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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 Peach State Health Plan Clinical Policy Manual apply to Peach State Health Plan members. Policies in the Peach State Health Plan Clinical Policy Manual may have either a Peach State Health Plan or a “Centene” heading. Peach State Health Plan utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Peach State Health Plan 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 Peach State Health Plan. In addition, Peach State Health Plan 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 Peach State Health Plan.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

MEDICAID CLINICAL POLICIES 

POLICY TITLEPOLICY NUMBEREFFECTIVE DATE
25-hydroxyvitamin D Testing in Children and Adolescents (PDF)CP.MP.157December 29, 2017
Acupuncture (PDF)CP.MP.92December 31, 2013
Adopted Clinical Practice and Preventive Health Guidelines (PDF)CPG GridJune 22, 2023
Air Ambulance (PDF)CP.MP.175April 30, 2019
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF)CP.MP.108March 31, 2016
Articular Cartilage Defect Repairs (PDF)CP.MP.26October 31, 2008
Assisted Reproductive Technology (PDF)CP.MP.55March 31, 2014
Bariatric Surgery (PDF)CP.MP.37June 11, 2009
Biofeedback (PDF)CP.MP.168July 31, 2017
Bone-Anchored Hearing Aid (PDF)CP.MP.93December 31, 2013
Burn Surgery (PDF)CP.MP.186May 31, 2020
Cardiac Biomarker Testing (PDF)CP.MP.156December 29, 2017
Caudal or Interlaminar Epidural Steroid Injections (PDF)CP.MP.164August 31, 2018
Clinical Trials (PDF)CP.MP.94January 27, 2014
Cochlear Implant Replacements (PDF)CP.MP.14March 20, 2009
Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Cardiac Disorders (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Dermatologic Conditions (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Eye Disorders (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (PDF)V1.2024June 22, 2023
Concert Genetic Testing: General Approach to Genetic and Molecular Testing (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Hearing Loss (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Hematologic Conditions (non-cancerous) (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Kidney Disorders (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Lung Disorders (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Non-invasive Prenatal Screening (NIPS) (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Pharmacogenetics (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Preimplantation Genetic Testing (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS or PUBS) and Pregnancy Loss (PDF)V1.2024June 22, 2023
Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)V1.2024June 22, 2023
Concert Genetics Oncology: Algorithmic Testing (PDF)V1.2024June 22, 2023
Concert Genetics Oncology: Cancer Screening (PDF)V1.2024June 22, 2023
Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF)V1.2024June 22, 2023
Concert Genetics Oncology: Cytogenetic Testing (PDF)V1.2024June 22, 2023
Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)V1.2024June 22, 2023
Cosmetic and Reconstructive Procedures (PDF)CP.MP.31March 31, 2009
Diaphragmatic/Phrenic Nerve Stimulation (PDF)CP.MP.203December 31, 2020
Digital EEG Spike Analysis (PDF)CP.MP.105January 15, 2016
Disc Decompression Procedures (PDF)CP.MP.114July 31, 2016
Discography (PDF)CP.MP.115August 30, 2016
Donor Lymphocyte Infusion (PDF)CP.MP.101December 1, 2015
Drugs of Abuse: Definitive Drug Testing (PDF)CP.MP.50February 28, 2021
Durable Medical Equipment (PDF)CP.MP.107June 30, 2009
EEG in the Evaluation of Headache (PDF)CP.MP.155December 29, 2017
Electric Breast Pumps (PDF)GA.CP.MP.500April 1, 2020
Electric Tumor Treating Fields (Optune) (PDF)CP.MP.145May 31, 2017
Experimental Technologies (PDF)CP.MP.36June 30, 2009
Facet Joint Injections (PDF)CP.MP.171September 14, 2018
Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)CP.MP.248January 31, 2023
Fecal Incontinence Treatments (PDF)CP.MP.137December 30, 2016
Ferriscan R2-MRI (PDF)CP.MP.53November 14, 2012
Fertility Preservation (PDF)CP.MP.130October 30, 2016
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)CP.MP.129October 30, 2016
Functional MRI (PDF)CP.MP.43September 23, 2009
Gastric Electrical Stimulation (PDF)CP.MP.40July 30, 2009
Gender-Affirming Procedures (PDF)CP.MP.95November 28, 2014
Heart-Lung Transplant (PDF)CP.MP.132June 30, 2017
Helicobacter Pylori Serology Testing (PDF)CP.MP.153December 29, 2017
Home Births (PDF)CP.MP.136December 30, 2016
Home Ventilators (PDF)CP.MP.184June 30, 2022
Hospice Services (PDF)CP.MP.54July 30, 2014
Hyperhidrosis Treatments (PDF)CP.MP.62May 16, 2013
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)CP.MP.180November 30, 2020
Implantable Intrathecal or Epidural Pain Pump (PDF)CP.MP.173February 28, 2019
Implantable Loop Recorder (PDF)CP.MP.243June 22, 2023
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)CP.MP.160April 30, 2018
Incontinence and Ostomy Supplies (PDF)GA.CP.MP.07May 1, 2021
Infant Apnea Monitors (PDF)GA.CP.MP.06September 1, 2021
Insulin Testing in Pediatrics (PDF)GA.CP.MP.154November 1, 2021
Intensity-Modulated Radiotherapy (PDF)CP.MP.69March 31, 2014
Intestinal and Multivisceral Transplant (PDF)CP.MP.58February 28, 2014
Intradiscal Steroid Injections for Pain Management (PDF)CP.MP.167August 31, 2018
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)CP.MP.61June 1, 2013
Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy (PDF)CP.MP.250August 31, 2023
Liposuction for Lipedema (PDF)CP.MP.244May 30, 2022
Long Term Care Placement (PDF)CP.MP.71July 11, 2018
Lung Transplantation (PDF)CP.MP.57February 28, 2014
Lysis of Epidural Lesions (PDF)CP.MP.116July 31, 2018
Measurement of Serum 1,25-dihydroxyvitamin D (PDF)CP.MP.152December 29, 2017
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)CP.MP.144April 30, 2017
Multiple Sleep Latency Testing (PDF)CP.MP.24October 31, 2008
Nebulizer with Compressor (PDF)GA.CP.MP.501April 29, 2020
Neonatal Abstinence Syndrome Guidelines (PDF)CP.MP.86October 30, 2013
Neonatal Sepsis Management (PDF)CP.MP.85August 30, 2013
Nerve Blocks and Neurolysis for Pain Management (PDF)CP.MP.170August 31, 2018
Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)CP.MP.48July 31, 2021
NICU Apnea Bradycardia Guidelines (PDF)CP.MP.82June 30, 2013
NICU Discharge Guidelines (PDF)CP.MP.81June 30, 2013
Nonmyeloablative Allogeneic Stem Cell Transplants (PDF)CP.MP.141April 28, 2017
Obstetrical Home Care Programs (PDF)CP.MP.91January 27, 2014
Omisirge (Omidubicel): Nicotinamide-modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)CP.MP.249June 30, 2023
Orthognathic Surgery (PDF)CP.MP.202October 31, 2021
Osteogenic Stimulation (PDF)CP.MP.194September 30, 2021
Outpatient Cardiac Rehabilitation (PDF)CP.MP.176May 31, 2021
Outpatient Oxygen Use (PDF)CP.MP.190December 2, 2020
Pancreas Transplantation (PDF)CP.MP.102April 29, 2016
Panniculectomy (PDF)CP.MP.109April 30, 2016
Pediatric Heart Transplant (PDF)CP.MP.138January 31, 2017
Pediatric Kidney Transplant (PDF)CP.MP.246September 30,2022
Pediatric Liver Transplant (PDF)CP.MP.120April 30, 2018
Pediatric Oral Function Therapy (PDF)CP.MP.188May 31, 2020
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)CP.MP.147July 31, 2017
Phototherapy for Neonatal Hyperbilirubinemia (PDF)CP.MP.150December 21, 2017
Physical, Occupational, Speech, and Feeding Therapy  (PDF)GA.CP.MP.49 June 1, 2021
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)CP.MP.181August 1, 2020
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)CP.MP.133October 30, 2016
Proton and Neutron Beam Therapies (PDF)CP.MP.70March 31, 2014
Reduction Mammoplasty and Gynecomastia Surgery (PDF)CP.MP.51July 31, 2012
Repair of Nasal Valve Compromise (PDF)CP.MP.210May 31, 2021
Sacroiliac Joint Fusion (PDF)CP.MP.126September 30, 2016
Sacroiliac Joint Interventions for Pain Management (PDF)CP.MP.166August 31, 2018
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF)CP.MP.146June 30, 2017
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)CP.MP.174March 31, 2019
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)CP.MP.165August 31, 2018
Short Inpatient Hospital Stay (PDF)CP.MP.182May 29, 2020
Skin and Soft Tissue Substitutes for Chronic Wounds (PDF)CP.MP.185April 20, 2020
Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF)CP.MP.117July 31, 2016
Stereotactic Body Radiation Therapy (PDF)CP.MP.22December 30, 2008
Tandem Transplant (PDF)CP.MP.162July 31, 2018
Therapeutic Utilization of Inhaled Nitric Oxide (PDF)CP.MP.87August 30, 2013
Total Artificial Heart (PDF)CP.MP.127December 30, 2016
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)CP.MP.163May 31, 2016
Transcather Closer of Patent Foramen Ovale (PDF)CP.MP.151December 29, 2017
Transplant Service Documentation RequirementsCP.MP.247February 24, 2023
Trigger Point Injections for Pain Management (PDF)CP.MP.169August 31, 2018
Urinary Incontinence Devices and Treatments (PDF)CP.MP.142April 30, 2017
Vagus Nerve Stimulation (PDF)CP.MP.12September 30, 2008
Ventricular Assist Devices (PDF)CP.MP.46December 31, 2009
Wireless Motility Capsule (PDF)CP.MP.143April 30, 2017

AMBETTER CLINICAL POLICIES 

For Ambetter information, please visit our Ambetter website.

MEDICAID BEHAVIORAL HEALTH POLICIES 

POLICY TITLEPOLICY NUMBEREFFECTIVE DATE
Adaptive Behavior Services for Autism Spectrum Disorder (PDF)GA.CP.BH.504June 30, 2023
Applied Behavioral Analysis Documentation Requirements (PDF)CP.BH.105March 1, 2024
Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF)CP.BH.124December 31, 2013
Behavioral Health Treatment Documentation Requirements (PDF)CP.BH.500February 24, 2023
Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (PDF)CP.BH.201April 30, 2021
Biofeedback for Behavioral Health Disorders (PDF)CP.BH.300August 7, 2020
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF)CP.BH.200January 8, 2019

AMBETTER BEHAVIORAL HEALTH POLICIES 

For Ambetter information, please visit our Ambetter website.

VISION POLICIES 

POLICY TITLEPOLICY NUMBEREFFECTIVE DATE
Adjacent Tissue Transfer Grafts involving Eyelid (PDF)CP.VP.01January 1, 2017
Age Related Macular Degeneration (PDF)CP.VP.02October 1, 2017
Amblyopia (PDF)CP.VP.03January 1, 2017
Anterior Segment Photography with FA (PDF)CP.VP.67October 1, 2017
Aqueous Shunt (PDF)CP.VP.05January 1, 2016
Blepharoplasty, Ptosis and Canthoplasty (PDF)CP.VP.07January 1, 2017
B-Scan (PDF)CP.VP.68January 1, 2018
Cataract Extraction (PDF)CP.VP.08January 1, 2017
Chemodenervation (PDF)CP.VP.10January 1, 2017
Complex Cataract (PDF)CP.VP.12January 1, 2017
Corneal Hysteresis (PDF)CP.VP.17January 1, 2016
Corneal Pachymetry (PDF)CP.VP.16January 1, 2017
Corneal Topography (PDF)CP.VP.18Janury 1, 2017
Dark Adaptation and Color Vision Examinations (92283/92284) (PDF)CP.VP.23January 1, 2017
Destruction of a Localized Lesion of the Retina (PDF)CP.VP.21January 1, 2017
Destruction of Localized Lesion of Choroid (PDF)CP.VP.20January 2,2015
Destruction of Retinopathy (PDF)CP.VP.19January 1, 2018
Dilation Protocol (PDF)CPG.VP.24January 1, 2016
Ectropion and Entropion Repair (PDF)CP.VP.25October 1, 2017
Examination Guidelines for Diabetic Patients (PDF)CPG.VP.22January 1, 2018
Extended Ophthalmoscopy (PDF)CP.VP.26January 1, 2018
External Ocular Photography (PDF)CP.VP.43October 1, 2016
Fluorescein Angiography (PDF)CP.VP.28January 1, 2018
Fundus Photography (PDF)CP.VP.29January 1, 2018
Glaucoma (PDF)CPG.VP.30January 1, 2017
Gonioscopy (PDF)CP.VP.31October 1, 2016
Indocyanine Green (ICG) Angiography (PDF)CP.VP.32January 1, 2017
Infracture of the Inferior Turbinate (PDF)CP.VP.33January 2, 2016
Iris Coloboma (PDF)CP.VP.34January 1, 2018
Keratoplasty (PDF)CP.VP.36January 1, 2016
Laser Iridotomy and Iridectomy for Glaucoma (PDF)CP.VP.37January 1, 2018
Laser Trabeculoplasty for POAG (PDF)CP.VP.38January 1, 2018
Ocular Prosthesis (PDF)CP.VP.44January 1, 2017
Ophthalmic Biometry (PDF)CP.VP.45January 1, 2017
Photodynamic and Intravitreal Therapies and Pharmaceuticals (PDF)CP.VP.40September 1, 2017
Probing and Closure of the Lacrimal Duct System (PDF)CP.VP.11December 1, 2021
Prophylaxis of Retinal Detachment (PDF)CP.VP.53January 1, 2016
Recurrent Erosion Syndrome and PTK (PDF)CP.VP.49January 1, 2016
Refractive Surgery (PDF)CP.VP.52January 1, 2016
Refraction (PDF)CP.VP.35December 1, 2019
Repair of Retinal Detachment (PDF)CP.VP.54January 1, 2016
Secondary IOL (PDF)CP.VP.48January 1, 2016
Sensorimotor Examination (PDF)CP.VP.55January 1, 2017
Specular Microscopy (PDF)CP.VP.66January 1, 2018
Strabismus Surgeries (PDF)CP.VP.57January 1, 2016
Surgical Excision of Eyelid Lesions (PDF)CP.VP.75December 1, 2021
Teleretinal Screening for Diabetic Retinopathy (PDF)CP.VP.88January 1, 2017
Trabeculetomy Ab Externo (PDF)CP.VP.61January 1, 2016
Visual Field Testing (PDF)CP.VP.63January 1, 2018
Visual Therapy (PDF)CP.VP.46January 1, 2018
Vitrectomy (PDF)CP.VP.64January 1, 2017
YAG Laser Capsulotomy (PDF)CP.VP.65January 1, 2017

AMBETTER SPECIALTY PHARMACY POLICIES 

POLICY TITLEPOLICY NUMBEREFFECTIVE DATE
72 Hour Supply of Medication (PDF)GA.PHAR.07June 1, 2006
Abaloparatide (Tymlos) (PDF)CP.PHAR.345July 1, 2017
abatacept (Orencia) (PDF)CP.PHAR.241August 1, 2016
Abiraterone (Zytiga) (PDF)CP.PHAR.84October 1, 2011
Abiraterone (Zytiga, Yonsa) (PDF)CP.PHAR.84October 1, 2011
AbobotulinumtoxinA (Dysport) (PDF)CP.PHAR.230July 1, 2016
Adalimumab (Humira) (PDF)CP.PHAR.242August 1, 2016
Adefovir (Hepsera) (PDF)CP.PHAR.142August 28, 2018
Ado-Trastuzumab Emtansine (Kadcyla) (PDF)CP.PHAR.229June 1, 2016
Aducanumab (PDF)
CP.PHAR.468June 1, 2020
Afatinib (Gilotrif) (PDF)CP.PHAR.298June1/2017
Aflibercept (Eylea®) (PDF)CP.PHAR.184March 1, 2016
Agalsidase Beta (Fabrazyme) (PDF)CP.PHAR.158February 1, 2016
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF)CP.PMN.138March 13, 2018
Alectinib (Alecensa) (PDF)CP.PHAR.369November 16, 2016
Alemtuzumab (Lemtrada) (PDF)CP.PHAR.243August 1, 2016
Alendronate (Binosto, Fosamax plus D) (PDF)CP.PMN.88March 1, 2018
Alglucosidase Alfa (Lumizyme) (PDF)CP.PHAR.160February 1, 2016
Alirocumab (Praluent) (PDF)CP.PHAR.124October 1, 2015
Alpelisib (Piqray) (PDF)CP.PHAR.430September 1, 2019
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF)CP.PHAR.94March 1, 2012
Ambrisentan (Letairis®) (PDF)CP.PHAR.190March 1, 2016
Amifampridine (Firdapse, Ruzurgi) (PDF)CP.PHAR.411January 22, 2019
Amikacin (Arikayce) (PDF)CP.PHAR.401November 13, 2018
Antithymocyte Globulin (Thymoglobulin, Atgam) (PDF)HIM.PA.16September 1, 2018
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF)CP.PHAR.217May 1, 2016
Anakinra (Kineret) (PDF)CP.PHAR.244August 1, 2016
Apalutamide (Erleada) (PDF)CP.PHAR.376June 1, 2018
Apremilast (Otezla) (PDF)CP.PHAR.245August 1, 2016
Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF)CP.PMN.19November 30, 2016

Appropriate Use and Safety Edits (PDF)

Appropriate Use and Safety Edits: Attachment A (PDF)

GA.PMN.01May 1, 2012
Arformoterol Tartrate (Brovana) (PDF)CP.PMN.201September 1, 2019
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF)CP.PHAR.290December 1, 2016
Armodafinil (Nuvigil) (PDF)CP.PMN.35August 1, 2009
Asenapine (Saphris, Secuado) (PDF)CP.PMN.15December 1, 2014
asfotase alfa (Strensiq®) (PDF)CP.PHAR.328March 1, 2017
Aspirin-dipyridamole (Aggrenox) (PDF)CP.PMN.20September 1, 2006
Atezolizumab (Tecentriq®) (PDF)CP.PHAR.235June 1, 2016
Avapritinib (Ayvakit) (PDF)CP.PHAR.454March 1, 2020
Avatrombopag (Doptelet) (PDF)CP.PHAR.130July 17, 2018
Avelumab (Bavencio®) (PDF)CP.PHAR.333May 1, 2017
Axicabtagene Ciloleucel (Yescarta) (PDF)CP.PHAR.362October 31, 2017
Axitinib (Inlyta®) (PDF)CP.PHAR.100May 1, 2012
Azacitidine (Vidaza) (PDF)CP.PHAR.387August 28, 2017
Azelaic Acid (Finacea) (PDF)HIM.PA.119November 9, 2017
Aztreonam (Cayston®) (PDF)CP.PHAR.209May 1, 2016
Baclofen (Gablofen, Lioresal, Ozobax) (PDF)CP.PHAR.149November 9, 2017
Baloxavir Marboxil (Xofluza) (PDF)CP.PMN.185October 30, 2018
Bedaquiline (Sirturo) (PDF)CP.PMN.212December 1, 2019
Belantamab Mafodotin (PDF)CP.PHAR.469June 1, 2020
belatacept (Nulojix®) (PDF)CP.PHAR.201November 9, 2017
Belimumab (Benlysta) (PDF)CP.PHAR.88October 1, 2011
belinostat (Beleodaq®) (PDF)CP.PHAR.311February 1, 2017
Bendamustine (Bendeka®, Treanda®) (PDF)CP.PHAR.307June 1, 2010
Benralizumab (Fasenra) (PDF)CP.PHAR.373January 16, 2018
Benznidazole (PDF)CP.PMN.90October 17, 2017
Berotralstat (PDF)CP.PHAR.485June 1, 2020
Betaine (Cystadane) (PDF)CP.PHAR.143August 28, 2018
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF)CP.PHAR.93November 1, 2011
Bexarotene (Targretin) (PDF)CP.PHAR.75September 1, 2011
Bezlotoxumab (Zinplava) (PDF)CP.PHAR.300November 16, 2016
Bimatoprost Implant (Durysta) (PDF)CP.PHAR.486June 1, 2020
Binimetinib (Mektovi) (PDF)CP.PHAR.50July 24, 2018
Biologic DMARDs (PDF)HIM.PA.SP60January 1, 2020
Biologic Drug Dose Escalation (PDF)GA.PMN.21September 1, 2017
Blinatumomab (Blincyto) (PDF)CP.PHAR.312February 1, 2017
Blocking Adjudication of Controlled Substance Prescriptions for Selected Prescribers (PDF)GA.PHAR.19November 1, 2001
Bortezomib (Velcade) (PDF)CP.PHAR.410December 11, 2018
Bosentan (Tracleer®) (PDF)CP.PHAR.191March 1, 2016
Bosutinib (Bosulif) (PDF)CP.PHAR.105October 1, 2012
Brand Name Override and Non-Formulary Medications (PDF)HIM.PA.103December 1, 2014
Brentuximab Vedotin (Adcetris) (PDF)CP.PHAR.303February 1, 2017
Brexanolone (Zulresso) (PDF)CP.PHAR.417April 16, 2019
Brexpiprazole (Rexulti) (PDF)CP.PMN.68November 5, 2015
Brexucabtagene Autoleucel (Tecartus) (PDF)
CP.PHAR.472June 1, 2020
Brigatinib (Alunbrig) (PDF)CP.PHAR.342July 17, 2017
Brimonidine Tartrate (Mirvaso) (PDF)CP.PMN.192November 16, 2016
Brinzolamide/Brimonidine (Simbrinza) (PDF)HIM.PA.15September 4, 2018
Brivaracetam (Briviact) (PDF)HIM.PA.07September 1, 2019
Brolucizumab-dbll (Beovu) (PDF)CP.PHAR.445March 1, 2020
Budesonide Suspension (Pulmicort Respules) (PDF)HIM.PA.48September 1, 2018
Buprenorphine Implant/Injection (Probuphine, Sublocade) (PDF)CP.PHAR.289November 16, 2016
Buprenorphine implant (Probuphine) (PDF)CP.PHAR.289November 16, 2016
Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone) (PDF)HIM.PA.35February 1, 2017
Buprenorphine (Subutex) (PDF)CP.PMN.82September 1, 2017
Burosumab-twza (Crysvita)(PDF)CP.PHAR.11May 8, 2018
Butorphanol Nasal Spray (PDF)HIM.PA.46December 1, 2014
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF)CP.PHAR.202March 1, 2016
C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF)CP.PHAR.202March 1, 2016
cabazitaxel (Jevtana® (PDF)CP.PHAR.316February 1, 2017
Cabozantinib (Cometriq®, Cabometyx®) (PDF)CP.PHAR.111June 1, 2013
Canakinumab (Ilaris) (PDF)CP.PHAR.246August 1, 2016
Cannabidiol (Epidiolex) (PDF)CP.PMN.164July 17, 2018
capecitabine (Xeloda) (PDF)CP.PHAR.60May 1, 2011
Caplacizumab-yhdp (Cablivi) (PDF)CP.PHAR.416March 12, 2019
carfilzomib (Kyprolis®) (PDF)CP.PHAR.309February 1, 2017
Carglumic acid (Carbaglu®) (PDF)CP.PHAR.206May 1, 2016
Casimersen (PDF)CP.PHAR.470June 1, 2020
Cedazuridine/Decitabine (ASTX-727) (PDF)CP.PHAR.479June 1, 2020
Celecoxib (Celebrex, Elyxyb) (PDF)CP.PMN.122January 1, 2007
Cemiplimab-rwlc (Libtayo) (PDF)CP.PHAR.397October 16, 2018
Cenegermin-bkbj (Oxervate) (PDF)CP.PMN.186October 9, 2018
Cenobamate (Xcopri) (PDF)CP.PMN.231March 1, 2020
Ceritinib (Zykadia) (PDF)CP.PHAR.349July 1, 2017
Cerliponase alfa (Brineura) (PDF)CP.PHAR.338July 1, 2017
Certolizumab (Cimzia) (PDF)CP.PHAR.247August 1, 2016
Cetuximab (Erbitux®) (PDF)CP.PHAR.317February 1, 2017
Chlorambucil (Leukeran) (PDF)HIM.PA.SP59August 28, 2018
Chloramphenicol Sodium Succinate (PDF)CP.PHAR.388December 1, 2018
Cholic Acid (Cholbam) (PDF)CP.PHAR.390December 1, 2018
Ciclesonide (Alvesco) (PDF)HIM.PA.65September 1, 2018
Cinacalcet (Sensipar) (PDF)CP.PHAR.61May 1, 2011
Ciprofloxacin-Dexamethasone (Ciprodex) (PDF)HIM.PA.120November 9, 2017
Ciprofloxacin/Fluocinolone (Otovel) (PDF)HIM.PA.14September 4, 2018
Cladribine (Mavenclad) (PDF)CP.PHAR.422September 1, 2019
Clindamycin (Evoclin) (PDF)HIM.PA.21August 28, 2018
Clindamycin Phosphate/Benzoyl Peroxide (BenzaClin) (PDF)HIM.PA.31December 1, 2018
Clinical Pharmacy Services Inter-rater Reliability (PDF)GA.PHAR.04April 1, 2021
Clobazam (Onfi) (PDF)CP.PMN.54November 1, 2012
CNS Stimulants (PDF)CP.PMN.92March 1, 2018
Cobimetinib (Cotellic) (PDF)CP.PHAR.380November 16, 2016
Colesevelam (Welchol) (PDF)HIM.PA.121November 9, 2017
Collagenase (Xiaflex) (PDF)CP.PHAR.82October 1, 2011
Colonoscopy Preparation Products (PDF)HIM.PA.04January 1, 2020
Conjugated Estrogens/Bazedoxifene (Duavee) (PDF)HIM.PA.140October 24, 2017
Continuous Glucose Monitors (PDF)CP.PMN.214December 1, 2019
copanlisib (Aliqopa®) (PDF)CP.PHAR.357October 17, 2017
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF)CP.PHAR.385May 29, 2018
Cosyntropin (Cortrosyn®) (PDF)CP.PHAR.203April 1, 2016
Crisaborole (Eucrisa) (PDF)CP.PMN.110February 21, 2017
Crizanlizumab-tmca (Adakveo) (PDF)CP.PHAR.449March 1, 2020
Crizotinib (Xalkori) (PDF)CP.PHAR.90November 1, 2011
Cyclosporine (Cequa, Restasis) (PDF)CP.PMN.48May 1, 2012
Cysteamine ophthalmic (Cystaran) (PDF)CP.PMN.130August 1, 2017
Cysteamine oral (Cystagon, Procysbi) (PDF)CP.PHAR.155Februay 1, 2016
Cytomegalovirus Immune Globulin (Cytogam)(PDF)CP.PHAR.277September 1, 2018
Dabrafenib (Tafinlar) (PDF)CP.PHAR.239November 16, 2016
Dacomitinib (Vizimpro) (PDF)CP.PHAR.399October 16, 2018
Dalfampridine (Ampyra) (PDF)CP.PHAR.248August 1, 2016
Dalteparin (Fragmin) (PDF)CP.PHAR.225May 1, 2016
Daptomycin (Cubicin, Cubicin RF)(PDF)CP.PHAR.351November 30, 2017
Daratumumab (Darzalex) (PDF)CP.PHAR.310July 1, 2017
Darbepoetin Alfa (Aranesp) (PDF)CP.PHAR.236June 1, 2016
Darolutamide (Nubeqa) (PDF)CP.PHAR.435December 1, 2019
Dasatinib (Sprycel) (PDF)CP.PHAR.72June 1, 2012
daunorubicin/cytarabine (Vyxeos®) (PDF)CP.PHAR.352December 1, 2017
Deferasirox (Exjade Jadenu) (PDF)CP.PHAR.145November 1, 2015
Deferiprone (Ferriprox) (PDF)CP.PHAR.147November 1, 2015
Deferoxamine (Desferal) (PDF)CP.PHAR.146November 1, 2015
Deflazacort (Emflaza) (PDF)CP.PHAR.331March 1, 2017
Degarelix acetate (Firmagon®) (PDF)CP.PHAR.170November 9, 2017
Delafloxacin (Baxdela) (PDF)CP.PMN.115November 9, 2017
Denosumab (Prolia, Xgeva) (PDF)CP.PHAR.58March 1, 2011
Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF)CP.PHAR.214May 1, 2016
Deutetrabenazine (Austedo) (PDF)CP.PHAR.341June 13, 2017
Dexlansoprazole (Dexilant) (PDF)HIM.PA.05January 1, 2020
Dexrazoxane (Zinecard, Totect) (PDF)CP.PHAR.418March 19, 2019
Dextromethorphan-Quinidine (Nuedexta) (PDF)CP.PMN.93March 1, 2018
Diazepam Nasal Spray (Valtoco) (PDF)CP.PMN.216December 1, 2019
Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity) (PDF)CP.PHAR.249August 1, 2016
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF)HIM.PA.58March 1, 2018
Dolasetron (Anzemet) (PDF)CP.PMN.141September 1, 2006
Dornase alfa (Pulmozyme) (PDF)CP.PHAR.212May 1, 2016
Dose Escalation of Biologics (PDF)GA.PMN.21September 1, 2017
Doxepin (Silenor, Prudoxin, Zonalon) (PDF)HIM.PA.147November 17, 2017
Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF)CP.PMN.79May 1, 2017
Drug Recall Notification Process (PDF)GA.PHAR.08July 1, 2008
Drug Utilization Review (PDF)GA.PHAR.13April 1, 2007
Dupilumab (Dupixent) (PDF)CP.PHAR.336May 1, 2017
Durvalumab (Imfinzi) (PDF)CP.PHAR.339July 1, 2017
Duvelisib (Copiktra) (PDF)CP.PHAR.400October 16, 2018
Early and Periodic Screening, Diagnostic, and Treatment Benefit for Pediatric Members (PDF)CP.PMN.234June 1, 2020
Ecallantide (Kalbitor®) (PDF)CP.PHAR.177March 1, 2016
Eculizumab (Soliris®) (PDF)CP.PHAR.97March 1, 2012
Edaravone (Radicava) (PDF)CP.PHAR.343July 1, 2017
Efinaconazole (Jublia) (PDF)CP.PMN.25August 1, 2016
Elagolix (Orilissa) (PDF)CP.PHAR.136August 28, 2018
Elapegademase-lvlr (Revcovi) (PDF)CP.PHAR.419April 23, 2019
Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (PDF)CP.PHAR.440December 1, 2019
Eliglustat (Cerdelga) (PDF)CP.PHAR.153February 1, 2016
Elosulfase Alfa (Vimizim) (PDF)CP.PHAR.162February 1, 2016
Elotuzumab (Empliciti®) (PDF)CP.PHAR.308February 1, 2017
Eltrombopag (Promacta®) (PDF)CP.PHAR.180March 1, 2016
Emapalumab-lzsg (Gamifant) (PDF)CP.PHAR.402December 11, 2018
Emicizumab-kxwh (Hemlibra) (PDF)CP.PHAR.370March 1, 2018
Emtricitabine/Tenofovir Alafenamide (Descovy)(PDF)CP.PMN.235June 1, 2020
Emtricitabine/Tenofovir (Truvada®) (PDF)HIM.PA.78December 1, 2014
Enasidenib (Idhifa) (PDF)CP.PHAR.363September 5, 2017
Encorafenib (Braftovi) (PDF)CP.PHAR.127July 24, 2018
Enfortumab Vedotin-ejfv (Padcev) (PDF)CP.PHAR.455March 1, 2020
Enfuvirtide (Fuzeon) (PDF)CP.PHAR.41June 1, 2010
Entecavir (Baraclude) (PDF)HIM.PA.08February 19, 2019
Entrectinib (Rozlytrek) (PDF)CP.PHAR.441December 1, 2019
Enzalutamide (Xtandi) (PDF)CP.PHAR.106October 1, 2012
Epoetin Alfa (Epogen® and Procrit) (PDF)CP.PHAR.237June 1, 2016
Epoprostenol (Flolan®), Veletri®) (PDF)CP.PHAR.192March 1, 2016
Erdafitinib (Balversa)(PDF)CP.PHAR.423September 1, 2019
Erenumab-aaoe (Aimovig) (PDF)CP.PHAR.128July 10, 2018
Eribulin Mesylate (Halaven®) (PDF)CP.PHAR.318March 1, 2017
Erlotinib (Tarceva) (PDF)CP.PHAR.74September 1, 2011
Erwinia Asparaginase (Erwinaze) (PDF)CP.PHAR.301February 1, 2017
Esketamine (Spravato) (PDF)CP.PMN.199March 12, 2019
Etelcalcetide (Parsabiv) (PDF)CP.PHAR.379March 20, 2018
Etanercept (Enbrel) (PDF)CP.PHAR.250August 1, 2016
Eteplirsen (Exondys 51) (PDF)CP.PHAR.288December 1, 2016
Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF)CP.PHAR.63June 1, 2011
Evolocumab (Repatha) (PDF)CP.PHAR.123October 1, 2015
Factor IX (Human, Recombinant) (PDF)CP.PHAR.218May 1, 2016
Factor IX Complex, Human (Profilnine) (PDF)CP.PHAR.219May 1, 2016
Factor VIII (Human Recombinant) (PDF)CP.PHAR.215May 1, 2016
Factor VIIa, Recombinant (NovoSeven® RT) (PDF)CP.PHAR.220May 1, 2016
Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (PDF)CP.PHAR.220May 1, 2016
Factor VIII/von Willebrand Factor Complex (Human - Alphanate, Humate-P, Wilate) (PDF)CP.PHAR.216May 1, 2016
Factor XIII A-Subunit, Recombinant (Tretten®) (PDF)CP.PHAR.222May 1, 2016
Factor XIII, Human (Corifact®) (PDF)CP.PHAR.221May 1, 2016
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF)CP.PHAR.456March 1, 2020
Febuxostat (Uloric) (PDF)CP.PMN.57August 1, 2013
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF)CP.PMN.127June 1, 2015
Ferumoxytol (Feraheme®) (PDF)CP.PHAR.165March 1, 2016
Ferric Carboxymaltose (Injectafer) (PDF)CP.PHAR.234June 1, 2016
Ferric Derisomaltose (Monoferric) (PDF)CP.PHAR.480June 1, 2020
Ferric gluconate (Ferrlecit®) (PDF)CP.PHAR.166March 1, 2016
Filgrastim (Neupogen, Zarxio) (PDF)CP.CPA.129November 16, 2016
Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF)CP.PHAR.297December 1, 2016
Fingolimod (Gilenya) (PDF)CP.PHAR.251August 1, 2016
Fondaparinux (Arixtra) (PDF)CP.PHAR.226May 1, 2016
Formulary Medications without Specific Guidelines (PDF)HIM.PA.33May 1, 2016
Fosdenopterin (PDF)CP.PHAR.471June 1, 2020
Fostamatinib (Tavalisse) (PDF)CP.PHAR.24June 5, 2018
Fluorouracil Cream (Tolak)(PDF)CP.PMN.165December 1, 2018
Fluticasone Propionate (Xhance) (PDF)CP.PMN.95October 24, 2017
Fulvestrant (Faslodex Injection)(PDF)CP.PHAR.424September 1, 2019
Galsulfase (Naglazyme) (PDF)CP.PHAR.161February 1, 2016
Gefitinib (Iressa) (PDF)CP.PHAR.68November 16, 2016
gemtuzumab ozogamicin (Mylotarg®) (PDF)CP.PHAR.358October 3, 2017
Gilteritinib (Xospata) (PDF)CP.PHAR.412January 15, 2019
Givosiran (Givlaari) (PDF)CP.PHAR.457March 1, 2020
Glasdegib (Daurismo) (PDF)CP.PHAR.413January 8, 2019
Glatiramer (Copaxone, Glatopa) (PDF)CP.PHAR.252August 1, 2016
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF)CP.CPA.16November 16, 2016
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF)HIM.PA.53March 1, 2018
Glycerol phenylbutyrate (Ravicti®) (PDF)CP.PHAR.207May 1, 2016
Golimumab (Simponi, Simponi Aria) (PDF)CP.PHAR.253July 1, 2016
Golodirsen (Vyondys 53) (PDF)CP.PHAR.453March 1, 2020
goserelin acetate (Zoladex®) (PDF)CP.PHAR.171November 9, 2017
Granisetron (Kytril, Sancuso, Sustol) (PDF)CP.PMN.74November 1, 2016
Halcinonide (Halog) (PDF)HIM.PA.20August 28, 2018
Hemin (Panhematin®) (PDF)CP.PHAR.181February 1, 2016
histrelin acetate (Vantas®, Supprelin LA®) (PDF)CP.PHAR.172November 9, 2017
Hyaluronate Derivatives (PDF)CP.PHAR.05October 1, 2008
Hydroxyprogesterone Caproate (Makena/compound)CP.PHAR.14November 20, 2017
Hydroxyurea (Siklos) (PDF)CP.PMN.193February 19, 2019
Ibalizumab-uiyk (Trogarzo) (PDF)CP.PHAR.378April 17, 2018
Ibandronate sodium (Boniva®) (PDF)CP.PHAR.189November 15, 2017
Ibrutinib (Imbruvica) (PDF)CP.PHAR.126October 1, 2015
Ibuprofen/Famotidine (Duexis) (PDF)CP.PMN.120June 1, 2018
Icatibant (Firazyr) (PDF)CP.PHAR.178March 1, 2016
Icosapent ethyl (Vascepa) (PDF)CP.PMN.187November 20, 2018
Idelalisib (Zydelig) (PDF)CP.PHAR.133December 1, 2018
Idecabtagene Vicleucel (BB2121) (PDF)CP.PHAR.481June 1, 2020
Idursulfase (Elaprase) (PDF)CP.PHAR.156February 1, 2016
Iloperidone (Fanapt) (PDF)CP.PMN.32December 1, 2014
Iloprost (Ventavis®) (PDF)CP.PHAR.193March 1, 2016
Imatinib (Gleevec) (PDF)CP.PHAR.65June 1, 2011
Imiglucerase (Cerezyme) (PDF)CP.PHAR.154February 1, 2016
Immune Globulins (PDF)CP.PHAR.103August 1, 2012
IncobotulinumtoxinA (Xeomin) (PDF)CP.PHAR.231July 1, 2016
Indacaterol/Glycopyrrolate (Utibron Neohaler) (PDF)HIM.PA.102September 1, 2018
Inebilizumab (PDF)CP.PHAR.458March 1, 2020
Infertility and Fertility Preservation (PDF)CP.PHAR.131November 16, 2016
Infliximab (Remicade, Inflectra, Renflexis) (PDF)CP.PHAR.254July 1, 2016
Inotersen (Tegsedi) (PDF)CP.PHAR.405November 20, 2018
inotuzumab ozogamicin (Besponsa®) (PDF)CP.PHAR.359September 26, 2017
Insulin Delivery Systems (V-Go, OmniPod, InPen) (PDF)CP.PHAR.534 June 1, 2021
Insulin Degludec (Tresiba) (PDF)HIM.PA.09March 1, 2019
Interferon beta-1a (Avonex, Rebif) (PDF)CP.PHAR.255August 1, 2016
Interferon beta-1b (Betaseron, Extavia) (PDF)CP.PHAR.256August 1, 2016
Interferon Gamma- 1b (Actimmune) (PDF)CP.PHAR.52June 1, 2010
Intrathecal Baclofen (Gablofen, Lioresal) (PDF)CP.PHAR.149November 9, 2017
Iobenguane I-131 (Azedra) (PDF)CP.PHAR.459March 1, 2020
Ipilimumab (Yervoy) (PDF)CP.PHAR.319April 17, 2018
irinotecan Liposome (Onivyde®) (PDF)CP.PHAR.304February 1, 2017
Iron sucrose (Venofer®) (PDF)CP.PHAR.167March 1, 2016
Isatuximab-irfc (Sarclisa)(PDF)CP.PHAR.482June 1, 2020
Isavuconazonium (Cresemba) (PDF)CP.PMN.154November 16, 2016
Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (PDF)CP.PMN.143December 1, 2014
Istradefylline (Nourianz) (PDF)CP.PMN.217March 1, 2020
Itraconazole (Sporanox, Onmel, Tolsura) (PDF)CP.PMN.124November 1, 2006
Ivabradine (Corlanor) (PDF)CP.PMN.70November 1, 2015
Ivacaftor (Kalydeco) (PDF)CP.PHAR.210May 1, 2016
Ivermectin (Sklice®) (PDF)HIM.PA.124December 1, 2017
Ivosidenib (Tibsovo) (PDF)CP.PHAR.137August 21, 2018
Ixazomib (Ninlaro) (PDF)CP.PHAR.302February 1, 2017
Lacosamide (Vimpat) (PDF)CP.PMN.155December 1, 2014
Lanadelumab-fylo (Takhzyro) (PDF)CP.PHAR.396September 25, 2018
Lanreotide (Somatuline Depot) (PDF)CP.PHAR.391August 14, 2018
lapatinib (Tykerb®) (PDF)CP.PHAR.79November 9, 2017
Laronidase (Aldurazyme) (PDF)CP.PHAR.152February 1, 2016
Larotrectinib (Vitrakvi) (PDF)CP.PHAR.414January 15, 2018
Lasmiditan (Reyvow) (PDF)CP.PMN.218March 1, 2020
Lefamulin (Xenleta) (PDF)CP.PMN.219March 1, 2020
Lemborexant (Dayvigo)(PDF)CP.PMN.233June 1, 2020
Lenalidomide (Revlimid) (PDF)CP.PHAR.71July 1, 2011
Lenvatinib (Lenvima) (PDF)CP.PHAR.138December 1, 2018
Lesinurad (Zurampic), Lesinurad/Allopurinol (Duzallo) (PDF)CP.PMN.150November 16, 2016
Letermovir (Prevymis) (PDF)CP.PHAR.367March 1, 2018
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF)CP.PHAR.173November 9, 2017
Levalbuterol (Xopenex HFA/Inhalation Solution) (PDF)CP.PMN.07September 1, 2006
Levoleucovorin (Fusilev®) (PDF)CP.PHAR.151November 9, 2017
Levomilnacipran (Fetzima) (PDF)HIM.PA.125November 9, 2017
Lidocaine Transdermal (Lidoderm, ZTlido) (PDF)CP.PMN.08September 1, 2006
Lifitegrast (Xiidra®) (PDF)CP.PMN.73November 9, 2017
Linaclotide (Linzess) (PDF)CP.PMN.71November 1, 2015
Linezolid (Zyvox) (PDF)CP.PMN.27September 1, 2016
Lofexidine (Lucemyra) (PDF)CP.PMN.152August 1, 2018
Lomustine (Gleostine) (PDF)HIM.PA.19August 28, 2018
Lorlatinib (Lorbrena) (PDF)CP.PHAR.406December 11, 2018
Lumacaftor-Ivacaftor (Orkambi) (PDF)CP.PHAR.213May 1, 2016
Lumateperone (Caplyta) (PDF)CP.PMN.232March 1, 2020
Lubiprostone (Amitiza) (PDF)CP.PMN.142December 1, 2014
Luliconazole Cream (Luzu) (PDF)CP.PMN.166August 28, 2018
Lumasiran (ALN-GO1) (PDF)CP.PHAR.473June 1, 2020
Luspatercept-aamt (Reblozyl) (PDF)CP.PHAR.450March 1, 2020
Lusutrombopag (Mulpleta) (PDF)CP.PHAR.407September 18, 2018
Lutetium Lu 177 Dotatate (Lutathera)(PDF)CP.PHAR.384May 22, 2018
Lurasidone (Latuda) (PDF)CP.PMN.50December 1, 2014
Macitentan (Opsumit) (PDF)CP.PCH.31September 1, 2020
Macitentan (Opsumit®) (PDF)CP.PHAR.194March 1, 2016
Mecamylamine (Vecamyl) (PDF)CP.PMN.136May 1, 2017
Mecasermin (Increlex) (PDF)CP.PHAR.150March 1, 2011
Medication Safety Policy (PDF)GA.PMN.22July 1, 2017
Megestrol Acetate (Megace ES) (PDF)CP.PMN.179December 1, 2018
Mepolizumab (Nucala) (PDF)CP.PHAR.200April 1, 2016
Methoxsalen (Uvadex) (PDF)HIM.PA.17September 4, 2018
Mometasone Furoate (Sinuva) (PDF)CP.PHAR.448March 1, 2020
Monomethyl Fumarate (Bafiertam) (PDF)CP.PHAR.460March 1, 2020
Montelukast oral granules (Singulair) (PDF)HIM.PA.129November 9, 2017
Mepolizumab (Nucala) (PDF)CP.PHAR.200April 1, 2016
Mesalamine (Apriso) (PDF)HIM.PA.42September 4, 2018
Metformin ER (Fortamet, Glumetza) (PDF)CP.PMN.72November 1, 2015
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF)CP.PHAR.134December 1, 2018
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF)CP.PHAR.238June 1, 2016
Methylnaltrexone Bromide (Relistor) (PDF)CP.PMN.169December 1, 2018
Metreleptin (Myalept) (PDF)CP.PHAR.425September 1, 2019
Midazolam (Nayzilam) (PDF)CP.PMN.211September 1, 2019
Midostaurin (Rydapt) (PDF)CP.PHAR.344June 1, 2017
Mifepristone (Korlym) (PDF)CP.PHAR.101May 1, 2012
Migalastat (Galafold) (PDF)CP.PHAR.394September 11, 2018
Miglustat (Zavesca) (PDF)CP.PHAR.164February 1, 2016
Milnacipran (Savella) (PDF)CP.PMN.125August 1, 2012
Minocycline ER (Solodyn, Ximino, Minolira) and Microspheres (Arestin) (PDF)CP.PMN.80May 1, 2017
Mitoxantrone (Novantrone) (PDF)CP.PHAR.258August 1, 2016
Modafinil (Provigil) (PDF)CP.PMN.39May 1, 2008
Mogamulizumab-kpkc (Poteligeo) (PDF)CP.PHAR.139September 4, 2018
Mometasone (Nasonex) (PDF)HIM.PA.9312/01/2014
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF)CP.PHAR.398October 16, 2018
Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)CC.PP.068December 16, 2020
Nadofaragene Firadenovec (Instiladrin) (PDF)CP.PHAR.461March 1, 2020
nafarelin acetate (Synarel®) (PDF)CP.PHAR.174November 9, 2017
Naltrexone (Vivitrol®) (PDF)CP.PHAR.96March 1, 2012
Naproxen/Esomeprazole (Vimovo) (PDF)CP.PMN.117June 1, 2018
Naproxen oral suspension (Naprosyn) (PDF)HIM.PA.130November 9, 2017
Natalizumab (Tysabri) (PDF)HIM.PA.SP17May 1, 2017
Nebivolol (Bystolic) (PDF)HIM.PA.131November 9, 2017
Necitumumab (Portrazza®) (PDF)CP.PHAR.320March 1, 2017
Neomycin/Fluocinolone Cream (Neo-Synalar)_(PDF)CP.PMN.167August 28, 2018
Neratinib (Nerlynx) (PDF)CP.PHAR.365September 5, 2017
Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan)  (PDF)CP.PMN.118February 13, 2018
Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (PDF)CP.PMN.158September 1, 2006
nilotinib (Tasigna) (PDF)CP.PHAR.76September 1, 2011 
Nintedanib (Ofev) (PDF)CP.PHAR.285October 1, 2016
Nitisinone (Nityr, Orfadin) (PDF)CP.PHAR.132August 28, 2018
Nivolumab (Opdivo) (PDF)CP.PHAR.121July 1, 2015
No Coverage Criteria/Off-Label Use Policy (PDF)CP.PMN.53September 12, 2017
Non-Formulary and Formulary Contraceptives (PDF)HIM.PA.100May 1, 2015
Non-Formulary Test Strips (PDF)HIM.PA.34February 1, 2016
Nusinersen (Spinraza®)(PDF)CP.PHAR.327November 28, 2017
Obeticholic (Ocaliva) (PDF)CP.PHAR.287November 1, 2016
Obinutuzumab (Gazyva®) (PDF)CP.PHAR.305February 1, 2017
Ocrelizumab (Ocrevus) (PDF)CP.PHAR.335April 1, 2017
Octreotide (Sandostatin, Sandostatin LAR) (PDF)CP.PHAR.40March 1, 2010
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia) (PDF)CP.PHAR.40March 1, 2010
ofatumumab (Arzerra®) (PDF)CP.PHAR.306February 1, 2017
Olanzapine Long-Acting Injection (Zyprexa Relprevv)(PDF)CP.PHAR.292December 1, 2016
Olaparib (Lynparza) (PDF)CP.PHAR.360October 3, 2017
olaratumab (Lartruvo®) (PDF)CP.PHAR.326March 1, 2017
Omadacycline (Nuzyra) (PDF)CP.PMN.188November 20, 2018
Omacetaxine (Synribo) (PDF)CP.PHAR.108April 1, 2013
Omalizumab (Xolair®) (PDF)CP.PHAR.01October 1, 2008
OnabotulinumtoxinA (Botox) (PDF)CP.PHAR.232July 1, 2016
Onasemnogene Abeparvovec (Zolgensma) (PDF)CP.PHAR.421June 7, 2019
Ondansetron (Zuplenz) (PDF)CP.PMN.45September 1, 2006
Ophthalmic Corticosteroids (PDF)HIM.PA.03January 1, 2020
Osimertinib (Tagrisso) (PDF)CP.PHAR.294December 1, 2016
Ospemifene (Osphena) (PDF)CP.PMN.168August 28, 2018
Overactive Bladder Agents (PDF)CP.PMN.198May 1, 2016
Ozanimod (PDF)CP.PHAR.462March 1, 2020
Ozenoxacin (Xepi) (PDF)CP.PMN.119January 30, 2018
Paclitaxel, Protein-Bound (Abraxane) (PDF)CP.PHAR.176July 1, 2015
Palbociclib (Ibrance®) (PDF)CP.PHAR.125October 1, 2015
Palivizumab (Synagis) (PDF)CP.PHAR.16August 1, 2009
panitumumab (Vectibix®) (PDF)CP.PHAR.321March 1, 2017
Parathyroid Hormone (Natpara) (PDF)CP.PHAR.282November 16, 2016
Paricalcitol Injection (Zemplar) (PDF)CP.PHAR.270August 1, 2016
Pasireotide (Signifor LAR®) (PDF)CP.PHAR.332March 1, 2017
Patisiran (Onpattro) (PDF)CP.PHAR.395September 11, 2018
Pazopanib (Votrient) (PDF)CP.PHAR.81October 1, 2011
Peanut Allergen Powder-dnfp (Palforzia) (PDF)CP.PMN.220March 1, 2020
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF)CP.PHAR.353September 5, 2017
Pegfilgrastim (Neulasta) (PDF)CP.PHAR.296December 1, 2016
peginterferon alfa-2b (PegIntron, Sylatron®) (PDF)CP.PHAR.89October 1, 2011
Peginterferon beta-1a (Plegridy) (PDF)CP.PHAR.271August 1, 2016
Pegloticase (Krystexxa®) (PDF)CP.PHAR.115June 1, 2013
Pegvaliase-pqpz (Palynziq) (PDF)CP.PHAR.140July 31, 2018
Pegvisomant (Somavert) (PDF)CP.PHAR.389December 1, 2018
pembrolizumab (Keytruda®) (PDF)CP.PHAR.322March 1, 2017
Pemetrexed (Alimta, Pemfexy) (PDF)CP.PHAR.368October 31, 2017
Perampanel (Fycompa) (PDF)CP.PMN.156November 16, 2016
Pertuzumab (Perjeta) (PDF)CP.PHAR.227June 1, 2016
Pexidartinib (Turalio) (PDF)CP.PHAR.436December 1, 2019
Pharmaceutical Management (PDF)GA.PHAR.03February 1, 2003
Pharmacy and Therapeutics Committee (PDF)HIM.PHAR.03February 1, 2014
Pharmacy Lock-In Program (PDF)GA.PHAR.26November 1, 2019
Pharmacy Prior Authorization and Medical Necessity Criteria (PDF)GA.PHAR.16July 9, 2010
Phendimetrazine IR (Bontril PDM) (PDF)HIM.PA.114May 1, 2017
Pitolisant (Wakix) (PDF)CP.PMN.221March 1, 2020
Plerixafor (Mozobil) (PDF)CP.PHAR.323March 1, 2017
Polatuzumab Vedotin-piiq (Polivy) (PDF)CP.PHAR.433September 1, 2019
Pomalidomide (Pomalyst) (PDF)CP.PHAR.116July 1, 2013
Ponatinib (Iclusig) (PDF)CP.PHAR.112June 1, 2013
Potassium Chloride for Oral Solution (Klor-Con Powder) (PDF)HIM.PA.143October 31, 2017
Pralatrexate (Folotyn®) (PDF)CP.PHAR.313February 1, 2017
Pramlintide (Symlin) (PDF)CP.PMN.129June 1, 2018
Pregabalin (Lyrica, Lyrica CR) (PDF)CP.PMN.33January 1, 2007
Pretomanid (PDF)CP.PMN.222March 1, 2020
Progesterone (Crinone, Endometrin) (PDF)CP.CPA.03November 16, 2016
Propranolol HCl Oral Solution (Hemangeol) (PDF)CP.PMN.58May 1, 2014
Protein C Concentrate, Human (Ceprotin) (PDF)CP.PHAR.330March 1, 2017
Prucalopride (Motegrity) (PDF)CP.PMN.194January 29, 2019
pyrimethamine (Daraprim®) (PDF)CP.PMN.44November 1, 2015
Quetiapine ER (Seroquel XR) (PDF)CP.PMN.64December 1, 2014
Ramucirumab (Cyramza®) (PDF)CP.PHAR.119May 1, 2015
Ranibizumab (Lucentis®) (PDF)CP.PHAR.186March 1, 2016
Rasagiline (Azilect®) (PDF)HIM.PA.89December 1, 2014
Regorafenib (Stivarga) (PDF)CP.PHAR.107December 1, 2012
Remestemcel-L (Prochymal) (PDF)CP.PHAR.474June 1, 2020
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF)CP.PHAR.168March 1, 2016
Reslizumab (Cinqair) (PDF)CP.PHAR.223May 1, 2016
Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF)CP.PHAR.141November 16, 2016
Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) (PDF)CP.PMN.223March 1, 2020
Rifamycin (Aemcolo) (PDF)CP.PMN.196January 8, 2019
rifaximin (Xifaxan®)(PDF)CP.PMN.47November 1, 2011
Rilonacept (Arcalyst) (PDF)CP.PHAR.266November 16, 2016
RimabotulinumtoxinB (Myobloc) (PDF)CP.PHAR.233July 1, 2016
Riociguat (Adempas®) (PDF)CP.PHAR.195March 1, 2016
Risdiplam (PDF)CP.PHAR.477June 1, 2020
Risedronate (Actonel, Atelvia) (PDF)CP.PMN.100March 1, 2018
Risperidone Long-Acting Injection (Risperdal Consta) (PDF)CP.PHAR.293December 1, 2016
Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF)CP.PHAR.260July 1, 2016
Rolapitant (Varubi) (PDF)CP.PMN.102February 1, 2017
romidepsin (Istodax®) (PDF)CP.PHAR.314January 1, 2017
Romiplostim (Nplate®) (PDF)CP.PHAR.179March 1, 2016
Romosozumab-aqqg (Evenity) (PDF)CP.PHAR.428September 1, 2019
Rucaparib (Rubraca®) (PDF)CP.PHAR.350Septemner 1, 2017
Rufinamide (Banzel) (PDF)CP.PMN.157December 1, 2014
Sacubitril/Valsartan (Entresto) (PDF)CP.PMN.67November 1, 2015
Sacitizumab Govitecan (PDF)CP.PHAR.475June 1, 2020
Safinamide (Xadago) (PDF)CP.PMN.113July 1, 2017
Sarecycline (Seysara) (PDF)CP.PMN.189November 13, 2018
Sargramostim (Leukine) (PDF)CP.PHAR.295December 1, 2016
Sapropterin Dihydrochloride (Kuvan) (PDF)CP.PHAR.43February 1, 2010
Satralizumab (PDF)CP.PHAR.463March 1, 2020
Secnidazole (Solosec) (PDF)CP.PMN.103October 24, 2017
Sebelipase Alfa (Kanuma) (PDF)CP.PHAR.159February 1, 2016
Selexipag (Uptravi®) (PDF)CP.PHAR.196March 1, 2016
Selinexor (Xpovio) (PDF)CP.PHAR.431September 1, 2019
Selpercatinib (LOXO-292) (PDF)CP.PHAR.478June 1, 2020
Selumetinib (Koselugo) (PDF)CP.PHAR.464March 1, 2020
Semaglutide (Rybelsus) (PDF)HIM.PA.02March 1, 2020
Sildenafil (Revatio®) (PDF)CP.PHAR.197March 1, 2016
Siltuximab (Sylvant®) (PDF)CP.PHAR.329March 1, 2017
Siponimod (Mayzent) (PDF)CP.PHAR.427September 1, 2019
Sipuleucel-T (Provenge) (PDF)CP.PHAR.120June 1, 2015
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF)CP.PMN.14January 1, 2015
sodium oxybate (Xyrem) (PDF)CP.PMN.42May 1, 2011
Sodium Phenylbutyrate (Buphenyl) (PDF)CP.PHAR.208May 1, 2016
Solriamfetol (Sunosi) (PDF)CP.PMN.209September 1, 2019
Somatropin (Growth Hormone) (PDF)CP.PHAR.55March 1, 2011
Somatropin (HGH) (PDF)CP.CPA.84November 16, 2016
Sonidegib (Odomzo) (PDF)CP.PHAR.272May 1, 2012
sorafenib (Nexavar) (PDF)CP.PHAR.69July 1, 2011
Spinosad (Natroba) (PDF)HIM.PA.134November 9, 2017
Step Therapy (PDF)HIM.PA.109August 1, 2017
Stiripentol (Diacomit) (PDF)CP.PMN.184September 25, 2018
Sucroferric Oxyhydroxide (Velphoro) (PDF)HIM.PA.SP30January 1, 2015
sunitinib (Sutent) (PDF)CP.PHAR.73September 1, 2011
Suvorexant (Belsomra®) (PDF)CP.PMN.109February 1, 2017
Tadalafil (Adcirca®) (PDF)CP.PHAR.198March 1, 2016
Tadalafil BHP - ED (Cialis) (PDF)CP.PMN.132June 1, 2018
Tafamidis (Vyndaqel, Vyndamax) (PDF)CP.PHAR.432September 1, 2019
Talazoparib (Talzenna) (PDF)CP.PHAR.409November 27, 2018
Taliglucerase Alfa (Elelyso) (PDF)CP.PHAR.157February 1, 2016
Tasimelteon (Hetlioz) (PDF)CP.PMN.104February 1, 2017
Tavaborole (Kerydin) (PDF)CP.PMN.105March 1, 2018
Tazemetostat (Tazverik) (PDF)CP.PHAR.452March 1, 2020
Tedizolid (Sivextro) (PDF)CP.PMN.62March 1, 2015
Teduglutide (Gattex) (PDF)CP.PHAR.114May 1, 2013
Tegaserod (Zelnorm) (PDF)CP.PMN.206September 1, 2019
Telotristat Ethyl (Xermelo) (PDF)CP.PHAR.337June 1, 2017
Temozolomide (Temodar) (PDF)CP.PHAR.77September 1, 2011
temsirolimus (Torisel®) (PDF)CP.PHAR.324March 1, 2017
Tenapanor (Ibsrela) (PDF)CP.PMN.224March 1, 2020
Teprotumumab (Tepezza) (PDF)CP.PHAR.465January 21, 2020
Teriparatide (Forteo®) (PDF)CP.PHAR.188November 15, 2017
Tesamorelin (Egrifta) (PDF)CP.PHAR.109March 1, 2014
Testosterone (Androderm) (PDF)HIM.PA.87December 1, 2014
Testosterone (Testopel, Jatenzo) (PDF)CP.PHAR.354August 1, 2017
tetrabenazine (Xenazine) (PDF)CP.PHAR.92December 1, 2011
Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF)CP.PHAR.377April 3, 2018
Thalidomide (Thalomid) (PDF)CP.PHAR.78September 1, 2011
Thioguanine (Tabloid) (PDF)CP.PHAR.437December 1, 2019
Thyrotropin Alfa (Thyrogen) (PDF) CP.PHAR.95March 1, 2012
Timothy grass pollen allergen extract (Grastek®) (PDF)CP.PMN.84August 31, 2017
Tisagenlecleucel (Kymriah) (PDF)CP.PHAR.361September 26, 2017
Tobramycin (Bethkis®, Kitabis Pak®, TOBI®, TOBI Podhaler®) (PDF)CP.PHAR.211May 1, 2016
Tocilizumab (Actemra) (PDF)CP.PHAR.263July 1, 2016
Tofacitinib (Xeljanz, Xeljanz Poor girl.XR) (PDF)CP.PHAR.267January 30, 2018
Tolvaptan (Jynarque) (PDF)CP.PHAR.27June 5, 2018
Topical Acne Treatment (PDF)HIM.PA.71December 1, 2014
Topical Diclofenac (Solaraze, Flector) (PDF)HIM.PA.123December 1, 2017
Topical Immunomodulators (PDF)CP.PMN.107September 1, 2006
Topotecan (Hycamtin)(PDF)CP.PHAR.64June 1, 2011
Trabectedin (Yondelis®) (PDF)CP.PHAR.204May 1, 2016
Trametinib (Mekinist) (PDF)CP.PHAR.240July 1, 2016
Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF)CP.PHAR.228June 1, 2016
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF)CP.PHAR.199June 1, 2016
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF)CP.PHAR.199 March 1, 2016
Triamcinolone ER Injection (Zilretta) (PDF)CP.PHAR.371March 1, 2018
Trientine (Syprine) (PDF)CP.PHAR.438December 1, 2019
Triptans (PDF)CP.CPA.217November 16, 2016
triptorelin pamoate (Trelstar®, Triptodur®) (PDF)CP.PHAR.175November 9, 2017
Ubrogepant (Ubrelvy) (PDF)CP.PHAR.476June 1, 2020
Unoprostone Isopropyl (Rescula) (PDF)HIM.PA.11September 4, 2018
Uridine acetate (Vistogard) (PDF)HIM.PA.SP55November 9, 2017
Ustekinumab (Stelara) (PDF)CP.PHAR.264August 1, 2016
Valoctocogene Roxaparvovec (PDF)CP.PHAR.466March 1, 2020
Valproate Sodium for Intravenous Injection (Depacon) (PDF)CP.PHAR.429September 1, 2019
Valrubicin (Valstar) (PDF)CP.PHAR.439December 1, 2019
Vandetanib (Caprelsa®) (PDF)CP.PHAR.80October 1, 2011
Velaglucerase Alfa (VPRIV) (PDF)CP.PHAR.163February 1, 2016
Vemurafenib (Zelboraf®) (PDF)CP.PHAR.91November 1, 2011
Verteporfin (Visudyne®) (PDF)CP.PHAR.187March 1, 2016
Vestronidase alfa-vjbk (Mepsevii) (PDF)CP.PHAR.374January 19, 2018
Vigabatrin (Sabril) (PDF)CP.PHAR.169February 1, 2016
Vilazodone (Viibryd) (PDF)CP.PMN.145August 1, 2012
Viltolarsen (PDF)CP.PHAR.484June 1, 2020
vincristine sulfate liposome injection (Marqibo®) (PDF)CP.PHAR.315February 1, 2017
Vismodegib (Erivedge) (PDF)CP.PHAR.273August 1, 2016
Vorapaxar (Zontivity) (PDF)HIM.PA.146October 31, 2017
Voretigene neparvovec-rzyl (Luxturna) (PDF)CP.PHAR.372March 1, 2018
Vorinostat (Zolinza) (PDF)CP.PHAR.83December 1, 2012
Vortioxetine (Trintellix®) (PDF)CP.PMN.65May 31, 2017
Voxelotor (Oxbryta) (PDF)CP.PHAR.451March 1, 2020
Zanubrutinib (Brukinsa) (PDF)CP.PHAR.467March 1, 2020
ziv-aflibercept (Zaltrap®) (PDF)CP.PHAR.325March 1, 2017
Zoledronic acid (Reclast, Zometa) (PDF)CP.PHAR.59March 1, 2011

MEDICAID SPECIALTY PHARMACY POLICIES

POLICY TITLEPOLICY NUMBEREFFECTIVE DATE
340B Shared Savings Model (PDF)GA.PHAR.20April 1, 2017
72 Hour Supply of Medication (PDF)CC.PHAR.01April 1, 2007
Abaloparatide (Tymlos) (PDF)CP.PHAR.345July 1, 2017
abatacept (Orencia) (PDF)CP.PHAR.241August 1, 2016
Abiraterone (Zytiga) (PDF)CP.PHAR.84October 1, 2011
Abiraterone (Zytiga, Yonsa) (PDF)CP.PHAR.84October 1, 2011
AbobotulinumtoxinA (Dysport) (PDF)CP.PHAR.230July 1, 2016
Adalimumab (Humira) (PDF)CP.PHAR.242August 1, 2016
Addendum (PDF)CC.PHAR.10April 1, 2007
Adefovir (Hepsera) (PDF)CP.PHAR.142August 28, 2018
Aducanumab (PDF)CP.PHAR.468June 1, 2020
Afatinib (Gilotrif) (PDF)CP.PHAR.298January 1, 2017
Aflibercept (Eylea®) (PDF)CP.PHAR.184March 1, 2016
Agalsidase Beta (Fabrazyme) (PDF)CP.PHAR.158February 1, 2016
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF)CP.PMN.138March 13, 2018
Age Limit for Tazarotene (Tazorac, Arazlo) (PDF)CP.PMN.244November 9, 2017
Alectinib (Alecensa) (PDF)CP.PHAR.369November 16, 2016
Alemtuzumab (Lemtrada) (PDF)CP.PHAR.243August 1, 2016
Alendronate (Binosto, Fosamax plus D) (PDF)CP.PMN.88March 1, 2018
Alglucosidase Alfa (Lumizyme) (PDF)CP.PHAR.160February 1, 2016
Alirocumab (Praluent) (PDF)CP.PHAR.124October 1, 2015
Alpelisib (Piqray) (PDF)CP.PHAR.430September 1, 2019
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF)CP.PHAR.94March 1, 2012
Ambrisentan (Letairis®) (PDF)CP.PHAR.190March 1, 2016
Amifampridine (Firdapse, Ruzurgi) (PDF)CP.PHAR.411January 22, 2019
Amikacin (Arikayce) (PDF)CP.PHAR.401November 13, 2018
Anakinra (Kineret) (PDF)CP.PHAR.244August 1, 2016
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF)CP.PHAR.217May 1, 2016
Apalutamide (Erleada) (PDF)CP.PHAR.376June 1, 2018

Appropriate Use and Safety Edits (PDF)

Appropriate Use and Safety Edits: Attachment A (PDF)

GA.PMN.01May 1, 2012
Apremilast (Otezla) (PDF)CP.PHAR.245August 1, 2016
Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF)CP.PMN.19November 30, 2016
Arformoterol Tartrate (Brovana) (PDF)CP.PMN.259September 1, 2019
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF)CP.PHAR.290December 1, 2016
Armodafinil (Nuvigil) (PDF)CP.PMN.35August 1, 2009
Asenapine (Saphris, Secuado) (PDF)CP.PMN.15December 1, 2014
asfotase alfa (Strensiq®) (PDF)CP.PHAR.328March 1, 2017
Aspirin-dipyridamole (Aggrenox) (PDF)CP.PMN.20September 1, 2006
Atezolizumab (Tecentriq®) (PDF)CP.PHAR.235June 1, 2016
Avapritinib (Ayvakit) (PDF)CP.PHAR.454March 1, 2020
Avatrombopag (Doptelet) (PDF)CP.PHAR.130July 17, 2018
Avelumab (Bavencio®) (PDF)CP.PHAR.333May 1, 2017
Axicabtagene Ciloleucel (Yescarta) (PDF)CP.PHAR.362October 31, 2017
Axitinib (Inlyta®) (PDF)CP.PHAR.100May 1, 2012
Azacitidine (Vidaza) (PDF)CP.PHAR.387August 28, 2017
Aztreonam (Cayston®) (PDF)CP.PHAR.209May 1, 2016
Baclofen (Gablofen, Lioresal, Ozobax) (PDF)CP.PHAR.149November 9, 2017
Baloxavir Marboxil (Xofluza) (PDF)CP.PMN.185October 30, 2018
Bedaquiline (Sirturo) (PDF)CP.PMN.212December 1, 2019
belatacept (Nulojix®) (PDF)CP.PHAR.201November 9, 2017
Belantamab Mafodotin (PDF)CP.PHAR.469June 1, 2020
Belimumab (Benlysta) (PDF)CP.PHAR.88October 1, 2011
belinostat (Beleodaq®) (PDF)CP.PHAR.311February 1, 2017
Bendamustine (Bendeka®, Treanda®) (PDF)CP.PHAR.307February 1, 2017
Benralizumab (Fasenra) (PDF)CP.PHAR.373January 16, 2018
Benzodiazepine Use in Pediatric Seizure Disorders (PDF)GA.PMN.08March 1, 2016
Benznidazole (PDF)CP.PMN.90October 17, 2017
Berotralstat (PDF)CP.PHAR.485June 1, 2020
Betaine (Cystadane) (PDF)CP.PHAR.143August 28, 2018
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF)CP.PHAR.93November 1, 2011
Bexarotene (Targretin) (PDF)CP.PHAR.75September 1, 2011
Bezlotoxumab (Zinplava) (PDF)CP.PHAR.300November 16, 2016
Bimatoprost Implant (Durysta) (PDF)CP.PHAR.486June 1, 2020
Binimetinib (Mektovi) (PDF)CP.PHAR.50July 24, 2018
Biologic Drug Dose Escalation (PDF)GA.PMN.21September 1, 2017
Blinatumomab (Blincyto) (PDF)CP.PHAR.312February 1, 2017
Blocking Adjudication of Controlled Substance Prescriptions for Selected Prescribers (PDF)GA.PHAR.19November 1, 2001
Bortezomib (Velcade) (PDF)CP.PHAR.410December 11, 2018
Bosentan (Tracleer®) (PDF)CP.PHAR.191March 1, 2016
Bosutinib (Bosulif) (PDF)CP.PHAR.105October 1, 2012
Brentuximab Vedotin (Adcetris) (PDF)CP.PHAR.303February 1, 2017
Brexanolone (Zulresso) (PDF)CP.PHAR.417April 16, 2019
Brexpiprazole (Rexulti) (PDF)CP.PMN.68November 5, 2015
Brexucabtagene Autoleucel (Tecartus) (PDF)
CP.PHAR.472June 1, 2020
Brigatinib (Alunbrig) (PDF)CP.PHAR.342July 17, 2017
Brimonidine Tartrate (Mirvaso) (PDF)CP.PMN.192November 16, 2016
Brolucizumab-dbll (Beovu) (PDF)CP.PHAR.445March 1, 2020
Buprenorphine Implant/Injection (Probuphine, Sublocade) (PDF)CP.PHAR.289November 16, 2016
Buprenorphine implant (Probuphine) (PDF)CP.PHAR.289November 16, 2016
Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF)CP.PMN.81September 1, 2017
Buprenorphine (Subutex) (PDF)CP.PMN.82September 1, 2017
Burosumab-twza (Crysvita)(PDF)CP.PHAR.11May 8, 2018
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF)CP.PHAR.202March 1, 2016
C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF)CP.PHAR.202March 1, 2016
cabazitaxel (Jevtana® (PDF)CP.PHAR.316February 1, 2017
Cabozantinib (Cometriq®, Cabometyx®) (PDF)CP.PHAR.111June 1, 2013
Cannabidiol (Epidiolex) (PDF)CP.PMN.164July 17, 2018
Canakinumab (Ilaris) (PDF)CP.PHAR.246August 1, 2016
capecitabine (Xeloda) (PDF)CP.PHAR.60May 1, 2011
Caplacizumab-yhdp (Cablivi) (PDF)CP.PHAR.416March 12, 2019
carfilzomib (Kyprolis®) (PDF)CP.PHAR.309February 1, 2017
Carglumic acid (Carbaglu®) (PDF)CP.PHAR.206May 1, 2016
Casimersen (PDF)CP.PHAR.470June 1, 2020
Cedazuridine/Decitabine (ASTX-727) (PDF)CP.PHAR.479June 1, 2020
Celecoxib (Celebrex, Elyxyb) (PDF)CP.PMN.122January 1, 2007
Cenegermin-bkbj (Oxervate) (PDF)CP.PMN.186October 9, 2018
Cenobamate (Xcopri) (PDF)CP.PMN.231March 1, 2020
Cemiplimab-rwlc (Libtayo) (PDF)CP.PHAR.397October 16, 2018
Ceritinib (Zykadia) (PDF)CP.PHAR.349July 1, 2017
Cerliponase alfa (Brineura) (PDF)CP.PHAR.338July 1, 2017
Certolizumab (Cimzia) (PDF)CP.PHAR.247August 1, 2016
Cetuximab (Erbitux®) (PDF)CP.PHAR.317February 1, 2017
Chloramphenicol Sodium Succinate (PDF)CP.PHAR.388December 1, 2018
Cholic Acid (Cholbam) (PDF)CP.PHAR.390December 1, 2018
Cinacalcet (Sensipar) (PDF)CP.PHAR.61May 1, 2011
Cladribine (Mavenclad) (PDF)CP.PHAR.422September 1, 2019
Clinical Pharmacy Services Inter-rater Reliability (PDF)GA.PHAR.04April 1, 2021
Clobazam (Onfi) (PDF)CP.PMN.54November 1, 2012
CNS Stimulants (PDF)CP.PMN.92March 1, 2018
Cobimetinib (Cotellic) (PDF)CP.PHAR.380November 16, 2016
Collagenase (Xiaflex) (PDF)CP.PHAR.82October 1, 2011
Continuous Glucose Monitors (PDF)CP.PMN.214December 1, 2019
copanlisib (Aliqopa®) (PDF)CP.PHAR.357October 17, 2017
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF)CP.PHAR.385May 29, 2018
Cosyntropin (Cortrosyn®) (PDF)CP.PHAR.203April 1, 2016
Crisaborole (Eucrisa) (PDF)CP.PMN.110February 21, 2017
Crizanlizumab-tmca (Adakveo) (PDF)CP.PHAR.449March 1, 2020
Crizotinib (Xalkori) (PDF)CP.PHAR.90November 1, 2011
Cyclosporine (Cequa, Restasis) (PDF)CP.PMN.48May 1, 2012
Cysteamine ophthalmic (Cystaran) (PDF)CP.PMN.130August 1, 2017
Cysteamine oral (Cystagon, Procysbi) (PDF)CP.PHAR.155February 1, 2016
Cytomegalovirus Immune Globulin (Cytogam)(PDF)CP.PHAR.277September 1, 2018
Dabrafenib (Tafinlar) (PDF)CP.PHAR.239November 16, 2016
Daclatasvir (Daklinza) (PDF)CP.PHAR.278September 1, 2016
Dacomitinib (Vizimpro) (PDF)CP.PHAR.399October 16, 2018
Dalfampridine (Ampyra) (PDF)CP.PHAR.248August 1, 2016
Dalteparin (Fragmin) (PDF)CP.PHAR.225May 1, 2016
Daptomycin (Cubicin, Cubicin RF) (PDF)CP.PHAR.351November 30, 2017
Daratumumab (Darzalex) (PDF)CP.PHAR.310July 1, 2017
Darbepoetin Alfa (Aranesp) (PDF)CP.PHAR.236June 1, 2016
Darolutamide (Nubeqa) (PDF)
CP.PHAR.435December 1, 2019
Dasabuvir Ombitasvir Paritaprevir Ritonavir (Viekira XR, Viekira Pak) (PDF)GA.PMN.12December 1, 2016
Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira XR, Viekira Pak) (PDF)CP.PHAR.278September 1, 2016
Dasatinib (Sprycel) (PDF)CP.PHAR.72June 1, 2012
daunorubicin/cytarabine (Vyxeos®) (PDF)CP.PHAR.352December 1, 2017
Deferasirox (Exjade Jadenu) (PDF)CP.PHAR.145November 1, 2015
Deferiprone (Ferriprox) (PDF)CP.PHAR.147November 1, 2015
Deferoxamine (Desferal) (PDF)CP.PHAR.146November 1, 2015
Deflazacort (Emflaza) (PDF)CP.PHAR.331March 1, 2017
Degarelix acetate (Firmagon®) (PDF)CP.PHAR.170November 9, 2017
Denosumab (Prolia, Xgeva) (PDF)CP.PHAR.58March 1, 2011
Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF)CP.PHAR.214May 1, 2016
Deutetrabenazine (Austedo) (PDF)CP.PHAR.341June 13, 2017
Dexrazoxane (Zinecard, Totect) (PDF)CP.PHAR.418March 19, 2019
Dextromethorphan-Quinidine (Nuedexta) (PDF)CP.PMN.93March 1, 2018
Diazepam Nasal Spray (Valtoco) (PDF)CP.PMN.216December 1, 2019
Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity) (PDF)CP.PHAR.249August 1, 2016
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF)CP.PMN.03September 19, 2018
Dolasetron (Anzemet) (PDF)CP.PMN.141September 1, 2006
Dornase alfa (Pulmozyme) (PDF)CP.PHAR.212May 1, 2016
Dose Escalation of Biologics (PDF)GA.PMN.21September 1, 2017
Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF)CP.PMN.79May 1, 2017
droxidopa (Northera®) (PDF)CP.PMN.17November 9, 2017
Dupilumab (Dupixent) (PDF)CP.PHAR.336May 1, 2017
Durvalumab (Imfinzi) (PDF)CP.PHAR.339July 1, 2017
Duvelisib (Copiktra) (PDF)CP.PHAR.400October 16, 2018
Early and Periodic Screening, Diagnostic, and Treatment Benefit for Pediatric Members (PDF)CP.PMN.234June 1, 2020
Ecallantide (Kalbitor®) (PDF)CP.PHAR.177March 1, 2016
Eculizumab (Soliris®) (PDF)CP.PHAR.97March 1, 2012
Edaravone (Radicava) (PDF)CP.PHAR.343July 1, 2017
Efinaconazole (Jublia) (PDF)CP.PMN.25August 1, 2016
Elagolix (Orilissa) (PDF)CP.PHAR.136August 28, 2018
Elapegademase-lvlr (Revcovi) (PDF)CP.PHAR.419April 23, 2019
Elbasvir/Grazoprevir (Zepatier) (PDF)GA.PMN.16December 1, 2016
Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (PDF)GA.PMN.04December 1, 2019
Eliglustat (Cerdelga) (PDF)CP.PHAR.153February 1, 2016
Elosulfase Alfa (Vimizim) (PDF)CP.PHAR.162February 1, 2016
Elotuzumab (Empliciti®)CP.PHAR.308February 1, 2017
Eltrombopag (Promacta®) (PDF)CP.PHAR.180March 1, 2016
Emapalumab-lzsg (Gamifant) (PDF)CP.PHAR.402December 11, 2018
Emicizumab-kxwh (Hemlibra) (PDF)CP.PHAR.370March 1, 2018
Emtricitabine/Tenofovir Alafenamide (Descovy)(PDF)CP.PMN.235June 1, 2020
Enasidenib (Idhifa) (PDF)CP.PHAR.363September 5, 2017
Encorafenib (Braftovi) (PDF)CP.PHAR.127July 24, 2018
Enfortumab Vedotin-ejfv (Padcev) (PDF)CP.PHAR.455March 1, 2020
Enfuvirtide (Fuzeon) (PDF)CP.PHAR.41June 1, 2010
Enoxaparin (Lovenox) (PDF)CP.PHAR.224May 1, 2016
Entrectinib (Rozlytrek) (PDF)CP.PHAR.441December 1, 2019
Enzalutamide (Xtandi) (PDF)CP.PHAR.106October 1, 2012
EoE (PDF)GA.PMN.11September 1, 2016
Epinephrine Injection Device - Quantity Limit Override (PDF)GA.PMN.03March 1, 2015
Epoetin Alfa (Epogen® and Procrit) (PDF)CP.PHAR.237June 1, 2016
Epoprostenol (Flolan®), Veletri®) (PDF)CP.PHAR.192March 1, 2016
Erdafitinib (Balversa)(PDF)CP.PHAR.423September 1, 2019
Erenumab-aaoe (Aimovig) (PDF)CP.PHAR.128July 10, 2018
Eribulin Mesylate (Halaven®) (PDF)CP.PHAR.318March 1, 2017
Erlotinib (Tarceva) (PDF)CP.PHAR.74September 1, 2011
Erwinia Asparaginase (Erwinaze) (PDF)CP.PHAR.301February 1, 2017
Esketamine (Spravato) (PDF)CP.PMN.199March 12, 2019
Etanercept (Enbrel) (PDF)CP.PHAR.250August 1, 2016
Etelcalcetide (Parsabiv) (PDF)CP.PHAR.379March 20, 2018
Eteplirsen (Exondys 51) (PDF)CP.PHAR.288December 1, 2016
Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF)CP.PHAR.63June 1, 2011
Evolocumab (Repatha) (PDF)CP.PHAR.123October 1, 2015
Factor IX (Human, Recombinant) (PDF)CP.PHAR.218May 1, 2016
Factor IX Complex, Human (Profilnine) (PDF)CP.PHAR.219May 1, 2016
Factor IX Complex Human (Bebulin®, Profilnine®) (PDF)CP.PHAR.219May 1, 2016
Factor VIII (Human Recombinant) (PDF)CP.PHAR.215May 1, 2016
Factor VIII/von Willebrand Factor Complex (Human - Alphanate, Humate-P, Wilate) (PDF)CP.PHAR.216May 1, 2016
Factor VIIa, Recombinant (NovoSeven® RT) (PDF)CP.PHAR.220May 1, 2016
Factor XIII A-Subunit, Recombinant (Tretten®) (PDF)CP.PHAR.222May 1, 2016
Factor XIII, Human (Corifact®) (PDF)CP.PHAR.221May 1, 2016
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF)CP.PHAR.456March 1, 2020
Febuxostat (Uloric) (PDF)CP.PMN.57August 1, 2013
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF)CP.PMN.127June 1, 2015
Ferric Carboxymaltose (Injectafer) (PDF)CP.PHAR.234June 1, 2016
Ferumoxytol (Feraheme®) (PDF)CP.PHAR.165March 1, 2016
Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF)CP.PHAR.297December 1, 2016
Fingolimod (Gilenya) (PDF)CP.PHAR.251August 1, 2016
Fondaparinux (Arixtra) (PDF)CP.PHAR.226May 1, 2016
Fosdenopterin (PDF)CP.PHAR.471June 1, 2020
Fostamatinib (Tavalisse) (PDF)CP.PHAR.24June 5, 2018
Fluorouracil Cream (Tolak(PDF)CP.PMN.165December 1, 2018
Fluticasone Propionate (Xhance) (PDF)CP.PMN.95October 24, 2017
Fluticasone/Vilanterol (Breo Ellipta) (PDF)CP.PMN.259March 1, 2020
Fremanezumab-vfrm (Ajovy) (PDF)CP.PHAR.403October 30, 2018
Fulvestrant (Faslodex Injection)(PDF)CP.PHAR.424September 1, 2019
Galcanezumab-gnlm (Emgality) (PDF)CP.PHAR.404November 13, 2018
Galsulfase (Naglazyme) (PDF)CP.PHAR.161February 1, 2016
Gefitinib (Iressa) (PDF)CP.PHAR.68November 16, 2016
gemtuzumab ozogamicin (Mylotarg®) (PDF)C.PHAR.358October 3, 2017
Gilteritinib (Xospata) (PDF)CP.PHAR.412January 15, 2019
Givosiran (Givlaari) (PDF)CP.PHAR.457March 1, 2020
Glasdegib (Daurismo) (PDF)CP.PHAR.413January 8, 2019
Glatiramer (Copaxone, Glatopa) (PDF)CP.PHAR.252Augustt 1, 2016
Glecaprevir/pibrentasvir (Mavyret) (PDF)GA.PMN.24September 1, 2017
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF)CP.PMN.183September 19, 2018
Glycerol phenylbutyrate (Ravicti®) (PDF)CP.PHAR.207May 1, 2016
Golimumab (Simponi, Simponi Aria) (PDF)CP.PHAR.253July 1, 2016
Golodirsen (Vyondys 53) (PDF)GA.PMN.30March 1, 2020
goserelin acetate (Zoladex®) (PDF)CP.PHAR.171November 9, 2017
Granisetron (Kytril, Sancuso, Sustol) (PDF)CP.PMN.74November 1, 2016
Hemin (Panhematin®) (PDF)CP.PHAR.181Februay 1, 2016
histrelin acetate (Vantas®, Supprelin LA®) (PDF)CP.PHAR.172November 9, 2017
Human Growth Hormone (Somapacitan, Somatropin) (PDF)GA.PMN.28January 1, 2022
Hyaluronate Derivatives (PDF)CP.PHAR.05October 1, 2008
Hydroxyprogesterone Caproate (Makena/compound)CP.PHAR.14November 20, 2017
Hydroxyurea (Siklos) (PDF)CP.PMN.193February 19, 2019
Ibalizumab-uiyk (Trogarzo) (PDF)CP.PHAR.378April 17, 2018
Ibandronate sodium (Boniva®) (PDF)CP.PHAR.189November 15, 2017
Ibrutinib (Imbruvica) (PDF)CP.PHAR.126October 1, 2015
Ibuprofen/Famotidine (Duexis) (PDF)CP.PMN.120June 1, 2018
Icatibant (Firazyr) (PDF)CP.PHAR.178March 1, 2016
Icosapent ethyl (Vascepa) (PDF)CP.PMN.187November 20, 2018
Idecabtagene Vicleucel (BB2121) (PDF)CP.PHAR.481June 1, 2020
Idelalisib (Zydelig) (PDF)CP.PHAR.133December 1, 2018
Idursulfase (Elaprase) (PDF)CP.PHAR.156February 1, 2016
Iloperidone (Fanapt) (PDF)CP.PMN.32December 1, 2014
Iloprost (Ventavis®) (PDF)CP.PHAR.193March 1, 2016
Imatinib (Gleevec) (PDF)CP.PHAR.65June 1, 2011
Imiglucerase (Cerezyme) (PDF)CP.PHAR.154February 1, 2016
Immune Globulins (PDF)CP.PHAR.103August 1, 2012
IncobotulinumtoxinA (Xeomin) (PDF)CP.PHAR.231July 1, 2016
Inebilizumab (PDF)CP.PHAR.458March 1, 2020
Infertility and Fertility Preservation (PDF)CP.PHAR.131November 16, 2016
Infliximab (Remicade, Inflectra, Renflexis) (PDF)CP.PHAR.254July 1, 2016
Inotersen (Tegsedi) (PDF)CP.PHAR.405November 20, 2018
inotuzumab ozogamicin (Besponsa®) (PDF)CP.PHAR.359September 26, 2017
Insulin Delivery Systems (V-Go, OmniPod, InPen) (PDF)CP.PHAR.534 June 1, 2021
Interferon beta-1a (Avonex, Rebif) (PDF)CP.PHAR.255August 1, 2016
Interferon beta-1b (Betaseron, Extavia) (PDF)CP.PHAR.256August 1, 2016
Interferon Gamma- 1b (Actimmune) (PDF)CP.PHAR.52June 1, 2010
Itraconazole (Sporanox, Onmel, Tolsura) (PDF)CP.PMN.124November 1, 2006
Intrathecal Baclofen (Gablofen, Lioresal) (PDF)CP.PHAR.149November 9, 2017
Iobenguane I-131 (Azedra) (PDF)CP.PHAR.459March 1, 2020
Ipilimumab (Yervoy) (PDF)CP.PHAR.319April 17, 2018
irinotecan Liposome (Onivyde®) (PDF)CP.PHAR.304February 1, 2017
Isatuximab-irfc (Sarclisa)(PDF)CP.PHAR.482June 1, 2020
Isavuconazonium (Cresemba) (PDF)CP.PMN.154November 16, 2016
Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (PDF)CP.PMN.143December 1, 2014
Istradefylline (Nourianz) (PDF)CP.PMN.217March 1, 2020
Ivabradine (Corlanor) (PDF)CP.PMN.70November 1, 2015
Ivacaftor (Kalydeco) (PDF)CP.PHAR.210May 1, 2016
Ivosidenib (Tibsovo) (PDF)
CP.PHAR.137August 21, 2018
Ixazomib (Ninlaro) (PDF)CP.PHAR.302February 1, 2017
Ixekizumab (Taltz) (PDF)CP.PHAR.257August 1, 2016
Lacosamide (Vimpat) (PDF)CP.PMN.155December 1, 2014
Lanadelumab-fylo (Takhzyro) (PDF)CP.PHAR.396September 25, 2018
Lanreotide (Somatuline Depot) (PDF)CP.PHAR.391August 28, 2018
lapatinib (Tykerb®) (PDF)CP.PHAR.79November 9, 2017
Laronidase (Aldurazyme) (PDF)CP.PHAR.152February 1, 2016
Larotrectinib (Vitrakvi) (PDF)CP.PHAR.414January 15, 2018
Lasmiditan (Reyvow) (PDF)CP.PMN.218March 1, 2020
Ledipasvir/Sofosbuvir (Harvoni) (PDF)GA.PMN.13December 1, 2016
Ledipasvir/Sofosbuvir (Harvoni) (PDF)CP.PHAR.279September 1, 2016
Lefamulin (Xenleta) (PDF)CP.PMN.219March 1, 2020
Lenalidomide (Revlimid) (PDF)CP.PHAR.71July 1, 2011
Lenvatinib (Lenvima) (PDF)CP.PHAR.138December 1, 2018
Letermovir (Prevymis) (PDF)CP.PHAR.367March 1, 2018
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF)CP.PHAR.173November 9, 2017
Levoleucovorin (Fusilev®) (PDF)CP.PHAR.151November 9, 2017
Levofloxacin (Levaquin) in Pediatric Community Acquired Pneumonia (PDF)GA.PMN.05March 1, 2016
Lidocaine Transdermal (Lidoderm, ZTlido) (PDF)CP.PMN.08September 1, 2006
Linaclotide (Linzess) (PDF)CP.PMN.71November 1, 2015
Linezolid (Zyvox) (PDF)CP.PMN.27September 1, 2016
Lifitegrast (Xiidra®) (PDF)CP.PMN.73November 9, 2017
Lofexidine (Lucemyra) (PDF)CP.PMN.152August 1, 2018
Lomitapide (Juxtapid) (PDF)CP.PHAR.283October 1, 2016
Lorlatinib (Lorbrena) (PDF)CP.PHAR.406December 11, 2018
Lubiprostone (Amitiza) (PDF)CP.PMN.142December 1, 2014
Luliconazole Cream (Luzu) (PDF)CP.PMN.166August 28, 2018
Lumacaftor-Ivacaftor (Orkambi) (PDF)CP.PHAR.213May 1, 2016
Lumasiran (ALN-GO1) (PDF)CP.PHAR.473June 1, 2020
Lumateperone (Caplyta) (PDF)CP.PMN.232March 1, 2020
Lurasidone (Latuda) (PDF)CP.PMN.50December 1, 2014
Luspatercept-aamt (Reblozyl) (PDF)CP.PHAR.450March 1, 2020
Lusutrombopag (Mulpleta) (PDF)CP.PHAR.407September 18, 2018
Lutetium Lu 177 Dotatate (Lutathera)(PDF)CP.PHAR.384May 22, 2018
Macitentan (Opsumit®) (PDF)CP.PHAR.194March 1, 2016
Maximum Allowable Cost Requirement (PDF)GA.PHAR.21July 1, 2017
Mecasermin (Increlex) (PDF)CP.PHAR.150March 1, 2011
Mecamylamine (Vecamyl) (PDF)CP.PMN.136May 1, 2017
Medication Safety Policy (PDF)GA.PMN.22July 1, 2017
Megestrol Acetate (Megace ES) (PDF)CP.PMN.179December 1, 2018
Mepolizumab (Nucala) (PDF)CP.PHAR.200April 1, 2016
Metformin ER (Fortamet, Glumetza) (PDF)CP.PMN.72November 1, 2015
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF)CP.PHAR.134December 1, 2018
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF)CP.PHAR.238June 1, 2016
Methylnaltrexone Bromide (Relistor) (PDF)CP.PMN.169December 1, 2018
Metreleptin (Myalept) (PDF)CP.PHAR.425September 1, 2019
Midazolam (Nayzilam) (PDF)CP.PMN.211September 1, 2019
Midostaurin (Rydapt) (PDF)CP.PHAR.344June 1, 2017
Mifepristone (Korlym) (PDF)CP.PHAR.101May 1, 2012
Migalastat (Galafold) (PDF)CP.PHAR.394September 11, 2018
Miglustat (Zavesca) (PDF)CP.PHAR.164February 1, 2016
Milnacipran (Savella) (PDF)CP.PMN.125August 1, 2012
Minocycline ER (Solodyn, Ximino, Minolira) and Microspheres (Arestin) (PDF)CP.PMN.80May 1, 2017
Mitoxantrone (Novantrone) (PDF)CP.PHAR.258August 1, 2016
Modafinil (Provigil) (PDF)CP.PMN.39May 1, 2008
Mogamulizumab-kpkc (Poteligeo) (PDF)CP.PHAR.139September 4, 2018
Mometasone/Formoterol (Dulera) (PDF)CP.PMN.259March 1, 2020
Mometasone Furoate (Sinuva) (PDF)CP.PHAR.448March 1, 2020
Monomethyl Fumarate (Bafiertam) (PDF)CP.PHAR.249March 1, 2020
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF)CP.PHAR.39810/16/2018
Nadofaragene Firadenovec (Instiladrin) (PDF)CP.PHAR.461March 1, 2020
nafarelin acetate (Synarel®) (PDF)CP.PHAR.17411/09/2017
Naproxen/Esomeprazole (Vimovo) (PDF)CP.PMN.11706/01/2018
Natalizumab (Tysabri) (PDF)CP.PHAR.25907/01/2016
Necitumumab (Portrazza®) (PDF)CP.PHAR.320March 1, 2017
Neomycin/Fluocinolone Cream (Neo-Synalar)_(PDF)CP.PMN.167August 28, 2018
Neratinib (Nerlynx) (PDF)CP.PHAR.365September 5, 2017
Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan)  (PDF)CP.PMN.86February 13, 2018
Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (PDF)CP.PMN.158September 1, 2006
nilotinib (Tasigna) (PDF)CP.PHAR.76September 1, 2011
Nintedanib (Ofev) (PDF)CP.PHAR.285October 1, 2016
Nitisinone (Nityr, Orfadin) (PDF)CP.PHAR.132August 28, 2018
Nivolumab (Opdivo) (PDF)CP.PHAR.121July 1, 2015
No Coverage Criteria/Off-Label Use Policy (PDF)CP.PMN.53September 12, 2017
Nusinersen (Spinraza®)(PDF)CP.PHAR.327November 28, 2017
Obeticholic (Ocaliva) (PDF)CP.PHAR.287November 1, 2016
Obinutuzumab (Gazyva®) (PDF)CP.PHAR.305Februay 1, 2017
Ocrelizumab (Ocrevus) (PDF)CP.PHAR.335April 1, 2017
Octreotide (Sandostatin, Sandostatin LAR) (PDF)CP.PHAR.40March 1, 2010
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia) (PDF)CP.PHAR.40March 1, 2010
ofatumumab (Arzerra®) (PDF)CP.PHAR.306February 1, 2017
Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF)CP.PHAR.292December 1, 2016
Olaparib (Lynparza) (PDF)CP.PHAR.360October 3, 2017
olaratumab (Lartruvo®) (PDF)CP.PHAR.326March 1, 2017
Omadacycline (Nuzyra) (PDF)CP.PMN.188November 20, 2018
Omacetaxine (Synribo) (PDF)CP.PHAR.108April 1, 2013
Omalizumab (Xolair®) (PDF)CP.PHAR.01October 1, 2008
OnabotulinumtoxinA (Botox) (PDF)CP.PHAR.232July 1, 2016
Onasemnogene Abeparvovec (Zolgensma) (PDF)CP.PHAR.421June 7, 2019
Ondansetron (Zuplenz) (PDF)CP.PMN.45September 1, 2006
Opioid Analgesics (PDF)GA.PMN.26October 1, 2019
Osimertinib (Tagrisso) (PDF)CP.PHAR.294December 1, 2016
Ospemifene (Osphena) (PDF)CP.PMN.168August 28, 2018
Overactive Bladder Agents (PDF)CP.PMN.198May 1, 2016
Ozanimod (PDF)CP.PHAR.462March 1, 2020
Ozenoxacin (Xepi) (PDF)CP.PMN.119January 30, 2018
Paclitaxel, Protein-Bound (Abraxane) (PDF)CP.PHAR.176July 1, 2015
Palbociclib (Ibrance®) (PDF)CP.PHAR.125October 1, 2015
Palivizumab (Synagis) (PDF)CP.PHAR.16August 1, 2009
panitumumab (Vectibix®) (PDF)CP.PHAR.321March 1, 2017
Parathyroid Hormone (Natpara) (PDF)CP.PHAR.282November 16, 2016
Paricalcitol Injection (Zemplar) (PDF)CP.PHAR.270August 1, 2016
Pasireotide (Signifor LAR®) (PDF)CP.PHAR.332March 1, 2017
Patisiran (Onpattro) (PDF)CP.PHAR.395September 11, 2018
Pazopanib (Votrient) (PDF)CP.PHAR.81October 1, 2011
Peanut Allergen Powder-dnfp (Palforzia) (PDF)CP.PMN.220March 1, 2020
Pediatric Benzodiazepine Use in Chemotherapy Induced Nausea and Vomiting CINV (PDF)GA.PMN.07August 1, 2016
Pediatric BZD Seizures (PDF)GA.PMN.08March 1, 2016
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF)CP.PHAR.353September 5, 2017
Pegfilgrastim (Neulasta) (PDF)CP.PHAR.296December 1, 2016
peginterferon alfa-2b (PegIntron, Sylatron®) (PDF)CP.PHAR.89October 1, 2011
Peginterferon beta-1a (Plegridy) (PDF)CP.PHAR.271August 1, 2016
Pegloticase (Krystexxa®) (PDF)CP.PHAR.115June 1, 2013
Pegvaliase-pqpz (Palynziq) (PDF)CP.PHAR.140July 31, 2018
Pegvisomant (Somavert) (PDF)CP.PHAR.389December 1, 2018
Pemetrexed (Alimta, Pemfexy) (PDF)CP.PHAR.368October 31, 2017
pembrolizumab (Keytruda®) (PDF)CP.PHAR.322March 1, 2017
Perampanel (Fycompa) (PDF)CP.PMN.156November 16, 2016
Pertuzumab (Perjeta) (PDF)CP.PHAR.227June 1, 2016
Pexidartinib (Turalio) (PDF)CP.PHAR.436December 1, 2019

Pharmacy Lock-In Program (PDF)

Lock-In Letter (PDF)

Lock-In Release Letter (PDF)

GA.PHAR.06July 1, 2006
Pharmaceutical Management (PDF)CC.PHAR.07February 1, 2003
Pharmacy Program (PDF)GA.PHAR.01October 1, 2006

Pharmacy Prior Authorization and Medical Necessity Criteria (PDF)

Addendum D (PDF)

CC.PHAR.08April 7, 2007
Pharmacy & Therapeutics Committee (PDF)CC.PHAR.13February 1, 2010
Pitolisant (Wakix) (PDF)CP.PMN.221March 1, 2020
Plerixafor (Mozobil) (PDF)CP.PHAR.323March 1, 2017
Polatuzumab Vedotin-piiq (Polivy) (PDF)CP.PHAR.433September 1, 2019
Pomalidomide (Pomalyst) (PDF)CP.PHAR.116July 1, 2013
Ponatinib (Iclusig) (PDF)CP.PHAR.112June 1, 2013
Pralatrexate (Folotyn®) (PDF)CP.PHAR.313February 1, 2017
Pramlintide (Symlin) (PDF)CP.PMN.129June 1, 2018
Preferred Drug List (PDF)CC.PHAR.10April 1, 2007
Pregabalin (Lyrica, Lyrica CR) (PDF)CP.PMN.33January 1, 2007
Pretomanid (PDF)CP.PMN.222March 1, 2020
Protein C Concentrate, Human (Ceprotin) (PDF)CP.PHAR.330March 1, 2017
Propranolol HCl Oral Solution (Hemangeol) (PDF)CP.PMN.58May 1, 2014
Prucalopride (Motegrity) (PDF)CP.PMN.194January 29, 2019
Psychotropic Medication Continuity of Care (COC) (PDF)GA.PMN.10December 1, 2016
pyrimethamine (Daraprim®) (PDF)CP.PMN.44November 1, 2015
Quetiapine ER (Seroquel XR) (PDF)CP.PMN.64December 1, 2014
Ramucirumab (Cyramza®) (PDF)CP.PHAR.119May 1, 2015
Ranibizumab (Lucentis®) (PDF)CP.PHAR.186March 1, 2016
Regorafenib (Stivarga) (PDF)CP.PHAR.107December 1, 2012
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF)CP.PHAR.168March 1, 2016
Request for Medically Necessary Drug Not on the PDL (PDF)CP.PMN.16November 9, 2017
Reslizumab (Cinqair) (PDF)CP.PHAR.223May 1, 2016
Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF)CP.PHAR.141November 16, 2016
Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) (PDF)CP.PMN.223March 1, 2020
Rifamycin (Aemcolo) (PDF)CP.PMN.196January 8, 2019
rifaximin (Xifaxan®)(PDF)CP.PMN.47November 1, 2011
Rilonacept (Arcalyst) (PDF)CP.PHAR.266November 16, 2016
RimabotulinumtoxinB (Myobloc) (PDF)CP.PHAR.233July 1, 2016
Riociguat (Adempas®) (PDF)CP.PHAR.195March 1, 2016
Risdiplam (PDF)CP.PHAR.477June 1, 2020
Risedronate (Actonel, Atelvia) (PDF)CP.PMN.100March 1, 2018
Risperidone Long-Acting Injection (Risperdal Consta) (PDF)CP.PHAR.293December 1, 2016
Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF)CP.PHAR.260July 1, 2016
Rolapitant (Varubi) (PDF)CP.PMN.102February 1, 2017
romidepsin (Istodax®) (PDF)CP.PHAR.314January 1, 2017
Romiplostim (Nplate®) (PDF)CP.PHAR.179March 1, 2016
Rucaparib (Rubraca®) (PDF)CP.PHAR.350September 1, 2017
Rufinamide (Banzel) (PDF)CP.PMN.157December 1, 2014
Sacubitril/Valsartan (Entresto) (PDF)CP.PMN.67November 1, 2015
Sacitizumab Govitecan (PDF)CP.PHAR.475June 1, 2020
Safinamide (Xadago) (PDF)CP.PMN.113July 1, 2017
Sapropterin Dihydrochloride (Kuvan) (PDF)CP.PHAR.43February 1, 2010
Sarecycline (Seysara) (PDF)CP.PMN.189November 13, 2018
Sargramostim (Leukine) (PDF)CP.PHAR.295December 1, 2016
Satralizumab (PDF)CP.PHAR.463March 1, 2020
Sebelipase Alfa (Kanuma) (PDF)CP.PHAR.159February 1, 2016
Secnidazole (Solosec) (PDF)CP.PMN.103October 24, 2017
Selexipag (Uptravi®) (PDF)CP.PHAR.196March 1, 2016
Selinexor (Xpovio) (PDF)CP.PHAR.431September 1, 2019
Selpercatinib (LOXO-292) (PDF)CP.PHAR.478June 1, 2020
Selumetinib (Koselugo) (PDF)CP.PHAR.464March 1, 2020
Sildenafil (Revatio®) (PDF)CP.PHAR.197March 1, 2016
Siltuximab (Sylvant®) (PDF)CP.PHAR.329March 1, 2017
Siponimod (Mayzent) (PDF)CP.PHAR.427September 1, 2019
Sipuleucel-T (Provenge) (PDF)CP.PHAR.120June 1, 2015
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF)CP.PMN.14September 18, 2018
sodium oxybate (Xyrem) (PDF)CP.PMN.42May 1, 2011
Sodium Phenylbutyrate (Buphenyl) (PDF)CP.PHAR.208May 1, 2016
Sofosbuvir/Ledipasvir (Harvoni) (PDF)GA.PMN.13December 1, 2016
Sofosbuvir (Sovaldi) (PDF)CP.PHAR.281September 1, 2016
Sofosbuvir (Sovaldi) (PDF)GA.PMN.17December 1, 2016
Sofosbuvir/Velpatasvir (Epclusa) (PDF)GA.PMN.06December 1, 2016
Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (PDF)GA.PMN.25September 1, 2017
Solriamfetol (Sunosi) (PDF)CP.PMN.209September 1, 2019
Somatropin (Human Growth Hormone) (PDF)GA.PMN.27August 1, 2020
Sonidegib (Odomzo) (PDF)CP.PHAR.272May 1, 2012
sorafenib (Nexavar) (PDF)CP.PHAR.69July 1, 2011
Specialty Drug Classification (PDF)GA.PHAR.15March 12, 2000
Specialty Pharmacy Program (PDF)GA.PHAR.18March 12, 2014
Step Therapy (PDF)CP.PST.01December 28, 2017
Stiripentol (Diacomit) (PDF)CP.PMN.184September 25, 2018
sunitinib (Sutent) (PDF)CP.PHAR.73September 1, 2011
Suvorexant (Belsomra®) (PDF)CP.PMN.109February 1, 2017
Tadalafil (Adcirca®) (PDF)CP.PHAR.198March 1, 2016
Tadalafil BHP - ED (Cialis) (PDF)CP.PMN.132June 1, 2018
Tafamidis (Vyndaqel, Vyndamax) (PDF)CP.PHAR.432September 1, 2019
Talazoparib (Talzenna) (PDF)CP.PHAR.409November 27, 2018
Taliglucerase Alfa (Elelyso) (PDF)CP.PHAR.157February 1, 2016
Tasimelteon (Hetlioz) (PDF)CP.PMN.104Februray 1, 2017
Tavaborole (Kerydin) (PDF)CP.PMN.105March 1, 2018
Tazemetostat (Tazverik) (PDF)CP.PHAR.452March 1, 2020
Tedizolid (Sivextro) (PDF)CP.PMN.62March 1, 2015
Teduglutide (Gattex) (PDF)CP.PHAR.114May 1, 2013
Tegaserod (Zelnorm) (PDF)CP.PMN.206September 1, 2019
Telotristat Ethyl (Xermelo) (PDF)CP.PHAR.337June 1, 2017
Temozolomide (Temodar) (PDF)CP.PHAR.77September 1, 2011
temsirolimus (Torisel®) (PDF)CP.PHAR.324March 1, 2017
Tenapanor (Ibsrela) (PDF)CP.PMN.224March 1, 2020
Teprotumumab (Tepezza) (PDF)CP.PHAR.465January 21, 2020
Teriflunomide (Aubagio) (PDF)CP.PHAR.262August 1, 2016
Teriparatide (Forteo®) (PDF)CP.PHAR.188November 15, 2017
Tesamorelin (Egrifta) (PDF)CP.PHAR.109March 1, 2014
Testosterone (Testopel, Jatenzo) (PDF)CP.PHAR.354August 1, 2017
tetrabenazine (Xenazine) (PDF)CP.PHAR.92December 1, 2011
Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF)CP.PHAR.377April 3, 2018
Thalidomide (Thalomid) (PDF)CP.PHAR.78September 1, 2011
Thioguanine (Tabloid) (PDF)CP.PHAR.437December 1, 2019
Thyrotropin Alfa (Thyrogen) (PDF) CP.PHAR.95March 1, 2012
Timothy grass pollen allergen extract (Grastek®) (PDF)CP.PMN.84August 31, 2017
Tisagenlecleucel (Kymriah) (PDF)CP.PHAR.361September 26, 2017
Tobramycin (Bethkis®, Kitabis Pak®, TOBI®, TOBI Podhaler®) (PDF)CP.PHAR.211May 1, 2016
Tocilizumab (Actemra) (PDF)CP.PHAR.263July 1, 2016
Tofacitinib (Xeljanz, Xeljanz XR) (PDF)CP.PHAR.267January 30, 2018
Tolvaptan (Jynarque) (PDF)CP.PHAR.27June 5, 2018
Topical Immunomodulators (PDF)CP.PMN.107September 1, 2006
Topical Steroid Use For Eosinophilic Esophagitis (PDF)GA.PMN.11September 1, 2016
Topical Tretinoin in Adult Acne Vulgaris (PDF)GA.PMN.09March 1, 2016
Topotecan (Hycamtin)(PDF)CP.PHAR.64June 1, 2011
Trabectedin (Yondelis®) (PDF)CP.PHAR.204May 1, 2016
Trametinib (Mekinist) (PDF)CP.PHAR.240July 1, 2016
Transition of Care (PDF)GA.PHAR.02October 1, 2020
Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF)CP.PHAR.228June 1, 2016
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF)CP.PHAR.199March 1, 2016
Triamcinolone ER Injection (Zilretta) (PDF)CP.PHAR.371March 1, 2018
Trientine (Syprine) (PDF)CP.PHAR.438December 1, 2019
triptorelin pamoate (Trelstar®, Triptodur®) (PDF)CP.PHAR.175November 9, 2017
Ubrogepant (Ubrelvy) (PDF)CP.PHAR.475June 1, 2020
Upadacitinib (Rinvoq) (PDF)CP.PHAR.443December 1, 2019
Ustekinumab (Stelara) (PDF)CP.PHAR.264August 1, 2016
Valoctocogene Roxaparvovec (PDF)CP.PHAR.466March 1, 2020
Valproate Sodium for Intravenous Injection (Depacon) (PDF)CP.PHAR.429September 1, 2019
Valrubicin (Valstar) (PDF)CP.PHAR.439December 1, 2019
Vandetanib (Caprelsa®) (PDF)CP.PHAR.80October 1, 2011
Vedolizumab (Entyvio) (PDF)CP.PHAR.265July 1, 2016
Velaglucerase Alfa (VPRIV) (PDF)CP.PHAR.163February 1, 2016
Vemurafenib (Zelboraf®) (PDF)CP.PHAR.91November 1, 2011
Verteporfin (Visudyne®) (PDF)CP.PHAR.187March 1, 2016
Vestronidase alfa-vjbk (Mepsevii) (PDF)CP.PHAR.374January 19, 2018
Vigabatrin (Sabril) (PDF)CP.PHAR.169February 1, 2016
Vilazodone (Viibryd) (PDF)CP.PMN.145August 1, 2012
Viltolarsen (PDF)CP.PHAR.484June 1, 2020
vincristine sulfate liposome injection (Marqibo®) (PDF)CP.PHAR.315February 1, 2017
Vismodegib (Erivedge) (PDF)CP.PHAR.273August 1, 2016
Voretigene neparvovec-rzyl (Luxturna) (PDF)CP.PHAR.372March 1, 2018
Vorinostat (Zolinza) (PDF)CP.PHAR.83December 1, 2012
Vortioxetine (Trintellix®) (PDF)CP.PMN.65May 31, 2017
Voxelotor (Oxbryta) (PDF)CP.PHAR.451March 1, 2020
Zanubrutinib (Brukinsa) (PDF)CP.PHAR.467March 1, 2020
ziv-aflibercept (Zaltrap®) (PDF)CP.PHAR.325March 1, 2017
Zoledronic acid (Reclast, Zometa) (PDF)CP.PHAR.59March 1, 2011

MEDICARE SPECIALTY PHARMACY POLICIES

POLICY TITLEPOLICY NUMBEREFFECTIVE DATE
72 Hour Supply of Medication (PDF)GA.PHAR.07June 1, 2006
Ado-Trastuzumab Emtansine (Kadcyla) (PDF)CP.PHAR.229June 1, 2016
Aflibercept (Eylea®) (PDF)CP.PHAR.184March 1, 2016
Alglucosidase Alfa (Lumizyme) (PDF)CP.PHAR.160February 1, 2016
Anakinra (Kineret) (PDF)CP.PHAR.244August 1, 2016
Ambrisentan (Letairis®) (PDF)CP.PHAR.190March 1, 2016

Appropriate Use and Safety Edits (PDF)

Appropriate Use and Safety Edits: Attachment A (PDF)

GA.PMN.01May 1, 2012
Benznidazole (PDF)CP.PMN.90October 17, 2017
Blocking Adjudication of Controlled Substance Prescriptions for Selected Prescribers (PDF)GA.PHAR.19November 1, 2001
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF)CP.PHAR.202March 1, 2016
Cabozantinib (Cometriq®, Cabometyx®) (PDF)CP.PHAR.111June 1, 2013
Carglumic acid (Carbaglu®) (PDF)CP.PHAR.206May 1, 2016
Dose Escalation of Biologics (PDF)GA.PMN.21September 1, 2017
Drug Recall Notification Process (PDF)GA.PHAR.08July 1, 2008
Drug Utilization Review (PDF)GA.PHAR.13April 1, 2007
Enoxaparin (Lovenox) (PDF)CP.PHAR.224May 1, 2016
Epoprostenol (Flolan®), Veletri®) (PDF)CP.PHAR.192March 1, 2016
Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF)CP.PHAR.297December 1, 2016
Hydroxyprogesterone Caproate (Makena®) (PDF)CP.PHAR.14November 20, 2017
Ibandronate sodium (Boniva®) (PDF)CP.PHAR.189November 15, 2017
Ibrutinib (Imbruvica) (PDF)CP.PHAR.126October 1, 2015
Iloprost (Ventavis®) (PDF)CP.PHAR.193March 1, 2016
Ivacaftor (Kalydeco) (PDF)CP.PHAR.210May 1, 2016
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF)CP.PHAR.173November 9, 2017
Lomitapide (Juxtapid) (PDF)CP.PHAR.283October 1, 2016
Lost, Stolen, Spilled or Broken Medications (PDF)GA.PHAR.10April 1, 2007
Maximum Allowable Cost (MAC) Requirement (PDF)GA.PHAR.21July 1, 2017
Mecasermin (Increlex) (PDF)CP.PHAR.150March 1, 2011
Medication Safety Policy (PDF)GA.PMN.22July 1, 2017
Mifepristone (Korlym) (PDF)CP.PHAR.101May 1, 2012
Mipomersen (Kynamro) (PDF)CP.PHAR.284October 1, 2016
Pegaptanib (Macugen®) (PDF)CP.PHAR.185March 1, 2016
Pegloticase (Krystexxa®) (PDF)CP.PHAR.115June 1, 2013
pembrolizumab (Keytruda®) (PDF)CP.PHAR.322March 1, 2017
Pharmacy and Therapeutics Committee (PDF)GA.PHAR.17August 9, 2011
Pharmaceutical Management (PDF)GA.PHAR.03February 1, 2003
Pharmacy Prior Authorization and Medical Necessity Criteria (PDF)GA.PHAR.16July 9, 2010
Plerixafor (Mozobil) (PDF)CP.PHAR.323March 1, 2017
Ranibizumab (Lucentis®) (PDF)CP.PHAR.186March 1, 2016
Riociguat (Adempas®) (PDF)CP.PHAR.195March 1, 2016
Step Therapy (PDF)MCPS.ST.00January 1, 2021
Tadalafil (Adcirca®) (PDF)CP.PHAR.198March 1, 2016
Vandetanib (Caprelsa®) (PDF)CP.PHAR.80October 1, 2011
vincristine sulfate liposome injection (Marqibo®) (PDF)CP.PHAR.315February 1, 2017

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 Peach State Health Plan Payment Policy Manual apply with respect to Peach State Health Plan members. Policies in the Peach State Health Plan Payment Policy Manual may have either a Peach State Health Plan or a “Centene” heading.  In addition, Peach State Health Plan 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 Peach State Health Plan.     

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 

For Ambetter information, please visit our Ambetter website.

MEDICAID PAYMENT POLICIES 

POLICY TITLEPOLICY NUMBEREFFECTIVE DATE
Allergy Testing and Therapy (PDF)CP.MP.100August 31, 2016
Bilateral Procedures (PDF)CC.PP.037January 1, 2014
Bronchial Thermoplasty (PDF)CP.MP.110May 31, 2016
Cerumen Removal Policy (PDF)CC.PP.008January 1, 2014
Clean Claims Policy (PDF)CC.PP.021January 1, 2013
Clean Claim Reviews (PDF)CC.PI.04November 1, 2012
Clinical Validation of Modifier 25 (PDF)CC.PP.013January 1, 2013
Clinical Validation of Modifier 59 (PDF)CC.PP.014January 1, 2013
Code Editing Overview (PDF)CC.PP.011January 1, 2013
Cosmetic Procedures (PDF)CC.PP.024January 1, 2014
Cost to Charge Adjustments on Clean Claim Reviews (PDF)CC.PI.06Sepember 1, 2022
Distinct Procedure Modifiers Policy (PDF)CC.PP.020January 1, 2013
Duplicate Primary Code Billing (PDF)CC.PP.044January 1, 2014
E&M Bundling with Labs and Radiology (PDF)CC.PP.010January 1, 2013
E&M Services Billed with Treatment Room Revenue Codes (PDF)CC.PP.071September 28, 2021
EM Medical Decision Making (PDF)CC.PP.051June 1, 2017
Endometrial Ablation (PDF)CP.MP.106March 1, 2016
Evoked Potential Testing (PDF)CP.MP.134November 30, 2016
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)CP.MP.209June 21, 2021
Holter Monitors (PDF)CP.MP.113August 30, 2016
Homocysteine Testing (PDF)CP.MP.121August 30, 2016
Hospital Visit Codes Billed with Labs (PDF)CC.PP.023January 1, 2016
Inpatient Consultation (PDF)CC.PP.038January 1, 2014
Inpatient Only Procedures Policy (PDF)CC.PP.018January 1, 2018
IV Hydration Policy (PDF)CC.PP.012January 1, 2013
Laser Therapy for Skin Conditions (PDF)CP.MP.123August 30, 2016
Leveling of Care: Evaluation and Management Overcoding (PDF)CC.PP.066February 6, 2020
Leveling Professional Fees for Emergency Room Services (PDF)GA.PP.053December 16, 2020
Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)CP.MP.139February 28, 2017
Max Units Payment Policy (PDFCC.PP.007January 1, 2013
Moderate Conscious Sedation (PDF)CC.PP.015January 1, 2013
Modifier DOS Validation (PDF)CC.PP.034January 1, 2015
Modifier to Procedure Code Validation (PDF)CC.PP.028January 1, 2013
Multiple CPT Code Replace (PDF)CC.PP.033January 1, 2013
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF)CC.PP.065February 6, 2020
Multiple Procedure Reduction: Ophthalmology (PDF)CC.PP.069August 18, 2020
Multiple Procedure Payment Reduction: Therapeutic Services (PDF)CC.PP.068July 1, 2021
NCCI Unbundling (PDF)CC.PP.031January 1, 2013
Never Paid Events (PDF)CC.PP.017January 1, 2013
New Patient (PDF)CC.PP.036January 1, 2014
Non-obstectrical Pelvic and Transvaginal Ultrasounds (PDF)CC.PP.061June 1, 2018
Not Medically Necessary Inpatient Service (PDF)CC.PP.060June 1, 2018
Outpatient Consultation (PDF)CC.PP.039January 1, 2014
Physician's Office Lab Testing (PDF)CC.PP.055December 1, 2019
Place of Service Mismatch (PDF)CC.PP.063September 1, 2018
Postoperative Visits (PDF)CC.PP.042January 1, 2014
Preoperative Visits (PDF)CC.PP.041January 1, 2014
Problem Oriented Visits with Surgical Procedures (PDF)CC.PP.052November 1, 2017
Professional Component Modifier (PDF)CC.PP.027January 1, 2013
Pulmonary Function Testing (PDF)CP.MP.242March 1, 2023
Pulse Oximetry w Office Visits (PDF)CC.PP.025January 1, 2013
Renal Hemodialysis (PDF)CC.PP.067March 1, 2021
Reporting the Global Maternity Package (PDF)GA.PP.016January 1, 2013
Robotic Surgeries (PDF)CC.PP.050August 1, 2017
Same Day Visits (PDF)CC.PP.040January 1, 2014
Sepsis Diagnosis (PDF)CC.PP.073March 1, 2022
Skilled Nursing Facility Leveling (PDF)CC.PP.206March 1, 2024
Sleep Studies POS (PDF)CC.PP.035June 15, 2017
Status B Bundled Services (PDF)CC.PP.046January 1, 2014
Status P Bundled Services (PDF)CC.PP.049January 1, 2014
Supplies Same Day as Surgery (PDF)CC.PP.032January 1, 2013
Testing for Select Genitourinary Conditions (PDF)CP.MP.97June 15, 2016
Transgender Related Services (PDF)CC.PP.047January 1, 2017
Ultrasound in Pregnancy (PDF)CP.MP.38January 31, 2011
Unbundled Professional Services (PDF)CC.PP.043March 15, 2017
Unbundled Surgical Procedures (PDF)CC.PP.045March 15, 2017
Unbundling Adjustments on Clean Claim Reviews (PDF)CC.PI.10September 1, 2022
Unlisted Procedure Codes Policy (PDF)CC.PP.009January 1, 2017
Urodynamic Testing (PDF)CP.MP.98October 30, 2015
Wheelchair Seating (PDF)CP.MP.99October 31, 2015
Wheelchairs and Accessories (PDF)CC.PP.502October 1, 2015

MEDICARE PAYMENT POLICIES 

POLICY TITLEPOLICY NUMBEREFFECTIVE DATE
3 Day Payment Window (PDF)CC.PP.500July 1, 2014
30 Day Readmission (PDF)CC.PP.501January 1, 2015
340B Drug Payment Reduction (PDF)CC.PP.070July 1, 2021
Add On Policy (PDF)CC.PP.030January 1, 2013
Assistant Surgeon (PDF)CC.PP.029January 1, 2014
Bilateral Procedures (PDF)CC.PP.037January 1, 2014
Cerumen Removal Policy (PDF)CC.PP.008January 1, 2014
Clean Claims Policy (PDF)CC.PP.021January 1, 2013
Clean Claim Reviews (PDF)CC.PI.04November 1, 2012
Clinical Validation of Modifier 25 (PDF)CC.PP.013January 1, 2013
Clinical Validation of Modifier 59 (PDF)CC.PP.014January 1, 2013
Code Editing Overview (PDF)CC.PP.011January 1, 2013
Cosmetic Procedures (PDF)CC.PP.024January 1, 2014
Cost to Charge Adjustments on Clean Claim Reviews (PDF)CC.PI.06Sepember 1, 2022
Distinct Procedure Modifiers Policy (PDF)CC.PP.020January 1, 2013
Duplicate Primary Code Billing (PDF)CC.PP.044January 1, 2014
E&M Bundling with Labs and Radiology (PDF)CC.PP.010January 1, 2013
E&M Services Billed with Treatment Room Revenue Codes (PDF)CC.PP.071September 28, 2021
EM Medical Decision Making (PDF)CC.PP.051June 1, 2017
Hospital Visit Codes Billed with Labs (PDF)CC.PP.023January 1, 2016
Inpatient Consultation (PDF)CC.PP.038January 1, 2014
Inpatient Only Procedures Policy (PDF)CC.PP.018January 1, 2018
IV Hydration Policy (PDF)CC.PP.012January 1, 2013
Leveling of Care: Evaluation and Management Overcoding (PDF)CC.PP.066February 6, 2020
Leveling of Emergency Room Services (PDF)GA.PP.506December 16, 2020
Maximum Units (PDF)CC.PP.007January 1, 2013
Moderate Conscious Sedation (PDF)CC.PP.015January 1, 2013
Modifier DOS Validation (PDF)CC.PP.034January 1, 2015
Modifier to Procedure Code Validation (PDF)CC.PP.028January 1, 2013
Multiple CPT Code Replace (PDF)CC.PP.033January 1, 2013
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF)CC.PP.065February 6, 2020
Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)CC.PP.068December 16, 2020
Multiple Procedure Reduction: Ophthalmology (PDF)CC.PP.069August 18, 2020
NCCI Unbundling (PDF)CC.PP.031January 1, 2013
Never Paid Events (PDF)CC.PP.017January 1, 2013
New Patient (PDF)CC.PP.036January 1, 2014
Non-obstectrical Pelvic and Transvaginal Ultrasounds (PDF)CC.PP.061June 1, 2018
Not Medically Necessary Inpatient Service (PDF)CC.PP.060June 1, 2018
Outpatient Consultation (PDF)CC.PP.039January 1, 2014
Physician's Office Lab Testing (PDF)CC.PP.055December 16, 2020
Place of Service Mismatch (PDF)CC.PP.063September 1, 2018
Postoperative Visits (PDF)CC.PP.042January 1, 2014
Preoperative Visits (PDF)CC.PP.041January 1, 2014
Problem Oriented Visits with Preventative Services (PDF)CC.PP.057October 1, 2017
Problem Oriented Visits with Surgical Procedures (PDF)CC.PP.052November 1, 2017
Professional Component Modifier (PDF)CC.PP.027January 1, 2013
Pulse Oximetry w Office Visits (PDF)CC.PP.025January 1, 2013
Renal Hemodialysis (PDF)CC.PP.067March 1, 2021
Same Day Visits (PDF)CC.PP.040January 1, 2014
Sepsis Diagnosis (PDF)CC.PP.073March 1, 2022
Sleep Studies POS (PDF)CC.PP.035June 15, 2017
Status B Bundled Services (PDF)CC.PP.046January 1, 2014
Status P Bundled Services (PDF)CC.PP.049January 1, 2014
Supplies Same Day as Surgery (PDF)CC.PP.032January 1, 2013
Transgender Related Services (PDF)CC.PP.047January 1, 2017
Unbundled Professional Services (PDF)CC.PP.043March 15, 2017
Unbundled Surgical Procedures (PDF)CC.PP.045March 15, 2017
Unbundling Adjustments on Clean Claim Reviews (PDF)CC.PI.10September 1, 2022
Unlisted Procedure Codes Policy (PDF)CC.PP.009January 1, 2013
Urine Specimen Validity Testing (PDF)CC.PP.056October 1, 2017
Wheelchairs and Accessories (PDF)CC.PP.502October 1, 2015