Skip to Main Content

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.

A-H I-Q R-Z

Dental Anesthesia in the Outpatient Hospital or in the Ambulatory Surgical Center (PDF)

Attachment (PDF)

Effective Date: 11/17/2014

Long Acting Reversible Contraception (PDF)

Effective Date: 09/17/2017

Summary Guidelines on Prevention and Management of Diabetes Complications (PDF)

Effective Date: 01/01/2006

Emergency Air Ambulance Services (PDF)

Effective Date: 06/27/2012

Insulin Testing in Pediatrics (PDF)

Effective Date: 07/01/2018

Reduction Mammaplasty (PDF)

Effective Date: 07/31/2012

Hyperbaric Oxygen Therapy (PDF)

Effective Date: 06/30/2009

Physical, Occupational, Speech, and/or Feeding Therapy (PDF)

Effective Date: 03/23/2009

Stereotactic Body Radiation Therapy (PDF)

Effective Date: 12/30/2008

Allogeneic Hematopoietic Cell Transplants for Sickle Cell (PDF)

Effective Date: 03/31/2016

Medical Necessity for Infant Apnea Monitors (PDF)

Effective Date: 11/18/2015

Vagus Nerve Stimulation (PDF)

Effective Date: 09/30/2008


Articular Cartilage Defect Repairs (PDF)

Effective Date: 10/31/2008


Medical Necessity for Authorizing Incontinence Supplies (PDF)

Effective Date: 11/18/2015


Ventriculectomy and Cardiomyoplasty (PDF)

Effective Date: 05/06/2013


Clinical Trials (PDF)

Effective Date: 01/27/2014


Intradiscal Steroid Injections for Pain Management (PDF)

Effective Date: 08/31/2018

Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF)

Effective Date: 08/31/2018


Digital EEG Spike Analysis (PDF)

Effective Date: 01/15/2016


Medical Necessity Criteria (PDF)

Effective Date: 06/14/2013

Sacroiliac Joint Interventions for Pain Management (PDF)

Effective Date: 08/31/2018


Donor Lymphocyte Infusion (PDF)

Effective Date: 12/01/2015


OB Home Health Programs (PDF)

Effective Date: 01/27/2014

Trigger Point Injections for Pain Management (PDF)

Effective Date: 08/31/2018


Endometrial Ablation (PDF)

Effective Date: 03/01/2016


Outpatient Testing for Drugs of Abuse (PDF)

Effective Date: 09/30/2012

Radial Head Implant (PDF)

Effective Date: 08/31/2017


Ferriscan R2-MRI (PDF)

Effective Date: 11/14/2012

Nerve Blocks for Pain Management (PDF)

Effective Date: 08/31/2018

Sacroiliac Joint Fusion (PDF)

Effective Date: 09/30/2016


Fractionated Exhaled Nitric Oxide (FeNO) measurement (PDF)

Effective Date: 01/27/2016

Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)

Effective Date: 04/30/2018

Sclerotherapy for Varicose Veins (PDF)

Effective Date: 06/30/2017


Functional MRI (PDF)

Effective Date: 09/23/2009

Inhaled Nitric Oxide (PDF)

Effective Date: 08/30/2013

Sickle Cell Disease Observation (PDF)

Effective Date: 09/30/2013


Gastric Electrical Stimulation (PDF)

Effective Date: 07/30/2009

Intensity-Modulated Radiotherapy (PDF)

Effective Date: 03/31/2014

Spinal Cord Stimulation (PDF)

Effective Date: 07/31/2016


Hyperemesis Gravidarum Treatment (PDF)

Effective Date: 03/31/2009

Intestinal and Multivisceral Transplant (PDF)

Effective Date: 02/28/2014

Tandem Transplant (PDF)

Effective Date: 07/31/2018

Hyperhidrosis Treatments (PDF)

Effective Date: 05/16/2013

Laser Therapy for Skin Conditions (PDF)

Effective Date: 08/30/2016

Testing for Select Genitourinary Conditions (PDF)

Effective Date: 06/15/2016

Facet Joint Interventions for Pain Management (PDF)

Effective Date: 08/31/2018

Long Term Care Placement Criteria (PDF)

Effective Date: 07/11/2018

Testing of Rupture of Fetal Membranes (PDF)

Effective Date: 08/30/2017

 

Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF)

Effective Date: 08/31/2018

Low-Frequency Ultrasound Therapy for Wound Management (PDF)

Effective Date: 02/28/2017

Total Artificial Heart (PDF)

Effective Date: 12/30/2016

25-Hydroxyvitamin D Testing in Children and Adolescents (PDF)

Effective Date: 12/29/2017

Lung Transplantation (PDF)

Effective Date: 02/28/2014

Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)

Effective Date: 05/31/2016

Acupuncture (PDF)

Effective Date: 12/31/2013

Lysis of Epidural Lesions (PDF)

Effective Date: 07/31/2016

Transcather Closer of Patent Foramen Ovale (PDF)

Effective Date: 12/29/2017

ADHD Assessment and Treatment (PDF)

Effective Date: 12/31/2013

Measurement of Serum 1,25-dihydroxyvitamin D (PDF)

Effective Date: 12/29/2017

Ultrasound in Pregnancy (PDF)

Effective Date: 01/31/2011

Allergy Testinng and Therapy (PDF)

Effective Date: 08/31/2016

Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)

Effective Date: 04/30/2017

Urinary Incontinence Devices and Treatments (PDF)

Effective Date: 04/30/2017

Ambulatory EEG (PDF)

Effective Date: 09/30/2015

Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF)

Effective Date: 05/31/2018

Urodynamic Testing (PDF)

Effective Date: 10/30/2015

Applied Behavioral Analysis for Autism (PDF)

Effective Date: 08/31/2019

Multiple Sleep Latency Testing (PDF)

Effective Date: 10/31/2008

Ventricular Assist Devices (PDF)

Effective Date: 12/31/2009

Ambulatory Surgery Center Optimization (PDF)

Effective Date: 02/16/2018

Neonatal Abstinence Syndrome Guidelines (PDF)

Effective Date: 10/30/2013

Wheelchair Seating (PDF)

Effective Date: 10/31/2015

Assisted Reproductive Technology (PDF)

Effective Date: 03/31/2014

Neonatal Sepsis Management (PDF)

Effective Date: 08/30/2013

Wireless Motility Capsule (PDF)

Effective Date: 04/30/2017

Balloon Sinus Ostial Dilation (PDF)

Effective Date: 07/29/2016

NICU Apnea Bradycardia Guidelines (PDF)

Effective Date: 06/30/2013

Zika Virus Testing (PDF)

Effective Date: 06/30/2016

Bariatric Surgery (PDF)

Effective Date: 06/11/2009

NICU Discharge Guidelines (PDF)

Effective Date: 06/30/2013

 

Biofeedback (PDF)

Effective Date: 07/31/2017

Non-myeloablative Allogeneic Stem Cell Transplants (PDF)

Effective Date: 04/28/2017

 

Bone-Anchored Hearing Aid (PDF)

Effective Date: 12/31/2013

Optic Nerve Decompression Surgery (PDF)

Effective Date: 09/30/2016

 

Bronchial Thermoplasty (PDF)

Effective Date: 05/31/2016

Pancreas Transplant (PDF)

Effective Date: 04/29/2016

 

Cardiac Biomarker Testing (PDF)

Effective Date: 12/29/2017

Panniculectomy (PDF)

Effective Date: 04/30/2016

 

Carrier Screening in Pregnancy (PDF)

Effective Date: 07/31/2013

Pediatric Heart Transplant (PDF)

Effective Date: 01/31/2017

 

Cell-Free Fetal DNA Testing (PDF)

Effective Date: 08/31/2013

Pediatric Liver Transplant (PDF)

Effective Date: 04/30/2018

 

Cochlear Implant Replacements (PDF)

Effective Date: 03/20/2009

Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)

Effective Date: 07/31/2017

 

Cosmetic and Reconstructive Surgery (PDF)

Effective Date: 03/31/2009

Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)

Effective Date: 10/30/2016

 

Disc Decompression Procedures (PDF)

Effective Date: 07/31/2016

Proton and Neutron Beam Therapy (PDF)

Effective Date: 03/31/2014

 

Discography (PDF)

Effective Date: 08/30/2016

   

DNA Analysis of Stool to Screen for Colorectal Cancer (PDF)

Effective Date: 09/30/2016

   

Durable Medical Equipment (DME) (PDF)

Effective Date: 06/30/2009

   

Electric Tumor Treating Fields (PDF)

Effective Date: 05/31/2017

   

Electroencephalography in the Evaluation of Headache (PDF)

Effective Date: 12/29/2017

   

EpiFix Wound Treatment (PDF)

Effective Date: 04/30/2017

   

Essure Removal (PDF)

Effective Date: 11/30/2016

   

Evoked Potential Testing (PDF)

Effective Date: 11/30/2016

   

Experimental Technologies (PDF)

Effective Date: 06/30/2009

   

Facet Joint Interventions for Pain Management (PDF)

Effective Date: 09/14/2018

   

Hospice Services (PDF)

Effective Date: 07/31/2014

   

Fecal Incontinence Treatments (PDF)

Effective Date: 12/30/2016

   

Fertility Preservation (PDF)

Effective Date: 10/30/2016

   

Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)

Effective Date: 10/30/2016

   

Gender Reassignment Surgery (PDF)

Effective Date: 11/28/2014

   

Genetic Testing (PDF)

Effective Date: 11/30/2013

   

H. Pylori Serology Testing (PDF)

Effective Date: 12/29/2017

   

Heart-Lung Transplant (PDF)

Effective Date: 06/30/2017

   

Holter Monitors (PDF)

Effective Date: 08/30/2016

   

Home Birth (PDF)

Effective Date: 12/30/2016

   

Home Phototherapy for Neonatal Hyperbilirubiniemia (PDF)

Effective Date: 12/21/2017

   

Homocysteine Testing (PDF)

Effective Date: 08/30/2016

   
     
A-K L-Z

72 Hour Supply of Medication (PDF)

Effective Date: 06/01/2006


Lost, Stolen, Spilled or Broken Medications (PDF)

Effective Date: 04/01/2007

Appropriate Use and Safety Edits (PDF)

Appropriate Use and Safety Edits: Attachment A (PDF)

Effective Date: 05/01/2012


Medication Safety Policy (PDF)

Effective Date: 07/01/2017

Blocking Adjudication of Controlled Substance Prescriptions for Selected Prescribers (PDF)

Effective Date: 11/01/2001


Pharmaceutical Management (PDF)

Effective Date: 02/01/2003

Dose Escalation of Biologics (PDF)

Effective Date: 09/01/2017


Pharmacy and Therapeutics Committee (PDF)

Effective Date: 08/19/2011

Drug Recall Notification Process (PDF)

Effective Date: 07/01/2008


Pharmacy Prior Authorization and Medical Necessity Criteria (PDF)

Effective Date: 07/09/2010


Drug Utilization Review (PDF)

Effective Date: 04/01/2007

Progesterone (Crinone, Endometrin) (PDF)

Effective Date: 11/16/2016

Filgrastim (Neupogen, Zarxio) (PDF)

Effective Date: 11/16/2016

Somatropin (HGH) (PDF)

Effective Date: 11/16/2016

Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF)

Effective Date: 12/01/2016

Lumacaftor-Ivacaftor (Orkambi) (PDF)

Effective Date: 05/01/2016

Ibalizumab-uiyk (Trogarzo) (PDF)

Effective Date: 04/17/2018

Nusinersen (Spinraza®)(PDF)

Effective Date: 11/28/2017

Brentuximab Vedotin (Adcetris) (PDF)

Effective Date: 02/01/2017

Somatropin (Growth Hormone) (PDF)

Effective Date: 03/01/2011

Interferon Gamma- 1b (Actimmune) (PDF)

Effective Date: 06/01/2010

Step Therapy (PDF)

Effective Date: 08/01/2017

Bendamustine (Bendeka®, Treanda®) (PDF)

Effective Date: 02/01/2017

Riociguat (Adempas®) (PDF)

Effective Date: 03/01/2016

Belimumab (Benlysta) (PDF)

Effective Date: 10/01/2011

Tadalafil (Adcirca®) (PDF)

Effective Date: 03/01/2016

C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF)

Effective Date: 03/01/2016

Tocilizumab (Actemra) (PDF)

Effective Date: 07/01/2016

Immune Globulins (PDF)

Effective Date: 08/01/2012

OnabotulinumtoxinA (Botox) (PDF)

Effective Date: 07/01/2016

Blinatumomab (Blincyto) (PDF)

Effective Date: 02/01/2017

Vandetanib (Caprelsa®) (PDF)

Effective Date: 10/01/2011

Ibandronate sodium (Boniva®) (PDF)

Effective Date: 11/15/2017

Reslizumab (Cinqair) (PDF)

Effective Date: 05/01/2016

Bosutinib (Bosulif) (PDF)

Effective Date: 10/01/2012

Tesamorelin (Egrifta) (PDF)

Effective Date: 03/01/2014

Cerliponase alfa (Brineura) (PDF)

Effective Date: 07/01/2017

Perampanel (Fycompa) (PDF)

Effective Date: 11/16/2016

Carglumic acid (Carbaglu®) (PDF)

Effective Date: 05/01/2016

Taliglucerase Alfa (Elelyso) (PDF)

Effective Date: 02/01/2016

Imiglucerase (Cerezyme) (PDF)

Effective Date: 02/01/2016

Pralatrexate (Folotyn®) (PDF)

Effective Date: 02/01/2017

Certolizumab (Cimzia) (PDF)

Effective Date: 08/01/2016

Teriparatide (Forteo®) (PDF)

Effective Date: 11/15/2017

Cabozantinib (Cometriq®, Cabometyx®) (PDF)

Effective Date: 06/01/2013

Levoleucovorin (Fusilev®) (PDF)

Effective Date: 11/09/2017

Glatiramer (Copaxone, Glatopa) (PDF)

Effective Date: 08/01/2016

Teduglutide (Gattex) (PDF)

Effective Date: 05/01/2013

Daratumumab (Darzalex) (PDF)

Effective Date: 07/01/2017

Obinutuzumab (Gazyva®) (PDF)

Effective Date: 02/01/2017

Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF)

Effective Date: 05/01/2016

Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF)

Effective Date: 06/01/2016

Deferoxamine (Desferal) (PDF)

Effective Date: 11/01/2015

Repository Corticotropin Injection (H.P. Acthar Gel) (PDF)

Effective Date: 03/01/2016

Dupilumab (Dupixent) (PDF)

Effective Date: 05/01/2017

Topotecan (Hycamtin)(PDF)

Effective Date: 06/01/2011

AbobotulinumtoxinA (Dysport) (PDF)

Effective Date: 07/01/2016

RimabotulinumtoxinB (Myobloc) (PDF)

Effective Date: 07/01/2016

Etanercept (Enbrel) (PDF)

Effective Date: 08/01/2016

Pegfilgrastim (Neulasta) (PDF)

Effective Date: 12/01/2016

Epoetin Alfa (Epogen® and Procrit) (PDF)

Effective Date: 06/01/2016

sorafenib (Nexavar) (PDF)

Effective Date: 07/01/2011

Cetuximab (Erbitux®) (PDF)

Effective Date: 02/01/2017

Mepolizumab (Nucala) (PDF)

Effective Date: 04/01/2016

Eteplirsen (PDF)

Effective Date: 12/01/2016

Obeticholic (Ocaliva) (PDF)

Effective Date: 11/01/2016

Deferasirox (Exjade Jadenu) (PDF)

Effective Date: 11/1/2015

Nivolumab (Opdivo) (PDF)

Effective Date: 07/01/2015

Aflibercept (Eylea®) (PDF)

Effective Date: 03/01/2016

Lumacaftor-ivacaftor (Orkambi) (PDF)

Effective Date: 05/01/2016

Agalsidase Beta (Fabrazyme) (PDF)

Effective Date: 02/01/2016

Pertuzumab (Perjeta) (PDF)

Effective Date: 06/01/2016

Deferiprone (Ferriprox) (PDF)

Effective Date: 11/01/2015

Peginterferon beta-1a (Plegridy) (PDF)

Effective Date: 08/01/2016

Degarelix acetate (Firmagon®) (PDF)

Effective Date: 11/09/2017

Pomalidomide (Pomalyst) (PDF)

Effective Date: 07/01/2013

Dalteparin (Fragmin) (PDF)

Effective Date: 05/01/2016

Necitumumab (Portrazza®) (PDF)

Effective Date: 03/01/2017

Enfuvirtide (Fuzeon) (PDF)

Effective Date: 06/01/2010

Palbociclib (Ibrance®) (PDF)

Effective Date: 10/01/2015

Fingolimod (Gilenya) (PDF)

Effective Date: 08/01/2016

Ponatinib (Iclusig) (PDF)

Effective Date: 06/01/2013

Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF)

Effective Date: 03/01/2012

Mecasermin (Increlex) (PDF)

Effective Date: 03/01/2011

Imatinib (Gleevec) (PDF)

Effective Date: 06/01/2011

Sebelipase Alfa (Kanuma) (PDF)

Effective Date: 02/01/2016

Eribulin Mesylate (Halaven®) (PDF)

Effective Date: 03/01/2017

Ivacaftor (Kalydeco) (PDF)

Effective Date: 05/01/2016

Adalimumab (Humira) (PDF)

Effective Date: 08/01/2016

pembrolizumab (Keytruda®) (PDF)

Effective Date: 3/1/2017

Hydroxyprogesterone Caproate (Makena®) (PDF)

Effective Date: 11/20/2017

Sipuleucel-T (Provenge) (PDF)

Effective Date: 06/01/2015

Galsulfase (Naglazyme) (PDF)

Effective Date: 02/01/2016

Tobramycin (Bethkis®, Kitabis Pak®, TOBI®, TOBI Podhaler®) (PDF)

Effective Date: 05/01/2016

Ixazomib (Ninlaro) (PDF)

Effective Date: 02/01/2017

Zoledronic acid (Reclast, Zometa) (PDF)

Effective Date: 03/01/2011

belatacept (Nulojix®) (PDF)

Effective Date: 11/09/2017

Sildenafil (Revatio®) (PDF)

Effective Date: 03/01/2016

abatacept (Orencia) (PDF)

Effective Date: 08/01/2016

romidepsin (Istodax®) (PDF)

Effective Date: 01/01/2017

irinotecan Liposome (Onivyde®) (PDF)

Effective Date: 02/01/2017

olaratumab (Lartruvo®) (PDF)

Effective Date: 03/01/2017

Apremilast (Otezla) (PDF)

Effective Date: 08/01/2016

Sargramostim (Leukine) (PDF)

Effective Date: 12/01/2016

Buprenorphine implant (Probuphine) (PDF)

Effective Date: 11/16/2016

Intrathecal Baclofen (Gablofen, Lioresal) (PDF)

Effective Date: 11/09/2017

Alirocumab (Praluent) (PDF)

Effective Date: 10/01/2015

vincristine sulfate liposome injection (Marqibo®) (PDF)

Effective Date: 02/01/2017

Eltrombopag (Promacta®) (PDF)

Effective Date: 03/01/2016

Plerixafor (Mozobil) (PDF)

Effective Date: 03/01/2017

Ibrutinib (Imbruvica) (PDF)

Effective Date: 10/01/2015

Lenalidomide (Revlimid) (PDF)

Effective Date: 07/01/2011

Axitinib (Inlyta®) (PDF)

Effective Date: 05/01/2012

Risperidone Long-Acting Injection (Risperdal Consta) (PDF)

Effective Date: 12/01/2016

Ado-Trastuzumab Emtansine (Kadcyla) (PDF)

Effective Date: 06/01/2016

Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF)

Effective Date: 07/01/2016

Dornase alfa (Pulmozyme) (PDF)

Effective Date: 05/01/2016

Vigabatrin (Sabril) (PDF)

Effective Date: 02/01/2016

Evolocumab (Repatha) (PDF)

Effective Date: 10/01/2015

Octreotide (Sandostatin, Sandostatin LAR) (PDF)

Effective Date: 03/01/2010

Durvalumab (Imfinzi) (PDF)

Effective Date: 07/01/2017

Pasireotide (Signifor LAR®) (PDF)

Effective Date: 03/01/2017

Infliximab (Remicade, Inflectra, Renflexis) (PDF)

Effective Date: 07/01/2016

Tedizolid (Sivextro) (PDF)

Effective Date: 03/01/2015

cabazitaxel (Jevtana® (PDF)

Effective Date: 02/01/2017

Ustekinumab (Stelara) (PDF)

Effective Date: 08/01/2016

Anakinra (Kineret) (PDF)

Effective Date: 08/01/2016

Regorafenib (Stivarga) (PDF)

Effective Date: 12/01/2012

carfilzomib (Kyprolis®) (PDF)

Effective Date: 02/01/2017

sunitinib (Sutent) (PDF)

Effectove Date: 09/01/2011

Alemtuzumab (Lemtrada) (PDF)

Effective Date: 08/01/2016

peginterferon alfa-2b (PegIntron, Sylatron®) (PDF)

Effective Date: 10/01/2011

Ambrisentan (Letairis®) (PDF)

Effective Date: 03/01/2016

Paricalcitol Injection (Zemplar) (PDF)

Effective Date: 08/01/2016

Alglucosidase Alfa (Lumizyme) (PDF)

Effective Date: 02/01/2016

Vorinostat (Zolinza) (PDF)

Effective Date: 12/01/2012

Cinacalcet (Sensipar) (PDF)

Effective Date: 05/01/2011

Vemurafenib (Zelboraf®) (PDF)

Effective Date: 11/01/2011

Golimumab (Simponi, Simponi Aria) (PDF)

Effective Date: 07/01/2016

Miglustat (Zavesca) (PDF)

Effective Date: 02/01/2016

Eculizumab (Soliris®) (PDF)

Effective Date: 03/01/2012

ziv-aflibercept (Zaltrap®) (PDF)

Effective Date: 03/01/2017

Dasatinib (Sprycel) (PDF)

Effective Date: 06/01/2012

sodium oxybate (Xyrem) (PDF)

Effective Date: 05/01/2011

asfotase alfa (Strensiq®) (PDF)

Effective Date: 03/01/2017

Telotristat Ethyl (Xermelo) (PDF)

Effective Date: 06/01/2017

histrelin acetate (Vantas®, Supprelin LA®) (PDF)

Effective Date: 11/09/2017

tetrabenazine (Xenazine) (PDF)

Effective Date: 12/01/2011

Abiraterone (Zytiga) (PDF)

Effective Date: 10/01/2011

Tofacitinib (Xeljanz, Xeljanz XR) (PDF)

Effective Date: 01/30/2018

Ipilimumab (Yervoy) (PDF)

Effective Date: 04/17/2018

Velaglucerase Alfa (VPRIV) (PDF)

Effective Date: 02/01/2016

Enzalutamide (Xtandi) (PDF)

Effective Date: 10/01/2012

Pazopanib (Votrient) (PDF)

Effective Date: 10/01/2011

Collagenase (Xiaflex) (PDF)

Effective Date: 10/01/2011

Verteporfin (Visudyne®) (PDF)

Effective Date: 03/01/2016

IncobotulinumtoxinA (Xeomin) (PDF)

Effective Date: 07/01/2016

panitumumab (Vectibix®) (PDF)

Effective Date: 03/01/2017

capecitabine (Xeloda) (PDF)

Effective Date: 05/01/2011

lapatinib (Tykerb®) (PDF)

Effective Date: 11/09/2017

Crizotinib (Xalkori) (PDF)

Effective Date: 11/01/2011

Palivizumab (Synagis) (PDF)

Effectiive Date: 08/01/2009

Elosulfase Alfa (Vimizim) (PDF)

Effective Date: 02/01/2016

nafarelin acetate (Synarel®) (PDF)

Effective Date: 11/09/2017

Iloprost (Ventavis®) (PDF)

Effective Date: 03/01/2016

Omacetaxine (Synribo) (PDF)

Effective Date: 04/01/2013

Epoprostenol (Flolan®), Veletri®) (PDF)

Effective Date: 03/01/2016

nilotinib (Tasigna) (PDF)

Effective Date: 09/01/2011

Erlotinib (Tarceva) (PDF)

Effective Date: 09/01/2011

Temozolomide (Temodar) (PDF)

Effective Date: 09/01/2011

Bexarotene (Targretin) (PDF)

Effective Date: 09/01/2011

Thalidomide (Thalomid) (PDF)

Effective Date: 09/01/2011

Bosentan (Tracleer®) (PDF)

Effective Date: 03/01/2016

Thyrotropin Alfa (Thyrogen) (PDF) 

Effective Date: 03/01/2012

 

temsirolimus (Torisel®) (PDF)

Effective Date: 03/01/2017

 

triptorelin pamoate (Trelstar®, Triptodur®) (PDF)

Effective Date: 11/09/2017

 

lapatinib (Tykerb®) (PDF)

Effective Date: 11/09/2017

 

A-H I-Q R-Z

340 B Shared Savings Model

Effective Date: 04/01/2017


Ledipasvir Sofosbuvir (Harvoni) (PDF)

Effective Date: 12/01/2016

Simpeprevir (Olysio) (PDF)

Effective Date: 12/01/2016


72 Hour Supply of Medication (PDF)

Effective Date: 06/01/2006


Levofloxacin (Levaquin) in Pediatric Community Acquired Pneumonia (PDF)

Effective Date: 03/01/2016

Sofosbuvir (Sovaldi) (PDF)

Effective Date: 12/01/2016


Appropriate Use and Safety Edits (PDF)

Appropriate Use and Safety Edits: Attachment A (PDF)

Effective Date: 05/01/2012


PBM Inquiry for Additional information During PA/MN Review Process (PDF)

Attachment A (PDF)

Effective Date: 04/01/2007

Sofosbuvir Velpatasvir (Epclusa) (PDF)

Effective Date: 12/01/2016


Approval of Brand Name Override (PDF)

Effective Date: 04/01/2007


Lost, Stolen, Spilled or Broken Medications (PDF)

Effective Date: 04/01/2007

Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (PDF)

Effective Date: 09/01/2017


Blocking Adjudication of Controlled Substance Prescriptions for Selected Prescribers (PDF)

Effective Date: 11/01/2001


Medication Safety Policy (PDF)

Effective Date: 07/01/2017

Specialty Drug Classification (PDF)

Effective Date: 03/12/2000


Daclatasvir (Daklinza) (PDF)

Effective Date: 12/01/2016


Pediatric BZD Seizures (PDF)

Effective Date: 03/01/2016

Specialty Pharmacy Program (PDF)

Effective Date: 03/12/2014


Dasabuvir Ombitasvir Paritaprevir Ritonavir (Viekira XR, Viekira Pak) (PDF)

Effective Date: 12/01/2016


Peds BZD in CINV (PDF)

Effective Date: 08/01/2016

Tretinoin in Adult Acne (PDF)

Effective Date: 03/01/2016


Dose Escalation of Biologics (PDF)

Effective Date: 09/01/2017


Pharmaceutical Management (PDF)

Effective Date: 02/01/2003

Varenicline (Chantix) (PDF)

Effective Date: 01/01/2017

Drug Recall Notification Process (PDF)

Effective Date: 07/01/2008


Pharmacy and Therapeutics Committee (PDF)

Effective Date: 08/09/2011

Somatropin (Growth Hormone) (PDF)

Effective Date: 03/01/2011

Drug Utilization Review (PDF)

Effective Date: 04/01/2007


Pharmacy Lock-In Program (PDF)

Lock-In Letter (PDF)

Lock-In Release Letter (PDF)

Effective Date: 07/01/2006

Riociguat (Adempas®) (PDF)

Effective Date: 03/01/2016


Elbasvir Grazoprevir (Zepatier) (PDF)

Effective Date: 12/01/2016


Pharmacy Prior Authorization and Medical Necessity Criteria (PDF)

Effective Date: 07/09/2010

Tadalafil (Adcirca®) (PDF)

Effective Date: 03/01/2016


EoE (PDF)

Effective Date: 09/01/2016


Pharmacy Program (PDF)

Effective Date: 04/01/2007

Tocilizumab (Actemra) (PDF)

Effective Date: 07/01/2016


Epinephrine Injection Device (PDF)

Effective Date: 03/01/2015


Psychotropic Medication Continuity of Care (COC) (PDF)

Effective Date: 12/01/2016

Vandetanib (Caprelsa®) (PDF)

Effective Date: 10/01/2011


Glecaprevir/Pibrentasvir (Mavyret) (PDF)

Effective Date: 09/01/2017

Ibalizumab-uiyk (Trogarzo) (PDF)

Effective Date: 04/17/2018

Reslizumab (Cinqair) (PDF)

Effective Date: 05/01/2016

Benznidazole (PDF)

Effective Date: 10/17/2017

Nusinersen (Spinraza®)(PDF)

Effective Date: 11/28/2017

Ramucirumab (Cyramza®) (PDF)

Effective Date: 05/01/2015

Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF)

Effective Date: 12/01/2016

Lumacaftor-Ivacaftor (Orkambi) (PDF)

Effective Date: 05/01/2016

Tesamorelin (Egrifta) (PDF)

Effective Date: 03/01/2014

Brentuximab Vedotin (Adcetris) (PDF)

Effective Date: 02/01/2017

Interferon Gamma- 1b (Actimmune) (PDF)

Effective Date: 06/01/2010

Taliglucerase Alfa (Elelyso) (PDF)

Effective Date: 02/01/2016

Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF)

Effective Date: 12/01/2016

Interferon beta-1b (Betaseron, Extavia) (PDF)

Effective Date: 08/01/2016

Vedolizumab (Entyvio) (PDF)

Effective Date: 07/01/2016

Bendamustine (Bendeka®, Treanda®) (PDF)

Effective Date: 02/01/2017

Immune Globulins (PDF)

Effective Date: 08/01/2012

Teriparatide (Forteo®) (PDF)

Effective Date: 11/15/2017

Belimumab (Benlysta) (PDF)

Effective Date: 10/01/2011

Ibandronate sodium (Boniva®) (PDF)

Effective Date: 11/15/2017

Teduglutide (Gattex) (PDF)

Effective Date: 05/01/2013

C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF)

Effective Date: 03/01/2016

OnabotulinumtoxinA (Botox) (PDF)

Effective Date: 07/01/2016

Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF)

Effective Date: 06/01/2016

Blinatumomab (Blincyto) (PDF)

Effective Date: 02/01/2017

Protein c concentrate, human (Ceprotin®) (PDF)

Effective Date: 03/01/2017

Repository Corticotropin Injection (H.P. Acthar Gel) (PDF)

Effective Date: 03/01/2016

Bosutinib (Bosulif) (PDF)

Effective Date: 10/01/2012

 

Imiglucerase (Cerezyme) (PDF)

Effective Date: 02/01/2016

Topotecan (Hycamtin)(PDF)

Effective Date: 06/01/2011

Cerliponase alfa (Brineura) (PDF)

Effective Date: 07/01/2017

Perampanel (Fycompa) (PDF)

Effective Date: 11/16/2016

RimabotulinumtoxinB (Myobloc) (PDF)

Effective Date: 07/01/2016

Carglumic acid (Carbaglu®) (PDF)

Effective Date: 05/01/2016

Pralatrexate (Folotyn®) (PDF)

Effective Date: 02/01/2017

sorafenib (Nexavar) (PDF)

Effective Date: 07/01/2011

Aztreonam (Cayston®) (PDF)

Effective Date: 05/01/2016

Levoleucovorin (Fusilev®) (PDF)

Effective Date: 11/09/2017

romidepsin (Istodax®) (PDF)

Effective Date: 01/01/2017

Certolizumab (Cimzia) (PDF)

Effective Date: 08/01/2016

Obinutuzumab (Gazyva®) (PDF)

Effective Date: 02/01/2017

Sebelipase Alfa (Kanuma) (PDF)

Effective Date: 02/01/2016

Cabozantinib (Cometriq®, Cabometyx®) (PDF)

Effective Date: 06/01/2013

Imatinib (Gleevec) (PDF)

Effective Date: 06/01/2011

Sipuleucel-T (Provenge) (PDF)

Effective Date: 06/01/2015

Glatiramer (Copaxone, Glatopa) (PDF)

Effective Date: 08/01/2016

Pegfilgrastim (Neulasta) (PDF)

Effective Date: 12/01/2016

Tobramycin (Bethkis®, Kitabis Pak®, TOBI®, TOBI Podhaler®) (PDF)

Effective Date: 05/01/2016

Factor XIII, Human (Corifact®) (PDF)

Effective Date: 05/01/2016

Ixazomib (Ninlaro) (PDF)

Effective Date: 02/01/2017

Zoledronic acid (Reclast, Zometa) (PDF)

Effective Date: 03/01/2011

Cosyntropin (Cortrosyn®) (PDF)

Effective Date: 04/01/2016

Mitoxantrone (Novantrone) (PDF)

Effective Date: 08/01/2016

Sildenafil (Revatio®) (PDF)

Effective Date: 03/01/2016

Daptomycin (Cubicin, Cubicin RF) (PDF)

Effective Date: 11/30/2017

Factor VIIa, Recombinant (NovoSeven® RT) (PDF)

Effective Date: 05/01/2016

Sapropterin Dihydrochloride (Kuvan®) (PDF)

Effective Date: 02/01/2010

Daratumumab (Darzalex) (PDF)

Effective Date: 07/01/2017

Mepolizumab (Nucala) (PDF)

Effective Date: 04/01/2016

Sargramostim (Leukine) (PDF)

Effective Date: 12/01/2016

Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF)

Effective Date: 05/01/2016

Obeticholic (Ocaliva) (PDF)

Effective Date: 11/01/2016

Ranibizumab (Lucentis®) (PDF)

Effective Date: 03/01/2016

Deferoxamine (Desferal) (PDF)

Effective Date: 11/01/2015

Ocrelizumab (Ocrevus) (PDF)

Effective Date: 04/01/2017

vincristine sulfate liposome injection (Marqibo®) (PDF)

Effective Date: 02/01/2017

Dupilumab (Dupixent) (PDF)

Effective Date: 05/01/2017

irinotecan Liposome (Onivyde®) (PDF)

Effective Date: 02/01/2017

Risperidone Long-Acting Injection (Risperdal Consta) (PDF)

Effective Date: 12/01/2016

AbobotulinumtoxinA (Dysport) (PDF)

Effective Date: 07/01/2016

Nivolumab (Opdivo) (PDF)

Effective Date: 07/01/2015

Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF)

Effective Date: 07/01/2016

Factor VIII (Human Recombinant) (PDF)

Effective Date: 05/01/2016

Lumacaftor-ivacaftor (Orkambi) (PDF)

Effective Date: 05/01/2016

Vigabatrin (Sabril) (PDF)

Effective Date: 02/01/2016

Etanercept (Enbrel) (PDF)

Effective Date: 08/01/2016

Pertuzumab (Perjeta) (PDF)

Effective Date: 06/01/2016

Tedizolid (Sivextro) (PDF)

Effective Date: 03/01/2015

Epoetin Alfa (Epogen® and Procrit) (PDF)

Effective Date: 06/01/2016

Peginterferon beta-1a (Plegridy) (PDF)

Effective Date: 08/01/2016

Ustekinumab (Stelara) (PDF)

Effective Date: 08/01/2016

Cetuximab (Erbitux®) (PDF)

Effective Date: 02/01/2017

Pomalidomide (Pomalyst) (PDF)

Effective Date: 07/01/2013

Regorafenib (Stivarga) (PDF)

Effective Date: 12/01/2012

Erwina asparaginase (Erwinaze®) (PDF)

Effective Date: 02/01/2017

Necitumumab (Portrazza®) (PDF)

Effective Date: 03/01/2017

sunitinib (Sutent) (PDF)

Effectove Date: 09/01/2011

Deferasirox (Exjade Jadenu) (PDF)

Effective Date: 11/1/2015

Palbociclib (Ibrance®) (PDF)

Effective Date: 10/01/2015

Vorinostat (Zolinza) (PDF)

Effective Date: 12/01/2012

Eteplirsen (PDF)

Effective Date: 12/01/2016

Ponatinib (Iclusig) (PDF)

Effective Date: 06/01/2013

Vemurafenib (Zelboraf®) (PDF)

Effective Date: 11/01/2011

Aflibercept (Eylea®) (PDF)

Effective Date: 03/01/2016

Ibrutinib (Imbruvica) (PDF)

Effective Date: 10/01/2015

ziv-aflibercept (Zaltrap®) (PDF)

Effective Date: 03/01/2017

Agalsidase Beta (Fabrazyme) (PDF)

Effective Date: 02/01/2016

Mecasermin (Increlex) (PDF)

Effective Date: 03/01/2011

Trabectedin (Yondelis®) (PDF)

Effective Date: 05/01/2016

Ferumoxytol (Feraheme®) (PDF)

Effective Date: 03/01/2016

Infliximab (Remicade, Inflectra, Renflexis) (PDF)

Effective Date: 07/01/2016

sodium oxybate (Xyrem) (PDF)

Effective Date: 05/01/2011

Deferiprone (Ferriprox) (PDF)

Effective Date: 11/01/2015

Lomitapide (Juxtapid) (PDF)

Effective Date: 10/01/2016

Telotristat Ethyl (Xermelo) (PDF)

Effective Date: 06/01/2017

Ferric gluconate (Ferrlecit®) (PDF)

Effective Date: 03/01/2016

Ivacaftor (Kalydeco) (PDF)

Effective Date: 05/01/2016

tetrabenazine (Xenazine) (PDF)

Effective Date: 12/01/2011

Degarelix acetate (Firmagon®) (PDF)

Effective Date: 11/09/2017

pembrolizumab (Keytruda®) (PDF)

Effective Date: 3/1/2017

Tofacitinib (Xeljanz, Xeljanz XR) (PDF)

Effective Date: 01/30/2018

Dalteparin (Fragmin) (PDF)

Effective Date: 05/01/2016

Mifepristone (Korlym) (PDF)

Effective Date: 05/01/2012

Velaglucerase Alfa (VPRIV) (PDF)

Effective Date: 02/01/2016

Enfuvirtide (Fuzeon) (PDF)

Effective Date: 06/01/2010

Pegloticase (Krystexxa®) (PDF)

Effective Date: 06/01/2013

Verteporfin (Visudyne®) (PDF)

Effective Date: 03/01/2016

Fingolimod (Gilenya) (PDF)

Effective Date: 08/01/2016

Mipomersen (Kynamro) (PDF)

Effective Date: 10/01/2016

siltuximab (Sylvant®) (PDF)

Effective Date: 03/01/2017

Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF)

Effective Date: 03/01/2012

olaratumab (Lartruvo®) (PDF)

Effective Date: 03/01/2017

Temozolomide (Temodar) (PDF)

Effective Date: 09/01/2011

Eribulin Mesylate (Halaven®) (PDF)

Effective Date: 03/01/2017

Intrathecal Baclofen (Gablofen, Lioresal) (PDF)

Effective Date: 11/09/2017

Thalidomide (Thalomid) (PDF)

Effective Date: 09/01/2011

Adalimumab (Humira) (PDF)

Effective Date: 08/01/2016

leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF)

Effective Date: 11/09/2017

Thyrotropin Alfa (Thyrogen) (PDF) 

Effective Date: 03/01/2012

Hydroxyprogesterone Caproate (Makena®) (PDF)

Effective Date: 11/20/2017

Pegaptanib (Macugen®) (PDF)

Effective Date: 03/01/2016

temsirolimus (Torisel®) (PDF)

Effective Date: 03/01/2017

 

Galsulfase (Naglazyme) (PDF)

Effective Date: 02/01/2016

Plerixafor (Mozobil) (PDF)

Effective Date: 03/01/2017

triptorelin pamoate (Trelstar®, Triptodur®) (PDF)

Effective Date: 11/09/2017

droxidopa (Northera®) (PDF)

Effective Date: 11/09/2017

Lenalidomide (Revlimid) (PDF)

Effective Date: 07/01/2011

 

belatacept (Nulojix®) (PDF)

Effective Date: 11/09/2017

Octreotide (Sandostatin, Sandostatin LAR) (PDF)

Effective Date: 03/01/2010

 

abatacept (Orencia) (PDF)

Effective Date: 08/01/2016

Pasireotide (Signifor LAR®) (PDF)

Effective Date: 03/01/2017

 

Apremilast (Otezla) (PDF)

Effective Date: 08/01/2016

peginterferon alfa-2b (PegIntron, Sylatron®) (PDF)

Effective Date: 10/01/2011

 

Hemin (Panhematin®) (PDF)

Effective Date: 02/01/2016

Paricalcitol Injection (Zemplar) (PDF)

Effective Date: 08/01/2016

 

Buprenorphine implant (Probuphine) (PDF)

Effective Date: 11/16/2016

Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF)

Effective Date: 12/01/2016

 

Alirocumab (Praluent) (PDF)

Effective Date: 10/01/2015

Miglustat (Zavesca) (PDF)

Effective Date: 02/01/2016

 

Cysteamine oral (Cystagon, Procysbi) (PDF)

Effective Date: 02/01/2016

Ipilimumab (Yervoy) (PDF)

Effective Date: 04/17/2018

 

Denosumab (Prolia, Xgeva) (PDF)

Effective Date: 03/01/2011

IncobotulinumtoxinA (Xeomin) (PDF)

Effective Date: 07/01/2016

 

Eltrombopag (Promacta®) (PDF)

Effective Date: 03/01/2016

Pazopanib (Votrient) (PDF)

Effective Date: 10/01/2011

 

Canakinumab (Ilaris) (PDF)

Effective Date: 08/01/2016

Naltrexone (Vivitrol®) (PDF)

Effective Date: 03/01/2012

 

Durvalumab (Imfinzi) (PDF)

Effective Date: 07/01/2017

Iloprost (Ventavis®) (PDF)

Effective Date: 03/01/2016

 

ferric carboxymaltose (Injectafer®) (PDF)

Effective Date: 06/01/2016

Iron sucrose (Venofer®) (PDF)

Effective Date: 03/01/2016

 

Axitinib (Inlyta®) (PDF)

Effective Date: 05/01/2012

panitumumab (Vectibix®) (PDF)

Effective Date: 03/01/2017

 

cabazitaxel (Jevtana® (PDF)

Effective Date: 02/01/2017

Natalizumab (Tysabri) (PDF)

Effective Date: 07/01/2016

 

Anakinra (Kineret) (PDF)

Effective Date: 08/01/2016

lapatinib (Tykerb®) (PDF)

Effective Date: 11/09/2017

 

Factor IX Complex Human (Bebulin®, Profilnine®) (PDF)

Effective Date: 05/01/2016

Palivizumab (Synagis) (PDF)

Effectiive Date: 08/01/2009

 

Dornase alfa (Pulmozyme) (PDF)

Effective Date: 05/01/2016

nafarelin acetate (Synarel®) (PDF)

Effective Date: 11/09/2017

 

Evolocumab (Repatha) (PDF)

Effective Date: 10/01/2015

Omacetaxine (Synribo) (PDF)

Effective Date: 04/01/2013

 

carfilzomib (Kyprolis®) (PDF)

Effective Date: 02/01/2017

Ixekizumab (Taltz) (PDF)

Effective Date: 08/01/2016

 

Alemtuzumab (Lemtrada) (PDF)

Effective Date: 08/01/2016

nilotinib (Tasigna) (PDF)

Effective Date: 09/01/2011

 

Ambrisentan (Letairis®) (PDF)

Effective Date: 03/01/2016

lapatinib (Tykerb®) (PDF)

Effective Date: 11/09/2017

 

Enoxaparin (Lovenox) (PDF)

Effective Date: 05/01/2016

Ombitasvir Paritaprevir Ritonavir (Technivie) (PDF)

Effective Date: 12/01/2016

 

Alglucosidase Alfa (Lumizyme) (PDF)

Effective Date: 02/01/2016

   

Cinacalcet (Sensipar) (PDF)

Effective Date: 05/01/2011

   

Golimumab (Simponi, Simponi Aria) (PDF)

Effective Date: 07/01/2016

   

Eculizumab (Soliris®) (PDF)

Effective Date: 03/01/2012

   

Dasatinib (Sprycel) (PDF)

Effective Date: 06/01/2012

   

asfotase alfa (Strensiq®) (PDF)

Effective Date: 03/01/2017

   

histrelin acetate (Vantas®, Supprelin LA®) (PDF)

Effective Date: 11/09/2017

   

Elbasvir Grazoprevir (Zepatier) (PDF)

Effective Date: 12/01/2016

   

Daclizumab (Zinbryta) (PDF)

Effective Date: 08/01/2016

   

Bezlotoxumab (Zinplava) (PDF)

Effective Date: 11/16/2016

   

goserelin acetate (Zoladex®) (PDF)

Effective Date: 11/09/2017

   

Abiraterone (Zytiga) (PDF)

Effective Date: 10/01/2011

   

Enzalutamide (Xtandi) (PDF)

Effective Date: 10/01/2012

   

Collagenase (Xiaflex) (PDF)

Effective Date: 10/01/2011

   

capecitabine (Xeloda) (PDF)

Effective Date: 05/01/2011

   

Crizotinib (Xalkori) (PDF)

Effective Date: 11/01/2011

   

Elosulfase Alfa (Vimizim) (PDF)

Effective Date: 02/01/2016

   

Dasabuvir Ombitasvir Paritaprevir Ritonavir (Viekira XR, Viekira Pak) (PDF)

Effective Date: 12/01/2016

   

Epoprostenol (Flolan®), Veletri®) (PDF)

Effective Date: 03/01/2016

   

Factor XIII A-Subunit, Recombinant (Tretten®) (PDF)

Effective Date: 05/01/2016

   

Erlotinib (Tarceva) (PDF)

Effective Date: 09/01/2011

   

Bexarotene (Targretin) (PDF)

Effective Date: 09/01/2011

   

atezolizumab (Tecentrip®) (PDF)

Effective Date: 06/01/2016

   

Bosentan (Tracleer®) (PDF)

Effective Date: 03/01/2016

   
A-H I-Z

72 Hour Supply of Medication (PDF)

Effective Date: 06/01/2006

Pharmacy Prior Authorization and Medical Necessity Criteria (PDF)

Effective Date: 07/09/2010

Appropriate Use and Safety Edits (PDF)

Appropriate Use and Safety Edits: Attachment A (PDF)

Effective Date: 05/01/2012

Pharmacy and Therapeutics Committee (PDF)

Effective Date: 08/09/2011

Blocking Adjudication of Controlled Substance Prescriptions for Selected Prescribers (PDF)

Effective Date: 11/01/2001

Pharmaceutical Management (PDF)

Effective Date: 02/01/2003

Dose Escalation of Biologics (PDF)

Effective Date: 09/01/2017

Medication Safety Policy (PDF)

Effective Date: 07/01/2017


Drug Recall Notification Process (PDF)

Effective Date: 07/01/2008


Maximum Allowable Cost (MAC) Requirement (PDF)

Effective Date: 07/01/2017

Drug Utilization Review (PDF)

Effective Date: 04/01/2007

Lost, Stolen, Spilled or Broken Medications (PDF)

Effective Date: 04/01/2007

Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF)

Effective Date: 12/01/2016

Riociguat (Adempas®) (PDF)

Effective Date: 03/01/2016

Benznidazole (PDF)

Effective Date: 10/17/2017

Tadalafil (Adcirca®) (PDF)

Effective Date: 03/01/2016

C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF)

Effective Date: 03/01/2016

Ibandronate sodium (Boniva®) (PDF)

Effective Date: 11/15/2017

Carglumic acid (Carbaglu®) (PDF)

Effective Date: 05/01/2016

Vandetanib (Caprelsa®) (PDF)

Effective Date: 10/01/2011

Cabozantinib (Cometriq®, Cabometyx®) (PDF)

Effective Date: 06/01/2013

Ibrutinib (Imbruvica) (PDF)

Effective Date: 10/01/2015

Aflibercept (Eylea®) (PDF)

Effective Date: 03/01/2016

Mecasermin (Increlex) (PDF)

Effective Date: 03/01/2011

Hydroxyprogesterone Caproate (Makena®) (PDF)

Effective Date: 11/20/2017

Ivacaftor (Kalydeco) (PDF)

Effective Date: 05/01/2016

pembrolizumab (Keytruda®) (PDF)

Effective Date: 3/1/2017

Mifepristone (Korlym) (PDF)

Effective Date: 05/01/2012

Ado-Trastuzumab Emtansine (Kadcyla) (PDF)

Effective Date: 06/01/2016

Lomitapide (Juxtapid) (PDF)

Effective Date: 10/01/2016

Anakinra (Kineret) (PDF)

Effective Date: 08/01/2016

Pegloticase (Krystexxa®) (PDF)

Effective Date: 06/01/2013

Ambrisentan (Letairis®) (PDF)

Effective Date: 03/01/2016

Mipomersen (Kynamro) (PDF)

Effective Date: 10/01/2016

Enoxaparin (Lovenox) (PDF)

Effective Date: 05/01/2016

Ranibizumab (Lucentis®) (PDF)

Effective Date: 03/01/2016

Alglucosidase Alfa (Lumizyme) (PDF)

Effective Date: 02/01/2016

leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF)

Effective Date: 11/09/2017

Epoprostenol (Flolan®), Veletri®) (PDF)

Effective Date: 03/01/2016

Pegaptanib (Macugen®) (PDF)

Effective Date: 03/01/2016

 

vincristine sulfate liposome injection (Marqibo®) (PDF)

Effective Date: 02/01/2017

 

Plerixafor (Mozobil) (PDF)

Effective Date: 03/01/2017

 

Iloprost (Ventavis®) (PDF)

Effective Date: 03/01/2016

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.

A-H I-Q R-Z

3 Day Payment Window (PDF)

Effective Date: 07/01/2014

Inpatient Only Procedures Policy (PDF)

Effective Date: 1/1/18

Ultrasound in Pregnancy (PDF)

Effective Date: 01/31/2011

30 Day Readmission (PDF)

Effective Date: 01/01/2015

IV Hydration Policy (PDF)

Effective Date: 01/01/2013


Robotic Surgeries (PDF)

Effective Date: 08/01/2017

Add On Policy (PDF)

Effective Date: 01/01/2013

Inpatient Consultation (PDF)

Effective Date: 01/01/2014

Same Day Visits (PDF)

Effective Date: 01/01/2014

Assistant Surgeon (PDF)

Effective Date: 01/01/2014

Moderate Conscious Sedation (PDF)

Effective Date: 01/01/2013

Status B Bundled Services (PDF)

Effective Date: 01/01/2014

Bilateral Procedures (PDF)

Effective Date: 01/01/2014

Max Units Payment Policy (PDF)

Effective Date: 01/01/2013

Status P Bundled Services (PDF)

Effective Date: 01/01/2014

Cerumen Removal Policy (PDF)

Effective Date: 01/01/2014

Modifier DOS Validation (PDF)

Effective Date: 01/01/2015

Supplies Same Day as Surgery (PDF)

Effective Date: 01/01/2013

Clean Claims Policy (PDF)

Effective Date: 01/01/2013

Multiple CPT Code Replace (PDF)

Effective Date: 01/01/2013

Transgender Related Services (PDF)

Effective Date: 01/01/2017

Clinical Laboratory Improvement Amendments (CLIA) (PDF)

Effective Date: 01/01/2016

Modifier to Procedure Code Validation (PDF)

Effective Date: 01/01/2013



Unbundled Professional Services (PDF)

Effective Date: 03/15/2017


Clinical Validation of Modifier 25 (PDF)

Effective Date: 01/01/2013

NCCI Unbundling (PDF)

Effective Date: 01/01/2013

Unbundled Surgical Procedures (PDF)

Effective Date: 03/15/2017

Clinical Validation of Modifier 59 (PDF)

Effective Date: 01/01/2013

New Patient (PDF)

Effective Date: 01/01/2014

Unlisted Procedure Codes Policy (PDF)

Effective Date: 01/01/2013

Code Editing Overview (PDF)

Effective Date: 01/01/2013

Never Paid Events (PDF)

Effective Date: 01/01/2013

Urine Specimen Validity Testing (PDF)

Effective Date: 10/01/2017

Cosmetic Procedures (PDF)

Effective Date: 01/01/2014

Outpatient Consultation (PDF)

Effective Date: 01/01/2014

Visual Field Testing (PDF)

Effective Date: 01/01/2017

Distinct Procedure Modifiers Policy (PDF)

Effective Date: 01/01/2013

Physician Visit Codes Billed with Labs (PDF)

Effective Date: 01/01/2013

Wheelchairs and Accessories (PDF)

Effective Date: 10/01/2015

Duplicate Primary Code Billing (PDF)

Effective Date: 01/01/2014


Physicians Consultation Services (PDF)

Effective Date: 10/01/2017

 

EM Medical Decision Making (PDF)

Effective Date: 06/01/2017

Postoperative Visits (PDF)

Effective Date: 01/01/2014

 

E&M Bundling with Labs and Radiology (PDF)

Effective Date: 01/01/2013

Preoperative Visits (PDF)

Effective Date: 01/01/2014

 

Hospital Visit Codes Billed with Labs (PDF)

Effective Date: 01/01/2016

Problem Oriented Visits with Preventative Services (PDF)

Effective Date: 10/01/2017

 
 

Problem Oriented Visits with Surgical Procedures (PDF)

Effective Date: 10/01/2017

 
 

Professional Component Modifier (PDF)

Effective Date: 01/01/2013

 
 

Pulse Oximetry w Office Visits (PDF)

Effective Date: 01/01/2013

 
 

Place of Service Mismatch (PDF)

Effective Date: 09/01/2018

 
 

Non-obstectrical Pelvic and Transvaginal Ultrasounds (PDF)

Effective Date: 06/01/2018 

 
 

Not Medically Necessary Inpatient Service (PDF)

Effective Date: 06/01/2018

 
A-H I-Q R-Z

3 Day Payment Window (PDF)

Effective Date: 07/01/2014

Max Units Payment Policy (PDF

Effective Date: 01/01/2013


Reporting the Global Maternity Package (PDF)

Effective Date: 01/01/2013

30 Day Readmission (PDF)

Effective Date: 01/01/2015

Physician Visit Codes Billed with Labs (PDF)

Effective Date: 01/01/2013

Unlisted Procedure Codes Policy

Effective Date: 01/01/2013

Cerumen Removal Policy (PDF)

Effective Date: 01/01/2014


Moderate Conscious Sedation (PDF)

Effective Date: 01/01/2013

Scan Comp Oph Diag Imaging

Effective Date: 01/01/2017

E&M Bundling with Labs and Radiology (PDF)

Effective Date: 01/01/2013

Never Paid Events (PDF)

Effective Date: 01/01/2013


Visual Field Testing

Effective Date: 01/01/2017

Hospital Visit Codes Billed with Labs (PDF)

Effective Date: 01/01/2016

Inpatient Only Procedures Policy (PDF)

Effective Date: 1/1/18

Supplies Same Day as Surgery (PDF)

Effective Date: 01/01/2013


Clinical Laboratory Improvement Amendments (CLIA) (PDF)

Effective Date: 01/01/2016

IV Hydration Policy (PDF)

Effective Date: 01/01/2013


Sleep Studies POS (PDF)

Effective Date: 06/15/2017

Clean Claims Policy (PDF)

Effective Date: 01/01/2013

Modifier DOS Validation (PDF)

Effective Date: 01/01/2015


Status P Bundled Services (PDF)

Effective Date: 01/01/2014

Code Editing Overview (PDF)

Effective Date: 01/01/2013

Modifier to Procedure Code Validation (PDF)

Effective Date: 01/01/2013


Wheelchairs and Accessories (PDF)

Effective Date: 10/01/2015

Distinct Procedure Modifiers Policy (PDF)

Effective Date: 01/01/2013

Multiple CPT Code Replace (PDF)

Effective Date: 01/01/2013

Transgender Related Services (PDF)


Effective Date: 01/01/2017

Clinical Validation of Modifier 25 (PDF)

Effective Date: 01/01/2013

NCCI Unbundling (PDF)

Effective Date: 01/01/2013


Status B Bundled Services (PDF)

Effective Date: 01/01/2014


Clinical Validation of Modifier 59 (PDF)

Effective Date: 01/01/2013


Professional Component Modifier (PDF)

Effective Date: 01/01/2013


Same Day Visits (PDF)

Effective Date: 01/01/2014

Extended Ophthalmoscopy (PDF)

Effective Date: 01/01/2017

Pulse Oximetry w Office Visits (PDF)

Effective Date: 01/01/2013


Unbundled Professional Services (PDF)

Effective Date: 03/15/2017

External Ocular Photography (PDF)

Effective Date: 01/01/2017

Inpatient Consultation (PDF)

Effective Date: 01/01/2014


Unbundled Surgical Procedures (PDF)

Effective Date: 03/15/2017

Fluorescein Angiography (PDF)

Effective Date: 01/01/2017

Outpatient Consultation (PDF)

Effective Date: 01/01/2014


Robotic Surgeries (PDF)

Effective Date: 08/01/2017

Fundus Photography (PDF)

Effective Date: 01/01/2017

Postoperative Visits (PDF)

Effective Date: 01/01/2014

Ultrasound in Pregnancy (PDF)

Effective Date: 01/31/2011

Gonioscopy (PDF)

Effective Date: 10/01/2016

Preoperative Visits (PDF)

Effective Date: 01/01/2014

 

Add On Policy (PDF)

Effective Date: 01/01/2013

New Patient (PDF)

Effective Date: 01/01/2014

 

Cosmetic Procedures (PDF)

Effective Date: 01/01/2014

Non-obstectrical Pelvic and Transvaginal Ultrasounds (PDF)

Effective Date: 06/01/2018 

 

Assistant Surgeon (PDF)

Effective Date: 01/01/2014

Place of Service Mismatch (PDF)

Effective Date: 09/01/2018

 

Bilateral Procedures (PDF)

Effective Date: 01/01/2014

Not Medically Necessary Inpatient Service (PDF)

Effective Date: 06/01/2018

 

Duplicate Primary Code Billing (PDF)

Effective Date: 01/01/2014

Leveling Professional Fees for Emergency Room Services (PDF)

Effective Date: 11/05/2018

 

EM Medical Decision Making (PDF)

Effective Date: 06/01/2017

   
A-H I-Q R-Z

3 Day Payment Window (PDF)

Effective Date: 07/01/2014

Maximum Units (PDF)

Effective Date: 01/01/2013

Unlisted Procedure Codes Policy (PDF)

Effective Date: 01/01/2013

Cerumen Removal Policy (PDF)

Effective Date: 01/01/2014

Inpatient Only Procedures Policy (PDF)

Effective Date: 1/1/18

Wheelchairs and Accessories (PDF)

Effective Date: 10/01/2015

E&M Bundling with Labs and Radiology (PDF)

Effective Date: 01/01/2013

IV Hydration Policy (PDF)

Effective Date: 01/01/2013

Ultrasound in Pregnancy (PDF)

Effective Date: 01/31/2011

Clean Claims (PDF)

Effective Date: 01/01/2013

Never Paid Events (PDF)

Effective Date: 01/01/2013

Supplies Same Day as Surgery (PDF)

Effective Date: 01/01/2013

Code Editing Overview (PDF)

Effective Date: 01/01/2013

Moderate Conscious Sedation (PDF)

Effective Date: 01/01/2013

Visits on Same Day as Surgery (PDF)

Effective Date: 01/01/2014

Distinct Procedure Modifiers (PDF)

Effective Date: 01/01/2013

Physician Visit Codes Billed with Labs (PDF)

Effective Date: 01/01/2013

Status B Bundled Services (PDF)

Effective Date: 01/01/2014

Clinical Validation of Modifier 25 (PDF)

Effective Date: 01/01/2013

Modifier DOS Validation (PDF)

Effective Date: 01/01/2015

Transgender Related Services (PDF)

Effective Date: 01/01/2017

Clinical Validation of Modifier 59 (PDF)

Effective Date: 01/01/2013

Modifier to Procedure Code Validation (PDF)

Effective Date: 01/01/2013

Status P Bundled Services (PDF)

Effective Date: 01/01/2014

Clinical Laboratory Improvement Amendments (CLIA) (PDF)

Effective Date: 01/01/2016

Multiple CPT Code Replace (PDF)

Effective Date: 01/01/2013

Sleep Studies POS (PDF)

Effective Date: 06/15/2017

Hospital Visit Codes Billed with Labs (PDF)

Effective Date: 01/01/2016

NCCI Unbundling (PDF)

Effective Date: 01/01/2013

Unbundled Surgical Procedures (PDF)

Effective Date: 03/15/2017

Add On Policy (PDF)

Effective Date: 01/01/2013

Professional Component Modifier (PDF)

Effective Date: 01/01/2013

Unbundled Professional Services (PDF)

Effective Date: 03/15/2017

Cosmetic Procedures (PDF)

Effective Date: 01/01/2014

Pulse Oximetry w Office Visits (PDF)

Effective Date: 01/01/2013


Urine Specimen Validity Testing (PDF)

Effective Date: 10/01/2017

30 Day Readmission (PDF)

Effective Date: 01/01/2015

Inpatient Consultation (PDF)

Effective Date: 01/01/2014

 

Assistant Surgeon (PDF)

Effective Date: 01/01/2014

Outpatient Consultation (PDF)

Effective Date: 01/01/2014

 

Bilateral Procedures (PDF)

Effective Date: 01/01/2014

New Patient (PDF)

Effective Date: 01/01/2014

 

Duplicate Primary Code Billing (PDF)

Effective Date: 01/01/2014

Postoperative Visits (PDF)

Effective Date: 01/01/2014

 

EM Medical Decision Making (PDF)

Effective Date: 06/01/2017

Preoperative Visits (PDF)

Effective Date: 01/01/2014

 
 

Problem Oriented Visits with Preventative Services (PDF)

Effective Date: 10/01/2017

 
 

Problem Oriented Visits with Surgical Procedures (PDF)

Effective Date: 10/01/2017

 
 

Place of Service Mismatch (PDF)

Effective Date: 09/01/2018

 
 

Non-obstectrical Pelvic and Transvaginal Ultrasounds (PDF)

Effective Date: 06/01/2018 

 
 

Not Medically Necessary Inpatient Service (PDF)

Effective Date: 06/01/2018