Clinical & Payment Policies
Clinical Policies
Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information.
All policies found in the MHS Clinical Policy Manual apply to MHS members. Policies in the MHS Clinical Policy Manual may have either a MHS or a “Centene” heading. MHS utilizes MCG criteria for those medical technologies, procedures or pharmaceutical treatments for which a MHS clinical policy does not exist. MCG is a nationally recognized evidence-based decision support tool. In addition, MHS 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 MCG criteria is payable by MHS.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Ambetter Clinical Policies
For Ambetter information, please visit our Ambetter website.
Ambetter Pharmacy Policies
- Abaloparatide (Tymlos®) (CP.PHAR.345) (PDF)
- Abemaciclib (Verzenio™) (CP.PHAR.355) (PDF)
- Abiraterone (Zytiga) (CP.PHAR.84) (PDF)
- AbobotulinumtoxinA (Dysport®) (CP.PHAR.230) (PDF)
- Acalabrutinib (Calquence®) (CP.PHAR.366) (PDF)
- Acyclovir buccal tab (Sitavig) ophthalimic ointment (Avaclyr) (CP.PMN.210) (PDF)
- Ado-Trastuzumab Emtansine (Kadcyla®) (CP.PHAR.229) (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)
- Alirocumab (Praluent) (CP.PHAR.124) (PDF)
- Alosetron (Lotronex) (CP.PMN.153) (PDF)
- Alpelisib (Piqray) (CP.PHAR.430) (PDF)
- Alpha-1 Proteinase Inhibitors (CP.PHAR.94) (PDF)
- Amantadine ER (Gocovri®) (CP.PMN.89) (PDF)
- Ambrisentan (Letairis®) (CP.PHAR.190) (PDF)
- Amifampridine (Firdapse) (CP.PHAR.411) (PDF)
- Amikacin (Arikayce) (CP.PHAR.401) (PDF)
- Anti-inhibitor Coagulant Complex (Feiba®) (CP.PHAR.217) (PDF)
- Antipsychotic Therapy and Metabolic Monitoring (IN.CP.PMN.502) (PDF)
- Apalutamide (Erleada™) (CP.PHAR.376) (PDF)
- Aprepitant (Emend) (CP.PMN.19) (PDF)
- Arformoterol tartrate (Brovana) (CP.PMN.201) (PDF)
- Asenapine (Saphris®) (CP.PMN.15) (PDF)
- Asfotase Alfa (Strensiq®) (CP.PHAR.328) (PDF)
- Aspirin-dipyridamole (Aggrenox®) (CP.PMN.20) (PDF)
- Atezolizumab (Tecentriq®) (CP.PHAR.235) (PDF)
- Avatrombopag (Doptelet) (CP.PHAR.130) (PDF)
- Avelumab (Bavencio®) (CP.PHAR.333) (PDF)
- Axitinib (Inlyta®) (CP.PHAR.100) (PDF)
- Azacitidine (Vidaza) (CP.PHAR.387) (PDF)
- Aztreonam (Cayston®) (CP.PHAR.209) (PDF)
- Bedaquiline (Sirturo) (CP.PMN.212) (PDF)
- Belatacept (Nulojix®) (CP.PHAR.201) (PDF)
- Belimumab (Benlysta) (CP.PHAR.88) (PDF)
- Belinostat (Beleodaq®) (CP.PHAR.311) (PDF)
- Bendamustine (Bendeka®, Treanda®) (CP.PHAR.307) (PDF)
- Benralizumab (FasenraTM) (CP.PHAR.373) (PDF)
- Benzinadazole (CP.PMN.90) (PDF)
- Benzyl alcohol (Ulesfia) (CP.PMN.202) (PDF)
- Betaine (Cystadane) (CP.PHAR.143) (PDF)
- Betamethasone dipropionate (Sernivo) (CP.PMN.182) (PDF)
- Bevacizumab (Avastin®) (CP.PHAR.93) (PDF)
- Bexarotene (Targretin®) (CP.PHAR.75) (PDF)
- Bezlotoxumab (Zinplava®) (CP.PHAR.300) (PDF)
- Binimetinib (Mektovi®) (CP.PHAR.50) (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 (CP.PMN.22) (PDF)
- Brentuximab Vedotin (Adcetris) (CP.PHAR.303) (PDF)
- Brexanolone (Zulresso) (IN.CP.PHAR.417) (PDF)
- Brexpiprazole (Rexulti®) (CP.PMN.68) (PDF)
- Brigatinib (AlunbrigTM) (CP.PHAR.342) (PDF)
- Brimonidine (Mirvaso®) (CP.PMN.192) (PDF)
- Brodalumab (Siliq™) (CP.PHAR.375) (PDF)
- Brolucizumab (Beovu) (CP.PHAR.445) (PDF)
- Buprenorphine (Probuphine®, Sublocade®) (CP.PHAR.289) (PDF)
- Buprenorphine (Subutex®) (CP.PMN.82) (PDF)
- Buprenorphine and Buprenorphine/Naloxone Approval Criteria for MAT (CP.PMN.81) (PDF)
- Burosumab-twza (Crysvita) (CP.PHAR.11) (PDF)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (CP.PHAR.202) (PDF)
- Cabazitaxel (Jevtana®) (CP.PHAR.316) (PDF)
- Cabozantinib (Cabometyx, Cometriq) (CP.PHAR.111) (PDF)
- Calcifediol (Rayaldee®) (CP.PMN.76) (PDF)
- Canakinumab (Ilaris®) (CP.PHAR.246) (PDF)
- Capecitabine (Xeloda®) (CP.PHAR.60) (PDF)
- Caplacizumab-yhdp (Cablivi) (CP.PHAR.416) (PDF)
- Carfilzomib (Kyprolis®) (CP.PHAR.309) (PDF)
- Carglumic acid (Carbaglu®) (CP.PHAR.206) (PDF)
- Cariprazine (Vraylar®) (CP.PMN.91) (PDF)
- Celecoxib (Celebrex®) (CP.PMN.122) (PDF)
- Cenegermin-bkbj (Oxervate) (CP.PMN.186) (PDF)
- Ceritinib (Zykadia®) (CP.PHAR.349) (PDF)
- Cerliponase alfa (Brineura) (CP.PHAR.338) (PDF)
- Certolizumab (Cimzia) (CP.PHAR.247) (PDF)
- Cetuximab (Erbitux®) (CP.PHAR.317) (PDF)
- Chloramphenicol (CP.PHAR.388) (PDF)
- Ciclopirox (Penlac®) (CP.PMN.24) (PDF)
- Cholic acid (Cholbam) (CP.PHAR.390) (PDF)
- Cinacalcet (Sensipar) (CP.PHAR.61) (PDF)
- Cladribine (Mavenclad) (CP.PHAR.422) (PDF)
- Clobazam (Onfi) (CP.PMN.54) (PDF)
- Clozapine orally disintegrating tablet (Fazaclo®) (CP.PMN.12) (PDF)
- CNS Stimulants (CP.PMN.92) (PDF)
- Cobimetinib (Cotellic) (CP.PHAR.380) (PDF)
- Colchicine (Colcrys®) (CP.PMN.123) (PDF)
- Collagenase Clostridium Histolyticum (Xiaflex®) (CP.PHAR.82) (PDF)
- Copanlisib (Aliqopa®) (CP.PHAR.357) (PDF)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert) (CP.PHAR.385) (PDF)
- Corticotropin (H.P. Acthar) (CP.PHAR.168) (PDF)
- Cosyntropin (Cortrosyn®) (CP.PHAR.203) (PDF)
- Coverage of Diabetic Testing Meters and Strips (IN.PHAR.11) (PDF)
- Crisaborole (Eucrisa) (CP.PMN.110) (PDF)
- Crizotinib (Xalkori®) (CP.PHAR.90) (PDF)
- Cyclosporine (Restasis®) (CP.PMN.48) (PDF)
- Cysteamine ophthalmic (Cystaran™) (CP.PMN.130) (PDF)
- Cysteamine oral bitartrate (Cystagon®, Procysbi®) (CP.PHAR.155) (PDF)
- Cytomegalovirus Immune Globulin (CytoGam) (CP.PHAR.277) (PDF)
- Dabigatran (Pradaxa®) (CP.PMN.49) (PDF)
- Dabrafenib (Tafinlar) (CP.PHAR.239) (PDF)
- Dalfampridine (Ampyra) (CP.PHAR.248) (PDF)
- Dalteparin (Fragmin®) (CP.PHAR.225) (PDF)
- Daptomycin (Cubicin Cubicin RF) (CP.PHAR.351) (PDF)
- Daratumumab (Darzalex) (CP.PHAR.310) (PDF)
- Darbepoetin alfa (Aranesp®) (CP.PHAR.236) (PDF)
- Darolutamide (Nubeqa) (CP.PHAR.435) (PDF)
- Dasatinib (Sprycel®) (CP.PHAR.72) (PDF)
- Daunorubicin/Cytarabine (Vyxeos®) (CP.PHAR.352) (PDF)
- Deferasirox (Exjade, Jadenu) (CP.PHAR.145) (PDF)
- Deferiprone (Ferriprox) (CP.PHAR.147) (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®) (CP.PHAR.214) (PDF)
- Deutetrabenazine (Austedo®) (CP.PHAR.341) (PDF)
- Dextromethorphan-Quinidine (Nuedexta®) (CP.PMN.93) (PDF)
- Dimethyl fumarate (Tecfidera®) (CP.PHAR.249) (PDF)
- Dolasetron (Anzemet) (CP.PMN.141) (PDF)
- Dornase alfa (Pulmozyme®) (CP.PHAR.212) (PDF)
- Dose Optimization (CP.PMN.13) (PDF)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (CP.PMN.79) (PDF)
- DPP-4 inhibitors (CP.PMN.03) (PDF)
- Dronabinol (Marinol, Syndros) (CP.PMN.159) (PDF)
- Droxidopa (Northera®) (CP.PMN.17) (PDF)
- Dupilumab (Dupixent®) (IN.CP.PHAR.336) (PDF)
- Durvalumab (Imfinzi®) (CP.PHAR.339) (PDF)
- Dutasteride (Avodart®) and dutasteride/tamsulosin (Jalyn®) (CP.PMN.128) (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)
- Elagolix (Orilissa) (CP.PHAR.136) (PDF)
- Eliglustat (Cerdelga®) (CP.PHAR.153) (PDF)
- Elosulfase alfa (Vimizim®) (CP.PHAR.162) (PDF)
- Elotuzumab (Empliciti®) (CP.PHAR.308) (PDF)
- Eltrombopag (Promacta®) (CP.PHAR.180) (PDF)
- Emapalumab-lzsg (Gamifant) (CP.PHAR.402) (PDF)
- Emicizumab-rzyl (Hemlibra) (CP.PHAR.370) (PDF)
- Enasidenib (Idhifa®) (CP.PHAR.363) (PDF)
- Encorafenib (Braftovi™) (CP.PHAR.127) (PDF)
- Enfuvirtide (Fuzeon) (CP.PHAR.41) (PDF)
- Enoxaparin (Lovenox) (CP.PHAR.224) (PDF)
- Enzalutamide (Xtandi) (CP.PHAR.106) (PDF)
- Epinephrine (EpiPen and EpiPen Jr) Quanity Limit Override (CP.PMN.144) (PDF)
- Epoetin Alfa (Epogen and Procrit) (CP.PHAR.237) (PDF)
- Epoprostenol (Flolan®, Veletri®) (CP.PHAR.192) (PDF)
- Erdafitinib (Balversa) (CP.PHAR.423) (PDF)
- Erenumab-aaoe (Aimovig) (CP.PHAR.128) (PDF)
- Eribulin Mesylate (Halaven®) (CP.PHAR.318) (PDF)
- Erlotinib (Tarceva®) (CP.PHAR.74) (PDF)
- Erwinia Asparaginase (Erwinaze®) (CP.PHAR.301) (PDF)
- Etanercept (Enbrel) (CP.PHAR.250) (PDF)
- Etelcalcetide (Parsabiv) (CP.PHAR.379) (PDF)
- Eteplirsen (Exondys 51®) (CP.PHAR.288) (PDF)
- Etidronate (Didronel®) (CP.PMN.94) (PDF)
- Everolimus (Afinitor, Afinitor Disperz) (CP.PHAR.63) (PDF)
- Evolocumab (Repatha) (CP.PHAR.123) (PDF)
- Febuxostat (Uloric®) (CP.PMN.57) (PDF)
- Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (CP.PMN.127) (PDF)
- Ferric Carboxymaltose (Injectafer®) (CP.PHAR.234.) (PDF)
- Ferric Gluconate (Ferrlecit®) (CP.PHAR.166) (PDF)
- Ferric maltol (Accrufer) (CP.PMN.213) (PDF)
- Ferumoxytol (Feraheme®) (CP.PHAR.165) (PDF)
- Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) (CP.PHAR.297) (PDF)
- Fingolimod (Gilenya®) (CP.PHAR.251) (PDF)
- Fluticasone Propionate (Xhance®) (CP.PMN.95) (PDF)
- Fluticasone/Salmeterol (Advair Diskus, Advair HFA) (CP.PMN.31) (PDF)
- Fluticasone-umeclidinium-vilanterol (Trelegy Ellipta) (CP.PMN.146) (PDF)
- Fondaparinux (Arixtra®) (CP.PHAR.226) (PDF)
- Fostamatinib (Tavalisse) (CP.PHAR.24) (PDF)
- Fremanezumab (Ajovy) (CP.PHAR.403) (PDF)
- Fulvestrant (Faslodex Injection) (CP.PHAR.424) (PDF)
- Galcanezumab-gnlm (Emgality) (CP.PHAR.404) (PDF)
- Galsulfase (Naglazyme®) (CP.PHAR.161) (PDF)
- Gefitinib (Iressa®) (CP.PHAR.68) (PDF)
- Glasdegib (Daurismo) (CP.PHAR.413) (PDF)
- Gemtuzumab ozogamicin (Mylotarg®) (CP.PHAR.358) (PDF)
- Gilteritinib (Xospata) (CP.PHAR.412) (PDF)
- GLP-1 receptor agonists (CP.PMN.183) (PDF)
- Glycerol phenylbutyrate (Ravicti®) (CP.PHAR.207) (PDF)
- Golimumab (Simponi®, Simponi Aria®) (CP.PHAR.253) (PDF)
- Goserelin Acetate (Zoladex®) (CP.PHAR.171) (PDF)
- Granisetron (Kytril, Sancuso) (CP.PMN.74) (PDF)
- Guselkumab (Tremfya®) (CP.PHAR.364) (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)
- 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)
- Ibandronate Oral (Boniva®) (CP.PMN.96) (PDF)
- Ibrutinib (Imbruvica) (CP.PHAR.126) (PDF)
- Ibuprofen and Famotidine (Duexis) (CP.PMN.120) (PDF)
- Icatibant (Firazyr®) (CP.PHAR.178) (PDF)
- Icosapent ethyl (Vascepa) (CP.PMN.187) (PDF)
- Idelalisib (Zydelig) (CP.PHAR.133) (PDF)
- Idursulfase (Elaprase®) (CP.PHAR.156) (PDF)
- Ifaximin (Xifaxan®) (CP.PMN.47) (PDF)
- Iloperidone (Fanapt®) (CP.PMN.32) (PDF)
- Iloprost (Ventavis®) (CP.PHAR.193) (PDF)
- Imatinib mesylate (Gleevec®) (CP.PHAR.65) (PDF)
- Imiglucerase (Cerezyme®) (CP.PHAR.154) (PDF)
- Immune Globulins (CP.PHAR.103) (PDF)
- Immunization Coverage (CP.PHAR.28) (PDF)
- IncobotulinumtoxinA (Xeomin®) (CP.PHAR.231) (PDF)
- Indacaterol (Arcapta Neohaler) (CP.PMN.203) (PDF)
- Indacaterol-glycopyrrolate (Utibron Neohaler) (CP.PMN.147) (PDF)
- Infliximab (Remicade®, Inflectra®, Renflexis™) (CP.PHAR.254) (PDF)
- Inotersen (Tegsedi) (CP.PHAR.405) (PDF)
- Inotuzumab ozogamicin (Besponsa®) (CP.PHAR.359) (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)
- Intra baclofen (Gablofen®) (CP.PHAR.149) (PDF)
- Ipilimumab (Yervoy) (CP.PHAR.319) (PDF)
- Irinotecan Liposome (Onivyde®) (CP.PHAR.304) (PDF)
- Iron Sucrose (Venofer®) (CP.PHAR.167) (PDF)
- Isavuconazonium (Cresemba) (CP.PMN.154) (PDF)
- Isotretinoin (Claravis, Absorica, Myorisan, Zenatane) (CP.PMN.143) (PDF)
- Istradefylline (Nourianz) (CP.PMN.217) (PDF)
- Itraconazole (Sporanox®, Onmel®) (CP.PMN.124) (PDF)
- Ivabradine (Corlanor®) (CP.PMN.70) (PDF)
- Ivosidenib (Tibsovo) (CP.PHAR.137) (PDF)
- Ixazomib (Ninlaro) (CP.PHAR.302) (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)
- Lantanoprostene Bunod (Vyzylta®) (CP.PMN.108) (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)
- Lefamulin (Xenleta) (CP.PMN.219) (PDF)
- Lenalidomide (Revlimid®) (CP.PHAR.71) (PDF)
- Lenvatinib (Lenvima) (CP.PHAR.138) (PDF)
- Lesinurad (Zurampic), lesinurad-allopurinol (Duzallo) (CP.PMN.150) (PDF)
- Letermovir (Prevymis®) (CP.PHAR.367) (PDF)
- Leucovorin Injection (CP.PHAR.393) (PDF)
- Leuprolide Acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (CP.PHAR.173) (PDF)
- Levoleucovorin (Fusilev®) (CP.PHAR.151) (PDF)
- L-glutamine (Endari®) (CP.PMN.116) (PDF)
- Lidocaine Transdermal (Lidoderm®) (CP.PMN.08) (PDF)
- Lifitegrast (Xiidra®) (CP.PMN.73) (PDF)
- Linaclotide (Linzess®) (CP.PMN.71) (PDF)
- Lindane Shampoo (CP.PMN.09) (PDF)
- Linezolid (Zyvox®) (CP.PMN.27) (PDF)
- Lomitapide (Juxtapid) (CP.PHAR.283) (PDF)
- Lorcaserin (Belviq®, Belviq XR®) (CP.PCH.03) (PDF)
- Lorlatinib (Lorbrena) (CP.PHAR.406) (PDF)
- Lubiprostone (Amitiza) (CP.PMN.142) (PDF)
- Luliconazole Cream (Luzu) (CP.PMN.166) (PDF)
- Lurasidone (Latuda®) (CP.PMN.50) (PDF)
- Lusutrombopag (Mulpleta) (CP.PHAR.407) (PDF)
- Lutetium Lu 177 dotatate (Lutathera) (CP.PHAR.384) (PDF)
- Macitentan (Opsumit®) (CP.PHAR.194) (PDF)
- Mecamylamine (Vecamyl®) (CP.PMN.136) (PDF)
- Mecasermin (Increlex) (CP.PHAR.150) (PDF)
- Mechlorethamine (Valchlor) (CP.PHAR.381) (PDF)
- Mepolizumab (Nucala) (CP.PHAR.200) (PDF)
- Mercaptopurine (Purixan) (CP.PHAR.447) (PDF)
- Metformin ER (Glumetza®) (CP.PMN.72) (PDF)
- Methadone for Management of Pain (IN.CP.PMN.02) (PDF)
- Methotrexate (Otrexup, Rasuvo, Xatmep) (CP.PHAR.134) (PDF)
- Methoxy polyethylene glycol-epoetin beta (Mircera®) (CP.PHAR.238) (PDF)
- Metreleptin (Myalept) (CP.PHAR.425) (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)
- Minocycline ER (Solodyn®) and Microspheres (Arestin®) (CP.PMN.80) (PDF)
- Mipomersen (Kynamro) (CP.PHAR.284) (PDF)
- Mitoxantrone (Novantrone®) (CP.PHAR.258) (PDF)
- Mogamulizumab-kpkc (Poteligeo) (CP.PHAR.139) (PDF)
- Mometasone furoate (Sinuva) (CP.PHAR.448) (PDF)
- Nabilone (Cesamet) (CP.PMN.160) (PDF)
- Nafarelin Acetate (Synarel®) (CP.PHAR.174) (PDF)
- Naldemedine (Symproic®) (CP.PMN.112) (PDF)
- Naloxone (Evzio) (CP.PMN.139) (PDF)
- Naltrexone (Vivitrol®) (CP.PHAR.96) (PDF)
- Naproxen and esomeprazole magnesium (Vimovo®) (CP.PMN.117) (PDF)
- Narcolepsy Agents (IN.CP.PMN.500) (PDF)
- Natalizumab (Tysabri®) (CP.PHAR.259) (PDF)
- Necitumumab (Portrazza®) (CP.PHAR.320) (PDF)
- Neratinib (Nerlynx®) (CP.PHAR.365) (PDF)
- Netarsudil (Rhopressa®) (CP.PMN.118) (PDF)
- Netupitant;palonosetron (Akynzeo) (CP.PMN.158) (PDF)
- Nilotinib (Tasigna®) (CP.PHAR.76) (PDF)
- Nintedanib (Ofev) (CP.PHAR.285) (PDF)
- Niraparib (Zejula) (CP.PHAR.408) (PDF)
- Nitisinone (Orfadin, Nityr) (CP.PHAR.132) (PDF)
- Nivolumab (Opdivo) (CP.PHAR.121) (PDF)
- No Coverage Criteria/Off-Label Use Policy (CP.PMN.53) (PDF)
- Non-Calcium Phosphate Binders (CP.PMN.04) (PDF)
- Nusinersen (Spinraza) (CP.PHAR.327) (PDF)
- Obeticholic acid (Ocaliva) (CP.PHAR.287) (PDF)
- Obinutuzumab (Gazyva®) (CP.PHAR.305) (PDF)
- Ocrelizumab (OcrevusTM) (CP.PHAR.335) (PDF)
- Octreotide Acetate (Sandostatin®, Sandostatin LAR Depot®) (CP.PHAR.40) (PDF)
- Ofatumumab (Arzerra®) (CP.PHAR.306) (PDF)
- Olanzapine ODT (Zyprexa Zydis®) (CP.PMN.29) (PDF)
- Olaparib (Lynparza) (CP.PHAR.360) (PDF)
- Olaratumab (Lartruvo®) (CP.PHAR.326) (PDF)
- Olodaterol (Striverdi Respimat) (CP.PMN.204) (PDF)
- Omacetaxine (Synribo®) (CP.PHAR.108) (PDF)
- Omadacycline (Nuzyra) (CP.PMN.188) (PDF)
- Omalizumab (Xolair®) (CP.PHAR.01) (PDF)
- Omega-3-Acid Ethyl Esters (Lovaza®) (CP.PMN.52) (PDF)
- OnabotulinumtoxinA (Botox) (CP.PHAR.232) (PDF)
- Ondansetron (Zuplenz) (CP.PMN.45) (PDF)
- Opiates with concurrent buprenorphine (Subutex®) and buprenorphine naloxone (Suboxone®) (CP.PMN.47) (PDF)
- Opioid Analgesics (CP.PMN.97) (PDF)
- Opioid Analgesics (IN.CP.PPA.12) (PDF)
- Osimertinib (Tagrisso) (CP.PHAR.294) (PDF)
- Overactive Bladder Agents (CP.PMN.198) (PDF)
- Oxymetazoline (Rhofade™) (CP.PMN.86) (PDF)
- Ozenoxacin (Xepi) (CP.PMN.119) (PDF)
- Paclitaxel, protein-bound (Abraxane®) (CP.PHAR.176) (PDF)
- Palbociclib (Ibrance®) (CP.PHAR.125) (PDF)
- Palivizumab (Synagis®) (CP.PHAR.16) (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 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)
- Pegademase Bovine (Adagen) (CP.PHAR.392) (PDF)
- Pegaptanib (Macugen®) (CP.PHAR.185) (PDF)
- Pegaspargase (Oncaspar®) (CP.PHAR.353) (PDF)
- Pegfilgrastim (Neulasta) (CP.PHAR.296) (PDF)
- Peginterferon Alfa-2b (PegIntron, Sylatron) (CP.PHAR.89) (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)
- Pembrolizumab (Keytruda®) (CP.PHAR.322) (PDF)
- Pemetrexed (Alimta®) (CP.PHAR.368) (PDF)
- Perampanel (Fycompa) (CP.PMN.156) (PDF)
- Pertuzumab (Perjeta®) (CP.PHAR.227) (PDF)
- Pexidartinib (Turalio) (CP.PHAR.436) (PDF)
- Pimavanserin (Nuplazid) (CP.PMN.140) (PDF)
- Pirfenidone (Esbriet) (CP.PHAR.286) (PDF)
- Plecanatide (Trulance®) (CP.PMN.87) (PDF)
- Plerixafor (Mozobil) (CP.PHAR.323) (PDF)
- Polatuzuman vedotin – piiq (Polivy) (CP.PHAR.433) (PDF)
- Pomalidomide (Pomalyst®) (CP.PHAR.116) (PDF)
- Ponatinib (Iclusig®) (CP.PHAR.112) (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)
- Propranolol HCl oral solution (Hemangeol®) (CP.PMN.58) (PDF)
- Protein C Concentrate Human (Ceprotin®) (CP.PHAR.330) (PDF)
- Prucalopride (Motegrity) (CP.PMN.194) (PDF)
- Pyrimethamine (Daraprin®) (CP.PMN.44) (PDF)
- QL of Diabetic Test Strips not receiving insulin (CP.PMN.151) (PDF)
- Quantity Limit Override (CP.PMN.59) (PDF)
- Quetiapine ER (Seroquel XR®) (CP.PMN.64) (PDF)
- Ramucirumab (Cyramza®) (CP.PHAR.119) (PDF)
- Ranibizumab (Lucentis®) (CP.PHAR.186) (PDF)
- Ranolazine (Ranexa®) (CP.PMN.34) (PDF)
- Ravulizumab-cwvz (Ultomiris) (CP.PHAR.415) (PDF)
- Regorafenib (Stivarga®) (CP.PHAR.107) (PDF)
- Request for Medically Necessary Drug not on the PDL (CP.PMN.16) (PDF)
- Reslizumab (Cinqair®) (CP.PHAR.223) (PDF)
- Revefenacin (Yupelri) (CP.PMN.195) (PDF)
- Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (CP.PHAR.141) (PDF)
- Ribociclib (Kisqali®, Kisqali Femara®) (CP.PHAR.334) (PDF)
- Rifabutin (Mycobutin),Rifabutin,omeprazole,amoxicillin (Talicia) (CP.PMN.223) (PDF)
- Rifamycin (Aemcolo) (CP.PMN.196) (PDF)
- Rifapentine (Priftin®) (CP.PMN.05) (PDF)
- Rilonacept (Arcalyst®) (CP.PHAR.266) (PDF)
- RimabotulinumtoxinB (Myobloc®) (CP.PHAR.233) (PDF)
- Riociguat (Adempas®) (CP.PHAR.195) (PDF)
- Risankizumab-rsaa (Skyrizi) (CP.PHAR.426) (PDF)
- Risedronate (Actonel®, Atelvia®) (CP.PMN.100) (PDF)
- Rituximab (Rituxan®), Rituximab and hyaluronidase (Rituxan Hycela™) (CP.PHAR.260) (PDF)
- Rivastigmine (Exelon®) (CP.PMN.101) (PDF)
- Roflumilast (Daliresp) (CP.PMN.46) (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)
- Rucaparib (Rubraca®) (CP.PHAR.350) (PDF)
- Rufinamide (Banzel) (CP.PMN.157) (PDF)
- Ruxolitinib (Jakafi®) (CP.PHAR.98) (PDF)
- Sacubitril and 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)
- Sarilumab (Kevzara®) (CP.PHAR.346) (PDF)
- Sebelipase alfa (Kanuma®) (CP.PHAR.159) (PDF)
- Secnidazole (Solosec®) (CP.PMN.103) (PDF)
- Secukinumab (Cosentyx®) (CP.PHAR.261) (PDF)
- Segesterone-Ethinyl Estradiol (Annovera) (CP.PMN.190) (PDF)
- Selexipag (Uptravi®) (CP.PHAR.196) (PDF)
- Selinexor (Xpovio) (CP.PHAR.431) (PDF)
- Short Ragweed Pollen Allergen Extract (Ragwitek) (CP.PMN.83) (PDF)
- Sildenafil (Revatio®) (CP.PHAR.197) (PDF)
- Siltuximab (Sylvant®) (CP.PHAR.329) (PDF)
- Siponimod (Mayzent) (CP.PHAR.427) (PDF)
- Sipuleucel-T (Provenge®) (CP.PHAR.120) (PDF)
- Sodium phenylbutyrate (Buphenyl®) (CP.PHAR.208) (PDF)
- Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (CP.PMN.14) (PDF)
- Solriamfetol (Sunosi) (CP.PMN.209) (PDF)
- Sonidegib (Odomzo®) (CP.PHAR.272) (PDF)
- Sorafenib (Nexavar®) (CP.PHAR.69) (PDF)
- SSRI SNRI Duplicate Thearapy (CP.PMN.60) (PDF)
- Step Therapy (CP.PST.01) (PDF)
- Sunitinib (Sutent®) (CP.PHAR.73) (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®) (CP.PHAR.198) (PDF)
- Tadalafil BHP - ED (Cialis) (CP.PMN.132) (PDF)
- Tafamidis meglumine, Tafamidis (Vyndaquel, Vyndamax) (CP.PHAR.432) (PDF)
- Tafenoquine (Arakoda) (CP.PMN.178) (PDF)
- Talazoparib (Talzenna) (CP.PHAR.409) (PDF)
- Taliglucerase alfa (Elelyso®) (CP.PHAR.157) (PDF)
- Tasimelteon (Hetlioz®) (CP.PMN.104) (PDF)
- Tavaborole (Kerydin®) (CP.PMN.105) (PDF)
- Tedizolid (Sivextro®) (CP.PMN.62) (PDF)
- Teduglutide (Gattex) (CP.PHAR.114) (PDF)
- Tegaserod (Zelnorm) (CP.PMN.206) (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)
- Teriflunomide (Aubagio®) (CP.PHAR.262) (PDF)
- Teriparatide (Forteo®) (CP.PHAR.188) (PDF)
- Tesamorelin (Egrifta) (CP.PHAR.109) (PDF)
- Testosterone Pellet (Testopel®) (CP.PHAR.354) (PDF)
- Tetrabenazine (Xenazine®) (CP.PHAR.92) (PDF)
- Tezacaftor/iv acafter; ivacaftor (Symdeko™ ) (CP.PHAR.377) (PDF)
- Thalidomide (Thalomid) (CP.PHAR.78) (PDF)
- Thioguanine (Tabloid) (CP.PHAR.437) (PDF)
- Thyrotropin Alfa (Thyrogen) (CP.PHAR.95) (PDF)
- Tildrakizumab-asmn (Ilumya) (CP.PHAR.386) (PDF)
- Timothy Grass Pollen Allergen Extract (Grastek) (CP.PMN.84) (PDF)
- Tiotropium-olodaterol (Stiolto Respimat) (CP.PMN.148) (PDF)
- Tisagenlecleucel (Kymriah®) (CP.PHAR.361) (PDF)
- Tobramycin (CP.PHAR.211) (PDF)
- Tocilizumab (Actemra®) (CP.PHAR.263) (PDF)
- Tofacitinib (Xeljanz®, Xeljanz® XR) (CP.PHAR.267) (PDF)
- Tolvaptan (Jynarque) (CP.PHAR.27) (PDF)
- Topical Immunomodulators (CP.PMN.107) (PDF)
- Topotecan (Hycamtin®) (CP.PHAR.64) (PDF)
- Toremifene (Fareston®) (CP.PMN.126) (PDF)
- Trametinib (Mekinist) (CP.PHAR.240) (PDF)
- Trastuzumab (Herceptin®), Trastuzumab-dkst (Ogivri®) (CP.PHAR.228) (PDF)
- Treprostinil (Orenitram®, Remodulin®, Tyvaso®) (CP.PHAR.199) (PDF)
- Triclabendazole (Egaten) (CP.PMN.207) (PDF)
- Triamcinolone ER Injection (Zilretta) (CP.PHAR.371) (PDF)
- Trientine (Syprine) (CP.PHAR.438) (PDF)
- Trifarontene (Aklief) (CP.PMN.225) (PDF)
- Trifluridine_Tipiracil (Lonsurf) (CP.PHAR.383) (PDF)
- Triptorelin Pamoate (Trelstar®, Triptodur®) (CP.PHAR.175) (PDF)
- Umeclidinium-vilanterol (Anoro Ellipta) (CP.PMN.149) (PDF)
- Ustekinumab (Stelara®) (CP.PHAR.264) (PDF)
- Valbenazine (Ingrezza™) (CP.PHAR.340) (PDF)
- Valproate (Depacon) (CP.PHAR.429) (PDF)
- Valrubicin (Valstar) (CP.PHAR.439) (PDF)
- Vandetanib (Caprelsa®) (CP.PHAR.80) (PDF)
- Vedolizumab (Entyvio®) (CP.PHAR.265) (PDF)
- Velaglucerase alfa (VPRIV®) (CP.PHAR.163) (PDF)
- Vemurafenib (Zelboraf®) (CP.PHAR.91) (PDF)
- Verteporfin (Visudyne®) (CP.PHAR.187) (PDF)
- Vestronidase alfa-vjbk (Mepsevii™) (CP.PHAR.374) (PDF)
- Vigabatrin (Sabril) (CP.PHAR.169) (PDF)
- Vincristine Sulfate Liposome Injection (Marqibo®) (CP.PHAR.315) (PDF)
- Vismodegib (Erivedge®) (CP.PHAR.273) (PDF)
- Voretigene Neparvovec-rzyl (Luxturna) (CP.PHAR.372) (PDF)
- Vorinostat (Zolinza®) (CP.PHAR.83) (PDF)
- Ziv-aflibercept (Zaltrap®) (CP.PHAR.325) (PDF)
- Zoledronic Acid (Reclast®, Zometa®) (CP.PHAR.59) (PDF)
Medicaid Clinical Policies
- 25-hydroxyvitamin D Testing in Children and Adolescents (CP.MP.157) (PDF)
- Acupuncture (CP.MP.92) (PDF)
- ADHD Assessment and Treatment (CP.MP.124) (PDF)
- Adopted Clinical Practice and Preventive Health Guidelines (CPG Grid) (PDF)
- Air Ambulance (CP.MP.175) (PDF)
- Allergy Testing and Therapy (CP.MP.100) (PDF)
- Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-Thalassemia (CP.MP.108) (PDF)
- Ambulatory Surgery Center Optimization (CP.MP.158) (PDF)
- Applied Behavior Analysis (CP.BH.104) (PDF)
- Articular Cartilage Defect Repairs (CP.MP.26) (PDF)
- Assisted Reproductive Technology (CP.MP.55) (PDF)
- Bariatric Surgery (CP.MP.37) (PDF)
- Behavioral Health Treatment Documentation Requirements (CP.BH.500) (PDF)
- Biofeedback for Behavioral Health Disorders (CP.BH.300) (PDF)
- Bone-Anchored Hearing Aid (CP.MP.93) (PDF)
- Burn Surgery (CP.MP.186) (PDF)
- Cardiac Biomarker Testing (CP.MP.156) (PDF)
- Caudal or Interlaminar Epidural Steroid Injections (CP.MP.164) (PDF)
- Clinical Trials (CP.MP.94) (PDF)
- Cochlear Implant Replacements (CP.MP.14) (PDF)
- Cosmetic and Reconstructive Procedures (CP.MP.31) (PDF)
- Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (CP.BH.201) (PDF)
- Diaphragmatic/Phrenic Nerve Stimulation (CP.MP.203) (PDF)
- Digital EEG Spike Analysis (CP.MP.105) (PDF)
- Disc Decompression Procedures (CP.MP.114) (PDF)
- Discography (CP.MP.115) (PDF)
- Donor Lymphocyte Infusion (CP.MP.101) (PDF)
- Drugs of Abuse: Definitive Testing (CP.MP.50) (PDF)
- Durable Medical Equipment (DME) (CP.MP.107) (PDF)
- Electric Tumor Treating Fields (CP.MP.145) (PDF)
- EEG in the Evaluation of Headache (CP.MP.155) (PDF)
- Experimental Technologies (CP.MP.36) (PDF)
- Facet Joint Interventions (CP.MP.171)
- Facility-based Sleep Studies for Obstructive Sleep Apnea (CP.MP.248) (PDF)
- Fecal Incontinenece Treatments (CP.MP.137) (PDF)
- Ferriscan R2-MRI (CP.MP.53) (PDF)
- Fertility Preservation (CP.MP.130) (PDF)
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (CP.MP.129) (PDF)
- Functional MRI (CP.MP.43) (PDF)
- Gastric Electrical Stimulation (CP.MP.40) (PDF)
- Gender-Affirming Procedures (CP.MP.95) (PDF)
- H. Pylori Serology Testing (CP.MP.153) (PDF)
- Heart-Lung Transplant (CP.MP.132) (PDF)
- Home Births (CP.MP.136) (PDF)
- Home Ventilators (CP.MP.184) (PDF)
- Hospice Services (CP.MP.54) (PDF)
- Hyperhidrosis Treatments (CP.MP.62) (PDF)
- Implantable Intrathecal or Epidural Pain Pump (CP.MP.173) (PDF)
- Implantable Loop Recorder (CP.MP.243) (PDF)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (CP.MP.160) (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)
- IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (CP.MP.61) (PDF)
- Liposuction for Lipedema (CP.MP.244) (PDF)
- Long Term Care Placement (CP.MP.71) (PDF)
- Lung Transplantation (CP.MP.57) (PDF)
- Lysis of Epidural Lesions (CP.MP.116) (PDF)
- Mechanical Stretching Devices for Joint Stiffness and Contracture (CP.MP.144) (PDF)
- Measurement of Serum 1,25-dihydroxyvitamin D (CP.MP.152) (PDF)
- Multiple Sleep Latency Testing (CP.MP.24) (PDF)
- Neonatal Abstinence Syndrome Guidelines (CP.MP.86) (PDF)
- Neonatal Sepsis Management (CP.MP.85) (PDF)
- Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (CP.MP.48) (PDF)
- Nerve Blocks and Neurolysis for Pain Management (CP.MP.170) (PDF)
- NICU Apnea Bradycardia Guidelines (CP.MP.82) (PDF)
- NICU Discharge Guidelines (CP.MP.81) (PDF)
- Non-Myeloablative Allogeneic Stem Cell Transplants (CP.MP.141) (PDF)
- Obstetrical Home Care Programs (CP.MP.91) (PDF)
- Omisirge (omidubicel): Nicotinamide-modified Allogeneic Hematopoietic Progenitor Cell Therapy (CP.MP.249) (PDF)
- Orthognathic Surgery (CP.MP.202) (PDF)
- Osteogenic Stimulation (CP.MP.194) (PDF)
- Outpatient Cardiac Rehabilitation (CP.MP.176) (PDF)
- Outpatient Oxygen Use (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)
- Pediatric Oral Function Therapy (CP.MP.188) (PDF)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (CP.MP.147) (PDF)
- Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150) (PDF)
- Physical, Occupational, and Speach Therapy Services (CP.MP.49) (PDF)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (CP.MP.181) (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (CP.MP.133) (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF)
- Repair of Nasal Valve Compromise (CP.MP.210) (PDF)
- Sacroiliac Joint Infusion (CP.MP.126) (PDF)
- Sacroiliac Joint Interventions for Pain Management (CP.MP.166) (PDF)
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (CP.MP.146) (PDF)
- Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (CP.MP.165) (PDF)
- Short Inpatient Hospital Stay (CP.MP. 182) (PDF)
- Skilled Nursing Facility Leveling (CP.MP.206) (PDF)
- Skin and Soft Tissue Substitutes for Chronic Wounds (CP.MP.185) (PDF)
- Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (CP.MP.117) (PDF)
- Stereotatic Body Radiation Therapy (CP.MP.22) (PDF)
- Substance Use Disorders Treatment and Services (CP.BH.100) (PDF)
- Tandem Transplant (CP.MP.162) (PDF)
- Therapeutic Utilization of Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Thyroid Hormones and Insulin Testing in Pediatrics (CP.MP.154) (PDF)
- TMS for Treatment Resistant Major Depression (CP.BH.200) (PDF)
- Total Artificial Heart (CP.MP.127) (PDF)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (CP.MP.163) (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)
- Wireless Motility Capsule (CP.MP.143) (PDF)
Medicaid Medical Pharmacy Policies
- Abaloparatide (Tymlos®) (CP.PHAR.345) (PDF)
- Abatacept (Orencia®) (CP.PHAR.241) (PDF)
- Abemaciclib (Verzenio™) (CP.PHAR.355) (PDF)
- Abiraterone (Zytiga) (CP.PHAR.84) (PDF)
- AbobotulinumtoxinA (Dysport®) (CP.PHAR.230) (PDF)
- Acalabrutinib (Calquence®) (CP.PHAR.366) (PDF)
- ACEI and ARB Duplicate Therapy (CP.PMN.61) (PDF)
- Acitretin (Soriatane) (IN.CP.PMN.40) (PDF)
- Aclidinium-formoterol (Duaklir Pressair) (CP.PMN.200) (PDF)
- Acyclovir buccal tab (Sitavig) ophthalimic ointment (Avaclyr) (CP.PMN.210) (PDF)
- Adalimumab (Humira®) (IN.CP.PHAR.242) (PDF)
- Adefovir (Hepsera) (CP.PHAR.142) (PDF)
- Aducanumab-avwa (Aduhelm) (IN.CP.PHAR.468) (PDF)
- Ado-Trastuzumab Emtansine (Kadcyla®) (CP.PHAR.229) (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 for Topical Tretinoin (CP.PMN.191) (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)
- Alirocumab (Praluent) (CP.PHAR.124) (PDF)
- Alosetron (Lotronex) (CP.PMN.153) (PDF)
- Alpelisib (Piqray) (CP.PHAR.430) (PDF)
- Alpha-1 Proteinase Inhibitors (CP.PHAR.94) (PDF)
- Amantadine ER (Gocovri®) (CP.PMN.89) (PDF)
- Ambrisentan (Letairis®) (CP.PHAR.190) (PDF)
- Amifampridine (Firdapse) (CP.PHAR.411) (PDF)
- Amikacin (Arikayce) (CP.PHAR.401) (PDF)
- Amlodipine-Atorvastatin (Caduet) (CP.PMN.176) (PDF)
- Amisulpride (Barhemsys) (CP.PMN.236) (PDF)
- Anakinra (Kineret®) (CP.PHAR.244) (PDF)
- Antipsychotic Therapy and Metabolic Monitoring (IN.CP.PMN.502) (PDF)
- Apalutamide (Erleada™) (CP.PHAR.376) (PDF)
- Apomorphine (Apokyn) (CP.PHAR.488) (PDF).
- Appropriate Use and Safety Pharmacy Edits (IN.CP.PMN.01) (PDF)
- Apremilast (Otezla®) (CP.PHAR.245) (PDF)
- Aprepitant (Emend) (CP.PMN.19) (PDF)
- Arformoterol tartrate (Brovana) (CP.PMN.201) (PDF)
- Asenapine (Saphris®) (CP.PMN.15) (PDF)
- Asfotase Alfa (Strensiq®) (CP.PHAR.328) (PDF)
- Aspirin-dipyridamole (Aggrenox®) (CP.PMN.20) (PDF)
- Atezolizumab (Tecentriq®) (CP.PHAR.235) (PDF)
- Atovaquone (Mepron) (IN.CP.PHAR.36) (PDF)
- Avapritinib (Ayvakit) (CP.PHAR.454) (PDF)
- Avatrombopag (Doptelet) (CP.PHAR.130) (PDF)
- Avelumab (Bavencio®) (CP.PHAR.333) (PDF)
- Axitinib (Inlyta®) (CP.PHAR.100) (PDF)
- Azacitidine (Vidaza) (CP.PHAR.387) (PDF)
- Aztreonam (Cayston®) (CP.PHAR.209) (PDF)
- Baloxavir Marboxil (Xofluza) (CP.PMN.185) (PDF)
- Baricitinib (Olumiant) (CP.PHAR.135) (PDF)
- Becaplermin (Regranex®) (CP.PMN.21) (PDF)
- Bedaquiline (Sirturo) (CP.PMN.212) (PDF)
- Belatacept (Nulojix®) (CP.PHAR.201) (PDF)
- Belantamab mafodotin (Blenrep) (CP.PHAR.469) (PDF)
- Belimumab (Benlysta) (CP.PHAR.88) (PDF)
- Belinostat (Beleodaq®) (CP.PHAR.311) (PDF)
- Bempedoic acid, bempedoic acid-ezetimibe (Nexletol, Nexlizet) (CP.PMN.237) (PDF)
- Bendamustine (Bendeka®, Treanda®) (CP.PHAR.307) (PDF)
- Benralizumab (FasenraTM) (CP.PHAR.373) (PDF)
- Benzinadazole (CP.PMN.90) (PDF)
- Benzodiazepine Sedative Hypnotics (IN.CP.PPA.13) (PDF)
- Benzyl alcohol (Ulesfia) (CP.PMN.202) (PDF)
- Betaine (Cystadane) (CP.PHAR.143) (PDF)
- Betamethasone dipropionate (Sernivo) (CP.PMN.182) (PDF)
- Bevacizumab (Avastin®) (CP.PHAR.93) (PDF)
- Bexarotene (Targretin®) (CP.PHAR.75) (PDF)
- Bezlotoxumab (Zinplava®) (CP.PHAR.300) (PDF)
- Bimatoprost Implant (Durysta) (CP.PHAR.486) (PDF)
- Binimetinib (Mektovi®) (CP.PHAR.50) (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 (CP.PMN.22) (PDF)
- Brentuximab Vedotin (Adcetris) (CP.PHAR.303) (PDF)
- Brexanolone (Zulresso) (IN.CP.PHAR.417) (PDF)
- Brigatinib (AlunbrigTM) (CP.PHAR.342) (PDF)
- Brimonidine (Mirvaso®) (CP.PMN.192) (PDF)
- Brodalumab (Siliq™) (CP.PHAR.375) (PDF)
- Brolucizumab (Beovu) (CP.PHAR.445) (PDF)
- Buprenorphine (Probuphine®, Sublocade®) (CP.PHAR.289) (PDF)
- Buprenorphine and Buprenorphine/Naloxone Approval Criteria for MAT (IN.CP.PMN.81) (PDF)
- Burosumab-twza (Crysvita) (CP.PHAR.11) (PDF)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (CP.PHAR.202) (PDF)
- Cabazitaxel (Jevtana®) (CP.PHAR.316) (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)
- Capecitabine (Xeloda®) (CP.PHAR.60) (PDF)
- Caplacizumab-yhdp (Cablivi) (CP.PHAR.416) (PDF)
- Capmatinib (Tabrecta) (CP.PHAR.494) (PDF)
- Carbamazepine ER (Equetro) (CP.PMN.137) (PDF)
- Carbidopa-levodopa ER Capsules (Rytary) (CP.PMN.238) (PDF)
- Carfilzomib (Kyprolis®) (CP.PHAR.309) (PDF)
- Carglumic acid (Carbaglu®) (CP.PHAR.206) (PDF)
- Celecoxib (Celebrex®) (CP.PMN.122) (PDF)
- Cemiplimab-rwlc (Libtayo) (CP.PHAR.397) (PDF)
- Cenegermin-bkbj (Oxervate) (IN.CP.PMN.186) (PDF)
- Cenobamate (Xcopri) (CP.PMN.231) (PDF)
- Ceritinib (Zykadia®) (CP.PHAR.349) (PDF)
- Cerliponase alfa (Brineura) (CP.PHAR.338) (PDF)
- Certolizumab (Cimzia) (IN.PHAR.247) (PDF)
- Cetuximab (Erbitux®) (CP.PHAR.317) (PDF)
- Chloramphenicol (CP.PHAR.388) (PDF)
- Ciclopirox (Penlac®) (CP.PMN.24) (PDF)
- Chenodiol (Chenodal) (CP.PMN.239) (PDF)
- Cholic acid (Cholbam) (CP.PHAR.390) (PDF)
- Cinacalcet (Sensipar) (CP.PHAR.61) (PDF)
- Cladribine (Mavenclad) (CP.PHAR.422) (PDF)
- Clascoterone (Winlevi) (CP.PMN.257) (PDF)
- Clinical Trials (CP.MP.94) (PDF)
- Clobazam (Onfi) (CP.PMN.54) (PDF)
- Clomipramine (Anafranil) (CP.PMN.197) (PDF)
- Clonidine_Guanfacine (IN.CP.PMN.04) (PDF)
- Cobimetinib (Cotellic) (CP.PHAR.380) (PDF)
- Colchicine (Colcrys®) (CP.PMN.123) (PDF)
- Collagenase Clostridium Histolyticum (Xiaflex®) (CP.PHAR.82) (PDF)
- Continuous Insulin Delivery System (V-Go, Omnipod) (CP.PHAR.505) (PDF)
- Copanlisib (Aliqopa®) (CP.PHAR.357) (PDF)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert) (CP.PHAR.385) (PDF)
- Corticotropin (H.P. Acthar) (CP.PHAR.168) (PDF)
- Cosyntropin (Cortrosyn®) (CP.PHAR.203) (PDF)
- Crisaborole (Eucrisa) (CP.PMN.110) (PDF)
- Crizotinib (Xalkori®) (CP.PHAR.90) (PDF)
- Cushing Syndrome Agents (Lysodren, Metopirone) (IN.CP.PHAR.600) (PDF)
- Cyclosporine (Restasis®) (CP.PMN.48) (PDF)
- Cysteamine ophthalmic (Cystaran™) (CP.PMN.130) (PDF)
- Cysteamine oral bitartrate (Cystagon®, Procysbi®) (CP.PHAR.155) (PDF)
- Cytomegalovirus Immune Globulin (CytoGam) (CP.PHAR.277) (PDF)
- Dabigatran (Pradaxa®) (CP.PMN.49) (PDF)
- Dabrafenib (Tafinlar) (CP.PHAR.239) (PDF)
- Dacomitinib (Vizimpro) (CP.PHAR.399) (PDF)
- Dalfampridine (Ampyra) (IN.PHAR.248) (PDF)
- Dalteparin (Fragmin®) (CP.PHAR.225) (PDF)
- Daptomycin (Cubicin Cubicin RF) (CP.PHAR.351) (PDF)
- Daratumumab (Darzalex) (CP.PHAR.310) (PDF)
- Darbepoetin alfa (Aranesp®) (CP.PHAR.236) (PDF)
- Darolutamide (Nubeqa) (CP.PHAR.435) (PDF)
- Dasatinib (Sprycel®) (CP.PHAR.72) (PDF)
- Daunorubicin/Cytarabine (Vyxeos®) (CP.PHAR.352) (PDF)
- Deferasirox (Exjade, Jadenu) (CP.PHAR.145) (PDF)
- Deferiprone (Ferriprox) (CP.PHAR.147) (PDF)
- Deferoxamine (Desferal) (CP.PHAR.146) (PDF)
- Deflazacort (Emflaza®) (IN.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®) (CP.PHAR.214) (PDF)
- Deutetrabenazine (Austedo®) (CP.PHAR.341) (PDF)
- Dextromethorphan-Quinidine (Nuedexta®) (CP.PMN.93) (PDF)
- Diazepam nasal spray (Valtoco) (IN.CP.PMN.216) (PDF)
- Dichlorphenamide (Keveyis) (CP.PMN.261) (PDF)
- Dimethyl fumarate (Tecfidera®) (IN.PHAR.249) (PDF)
- Dolasetron (Anzemet) (CP.PMN.141) (PDF)
- Dornase alfa (Pulmozyme®) (IN.CP.PHAR.212) (PDF)
- Dose Optimization (CP.PMN.13) (PDF)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (CP.PMN.79) (PDF)
- DPP-4 inhibitors (CP.PMN.03) (PDF)
- Dronabinol (Marinol, Syndros) (CP.PMN.159) (PDF)
- Droxidopa (Northera®) (CP.PMN.17) (PDF)
- Dupilumab (Dupixent®) (IN.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)
- Edoxaban (Savausa) (CP.PMN.227) (PDF)
- Efinaconazole (Jublia®) (CP.PMN.25) (PDF)
- Elagolix (Orilissa) (IN.CP.PHAR.136) (PDF)
- Eliglustat (Cerdelga®) (CP.PHAR.153) (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)
- Emtricitabine-tenofovir (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)
- Entrectinib (Rozlytrek) (CP.PHAR.441) (PDF)
- Enzalutamide (Xtandi) (CP.PHAR.106) (PDF)
- Epinephrine (EpiPen and EpiPen Jr) Quanity Limit Override (CP.PMN.144) (PDF)
- Epoetin Alfa (Epogen and Procrit) (IN.CP.PHAR.237) (PDF)
- Epoprostenol (Flolan®, Veletri®) (CP.PHAR.192) (PDF)
- EPSDT Benefit for Pediatric Members (CP.PMN.234) (PDF)
- Eptinezumab (Vyepti) (CP.PHAR.489) (PDF)
- Erdafitinib (Balversa) (CP.PHAR.423) (PDF)
- Erenumab-aaoe (Aimovig) (IN.CP.PHAR.128) (PDF)
- Eribulin Mesylate (Halaven®) (CP.PHAR.318) (PDF)
- Erlotinib (Tarceva®) (CP.PHAR.74) (PDF)
- Erwinia Asparaginase (Erwinaze®) (CP.PHAR.301) (PDF)
- Esketamine (Spravato) (IN.CP.PMN.199) (PDF)
- Etanercept (Enbrel) (IN.PHAR.250) (PDF)
- Etelcalcetide (Parsabiv) (CP.PHAR.379) (PDF)
- Etidronate (Didronel®) (CP.PMN.94) (PDF)
- Everolimus (Afinitor, Afinitor Disperz) (CP.PHAR.63) (PDF)
- Evolocumab (Repatha) (IN.CP.PHAR.123) (PDF)
- Evinacumab-dgnb (Evkeeza) (CP.PHAR.511) (PDF)
- Fam-trastuzumab deruxtecan-nxki (Enhertu) (CP.PHAR.456) (PDF)
- Febuxostat (Uloric®) (CP.PMN.57) (PDF)
- Fedratinib (Inrebic) (CP.PHAR.442) (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)
- Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) (CP.PHAR.297) (PDF)
- Fingolimod (Gilenya®) (IN.PHAR.251) (PDF)
- Fluorouracil Cream (Tolak) (CP.PMN.165) (PDF)
- Fluticasone Propionate (Xhance®) (CP.PMN.95) (PDF)
- Fluticasone/Salmeterol (Advair Diskus, Advair HFA) (CP.PMN.31) (PDF)
- Fluticasone-umeclidinium-vilanterol (Trelegy Ellipta) (CP.PMN.146) (PDF)
- Fluticasone-vilanterol (Breo Ellipta) (CP.PMN.229) (PDF)
- Fondaparinux (Arixtra®) (CP.PHAR.226) (PDF)
- Fostamatinib (Tavalisse) (CP.PHAR.24) (PDF)
- Fostemsavir (Rukobia) (CP.PHAR.516) (PDF)
- Fremanezumab (Ajovy) (IN.CP.PHAR.403) (PDF)
- Fulvestrant (Faslodex Injection) (CP.PHAR.424) (PDF)
- Galcanezumab-gnlm (Emgality) (IN.CP.PHAR.404) (PDF)
- Galsulfase (Naglazyme®) (CP.PHAR.161) (PDF)
- Gabapentin ER (Gralise, Horizant) (CP.PMN.240) (PDF)
- Gefitinib (Iressa®) (CP.PHAR.68) (PDF)
- Glasdegib (Daurismo) (CP.PHAR.413) (PDF)
- Glatiramer (Copaxone, Glatopa) (IN.PHAR.252) (PDF)
- Gemtuzumab ozogamicin (Mylotarg®) (CP.PHAR.358) (PDF)
- Givosiran (Givlaari) (CP.PHAR.457) (PDF)
- Gilteritinib (Xospata) (CP.PHAR.412) (PDF)
- Glycopyrronium (Qbrexza) (CP.PMN.177) (PDF)
- GLP-1 receptor agonists (CP.PMN.183) (PDF)
- Glycerol phenylbutyrate (Ravicti®) (CP.PHAR.207) (PDF)
- Golimumab (Simponi®, Simponi Aria®) (IN.PHAR.253) (PDF)
- Granisetron (Kytril, Sancuso) (CP.PMN.74) (PDF)
- Guselkumab (Tremfya®) (CP.PHAR.364) (PDF)
- Halobetasol-Propionate (Bryhali, Lexette, Ultravate) (CP.PMN.180) (PDF)
- Halobetasol-Tazarotene (Duobrii) (CP.PMN.208) (PDF)
- Hemin (Panhematin®) (CP.PHAR.181) (PDF)
- House dust mite allergen extract (Odactra®) (CP.PMN.111) (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)
- Ibandronate Oral (Boniva®) (CP.PMN.96) (PDF)
- Ibrutinib (Imbruvica) (CP.PHAR.126) (PDF)
- Ibuprofen and Famotidine (Duexis) (CP.PMN.120) (PDF)
- Icatibant (Firazyr®) (CP.PHAR.178) (PDF)
- Icosapent ethyl (Vascepa) (CP.PMN.187) (PDF)
- Idelalisib (Zydelig) (CP.PHAR.133) (PDF)
- Idursulfase (Elaprase®) (CP.PHAR.156) (PDF)
- Ifaximin (Xifaxan®) (CP.PMN.47) (PDF)
- Iloprost (Ventavis®) (CP.PHAR.193) (PDF)
- Iobenguane I 131 (Azedra) (CP.PHAR.459) (PDF)
- Imatinib mesylate (Gleevec®) (CP.PHAR.65) (PDF)
- Imiglucerase (Cerezyme®) (CP.PHAR.154) (PDF)
- Immune Globulins (CP.PHAR.103) (PDF)
- Immunization Coverage (CP.PHAR.28) (PDF)
- IncobotulinumtoxinA (Xeomin®) (CP.PHAR.231) (PDF)
- Indacaterol (Arcapta Neohaler) (CP.PMN.203) (PDF)
- Indacaterol-glycopyrrolate (Utibron Neohaler) (CP.PMN.147) (PDF)
- Infliximab (Remicade®, Inflectra®, Renflexis™) (CP.PHAR.254) (PDF)
- Inotersen (Tegsedi) (CP.PHAR.405) (PDF)
- Inotuzumab ozogamicin (Besponsa®) (CP.PHAR.359) (PDF)
- Interferon beta-1a (Avonex®, Rebif®) (IN.PHAR.255) (PDF)
- Interferon beta-1b (Betaseron®, Extavia®) (IN.PHAR.256) (PDF)
- Interferon Gamma- 1b (Actimmune®) (CP.PHAR.52) (PDF)
- Intra baclofen (Gablofen®) (CP.PHAR.149) (PDF)
- Ipilimumab (Yervoy) (CP.PHAR.319) (PDF)
- Irinotecan Liposome (Onivyde®) (CP.PHAR.304) (PDF)
- Iron Sucrose (Venofer®) (CP.PHAR.167) (PDF)
- Isavuconazonium (Cresemba) (CP.PMN.154) (PDF)
- Isatuximab-irfc (Sarclisa) (CP.PHAR.482) (PDF)
- Isotretinoin (Claravis, Absorica, Myorisan, Zenatane) (CP.PMN.143) (PDF)
- Itraconazole (Sporanox®, Onmel®) (CP.PMN.124) (PDF)
- Ivabradine (Corlanor®) (CP.PMN.70) (PDF)
- Ivosidenib (Tibsovo) (CP.PHAR.137) (PDF)
- Ixazomib (Ninlaro) (CP.PHAR.302) (PDF)
- Ixekizumab (Taltz®) (IN.PHAR.257) (PDF)
- Lacosamide (Vimpat) (CP.PMN.155) (PDF)
- Lactitol (Pizensy) (CP.PMN.241) (PDF)
- Lanadelumab-fylo (Takhzyro) (CP.PHAR.396) (PDF)
- Lanreotide (Somatuline Depot) (CP.PHAR.391) (PDF)
- Lantanoprostene Bunod (Vyzylta®) (CP.PMN.108) (PDF)
- Lapatinib (Tykerb®) (CP.PHAR.79) (PDF)
- Laronidase (Aldurazyme®) (CP.PHAR.152) (PDF)
- Larotrectinib (Vitrakvi) (CP.PHAR.414) (PDF)
- Lasmiditan (Reyvow) (IN.CP.PMN.218) (PDF)
- Lefamulin (Xenleta) (CP.PMN.219) (PDF)
- Lenalidomide (Revlimid®) (CP.PHAR.71) (PDF)
- Lenvatinib (Lenvima) (CP.PHAR.138) (PDF)
- Lesinurad (Zurampic), lesinurad-allopurinol (Duzallo) (CP.PMN.150) (PDF)
- Letermovir (Prevymis®) (CP.PHAR.367) (PDF)
- Leucovorin Injection (CP.PHAR.393) (PDF)
- Levalbuterol (Xopenex®) (CP.PMN.07) (PDF)
- Levoleucovorin (Fusilev®) (CP.PHAR.151) (PDF)
- L-glutamine (Endari®) (IN.CP.PMN.116) (PDF)
- Lidocaine Transdermal (Lidoderm®) (CP.PMN.08) (PDF)
- Lifitegrast (Xiidra®) (CP.PMN.73) (PDF)
- Linaclotide (Linzess®) (CP.PMN.71) (PDF)
- Lindane Shampoo (CP.PMN.09) (PDF)
- Linezolid (Zyvox®) (CP.PMN.27) (PDF)
- Lofexidine (Lucemyra) (IN.CP.PMN.279) (PDF)
- Lomitapide (Juxtapid) (CP.PHAR.283) (PDF)
- Lorazepam ER (Loreev) (IN.CP.PHAR.20) (PDF)
- Lorlatinib (Lorbrena) (CP.PHAR.406) (PDF)
- Lubiprostone (Amitiza) (CP.PMN.142) (PDF)
- Luliconazole Cream (Luzu) (CP.PMN.166) (PDF)
- Lusutrombopag (Mulpleta) (CP.PHAR.407) (PDF)
- Lutetium Lu 177 dotatate (Lutathera) (CP.PHAR.384) (PDF)
- Margetuximab-cmkb (Margenza) (CP.PHAR.522) (PDF)
- Macitentan (Opsumit®) (CP.PHAR.194) (PDF)
- Mecamylamine (Vecamyl®) (CP.PMN.136) (PDF)
- Mecasermin (Increlex) (CP.PHAR.150) (PDF)
- Mechlorethamine (Valchlor) (CP.PHAR.381) (PDF)
- Megestrol Acetate Oral Suspension (Megace ES) (CP.PMN.179) (PDF)
- Mepolizumab (Nucala) (CP.PHAR.200) (PDF)
- Mercaptopurine (Purixan) (CP.PHAR.447) (PDF)
- Metformin ER (Glumetza®) (CP.PMN.72) (PDF)
- Methadone for Management of Pain (IN.CP.PMN.02) (PDF)
- Methotrexate (Otrexup, Rasuvo, 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)
- Midostaurin (Rydapt) (CP.PHAR.344) (PDF)
- Mifepristone (Korlym®) (CP.PHAR.101) (PDF)
- Migalastat (Galafold) (CP.PHAR.394) (PDF)
- Miglustat (Zavesca®) (CP.PHAR.164) (PDF)
- Minocycline ER (Solodyn®) and Microspheres (Arestin®) (CP.PMN.80) (PDF)
- Minocycline micronized foam (Amzeeq) (CP.PMN.242) (PDF)
- Mipomersen (Kynamro) (CP.PHAR.284) (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)
- Moxetumomab pasudotox-tdfk (Lumoxiti) (CP.PHAR.398) (PDF)
- Nabilone (Cesamet) (CP.PMN.160) (PDF)
- Nafarelin Acetate (Synarel®) (CP.PHAR.174) (PDF)
- Naldemedine (Symproic®) (CP.PMN.112) (PDF)
- Naloxegol (Movantik) (CP.PMN.171) (PDF)
- Naloxone (Evzio) (CP.PMN.139) (PDF)
- Naproxen and esomeprazole magnesium (Vimovo®) (CP.PMN.117) (PDF)
- Narcolepsy Agents (IN.CP.PMN.500) (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)
- Netarsudil (Rhopressa®) (CP.PMN.118) (PDF)
- Netupitant;palonosetron (Akynzeo) (CP.PMN.158) (PDF)
- Nilotinib (Tasigna®) (CP.PHAR.76) (PDF)
- Nintedanib (Ofev) (CP.PHAR.285) (PDF)
- Niraparib (Zejula) (CP.PHAR.408) (PDF)
- Nitisinone (Orfadin, Nityr) (CP.PHAR.132) (PDF)
- Nivolumab (Opdivo) (CP.PHAR.121) (PDF)
- No Coverage Criteria (CP.PMN.255) (PDF)
- Non-Calcium Phosphate Binders (CP.PMN.04) (PDF)
- Obeticholic acid (Ocaliva) (CP.PHAR.287) (PDF)
- Obinutuzumab (Gazyva®) (CP.PHAR.305) (PDF)
- Ocrelizumab (OcrevusTM) (CP.PHAR.335) (PDF)
- Octreotide Acetate (Sandostatin®, Sandostatin LAR Depot®) (IN.CP.PHAR.40) (PDF)
- Ofatumumab (Arzerra®) (CP.PHAR.306) (PDF)
- Off-Label Use (CP.PMN.53) (PDF)
- Olanzapine/Samidorphan (Lybalvi) (IN.CP.PMN.265) (PDF)
- Olaparib (Lynparza) (CP.PHAR.360) (PDF)
- Olaratumab (Lartruvo®) (CP.PHAR.326) (PDF)
- Olodaterol (Striverdi Respimat) (CP.PMN.204) (PDF)
- Omacetaxine (Synribo®) (CP.PHAR.108) (PDF)
- Omadacycline (Nuzyra) (CP.PMN.188) (PDF)
- Omalizumab (Xolair®) (CP.PHAR.01) (PDF)
- Omega-3-Acid Ethyl Esters (Lovaza®) (CP.PMN.52) (PDF)
- OnabotulinumtoxinA (Botox) (CP.PHAR.232) (PDF)
- Ondansetron (Zuplenz) (CP.PMN.45) (PDF)
- Opiates with concurrent buprenorphine (Subutex®) and buprenorphine naloxone (Suboxone®) (IN.CP.PMN.47) (PDF)
- Opioid Analgesics (IN.CP.PPA.12) (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™) (CP.PMN.86) (PDF)
- Ozanimod (Zeposia) (CP.PHAR.462) (PDF)
- Ozenoxacin (Xepi) (CP.PMN.119) (PDF)
- Paclitaxel, protein-bound (Abraxane®) (CP.PHAR.176) (PDF)
- Palbociclib (Ibrance®) (CP.PHAR.125) (PDF)
- Palivizumab (Synagis®) (IN.CP.PHAR.16) (PDF)
- Pancrelipase (Pertyze, Viokace, Zenpep) (CP.PMN.226) (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 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)
- Pegademase Bovine (Adagen) (CP.PHAR.392) (PDF)
- Pegaptanib (Macugen®) (CP.PHAR.185) (PDF)
- Pegaspargase (Oncaspar®) (CP.PHAR.353) (PDF)
- Pegfilgrastim (Neulasta) (IN.CP.PHAR.296) (PDF)
- Peginterferon beta-1a (Plegridy®) (IN.PHAR.271) (PDF)
- Pegloticase (Krystexxa®) (CP.PHAR.115) (PDF)
- Pegvaliase-pqpz (Palynziq) (CP.PHAR.140) (PDF)
- Pegvisomant (Somavert) (CP.PHAR.389) (PDF)
- Pembrolizumab (Keytruda®) (CP.PHAR.322) (PDF)
- Pemetrexed (Alimta®) (CP.PHAR.368) (PDF)
- Pemigatinib (Pemazyre) (CP.PHAR.496) (PDF)
- Pentosan Polysulfate Sodium (Elmiron) (IN.CP.PHAR.35) (PDF)
- Perampanel (Fycompa) (CP.PMN.156) (PDF)
- Perindopril-Amlodipine (Prestalia) (CP.PMN.174) (PDF)
- Pertuzumab (Perjeta®) (CP.PHAR.227) (PDF)
- Pexidartinib (Turalio) (CP.PHAR.436) (PDF)
- Pirfenidone (Esbriet) (CP.PHAR.286) (PDF)
- Plecanatide (Trulance®) (CP.PMN.87) (PDF)
- Plerixafor (Mozobil) (CP.PHAR.323) (PDF)
- Polatuzuman vedotin – piiq (Polivy) (CP.PHAR.433) (PDF)
- Pomalidomide (Pomalyst®) (CP.PHAR.116) (PDF)
- Ponatinib (Iclusig®) (CP.PHAR.112) (PDF)
- Pralatrexate (Folotyn®) (CP.PHAR.313) (PDF)
- Pramlintide (Symlin®) (CP.PMN.129) (PDF)
- Prasterone (Intrarosa®) (CP.PMN.99) (PDF)
- Pretomanid (CP.PMN.222) (PDF)
- Propranolol HCl oral solution (Hemangeol®) (CP.PMN.58) (PDF)
- Protein C Concentrate Human (Ceprotin®) (CP.PHAR.330) (PDF)
- Prucalopride (Motegrity) (CP.PMN.194) (PDF)
- Pyrimethamine (Daraprin®) (CP.PMN.44) (PDF)
- QL of Diabetic Test Strips not receiving insulin (CP.PMN.151) (PDF)
- Quantity Limit Override (CP.PMN.59) (PDF)
- Quinine Sulfate (Qualaquin) (CP.PMN.262) (PDF)
- Ramucirumab (Cyramza®) (CP.PHAR.119) (PDF)
- Ranibizumab (Lucentis®) (CP.PHAR.186) (PDF)
- Ranolazine (Ranexa®) (CP.PMN.34) (PDF)
- Ravulizumab-cwvz (Ultomiris) (CP.PHAR.415) (PDF)
- Regorafenib (Stivarga®) (CP.PHAR.107) (PDF)
- Request for Medically Necessary Drug not on the PDL (CP.PMN.16) (PDF)
- Reslizumab (Cinqair®) (CP.PHAR.223) (PDF)
- Revefenacin (Yupelri) (CP.PMN.195) (PDF)
- Ribociclib (Kisqali®, Kisqali Femara®) (CP.PHAR.334) (PDF)
- Rifamycin (Aemcolo) (CP.PMN.196) (PDF)
- Rifapentine (Priftin®) (CP.PMN.05) (PDF)
- Rilonacept (Arcalyst®) (IN.PHAR.266) (PDF)
- RimabotulinumtoxinB (Myobloc®) (CP.PHAR.233) (PDF)
- Rimegepant (Nurtec ODT) (CP.PHAR.490) (PDF)
- Riociguat (Adempas®) (CP.PHAR.195) (PDF)
- Risankizumab-rsaa (Skyrizi) (CP.PHAR.426) (PDF)
- Risdiplam (Evrysdi) (CP.PHAR.477) (PDF)
- Risedronate (Actonel®, Atelvia®) (CP.PMN.100) (PDF)
- Rituximab (Rituxan®), Rituximab and hyaluronidase (Rituxan Hycela™) (CP.PHAR.260) (PDF)
- Rivastigmine (Exelon®) (CP.PMN.101) (PDF)
- Roflumilast (Daliresp) (CP.PMN.46) (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)
- Rucaparib (Rubraca®) (CP.PHAR.350) (PDF)
- Rufinamide (Banzel) (CP.PMN.157) (PDF)
- Ruxolitinib (Jakafi®) (CP.PHAR.98) (PDF)
- Sacubitril and Valsartan (Entresto®) (CP.PMN.67) (PDF)
- Sacituzumab govitecan-hziy (Trodelvy) (CP.PHAR.475) (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)
- Sarilumab (Kevzara®) (IN.PHAR.346) (PDF)
- Sebelipase alfa (Kanuma®) (CP.PHAR.159) (PDF)
- Secnidazole (Solosec®) (CP.PMN.103) (PDF)
- Secukinumab (Cosentyx®) (IN.PHAR.261) (PDF)
- Segesterone-Ethinyl Estradiol (Annovera) (CP.PMN.190) (PDF)
- Selexipag (Uptravi®) (CP.PHAR.196) (PDF)
- Selinexor (Xpovio) (CP.PHAR.431) (PDF)
- Short Ragweed Pollen Allergen Extract (Ragwitek) (CP.PMN.83) (PDF)
- Sildenafil (Revatio®) (CP.PHAR.197) (PDF)
- Siltuximab (Sylvant®) (CP.PHAR.329) (PDF)
- Siponimod (Mayzent) (CP.PHAR.427) (PDF)
- Sipuleucel-T (Provenge®) (CP.PHAR.120) (PDF)
- Sodium phenylbutyrate (Buphenyl®) (CP.PHAR.208) (PDF)
- Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (CP.PMN.14) (PDF)
- Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, and Sodium Oxybate (Xywav) (IN.CP.PMN.42) (PDF)
- Sodium zirconium cyclosilicate (Lokelma) (CP.PMN.163) (PDF)
- Solriamfetol (Sunosi) (CP.PMN.209) (PDF)
- Somatropin (Human Growth Hormone) (IN.CP.PHAR.55) (PDF)
- Sonidegib (Odomzo®) (CP.PHAR.272) (PDF)
- Sorafenib (Nexavar®) (CP.PHAR.69) (PDF)
- SSRI SNRI Duplicate Thearapy (IN.CP.PMN.60) (PDF)
- Step Therapy (CP.PST.01) (PDF)
- Stimulants (IN.CP.PMN.274) (PDF)
- Stiripentol (Diacomit) (CP.PMN.184) (PDF)
- Sunitinib (Sutent®) (CP.PHAR.73) (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®) (CP.PHAR.198) (PDF)
- Tadalafil BHP - ED (Cialis) (CP.PMN.132) (PDF)
- Tafamidis meglumine, Tafamidis (Vyndaquel, Vyndamax) (IN.CP.PHAR.432) (PDF)
- Tafenoquine (Arakoda) (CP.PMN.178) (PDF)
- Talazoparib (Talzenna) (CP.PHAR.409) (PDF)
- Taliglucerase alfa (Elelyso®) (CP.PHAR.157) (PDF)
- Tasimelteon (Hetlioz, Hetlioz LQ) (IN.CP.PMN.104) (PDF)
- Tavaborole (Kerydin®) (CP.PMN.105) (PDF)
- Tazarotene (Arazlo, Fabior, Tazoraz) (CP.PMN.244) (PDF)
- Tazemetostat (Tazverik) (CP.PHAR.452) (PDF)
- Tedizolid (Sivextro®) (CP.PMN.62) (PDF)
- Teduglutide (Gattex) (CP.PHAR.114) (PDF)
- Tegaserod (Zelnorm) (CP.PMN.206) (PDF)
- Telotristat ethyl (Xermelo™) (CP.PHAR.337) (PDF)
- Temozolomide (Temodar®) (CP.PHAR.77) (PDF)
- Temsirolimus (Torisel®) (CP.PHAR.324) (PDF)
- Tenofovir Alafenamide Fumarate (Vemlidy) (IN.CP.PMN.268) (PDF)
- Tepotinib (Tepmetko) (CP.PHAR.530) (PDF)
- Teprotumumab (Tepezza) (CP.PHAR.465) (PDF)
- Teriflunomide (Aubagio®) (IN.PHAR.262) (PDF)
- Teriparatide (Forteo®) (CP.PHAR.188) (PDF)
- Tesamorelin (Egrifta) (CP.PHAR.109) (PDF)
- Testosterone Pellet (Testopel®) (CP.PHAR.354) (PDF)
- Tetrabenazine (Xenazine®) (CP.PHAR.92) (PDF)
- Thalidomide (Thalomid) (CP.PHAR.78) (PDF)
- Thioguanine (Tabloid) (CP.PHAR.437) (PDF)
- Thyrotropin Alfa (Thyrogen) (CP.PHAR.95) (PDF)
- Tildrakizumab-asmn (Ilumya) (CP.PHAR.386) (PDF)
- Timothy Grass Pollen Allergen Extract (Grastek) (CP.PMN.84) (PDF)
- Tiotropium-olodaterol (Stiolto Respimat) (CP.PMN.148) (PDF)
- Tiotropium/Bromide (Spiriva Respimat) (IN.PMN.501) (PDF)
- Tobramycin (CP.PHAR.211) (PDF)
- Tocilizumab (Actemra®) (IN.PHAR.263) (PDF)
- Tofacitinib (Xeljanz®, Xeljanz® XR) (CP.PHAR.267) (PDF)
- Tolvaptan (Jynarque) (CP.PHAR.27) (PDF)
- Topical Immunomodulators (CP.PMN.107) (PDF)
- Topotecan (Hycamtin®) (CP.PHAR.64) (PDF)
- Toremifene (Fareston®) (CP.PMN.126) (PDF)
- Trabectedin (Yondelis) (CP.PHAR.204) (PDF)
- Trametinib (Mekinist) (CP.PHAR.240) (PDF)
- Trastuzumab (Herceptin®), Trastuzumab-dkst (Ogivri®) (CP.PHAR.228) (PDF)
- Treprostinil (Orenitram®, Remodulin®, Tyvaso®) (CP.PHAR.199) (PDF)
- Triclabendazole (Egaten) (CP.PMN.207) (PDF)
- Triamcinolone ER Injection (Zilretta) (CP.PHAR.371) (PDF)
- Trientine (Syprine) (CP.PHAR.438) (PDF)
- Trifarontene (Aklief) (CP.PMN.225) (PDF)
- Trifluridine_Tipiracil (Lonsurf) (CP.PHAR.383) (PDF)
- Triptorelin Pamoate (Trelstar®, Triptodur®) (CP.PHAR.175) (PDF)
- Tucatinib (Tukysa) (CP.PHAR.497) (PDF)
- Ubrogepant (Ubrelvy) (IN.CP.PHAR.476) (PDF)
- Umbralisib (Ukoniq) (CP.PHAR.531) (PDF)
- Umeclidinium-vilanterol (Anoro Ellipta) (CP.PMN.149) (PDF)
- Upadacitinib (Rinvoq) (CP.PHAR.443) (PDF)
- Ustekinumab (Stelara®) (IN.PHAR.264) (PDF)
- Valbenazine (Ingrezza™) (CP.PHAR.340) (PDF)
- Valproate (Depacon) (CP.PHAR.429) (PDF)
- Valrubicin (Valstar) (CP.PHAR.439) (PDF)
- Vandetanib (Caprelsa®) (CP.PHAR.80) (PDF)
- Vedolizumab (Entyvio®) (CP.PHAR.265) (PDF)
- Velaglucerase alfa (VPRIV®) (CP.PHAR.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)
- Vincristine Sulfate Liposome Injection (Marqibo®) (CP.PHAR.315) (PDF)
- Vismodegib (Erivedge®) (CP.PHAR.273) (PDF)
- Voclosporin (Lupkynis) (CP.PHAR.504) (PDF)
- Vorinostat (Zolinza®) (CP.PHAR.83) (PDF)
- Zanubrutinib (Brukinsa) (CP.PHAR.467) (PDF)
- Ziv-aflibercept (Zaltrap®) (CP.PHAR.325) (PDF)
- Zoledronic Acid (Reclast®, Zometa®) (CP.PHAR.59) (PDF)
Medicare Clinical Policies
- Burn Surgery (CP.MP.186) (PDF)
- Diaphragmatic/Phrenic Nerve Stimulation (CP.MP.203) (PDF)
- EG and NCS (CP.MP.211) (PDF)
- Endometrial Ablation (CP.MP.106) (PDF)
- Functional MRI (CP.MP.43) (PDF)
- Heart Lung Transplant (CP.MP.132) (PDF)
- Holter Monitor (CP.MP.113) (PDF)
- Homocysteine Testing (CP.MP.121) (PDF)
- Hyperhidrosis Treatments (CP.MP.62) (PDF)
- Implantable Loop Recorder (CP.MP.243) (PDF)
- Implantable Wireless Pulmonary Artery Pressure Monitor (CP.MP.50) (PDF)
- Implantable Intrathecal or Epidural Pain Pump (CP.MP.173) (PDF)
- Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Mechanical Stretching Devices for Joint Stiffness and Contracture (CP.MP.144) (PDF)
- Multiple Sleep Latency Testing (CP.MP.24) (PDF)
- Non-Myeloablative Allogeneic Stem Cell Transplants (CP.MP.141) (PDF)
- Oxygen Use and Concentrators (CP.MP.190) (PDF)
- Pediatric Heart Transplant (CP.MP.138) (PDF)
- Pediatric Liver Transplant - Edited Contraindications (CP.MP.120) (PDF)
- Post-Acute Care (CP.MP.213) (PDF)
- Radiofrequency Ablation of Uterine Fibroids (CP.MP.187) (PDF)
- Short Inpatient Hospital Stay (CP.MP. 182) (PDF)
- Skilled Nursing Facility Leveling (CP.MP.206) (PDF)
- Skin Substitutes for Chronic Wounds (CP.MP.185) (PDF)
- Spinal Cord, Peripheral, Nerve and Percutaneous (CP.MP.117) (PDF)
- Step Therapy: Medicare Part B - Effective 1/1/2021 (MCPB.ST.00) (PDF)
- Tandem Transplant (CP.MP.162) (PDF)
- Total Parenteral Nutrition and Intradialytic Parenteral (CP.MP.163) (PDF)
- Video Electroencephalographic (VEEG) Monitoring (CP.MP.177) (PDF)
Payment Policies
Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.
All policies found in the MHS Payment Policy Manual apply with respect to MHS members. Policies in the MHS Payment Policy Manual may have either a MHS or a “Centene” heading. In addition, MHS 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 MHS.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Ambetter Payment Policies
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Medicaid Payment Policies
- 3-Day Payment Window (CC.PP.500) (PDF)
- Add on Code Billed Without Primary Code (CC.PP.030) (PDF)
- Assistant Surgeon (CC.PP.029) (PDF)
- 340 B Claim Submission (IN.PHAR.15) (PDF)
- Bevacizumab (Avastin®) (CP.PHAR.93) (PDF)
- Bilateral Procedures (CC.PP.037) (PDF)
- Bronchial Thermoplasty (CP.MP.110) (PDF)
- Cerumen Removal (CC.PP.008) (PDF)
- Clean Claims (CC.PP.021) (PDF)
- Code Editing Overview (CC.PP.011) (PDF)
- Cosmetic Procedures (CC.PP.024) (PDF)
- Distinct Procedural Modifiers: XE, XS, XP, & XU (CC.PP.020) (PDF)
- Duplicate Primary Code Billing (CC.PP.044) (PDF)
- E&M Bundling with Labs and Radiology (CC.PP.010) (PDF)
- E&M Medical Decision-Making (CC.PP.051) (PDF)
- Endometrial Ablation (CP.MP.106) (PDF)
- Evoked Potential Testing (CP.MP.134) (PDF)
- GI Pathogen Nucleic Acid Detection Panel Testing (CP.MP.209) (PDF)
- Global Maternity Billing (CC.PP.016) (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)
- Laser Therapy for Skin Conditions (CP.MP.123) (PDF)
- Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (CP.MP.139) (PDF)
- Maximum Units (CC.PP.007) (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)
- NCCI Unbundling (CC.PP.031) (PDF)
- Never Paid Events (CC.PP.017) (PDF)
- New Patient (CC.PP.036) (PDF)
- Not Medically Necessary Inpatient Services (CC.PP.060) (PDF)
- Outpatient Consultation (CC.PP.039) (PDF)
- Paclitaxel, Protein-bound (Abraxane) (CP.PHAR.176) (PDF)
- Physician's Consultation Services (CC.PP.054) (PDF)
- Physician's Office Lab Testing (CC.PP.055) (PDF)
- Place of Service Mismatch (CC.PP.063) (PDF)
- Post-Operative Visits (CC.PP.042) (PDF)
- Pre-Operative Visits (CC.PP.041) (PDF)
- Professional Component (CC.PP.027) (PDF)
- Professional Services (Visit Codes) Billed With Labs (CC.PP.019) (PDF)
- Pulmonary Function Testing (CP.MP.242) (PDF)
- Pulse Oximetry (CC.PP.025) (PDF)
- Sepsis Diagnosis (CP.PP.073) (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)
- 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)
- Visits On Same Day As Surgery (CC.PP.040) (PDF)
- Wheelchair Seating (CP.MP.99) (PDF)