDF)
- Sacubitril-Valsartan (Entresto) (CP.PMN.67) (PDF)
- Safinamide (Xadago) (CP.PMN.113) (PDF)
- Sapropterin (Kuvan) (CP.PHAR.43) (PDF)
- Sarecycline (Seysara) (CP.PMN.189) (PDF)
- Sargramostim (Leukine) (CP.PHAR.295)(PDF)
- Satralizumab-mwge (Enspryng) (CP.PHAR.463) (PDF)
- Sebelipase Alfa (Kanuma) (CP.PHAR.159) (PDF)
- Secnidazole (Solosec) (CP.PMN.103) (PDF)
- Selexipag (Uptravi) (CP.PHAR.196) (PDF)
- Selinexor (Xpovio) (CP.PHAR.431) (PDF)
- Selpercatinib (Retevmo) (CP.PHAR.478) (PDF)
- Selumetinib (Koselugo) (CP.PHAR.464) (PDF)
- Setmelanotide (Imcivree) (CP.PHAR.491) (PDF)
- Sildenafil (Revatio) (CP.PHAR.197) (PDF)
- Sildenafil for ED (Viagra) (CP.PCH.07) (PDF)
- Siltuximab (Sylvant) (CP.PHAR.329) (PDF)
- Siponimod (Mayzent) (CP.PHAR.427) (PDF)
- Sirolimus Protein-Bound Particles (Fyarro), Topical Gel (Hyftor) (CP.PHAR.574) (PDF)
- Short Ragweed Pollen Allergen Extract (Ragwitek) (CP.PMN.83) (PDF)
- Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, Sodium Oxybate (Xywav) (CP.PMN.42) (PDF)
- Sodium phenylbutyrate (Buphenyl, Pheburane) (CP.PHAR.208) (PDF)
- Sodium Phenylbutyrate-Taurursodiol (Relyvrio) (CP.PHAR.584)
- Sodium thiosulfate (Pedmark) (CP.PHAR.610) (PDF)
- Sodium zirconium cyclosilicate (Lokelma) (CP.PMN.163) (PDF)
- SGLT2 inhibitors (HIM.PA.91) (PDF)
- Sofosbuvir (Sovaldi) (HIM.PA.SP2) (PDF)
- Sofosbuvir/Velpatasvir (Epclusa) (HIM.PA.SP1) (PDF)
- Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (HIM.PA.SP63) (PDF)
- Solriamfetol (Sunosi) (CP.PMN.209) (PDF)
- Sonidegib (Odomzo) (CP.PHAR.272) (PDF)
- Sorafenib (Nexavar) (CP.PHAR.69) (PDF)
- Sotorasib (Lumakras) (CP.PHAR.549) (PDF)
- Sotrovimab (VIR-7831) (CP.PHAR.541) (PDF)
- Spesolimab-sbzo (Spevigo) (CP.PHAR.606) (PDF)
- Spinosad (Natroba) (HIM.PA.134) (PDF)
- Step Therapy (HIM.PA.109) (PDF)
- Stiripentol (Diacomit) (CP.PMN.184) (PDF)
- Sunitinib (Sutent) (CP.PHAR.73) (PDF)
- Sutimlimab-jome (Enjaymo) (CP.PHAR.503) (PDF)
- Suvorexant (Belsomra) (CP.PMN.109) (PDF)
- Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair) (CP.PMN.85) (PDF)
- Tadalafil (Adcirca, Alyq, Tadliq) (CP.PHAR.198) (PDF)
- Tadalafil BPH - ED (Cialis) (CP.PMN.132) (PDF)
- Tafamidis (Vyndaqel, Vyndamax) (CP.PHAR.432) (PDF)
- Tafasitamab-cxix (Monjuvi) (CP.PHAR.508) (PDF)
- Talazoparib (Talzenna) (CP.PHAR.409) (PDF)
- Taliglucerase Alfa (Elelyso) (HIM.PA.162) (PDF)
- Talimogene laherparepvec (Imlygic) (CP.PHAR.542) (PDF)
- Tapinarof (Vtama) (CP.PMN.283) (PDF)
- Tazarotene (Arazlo, Fabior, Tazorac) (CP.PMN.244) (PDF)
- Tasimelteon (Hetlioz) (CP.PMN.104) (PDF)
- Tavaborole (Kerydin) (CP.PMN.105) (PDF)
- Tazemetostat (Tazverik) (CP.PHAR.452) (PDF)
- Tebentafusp-tebn (Kimmtrak) (CP.PHAR.575) (PDF)
- Teclistamab-cqyv (Tecvayli) (CP.PHAR.611) (PDF)
- Tedizolid (Sivextro) (CP.PMN.62) (PDF)
- Teduglutide (Gattex) (CP.PHAR.114) (PDF)
- Tegaserod (Zelnorm) (HIM.PA.160) (PDF)
- Telotristat Ethyl (Xermelo) (CP.PHAR.337) (PDF)
- Temozolomide (Temodar) (CP.PHAR.77) (PDF)
- Temsirolimus (Torisel) (CP.PHAR.324) (PDF)
- Tenapanor (Ibsrela) (CP.PMN.224) (PDF)
- Tenofovir Alafenamide Fumarate (Vemlidy) (CP.PMN.268) (PDF)
- Teplizumab (PRV-031) (CP.PHAR.492) (PDF)
- Tepotinib (Tepmetko) (CP.PHAR.530) (PDF)
- Teprotumumab (Tepezza) (CP.PHAR.465) (PDF)
- Teriflunomide (Aubagio) (CP.PCH.40) (PDF)
- Teriparatide (Forteo) (CP.PHAR.188) (PDF)
- Tesamorelin (Egrifta) (CP.PHAR.109) (PDF)
- Testosterone (Androderm) (HIM.PA.87) (PDF)
- Testosterone (Testopel, Jatenzo, Kyzatrex, Tlando) (CP.PHAR.354) (PDF)
- Tetrabenazine (Xenazine) (CP.PHAR.92) (PDF)
- Tezacaftor-Ivacaftor (Symdeko) (CP.PHAR.377) (PDF)
- Tezepelumab-ekko (Tezspire) (CP.PHAR.576) (PDF)
- Thalidomide (Thalomid) (CP.PHAR.78) (PDF)
- Thioguanine (Tabloid) (CP.PHAR.437) (PDF)
- Thyrotropin Alfa (Thyrogen) (CP.PHAR.95) (PDF)
- Timothy Grass Pollen Allergen Extract (Grastek) (CP.PMN.84) (PDF)
- Tisagenlecleucel (Kymriah) (CP.PHAR.361) (PDF)
- Tisotumab vedotin-tftv (Tivdak) (CP.PHAR.561) (PDF)
- Tivozanib (Fotivda) (CP.PHAR.538) (PDF)
- Tixagevimab-Cilgavimab (Evusheld) (CP.PHAR.571) (PDF)
- Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (CP.PHAR.211) (PDF)
- Tofersen (BIIB067) (CP.PHAR.591) (PDF)
- Tolvaptan (Jynarque, Samsca) (CP.PHAR.27) (PDF)
- Topical Acne Treatment (HIM.PA.71) (PDF)
- Topical Immunomodulators (CP.PMN.107) (PDF)
- Topiramate ER (Qudexy XR, Trokendi XR) (CP.PMN.281) (PDF)
- Topotecan (Hycamtin) (CP.PHAR.64) (PDF)
- Trabectedin (Yondelis) (CP.PHAR.204) (PDF)
- Tralokinumab-ldrm (Adbry) (CP.PHAR.577) (PDF)
- Trametinib (Mekinist) (CP.PHAR.240) (PDF)
- Trastuzumab, Biosimilars, Trastuzumab-Hyaluronidase (CP.PHAR.228) (PDF)
- Tremelimumab-actl (Imjudo) (CP.PHAR.612) (PDF)
- Treprostinil (Orenitram, Remodulin, Tyvaso) (CP.PHAR.199) (PDF)
- Triamcinolone ER Injection (Zilretta) (CP.PHAR.371) (PDF)
- Triclabendazole (Egaten) (CP.PMN.207) (PDF)
- Trientine (Syprine, Cuvrior) (CP.PHAR.438) (PDF)
- Trifarotene (Aklief) (CP.PMN.225) (PDF)
- Trifluridine-tipiracil (Lonsurf) (CP.PHAR.383) (PDF)
- Triheptanoin (Dojolvi) (CP.PHAR.509) (PDF)
- Triptorelin pamoate (Trelstar, Triptodur) (CP.PHAR.175) (PDF)
- Tucatinib (Tukysa) (CP.PHAR.497) (PDF)
- Ubrogepant (Ubrelvy) (CP.PHAR.476) (PDF)
- Ulcer Therapy Combinations (Omeclamox Pak, Pylera, Talicia, Voquezna)(CP.PMN.277) (PDF)
- Umbralisib (Ukoniq) (CP.PHAR.531) (PDF)
- Udenafil (CP.PHAR.557) (PDF)
- Unoprostone Isopropyl (Rescula) (HIM.PA.11) (PDF)
- Uridine triacetate (Vistogard) (HIM.PA.SP55) (PDF)
- Valbenazine (Ingrezza)(CP.PCH.48)
- Valganciclovir (Valcyte) (CP.PCH.06) (PDF)
- Valoctocogene Roxaparvovec (CP.PHAR.466) (PDF)
- Valrubicin (Valstar) (CP.PHAR.439) (PDF)
- Vandetanib (Caprelsa) (CP.PHAR.80) (PDF)
- Varenicline (Tyrvaya) (CP.PMN.273) (PDF)
- Velaglucerase Alfa (VPRIV) (HIM.PA.163) (PDF)
- Vemurafenib (Zelboraf) (CP.PHAR.91) (PDF)
- Venetoclax (Venclexta) (CP.PHAR.129) (PDF)
- Verteporfin (Visudyne) (CP.PHAR.187) (PDF)
- Vestronidase alfa-vjbk (Mepsevii) (CP.PHAR.374) (PDF)
- Vigabatrin (Sabril) (CP.PHAR.169) (PDF)
- Vilazodone (Viibryd) (CP.PMN.145) (PDF)
- Viloxazine (Qelbree) (CP.PMN.264) (PDF)
- Viltolarsen (Viltepso) (CP.PHAR.484) (PDF)
- Vincristine Sulfate Liposome Injection (Marqibo) (CP.PHAR.315) (PDF)
- Vismodegib (Erivedge) (CP.PHAR.273) (PDF)
- Voclosporin (Lupkynis) (CP.PHAR.504) (PDF)
- Vorapaxar (Zontivity) (HIM.PA.146) (PDF)
- Voretigene Neparvovec-rzyl (Luxturna) (CP.PHAR.372) (PDF)
- Vorinostat (Zolinza) (CP.PHAR.83) (PDF)
- Vortioxetine (Trintellix) (CP.PMN.65) (PDF)
- Vosoritide (Voxzogo) (CP.PHAR.525) (PDF)
- Voxelotor (Oxbryta) (CP.PHAR.451) (PDF)
- Vutrisiran (Amvuttra) (CP.PHAR.550) (PDF)
- Zanubrutinib (Brukinsa) (CP.PHAR.467) (PDF)
- Ziv-aflibercept (Zaltrap) (CP.PHAR.325) (PDF)
- Zoledronic Acid (Reclast, Zometa) (CP.PHAR.59) (PDF)
Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP Policies
- Allergy Testing and Therapy (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)
- 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)
- Global Maternity Billing (CC.PP.016) (PDF)
- Gastric Electrical Stimulation (CP.MP.40) (PDF)
- Gender-Affirming Procedures (CP.MP.95) (PDF)
- Heart-Lung Transplant (CP.MP.132) (PDF)
- Home Birth (CP.MP.136) (PDF)
- Home Phototherapy (TX.CP.MP.510) (PDF)
- Hyperemesis Gravidarum Treatment (TX.CP.MP.534)
- 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)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (CP.MP.160) (PDF)
- Influenza Testing (TX.CP.MP.115) (PDF)
- Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Intensity-Modulated Radiotherapy (CP.MP.69) (PDF)
- Intestinal and Multivisceral Transplant (CP.MP.58) (PDF)
- Intradiscal Steroid Injections for Pain Management (CP.MP.167) (PDF)
- Kidney Disorders (CP.MP.227)
- Long Term Care Placement Criteria (CP.MP.71) (PDF)
- Lung Transplantation (CP.MP.57) (PDF)
- Mastectomy for Pubertal Gynecomastia (TX.CP.MP.571) (PDF)
- Mechanical Stretch Devices (CP.MP.144) (PDF)
- Medical Necessity Criteria (TX.CP.MP.500) (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)
- Oncology Algorithmic Testing (CP.MP.237)
- Oncology Cancer Screening (CP.MP.238)
- Oncology Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (CP.MP.239)
- Oncology Cytogenetic Testing (CP.MP.240)
- Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (CP.MP.241)
- Orthognathic Surgery (CP.MP.202) (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 Kidney Transplant (CP.MP.246) (PDF)
- Pediatric Liver Transplant (CP.MP.120) (PDF)
- Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150) (PDF)
- Physical, Occupational and Speech Therapy Services (TX.CP.MP.549) (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)
- 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 (TX.CP.MP.582) (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)
- 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)
- Transplant Service Documentation Requirements (CP.MP.247) (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 Texas Medicaid Provider Procedures Manual (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. TMPPM is regularly updated to reflect the most recent policy and procedure changes. Advanced notification of upcoming changes appear as banner messages located at the TMHP Banner Messages.
- Abaloparatide (Tymlos) (CP.PHAR.345) (PDF)
- AbobotulinumtoxinA (Dysport) (CP.PHAR.230) (PDF)
- Adalimumab (Humira), Adalimumab-afzb (Abrilada), Adalimumab-atto (Amjevita), Adalimumab-adbm (Cyltezo), Adalimumab-bwwd (Hadlima), Adalimumab-fkjp (Hulio), Adalimumab-adaz (Hyrimoz) (CP.PHAR.242) (PDF)
- Ado-Trastuzumab Emtansine (Kadcyla) (CP.PHAR.229) (PDF)
- Aducanumab-avwa (Aduhelm) (TX.PHAR.101) (PDF)
- Afamelanotide (Scenesse) (CP.PHAR.444) (PDF)
- Aflibercept (Eylea) (CP.PHAR.184) (PDF)
- Alemtuzumab (Lemtrada) (CP.PHAR.243) (PDF)
- Alirocumab (Praluent) (CP.PHAR.124) (PDF)
- Allogeneic cultured keratinocytes and dermal fibroblasts (StrataGraft) (CP.PHAR.562) (PDF)
- Allogenic processed thymus tissue-agdc (Rethymic) (CP.PHAR.563) (PDF)
- Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (CP.PHAR.94) - (PDF)
- Amikacin (Arikayce) (CP.PHAR.401) (PDF)
- Amisulpride (Barhemsys) (CP.PMN.236) (PDF)
- Amivantamab-vmjw (Rybrevant) (CP.PHAR.544) (PDF)
- Anakinra (Kineret) (CP.PHAR.244) (PDF)
- Anti-Inhibitor Coagulant Complex, Human (Feiba) (CP.PHAR.217) (PDF)
- Antithrombin III (ATryn, Thrombate III) (CP.PHAR.564) (PDF)
- Antithymocyte Globulin (Atgam, Thymoglobulin) (CP.PHAR.506) (PDF)
- Apomorphine (Apokyn, Kynmobi) (CP.PHAR.488) (PDF)
- Aprepitant (Aponvie, Cinvanti, Emend) (CP.PMN.19) (PDF)
- Aripiprazole LA Injections (Abilify Maintena Aristada Aristada Initio) (CP.PHAR.290) (PDF)
- Asfotase Alfa (Strensiq) (CP.PHAR.328) (PDF)
- Atezolizumab (Tecentriq) (CP.PHAR.235) (PDF)
- Atidarsagene autotemcel (OTL-200) (CP.PHAR.602) (PDF)
- Avelumab (Bavencio) (CP.PHAR.333) (PDF)
- Axicabtagene Ciloleucel (Yescarta®) (TX.PHAR.48) (PDF)
- Azacitidine (Onureg, Vidaza) (CP.PHAR.387) (PDF)
- Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispah, Ozobax) (CP.PHAR.149) (PDF)
- Bamlanivimab-etesevimab (LY-CoV555-LY-CoV016) (CP.PHAR.532) (PDF)
- Bebtelovimab (LY-CoV1404) (CP.PHAR.579) (PDF)
- Belantamab Mafodotin (Blenrep) (CP.PHAR.469) (PDF)
- Belatacept (Nulojix) (CP.PHAR.201) (PDF)
- Belinostat (Beleodaq) (CP.PHAR.311) (PDF)
- Bendamustine (Belrapzo, Bendeka, Treanda) (CP.PHAR.307) (PDF)
- Benralizumab (Fasenra) (TX.PHAR.99) (PDF)
- Beremagene Geperpavec (Vyjuvek) (CP.PHAR.592) (PDF)
- Betibeglogene autotemcel (CP.PHAR.545) (PDF)
- Bevacizumab (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev) (CP.PHAR.93) (PDF)
- Bezlotoxumab (Zinplava) (CP.PHAR.300) (PDF)
- Bimatoprost Implant (Durysta) (CP.PHAR.486) (PDF)
- Blinatumomab (Blincyto) (CP.PHAR.312) (PDF)
- Bortezomib (Velcade) (CP.PHAR.410) (PDF)
- Brentuximab Vedotin (Adcetris) (CP.PHAR.303) (PDF)
- Brexucabtagene autoleucel (Tecartus) (TX.PHAR.106) (PDF)
- Brodalumab (Siliq) (CP.PHAR.375) (PDF)
- Brolucizumab (Beovu) (CP.PHAR.445) (PDF)
- Bulevirtide (Hepcludex) (CP.PHAR.589) (PDF)
- Buprenorphine (Probuphine, Sublocade) (CP.PHAR.289) (PDF)
- Buprenorphine Injection (Brixadi) (CP.PHAR.498) (PDF)
- Burosumab-Twza (Crysvita) (TX.PHAR.55) (PDF)
- C1 Esterase Inhibitors (Berinert Cinryze Haegarda Ruconest) (CP.PHAR.202) (PDF)
- Cabazitaxel (Jevtana) (CP.PHAR.316) (PDF)
- Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) (CP.PHAR.573) (PDF)
- Casimersen (Amondys 45) (TX.PHAR.91) (PDF)
- Canakinumab (Ilaris) (CP.PHAR.246) (PDF)
- Caplacizumab-yhdp (Cablivi) (CP.PHAR.416) (PDF)
- Carbetocin (CP.PHAR.546) (PDF)
- Carfilzomib (Kyprolis) (CP.PHAR.309) (PDF)
- Casirivimab and imdevimab (REGN-COV2) (CP.PHAR.520) (PDF)
- Cemiplimab-rwlc (Libtayo) (CP.PHAR.397) (PDF)
- Cenegermin-bkbj (Oxervate) (CP.PMN.186) (PDF)
- Certolizumab (Cimzia) (CP.PHAR.247) (PDF)
- Cetuximab (Erbitux) (CP.PHAR.317) (PDF)
- Chloramphenicol (CP.PHAR.388) (PDF)
- Ciltacabtagene autoleucel (Carvykti) (TX.PHAR.107)
- Cipaglucosidase alfa-miglustat (AT-GAA) (CP.PHAR.567) (PDF)
- Collagenase Clostridium Histolyticum (Xiaflex) (CP.PHAR.82) (PDF)
- Copanlisib (Aliqopa) (CP.PHAR.357) (PDF)
- Corticosteroids for Ophthalmic Injection (Iluvien, Ozurdex, Retisert, Xipere, Yutiq) (CP.PHAR.385) (PDF)
- Cosyntropin (Cortrosyn) (CP.PHAR.203) (PDF)
- Cytomegalovirus Immune Globulin (Cytogam) (CP.PHAR.277) (PDF)
- Dalteparin (Fragmin) (CP.PHAR.225) (PDF)
- Daptomycin (Cubicin, Cubicin RF) (CP.PHAR.351) (PDF)
- Daratumumab, Daratumumab-Hyaluronidase-fihj (Darzalex, Darzalex Faspro) (CP.PHAR.310) (PDF)
- Darbepoetin Alfa (Aranesp) (CP.PHAR.236) (PDF)
- Daunorubicin-cytarabine (Vyxeos) (CP.PHAR.352) (PDF)
- Deferoxamine (Desferal) (CP.PHAR.146) (PDF)
- Degarelix Acetate (Firmagon) (CP.PHAR.170) (PDF)
- Delafloxacin (Baxdela) (CP.PMN.115) (PDF)
- Denosumab (Prolia Xgeva) (CP.PHAR.58) (PDF)
- Desmopressin (DDAVP, Stimate, Nocdurna, Noctiva) (CP.PHAR.214) (PDF)
- Dexrazoxane (Zinecard, Totect) (CP.PHAR.418) (PDF)
- Donislecel (Lantidra) (CP.PHAR.569) (PDF)
- Dornase Alfa (Pulmozyme) (CP.PHAR.212) (PDF)
- Dostarlimab-gxly (Jemperli) (CP.PHAR.540) (PDF)
- Dupilumab (Dupixent) (CP.PHAR.336) (PDF)
- Durvalumab (Imfinzi) (CP.PHAR.339) (PDF)
- Ecallantide (Kalbitor) (CP.PHAR.177) (PDF)
- Eculizumab (Soliris) (CP.PHAR.97) (PDF)
- Edaravone (Radicava) (CP.PHAR.343) (PDF)
- Efgartigimod Alfa-fcab (Vyvgart) (CP.PHAR.555) (PDF)
- Elapegademase-lvlr (Revcovi) (CP.PHAR.419) (PDF)
- Elivaldogene Autotemcel (Skysona) (CP.PHAR.556) (PDF)
- Elotuzumab (Empliciti) (CP.PHAR.308) (PDF)
- Emicizumab-kxwh (Hemlibra) (CP.PHAR.370) (PDF)
- Enfortumab Vedotin-ejfv (Padcev) (CP.PHAR.455) (PDF)
- Enfuvirtide (Fuzeon) (CP.PHAR.41) (PDF)
- Enoxaparin (Lovenox) (CP.PHAR.224) (PDF)
- Enzyme Replacement Therapy (Fabrazyme, Lumizyme, Nexviazyme, Brineura, Vimizim, Naglazyme, Elaprase, Cerezyme, Aldurazyme, Ceprotin, Kanuma, Elelyso, Vpriv, Xenpozyme) (TX.PHAR.104) (PDF)
- Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) (CP.PHAR.237) (PDF)
- Epoprostenol (Flolan, Veletri) (CP.PHAR.192) (PDF)
- Eptinezumab (Vyepti) (CP.PHAR.489) (PDF)
- Eribulin Mesylate (Halaven) (CP.PHAR.318) (PDF)
- Erenumab-aaoe (Aimovig) (CP.PHAR.128) (PDF)
- Erwinia Asparaginase (Erwinaze, Rylaze) (CP.PHAR.301) (PDF)
- Etanercept (Enbrel) (CP.PHAR.250) (PDF)
- Etelcalcetide (Parsabiv) (CP.PHAR.379) (PDF)
- Eteplirsen (Exondys51) (TX.PHAR.56) (PDF)
- Evinacumab-dgnb (Evkeeza) (CP.PHAR.511) (PDF)
- Evolocumab (Repatha) (CP.PHAR.123) (PDF)
- Exagamglogene autotemcel (Exa-Cel) (CP.PHAR.603) (PDF)
- Factor IX (Human, Recombinant) (CP.PHAR.218) (PDF)
- Factor IX Complex, Human (Profilnine) (CP.PHAR.219) (PDF)
- Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (CP.PHAR.220) (PDF)
- Factor VIII (Human, Recombinant) (CP.PHAR.215) (PDF)
- Factor VIII/von Willebrand Factor Complex (Human – Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi) (CP.PHAR.216) (PDF)
- Factor XIIIa_Recombinant (Tretten) (CP.PHAR.222) (PDF)
- Factor XIII, Human (Corifact) (CP.PHAR.221) (PDF)
- Fam-trastuzumab Deruxtecan-nxki (Enhertu) (CP.PHAR.456) (PDF)
- Faricimab-svoa (Vabysmo) (CP.PHAR.581) (PDF)
- Ferric Carboxymaltose (Injectafer) (CP.PHAR.234) (PDF)
- Ferric Derisomaltose (Monoferric) (CP.PHAR.480) (PDF)
- Ferric Gluconate (Ferrlecit) (CP.PHAR.166) (PDF)
- Ferumoxytol (Feraheme) (CP.PHAR.165) (PDF)
- Fibrinogen concentrate (human) (Fibryga, RiaSTAP) (CP.PHAR.526) (PDF)
- Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastim-aafi (Nivestym) (CP.PHAR.297) (PDF)
- Fondaparinux (Arixtra) (CP.PHAR.226) (PDF)
- Fosdenopterin (Nulibry) (CP.PHAR.471) (PDF)
- Fremanezumab-vfrm (Ajovy) (CP.PHAR.403) (PDF)
- Fulvestrant (Faslodex Injection) (CP.PHAR.424) (PDF)
- Furosemide (Furoscix) (CP.PHAR.608) (PDF)
- Galcanezumab-gnlm (Emgality) (CP.PHAR.404) (PDF)
- Gemtuzumab Ozogamicin (Mylotarg) (CP.PHAR.358) (PDF)
- Givosiran (Givlaari) (CP.PHAR.457) (PDF)
- Glatiramer (Copaxone, Glatopa) (CP.PHAR.252) (PDF)
- Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (CP.PMN.183) (PDF)
- Glaucoma Agents (Omlonti, Rhopressa, Rocklatan, Vyzulta) (CP.PMN.286) (PDF)
- Golimumab (Simponi, Simponi Aria) (CP.PHAR.253) (PDF)
- Golodirsen (Vyondys53) (TX.PHAR.85) (PDF)
- Goserelin Acetate (Zoladex) (CP.PHAR.171) (PDF)
- Granisetron (Sancuso, Sustol) (CP.PMN.74) (PDF)
- Guselkumab (Tremfya) (CP.PHAR.364) (PDF)
- Hemin (panhematin) (CP.PHAR.181) (PDF)
- Histrelin Acetate (Vantas, Supprelin LA) (CP.PHAR.172) (PDF)
- Human Growth Hormone (Somapacitan, Somatropin) (CP.PHAR.517) (PDF)
- Hyaluronate Derivatives (CP.PHAR.05) (PDF)
- Ibandronate Injection (Boniva) (CP.PHAR.189) (PDF)
- Icatibant (Firazyr) (CP.PHAR.178) (PDF)
- Idecabtagene Vicleucel (Abecma) (TX.PHAR.94) (PDF)
- Iloprost (Ventavis) (CP.PHAR.193) (PDF)
- Immune Globulins (CP.PHAR.103) (PDF)
- Inclisiran (Leqvio) (CP.PHAR.568) (PDF)
- IncobotulinumtoxinA (Xeomin) (CP.PHAR.231) (PDF)
- Infertility and Fertility Preservation (CP.PHAR.131) (PDF)
- Infliximab (Remicade), Infliximab-axxq (Avsola), Infliximab-dyyb (Inflectra), and Infliximab-abda (Renflexis) (CP.PHAR.254) (PDF)
- Inotersen (Tegsedi) (CP.PHAR.405) (PDF)
- Inotuzumab ozogamicin (Besponsa) (TX.PHAR.47) (PDF)
- Interferon Beta-1a (Avonex, Rebif) (CP.PHAR.255) (PDF)
- Interferon Beta-1b (Betaseron, Extavia) (CP.PHAR.256) (PDF)
- Interferon Gamma- 1b (Actimmune) (CP.PHAR.52) (PDF)
- Iobenguane I 131 (Azedra) (CP.PHAR.459) (PDF)
- Ipilimumab (Yervoy) (CP.PHAR.319) (PDF)
- Irinotecan Liposome (Onivyde) (CP.PHAR.304) (PDF)
- Iron Sucrose (Venofer) (CP.PHAR.167) (PDF)
- Isatuximab-irfc (Sarclisa) (CP.PHAR.482) (PDF)
- Isavuconazonium (Cresemba) (CP.PMN.154) (PDF)
- Ixekizumab (Taltz) (CP.PHAR.257) (PDF)
- Lacosamide (Vimpat) (CP.PMN.155) (PDF)
- Lanadelumab-fylo (Takhzyro) (CP.PHAR.396) (PDF)
- Lanreotide (Somatuline Depot) (CP.PHAR.391) (PDF)
- Lefamulin (Xenleta) (CP.PMN.219) (PDF)
- Letermovir (Prevymis) (CP.PHAR.367) (PDF)
- Leucovorin Injection (CP.PHAR.393) (PDF)
- Leuprolide Acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi, Camcevi) (CP.PHAR.173) (PDF)
- Levoleucovorin (Fusilev, Khapzory) (CP.PHAR.151) (PDF)
- Lisocabtagene maraleucel (Breyanzi) (TX.PHAR.95) (PDF)
- Linezolid (Zyvox) (CP.PMN.27) (PDF)
- Loncastuximab tesirine-lpyl (Zynlonta) (CP.PHAR.539) (PDF)
- Lumasiran (Oxlumo) (CP.PHAR.473) (PDF)
- Lurbinectedin (Zepzelca) (CP.PHAR.500) (PDF)
- Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) (CP.PHAR.582) (PDF)
- Lutetium Lu 177 dotatate (Lutathera) (CP.PHAR.384) (PDF)
- Maralixibat (Livmarli) (CP.PHAR.543) (PDF)
- Margetuximab-cmkb (Margenza) (CP.PHAR.522) (PDF)
- Melphalan flufenamide (Pepaxto) (CP.PHAR.535) (PDF)
- Mepolizumab (Nucala) (TX.PHAR.96) (PDF)
- Methotrexate (Otrexup, Rasuvo, Reditrex, Xatmep) (CP.PHAR.134) (PDF)
- Methoxy polyethylene glycol-epoetin beta (Mircera) (CP.PHAR.238) (PDF)
- Methylnaltrexone Bromide (Relistor) (CP.PMN.169) (PDF)
- Metreleptin (Myalept) (CP.PHAR.425) (PDF)
- Mirvetuximab soravtansine-gynx (Elahere) (CP.PHAR.617) (PDF)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) (CP.PHAR.495) (PDF)
- Mitoxantrone (Novantrone) (CP.PHAR.258) (PDF)
- Mogamulizumab-kpkc (Poteligeo) (CP.PHAR.139) (PDF)
- Mometasone Furoate (Sinuva) (CP.PHAR.448) (PDF)
- Nadofaragene FiradeNovec (Instiladrin) (CP.PHAR.461) (PDF)
- Naloxone (Evzio) (CP.PMN.139) (PDF)
- Naltrexone (Vivitrol) (CP.PHAR.96) (PDF)
- Natalizumab (Tysabri) (CP.PHAR.259) (PDF)
- Naxitamab-gqgk (Danyelza) (CP.PHAR.523) (PDF)
- Necitumumab (Portrazza) (CP.PHAR.320) (PDF)
- Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (CP.PMN.158) (PDF)
- Nivolumab (Opdivo) (CP.PHAR.121) (PDF)
- Nivolumab and Relatlimab (Opdualag) (CP.PHAR.588) (PDF)
- No Coverage Criteria, Recent Label Changes Pending Clinical Policy Update (CP.PMN.255) (PDF)
- Nusinersen (Spinraza) (TX.PHAR.44) (PDF)
- Obinutuzumab (Gazyva) (CP.PHAR.305) (PDF)
- Ocrelizumab (Ocrevus) (CP.PHAR.335) (PDF)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (CP.PHAR.40) (PDF)
- Ofatumumab (Arzerra, Kesimpta) (CP.PHAR.306) (PDF)
- Off-Label Use (CP.PMN.53)(PDF)
- Olanzapine Long-Acting Injection (Zyprexa Relprevv) (CP.PHAR.292) (PDF)
- Olaratumab (Lartruvo) (CP.PHAR.326) (PDF)
- Omacetaxine (Synribo) (CP.PHAR.108) (PDF)
- Omadacycline (Nuzyra) (CP.PMN.188) (PDF)
- Omalizumab (Xolair) (TX.PHAR.97) (PDF)
- OnabotulinumtoxinA (Botox) (CP.PHAR.232) (PDF)
- Omburtamab (Omblastys) (CP.PHAR.585) (PDF)
- Onasemnogene Abeparvovec-xioi (Zolgensma) (TX.PHAR.79) (PDF)
- Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (CP.PHAR.536) (PDF)
- Paclitaxel, Protein-Bound (Abraxane) (CP.PHAR.176) (PDF)
- Paliperidone inj (Invega Sustenna, Invega Trinza, Invega Hafyera) (CP.PHAR.291) (PDF)
- Panitumumab (Vectibix) (CP.PHAR.321) (PDF)
- Parathyroid Hormone (Natpara) (CP.PHAR.282) (PDF)
- Paricalcitol Injection (Zemplar) (CP.PHAR.270) (PDF)
- Pasireotide (Signifor, Signifor LAR) (CP.PHAR.332) (PDF)
- Patisiran (Onpattro) (CP.PHAR.395)
- Pegcetacoplan (Empaveli, APL-2) (CP.PHAR.524) (PDF)
- Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (CP.PHAR.353) (PDF)
- Pegfilgrastim (Neulasta, Neulasta Onpro), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-pbbk (Fylnetra), Pegfilgrastim-apgf (Nyvepria), Eflapegrastim-xnst (Rolvedon), Pegfilgrastim-fpgk (Stimufend), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo) (CP.PHAR.296) (PDF)
- Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) (CP.PHAR.89)(PDF)
- Peginterferon Beta-1a (Plegridy) (CP.PHAR.271) (PDF)
- Pegloticase (Krystexxa) (CP.PHAR.115) (PDF)
- Pegunigalsidase Alfa (PRX-102) (CP.PHAR.512) (PDF)
- Pegvisomant (Somavert) (CP.PHAR.389) (PDF)
- Pegzilarginase (AEB1102) (CP.PHAR.587) (PDF)
- Pembrolizumab (Keytruda) (CP.PHAR.322) (PDF)
- Pemetrexed (Alimta, Pemfexy) (CP.PHAR.368) (PDF)
- Pertuzumab (Perjeta) (CP.PHAR.227) (PDF)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (CP.PHAR.501) (PDF)
- Plasminogen, human-tvmh (Ryplazim) (CP.PHAR.513) (PDF)
- Plerixafor (Mozobil) (CP.PHAR.323) (PDF)
- Polatuzumab Vedotin-piiq (Polivy) (CP.PHAR.433) (PDF)
- Prademagene Zamikeracel (EB-101) (CP.PHAR.609) (PDF)
- Pralatrexate (Folotyn) (CP.PHAR.313) (PDF)
- Pramlintide (Symlin) (CP.PMN.129)(PDF)
- Ramucirumab (Cyramza) (CP.PHAR.119) (PDF)
- Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo) (CP.PHAR.186) (PDF)
- Ravulizumab-cwvz (Ultomiris) (CP.PHAR.415) (PDF)
- Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel) (CP.PHAR.168) (PDF)
- Reslizumab (Cinqair) (TX.PHAR.98) (PDF)
- Rilonacept (Arcalyst) (CP.PHAR.266) (PDF)
- RimabotulinumtoxinB (Myobloc) (CP.PHAR.233) (PDF)
- Risankizumab-rzaa (Skyrizi) (CP.PHAR.426) (PDF)
- Risperidone LA Injection (Risperdal Consta, Perseris, Rykindo) (CP.PHAR.293) (PDF)
- Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), RituximabHyaluronidase (Rituxan Hycela) (CP.PHAR.260) (PDF)
- Rolapitant (Varubi) (CP.PMN.102) (PDF)
- Romidepsin (Istodax) (CP.PHAR.314)(PDF)
- Romiplostim (Nplate) (CP.PHAR.179) (PDF)
- Romosozumab-aqqg (Evenity) (CP.PHAR.428) (PDF)
- Ropeginterferon alfa-2b-njft (Besremi) (CP.PHAR.570) (PDF)
- RP-L201 (CP.PHAR.599) (PDF)
- Sacituzumab govitecan-hziy (Trodelvy) (CP.PHAR.475) (PDF)
- Sargramostim (Leukine) (CP.PHAR.295) (PDF)
- Sarilumab (Kevzara) (CP.PHAR.346) (PDF)
- Satralizumab-mwge (Enspryng) (CP.PHAR.463) (PDF)
- Secukinumab (Cosentyx) (CP.PHAR.261) (PDF)
- Selpercatinib (Retevmo) (CP.PHAR.478) (PDF)
- Setmelanotide (Imcivree) (CP.PHAR.491) (PDF)
- Sildenafil (Revatio) (CP.PHAR.197) (PDF)
- Siltuximab (Sylvant) (CP.PHAR.329) (PDF)
- Sipuleucel-T (Provenge) (CP.PHAR.120) (PDF)
- Sirolimus Protein-Bound Particles (Fyarro), Topical Gel (Hyftor) (CP.PHAR.574) (PDF)
- Sodium Phenylbutyrate-Taurursodiol (Relyvrio) (CP.PHAR.584) (PDF)
- Sodium thiosulfate (Pedmark) (CP.PHAR.610) (PDF)
- Sotrovimab (VIR-7831) (CP.PHAR.541) (PDF)
- Spesolimab-sbzo (Spevigo) (CP.PHAR.606) (PDF)
- Sutimlimab-jome (Enjaymo) (CP.PHAR.503) (PDF)
- Tafasitamab-cxix (Monjuvi) (CP.PHAR.508) (PDF)
- Talimogene laherparepvec (Imlygic) (CP.PHAR.542) (PDF)
- Tebentafusp-tebn (Kimmtrak) (CP.PHAR.575) (PDF)
- Teclistamab-cqyv (Tecvayli) (CP.PHAR.611) (PDF)
- Tedizolid (Sivextro) (CP.PMN.62) (PDF)
- Teduglutide (Gattex) (CP.PHAR.114) (PDF)
- Temozolomide (Temodar) (CP.PHAR.77) (PDF)
- Temsirolimus (Torisel) (CP.PHAR.324) (PDF)
- Teplizumab (PRV-031) (CP.PHAR.492) (PDF)
- Teriparatide (Forteo) (CP.PHAR.188) (PDF)
- Testosterone (Testopel, Jatenzo, Kyzatrex, Tlando) (CP.PHAR.354) (PDF)
- Tezepelumab-ekko (Tezspire) (TX.PHAR.105) (PDF)
- Thyrotropin alfa (Thyrogen) (CP.PHAR.95) (PDF)
- Tildrakizumab-asmn (Ilumya) (CP.PHAR.386) (PDF)
- Tisagenlecleucel (Kymriah) (TX.PHAR.58) (PDF)
- Tisotumab vedotin-tftv (Tivdak) (CP.PHAR.561) (PDF)
- Tixagevimab-Cilgavimab (Evusheld) (CP.PHAR.571) (PDF)
- Tocilizumab (Actemra) (CP.PHAR.263) (PDF)
- Tofersen (BIIB067) (CP.PHAR.591) (PDF)
- Topotecan (Hycamtin) (CP.PHAR.64) (PDF)
- Trabectedin (Yondelis) (CP.PHAR.204) (PDF)
- Tralokinumab-ldrm (Adbry) (CP.PHAR.577) (PDF)
- Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (CP.PHAR.228) (PDF)
- Tremelimumab-actl (Imjudo) (CP.PHAR.612) (PDF)
- Treprostinil (Orenitram, Remodulin, Tyvaso) (CP.PHAR.199) (PDF)
- Triamcinolone ER Injection (Zilretta) (CP.PHAR.371) (PDF)
- Triptorelin pamoate (Trelstar, Triptodur) (CP.PHAR.175) (PDF)
- Ustekinumab (Stelara) (CP.PHAR.264) (PDF)
- Valoctocogene Roxaparvovec (CP.PHAR.466) (PDF)
- Valrubicin (Valstar) (CP.PHAR.439) (PDF)
- Vedolizumab (Entyvio) (CP.PHAR.265) (PDF)
- Verteporfin (Visudyne) (CP.PHAR.187) (PDF)
- Vestronidase alfa-vjbk (Mepsevii) (CP.PHAR.374) (PDF)
- Viltolarsen (Viltepso) (TX.PHAR.88) (PDF)
- Vincristine Sulfate Liposome Injection (Marqibo) (CP.PHAR.315) (PDF)
- Voretigene neparvovec-rzyl (Luxturna®) Criteria (TX.PHAR.49) (PDF)
- Vosoritide (Voxzogo) (CP.PHAR.525) (PDF)
- Ziv-aflibercept (Zaltrap) (CP.PHAR.325) (PDF)
- Zoledronic Acid (Reclast, Zometa) (CP.PHAR.59) (PDF)
- Add on Code Billed Without Primary Code (CC.PP.030) (PDF)
- Acute Care Inpatient Hospital Claims - Sepsis Diagnosis (CC.PP.073) (PDF)
- ADHD Assessment and Treatment (CP.MP.124) (PDF)
- Allergy Testing and Therapy (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 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)
- 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)
- Acute Care Inpatient Hospital Claims - Sepsis Diagnosis (CC.PP.073) (PDF)
- ADHD Assessment and Treatment (TX.CP.MP.124) (PDF)
- Allergy Testing and Therapy (TX.CP.MP.100) (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)
- Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (CP.BH.201) (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)
- 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)
- 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 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)
- Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (CP.BH.200) (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
- Ultrasound in Pregnancy (CP.MP.38) (RETIRED Ambetter May 17, 2023) (PDF)
- Testing for Select Genitourinary Conditions (CP.MP.97) (RETIRED Ambetter and Medicaid May 17, 2023) (PDF)
- Endometrial Ablation (CP.MP.106) (RETIRED Ambetter May 17, 2023) (PDF)
- Bronchial Thermoplasty (CP.MP.110) (RETIRED Ambetter and Medicaid May 17, 2023) (PDF)
- Homocysteine Testing (CP.MP.121) (PDF)
- Laser Therapy for Skin Conditions (CP.MP.123) (RETIRED Ambetter May 17, 2023) (PDF)
- Low-frequency Ultrasound and Noncontact Wound Therapy (CP.MP.139) (RETIRED Ambetter and Medicaid May 17, 2023) (PDF)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (CP.MP.181) (RETIRED Ambetter May 17, 2023) (PDF)
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (CP.MP.209) (RETIRED Ambetter and Medicaid May 17, 2023) (PDF)
- Pulmonary Function Testing (CP.MP.242) (RETIRED Ambetter May 17, 2023) (PDF)
- Holter Monitors (CP.MP.113) (RETIRED Ambetter May 17, 2023) (PDF)
- Evoked Potentials (CP.MP.134) (RETIRED Ambetter May 17, 2023) (PDF)
- Incontinence Supplies (TX.CP.MP.508) (RETIRED Medicaid June 1, 2023) (PDF)
- Hydroxyprogesterone caproate (Makena) (CP.PHAR.14) - RETIRED (Ambetter April 10, 2022) (PDF)
- Makena Clinical Criteria for Authorization via Medical Benefit (TX.PHAR.15) - RETIRED (Medicaid April 10, 2022) (PDF)
- Hyperemesis Gravidarum Treatment (CP.MP.34) - RETIRED (Medicaid and Ambetter March 22, 2023 (PDF)
- Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) - RETIRED (Medicaid March 1, 2023) (CP.PHAR.211) (PDF)
- Protein C Concentrate Human (Ceprotin) (CP.PHAR.330) - RETIRED (Medicaid March 1, 2023) (PDF)
Enzalutamide (Xtandi) (HIM.PA.164) - RETIRED (Ambetter March 1, 2023) (PDF) - Evinacumab-dgnb (Evkeeza) (CP.PHAR.511) - RETIRED (Ambetter March 1, 2023) (PDF)
- Latanoprostene Bunod (Vyzulta) (CP.PMN.108)- RETIRED (Ambetter March 1, 2023) (PDF)
- Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan) (CP.PMN.118)- RETIRED (Ambetter March 1, 2023) (PDF)
- Pegaptanib (Macugen) (CP.PHAR.185)- RETIRED (Medicaid and Ambetter March 1, 2023) (PDF)
- Genetic and Pharmacogenetic Testing (CP.MP.89) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing: Aortopathies and Connective Tissue Disorders (CP.MP.215) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing Cardiac Disorders (CP.MP.216) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing: Dermatologic Conditions (CP.MP.217) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing Epilepsy, Neurodegenerative, and Neuromuscular Disorders (CP.MP.218) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (CP.MP.219) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing Eye Disorders (CP.MP.220) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing Gastroenterologic Disorders (non-cancerous) (CP.MP.221)
- Genetic Testing General Approach to Genetic Testing (CP.MP.222) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing Hearing Loss (CP.MP.223) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing Hematologic Condition (non-cancerous) (CP.MP.224) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing Hereditary Cancer Susceptibility (CP.MP.225) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing Immune, Autoimmune, and Rheumatoid Disorders (CP.MP.226) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing Lung Disorders (CP.MP.228) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing Metabolic, Endocrine, and Mitochondrial Disorders (CP.MP.229) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (CP.MP.230) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing for Non-Invasive Prenatal Screening (NIPS) (CP.MP.231) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing Pharmacogenetics (CP.MP.232) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing Preimplantation Genetic Testing (CP.MP.233) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing Prenatal and Preconception Carrier Screening (CP.MP.234) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing Prenatal Diagnosis (Via Amniocentises, CVS, or PUBS) and Pregnancy Loss (CP.MP.235) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Genetic Testing Skeletal Dysplasia and Rare Bone Disorders (CP.MP.236) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF)
- Patisiran (Onpattro) (CP.PHAR.395) - RETIRED (Medicaid February 7, 2023) (PDF)
- PROM Testing (CP.MP.149) - RETIRED (Medicaid and Ambetter January 16, 2023) (PDF)
- Ambulatory EEG (CP.MP.96) - RETIRED (Medicare January 16, 2023) (PDF)
- Measure Serum 1,25 Vitamin D (CP.MP.152) - RETIRED (Medicare January 16, 2023) (PDF)
- Holter Monitors (CP.MP.113) - RETIRED (Medicare January 16, 2023) (PDF)
- Genetic Testing (TX.CP.MP.531) - RETIRED (Medicaid January 1, 2023) (PDF)
- Pharmacogenetic Testing - RETIRED (Medicaid January 1, 2023) (TX.CP.MP.528) (PDF)
- Podiatry Services (TX.CP.MP.527) - RETIRED (Medicaid October 17, 2022) (PDF)
- Compounded Medications (CP.PCH.27) - RETIRED (Ambetter September 1, 2022) (PDF)
- Lactitol (Pizensy) (CP.PMN.241) - RETIRED (Ambetter September 1, 2022) (PDF)
- Valproate (Depacon) (CP.PHAR.429) -- RETIRED (Medicaid and Ambetter September 1, 2022) (PDF)
- Home Cardiorespiratory Monitors (TX.CP.MP.501) - RETIRED (Medicaid August 15, 2022)(PDF)
- Nebivolol (Bystolic) (HIM.PA.131) - RETIRED (Ambetter June 1, 2022) (PDF)
- Natalizumab (Tysabri) (HIM.PA.SP17) - RETIRED (Ambetter June 1, 2022) (PDF)
- Lorcaserin (Belviq, Belviq XR) (CP.PCH.03) - RETIRED (Ambetter June 1, 2022) (PDF)
- 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)
- Halobetasol-Tazarotene (Duobrii) (CP.PMN.208) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Naloxone (Evzio) (CP.PMN.139) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Sodium Zirconium Cyclosilicate (Lokelma) (CP.PMN.163) (PDF) - RETIRED (Ambetter - 6/1/2020)
- 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)