Clinical & Payment Policies
Clinical Policies
Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information.
All policies found in the Coordinated Care Clinical Policy Manual apply to Coordinated Care members. Policies in the Coordinated Care Clinical Policy Manual may have either a Coordinated Care or a “Centene” heading. Coordinated Care utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Coordinated Care clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Coordinated Care. In addition, Coordinated Care may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or InterQual®criteria is payable by Coordinated Care.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Clinical Policies Listing
- AAT Deficiency Treatment (PDF) (CP.PHAR.94)
- Actimmune (PDF) (CP.PHAR.52)
- ADHD Assessment and Treatment (PDF) (CP.MP.124)
- Administrative Day (PDF) (WA.UM.03.01)
- Afinitor (everolimus) (PDF) (CP.PHAR.63)
- Allergy Testing (PDF) (CP.MP.100)
- Ambulatory EEG (PDF) (CP.MP.96)
- Applied Behavioral Analysis Therapy (PDF) (WA.UM.35)
- Bariatric Surgery (PDF) (WA.UM.30)
- Benlysta (belimumab) (PDF) (CP.PHAR.88)
- Bevacizumab (PDF) (CP.PHAR.93)
- Bilateral Cochlear Implants (PDF) (WA.UM.28)
- Bosulif® (PDF) (CP.PHAR.105)
- Botulinum Toxins (PDF) (CP.PHAR.09)
- Bronchial Thermoplasty (PDF) (CP.MP.110)
- Cardiac Biomarker Testing (PDF) (CP.MP.156)
- Clinical Decision Criteria and Application (PDF) (WA.UM.02)
- Concurrent Review for NICU Inpatient Hospitalization (PDF) (WA.UM.01.09)
- Cyramza® (PDF) (CP.PHAR.119)
- Diagnosis of Vaginitis (PDF) (CP.MP.97)
- Digital electroencephalography spike analysis (PDF) (CP.MP.105)
- Discharge Planning (PDF) (WA.UM.40)
- DNA Analysis of Stool (PDF) (CP.MP.125)
- Egrifta® (PDF) (CP.PHAR.109)
- Electroencephalography in the evaluation of headache (PDF) (CP.MP.155)
- Elective Deliveries Before 39 Weeks Gestation (PDF) (WA.UM.17.01)
- Endometrial ablation (PDF) (CP.MP.106)
- EpiFix Wound Treatment (PDF) (CP.MP.140)
- Evoked Potential Testing (PDF) (CP.MP.134)
- Experimental Technologies (PDF) (WA.UM.33)
- Fecal Calprotectin Assay (PDF) (CP.MP.135)
- FeNo Testing (PDF) (CP.MP.103)
- Fuzeon (enfuvirtide) (PDF) (CP.PHAR.41)
- Gattex (PDF) (CP.PHAR.114)
- Gleevec (imatinib mesylate) (PDF) (CP.PHAR.65)
- Global Biopharm Policy (PDF) (CP.PHAR.57)
- Growth Hormone Treatments (PDF) (CP.PHAR.55)
- H. Pylori serology testing (PDF) (CP.MP.153)
- Holter Monitors (PDF) (CP.MP.113)
- Home Health Authorizations (PDF) (WA.UM.18)
- Homocysteine testing (PDF) (CP.MP.121)
- Hospice Coverage (PDF) (WA.UM.21)
- Ibrance (palbociclib) (PDF) (CP.PHAR.125)
- Immune Globulin Injections (PDF) (CP.PHAR.103)
- Iron Overload Treatment (PDF) (CP.PHAR.104)
- Jakafi™ (ruxolitinib) (PDF) (CP.PHAR.98)
- Korlym (mifepristone) (PDF) (CP.PHAR.101)
- Krystexxa (PDF) (CP.PHAR.115)
- Kuvan (PDF) (CP.PHAR.43)
- Laser therapy for skin conditions (PDF) (CP.MP.123)
- Low-Frequency Ultrasound Wound Therapy (PDF) (CP.MP.139)
- Measurement of serum 1,25-dihydroxyvitamin D (PDF) (CP.MP.152)
- Mechanical Stretch Devices (PDF) (CP.MP.144)
- Medical Necessity Review - TruCare (PDF) (WA.UM.02.01)
- Medical Necessity Review for Behavioral Health and Substance Use Disorder (PDF) (WA.UM.02.03)
- Microprocessor-Controlled Lower Limb Prosthetics (PDF) (WA.UM.27)
- Monitored Anesthesia Care for Gastroinestinal Endoscopy (PDF) (CP.MP.161)
- Nusinersen (Spinraza) (PDF) (WA.UM.34)
- Observation Level of Care (PDF) (WA.UM.02.04)
- Ocreotide acetate (PDF) (CP.PHAR.40)
- Oral Enteral Nutrition (PDF) (WA.UM.41)
- Outpatient Testing for Drugs of Abuse (PDF) (WA.UM.29)
- Paclitaxel (PDF) (CP.PHAR.176)
- Pediatric Palliative Care (PDF) (WA.UM.21.01)
- Pelvic Transabdominal US (PDF) (CC.PP.061)
- Personal Care Services (PDF) (WA.UM.42)
- Physician's Office Lab Testing (PDF) (CC.PP.055)
- Place of Service Mismatch (PDF) (CC.PP.063)
- Pomalyst (PDF) (CP.PHAR.116)
- Post-Acute Sub-Acute Care Review and Coordination (PDF) (WA.UM.03)
- Private Duty Nursing (PDF) (WA.UM.32)
- PROM Testing (PDF) (CP.MP.149)
- Protocols for Authorizing Ambulatory Insulin Pumps (PDF) (WA.UM.25)
- Protocols for Authorizing Noninvasive Positive Pressure Ventilation (NIPPV) (PDF)(WA.UM.24)
- Proton and Neutron Beam Therapy (PDF) (CP.MP.70)
- Provenge (PDF) (CP.PHAR.120)
- Psychological Testing (PDF) (WA.UM.39)
- Psychotropic Medical Utilization Review 360 (PDF) (WA.UM.01.03.04)
- Repeat Lab Services (CC.PP.026)
- Revlimid (PDF) (CP.PHAR.71)
- Sensipar (PDF) (CP.PHAR.61)
- Soliris (eculizumab) (PDF) (CP.PHAR.97)
- Synagis_palivizumab (PDF) (CP.PHAR.16)
- Temodar (PDF) (CP.PHAR.77)
- Testing for Select Genitourinary Conditions (PDF) (WA.CP.MP.97)
- Thyrogen® (PDF) (CP.PHAR.95)
- Thyroid hormones and insulin testing in pediatrics (PDF) (CP.MP.154)
- Ultrasound in Pregnancy (PDF) (CP.MP.38)
- Urodynamic testing (PDF) (CP.MP.98)
- Video Electroencephalography (V-EEG) (PDF) (WA.UM.23)
- Viscosupplementation of the Knee for Osteoarthritis (PDF) (WA.UM.26)
- Vitamin D Testing in Children (PDF) (CP.MP.157)
- Wheelchair seating (PDF) (CP.MP.99)
- Wireless Motility Capsule (PDF) (CP.MP.143)
- Wraparound Intensive Services Program (PDF) (WA.UM.37)
- Xgeva (PDF) (CP.PHAR.58)
- Xiaflex™ (PDF) (CP.PHAR.82)
- Xolair® (PDF) (CP.PHAR.01)
- Zometa (PDF) (CP.PHAR.59)
Ambetter Specialty Pharmacy Policies Listing
- AAT Deficiency Treatment (PDF) (CP.PHAR.94)
- Administrative Day Policy (PDF) (WA.UM.03.01)
- Afinitor (everolimus) (PDF) (CP.PHAR.63)
- Agents For Gauchers Disease (PDF) (WA.PHAR.26)
- Allergy Testing and Therapy (PDF) (CP.MP.100)
- Allergenic Extracts (Oral) (PDF) (WA.PHAR.27)
- Androgenic Agents-Testosterone Replacement Therapy (TRT) (PDF) (WA.PHAR.28)
- Antiasthmatic Monoclonal Antibodies Anti IgE Antibodies (PDF) (WA.PHAR.29)
- Antiasthmatic Monoclonal Antibodies IL-5 Antagonists (PDF) (WA.PHAR.30)
- Antibiotics Inhaled-Aztreonam (CAYSTON) (PDF) (WA.PHAR.31)
- Anticonvulsants-Midazolam (Intranasal) (PDF) (WA.PHAR.32)
- Anticonvulsants-Pregabalin (Lyrica) (PDF) (WA.PHAR.56)
- Antidiabetics-Amylin Analogs (PDF) (WA.PHAR.33)
- Antidiabetics-Inhaled Insulin (Afrezza) (PDF) (WA.PHAR.34)
- Antimemtic-Antivertigo Agents (Dronabinol) (PDF) (WA.PHAR.35)
- Antifungal Topical Solutions (PDF) (WA.PHAR.36)
- Antihyperlipidemics-APOB Synthesis Inhibitors (Kynamro) (PDF) (WA.PHAR.37)
- Antihyperlipidemics-APOB Synthesis Inhibitors (Juxtapid) (PDF) (WA.PHAR.38)
- Antihyperlipidemics-PCSK9 Inhibitors (PDF) (WA.PHAR.39)
- Antihyperuricemic Agents (PDF) (WA.PHAR.40)
- aprepitant (Emend®) (PDF) (HIM.PA.62)
- atomoxetine (Strattera®) (PDF) (HIM.PA.66)
- Atypical antipsychotics (PDF) (HIM.PA.59)
- Atopic Dermatitis Agents-Monoclonal Antibodies (PDF) (WA.PHAR.41)
- Atopic Dermatitis Agents-Topical Immunosuppressives (PDF) (WA.PHAR.42)
- Atopic Dermatitis Agents-Topical Phosphodiesterase-4 (PDE4) Inhibitors (PDF) (WA.PHAR.43)
- Avoidable Readmissions (WA.UM.17)
- Azelaic Acid (Finacea) (PDF) (HIM.PA.119)
- Bariatric Surgery (PDF) (WA.UM.30)
- Benign Prostatic Hyperplasia (BPH) Agents-PDE5 Inhibitors (PDF) (WA.PHAR.44)
- Bevacizumab (Avastin) (PDF) (CP.PHAR.93)
- Bilateral Cochlear Implants (PDF) (WA.UM.28)
- Bone-Anchored Hearing Aid (PDF) (CP.MP.93)
- Bone Density Regulators (PDF) (WA.PHAR.45)
- Bosulif® (PDF) (CP.PHAR.105)
- Brand Name Override and Non-Formulary Medications (PDF) (HIM.PA.103)
- buprenorphine and naloxone (Bunavail®, Suboxone®) (PDF) (HIM.PA.35)
- Butorphanol Nasal Spray (PDF) (HIM.PA.46)
- Cardiovascular Agents-Sinus Node Inhibitors (PDF) (WA.PHAR.46)
- Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF) (CP.MP.164)
- Cell-Free Fetal DNA Testing (PDF) (CP.MP.84)
- Cetrorelix (Cetrotide) and Ganirelix (PDF) (HIM.PA.148)
- Chronic GI Motility Agents (PDF) (WA.PHAR.47)
- Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) (HIM.PA.120)
- clomipramine (Anafranil) (PDF) (HIM.PA.149)
- Colesevelam (Welchol) (PDF) (HIM.PA.121)
- Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) (HIM.PA.140)
- Cosmetic Reconstructive Surgery (PDF) (CP.MP.31)
- Cyramza® (PDF) (CP.PHAR.119)
- Cysteamine (Cystagon-Procysbi) Policy (PDF) (WA.PHAR.21)
- Cystic Fibrosis Agents (Oral) (PDF) (WA.PHAR.48)
- Cystic Fibrosis Carrier Screening (PDF) (CP.MP.83)
- Cytokine and CAM Antagonists (PDF) (WA.PHAR.49)
- Daclatasvir (Daklinza) (PDF) (HIM.PA.SP27)
- daclizumab (Zinbryta) (PDF) (HIM.PA.SP6)
- Dichlorphenamide (Keveyis) (PDF) (HIM.PA.SP44)
- diclofenac sodium topical gel (Solaraze, Voltaren®) (PDF) (HIM.PA.123)
- Digital EEG Spike Analysis (PDF) (CP.MP.105 )
- Dipeptidyl Peptidase-4 Inhibitors (PDF) (HIM.PA.58)
- dolastron (Anzemet®) (PDF) (HIM.PA.85)
- Doxepin Hydrochloride Cream (Prudoxin, Zonalon) (PDF) (HIM.PA.147)
- Efinaconazole (Jublia) (PDF) (HIM.PA.25)
- Egrifta® (PDF) (CP.PHAR.109)
- Elective Deliveries Before 39 Weeks Gestational Age (PDF) (WA.UM.17.01)
- Emtricitabine/Tenofovir (Truvada®) (PDF) (HIM.PA.78)
- Endometrial Ablation (PDF) (CP.MP.106)
- Evolocumab (Repatha) (PDF) (HIM.PA.SP46)
- Experimental Policy (PDF) (CP.MP.36 )
- ezogabine (Potiga®) (PDF) (HIM.PA.60)
- Facet Joint Interventions for Pain Management (PDF) (CP.MP.171)
- famciclovir (Famvir®) (PDF) (HIM.PA.63)
- Formulary Medications Without Specific Guidelines (PDF) (HIM.PA.33)
- Fuzeon (enfuvirtide) (PDF) (CP.PHAR.41)
- Gastric Electrical Stimulation (PDF) (CP.MP.40)
- Gattex (PDF) (CP.PHAR.114)
- Gender Reassignment Surgery (PDF) (CP.MP.95)
- Genetic Testing (PDF) (CP.MP.89 )
- Glecaprevir-Pibrentasvir (PDF) (HIM.PA.SP36)
- Gleevec (imatinib mesylate) (PDF) (CP.PHAR.65)
- Global Biopharm Policy (PDF) (CP.PHAR.57)
- Glucagon-Like Peptide-1 Receptor Agonists (PDF) (HIM.PA.53)
- Growth Hormone Agents (PDF) (WA.PHAR.50)
- Guanfacine ER (Intuniv) (PDF) (HIM.PA.98)
- Home Health Authorizations (PDF) (WA.UM.18)
- Hormone Therapy Gender Disphoria (PDF) (WA.PHAR.25)
- Hospice Coverage (PDF) (WA.UM.21)
- Hydrocodone-chlorpheniramine (Vituz) (PDF) (HIM.PA.141)
- Hyperbaric Oxygen Therapy (PDF) (CP.MP.27)
- Hyperemesis Gravidarum Treatment (PDF) (CP.MP.34)
- Ibrance (palbociclib) (PDF) (CP.PHAR.125)
- Ibrutinib (Imbruvica) (PDF) (HIM.PA.SP48)
- Idelalisib (Zydelig) (PDF) (HIM.PA.SP49)
- Immune Globulin Infusion with Recombinant Human Hyaluronidase (Hyqvia®) (PDF) (HIM.PA.SP47)
- Immune Globulin Injections (2015 Update) (PDF) (CP.PHAR.103)
- Infliximab (Remicade, Renflexis, Inflectra) (PDF) (HIM.PA.SP58)
- Inhaled Corticosteroids (PDF) (HIM.PA.73)
- Inhaled Nitric Oxide (PDF) (CP.MP.87)
- Intensity-Modulated Radiotherapy (PDF) (CP.MP.69)
- interferon beta-1a (Avonex, Rebif) (PDF) (HIM.PA.SP14)
- interferon beta-1b (Betasero, Extavia) (PDF) (HIM.PA.SP15)
- Interventional Pain Management (PDF) (WA.UM.32)
- Intestinal & Multivisceral Transplant (PDF) (CP.MP.58)
- Intradiscal Steroid Injections for Pain Management (PDF) (CP.MP.167)
- isavuconazonium (Cresemba®) (PDF) (HIM.PA.108)
- isotretinoin (Claravis®, Sotret®, Amnesteem®, Myorisan®) (PDF) (HIM.PA.50)
- ivermectin (Sklice®) (PDF) (HIM.PA.124)
- Jakafi™ (ruxolitinib) (PDF) (CP.PHAR.98)
- Korlym (mifepristone) (PDF) (CP.PHAR.101)
- Krystexxa (PDF) (CP.PHAR.115)
- Kuvan (PDF) (CP.PHAR.43)
- lacosamide (Vimpat®) (PDF) (HIM.PA.49)
- ledipasvir sofosbuvir (Harvoni) (PDF) (HIM.PA.SP3)
- Lenvatinib (Lenvima) (PDF) (HIM.PA.SP50)
- Leucovorin (PDF) (HIM.PA.138)
- Leuprolide Acetate Norethindrone Acetate (Lupaneta Pack) (PDF) (HIM.PA.SP51)
- Levomilnacipran (Fetzima) (PDF) (HIM.PA.125)
- lidocaine transdermal (Lidoderm®) (PDF) (HIM.PA.126)
- long acting beta agonists and combination products (PDF) (HIM.PA.74)
- Long Acting Injectable Atypical Antipsychotics (PDF) (HIM.PA.99)
- Lovastatin ER (Altoprev) (PDF) (HIM.PA.127)
- lubiprostone (Amitiza®) (PDF) (HIM.PA.79)
- Lung Transplantation (PDF) (CP.MP.57)
- Medication Assisted Treatment (MAT) (PDF) (WA.PHAR.15)
- Megestrol acetate oral suspension (Megace ES) (PDF) (HIM.PA.128)
- Methadone (Dolophine) (PDF) (WA.PHAR.20)
- Microprocessor Controlled Lower Limb Prosthetics (PDF) (WA.UM.27)
- Mitoxantrone (Novantrone) (PDF) (HIM.PA.SP53)
- Mometasone (Nasonex) (PDF) (HIM.PA.93)
- Montelukast oral granules (Singulair) (PDF) (HIM.PA.129)
- Movement Disorder Agents (PDF) (WA.PHAR.51)
- Multiple Sclerosis Agents-Dalfampridine (Ampyra) (PDF) (WA.PHAR.52)
- Naproxen oral suspension (Naprosyn) (PDF) (HIM.PA.130)
- natalizumab (Tysabri) (PDF) (HIM.PA.SP17)
- Nebivolol (Bystolic) (PDF) (HIM.PA.131)
- Neonatal Abstinence Syndrome Guidelines (PDF) (CP.MP.85)
- Nerve Blocks for Pain Management (PDF) (CP.MP.170)
- netupitant;palonosetron (Akynzeo) (PDF) (HIM.PA.113)
- NICU Apnea Bradycardia Guidelines (PDF) (CP.MP.82)
- Non-Formulary and Formulary Contraceptives (PDF) (HIM.PA.100)
- Non-Formulary Test Strips (PDF) (HIM.PA.34)
- OB Home Health Programs (PDF) (CP.MP.91)
- OB UltraSound Guidelines (PDF) (WA.UM.20)
- Ocreotide acetate (PDF) (CP.PHAR.40)
- olaprib (Lynparza) (PDF) (HIM.PA.SP34)
- Opioid Analgesics (PDF) (HIM.PA.139)
- Opioid Policy (PDF) (WA.PHAR.23)
- Outpatient Testing for Drugs of Abuse (PDF) (WA.UM.29)
- Overactive Bladder Agents (PDF) (HIM.PA.40)
- Paclitaxel, protein bound (Abraxane) (PDF) (CP.PHAR.176)
- Pasireotide (Signifor) (PDF) (HIM.PA.SP54)
- peginterferon beta-1a (Plegridy) (PDF) (HIM.PA.SP18)
- Penicillamine (Cuprimine) (PDF) (HIM.PA.142)
- Perampanel (Fycompa) (PDF) (HIM.PA.132)
- Phendimetrazine IR (Bontril PDM) (PDF) (HIM.PA.114)
- Pituitary Suppressive Agents (PDF) (WA.PHAR.53)
- Pomalyst (PDF) (CP.PHAR.116)
- Potassium (Klor-Con) (PDF) (HIM.PA.143)
- Progesterone Hydroxyprogesterone Caproate (Makena) (PDF) (WA.PHAR.54)
- Protocols for Authorizing Noninvasive Positive Pressure Ventilation (NIPPV) (PDF)(WA.UM.24)
- Pulmonary Arterial Hypertension (PAH) Agents (Oral and Inhalation) (PDF) (WA.PHAR.55)
- Pyrimethamine (Daraprim) (PDF) (HIM.PA.133)
- Quinine Sulfate (Qualaquin) (PDF) (HIM.PA.144)
- rasagiline (Azilect®) (PDF) (HIM.PA.89)
- Reduction Mammaplasty (PDF) (CP.MP.51)
- Revlimid (PDF) (CP.PHAR.71)
- rifaximin (Xifaxan®) (PDF) (HIM.PA.68)
- Risperidone ODT, Risperidone solution (Risperdal) (PDF) (HIM.PA.81)
- Rufinamide (Banzel) (PDF) (HIM.PA.90)
- Sacroiliac Joint Interventions for Pain Management (PDF) (CP.MP.166)
- Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF) (CP.MP.165)
- Sensipar (PDF) (CP.PHAR.61)
- sodium oxabate (Zyrem®) (PDF) (HIM.PA.69)
- Sodium-Glucose Co-Transporter 2 Inhibitors (PDF) (HIM.PA.91)
- Sofosbuvir (Sovaldi) (PDF) (HIM.PA.SP2)
- Sofosbuvir-Velpatasvir (Epclusa) (PDF) (HIM.PA.SP1)
- Soliris (eculizumab) (PDF) (CP.PHAR.97)
- Spinosad (Natroba) (PDF) (HIM.PA.134)
- Step Therapy (PDF) (HIM.PA.109)
- Stereotactic Body Radiation Therapy (PDF) (CP.MP.22)
- sucroferric oxyhydoxide (Velphoro) (PDF) (HIM.PA.SP30)
- Sulfacetamide Sodium Sulfur (Sumadan) (PDF) (HIM.PA.145)
- Sylatron (peginterferon alfa-2b) (PDF) (CP.PHAR.89)
- Synagis_palivizumab (PDF) (CP.PHAR.16)
- tapentadol (Nucynta®) (PDF) (HIM.PA.86)
- tavaborole (Kerydin®) (PDF) (HIM.PA.117)
- Temodar (PDF) (CP.PHAR.77)
- Telbivudine (Tyzeka) (PDF) (HIM.PA.95)
- Thalomid (PDF) (CP.PHAR.78)
- Thyrogen® (PDF) (CP.PHAR.95)
- Timothy Grass Pollen Allergen Extract (Grastek) (PDF) (HIM.PA.137)
- Topical Acne Treatment (PDF) (HIM.PA.71)
- Topical Immunomodulators (PDF) (HIM.PA.56)
- topical testosterone (PDF) (HIM.PA.87)
- tresprostinil (Orenitram®, Romodulin®) (PDF) (HIM.PA.SP25)
- Trigger Point Injections for Pain Management (PDF) (CP.MP.169)
- Ultrasound in Pregnancy (PDF) (CP.MP.38)
- Uridine acetate (Vistogard) (PDF) (HIM.PA.SP55)
- Urodynamic Testing (PDF) (CP.MP.98)
- Varenicline-Chantix and Bupropion Zyban (PDF) (WA.PHAR.16)
- Video Electroencephalography (V-EEG) (PDF) (WA.UM.23)
- viladazone (Viibryd®) (PDF) (HIM.PA.135)
- Viscosupplementation of the Knee for Osteoarthritis (PDF) (WA.UM.26)
- Vorapaxar (Zontivity) (PDF) (HIM.PA.146)
- vortioxetine (Trintellex®) (PDF) (HIM.PA.136)
- Wheelchair Seating (PDF) (CP.MP.99)
- Xenazine (tetrabenazine) (PDF) (CP.PHAR.92)
- Xgeva (PDF) (CP.PHAR.58)
- Xiaflex™ (PDF) (CP.PHAR.82)
- Xolair® (PDF) (CP.PHAR.01)
- Zometa (PDF) (CP.PHAR.59)
Medicaid Specialty Pharmacy Policies Listing
- Abaloparatide (PDF) (CP.PHAR.345)
- Abatacept (PDF) (CP.PHAR.241)
- Abemaciclib (PDF) (CP.PHAR.355)
- Abiraterone (Zytiga) (PDF) (CP.PHAR.84)
- AbobotulinumtoxinA (PDF) (CP.PHAR.230)
- Abiraterone (Zytiga) (PDF) (CP.PHAR.84)
- AbobotulinumtoxinA (PDF) (CP.PHAR.230)
- Acalabrutinib (PDF) (CP.PHAR.366)
- ACEI and ARB Duplicate Therapy (PDF) (CP.PMN.61)
- Acitretin (Soriatane) (PDF) (CP.PMN.40)
- Adalimumab (PDF) (CP.PHAR.242)
- Ado-Trastuzumab Emtansine (PDF) (CP.PHAR.229)
- Administrative Day Policy (PDF) (WA.UM.03.01)
- Afatinib (PDF) (CP.PHAR.298)
- Alectinib (PDF) (CP.PHAR.369)
- Aflibercept (Eylea) (PDF) (CP.PHAR.184)
- Agalsidase Beta (PDF) (CP.PHAR.158)
- Age Limit Override (PDF) (CP.PMN.138)
- Agents For Gauchers Disease (PDF) (WA.PHAR.26)
- Alemtuzumab (PDF) (CP.PHAR.243)
- Alendronate (PDF) (CP.PMN.88)
- Alglucosidase Alfa (PDF) (CP.PHAR.160)
- Alirocumab (PDF) (CP.PHAR.124)
- Allergenic Extracts (Oral) (PDF) (WA.PHAR.27)
- Alpha-1 Proteinase Inhibitors (PDF) (CP.PHAR.94)
- Amantadine ER (PDF) (CP.PMN.89)
- Ambrisentan (Letairis) (PDF) (CP.PHAR.190)
- Anakinra (PDF) (SP.PHAR.244)
- Androgenic Agents-Testosterone Replacement Therapy (TRT) (PDF) (WA.PHAR.28)
- Anti-Allergy Ophthalmics (PDF) (CP.PST.03)
- Antiasthmatic Monoclonal Antibodies Anti IgE Antibodies (PDF) (WA.PHAR.29)
- Antiasthmatic Monoclonal Antibodies IL-5 Antagonists (PDF) (WA.PHAR.30)
- Anticonvulsants-Midazolam (Intranasal) (PDF) (WA.PHAR.32)
- Anticonvulsants-Pregabalin (Lyrica) (PDF) (WA.PHAR.56)
- Antidiabetics-Amylin Analogs (PDF) (WA.PHAR.33)
- Antidiabetics-Inhaled Insulin (Afrezza) (PDF) (WA.PHAR.34)
- Antihyperlipidemics-APOB Synthesis Inhibitors (Kynamro) (PDF) (WA.PHAR.37)
- Antihyperlipidemics-APOB Synthesis Inhibitors (Juxtapid) (PDF) (WA.PHAR.38)
- Antihyperlipidemics-PCSK9 Inhibitors (PDF) (WA.PHAR.39)
- Antihyperuricemic Agents (PDF) (WA.PHAR.40)
- Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) (CP.PHAR.217)
- Antifungal Topical Solutions (PDF) (WA.PHAR.36)
- Antimemetic-Antivertigo Agents (Dronabinol) (PDF) (WA.PHAR.35)
- Apalutamide (PDF) (CP.PHAR.376)
- Apremilast (PDF) (CP.PHAR.245)
- Aprepitant (Emend) (PDF) (SP.PMN.19)
- aripiprazole long-acting injections (PDF) (CP.PHAR.290)
- Armodafinil (PDF) (CP.PMN.35)
- Asenapine (PDF) (CP.PMN.15)
- asfotase alfa (PDF) (CP.PHAR.328)
- Aspirin-dipyridamole (PDF) (CP.PMN.20)
- Atezolizumab (Tecentriq) (PDF) (CP.PHAR.235)
- Atomoxetine (Strattera) (PDF) (CP.PST.17)
- Atopic Dermatitis Agents-Monoclonal Antibodies (PDF) (WA.PHAR.41)
- Atopic Dermatitis Agents-Topical Immunosuppressives (PDF) (WA.PHAR.42)
- Atopic Dermatitis Agents-Topical Phosphodiesterase-4 (PDE4) Inhibitors (PDF) (WA.PHAR.43)
- Atypical antipsychotics (PDF) (HIM.PA.59)
- Avelumab (Bavencio) (PDF) (SP.PHAR.333)
- Avoidable Readmissions (PDF) (WA.UM.17)
- Axicabtagene ciloleucel (PDF) (CP.PHAR.362)
- Axitinib (Inlyta) (PDF) (CP.PHAR.100)
- Azelaic Acid (Finacea) (PDF) (HIM.PA.119)
- Aztreonam (Cayston) (PDF) (CP.PHAR.209)
- Bariatric Surgery (PDF) (WA.UM.30)
- Becaplermin (Regranex) (PDF) (CP.PMN.21)
- Belatacept (Nulojix) (PDF) (CP.PHAR.201)
- Belimumab (PDF) (CP.PHAR.88)
- belinostat (PDF) (CP.PHAR.311)
- bendamustine (PDF) (CP.PHAR.307)
- Benign Prostatic Hyperplasia (BPH) Agents-PDE5 Inhibitors (PDF) (WA.PHAR.44)
- Benralizumab (PDF) (CP.PHAR.373)
- Benznidazole (PDF) (CP.PMN.90)
- Betrixaban (Bevyxxa) (PDF) (CP.PMN.114)
- Bevacizumab (Avastin) (PDF) (CP.PHAR.93)
- Bevacizumab-awwb (Mvasi) (PDF) (CP.PHAR.356)
- Bexarotene (Targretin) (PDF) (CP.PHAR.75)
- Bezlotoxumab (PDF) (CP.PHAR.300)
- Bilateral Cochlear Implants (PDF) (WA.UM.28)
- Blinatumomab (PDF) (CP.PHAR.312)
- Bone Density Regulators (PDF) (WA.PHAR.45)
- Bosentan (Tracleer) (PDF) (CP.PHAR.191)
- Bosutinib (PDF) (CP.PHAR.105)
- Brand Name Override (PDF) (CP.PMN.22)
- Brexpiprazole (PDF) (CP.PMN.68)
- Brentuximab (PDF) (CP.PHAR.303)
- Brigatinib (PDF) (CP.PHAR.342)
- Brimonidine Tartrate, Oxymetazoline (PDF) (CP.PMN.86)
- Brodalumab (PDF) (CP.PHAR.375)
- Buprenorphine (PDF) (CP.PMN.82)
- Buprenorphine Implant-Injection (PDF) (CP.PHAR.289)
- Buprenorphine-Naloxone (Bunavail, Suboxone, Zubsolv) (PDF) (CP.PMN.81)
- Bupropion-Naltrexone (PDF) (CP.PMN.133)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda) (PDF) (CP.PHAR.202)
- cabazitaxel (PDF) (CP.PHAR.316)
- Calcifediol (Rayaldee) (PDF) (CP.PMN.76)
- Canakinumab (PDF) (CP.PHAR.246)
- Capecitabine (Xeloda) (PDF) (CP.PHAR.60)
- Carbamazepine ER (PDF) (CP.PMN.137)
- Cardiovascular Agents-Sinus Node Inhibitors (PDF) (WA.PHAR.46)
- carfilzomib (PDF) (CP.PHAR.309)
- Carglumic Acid (Carbaglu) (PDF) (CP.PHAR.206)
- Cariprazine (PDF) (CP.PMN.91)
- Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF) (CP.MP.164)
- Celecoxib (PDF) (CP.PMN.122)
- Cell-Free Fetal DNA Testing (PDF) (CP.MP.84)
- Ceritinib (PDF) (CP.PHAR.349)
- Cerliponase Alfa (PDF) (CP.PHAR.338)
- Certolizumab (PDF) (CP.PHAR.247)
- Cetrorelix (Cetrotide) and Ganirelix (PDF) (HIM.PA.148)
- cetuximab (PDF) (CP.PHAR.317)
- Chronic GI Motility Agents (PDF) (WA.PHAR.47)
- Ciclopirox (Penlac) (PDF) (CP.PMN.24)
- Cinacalcet (PDF) (CP.PHAR.61)
- Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) (HIM.PA.120)
- Clobazam (Onfi) (PDF) (CP.PMN.54)
- clomipramine (Anafranil) (PDF) (HIM.PA.149)
- Clozapine orally disintegrating tablet (Fazaclo) (PDF) (CP.PMN.12)
- Colchicine (PDF) (CP.PMN.123)
- Collagenase (PDF) (CP.PHAR.82)
- Colesevelam (Welchol) (PDF) (HIM.PA.121)
- Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) (HIM.PA.140)
- copanlisib (PDF) (CP.PHAR.357)
- Corticotropin (H.P. Acthar Gel) (PDF) (CP.PHAR.168)
- Cosmetic Reconstructive Surgery (PDF) (CP.MP.31)
- Cosyntropin (Cortrosyn) (PDF) (CP.PHAR.203)
- Crisaborole (PDF) (CP.PMN.110)
- Crizotinib (PDF) (CP.PHAR.90)
- Cyclosporine ophthalmic emulsion (PDF) (CP.PMN.48)
- Cysteamine (Cystagon-Procysbi) Policy (PDF) (WA.PHAR.21)
- Cysteamine Ophthalmic (PDF) (CP.PMN.130)
- Cysteamine Oral (PDF) (CP.PHAR.155)
- Cystic Fibrosis Agents (Oral) (PDF) (WA.PHAR.48)
- Cystic Fibrosis Carrier Screening (PDF) (CP.MP.83)
- Cytokine and CAM Antagonists (PDF) (WA.PHAR.49)
- Dabigatran (PDF) (CP.PMN.49)
- Dabrafenib (PDF) (CP.PHAR.239)
- Daclatasvir (Daklinza) (PDF) (HIM.PA.SP27)
- Daclizumab (PDF) (CP.PHAR.269)
- Dalfampridine (PDF) (CP.PHAR.248)
- Dalteparin (PDF) (CP.PHAR.225)
- daptomycin (PDF) (CP.PHAR.351)
- Daratumumab (PDF) (CP.PHAR.310)
- Darbepoetin Alfa (PDF) (CP.PHAR.236)
- Dasatinib (Sprycel) (PDF) (CP.PHAR.72)
- daunorubicin cytarabine (PDF) (CP.PHAR.352)
- deferasirox (PDF) (CP.PHAR.145)
- deferiprone (PDF) (CP.PHAR.147)
- deferoxamine (PDF) (CP.PHAR.146)
- Deflazacort (PDF) (CP.PHAR.331)
- Degarelix Acetate (Firmagon) (PDF) (CP.PHAR.170)
- Delafloxacin (Baxdela) (PDF) (CP.PMN.115)
- Denosumab (PDF) (CP.PHAR.58)
- Desmopressin (DDAVP, Stimate) (PDF) (CP.PHAR.214)
- Dextromethorphan-Quinidine (PDF) (CP.PMN.93)
- Deutetrabenazine (PDF) (CP.PHAR.341)
- Dexmethylphenidate ER (Focalin) (PDF) (CP.PMN.63)
- Dichlorphenamide (Keveyis) (PDF) (HIM.PA.SP44)
- diclofenac sodium topical gel (Solaraze, Voltaren®) (PDF) (HIM.PA.123)
- Digital EEG Spike Analysis (PDF) (CP.MP.105)
- Dimethyl fumarate (PDF) (CP.PHAR.249)
- Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF) (CP.PST.18)
- DME Coverage Guidelines (PDF) (CP.DME.04)
- DNA Analysis of Stool (PDF) (CP.MP.125)
- dolastron (Anzemet®) (PDF) (HIM.PA.85)
- Dornase alfa (Pulmozyme) (PDF) (CP.PHAR.212)
- Dose optimization (PDF) (CP.PMN.13)
- Doxepin Hydrochloride Cream (Prudoxin, Zonalon) (PDF) (HIM.PA.147)
- Doxycycline Hyclate (PDF) (CP.PMN.79)
- Droxidopa (Northera) (PDF) (CP.PMN.17)
- Dupilumab (PDF) (CP.PHAR.336)
- Duplicate SSRI SNRI Therapy (PDF) (CP.PMN.60)
- Durvalumab (PDF) (CP.PHAR.339)
- Dutasteride (PDF) (CP.PMN.128)
- Ecallantide (Kalbitor) (PDF) (CP.PHAR.177)
- Eculizumab (Soliris) (PDF) (CP.PHAR.97)
- Edaravone (PDF) (CP.PHAR.343)
- Efinaconazole (PDF) (CP.PMN.25)
- Elective Deliveries Before 39 Weeks Gestational Age (PDF) (WA.UM.17.01)
- Eliglustat (PDF) (CP.PHAR.153)
- Elosulfase Alfa (PDF) (CP.PHAR.162)
- Eltrombopag (Promacta) (PDF) (CP.PHAR.180)
- elotuzumab (PDF) (CP.PHAR.308)
- Emicizumab-kxwh (PDF) (CP.PHAR.370)
- Emtricitabine/Tenofovir (Truvada®) (PDF) (HIM.PA.78)
- enasidenib (PDF) (CP.PHAR.363)
- Enfuvirtide (PDF) (CP.PHAR.41)
- Enoxaparin (PDF) (CP.PHAR.224)
- Enzalutamide (PDF) (CP.PHAR.106)
- Epinephrine (Epipen, Epipen Jr) (PDF) (CP.PPA.09)
- Epoetin Alfa (PDF) (CP.PHAR.237)
- Epoprostenol (Flolan, Veletri) (PDF) (CP.PHAR.192)
- eribulin Mesylate (PDF) (CP.PHAR.318)
- Erlotinib (Tarceva) (PDF) (CP.PHAR.74)
- Erwinia Asparaginase (Erwinaze) (PDF) (CP.PHAR.301)
- Etanercept (PDF) (CP.PHAR.250)
- Eteplirsen (PDF) (CP.PHAR.288)
- Etidronate (Didronel) (PDF) (CP.PMN.94)
- Everolimus (PDF) (CP.PHAR.63)
- Evolocumab (PDF) (CP.PHAR.123)
- Exemestane Step Therapy (PDF) (CP.PST.05)
- Experimental Policy (PDF) (CP.MP.36)
- Ezetimibe (Zetia) (PDF) (CP.PMN.78)
- Ezetimibe-Simvastatin (PDF) (CP.PMN.77)
- ezogabine (Potiga®) (PDF) (HIM.PA.60)
- Facet Joint Interventions for Pain Management (PDF) (CP.MP.171)
- Factor VIII (Human Recombinant) (PDF) (CP.PHAR.215)
- Factor VIII von Willebrand Factor Complex (PDF) (CP.PHAR.216)
- Factor IX (Human, Recombinant) (PDF) (CP.PHAR.218)
- Factor VIIa, Recombinant (NovoSeven RT) (PDF) (CP.PHAR.220)
- Factor XIII, Human (Corifact) (PDF) (CP.PHAR.221)
- Factor XIII A-Subunit, Recombinant (Tretten) (PDF) (CP.PHAR.222)
- Factor IX Complex, Human (Bebulin, Profilnine) (PDF) (CP.PHAR.219)
- Famciclovir (Famvir) (PDF) (CP.PMN.26)
- Febuxostat (Uloric) (PDF) (CP.PMN.57)
- Fentanyl IR (PDF) (CP.PMN.127)
- Ferric Carboxymaltose (Injectafer) (PDF) (CP.PHAR.234)
- Ferric Gluconate (Ferrlecit) (PDF) (CP.PHAR.166)
- Ferumoxytol (Feraheme) (PDF) (CP.PHAR.165)
- Filgrastim (PDF) (CP.PHAR.297)
- Fingolimod (PDF) (CP.PHAR.251)
- Fluticasone propionate (PDF) (CP.PMN.95)
- Fluticasone Salmeterol (Advair Diskus, Advair HFA) (PDF) (CP.PMN.31)
- Fondaparinux (PDF) (CP.PHAR.226)
- Formulary Medications Without Specific Guidelines (PDF) (HIM.PA.33)
- Galsulfase (PDF) (CP.PHAR.161)
- Gastric Electrical Stimulation (PDF) (CP.MP.40)
- Gattex (PDF) (CP.PHAR.114)
- Gefitinib (PDF) (CP.PHAR.68)
- gefitinib (PDF) (CP.PHAR.299)
- gemtuzumab ozogamicin (PDF) (CP.PHAR.358)
- Genetic Testing (PDF) (CP.MP.89)
- Glatiramer Acetate (PDF) (CP.PHAR.252)
- Glecaprevir-Pibrentasvir (PDF) (HIM.PA.SP36)
- Glucagon-Like Peptide-1 Receptor Agonists (PDF) (HIM.PA.53)
- Global Biopharm Policy (PDF) (CP.PHAR.57)
- Glucagon-Like Peptide-1 Receptor Agonists (PDF) (CP.PST.14)
- Glycerol phenylbutyrate (Ravicti) (PDF) (CP.PHAR.207)
- Golimumab (PDF) (CP.PHAR.253)
- Goserelin Acetate (Zoladex) (PDF) (CP.PHAR.171)
- Granisetron (Sancuso) (PDF) (CP.PMN.74)
- Growth Hormone Agents (PDF) (WA.PHAR.50)
- Guanfacine ER (Intuniv) (PDF) (CP.PMN.37)
- Guselkumab (PDF) (CP.PHAR.364)
- Hemin (Panhematin) (PDF) (CP.PHAR.181)
- Histrelin Acetate (Vantas, Supprelin LA) (PDF) (CP.PHAR.172)
- Home Health Authorizations (PDF) (WA.UM.18)
- Hormone Therapy Gender Disphoria (PDF) (WA.PHAR.25)
- Hospice Coverage (PDF) (WA.UM.21)
- Hyaluronate Derivatives (PDF) (CP.PHAR.05)
- Hydroxyprogesterone Caproate (Makena) (PDF) (CP.PHAR.14)
- Hyperbaric Oxygen Therapy (PDF) (CP.MP.27)
- Hyperemesis Gravidarum Treatment (PDF) (CP.MP.34)
- Ibalizumab-uiyk (PDF) (CP.PHAR.378)
- Ibandronate sodium (Boniva) (PDF) (CP.PHAR.189)
- Ibrance (palbociclib) (PDF) (CP.PHAR.125)
- Ibrutinib (Imbruvica) (PDF) (HIM.PA.SP48)
- Icatibant (Firazyr) (PDF) (CP.PHAR.178)
- Idelalisib (Zydelig) (PDF) (HIM.PA.SP49)
- Idursulfase (PDF) (CP.PHAR.156)
- Iloprost (Ventavis) (PDF) (CP.PHAR.193)
- Imatinib (Gleevec) (PDF) (CP.PHAR.65)
- Imiglucerase (PDF) (CP.PHAR.154)
- Immune Globulin Infusion with Recombinant Human Hyaluronidase (Hyqvia®) (PDF) (HIM.PA.SP47)
- Immune Globulins (PDF) (CP.PHAR.103)
- Immunization coverage (PDF) (CP.PHAR.28)
- IncobotulinumtoxinA (PDF) (CP.PHAR.231)
- Infliximab (PDF) (CP.PHAR.254)
- Inhaled Corticosteroids (PDF) (HIM.PA.73)
- Inhaled Nitric Oxide (PDF) (CP.MP.87)
- inotuzumab ozogamicin (PDF) (CP.PHAR.359)
- Intensity-Modulated Radiotherapy (PDF) (CP.MP.69)
- Interferon Beta-1a (PDF) (CP.PHAR.255)
- Interferon Beta-1b (PDF) (CP.PHAR.256)
- Interferon Gamma- 1b (Actimmune) (PDF) (CP.PHAR.52)
- Interventional Pain Management (PDF) (WA.UM.32)
- Intestinal & Multivisceral Transplant (PDF) (CP.MP.58)
- Intradiscal Steroid Injections for Pain Management (PDF) (CP.MP.167)
- Intrathecal Baclofen (Gablofen, Lioresal) (PDF) (CP.PHAR.149)
- Ipilimumab (PDF) (CP.PHAR.319)
- irinotecan Liposome (PDF) (CP.PHAR.304)
- Iron sucrose (Venofer) (Acthar Gel) (PDF) (CP.PHAR.167)
- isavuconazonium (Cresemba®) (PDF) (HIM.PA.108)
- isotretinoin (Claravis®, Sotret®, Amnesteem®, Myorisan®) (PDF) (HIM.PA.50)
- Ivacaftor (Kalydeco) (PDF) (CP.PHAR.210)
- ivermectin (Sklice®) (PDF) (HIM.PA.124)
- Ixazomib (PDF) (CP.PHAR.302)
- Ixekizumab (PDF) (CP.PHAR.257)
- Jakafi™ (ruxolitinib) (PDF) (CP.PHAR.98)
- Korlym (mifepristone) (PDF) (CP.PHAR.101)
- Krystexxa (PDF) (CP.PHAR.115)
- Kuvan (PDF) (CP.PHAR.43)
- lacosamide (Vimpat®) (PDF) (HIM.PA.49)
- Laronidase (PDF) (CP.PHAR.152)
- ledipasvir sofosbuvir (Harvoni) (PDF) (HIM.PA.SP3)
- Lenalidomide (Revlimid) (PDF) (CP.PHAR.71)
- Lenvatinib (Lenvima) (PDF) (HIM.PA.SP50)
- Letermovir (PDF) (CP.PHAR.367)
- Leucovorin (PDF) (HIM.PA.138)
- Leuprolide Acetate (Eligard, Lupaneta Pack, Lupron Depot, Lupron Depot Ped) (PDF) (CP.PHAR.173)
- Levoleucovorin (Fusilev) (PDF) (CP.PHAR.151)
- Levomilnacipran (Fetzima) (PDF) (HIM.PA.125)
- lidocaine transdermal (Lidoderm®) (PDF) (HIM.PA.126)
- Lomitapide (PDF) (CP.PHAR.283)
- long acting beta agonists and combination products (PDF) (HIM.PA.74)
- Long Acting Injectable Atypical Antipsychotics (PDF) (HIM.PA.99)
- Lovastatin ER (Altoprev) (PDF) (HIM.PA.127)
- lubiprostone (Amitiza®) (PDF) (HIM.PA.79)
- Lumacaftor - Ivacaftor (Orkambi) (PDF) (CP.PHAR.213)
- Lung Transplantation (PDF) (CP.MP.57)
- Macitentan (Opsumit) (PDF) (CP.PHAR.194)
- Mecasermin (PDF) (CP.PHAR.150)
- Medication Assisted Treatment (MAT) (PDF) (WA.PHAR.15)
- Megestrol acetate oral suspension (Megace ES) (PDF) (HIM.PA.128)
- Mepolizumab (PDF) (CP.PHAR.200)
- Methadone (Dolophine) (PDF) (WA.PHAR.20)
- Methoxy polyethylene glycol-epoetin beta (PDF) (CP.PHAR.238)
- Microprocessor Controlled Lower Limb Prosthetics (PDF) (WA.UM.27)
- Midostaurin (PDF) (CP.PHAR.344)
- Mifepristone (Korlym) (PDF) (CP.PHAR.101)
- Miglustat (PDF) (CP.PHAR.164)
- Mipomersen (PDF) (CP.PHAR.284)
- Mitoxantrone (PDF) (CP.PHAR.258)
- Mometasone (Nasonex) (PDF) (HIM.PA.93)
- Montelukast oral granules (Singulair) (PDF) (HIM.PA.129)
- Multiple Sclerosis Agents-Dalfampridine (Ampyra) (PDF) (WA.PHAR.52)
- Nafarelin Acetate (Synarel) (PDF) (CP.PHAR.174)
- Naltrexone (Vivitrol) (PDF) (CP.PHAR.96)
- Naproxen oral suspension (Naprosyn) (PDF) (HIM.PA.130)
- Natalizumab (PDF) (CP.PHAR.259)
- Nebivolol (Bystolic) (PDF) (HIM.PA.131)
- necitumumab (PDF) (CP.PHAR.320)
- Neonatal Abstinence Syndrome Guidelines (PDF) (CP.MP.85)
- neratinib (PDF) (CP.PHAR.365)
- Nerve Blocks for Pain Management (PDF) (CP.MP.170)
- netupitant;palonosetron (Akynzeo) (PDF) (HIM.PA.113)
- NICU Apnea Bradycardia Guidelines (PDF) (CP.MP.82)
- Nintedanib (PDF) (CP.PHAR.285)
- Nivolumab (PDF) (CP.PHAR.121)
- Non-Formulary and Formulary Contraceptives (PDF) (HIM.PA.100)
- Non-Formulary Test Strips (PDF) (HIM.PA.34)
- OB Home Health Programs (PDF) (CP.MP.91)
- OB UltraSound Guidelines (PDF) (WA.UM.20)
- Obeticholic (PDF) (CP.PHAR.287)
- obinutuzumab (PDF) (CP.PHAR.305)
- Ocrelizumab (PDF) (CP.PHAR.335)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot) (PDF) (CP.PHAR.40)
- ofatumumab (PDF) (CP.PHAR.306)
- olanzapine la inj (PDF) (CP.PHAR.292)
- Olaparib (PDF) (CP.PHAR.360)
- olaratumab (PDF) (CP.PHAR.326)
- Omalizumab (Xolair) (PDF) (CP.PHAR.01)
- ombitasvir paritaprevir ritonavir (PDF) (CP.PHAR.276)
- Omecetaxine (Synribo) (PDF) (CP.PHAR.108)
- OnabotulinumtoxinA (PDF) (CP.PHAR.232)
- Opioid Analgesics (PDF) (HIM.PA.139)
- Opioid Policy (PDF) (WA.PHAR.23)
- Osimertinib (PDF) (CP.PHAR.294)
- Outpatient Testing for Drugs of Abuse (PDF) (WA.UM.29)
- Overactive Bladder Agents (PDF) (HIM.PA.40)
- Paclitaxel Protein-Bound (PDF) (CP.PHAR.176)
- Palbociclib (Ibrance) (PDF) (CP.PHAR.125)
- paliperidone inj (PDF) (CP.PHAR.291)
- Palivizumab (PDF) (CP.PHAR.16)
- panitumumab (PDF) (CP.PHAR.321)
- Paricalcitol Injection (PDF) (CP.PHAR.270)
- pasireotide (PDF) (CP.PHAR.332)
- Pegaptanib (Macugen) (PDF) (CP.PHAR.185)
- pegaspargase (PDF) (CP.PHAR.353)
- Pegfilgrastim (PDF) (CP.PHAR.296)
- Peginterferon beta-1a (PDF) (CP.PHAR.271)
- Pegloticase (Jakafi) (PDF) (CP.PHAR.98)
- pembrolizumab (PDF) (CP.PHAR.322)
- Pemetrexed (Alimta) (PDF) (CP.PHAR.368)
- Penicillamine (Cuprimine) (PDF) (HIM.PA.142)
- Perampanel (Fycompa) (PDF) (HIM.PA.132)
- Pertuzumab (PDF) (CP.PHAR.227)
- Phendimetrazine IR (Bontril PDM) (PDF) (HIM.PA.114)
- Pirfenidone (PDF) (CP.PHAR.286)
- Pituitary Suppressive Agents (PDF) (WA.PHAR.53)
- Plerixafor (PDF) (CP.PHAR.323)
- Pomalidomide (Pomalyst) (PDF) (CP.PHAR.116)
- Pomalyst (PDF) (CP.PHAR.116)
- Ponatinib (Iclusig) (PDF) (CP.PHAR.112)
- Potassium (Klor-Con) (PDF) (HIM.PA.143)
- pralatrexate (PDF) (CP.PHAR.313)
- Progesterone Hydroxyprogesterone Caproate (Makena) (PDF) (WA.PHAR.54)
- Protein C Concentrate, Human (Ceprotin) (PDF) (CP.PHAR.330)
- Protocols for Authorizing Noninvasive Positive Pressure Ventilation (NIPPV) (PDF) (WA.UM.24)
- Pulmonary Arterial Hypertension (PAH) Agents (Oral and Inhalation) (PDF) (WA.PHAR.55)
- Pyrimethamine (Daraprim) (PDF) (HIM.PA.133)
- Quinine Sulfate (Qualaquin) (PDF) (HIM.PA.144)
- Ramucirumab (Cyramza) (PDF) (CP.PHAR.119)
- Ranibizumab (Lucentis) (PDF) (CP.PHAR.186)
- rasagiline (Azilect®) (PDF) (HIM.PA.89)
- Reduction Mammaplasty (PDF) (CP.MP.51)
- Regorafenib (PDF) (CP.PHAR.107)
- Revlimid (PDF) (CP.PHAR.71)
- Reslizumab (PDF) (CP.PHAR.223)
- Ribociclib (PDF) (CP.PHAR.334)
- rifaximin (Xifaxan®) (PDF) (HIM.PA.68)
- Rilonacept (PDF) (CP.PHAR.266)
- RimabotulinumtoxinB (PDF) (CP.PHAR.233)
- Riociguat (Adempas) (PDF) (CP.PHAR.195)
- Risperidone LA Inj (PDF) (CP.PHAR.293)
- Risperidone ODT, Risperidone solution (Risperdal) (PDF) (HIM.PA.81)
- romidepsin (PDF) (CP.PHAR.314)
- Romiplostim (Nplate) (PDF) (CP.PHAR.179)
- Rubraca (PDF) (CP.PHAR.350)
- Rufinamide (Banzel) (PDF) (HIM.PA.90)
- Sacroiliac Joint Interventions for Pain Management (PDF) (CP.MP.166)
- Sapropterin (PDF) (CP.PHAR.43)
- Sargramostim (PDF) (CP.PHAR.295)
- Sarilumab (PDF) (CP.PHAR.346)
- Sebelipase Alfa (PDF) (CP.PHAR.159)
- Secnidazole (PDF) (CP.PMN.103)
- Secukinumab (PDF) (CP.PHAR.261)
- Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF) (CP.MP.165)
- Selexipag (Uptravi) (PDF) (CP.PHAR.196)
- Sensipar (PDF) (CP.PHAR.61)
- Sildenafil (Revatio) (PDF) (CP.PHAR.197)
- Siltuximab (Sylvant) (PDF) (CP.PHAR.329)
- Sipuleucel-T (Provenge) (PDF) (CP.PHAR.120)
- Sodium-Glucose Co-Transporter 2 Inhibitors (PDF) (HIM.PA.91)
- sodium oxabate (Zyrem®) (PDF) (HIM.PA.69)
- Sodium phenylbutyrate (Buphenyl) (PDF) (CP.PHAR.208)
- Sofosbuvir (Sovaldi) (PDF) (HIM.PA.SP2)
- Sofosbuvir-Velpatasvir (Epclusa) (PDF) (HIM.PA.SP1)
- Soliris (eculizumab) (PDF) (CP.PHAR.97)
- Somatropin (Human Growth Hormone) (PDF) (CP.PHAR.55)
- Sonidegib (PDF) (CP.PHAR.272)
- Sorafenib (Nexavar) (PDF) (CP.PHAR.69)
- Spinraza (PDF) (CP.PHAR.327)
- Spinosad (Natroba) (PDF) (HIM.PA.134)
- Step Therapy (PDF) (HIM.PA.109)
- Stereotactic Body Radiation Therapy (PDF) (CP.MP.22)
- sucroferric oxyhydoxide (Velphoro) (PDF) (HIM.PA.SP30)
- Sulfacetamide Sodium Sulfur (Sumadan) (PDF) (HIM.PA.145)
- Sunitinib (Sutent) (PDF) (CP.PHAR.73)
- Sylatron (peginterferon alfa-2b) (PDF) (CP.PHAR.89)
- Synagis_palivizumab (PDF) (CP.PHAR.16)
- Tadalafil (Adcirca) (PDF) (CP.PHAR.198)
- tapentadol (Nucynta®) (PDF) (HIM.PA.86)
- Taliglucerase Alfa (PDF) (CP.PHAR.157)
- tavaborole (Kerydin®) (PDF) (HIM.PA.117)
- Telbivudine (Tyzeka) (PDF) (HIM.PA.95)
- Telotristat ethyl (PDF) (CP.PHAR.337)
- Temasmorelin (PDF) (CP.PHAR.109)
- Temodar (PDF) (CP.PHAR.77)
- Temozolomide (Temodar) (PDF) (CP.PHAR.77)
- temsirolimus (PDF) (CP.PHAR.324)
- Teriflunomide (PDF) (CP.PHAR.262)
- Teriparatide (Forteo) (PDF) (CP.PHAR.188)
- testosterone pellet (PDF) (CP.PHAR.354)
- Tetrabenazine (PDF) (CP.PHAR.92)
- Tezacaftor-Ivacaftor (PDF) (CP.PHAR.377)
- Thalidomide (Thalomid) (PDF) (CP.PHAR.78)
- Thyrotropin alfa (PDF) (CP.PHAR.95)
- Timothy Grass Pollen Allergen Extract (Grastek) (PDF) (HIM.PA.137)
- Tisagenlecleucel (PDF) (CP.PHAR.361)
- Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (PDF) (CP.PHAR.211)
- Tocilizumab (PDF) (CP.PHAR.263)
- Tofacitinib (PDF) (CP.PHAR.267)
- Topical Acne Treatment (PDF) (HIM.PA.71)
- Topical Immunomodulators (PDF) (HIM.PA.56)
- topical testosterone (PDF) (HIM.PA.87)
- Topotecan (Hycamtin) (PDF) (CP.PHAR.64)
- Trabectedin (Yondelis) (PDF) (CP.PHAR.204)
- Trametinib (PDF) (CP.PHAR.240)
- Trastuzumab, Trastuzumab-dkst (PDF) (CP.PHAR.228)
- Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF) (CP.PHAR.199)
- Triamcinolone ER Injection (PDF) (CP.PHAR.371)
- Trigger Point Injections for Pain Management (PDF) (CP.MP.169)
- Triptorelin Pamoate (Trelstar, Triptodur) (PDF) (CP.PHAR.175)
- Ultrasound in Pregnancy (PDF) (CP.MP.38)
- Uridine acetate (Vistogard) (PDF) (HIM.PA.SP55)
- Urodynamic Testing (PDF) (CP.MP.98)
- Ustekinumab (PDF) (CP.PHAR.264)
- Valbenazine (PDF) (CP.PHAR.340)
- Vandetanib (Caprelsa) (PDF) (CP.PHAR.80)
- Varenicline-Chantix and Bupropion Zyban (PDF) (WA.PHAR.16)
- Vedolizumab (PDF) (CP.PHAR.265)
- Velaglucerase Alfa (PDF) (CP.PHAR.163)
- Verteporfin (Visudyne) (PDF) (CP.PHAR.187)
- Vestronidase alfa-vjbk (PDF) (CP.PHAR.374)
- Video Electroencephalography (V-EEG) (PDF) (WA.UM.23)
- Vigabatrin (PDF) (CP.PHAR.169)
- viladazone (Viibryd®) (PDF) (HIM.PA.135)
- vincristine sulfate liposome injection (PDF) (CP.PHAR.315)
- Viscosupplementation of the Knee for Osteoarthritis (PDF) (WA.UM.26)
- Vismodegib (PDF) (CP.PHAR.273)
- Vorapaxar (Zontivity) (PDF) (HIM.PA.146)
- Voretigene neparvovec-rzyl (PDF) (CP.PHAR.372)
- Vorinostat (PDF) (CP.PHAR.83)
- vortioxetine (Trintellex®) (PDF) (HIM.PA.136)
- Wheelchair Seating (PDF) (CP.MP.99)
- Xenazine (tetrabenazine) (PDF) (CP.PHAR.92)
- Xgeva (PDF) (CP.PHAR.58)
- Xiaflex™ (PDF) (CP.PHAR.82)
- Xolair® (PDF) (CP.PHAR.01)
- ziv-aflibercept (PDF) (CP.PHAR.325)
- Zoledronic Acid (Reclast, Zometa) (PDF) (CP.PHAR.59)
Allwell Specialty Pharmacy Policies Listing
- Abaloparatide (PDF) (CP.PHAR.345)
- Abatacept (PDF) (CP.PHAR.241)
- Abemaciclib (PDF) (CP.PHAR.355)
- Abiraterone (Zytiga) (PDF) (CP.PHAR.84)
- AbobotulinumtoxinA (PDF) (CP.PHAR.230)
- Abiraterone (Zytiga) (PDF) (CP.PHAR.84)
- AbobotulinumtoxinA (PDF) (CP.PHAR.230)
- Acalabrutinib (PDF) (CP.PHAR.366)
- ACEI and ARB Duplicate Therapy (PDF) (CP.PMN.61)
- Acitretin (Soriatane) (PDF) (CP.PMN.40)
- Adalimumab (PDF) (CP.PHAR.242)
- Ado-Trastuzumab Emtansine (PDF) (CP.PHAR.229)
- Administrative Day Policy (PDF) (WA.UM.03.01)
- Agents For Gauchers Disease (PDF) (WA.PHAR.26)
- Afatinib (PDF) (CP.PHAR.298)
- Alectinib (PDF) (CP.PHAR.369)
- Aflibercept (Eylea) (PDF) (CP.PHAR.184)
- Agalsidase Beta (PDF) (CP.PHAR.158)
- Age Limit Override (PDF) (CP.PMN.138)
- Alemtuzumab (PDF) (CP.PHAR.243)
- Alendronate (PDF) (CP.PMN.88)
- Alglucosidase Alfa (PDF) (CP.PHAR.160)
- Alirocumab (PDF) (CP.PHAR.124)
- Allergenic Extracts (Oral) (PDF) (WA.PHAR.27)
- Alpha-1 Proteinase Inhibitors (PDF) (CP.PHAR.94)
- Amantadine ER (PDF) (CP.PMN.89)
- Ambrisentan (Letairis) (PDF) (CP.PHAR.190)
- Anakinra (PDF) (SP.PHAR.244)
- Androgenic Agents-Testosterone Replacement Therapy (TRT) (PDF) (WA.PHAR.28)
- Anti-Allergy Ophthalmics (PDF) (CP.PST.03)
- Antiasthmatic Monoclonal Antibodies Anti IgE Antibodies (PDF) (WA.PHAR.29)
- Antiasthmatic Monoclonal Antibodies IL-5 Antagonists (PDF) (WA.PHAR.30)
- Antibiotics Inhaled-Aztreonam (CAYSTON) (PDF) (WA.PHAR.31)
- Anticonvulsants-Midazolam (Intranasal) (PDF) (WA.PHAR.32)
- Anticonvulsants-Pregabalin (Lyrica) (PDF) (WA.PHAR.56)
- Antidiabetics-Amylin Analogs (PDF) (WA.PHAR.33)
- Antidiabetics-Inhaled Insulin (Afrezza) (PDF) (WA.PHAR.34)
- Antihyperlipidemics-APOB Synthesis Inhibitors (Kynamro) (PDF) (WA.PHAR.37)
- Antihyperlipidemics-APOB Synthesis Inhibitors (Juxtapid) (PDF) (WA.PHAR.38)
- Antihyperlipidemics-PCSK9 Inhibitors (PDF) (WA.PHAR.39)
- Antihyperuricemic Agents (PDF) (WA.PHAR.40)
- Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) (CP.PHAR.217)
- Antifungal Topical Solutions (PDF) (WA.PHAR.36)
- Antimemetic-Antivertigo Agents (Dronabinol) (PDF) (WA.PHAR.35)
- Apalutamide (PDF) (CP.PHAR.376)
- Apremilast (PDF) (CP.PHAR.245)
- Aprepitant (Emend) (PDF) (SP.PMN.19)
- aripiprazole long-acting injections (PDF) (CP.PHAR.290)
- Armodafinil (PDF) (CP.PMN.35)
- Asenapine (PDF) (CP.PMN.15)
- asfotase alfa (PDF) (CP.PHAR.328)
- Aspirin-dipyridamole (PDF) (CP.PMN.20)
- Atezolizumab (Tecentriq) (PDF) (CP.PHAR.235)
- Atomoxetine (Strattera) (PDF) (CP.PST.17)
- Atopic Dermatitis Agents-Monoclonal Antibodies (PDF) (WA.PHAR.41)
- Atopic Dermatitis Agents-Topical Immunosuppressives (PDF) (WA.PHAR.42)
- Atopic Dermatitis Agents-Topical Phosphodiesterase-4 (PDE4) Inhibitors (PDF) (WA.PHAR.43)
- Atypical antipsychotics (PDF) (HIM.PA.59)
- Avelumab (Bavencio) (PDF) (SP.PHAR.333)
- Avoidable Readmissions (PDF) (WA.UM.17)
- Axicabtagene ciloleucel (PDF) (CP.PHAR.362)
- Axitinib (Inlyta) (PDF) (CP.PHAR.100)
- Azelaic Acid (Finacea) (PDF) (HIM.PA.119)
- Aztreonam (Cayston) (PDF) (CP.PHAR.209)
- Bariatric Surgery (PDF) (WA.UM.30)
- Becaplermin (Regranex) (PDF) (CP.PMN.21)
- Belatacept (Nulojix) (PDF) (CP.PHAR.201)
- Belimumab (PDF) (CP.PHAR.88)
- belinostat (PDF) (CP.PHAR.311)
- bendamustine (PDF) (CP.PHAR.307)
- Benign Prostatic Hyperplasia (BPH) Agents-PDE5 Inhibitors (PDF) (WA.PHAR.44)
- Benralizumab (PDF) (CP.PHAR.373)
- Benznidazole (PDF) (CP.PMN.90)
- Betrixaban (Bevyxxa) (PDF) (CP.PMN.114)
- Bevacizumab (Avastin) (PDF) (CP.PHAR.93)
- Bevacizumab-awwb (Mvasi) (PDF) (CP.PHAR.356)
- Bexarotene (Targretin) (PDF) (CP.PHAR.75)
- Bezlotoxumab (PDF) (CP.PHAR.300)
- Bilateral Cochlear Implants (PDF) (WA.UM.28)
- Blinatumomab (PDF) (CP.PHAR.312)
- Bone Density Regulators (PDF) (WA.PHAR.45)
- Bosentan (Tracleer) (PDF) (CP.PHAR.191)
- Bosutinib (PDF) (CP.PHAR.105)
- Brand Name Override (PDF) (CP.PMN.22)
- Brexpiprazole (PDF) (CP.PMN.68)
- Brentuximab (PDF) (CP.PHAR.303)
- Brigatinib (PDF) (CP.PHAR.342)
- Brimonidine Tartrate, Oxymetazoline (PDF) (CP.PMN.86)
- Brodalumab (PDF) (CP.PHAR.375)
- Buprenorphine (PDF) (CP.PMN.82)
- Buprenorphine Implant-Injection (PDF) (CP.PHAR.289)
- Buprenorphine-Naloxone (Bunavail, Suboxone, Zubsolv) (PDF) (CP.PMN.81)
- Bupropion-Naltrexone (PDF) (CP.PMN.133)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda) (PDF) (CP.PHAR.202)
- cabazitaxel (PDF) (CP.PHAR.316)
- Calcifediol (Rayaldee) (PDF) (CP.PMN.76)
- Canakinumab (PDF) (CP.PHAR.246)
- Capecitabine (Xeloda) (PDF) (CP.PHAR.60)
- Carbamazepine ER (PDF) (CP.PMN.137)
- Cardiovascular Agents-Sinus Node Inhibitors (PDF) (WA.PHAR.46)
- carfilzomib (PDF) (CP.PHAR.309)
- Carglumic Acid (Carbaglu) (PDF) (CP.PHAR.206)
- Cariprazine (PDF) (CP.PMN.91)
- Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF) (CP.MP.164)
- Celecoxib (PDF) (CP.PMN.122)
- Cell-Free Fetal DNA Testing (PDF) (CP.MP.84)
- Ceritinib (PDF) (CP.PHAR.349)
- Cerliponase Alfa (PDF) (CP.PHAR.338)
- Certolizumab (PDF) (CP.PHAR.247)
- Cetrorelix (Cetrotide) and Ganirelix (PDF) (HIM.PA.148)
- cetuximab (PDF) (CP.PHAR.317)
- Chronic GI Motility Agents (PDF) (WA.PHAR.47)
- Ciclopirox (Penlac) (PDF) (CP.PMN.24)
- Cinacalcet (PDF) (CP.PHAR.61)
- Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) (HIM.PA.120)
- Clobazam (Onfi) (PDF) (CP.PMN.54)
- clomipramine (Anafranil) (PDF) (HIM.PA.149)
- Clozapine orally disintegrating tablet (Fazaclo) (PDF) (CP.PMN.12)
- Colchicine (PDF) (CP.PMN.123)
- Collagenase (PDF) (CP.PHAR.82)
- Colesevelam (Welchol) (PDF) (HIM.PA.121)
- Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) (HIM.PA.140)
- copanlisib (PDF) (CP.PHAR.357)
- Corticotropin (H.P. Acthar Gel) (PDF) (CP.PHAR.168)
- Cosmetic Reconstructive Surgery (PDF) (CP.MP.31)
- Cosyntropin (Cortrosyn) (PDF) (CP.PHAR.203)
- Crisaborole (PDF) (CP.PMN.110)
- Crizotinib (PDF) (CP.PHAR.90)
- Cyclosporine ophthalmic emulsion (PDF) (CP.PMN.48)
- Cysteamine (Cystagon-Procysbi) Policy (PDF) (WA.PHAR.21)
- Cysteamine Ophthalmic (PDF) (CP.PMN.130)
- Cysteamine Oral (PDF) (CP.PHAR.155)
- Cystic Fibrosis Agents (Oral) (PDF) (WA.PHAR.48)
- Cystic Fibrosis Carrier Screening (PDF) (CP.MP.83)
- Cytokine and CAM Antagonists (PDF) (WA.PHAR.49)
- Dabigatran (PDF) (CP.PMN.49)
- Dabrafenib (PDF) (CP.PHAR.239)
- Daclatasvir (Daklinza) (PDF) (HIM.PA.SP27)
- Daclizumab (PDF) (CP.PHAR.269)
- Dalfampridine (PDF) (CP.PHAR.248)
- Dalteparin (PDF) (CP.PHAR.225)
- daptomycin (PDF) (CP.PHAR.351)
- Daratumumab (PDF) (CP.PHAR.310)
- Darbepoetin Alfa (PDF) (CP.PHAR.236)
- Dasatinib (Sprycel) (PDF) (CP.PHAR.72)
- daunorubicin cytarabine (PDF) (CP.PHAR.352)
- deferasirox (PDF) (CP.PHAR.145)
- deferiprone (PDF) (CP.PHAR.147)
- deferoxamine (PDF) (CP.PHAR.146)
- Deflazacort (PDF) (CP.PHAR.331)
- Degarelix Acetate (Firmagon) (PDF) (CP.PHAR.170)
- Delafloxacin (Baxdela) (PDF) (CP.PMN.115)
- Denosumab (PDF) (CP.PHAR.58)
- Desmopressin (DDAVP, Stimate) (PDF) (CP.PHAR.214)
- Dextromethorphan-Quinidine (PDF) (CP.PMN.93)
- Deutetrabenazine (PDF) (CP.PHAR.341)
- Dexmethylphenidate ER (Focalin) (PDF) (CP.PMN.63)
- Dichlorphenamide (Keveyis) (PDF) (HIM.PA.SP44)
- diclofenac sodium topical gel (Solaraze, Voltaren®) (PDF) (HIM.PA.123)
- Digital EEG Spike Analysis (PDF) (CP.MP.105)
- Dimethyl fumarate (PDF) (CP.PHAR.249)
- Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF) (CP.PST.18)
- dolastron (Anzemet®) (PDF) (HIM.PA.85)
- Dornase alfa (Pulmozyme) (PDF) (CP.PHAR.212)
- Dose optimization (PDF) (CP.PMN.13)
- Doxepin Hydrochloride Cream (Prudoxin, Zonalon) (PDF) (HIM.PA.147)
- Doxycycline Hyclate (PDF) (CP.PMN.79)
- Droxidopa (Northera) (PDF) (CP.PMN.17)
- Dupilumab (PDF) (CP.PHAR.336)
- Duplicate SSRI SNRI Therapy (PDF) (CP.PMN.60)
- Durvalumab (PDF) (CP.PHAR.339)
- Dutasteride (PDF) (CP.PMN.128)
- Ecallantide (Kalbitor) (PDF) (CP.PHAR.177)
- Eculizumab (Soliris) (PDF) (CP.PHAR.97)
- Edaravone (PDF) (CP.PHAR.343)
- Efinaconazole (PDF) (CP.PMN.25)
- Elective Deliveries Before 39 Weeks Gestational Age (PDF) (WA.UM.17.01)
- Eliglustat (PDF) (CP.PHAR.153)
- Elosulfase Alfa (PDF) (CP.PHAR.162)
- Eltrombopag (Promacta) (PDF) (CP.PHAR.180)
- elotuzumab (PDF) (CP.PHAR.308)
- Emicizumab-kxwh (PDF) (CP.PHAR.370)
- Emtricitabine/Tenofovir (Truvada®) (PDF) (HIM.PA.78)
- enasidenib (PDF) (CP.PHAR.363)
- Enfuvirtide (PDF) (CP.PHAR.41)
- Enoxaparin (PDF) (CP.PHAR.224)
- Enzalutamide (PDF) (CP.PHAR.106)
- Epinephrine (Epipen, Epipen Jr) (PDF) (CP.PPA.09)
- Epoetin Alfa (PDF) (CP.PHAR.237)
- Epoprostenol (Flolan, Veletri) (PDF) (CP.PHAR.192)
- eribulin Mesylate (PDF) (CP.PHAR.318)
- Erlotinib (Tarceva) (PDF) (CP.PHAR.74)
- Erwinia Asparaginase (Erwinaze) (PDF) (CP.PHAR.301)
- Etanercept (PDF) (CP.PHAR.250)
- Eteplirsen (PDF) (CP.PHAR.288)
- Etidronate (Didronel) (PDF) (CP.PMN.94)
- Everolimus (PDF) (CP.PHAR.63)
- Evolocumab (PDF) (CP.PHAR.123)
- Exemestane Step Therapy (PDF) (CP.PST.05)
- Experimental Policy (PDF) (CP.MP.36)
- Ezetimibe (Zetia) (PDF) (CP.PMN.78)
- Ezetimibe-Simvastatin (PDF) (CP.PMN.77)
- ezogabine (Potiga®) (PDF) (HIM.PA.60)
- Facet Joint Interventions for Pain Management (PDF) (CP.MP.171)
- Factor VIII (Human Recombinant) (PDF) (CP.PHAR.215)
- Factor VIII von Willebrand Factor Complex (PDF) (CP.PHAR.216)
- Factor IX (Human, Recombinant) (PDF) (CP.PHAR.218)
- Factor VIIa, Recombinant (NovoSeven RT) (PDF) (CP.PHAR.220)
- Factor XIII, Human (Corifact) (PDF) (CP.PHAR.221)
- Factor XIII A-Subunit, Recombinant (Tretten) (PDF) (CP.PHAR.222)
- Factor IX Complex, Human (Bebulin, Profilnine) (PDF) (CP.PHAR.219)
- Famciclovir (Famvir) (PDF) (CP.PMN.26)
- Febuxostat (Uloric) (PDF) (CP.PMN.57)
- Fentanyl IR (PDF) (CP.PMN.127)
- Ferric Carboxymaltose (Injectafer) (PDF) (CP.PHAR.234)
- Ferric Gluconate (Ferrlecit) (PDF) (CP.PHAR.166)
- Ferumoxytol (Feraheme) (PDF) (CP.PHAR.165)
- Filgrastim (PDF) (CP.PHAR.297)
- Fingolimod (PDF) (CP.PHAR.251)
- Fluticasone propionate (PDF) (CP.PMN.95)
- Fluticasone Salmeterol (Advair Diskus, Advair HFA) (PDF) (CP.PMN.31)
- Fondaparinux (PDF) (CP.PHAR.226)
- Formulary Medications Without Specific Guidelines (PDF) (HIM.PA.33)
- Galsulfase (PDF) (CP.PHAR.161)
- Gastric Electrical Stimulation (PDF) (CP.MP.40)
- Gattex (PDF) (CP.PHAR.114)
- Gefitinib (PDF) (CP.PHAR.68)
- gefitinib (PDF) (CP.PHAR.299)
- gemtuzumab ozogamicin (PDF) (CP.PHAR.358)
- Genetic Testing (PDF) (CP.MP.89)
- Glatiramer Acetate (PDF) (CP.PHAR.252)
- Glecaprevir-Pibrentasvir (PDF) (HIM.PA.SP36)
- Glucagon-Like Peptide-1 Receptor Agonists (PDF) (HIM.PA.53)
- Global Biopharm Policy (PDF) (CP.PHAR.57)
- Glucagon-Like Peptide-1 Receptor Agonists (PDF) (CP.PST.14)
- Glycerol phenylbutyrate (Ravicti) (PDF) (CP.PHAR.207)
- Golimumab (PDF) (CP.PHAR.253)
- Goserelin Acetate (Zoladex) (PDF) (CP.PHAR.171)
- Granisetron (Sancuso) (PDF) (CP.PMN.74)
- Growth Hormone Agents (PDF) (WA.PHAR.50)
- Guanfacine ER (Intuniv) (PDF) (CP.PMN.37)
- Guselkumab (PDF) (CP.PHAR.364)
- Hemin (Panhematin) (PDF) (CP.PHAR.181)
- Histrelin Acetate (Vantas, Supprelin LA) (PDF) (CP.PHAR.172)
- Home Health Authorizations (PDF) (WA.UM.18)
- Hormone Therapy Gender Disphoria (PDF) (WA.PHAR.25)
- Hospice Coverage (PDF) (WA.UM.21)
- Hyaluronate Derivatives (PDF) (CP.PHAR.05)
- Hydroxyprogesterone Caproate (Makena) (PDF) (CP.PHAR.14)
- Hyperbaric Oxygen Therapy (PDF) (CP.MP.27)
- Hyperemesis Gravidarum Treatment (PDF) (CP.MP.34)
- Ibalizumab-uiyk (PDF) (CP.PHAR.378)
- Ibandronate sodium (Boniva) (PDF) (CP.PHAR.189)
- Ibrance (palbociclib) (PDF) (CP.PHAR.125)
- Ibrutinib (Imbruvica) (PDF) (HIM.PA.SP48)
- Icatibant (Firazyr) (PDF) (CP.PHAR.178)
- Idelalisib (Zydelig) (PDF) (HIM.PA.SP49)
- Idursulfase (PDF) (CP.PHAR.156)
- Iloprost (Ventavis) (PDF) (CP.PHAR.193)
- Imatinib (Gleevec) (PDF) (CP.PHAR.65)
- Imiglucerase (PDF) (CP.PHAR.154)
- Immune Globulin Infusion with Recombinant Human Hyaluronidase (Hyqvia®) (PDF) (HIM.PA.SP47)
- Immune Globulins (PDF) (CP.PHAR.103)
- Immunization coverage (PDF) (CP.PHAR.28)
- IncobotulinumtoxinA (PDF) (CP.PHAR.231)
- Infliximab (PDF) (CP.PHAR.254)
- Inhaled Corticosteroids (PDF) (HIM.PA.73)
- Inhaled Nitric Oxide (PDF) (CP.MP.87)
- inotuzumab ozogamicin (PDF) (CP.PHAR.359)
- Intensity-Modulated Radiotherapy (PDF) (CP.MP.69)
- Interferon Beta-1a (PDF) (CP.PHAR.255)
- Interferon Beta-1b (PDF) (CP.PHAR.256)
- Interferon Gamma- 1b (Actimmune) (PDF) (CP.PHAR.52)
- Interventional Pain Management (PDF) (WA.UM.32)
- Intestinal & Multivisceral Transplant (PDF) (CP.MP.58)
- Intrathecal Baclofen (Gablofen, Lioresal) (PDF) (CP.PHAR.149)
- Intradiscal Steroid Injections for Pain Management (PDF) (CP.MP.167)
- Ipilimumab (PDF) (CP.PHAR.319)
- irinotecan Liposome (PDF) (CP.PHAR.304)
- Iron sucrose (Venofer) (Acthar Gel) (PDF) (CP.PHAR.167)
- isavuconazonium (Cresemba®) (PDF) (HIM.PA.108)
- isotretinoin (Claravis®, Sotret®, Amnesteem®, Myorisan®) (PDF) (HIM.PA.50)
- Ivacaftor (Kalydeco) (PDF) (CP.PHAR.210)
- ivermectin (Sklice®) (PDF) (HIM.PA.124)
- Ixazomib (PDF) (CP.PHAR.302)
- Ixekizumab (PDF) (CP.PHAR.257)
- Jakafi™ (ruxolitinib) (PDF) (CP.PHAR.98)
- Korlym (mifepristone) (PDF) (CP.PHAR.101)
- Krystexxa (PDF) (CP.PHAR.115)
- Kuvan (PDF) (CP.PHAR.43)
- lacosamide (Vimpat®) (PDF) (HIM.PA.49)
- Laronidase (PDF) (CP.PHAR.152)
- ledipasvir sofosbuvir (Harvoni) (PDF) (HIM.PA.SP3)
- Lenalidomide (Revlimid) (PDF) (CP.PHAR.71)
- Lenvatinib (Lenvima) (PDF) (HIM.PA.SP50)
- Letermovir (PDF) (CP.PHAR.367)
- Leucovorin (PDF) (HIM.PA.138)
- Leuprolide Acetate (Eligard, Lupaneta Pack, Lupron Depot, Lupron Depot Ped) (PDF) (CP.PHAR.173)
- Levoleucovorin (Fusilev) (PDF) (CP.PHAR.151)
- Levomilnacipran (Fetzima) (PDF) (HIM.PA.125)
- lidocaine transdermal (Lidoderm®) (PDF) (HIM.PA.126)
- Lomitapide (PDF) (CP.PHAR.283)
- long acting beta agonists and combination products (PDF) (HIM.PA.74)
- Long Acting Injectable Atypical Antipsychotics (PDF) (HIM.PA.99)
- Lovastatin ER (Altoprev) (PDF) (HIM.PA.127)
- lubiprostone (Amitiza®) (PDF) (HIM.PA.79)
- Lumacaftor - Ivacaftor (Orkambi) (PDF) (CP.PHAR.213)
- Lung Transplantation (PDF) (CP.MP.57)
- Macitentan (Opsumit) (PDF) (CP.PHAR.194)
- Mecasermin (PDF) (CP.PHAR.150)
- Medication Assisted Treatment (MAT) (PDF) (WA.PHAR.15)
- Megestrol acetate oral suspension (Megace ES) (PDF) (HIM.PA.128)
- Mepolizumab (PDF) (CP.PHAR.200)
- Methadone (Dolophine) (PDF) (WA.PHAR.20)
- Methoxy polyethylene glycol-epoetin beta (PDF) (CP.PHAR.238)
- Microprocessor Controlled Lower Limb Prosthetics (PDF) (WA.UM.27)
- Midostaurin (PDF) (CP.PHAR.344)
- Mifepristone (Korlym) (PDF) (CP.PHAR.101)
- Miglustat (PDF) (CP.PHAR.164)
- Mipomersen (PDF) (CP.PHAR.284)
- Mitoxantrone (PDF) (CP.PHAR.258)
- Mometasone (Nasonex) (PDF) (HIM.PA.93)
- Montelukast oral granules (Singulair) (PDF) (HIM.PA.129)
- Movement Disorder Agents (PDF) (WA.PHAR.51)
- Multiple Sclerosis Agents-Dalfampridine (Ampyra) (PDF) (WA.PHAR.52)
- Nafarelin Acetate (Synarel) (PDF) (CP.PHAR.174)
- Naltrexone (Vivitrol) (PDF) (CP.PHAR.96)
- Naproxen oral suspension (Naprosyn) (PDF) (HIM.PA.130)
- Natalizumab (PDF) (CP.PHAR.259)
- Nebivolol (Bystolic) (PDF) (HIM.PA.131)
- necitumumab (PDF) (CP.PHAR.320)
- Neonatal Abstinence Syndrome Guidelines (PDF) (CP.MP.85)
- neratinib (PDF) (CP.PHAR.365)
- Nerve Blocks for Pain Management (PDF) (CP.MP.170)
- netupitant;palonosetron (Akynzeo) (PDF) (HIM.PA.113)
- NICU Apnea Bradycardia Guidelines (PDF) (CP.MP.82)
- Nintedanib (PDF) (CP.PHAR.285)
- Nivolumab (PDF) (CP.PHAR.121)
- Non-Formulary and Formulary Contraceptives (PDF) (HIM.PA.100)
- Non-Formulary Test Strips (PDF) (HIM.PA.34)
- OB Home Health Programs (PDF) (CP.MP.91)
- OB UltraSound Guidelines (PDF) (WA.UM.20)
- Obeticholic (PDF) (CP.PHAR.287)
- obinutuzumab (PDF) (CP.PHAR.305)
- Ocrelizumab (PDF) (CP.PHAR.335)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot) (PDF) (CP.PHAR.40)
- ofatumumab (PDF) (CP.PHAR.306)
- olanzapine la inj (PDF) (CP.PHAR.292)
- Olaparib (PDF) (CP.PHAR.360)
- olaratumab (PDF) (CP.PHAR.326)
- Omalizumab (Xolair) (PDF) (CP.PHAR.01)
- ombitasvir paritaprevir ritonavir (PDF) (CP.PHAR.276)
- Omecetaxine (Synribo) (PDF) (CP.PHAR.108)
- OnabotulinumtoxinA (PDF) (CP.PHAR.232)
- Opioid Analgesics (PDF) (HIM.PA.139)
- Opioid Policy (PDF) (WA.PHAR.23)
- Osimertinib (PDF) (CP.PHAR.294)
- Outpatient Testing for Drugs of Abuse (PDF) (WA.UM.29)
- Overactive Bladder Agents (PDF) (HIM.PA.40)
- Paclitaxel Protein-Bound (PDF) (CP.PHAR.176)
- Palbociclib (Ibrance) (PDF) (CP.PHAR.125)
- paliperidone inj (PDF) (CP.PHAR.291)
- Palivizumab (PDF) (CP.PHAR.16)
- panitumumab (PDF) (CP.PHAR.321)
- Paricalcitol Injection (PDF) (CP.PHAR.270)
- pasireotide (PDF) (CP.PHAR.332)
- Pegaptanib (Macugen) (PDF) (CP.PHAR.185)
- pegaspargase (PDF) (CP.PHAR.353)
- Pegfilgrastim (PDF) (CP.PHAR.296)
- Peginterferon beta-1a (PDF) (CP.PHAR.271)
- Pegloticase (Jakafi) (PDF) (CP.PHAR.98)
- pembrolizumab (PDF) (CP.PHAR.322)
- Pemetrexed (Alimta) (PDF) (CP.PHAR.368)
- Penicillamine (Cuprimine) (PDF) (HIM.PA.142)
- Perampanel (Fycompa) (PDF) (HIM.PA.132)
- Pertuzumab (PDF) (CP.PHAR.227)
- Phendimetrazine IR (Bontril PDM) (PDF) (HIM.PA.114)
- Pirfenidone (PDF) (CP.PHAR.286)
- Pituitary Suppressive Agents (PDF) (WA.PHAR.53)
- Plerixafor (PDF) (CP.PHAR.323)
- Pomalidomide (Pomalyst) (PDF) (CP.PHAR.116)
- Pomalyst (PDF) (CP.PHAR.116)
- Ponatinib (Iclusig) (PDF) (CP.PHAR.112)
- Potassium (Klor-Con) (PDF) (HIM.PA.143)
- pralatrexate (PDF) (CP.PHAR.313)
- Progesterone Hydroxyprogesterone Caproate (Makena) (PDF) (WA.PHAR.54)
- Protein C Concentrate, Human (Ceprotin) (PDF) (CP.PHAR.330)
- Protocols for Authorizing Noninvasive Positive Pressure Ventilation (NIPPV) (PDF) (WA.UM.24)
- Pulmonary Arterial Hypertension (PAH) Agents (Oral and Inhalation) (PDF) (WA.PHAR.55)
- Pyrimethamine (Daraprim) (PDF) (HIM.PA.133)
- Quinine Sulfate (Qualaquin) (PDF) (HIM.PA.144)
- Ramucirumab (Cyramza) (PDF) (CP.PHAR.119)
- Ranibizumab (Lucentis) (PDF) (CP.PHAR.186)
- rasagiline (Azilect®) (PDF) (HIM.PA.89)
- Reduction Mammaplasty (PDF) (CP.MP.51)
- Regorafenib (PDF) (CP.PHAR.107)
- Revlimid (PDF) (CP.PHAR.71)
- Reslizumab (PDF) (CP.PHAR.223)
- Ribociclib (PDF) (CP.PHAR.334)
- rifaximin (Xifaxan®) (PDF) (HIM.PA.68)
- Rilonacept (PDF) (CP.PHAR.266)
- RimabotulinumtoxinB (PDF) (CP.PHAR.233)
- Riociguat (Adempas) (PDF) (CP.PHAR.195)
- Risperidone LA Inj (PDF) (CP.PHAR.293)
- Risperidone ODT, Risperidone solution (Risperdal) (PDF) (HIM.PA.81)
- Rituximab, Rituxan and Hyaluronidase (PDF) (CP.PHAR.260)
- romidepsin (PDF) (CP.PHAR.314)
- Romiplostim (Nplate) (PDF) (CP.PHAR.179)
- Rubraca (PDF) (CP.PHAR.350)
- Rufinamide (Banzel) (PDF) (HIM.PA.90)
- Sacroiliac Joint Interventions for Pain Management (PDF) (CP.MP.166)
- Sapropterin (PDF) (CP.PHAR.43)
- Sargramostim (PDF) (CP.PHAR.295)
- Sarilumab (PDF) (CP.PHAR.346)
- Sebelipase Alfa (PDF) (CP.PHAR.159)
- Secnidazole (PDF) (CP.PMN.103)
- Secukinumab (PDF) (CP.PHAR.261)
- Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF) (CP.MP.165)
- Selexipag (Uptravi) (PDF) (CP.PHAR.196)
- Sensipar (PDF) (CP.PHAR.61)
- Sildenafil (Revatio) (PDF) (CP.PHAR.197)
- Siltuximab (Sylvant) (PDF) (CP.PHAR.329)
- Sipuleucel-T (Provenge) (PDF) (CP.PHAR.120)
- Sodium-Glucose Co-Transporter 2 Inhibitors (PDF) (HIM.PA.91)
- sodium oxabate (Zyrem®) (PDF) (HIM.PA.69)
- Sodium phenylbutyrate (Buphenyl) (PDF) (CP.PHAR.208)
- Sofosbuvir (Sovaldi) (PDF) (HIM.PA.SP2)
- Sofosbuvir-Velpatasvir (Epclusa) (PDF) (HIM.PA.SP1)
- Soliris (eculizumab) (PDF) (CP.PHAR.97)
- Somatropin (Human Growth Hormone) (PDF) (CP.PHAR.55)
- Sonidegib (PDF) (CP.PHAR.272)
- Sorafenib (Nexavar) (PDF) (CP.PHAR.69)
- Spinraza (PDF) (CP.PHAR.327)
- Spinosad (Natroba) (PDF) (HIM.PA.134)
- Step Therapy (PDF) (HIM.PA.109)
- Stereotactic Body Radiation Therapy (PDF) (CP.MP.22)
- sucroferric oxyhydoxide (Velphoro) (PDF) (HIM.PA.SP30)
- Sulfacetamide Sodium Sulfur (Sumadan) (PDF) (HIM.PA.145)
- Sunitinib (Sutent) (PDF) (CP.PHAR.73)
- Sylatron (peginterferon alfa-2b) (PDF) (CP.PHAR.89)
- Synagis_palivizumab (PDF) (CP.PHAR.16)
- Tadalafil (Adcirca) (PDF) (CP.PHAR.198)
- tapentadol (Nucynta®) (PDF) (HIM.PA.86)
- Taliglucerase Alfa (PDF) (CP.PHAR.157)
- tavaborole (Kerydin®) (PDF) (HIM.PA.117)
- Telbivudine (Tyzeka) (PDF) (HIM.PA.95)
- Telotristat ethyl (PDF) (CP.PHAR.337)
- Temasmorelin (PDF) (CP.PHAR.109)
- Temodar (PDF) (CP.PHAR.77)
- Temozolomide (Temodar) (PDF) (CP.PHAR.77)
- temsirolimus (PDF) (CP.PHAR.324)
- Teriflunomide (PDF) (CP.PHAR.262)
- Teriparatide (Forteo) (PDF) (CP.PHAR.188)
- testosterone pellet (PDF) (CP.PHAR.354)
- Tetrabenazine (PDF) (CP.PHAR.92)
- Tezacaftor-Ivacaftor (PDF) (CP.PHAR.377)
- Thalidomide (Thalomid) (PDF) (CP.PHAR.78)
- Thyrotropin alfa (PDF) (CP.PHAR.95)
- Timothy Grass Pollen Allergen Extract (Grastek) (PDF) (HIM.PA.137)
- Tisagenlecleucel (PDF) (CP.PHAR.361)
- Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (PDF) (CP.PHAR.211)
- Tocilizumab (PDF) (CP.PHAR.263)
- Tofacitinib (PDF) (CP.PHAR.267)
- Topical Acne Treatment (PDF) (HIM.PA.71)
- Topical Immunomodulators (PDF) (HIM.PA.56)
- topical testosterone (PDF) (HIM.PA.87)
- Topotecan (Hycamtin) (PDF) (CP.PHAR.64)
- Trabectedin (Yondelis) (PDF) (CP.PHAR.204)
- Trametinib (PDF) (CP.PHAR.240)
- Trastuzumab, Trastuzumab-dkst (PDF) (CP.PHAR.228)
- Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF) (CP.PHAR.199)
- Triamcinolone ER Injection (PDF) (CP.PHAR.371)
- Trigger Point Injections for Pain Management (PDF) (CP.MP.169)
- Triptorelin Pamoate (Trelstar, Triptodur) (PDF) (CP.PHAR.175)
- Ultrasound in Pregnancy (PDF) (CP.MP.38)
- Uridine acetate (Vistogard) (PDF) (HIM.PA.SP55)
- Urodynamic Testing (PDF) (CP.MP.98)
- Ustekinumab (PDF) (CP.PHAR.264)
- Valbenazine (PDF) (CP.PHAR.340)
- Vandetanib (Caprelsa) (PDF) (CP.PHAR.80)
- Varenicline-Chantix and Bupropion Zyban (PDF) (WA.PHAR.16)
- Vedolizumab (PDF) (CP.PHAR.265)
- Velaglucerase Alfa (PDF) (CP.PHAR.163)
- Verteporfin (Visudyne) (PDF) (CP.PHAR.187)
- Vestronidase alfa-vjbk (PDF) (CP.PHAR.374)
- Video Electroencephalography (V-EEG) (PDF) (WA.UM.23)
- Vigabatrin (PDF) (CP.PHAR.169)
- viladazone (Viibryd®) (PDF) (HIM.PA.135)
- vincristine sulfate liposome injection (PDF) (CP.PHAR.315)
- Viscosupplementation of the Knee for Osteoarthritis (PDF) (WA.UM.26)
- Vismodegib (PDF) (CP.PHAR.273)
- Vorapaxar (Zontivity) (PDF) (HIM.PA.146)
- Voretigene neparvovec-rzyl (PDF) (CP.PHAR.372)
- Vorinostat (PDF) (CP.PHAR.83)
- vortioxetine (Trintellex®) (PDF) (HIM.PA.136)
- Wheelchair Seating (PDF) (CP.MP.99)
- Xenazine (tetrabenazine) (PDF) (CP.PHAR.92)
- Xgeva (PDF) (CP.PHAR.58)
- Xiaflex™ (PDF) (CP.PHAR.82)
- Xolair® (PDF) (CP.PHAR.01)
- ziv-aflibercept (PDF) (CP.PHAR.325)
- Zoledronic Acid (Reclast, Zometa) (PDF) (CP.PHAR.59)
Payment Policies
Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.
All policies found in the Coordinated Care Payment Policy Manual apply with respect to Coordinated Care members. Policies in the Coordinated Care Payment Policy Manual may have either a Coordinated Care or a “Centene” heading. In addition, Coordinated Care may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Coordinated Care.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Ambetter Payment Policies
- 1-Day Payment Window (PDF) (WA.CC.PP.500)
- 3-Day Payment Window (PDF) (CC.PP.500)
- 30-Day Readmission (PDF) (CC.PP.501)
- Add on Code Billed Without Primary Code (PDF) (CC.PP.030)
- ADHD Assessment and Treatment (PDF) (CP.MP.124)
- Allergy Testing (PDF) (CP.MP.100)
- Ambulatory EEG (PDF) (CP.MP.96)
- Assistant Surgeon (PDF) (CC.PP.029)
- Bevacizumab (Avastin) (PDF) (CP.PHAR.93)
- Bilateral Procedures (PDF) (CC.PP.037)
- Bronchial Thermoplasty (PDF) (CP.MP.110)
- Cardiac Biomarker Testing for Acute MI (PDF) (CP.MP.156)
- Cerumen Removal (PDF) (CC.PP.008)
- Clean Claims (PDF) (CC.PP.021)
- CLIA Number (PDF) (CC.PP.022)
- Coding Overview (PDF) (CC.PP.011)
- Cosmetic Procedures (PDF) (CC.PP.024)
- Digital Analysis of EEGs (PDF) (CP.MP.105)
- Digital Breast Tomosynthesis (DBT) (PDF) (CP.MP.90)
- Distinct Procedural Modifiers (PDF) (CC.PP.020)
- DNA Analysis of Stool (PDF) (CP.MP.125)
- Duplicate Primary Code Billing (PDF) (CC.PP.044)
- EEG in Evaluation of Headache (PDF) (CP.MP.155)
- E&M Medical Decision-Making (PDF) (CC.PP.051)
- EM Bundling Edits (PDF) (CC.PP.010)
- Endometrial Ablation (EA) (PDF) (CP.MP.106)
- EpiFix Wound Treatment (PDF) (CP.MP.140)
- Evoked Potentials (PDF) (CP.MP.134)
- Fecal Calprotectin Assay (PDF) (CP.MP.135)
- FeNo Testing (PDF) (CP.MP.103)
- Global Maternity Billing (PDF) (CC.PP.016)
- H Pylori Testing (PDF) (CP.MP.153)
- Holter Monitors (PDF) (CP.MP.113)
- Homocysteine Testing (PDF) (CP.MP.121)
- Hospital Visit Codes Billed with Labs (PDF) (CC.PP.023)
- Inpatient Only Procedures (PDF) (CC.PP.018)
- Inpatient Only Procedures - Ambetter (PDF) (MP.PP.018)
- IV Hydration (PDF) (CC.PP.012)
- Laser Skin Treatment (PDF) (CP.MP.123)
- Low-Frequency Ultrasound Wound Therapy (PDF) (CP.MP.139)
- Maximum Units (PDF) (CC.PP.007)
- Measure Serum 1,25 Vitamin D (PDF) (CP.MP.152)
- Mechanical Stretch Devices (PDF) (CP.MP.144)
- Moderate Conscious Sedation (PDF) (CC.PP.015)
- Modifier -25 clinical validation (PDF) (CC.PP.013)
- Modifier -59 clinical validation (PDF) (CC.PP.014)
- Modifier DOS Validation (PDF) (CC.PP.034)
- Modifier to Procedure Code Validation (PDF) (CC.PP.028)
- Multiple CPT Code Replacement (PDF) (CC.PP.033)
- NCCI Unbundling (PDF) (CC.PP.031)
- Never Paid Events (PDF) (CC.PP.017)
- New Patient (PDF) (CC.PP.036)
- Not Medically Necessary IP Serv (PDF) (CC.PP.060)
- Inpatient Consultation (PDF) (CC.PP.038)
- Outpatient Consultation (PDF) (CC.PP.039)
- Paclitaxel, protein-bound (PDF) (CP.PHAR.176)
- Pelvic and Transabdominal US (PDF) (CC.PP.061)
- Physician's Consultation Services (PDF) (CC.PP.054)
- Physician Visit Codes Billed with Labs (PDF) (CC.PP.019)
- Physician's Office Lab Testing (PDF) (CC.PP.056)
- Place of Service Mismatch (PDF) (CC.PP.063)
- Post-Operative Visits (PDF) (CC.PP.042)
- Pre-Operative Visits (PDF) (CC.PP.041)
- Professional Component (PDF) (CC.PP.027)
- PROM Testing (PDF) (CP.MP.149)
- Proton and Neutron Beam Therapy (PDF) (CP.MP.70)
- Pulse Oximetry (PDF) (CC.PP.025)
- Rituximab (PDF) (CP.PHAR.260)
- Robotic Surgery (PDF) (CC.PP.050)
- Same Day Visits (PDF) (CC.PP.040)
- Sleep Studies Place of Services (PDF) (CC.PP.035)
- Status "B" Bundled Services (PDF) (CC.PP.046)
- Status P Bundled Services (PDF) (CC.PP.049)
- Supplies Billed on Same Day As Surgery (PDF) (CC.PP.032)
- Testing for Select Genitourinary Conditions (formerly Diagnosis of Vaginitis) (PDF) (WA.CP.MP.97)
- Thyroid Testing in Pediatrics (PDF) (CP.MP.154)
- Transgender Related Services (PDF) (CC.PP.047)
- Ultrasound in Pregnancy (PDF) (WA.CP.MP.38)
- Unbundled Surgical Procedures (PDF) (CC.PP.045)
- Unbundled Professional Services (PDF) (CC.PP.043)
- Unlisted Procedure Codes (PDF) (CC.PP.009)
- Urodynamic Testing (PDF) (CP.MP.98)
- Vitamin D Testing in Children (PDF) (CP.MP.157)
- Wheelchair Accessories (PDF) (CC.PP.502)
- Wheelchair Seating (PDF) (CP.MP.99)
- Wireless Motility Capsule (PDF) (CP.MP.143)
Medicaid Payment Policies
- 1-Day Payment Window (PDF) (WA.CC.PP.500)
- 3-Day Payment Window (PDF) (CC.PP.500)
- 30-Day Readmission (PDF) (CC.PP.501)
- Add on Code Billed Without Primary Code (PDF) (CC.PP.030)
- ADHD Assessment and Treatment (PDF) (CP.MP.124)
- Allergy Testing (PDF) (CP.MP.100)
- Ambulatory EEG (PDF) (CP.MP.96)
- Assistant Surgeon (PDF) (CC.PP.029)
- Bevacizumab (Avastin) (PDF) (CP.PHAR.93)
- Bilateral Procedures (PDF) (CC.PP.037)
- Bronchial Thermoplasty (PDF) (CP.MP.110)
- Cardiac Biomarker Testing for Acute MI (PDF) (CP.MP.156)
- Cerumen Removal (PDF) (CC.PP.008)
- Clean Claims (PDF) (CC.PP.021)
- CLIA Number (PDF) (CC.PP.022)
- Coding Overview (PDF) (CC.PP.011)
- Cosmetic Procedures (PDF) (CC.PP.024)
- Digital Analysis of EEGs (PDF) (CP.MP.105)
- Digital Breast Tomosynthesis (DBT) (PDF) (CP.MP.90)
- Distinct Procedural Modifiers (PDF) (CC.PP.020)
- DNA Analysis of Stool (PDF) (CP.MP.125)
- Duplicate Primary Code Billing (PDF) (CC.PP.044)
- EEG in Evaluation of Headache (PDF) (CP.MP.155)
- E&M Medical Decision-Making (PDF) (CC.PP.051)
- EM Bundling Edits (PDF) (CC.PP.010)
- Endometrial Ablation (EA) (PDF) (CP.MP.106)
- EpiFix Wound Treatment (PDF) (CP.MP.140)
- Evoked Potentials (PDF) (CP.MP.134)
- Fecal Calprotectin Assay (PDF) (CP.MP.135)
- FeNo Testing (PDF) (CP.MP.103)
- Global Maternity Billing (PDF) (CC.PP.016)
- H Pylori Testing (PDF) (CP.MP.153)
- Holter Monitors (PDF) (CP.MP.113)
- Homocysteine Testing (PDF) (CP.MP.121)
- Hospital Visit Codes Billed with Labs (PDF) (CC.PP.023)
- Inpatient Only Procedures (PDF) (CC.PP.018)
- IV Hydration (PDF) (CC.PP.012)
- Laser Skin Treatment (PDF) (CP.MP.123)
- Low-Frequency Ultrasound Wound Therapy (PDF) (CP.MP.139)
- Maximum Units (PDF) (CC.PP.007)
- Measure Serum 1,25 Vitamin D (PDF) (CP.MP.152)
- Mechanical Stretch Devices (PDF) (CP.MP.144)
- Moderate Conscious Sedation (PDF) (CC.PP.015)
- Modifier -25 clinical validation (PDF) (CC.PP.013)
- Modifier -59 clinical validation (PDF) (CC.PP.014)
- Modifier DOS Validation (PDF) (CC.PP.034)
- Modifier to Procedure Code Validation (PDF) (CC.PP.028)
- Multiple CPT Code Replacement (PDF) (CC.PP.033)
- NCCI Unbundling (PDF) (CC.PP.031)
- Never Paid Events (PDF) (CC.PP.017)
- New Patient (PDF) (CC.PP.036)
- Not Medically Necessary IP Serv (PDF) (CC.PP.060)
- Inpatient Consultation (PDF) (CC.PP.038)
- Outpatient Consultation (PDF) (CC.PP.039)
- Paclitaxel, protein-bound (PDF) (CP.PHAR.176)
- Pelvic and Transabdominal US (PDF) (CC.PP.061)
- Physician's Consultation Services (PDF) (CC.PP.054)
- Physician Visit Codes Billed with Labs (PDF) (CC.PP.019)
- Physician's Office Lab Testing (PDF) (CC.PP.056)
- Place of Service Mismatch (PDF) (CC.PP.063)
- Post-Operative Visits (PDF) (CC.PP.042)
- Pre-Operative Visits (PDF) (CC.PP.041)
- Professional Component (PDF) (CC.PP.027)
- PROM Testing (PDF) (CP.MP.149)
- Proton and Neutron Beam Therapy (PDF) (CP.MP.70)
- Pulse Oximetry (PDF) (CC.PP.025)
- Rituximab (PDF) (CP.PHAR.260)
- Robotic Surgery (PDF) (CC.PP.050)
- Same Day Visits (PDF) (CC.PP.040)
- Sleep Studies Place of Services (PDF) (CC.PP.035)
- Status "B" Bundled Services (PDF) (CC.PP.046)
- Status P Bundled Services (PDF) (CC.PP.049)
- Supplies Billed on Same Day As Surgery (PDF) (CC.PP.032)
- Testing for Select Genitourinary Conditions (formerly Diagnosis of Vaginitis) (PDF) (WA.CP.MP.97)
- Thyroid Testing in Pediatrics (PDF) (CP.MP.154)
- Transgender Related Services (PDF) (CC.PP.047)
- Ultrasound in Pregnancy (PDF) (WA.CP.MP.38)
- Unbundled Surgical Procedures (PDF) (CC.PP.045)
- Unbundled Professional Services (PDF) (CC.PP.043)
- Unlisted Procedure Codes (PDF) (CC.PP.009)
- Urodynamic Testing (PDF) (CP.MP.98)
- Vitamin D Testing in Children (PDF) (CP.MP.157)
- Wheelchair Accessories (PDF) (CC.PP.502)
- Wheelchair Seating (PDF) (CP.MP.99)
- Wireless Motility Capsule (PDF) (CP.MP.143)
Allwell Payment Policies
- 30-Day Readmission (PDF) (CC.PP.501)
- 3-Day Payment Window (PDF) (CC.PP.500)
- Add on Code Billed Without Primary Code (PDF) (CC.PP.030)
- Assistant Surgeon (PDF) (CC.PP.029)
- Bilateral Procedures (PDF) (CC.PP.037)
- Cerumen Removal (PDF) (CC.PP.008)
- Clean Claims (PDF) (CC.PP.021)
- CLIA Number (PDF) (CC.PP.022)
- Coding Overview (PDF) (CC.PP.011)
- Cosmetic Procedures (PDF) (CC.PP.024)
- Distinct Procedural Modifiers (PDF) (CC.PP.020)
- Duplicate Primary Code Billing (PDF) (CC.PP.044)
- E&M Medical Decision-Making (PDF) (CC.PP.051)
- EM Bundling Edits (PDF) (CC.PP.010)
- Global Maternity Billing (PDF) (CC.PP.016)
- Hospital Visit Codes Billed with Labs (PDF) (CC.PP.023)
- Inpatient Consultation (PDF) (CC.PP.038)
- Inpatient Only Procedures (PDF) (CC.PP.018)
- IV Hydration (PDF) (CC.PP.012)
- Maximum Units (PDF) (CC.PP.007)
- Moderate Conscious Sedation (PDF) (CC.PP.015)
- Modifier -25 clinical validation (PDF) (CC.PP.013)
- Modifier -59 clinical validation (PDF) (CC.PP.014)
- Modifier DOS Validation (PDF) (CC.PP.034)
- Modifier to Procedure Code Validation (PDF) (CC.PP.028)
- Multiple CPT Code Replacement (PDF) (CC.PP.033)
- NCCI Unbundling (PDF) (CC.PP.031)
- Never Paid Events (PDF) (CC.PP.017)
- New Patient (PDF) (CC.PP.036)
- Not Medically Necessary IP Serv (PDF) (CC.PP.060)
- Outpatient Consultation (PDF) (CC.PP.039)
- Pelvic and Transabdominal US (PDF) (CC.PP.061)
- Physician Visit Codes Billed with Labs (PDF) (CC.PP.019)
- Physician's Office Lab Testing (PDF) (CC.PP.055)
- Place of Service Mismatch (PDF) (CC.PP.063)
- Post-Operative Visits (PDF) (CC.PP.042)
- Pre-Operative Visits (PDF) (CC.PP.041)
- Problem Oriented Visits with Preventative Visits (PDF) (CC.PP.057)
- Problem Oriented Visits with Surgical Procedures (PDF) (CC.PP.052)
- Professional Component (PDF) (CC.PP.027)
- Pulse Oximetry (PDF) (CC.PP.025)
- Repeat Lab Services (PDF) (CC.PP.026)
- Same Day Visits (PDF) (CC.PP.040)
- Sleep Studies Place of Services (PDF) (CC.PP.035)
- Status "B" Bundled Services (PDF) (CC.PP.046)
- Status P Bundled Services (PDF) (CC.PP.049)
- Supplies Billed on Same Day As Surgery (PDF) (CC.PP.032)
- Transgender Related Services (PDF) (CC.PP.047)
- Unbundled Professional Services (PDF) (CC.PP.043)
- Unbundled Surgical Procedures (PDF) (CC.PP.045)
- Unlisted Procedure Codes (PDF) (CC.PP.009)
- Urine Specimen Validity Testing (PDF) (CC.PP.056)
- Wheelchair Accessories (PDF) (CC.PP.502)