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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.

 

POLICY TITLE POLICY NUMBER EFFECTIVE DATE
2019-Novel Coronavirus Testing (PDF) CP.MP.183 03/06/2020
25-Hydroxyvitamin D Testing in Children and Adolescents (PDF) CP.MP.157 12/29/2017
Acupuncture (PDF) CP.MP.92 12/31/2013
ADHD Assessment and Treatment (PDF) CP.MP.124 12/31/2013
Air Ambulance (PDF) CP.MP.175 04/30/2019
Allergy Testinng and Therapy (PDF) CP.MP.100 08/31/2016
Allogeneic Hematopoietic Cell Transplants for Sickle Cell (PDF) CP.MP.108 03/31/2016
Ambulatory EEG (PDF) CP.MP.96 09/30/2015
Ambulatory Surgery Center Optimization (PDF) CP.MP.158 02/16/2018
Articular Cartilage Defect Repairs (PDF) CP.MP.26 10/31/2008
Assisted Reproductive Technology (PDF) CP.MP.55 03/31/2014
Balloon Sinus Ostial Dilation (PDF) CP.MP.119 07/29/2016
Bariatric Surgery (PDF) CP.MP.37 06/11/2009
Biofeedback (PDF) CP.MP.168 07/31/2017
Bone-Anchored Hearing Aid (PDF) CP.MP.93 12/31/2013
Bronchial Thermoplasty (PDF) CP.MP.110 05/31/2016
Burn Surgery (PDF) CP.MP.186 05/31/2020
Cardiac Biomarker Testing (PDF) CP.MP.156 12/29/2017
Carrier Screening in Pregnancy (PDF) CP.MP.83 07/31/2013
Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF) CP.MP.164 08/31/2018
Cell-Free Fetal DNA Testing (PDF) CP.MP.84 08/31/2013
Clinical Trials (PDF) CP.MP.94 01/27/2014
Cochlear Implant Replacements (PDF) CP.MP.14 03/20/2009
Cosmetic and Reconstructive Surgery (PDF) CP.MP.31 03/31/2009
Dental Anesthesia (PDF) CP.MP.61 06/01/2013
Digital EEG Spike Analysis (PDF) CP.MP.105 01/15/2016
Disc Decompression Procedures (PDF) CP.MP.114 07/31/2016
Discography (PDF) CP.MP.115 08/30/2016
DNA Analysis of Stool to Screen for Colorectal Cancer (PDF) CP.MP.125 09/30/2016
Donor Lymphocyte Infusion (PDF) CP.MP.101 12/01/2015
Durable Medical Equipment (DME) (PDF) CP.MP.107 06/30/2009
Electric Breast Pumps (PDF) GA.CP.MP.500 04/01/2020
Electric Tumor Treating Fields (PDF) CP.MP.145 05/31/2017
Electroencephalography in the Evaluation of Headache (PDF) CP.MP.155 12/29/2017
Endometrial Ablation (PDF) CP.MP.106 03/01/2016
EpiFix Wound Treatment (PDF) CP.MP.140 04/30/2017
Essure Removal (PDF) CP.MP.131 11/30/2016
Evoked Potential Testing (PDF) CP.MP.134 11/30/2016
Experimental Technologies (PDF) CP.MP.36 06/30/2009
Facet Joint Interventions for Pain Management (PDF) CP.MP.171 09/14/2018
Fecal Incontinence Treatments (PDF) CP.MP.137 12/30/2016
Ferriscan R2-MRI (PDF) CP.MP.53 11/14/2012
Fertility Preservation (PDF) CP.MP.130 10/30/2016
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) CP.MP.129 10/30/2016
Fractionated Exhaled Nitric Oxide (FeNO) measurement (PDF) CP.MP.103 01/27/2016
Functional MRI (PDF) CP.MP.43 09/23/2009
Gastric Electrical Stimulation (PDF) CP.MP.40 07/30/2009
Gender Affirming Procedures (PDF) CP.MP.95 11/28/2014
Gender Reassignment Surgery (PDF) CP.MP.95 11/28/2014
Genetic Testing (PDF) CP.MP.89 11/30/2013
H. Pylori Serology Testing (PDF) CP.MP.153 12/29/2017
Heart-Lung Transplant (PDF) CP.MP.132 06/30/2017
Holter Monitors (PDF) CP.MP.113 08/30/2016
Home Birth (PDF) CP.MP.136 12/30/2016
Home Phototherapy for Neonatal Hyperbilirubiniemia (PDF) CP.MP.150 12/21/2017
Homocysteine Testing (PDF) CP.MP.121 08/30/2016
Hospice Services (PDF) CP.MP.54 07/30/2014
Hyperbaric Oxygen Therapy (PDF) CP.MP.27 06/30/2009
Hyperemesis Gravidarum Treatment (PDF) CP.MP.34 03/31/2009
Hyperhidrosis Treatments (PDF) CP.MP.62 05/16/2013
Implantable Intrathecal Pain Pump (PDF) CP.MP.173 02/28/2019
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 04/30/2018
Incontinence and Ostomy Supplies (PDF) GA.CP.MP.07 11/18/2015
Infant Apnea Monitors (PDF) GA.CP.MP.06 11/20/2015
Inhaled Nitric Oxide (PDF) CP.MP.87 08/30/2013
Insulin Testing in Pediatrics (PDF) GA.CP.MP.154 07/01/2018
Intensity-Modulated Radiotherapy (PDF) CP.MP.69 03/31/2014
Intestinal and Multivisceral Transplant (PDF) CP.MP.58 02/28/2014
Intradiscal Steroid Injections for Pain Management (PDF) CP.MP.167 08/31/2018
Laser Therapy for Skin Conditions (PDF) CP.MP.123 08/30/2016
Long Acting Reversible Contraception (LARC) (PDF) GA.CP.MP.10 09/17/2017
Long Term Care Placement Criteria (PDF) CP.MP.71 07/11/2018
Low-Frequency Ultrasound Therapy for Wound Management (PDF) CP.MP.139 02/28/2017
Lung Transplantation (PDF) CP.MP.57 02/28/2014
Lysis of Epidural Lesions (PDF) CP.MP.116 07/31/2018
Measurement of Serum 1,25-dihydroxyvitamin D (PDF) CP.MP.152 12/29/2017
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) CP.MP.144 04/30/2017
Medical Necessity for Authorizing Incontinence Supplies (PDF) GA.MP.07 11/18/2015
Multiple Sleep Latency Testing (PDF) CP.MP.24 10/31/2008
Nebulizer with Compressor (PDF) GA.CP.MP.501 04/29/2020
Neonatal Abstinence Syndrome Guidelines (PDF) CP.MP.86 10/30/2013
Neonatal Sepsis Management (PDF) CP.MP.85 08/30/2013
Nerve Blocks for Pain Management (PDF) CP.MP.170 08/31/2018
NICU Apnea Bradycardia Guidelines (PDF) CP.MP.82 06/30/2013
NICU Discharge Guidelines (PDF) CP.MP.81 06/30/2013
Non-Invasive Home Ventilator (PDF) CP.MP.184 05/31/2020
Non-myeloablative Allogeneic Stem Cell Transplants (PDF) CP.MP.141 04/28/2017
OB Home Health Programs (PDF) CP.MP.91 01/27/2014
Optic Nerve Decompression Surgery (PDF) CP.MP.128 09/30/2016
Outpatient Cardiac Rehabilitation (PDF) CP.MP.176 05/31/2019
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 09/30/2012
Pancreas Transplantation (PDF) CP.MP.102 04/29/2016
Panniculectomy (PDF) CP.MP.109 04/30/2016
Pediatric Heart Transplant (PDF) CP.MP.138 01/31/2017
Pediatric Liver Transplant (PDF) CP.MP.120 04/30/2018
Pediatric Oral Function Therapy (PDF) CP.MP.188 05/31/2020
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) CP.MP.147 07/31/2017
Physical, Occupational, Speech, and/or Feeding Therapy (PDF) GA.CP.MP.49 03/23/2009
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) CP.MP.133 10/30/2016
Proton and Neutron Beam Therapy (PDF) CP.MP.70 03/31/2014
Radial Head Implant (PDF) CP.MP.148 08/31/2017
Radiofrequency Ablation of Uterine Fibroids (PDF) CP.MP.187 04/30/2020
Reduction Mammaplasty (PDF) CP.MP.51 07/31/2012
Sacroiliac Joint Fusion (PDF) CP.MP.126 09/30/2016
Sacroiliac Joint Interventions for Pain Management (PDF) CP.MP.166 08/31/2018
Selective Dorsal Rhizotomy (PDF) CP.MP.174 03/31/2019
Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF) CP.MP.165 08/31/2018
Sclerotherapy for Varicose Veins (PDF) CP.MP.146 06/30/2017
Short Inpatient Hospital Stay (PDF) CP.MP.182 05/29/2020
Sickle Cell Disease Observation (PDF) CP.MP.88 09/30/2013
Skin Substitutes for Chronic Wounds (PDF) CP.MP.185 04/20/2020
Spinal Cord Stimulation (PDF) CP.MP.117 07/31/2016
Stereotactic Body Radiation Therapy (PDF) CP.MP.22 12/30/2008
Tandem Transplant (PDF) CP.MP.162 07/31/2018
Testing of Rupture of Fetal Membranes (PDF) CP.MP.149 08/30/17
Testing for Select Genitourinary Conditions (PDF) CP.MP.97 06/15/2016
Thymus Transplantation (PDF) CP.MP.189 06/30/2020
Total Artificial Heart (PDF) CP.MP.127 12/30/2016
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 05/31/2016
Transcather Closer of Patent Foramen Ovale (PDF) CP.MP.151 12/29/2017
Trigger Point Injections for Pain Management (PDF) CP.MP.169 08/31/2018
Ultrasound in Pregnancy (PDF) CP.MP.38 01/31/2011
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142 04/30/2017
Urodynamic Testing (PDF) CP.MP.98 10/30/2015
Vagus Nerve Stimulation (PDF) CP.MP.12 09/30/2008
Ventricular Assist Devices (PDF) CP.MP.46 12/31/2009
Ventriculectomy and Cardiomyoplasty (PDF) CP.MP.56 05/06/2013
Video Electroencephalographic (VEEG) Monitoring (PDF) CP.MP.177 10/31/2019
Wheelchair Seating (PDF) CP.MP.99 10/31/2015
Wireless Motility Capsule (PDF) CP.MP.143 04/30/2017
POLICY TITLE POLICY NUMBER EFFECTIVE DATE
Applied Behavioral Analysis (PDF) CP.BH.104 08/31/2009
Neurofeedback for Behavioral Health Disorders (PDF) CP.BH.300 08/07/2020
Transcranial Magnetic Stimulation (PDF) CP.BH.200 01/08/2019
POLICY TITLE POLICY NUMBER EFFECTIVE DATE
Adjacent Tissue Transfer Grafts involving Eyelid (PDF) CP.VP.01 01/01/2017
Age Related Macular Degeneration (PDF) CP.VP.02 10/01/2017
Amblyopia (PDF) CP.VP.03 01/01/2017
Anterior Segment Photography with FA (PDF) CP.VP.67 10/01/2017
Aqueous Shunt (PDF) CP.VP.05 01/01/2016
Blepharoplasty, Ptosis and Canthoplasty (PDF) CP.VP.07 01/01/2017
B-Scan (PDF) CP.VP.68 01/01/2018
Cataract Extraction (PDF) CP.VP.08 01/01/2017
Chemodenervation (PDF) CP.VP.10 01/01/2017
Complex Cataract (PDF) CP.VP.12 01/01/2017
Corneal Hysteresis (PDF) CP.VP.17 01/01/2016
Corneal Pachymetry (PDF) CP.VP.16 01/01/2017
Corneal Topography (PDF) CP.VP.18 01/01/2017
Dark Adaptation and Color Vision Examinations (92283/92284) (PDF) CP.VP.23 01/01/2017
Destruction of a Localized Lesion of the Retina (PDF) CP.VP.21 01/01/2017
Destruction of Localized Lesion of Choroid (PDF) CP.VP.20 01/02/2015
Destruction of Retinopathy (PDF) CP.VP.19 01/01/2018
Dilation Protocol (PDF) CPG.VP.24 01/01/2016
Ectropion and Entropion Repair (PDF) CP.VP.25 10/01/2017
Examination Guidelines for Diabetic Patients (PDF) CPG.VP.22 01/01/2018
Extended Ophthalmoscopy (PDF) OC.UM.CP.0026 01/01/2018
External Ocular Photography (PDF) CP.VP.43 10/01/2016
Fluorescein Angiography (PDF) CP.VP.28 01/01/2018
Fundus Photography (PDF) CP.VP.29 01/01/2018
Glaucoma (PDF) CPG.VP.30 01/01/2017
Gonioscopy (PDF) CP.VP.31 10/01/2016
Indocyanine Green (ICG) Angiography (PDF) CP.VP.32 01/01/2017
Infracture of the Inferior Turbinate (PDF) CP.VP.33 01/02/2016
Iris Coloboma (PDF) CP.VP.34 01/01/2018
Keratoplasty (PDF) CP.VP.36 01/01/2016
Laser Iridotomy and Iridectomy for Glaucoma (PDF) CP.VP.37 01/01/2018
Laser Trabeculoplasty for POAG (PDF) CP.VP.38 01/01/2018
Ocular Prosthesis (PDF) CP.VP.44 01/01/2017
Ophthalmic Biometry (PDF) CP.VP.45 01/01/2017

Photodynamic and Intravitreal Therapies and Pharmaceuticals (PDF)

Attachment A (PDF)

CP.VP.40 09/01/2017
Prophylaxis of Retinal Detachment (PDF) CP.VP.53 01/01/2016
Recurrent Erosion Syndrome and PTK (PDF) CP.VP.49 01/01/2016
Refractive Surgery (PDF) CP.VP.52 01/01/2016
Refraction (PDF) CP.VP.35 12/01/2019
Repair of Retinal Detachment (PDF) CP.VP.54 01/01/2016
Secondary IOL (PDF) CP.VP.48 01/01/2016
Sensorimotor Examination (PDF) CP.VP.55 01/01/2017
Specular Microscopy (PDF) CP.VP.66 01/01/2018
Strabismus Surgeries (PDF) CP.VP.57 01/01/2016
Teleretinal Screening for Diabetic Retinopathy (PDF) CP.VP.88 01/01/2017
Trabeculetomy Ab Externo (PDF) CP.VP.61 01/01/2016
Visual Field Testing (PDF) CP.VP.63 01/01/2018
Visual Therapy (PDF) CP.VP.46 01/01/2018
Vitrectomy (PDF) CP.VP.64 01/01/2017
YAG Laser Capsulotomy (PDF) CP.VP.65 01/01/2017

 

POLICY TITLE POLICY NUMBER EFFECTIVE DATE
72 Hour Supply of Medication (PDF) GA.PHAR.07 06/01/2006
Abaloparatide (Tymlos) (PDF) CP.PHAR.345 07/01/2017
abatacept (Orencia) (PDF) CP.PHAR.241 08/01/2016
Abiraterone (Zytiga) (PDF) CP.PHAR.84 10/01/2011
Abiraterone (Zytiga, Yonsa) (PDF) CP.PHAR.84 10/01/2011
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 07/01/2016
Adalimumab (Humira) (PDF) CP.PHAR.242 08/01/2016
Adefovir (Hepsera) (PDF) CP.PHAR.142 08/28/2018
Ado-Trastuzumab Emtansine (Kadcyla) (PDF) CP.PHAR.229 06/01/2016
Aducanumab (PDF)
CP.PHAR.468 06/01/2020
Afatinib (Gilotrif) (PDF) CP.PHAR.298 01/01/2017
Aflibercept (Eylea®) (PDF) CP.PHAR.184 03/01/2016
Agalsidase Beta (Fabrazyme) (PDF) CP.PHAR.158 02/01/2016
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) CP.PMN.138 03/13/2018
Alectinib (Alecensa) (PDF) CP.PHAR.369 11/16/2016
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 08/01/2016
Alendronate (Binosto, Fosamax plus D) (PDF) CP.PMN.88 03/01/2018
Alglucosidase Alfa (Lumizyme) (PDF) CP.PHAR.160 02/01/2016
Alirocumab (Praluent) (PDF) CP.PHAR.124 10/01/2015
Alpelisib (Piqray) (PDF) CP.PHAR.430 09/01/2019
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF) CP.PHAR.94 03/01/2012
Ambrisentan (Letairis®) (PDF) CP.PHAR.190 03/01/2016
Amifampridine (Firdapse, Ruzurgi) (PDF) CP.PHAR.411 01/22/2019
Amikacin (Arikayce) (PDF) CP.PHAR.401 11/13/2018
Antithymocyte Globulin (Thymoglobulin, Atgam) (PDF) HIM.PA.16 9/1/2018
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) CP.PHAR.217 05/01/2016
Anakinra (Kineret) (PDF) CP.PHAR.244 08/01/2016
Apalutamide (Erleada) (PDF) CP.PHAR.376 06/01/2018
Apremilast (Otezla) (PDF) CP.PHAR.245 08/01/2016
Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF) CP.PMN.19 11/30/2016

Appropriate Use and Safety Edits (PDF)

Appropriate Use and Safety Edits: Attachment A (PDF)

GA.PMN.01 05/01/2012
Arformoterol Tartrate (Brovana) (PDF) CP.PMN.201 09/01/2019
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF) CP.PHAR.290 12/01/2016
Armodafinil (Nuvigil) (PDF) CP.PMN.35 08/01/2009
Asenapine (Saphris, Secuado) (PDF) CP.PMN.15 12/01/2014
asfotase alfa (Strensiq®) (PDF) CP.PHAR.328 03/01/2017
Aspirin-dipyridamole (Aggrenox) (PDF) CP.PMN.20 09/01/2006
Atezolizumab (Tecentriq®) (PDF) CP.PHAR.235 06/01/2016
Avapritinib (Ayvakit) (PDF) CP.PHAR.454 03/01/2020
Avatrombopag (Doptelet) (PDF) CP.PHAR.130 07/17/2018
Avelumab (Bavencio®) (PDF) CP.PHAR.333 05/01/2017
Axicabtagene Ciloleucel (Yescarta) (PDF) CP.PHAR.362 10/31/2017
Axitinib (Inlyta®) (PDF) CP.PHAR.100 05/01/2012
Azacitidine (Vidaza) (PDF) CP.PHAR.387 08/28/2017
Azelaic Acid (Finacea) (PDF) HIM.PA.119 11/09/2017
Aztreonam (Cayston®) (PDF) CP.PHAR.209 05/01/2016
Baclofen (Gablofen, Lioresal, Ozobax) (PDF) CP.PHAR.149 11/09/2017
Baloxavir Marboxil (Xofluza) (PDF) CP.PMN.185 10/30/2018
Bedaquiline (Sirturo) (PDF) CP.PMN.212 12/01/2019
Belantamab Mafodotin (PDF) CP.PHAR.469 06/01/2020
belatacept (Nulojix®) (PDF) CP.PHAR.201 11/09/2017
Belimumab (Benlysta) (PDF) CP.PHAR.88 10/01/2011
belinostat (Beleodaq®) (PDF) CP.PHAR.311 02/01/2017
Bendamustine (Bendeka®, Treanda®) (PDF) CP.PHAR.307 06/01/2010
Benralizumab (Fasenra) (PDF) CP.PHAR.373 01/16/2018
Benznidazole (PDF) CP.PMN.90 10/17/2017
Berotralstat (PDF) CP.PHAR.485 06/01/2020
Betaine (Cystadane) (PDF) CP.PHAR.143 08/28/2018
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) CP.PHAR.93 11/01/2011
Bexarotene (Targretin) (PDF) CP.PHAR.75 09/01/2011
Bezlotoxumab (Zinplava) (PDF) CP.PHAR.300 11/16/2016
Bimatoprost Implant (Durysta) (PDF) CP.PHAR.486 06/01/2020
Binimetinib (Mektovi) (PDF) CP.PHAR.50 07/24/2018
Biologic DMARDs (PDF) HIM.PA.SP60 01/01/2020
Blinatumomab (Blincyto) (PDF) CP.PHAR.312 02/01/2017
Blocking Adjudication of Controlled Substance Prescriptions for Selected Prescribers (PDF) GA.PHAR.19 11/01/2001
Bortezomib (Velcade) (PDF) CP.PHAR.410 12/11/2018
Bosentan (Tracleer®) (PDF) CP.PHAR.191 03/01/2016
Bosutinib (Bosulif) (PDF) CP.PHAR.105 10/01/2012
Brand Name Override and Non-Formulary Medications (PDF) HIM.PA.103 12/01/2014
Brentuximab Vedotin (Adcetris) (PDF) CP.PHAR.303 02/01/2017
Brexanolone (Zulresso) (PDF) CP.PHAR.417 04/16/2019
Brexpiprazole (Rexulti) (PDF) CP.PMN.68 11/05/2015
Brigatinib (Alunbrig) (PDF) CP.PHAR.342 07/17/2017
Brimonidine Tartrate (Mirvaso) (PDF) CP.PMN.192 11/16/2016
Brinzolamide/Brimonidine (Simbrinza) (PDF) HIM.PA.15 9/4/2018
Brivaracetam (Briviact) (PDF) HIM.PA.07 09/01/2019
Brolucizumab-dbll (Beovu) (PDF) CP.PHAR.445 03/01/2020
Budesonide Suspension (Pulmicort Respules) (PDF) HIM.PA.48 09/01/2018
Buprenorphine Implant/Injection (Probuphine, Sublocade) (PDF) CP.PHAR.289 11/16/2016
Buprenorphine implant (Probuphine) (PDF) CP.PHAR.289 11/16/2016
Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone) (PDF) HIM.PA.35 02/01/2017
Buprenorphine (Subutex) (PDF) CP.PMN.82 09/01/2017
Burosumab-twza (Crysvita)(PDF) CP.PHAR.11 05/08/2018
Butorphanol Nasal Spray (PDF) HIM.PA.46 12/01/2014
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF) CP.PHAR.202 03/01/2016
C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF) CP.PHAR.202 03/01/2016
cabazitaxel (Jevtana® (PDF) CP.PHAR.316 02/01/2017
Cabozantinib (Cometriq®, Cabometyx®) (PDF) CP.PHAR.111 06/01/2013
Canakinumab (Ilaris) (PDF) CP.PHAR.246 08/01/2016
Cannabidiol (Epidiolex) (PDF) CP.PMN.164 07/17/2018
capecitabine (Xeloda) (PDF) CP.PHAR.60 05/01/2011
Caplacizumab-yhdp (Cablivi) (PDF) CP.PHAR.416 03/12/2019
carfilzomib (Kyprolis®) (PDF) CP.PHAR.309 02/01/2017
Carglumic acid (Carbaglu®) (PDF) CP.PHAR.206 05/01/2016
Casimersen (PDF) CP.PHAR.470 06/01/2020
Cedazuridine/Decitabine (ASTX-727) (PDF) CP.PHAR.479 06/01/2020
Celecoxib (Celebrex, Elyxyb) (PDF) CP.PMN.122 01/01/2007
Cemiplimab-rwlc (Libtayo) (PDF) CP.PHAR.397 10/16/2018
Cenegermin-bkbj (Oxervate) (PDF) CP.PMN.186 10/09/2018
Cenobamate (Xcopri) (PDF) CP.PMN.231 03/01/2020
Ceritinib (Zykadia) (PDF) CP.PHAR.349 07/01/2017
Cerliponase alfa (Brineura) (PDF) CP.PHAR.338 07/01/2017
Certolizumab (Cimzia) (PDF) CP.PHAR.247 08/01/2016
Cetuximab (Erbitux®) (PDF) CP.PHAR.317 02/01/2017
Chlorambucil (Leukeran) (PDF) HIM.PA.SP59 8/28/2018
Chloramphenicol Sodium Succinate (PDF) CP.PHAR.388 12/01/2018
Cholic Acid (Cholbam) (PDF) CP.PHAR.390 12/01/2018
Ciclesonide (Alvesco) (PDF) HIM.PA.65 09/01/2018
Cinacalcet (Sensipar) (PDF) CP.PHAR.61 05/01/2011
Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) HIM.PA.120 11/09/2017
Ciprofloxacin/Fluocinolone (Otovel) (PDF) HIM.PA.14 09/04/2018
Cladribine (Mavenclad) (PDF) CP.PHAR.422 09/01/2019
Clindamycin (Evoclin) (PDF) HIM.PA.21 08/28/2018
Clindamycin Phosphate/Benzoyl Peroxide (BenzaClin) (PDF) HIM.PA.31 12/01/2018
Clobazam (Onfi) (PDF) CP.PMN.54 11/1/2012
CNS Stimulants (PDF) CP.PMN.92 03/01/2018
Cobimetinib (Cotellic) (PDF) CP.PHAR.380 11/16/2016
Colesevelam (Welchol) (PDF) HIM.PA.121 11/9/2017
Collagenase (Xiaflex) (PDF) CP.PHAR.82 10/01/2011
Colonoscopy Preparation Products (PDF) HIM.PA.04 1/1/2020
Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) HIM.PA.140 10/24/2017
Continuous Glucose Monitors (PDF) CP.PMN.214 12/01/2019
copanlisib (Aliqopa®) (PDF) CP.PHAR.357 10/17/2017
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) CP.PHAR.385 05/29/2018
Cosyntropin (Cortrosyn®) (PDF) CP.PHAR.203 04/01/2016
Crisaborole (Eucrisa) (PDF) CP.PMN.110 02/21/2017
Crizanlizumab-tmca (Adakveo) (PDF) CP.PHAR.449 03/01/2020
Crizotinib (Xalkori) (PDF) CP.PHAR.90 11/01/2011
Cyclosporine (Cequa, Restasis) (PDF) CP.PMN.48 05/01/2012
Cysteamine ophthalmic (Cystaran) (PDF) CP.PMN.130 08/01/2017
Cysteamine oral (Cystagon, Procysbi) (PDF) CP.PHAR.155 02/01/2016
Cytomegalovirus Immune Globulin (Cytogam)(PDF) CP.PHAR.277 09/01/2018
Dabrafenib (Tafinlar) (PDF) CP.PHAR.239 11/16/2016
Dacomitinib (Vizimpro) (PDF) CP.PHAR.399 10/16/2018
Dalfampridine (Ampyra) (PDF) CP.PHAR.248 08/01/2016
Dalteparin (Fragmin) (PDF) CP.PHAR.225 05/01/2016
Daptomycin (Cubicin, Cubicin RF)(PDF) CP.PHAR.351 11/30/2017
Daratumumab (Darzalex) (PDF) CP.PHAR.310 07/01/2017
Darbepoetin Alfa (Aranesp) (PDF) CP.PHAR.236 06/01/2016
Darolutamide (Nubeqa) (PDF) CP.PHAR.435 12/01/2019
Dasatinib (Sprycel) (PDF) CP.PHAR.72 06/01/2012
daunorubicin/cytarabine (Vyxeos®) (PDF) CP.PHAR.352 12/01/2017
Deferasirox (Exjade Jadenu) (PDF) CP.PHAR.145 11/01/2015
Deferiprone (Ferriprox) (PDF) CP.PHAR.147 11/01/2015
Deferoxamine (Desferal) (PDF) CP.PHAR.146 11/01/2015
Deflazacort (Emflaza) (PDF) CP.PHAR.331 03/01/2017
Degarelix acetate (Firmagon®) (PDF) CP.PHAR.170 11/09/2017
Delafloxacin (Baxdela) (PDF) CP.PMN.115 11/09/2017
Denosumab (Prolia, Xgeva) (PDF) CP.PHAR.58 03/01/2011
Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF) CP.PHAR.214 05/01/2016
Deutetrabenazine (Austedo) (PDF) CP.PHAR.341 06/13/2017
Dexlansoprazole (Dexilant) (PDF) HIM.PA.05 01/01/2020
Dexrazoxane (Zinecard, Totect) (PDF) CP.PHAR.418 03/19/2019
Dextromethorphan-Quinidine (Nuedexta) (PDF) CP.PMN.93 03/01/2018
Diazepam Nasal Spray (Valtoco) (PDF) CP.PMN.216 12/01/2019
Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity) (PDF) CP.PHAR.249 08/01/2016
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF) HIM.PA.58 03/01/2018
Dolasetron (Anzemet) (PDF) CP.PMN.141 09/01/2006
Dornase alfa (Pulmozyme) (PDF) CP.PHAR.212 05/01/2016
Dose Escalation of Biologics (PDF) GA.PMN.21 09/01/2017
Doxepin (Silenor, Prudoxin, Zonalon) (PDF) HIM.PA.147 11/17/2017
Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF) CP.PMN.79 05/01/2017
Drug Recall Notification Process (PDF) GA.PHAR.08 07/01/2008
Drug Utilization Review (PDF) GA.PHAR.13 04/01/2007
Dupilumab (Dupixent) (PDF) CP.PHAR.336 05/01/2017
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 07/01/2017
Duvelisib (Copiktra) (PDF) CP.PHAR.400 10/16/2018
Early and Periodic Screening, Diagnostic, and Treatment Benefit for Pediatric Members (PDF) CP.PMN.234 06/01/2020
Ecallantide (Kalbitor®) (PDF) CP.PHAR.177 03/01/2016
Eculizumab (Soliris®) (PDF) CP.PHAR.97 03/01/2012
Edaravone (Radicava) (PDF) CP.PHAR.343 07/01/2017
Efinaconazole (Jublia) (PDF) CP.PMN.25 08/01/2016
Elagolix (Orilissa) (PDF) CP.PHAR.136 08/28/2018
Elapegademase-lvlr (Revcovi) (PDF) CP.PHAR.419 04/23/2019
Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (PDF) CP.PHAR.440 12/01/2019
Eliglustat (Cerdelga) (PDF) CP.PHAR.153 02/01/2016
Elosulfase Alfa (Vimizim) (PDF) CP.PHAR.162 02/01/2016
Elotuzumab (Empliciti®) (PDF) CP.PHAR.308 02/01/2017
Eltrombopag (Promacta®) (PDF) CP.PHAR.180 03/01/2016
Emapalumab-lzsg (Gamifant) (PDF) CP.PHAR.402 12/11/2018
Emicizumab-kxwh (Hemlibra) (PDF) CP.PHAR.370 03/01/2018
Emtricitabine/Tenofovir Alafenamide (Descovy)(PDF) CP.PMN.235 06/01/2020
Emtricitabine/Tenofovir (Truvada®) (PDF) HIM.PA.78 12/01/2014
Enasidenib (Idhifa) (PDF) CP.PHAR.363 09/05/2017
Encorafenib (Braftovi) (PDF) CP.PHAR.127 07/24/2018
Enfortumab Vedotin-ejfv (Padcev) (PDF) CP.PHAR.455 03/01/2020
Enfuvirtide (Fuzeon) (PDF) CP.PHAR.41 06/01/2010
Entecavir (Baraclude) (PDF) HIM.PA.08 02/19/2019
Entrectinib (Rozlytrek) (PDF) CP.PHAR.441 12/01/2019
Enzalutamide (Xtandi) (PDF) CP.PHAR.106 10/01/2012
Epoetin Alfa (Epogen® and Procrit) (PDF) CP.PHAR.237 06/01/2016
Epoprostenol (Flolan®), Veletri®) (PDF) CP.PHAR.192 03/01/2016
Erdafitinib (Balversa)(PDF) CP.PHAR.423 09/01/2019
Erenumab-aaoe (Aimovig) (PDF) CP.PHAR.128 07/10/2018
Eribulin Mesylate (Halaven®) (PDF) CP.PHAR.318 03/01/2017
Erlotinib (Tarceva) (PDF) CP.PHAR.74 09/01/2011
Erwinia Asparaginase (Erwinaze) (PDF) CP.PHAR.301 02/01/2017
Esketamine (Spravato) (PDF) CP.PMN.199 03/12/2019
Etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 03/20/2018
Etanercept (Enbrel) (PDF) CP.PHAR.250 08/01/2016
Eteplirsen (Exondys 51) (PDF) CP.PHAR.288 12/01/2016
Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF) CP.PHAR.63 06/01/2011
Evolocumab (Repatha) (PDF) CP.PHAR.123 10/01/2015
Factor IX (Human, Recombinant) (PDF) CP.PHAR.218 05/01/2016
Factor IX Complex, Human (Profilnine) (PDF) CP.PHAR.219 05/01/2016
Factor VIII (Human Recombinant) (PDF) CP.PHAR.215 05/01/2016
Factor VIIa, Recombinant (NovoSeven® RT) (PDF) CP.PHAR.220 05/01/2016
Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (PDF) CP.PHAR.220 05/01/2016
Factor VIII/von Willebrand Factor Complex (Human - Alphanate, Humate-P, Wilate) (PDF) CP.PHAR.216 05/01/2016
Factor XIII A-Subunit, Recombinant (Tretten®) (PDF) CP.PHAR.222 05/01/2016
Factor XIII, Human (Corifact®) (PDF) CP.PHAR.221 05/01/2016
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) CP.PHAR.456 03/01/2020
Febuxostat (Uloric) (PDF) CP.PMN.57 08/01/2013
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF) CP.PMN.127 06/01/2015
Ferumoxytol (Feraheme®) (PDF) CP.PHAR.165 03/01/2016
Ferric Carboxymaltose (Injectafer) (PDF) CP.PHAR.234 06/01/2016
Ferric Derisomaltose (Monoferric) (PDF) CP.PHAR.480 06/01/2020
Ferric gluconate (Ferrlecit®) (PDF) CP.PHAR.166 03/01/2016
Filgrastim (Neupogen, Zarxio) (PDF) CP.CPA.129 11/16/2016
Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF) CP.PHAR.297 12/01/2016
Fingolimod (Gilenya) (PDF) CP.PHAR.251 08/01/2016
Fondaparinux (Arixtra) (PDF) CP.PHAR.226 05/01/2016
Formulary Medications without Specific Guidelines (PDF) HIM.PA.33 05/01/2016
Fosdenopterin (PDF) CP.PHAR.471 06/01/2020
Fostamatinib (Tavalisse) (PDF) CP.PHAR.24 06/05/2018
Fluorouracil Cream (Tolak)(PDF) CP.PMN.165 12/1/2018
Fluticasone Propionate (Xhance) (PDF) CP.PMN.95 10/24/2017
Fulvestrant (Faslodex Injection)(PDF) CP.PHAR.424 09/01/2019
Galsulfase (Naglazyme) (PDF) CP.PHAR.161 02/01/2016
Gefitinib (Iressa) (PDF) CP.PHAR.68 11/16/2016
gemtuzumab ozogamicin (Mylotarg®) (PDF) CP.PHAR.358 10/03/2017
Gilteritinib (Xospata) (PDF) CP.PHAR.412 01/15/2019
Givosiran (Givlaari) (PDF) CP.PHAR.457 03/01/2020
Glasdegib (Daurismo) (PDF) CP.PHAR.413 01/08/2019
Glatiramer (Copaxone, Glatopa) (PDF) CP.PHAR.252 08/01/2016
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF) CP.CPA.16 11/16/2016
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF) HIM.PA.53 03/01/2018
Glycerol phenylbutyrate (Ravicti®) (PDF) CP.PHAR.207 05/01/2016
Golimumab (Simponi, Simponi Aria) (PDF) CP.PHAR.253 07/01/2016
Golodirsen (Vyondys 53) (PDF) CP.PHAR.453 03/01/2020
goserelin acetate (Zoladex®) (PDF) CP.PHAR.171 11/09/2017
Granisetron (Kytril, Sancuso, Sustol) (PDF) CP.PMN.74 11/01/2016
Halcinonide (Halog) (PDF) HIM.PA.20 08/28/2018
Hemin (Panhematin®) (PDF) CP.PHAR.181 02/01/2016
histrelin acetate (Vantas®, Supprelin LA®) (PDF) CP.PHAR.172 11/09/2017
Hyaluronate Derivatives (PDF) CP.PHAR.05 10/1/2008
Hydroxyprogesterone Caproate (Makena/compound) CP.PHAR.14 11/20/2017
Hydroxyurea (Siklos) (PDF) CP.PMN.193 02/19/2019
Ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 04/17/2018
Ibandronate sodium (Boniva®) (PDF) CP.PHAR.189 11/15/2017
Ibrutinib (Imbruvica) (PDF) CP.PHAR.126 10/01/2015
Ibuprofen/Famotidine (Duexis) (PDF) CP.PMN.120 06/01/2018
Icatibant (Firazyr) (PDF) CP.PHAR.178 03/01/2016
Icosapent ethyl (Vascepa) (PDF) CP.PMN.187 11/20/2018
Idelalisib (Zydelig) (PDF) CP.PHAR.133 12/01/2018
Idecabtagene Vicleucel (BB2121) (PDF) CP.PHAR.481 06/01/2020
Idursulfase (Elaprase) (PDF) CP.PHAR.156 02/01/2016
Iloperidone (Fanapt) (PDF) CP.PMN.32 12/01/2014
Iloprost (Ventavis®) (PDF) CP.PHAR.193 03/01/2016
Imatinib (Gleevec) (PDF) CP.PHAR.65 06/01/2011
Imiglucerase (Cerezyme) (PDF) CP.PHAR.154 02/01/2016
Immune Globulins (PDF) CP.PHAR.103 08/01/2012
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 07/01/2016
Indacaterol/Glycopyrrolate (Utibron Neohaler) (PDF) HIM.PA.102 09/01/2018
Inebilizumab (PDF) CP.PHAR.458 03/01/2020
Infertility and Fertility Preservation (PDF) CP.PHAR.131 11/16/2016
Infliximab (Remicade, Inflectra, Renflexis) (PDF) CP.PHAR.254 07/01/2016
Inotersen (Tegsedi) (PDF) CP.PHAR.405 11/20/2018
inotuzumab ozogamicin (Besponsa®) (PDF) CP.PHAR.359 09/26/2017
Insulin Infusion Pump (Omnipod, Omnipod DASH) (PDF) CP.PHAR.420 04/23/2019
Insulin Degludec (Tresiba) (PDF) HIM.PA.09 03/01/2019
Interferon beta-1a (Avonex, Rebif) (PDF) CP.PHAR.255 08/01/2016
Interferon beta-1b (Betaseron, Extavia) (PDF) CP.PHAR.256 08/01/2016
Interferon Gamma- 1b (Actimmune) (PDF) CP.PHAR.52 06/01/2010
Intrathecal Baclofen (Gablofen, Lioresal) (PDF) CP.PHAR.149 11/09/2017
Iobenguane I-131 (Azedra) (PDF) CP.PHAR.459 03/01/2020
Ipilimumab (Yervoy) (PDF) CP.PHAR.319 04/17/2018
irinotecan Liposome (Onivyde®) (PDF) CP.PHAR.304 02/01/2017
Iron sucrose (Venofer®) (PDF) CP.PHAR.167 03/01/2016
Isatuximab-irfc (Sarclisa)(PDF) CP.PHAR.482 06/01/2020
Isavuconazonium (Cresemba) (PDF) CP.PMN.154 11/16/2016
Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (PDF) CP.PMN.143 12/01/2014
Istradefylline (Nourianz) (PDF) CP.PMN.217 03/01/2020
Itraconazole (Sporanox, Onmel, Tolsura) (PDF) CP.PMN.124 11/01/2006
Ivabradine (Corlanor) (PDF) CP.PMN.70 11/01/2015
Ivacaftor (Kalydeco) (PDF) CP.PHAR.210 05/01/2016
Ivermectin (Sklice®) (PDF) HIM.PA.124 12/01/2017
Ivosidenib (Tibsovo) (PDF) CP.PHAR.137 08/21/2018
Ixazomib (Ninlaro) (PDF) CP.PHAR.302 02/01/2017
KTE-X19 (PDF)
CP.PHAR.472 06/01/2020
Lacosamide (Vimpat) (PDF) CP.PMN.155 12/01/2014
Lanadelumab-fylo (Takhzyro) (PDF) CP.PHAR.396 09/25/2018
Lanreotide (Somatuline Depot) (PDF) CP.PHAR.391 08/14/2018
lapatinib (Tykerb®) (PDF) CP.PHAR.79 11/09/2017
Laronidase (Aldurazyme) (PDF) CP.PHAR.152 02/01/2016
Larotrectinib (Vitrakvi) (PDF) CP.PHAR.414 01/15/2018
Lasmiditan (Reyvow) (PDF) CP.PMN.218 03/01/2020
Lefamulin (Xenleta) (PDF) CP.PMN.219 03/01/2020
Lemborexant (Dayvigo)(PDF) CP.PMN.233 06/01/2020
Lenalidomide (Revlimid) (PDF) CP.PHAR.71 07/01/2011
Lenvatinib (Lenvima) (PDF) CP.PHAR.138 12/01/2018
Lesinurad (Zurampic), Lesinurad/Allopurinol (Duzallo) (PDF) CP.PMN.150 11/16/2016
Letermovir (Prevymis) (PDF) CP.PHAR.367 03/01/2018
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) CP.PHAR.173 11/09/2017
Levalbuterol (Xopenex HFA/Inhalation Solution) (PDF) CP.PMN.07 09/01/2006
Levoleucovorin (Fusilev®) (PDF) CP.PHAR.151 11/09/2017
Levomilnacipran (Fetzima) (PDF) HIM.PA.125 11/9/2017
Lidocaine Transdermal (Lidoderm, ZTlido) (PDF) CP.PMN.08 09/01/2006
Lifitegrast (Xiidra®) (PDF) CP.PMN.73 11/09/2017
Linaclotide (Linzess) (PDF) CP.PMN.71 11/01/2015
Linezolid (Zyvox) (PDF) CP.PMN.27 09/01/2016
Lisocabtagene Maraleucel (JCAR017) (PDF) CP.PHAR.483 06/01/2020
Lofexidine (Lucemyra) (PDF) CP.PMN.152 08/01/2018
Lomustine (Gleostine) (PDF) HIM.PA.19 08/28/2018
Lorlatinib (Lorbrena) (PDF) CP.PHAR.406 12/11/2018
Lumacaftor-Ivacaftor (Orkambi) (PDF) CP.PHAR.213 05/01/2016
Lumateperone (Caplyta) (PDF) CP.PMN.232 03/01/2020
Lubiprostone (Amitiza) (PDF) CP.PMN.142 12/01/2014
Luliconazole Cream (Luzu) (PDF) CP.PMN.166 08/28/2018
Lumasiran (ALN-GO1) (PDF) CP.PHAR.473 06/01/2020
Luspatercept-aamt (Reblozyl) (PDF) CP.PHAR.450 03/01/2020
Lusutrombopag (Mulpleta) (PDF) CP.PHAR.407 09/18/2018
Lutetium Lu 177 Dotatate (Lutathera)(PDF) CP.PHAR.384 05/22/2018
Lurasidone (Latuda) (PDF) CP.PMN.50 12/01/2014
Macitentan (Opsumit) (PDF) CP.PCH.31 09/01/2020
Macitentan (Opsumit®) (PDF) CP.PHAR.194 03/01/2016
Mecamylamine (Vecamyl) (PDF) CP.PMN.136 05/01/2017
Mecasermin (Increlex) (PDF) CP.PHAR.150 03/01/2011
Medication Safety Policy (PDF) GA.PMN.22 07/01/2017
Megestrol Acetate (Megace ES) (PDF) CP.PMN.179 12/01/2018
Mepolizumab (Nucala) (PDF) CP.PHAR.200 04/01/2016
Methoxsalen (Uvadex) (PDF) HIM.PA.17 09/04/2018
Mometasone Furoate (Sinuva) (PDF) CP.PHAR.448 03/01/2020
Monomethyl Fumarate (Bafiertam) (PDF) CP.PHAR.460 03/01/2020
Montelukast oral granules (Singulair) (PDF) HIM.PA.129 11/09/2017
Mepolizumab (Nucala) (PDF) CP.PHAR.200 04/01/2016
Mesalamine (Apriso) (PDF) HIM.PA.42 09/04/2018
Metformin ER (Fortamet, Glumetza) (PDF) CP.PMN.72 11/01/2015
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF) CP.PHAR.134 12/01/2018
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) CP.PHAR.238 06/01/2016
Methylnaltrexone Bromide (Relistor) (PDF) CP.PMN.169 12/01/2018
Metreleptin (Myalept) (PDF) CP.PHAR.425 09/01/2019
Midazolam (Nayzilam) (PDF) CP.PMN.211 09/01/2019
Midostaurin (Rydapt) (PDF) CP.PHAR.344 06/01/2017
Mifepristone (Korlym) (PDF) CP.PHAR.101 05/01/2012
Migalastat (Galafold) (PDF) CP.PHAR.394 09/11/2018
Miglustat (Zavesca) (PDF) CP.PHAR.164 02/01/2016
Milnacipran (Savella) (PDF) CP.PMN.125 08/01/2012
Minocycline ER (Solodyn, Ximino, Minolira) and Microspheres (Arestin) (PDF) CP.PMN.80 05/01/2017
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 08/01/2016
Modafinil (Provigil) (PDF) CP.PMN.39 05/01/2008
Mogamulizumab-kpkc (Poteligeo) (PDF) CP.PHAR.139 09/04/2018
Mometasone (Nasonex) (PDF) HIM.PA.93 12/01/2014
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) CP.PHAR.398 10/16/2018
Nadofaragene Firadenovec (Instiladrin) (PDF) CP.PHAR.461 03/01/2020
nafarelin acetate (Synarel®) (PDF) CP.PHAR.174 11/09/2017
Naltrexone (Vivitrol®) (PDF) CP.PHAR.96 03/01/2012
Naproxen/Esomeprazole (Vimovo) (PDF) CP.PMN.117 06/01/2018
Naproxen oral suspension (Naprosyn) (PDF) HIM.PA.130 11/09/2017
Natalizumab (Tysabri) (PDF) HIM.PA.SP17 05/01/2017
Nebivolol (Bystolic) (PDF) HIM.PA.131 11/09/2017
Necitumumab (Portrazza®) (PDF) CP.PHAR.320 03/01/2017
Neomycin/Fluocinolone Cream (Neo-Synalar)_(PDF) CP.PMN.167 8/28/2018
Neratinib (Nerlynx) (PDF) CP.PHAR.365 09/05/2017
Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan)  (PDF) CP.PMN.118 02/13/2018
Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (PDF) CP.PMN.158 09/01/2006
nilotinib (Tasigna) (PDF) CP.PHAR.76 09/01/2011 
Nintedanib (Ofev) (PDF) CP.PHAR.285 10/01/2016
Nitisinone (Nityr, Orfadin) (PDF) CP.PHAR.132 08/28/2018
Nivolumab (Opdivo) (PDF) CP.PHAR.121 07/01/2015
No Coverage Criteria/Off-Label Use Policy (PDF) CP.PMN.53 09/12/2017
Non-Formulary and Formulary Contraceptives (PDF) HIM.PA.100 05/01/2015
Non-Formulary Test Strips (PDF) HIM.PA.34 02/01/2016
Nusinersen (Spinraza®)(PDF) CP.PHAR.327 11/28/2017
Obeticholic (Ocaliva) (PDF) CP.PHAR.287 11/01/2016
Obinutuzumab (Gazyva®) (PDF) CP.PHAR.305 02/01/2017
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 04/01/2017
Octreotide (Sandostatin, Sandostatin LAR) (PDF) CP.PHAR.40 03/01/2010
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia) (PDF) CP.PHAR.40 03/01/2010
ofatumumab (Arzerra®) (PDF) CP.PHAR.306 02/01/2017
Olanzapine Long-Acting Injection (Zyprexa Relprevv)(PDF) CP.PHAR.292 12/01/2016
Olaparib (Lynparza) (PDF) CP.PHAR.360 10/03/2017
olaratumab (Lartruvo®) (PDF) CP.PHAR.326 03/01/2017
Omadacycline (Nuzyra) (PDF) CP.PMN.188 11/20/2018
Omacetaxine (Synribo) (PDF) CP.PHAR.108 04/01/2013
Omalizumab (Xolair®) (PDF) CP.PHAR.01 10/01/2008
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 07/01/2016
Onasemnogene Abeparvovec (Zolgensma) (PDF) CP.PHAR.421 06/07/2019
Ondansetron (Zuplenz) (PDF) CP.PMN.45 09/01/2006
Ophthalmic Corticosteroids (PDF) HIM.PA.03 01/01/2020
Osimertinib (Tagrisso) (PDF) CP.PHAR.294 12/01/2016
Ospemifene (Osphena) (PDF) CP.PMN.168 08/28/2018
Overactive Bladder Agents (PDF) CP.PMN.198 05/01/2016
Ozanimod (PDF) CP.PHAR.462 03/01/2020
Ozenoxacin (Xepi) (PDF) CP.PMN.119 01/30/2018
Paclitaxel, Protein-Bound (Abraxane) (PDF) CP.PHAR.176 07/01/2015
Palbociclib (Ibrance®) (PDF) CP.PHAR.125 10/01/2015
Palivizumab (Synagis) (PDF) CP.PHAR.16 08/01/2009
panitumumab (Vectibix®) (PDF) CP.PHAR.321 03/01/2017
Parathyroid Hormone (Natpara) (PDF) CP.PHAR.282 11/16/2016
Paricalcitol Injection (Zemplar) (PDF) CP.PHAR.270 08/01/2016
Pasireotide (Signifor LAR®) (PDF) CP.PHAR.332 03/01/2017
Patisiran (Onpattro) (PDF) CP.PHAR.395 09/11/2018
Pazopanib (Votrient) (PDF) CP.PHAR.81 10/01/2011
Peanut Allergen Powder-dnfp (Palforzia) (PDF) CP.PMN.220 03/01/2020
Pegademase Bovine (Adagen) (PDF) CP.PHAR.392 08/28/2018
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF) CP.PHAR.353 09/05/2017
Pegfilgrastim (Neulasta) (PDF) CP.PHAR.296 12/01/2016
peginterferon alfa-2b (PegIntron, Sylatron®) (PDF) CP.PHAR.89 10/01/2011
Peginterferon beta-1a (Plegridy) (PDF) CP.PHAR.271 08/01/2016
Pegloticase (Krystexxa®) (PDF) CP.PHAR.115 06/01/2013
Pegvaliase-pqpz (Palynziq) (PDF) CP.PHAR.140 07/31/2018
Pegvisomant (Somavert) (PDF) CP.PHAR.389 12/01/2018
pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 03/01/2017
Pemetrexed (Alimta, Pemfexy) (PDF) CP.PHAR.368 10/31/2017
Perampanel (Fycompa) (PDF) CP.PMN.156 11/16/2016
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 06/01/2016
Pexidartinib (Turalio) (PDF) CP.PHAR.436 12/01/2019
Pharmaceutical Management (PDF) GA.PHAR.03 02/01/2003
Pharmacy and Therapeutics Committee (PDF) GA.PHAR.17 08/19/2011
Pharmacy Prior Authorization and Medical Necessity Criteria (PDF) GA.PHAR.16 07/09/2010
Phendimetrazine IR (Bontril PDM) (PDF) HIM.PA.114 05/01/2017
Pitolisant (Wakix) (PDF) CP.PMN.221 03/01/2020
Plerixafor (Mozobil) (PDF) CP.PHAR.323 03/01/2017
Polatuzumab Vedotin-piiq (Polivy) (PDF) CP.PHAR.433 09/01/2019
Pomalidomide (Pomalyst) (PDF) CP.PHAR.116 07/01/2013
Ponatinib (Iclusig) (PDF) CP.PHAR.112 06/01/2013
Potassium Chloride for Oral Solution (Klor-Con Powder) (PDF) HIM.PA.143 10/31/2017
Pralatrexate (Folotyn®) (PDF) CP.PHAR.313 02/01/2017
Pramlintide (Symlin) (PDF) CP.PMN.129 06/01/2018
Pregabalin (Lyrica, Lyrica CR) (PDF) CP.PMN.33 01/01/2007
Pretomanid (PDF) CP.PMN.222 03/01/2020
Progesterone (Crinone, Endometrin) (PDF) CP.CPA.03 11/16/2016
Propranolol HCl Oral Solution (Hemangeol) (PDF) CP.PMN.58 05/01/2014
Protein C Concentrate, Human (Ceprotin) (PDF) CP.PHAR.330 03/01/2017
Prucalopride (Motegrity) (PDF) CP.PMN.194 01/29/2019
pyrimethamine (Daraprim®) (PDF) CP.PMN.44 11/01/2015
Quetiapine ER (Seroquel XR) (PDF) CP.PMN.64 12/01/2014
Ramucirumab (Cyramza®) (PDF) CP.PHAR.119 05/01/2015
Ranibizumab (Lucentis®) (PDF) CP.PHAR.186 03/01/2016
Rasagiline (Azilect®) (PDF) HIM.PA.89 12/01/2014
Regorafenib (Stivarga) (PDF) CP.PHAR.107 12/01/2012
Remestemcel-L (Prochymal) (PDF) CP.PHAR.474 06/01/2020
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) CP.PHAR.168 03/01/2016
Reslizumab (Cinqair) (PDF) CP.PHAR.223 05/01/2016
Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF) CP.PHAR.141 11/16/2016
Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) (PDF) CP.PMN.223 03/01/2020
Rifamycin (Aemcolo) (PDF) CP.PMN.196 01/08/2019
rifaximin (Xifaxan®)(PDF) CP.PMN.47 11/01/2011
Rilonacept (Arcalyst) (PDF) CP.PHAR.266 11/16/2016
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 07/01/2016
Riociguat (Adempas®) (PDF) CP.PHAR.195 03/01/2016
Risdiplam (PDF) CP.PHAR.477 06/01/2020
Risedronate (Actonel, Atelvia) (PDF) CP.PMN.100 03/01/2018
Risperidone Long-Acting Injection (Risperdal Consta) (PDF) CP.PHAR.293 12/01/2016
Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) CP.PHAR.260 07/01/2016
Rolapitant (Varubi) (PDF) CP.PMN.102 02/01/2017
romidepsin (Istodax®) (PDF) CP.PHAR.314 01/01/2017
Romiplostim (Nplate®) (PDF) CP.PHAR.179 03/01/2016
Romosozumab-aqqg (Evenity) (PDF) CP.PHAR.428 09/01/2019
Rucaparib (Rubraca®) (PDF) CP.PHAR.350 09/01/2017
Rufinamide (Banzel) (PDF) CP.PMN.157 12/01/2014
Sacubitril/Valsartan (Entresto) (PDF) CP.PMN.67 11/01/2015
Sacitizumab Govitecan (PDF) CP.PHAR.475 06/01/2020
Safinamide (Xadago) (PDF) CP.PMN.113 07/01/2017
Sarecycline (Seysara) (PDF) CP.PMN.189 11/13/2018
Sargramostim (Leukine) (PDF) CP.PHAR.295 12/01/2016
Sapropterin Dihydrochloride (Kuvan) (PDF) CP.PHAR.43 02/01/2010
Satralizumab (PDF) CP.PHAR.463 03/01/2020
Secnidazole (Solosec) (PDF) CP.PMN.103 10/24/2017
Sebelipase Alfa (Kanuma) (PDF) CP.PHAR.159 02/01/2016
Selexipag (Uptravi®) (PDF) CP.PHAR.196 03/01/2016
Selinexor (Xpovio) (PDF) CP.PHAR.431 09/01/2019
Selpercatinib (LOXO-292) (PDF) CP.PHAR.478 06/01/2020
Selumetinib (Koselugo) (PDF) CP.PHAR.464 03/01/2020
Semaglutide (Rybelsus) (PDF) HIM.PA.02 03/01/2020
Sildenafil (Revatio®) (PDF) CP.PHAR.197 03/01/2016
Siltuximab (Sylvant®) (PDF) CP.PHAR.329 03/01/2017
Siponimod (Mayzent) (PDF) CP.PHAR.427 09/01/2019
Sipuleucel-T (Provenge) (PDF) CP.PHAR.120 06/01/2015
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF) HIM.PA.91 01/01/2015
sodium oxybate (Xyrem) (PDF) CP.PMN.42 05/01/2011
Sodium Phenylbutyrate (Buphenyl) (PDF) CP.PHAR.208 05/01/2016
Solriamfetol (Sunosi) (PDF) CP.PMN.209 09/01/2019
Somatropin (Growth Hormone) (PDF) CP.PHAR.55 03/01/2011
Somatropin (HGH) (PDF) CP.CPA.84 11/16/2016
Sonidegib (Odomzo) (PDF) CP.PHAR.272 05/01/2012
sorafenib (Nexavar) (PDF) CP.PHAR.69 07/01/2011
Spinosad (Natroba) (PDF) HIM.PA.134 11/09/2017
Step Therapy (PDF) HIM.PA.109 08/01/2017
Stiripentol (Diacomit) (PDF) CP.PMN.184 9/25/2018
Sucroferric Oxyhydroxide (Velphoro) (PDF) HIM.PA.SP30 01/01/2015
sunitinib (Sutent) (PDF) CP.PHAR.73 09/01/2011
Suvorexant (Belsomra®) (PDF) CP.PMN.109 02/01/2017
Tadalafil (Adcirca®) (PDF) CP.PHAR.198 03/01/2016
Tadalafil BHP - ED (Cialis) (PDF) CP.PMN.132 06/01/2018
Tafamidis (Vyndaqel, Vyndamax) (PDF) CP.PHAR.432 09/01/2019
Talazoparib (Talzenna) (PDF) CP.PHAR.409 11/27/2018
Taliglucerase Alfa (Elelyso) (PDF) CP.PHAR.157 02/01/2016
Tasimelteon (Hetlioz) (PDF) CP.PMN.104 02/01/2017
Tavaborole (Kerydin) (PDF) CP.PMN.105 03/01/2018
Tazemetostat (Tazverik) (PDF) CP.PHAR.452 03/01/2020
Tedizolid (Sivextro) (PDF) CP.PMN.62 03/01/2015
Teduglutide (Gattex) (PDF) CP.PHAR.114 05/01/2013
Tegaserod (Zelnorm) (PDF) CP.PMN.206 09/01/2019
Telotristat Ethyl (Xermelo) (PDF) CP.PHAR.337 06/01/2017
Temozolomide (Temodar) (PDF) CP.PHAR.77 09/01/2011
temsirolimus (Torisel®) (PDF) CP.PHAR.324 03/01/2017
Tenapanor (Ibsrela) (PDF) CP.PMN.224 03/01/2020
Teprotumumab (Tepezza) (PDF) CP.PHAR.465 01/21/2020
Teriparatide (Forteo®) (PDF) CP.PHAR.188 11/15/2017
Tesamorelin (Egrifta) (PDF) CP.PHAR.109 03/01/2014
Testosterone (Androderm) (PDF) HIM.PA.87 12/01/2014
Testosterone (Testopel, Jatenzo) (PDF) CP.PHAR.354 08/01/2017
tetrabenazine (Xenazine) (PDF) CP.PHAR.92 12/01/2011
Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF) CP.PHAR.377 04/03/2018
Thalidomide (Thalomid) (PDF) CP.PHAR.78 09/01/2011
Thioguanine (Tabloid) (PDF) CP.PHAR.437 12/01/2019
Thyrotropin Alfa (Thyrogen) (PDF)  CP.PHAR.95 03/01/2012
Timothy grass pollen allergen extract (Grastek®) (PDF) CP.PMN.84 08/31/2017
Tisagenlecleucel (Kymriah) (PDF) CP.PHAR.361 09/26/2017
Tobramycin (Bethkis®, Kitabis Pak®, TOBI®, TOBI Podhaler®) (PDF) CP.PHAR.211 05/01/2016
Tocilizumab (Actemra) (PDF) CP.PHAR.263 07/01/2016
Tofacitinib (Xeljanz, Xeljanz Poor girl.XR) (PDF) CP.PHAR.267 01/30/2018
Tolvaptan (Jynarque) (PDF) CP.PHAR.27 06/05/2018
Topical Acne Treatment (PDF) HIM.PA.71 12/01/2014
Topical Diclofenac (Solaraze, Flector) (PDF) HIM.PA.123 12/01/2017
Topical Immunomodulators (PDF) CP.PMN.107 09/01/2006
Topotecan (Hycamtin)(PDF) CP.PHAR.64 06/01/2011
Trabectedin (Yondelis®) (PDF) CP.PHAR.204 05/01/2016
Trametinib (Mekinist) (PDF) CP.PHAR.240 07/01/2016
Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF) CP.PHAR.228 06/01/2016
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF) CP.PHAR.199 06/01/2016
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF) CP.PHAR.199  03/01/2016
Triamcinolone ER Injection (Zilretta) (PDF) CP.PHAR.371 03/01/2018
Trientine (Syprine) (PDF) CP.PHAR.438 12/01/2019
Triptans (PDF) CP.CPA.217 11/16/2016
triptorelin pamoate (Trelstar®, Triptodur®) (PDF) CP.PHAR.175 11/09/2017
Ubrogepant (Ubrelvy) (PDF) CP.PHAR.476 06/01/2020
Unoprostone Isopropyl (Rescula) (PDF) HIM.PA.11 09/04/2018
Uridine acetate (Vistogard) (PDF) HIM.PA.SP55 11/09/2017
Ustekinumab (Stelara) (PDF) CP.PHAR.264 08/01/2016
Valoctocogene Roxaparvovec (PDF) CP.PHAR.466 03/01/2020
Valproate Sodium for Intravenous Injection (Depacon) (PDF) CP.PHAR.429 09/01/2019
Valrubicin (Valstar) (PDF) CP.PHAR.439 12/01/2019
Vandetanib (Caprelsa®) (PDF) CP.PHAR.80 10/01/2011
Velaglucerase Alfa (VPRIV) (PDF) CP.PHAR.163 02/01/2016
Vemurafenib (Zelboraf®) (PDF) CP.PHAR.91 11/01/2011
Verteporfin (Visudyne®) (PDF) CP.PHAR.187 03/01/2016
Vestronidase alfa-vjbk (Mepsevii) (PDF) CP.PHAR.374 01/19/2018
Vigabatrin (Sabril) (PDF) CP.PHAR.169 02/01/2016
Vilazodone (Viibryd) (PDF) CP.PMN.145 08/01/2012
Viltolarsen (PDF) CP.PHAR.484 06/01/2020
vincristine sulfate liposome injection (Marqibo®) (PDF) CP.PHAR.315 02/01/2017
Vismodegib (Erivedge) (PDF) CP.PHAR.273 08/01/2016
Vorapaxar (Zontivity) (PDF) HIM.PA.146 10/31/2017
Voretigene neparvovec-rzyl (Luxturna) (PDF) CP.PHAR.372 03/01/2018
Vorinostat (Zolinza) (PDF) CP.PHAR.83 12/01/2012
Vortioxetine (Trintellix®) (PDF) CP.PMN.65 05/31/2017
Voxelotor (Oxbryta) (PDF) CP.PHAR.451 03/01/2020
Zanubrutinib (Brukinsa) (PDF) CP.PHAR.467 03/01/2020
ziv-aflibercept (Zaltrap®) (PDF) CP.PHAR.325 03/01/2017
Zoledronic acid (Reclast, Zometa) (PDF) CP.PHAR.59 03/01/2011

 

POLICY TITLE POLICY NUMBER EFFECTIVE DATE
340B Shared Savings Model (PDF) GA.PHAR.20 04/01/2017
72 Hour Supply of Medication (PDF) GA.PHAR.07 06/01/2006
Abaloparatide (Tymlos) (PDF) CP.PHAR.345 07/01/2017
abatacept (Orencia) (PDF) CP.PHAR.241 08/01/2016
Abiraterone (Zytiga) (PDF) CP.PHAR.84 10/01/2011
Abiraterone (Zytiga, Yonsa) (PDF) CP.PHAR.84 10/01/2011
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 07/01/2016
Adalimumab (Humira) (PDF) CP.PHAR.242 08/01/2016
Adefovir (Hepsera) (PDF) CP.PHAR.142 08/28/2018
Aducanumab (PDF) CP.PHAR.468 06/01/2020
Afatinib (Gilotrif) (PDF) CP.PHAR.298 01/01/2017
Aflibercept (Eylea®) (PDF) CP.PHAR.184 03/01/2016
Agalsidase Beta (Fabrazyme) (PDF) CP.PHAR.158 02/01/2016
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) CP.PMN.138 03/13/2018
Age Limit for Tazarotene (Tazorac, Arazlo) (PDF) CP.PMN.75 11/09/2017
Alectinib (Alecensa) (PDF) CP.PHAR.369 11/16/2016
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 08/01/2016
Alendronate (Binosto, Fosamax plus D) (PDF) CP.PMN.88 03/01/2018
Alglucosidase Alfa (Lumizyme) (PDF) CP.PHAR.160 02/01/2016
Alirocumab (Praluent) (PDF) CP.PHAR.124 10/01/2015
Alpelisib (Piqray) (PDF) CP.PHAR.430 09/01/2019
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF) CP.PHAR.94 03/01/2012
Ambrisentan (Letairis®) (PDF) CP.PHAR.190 03/01/2016
Amifampridine (Firdapse, Ruzurgi) (PDF) CP.PHAR.411 01/22/2019
Amikacin (Arikayce) (PDF) CP.PHAR.401 11/13/2018
Anakinra (Kineret) (PDF) CP.PHAR.244 08/01/2016
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) CP.PHAR.217 05/01/2016
Apalutamide (Erleada) (PDF) CP.PHAR.376 06/01/2018

Appropriate Use and Safety Edits (PDF)

Appropriate Use and Safety Edits: Attachment A (PDF)

GA.PMN.01 05/01/2012
Apremilast (Otezla) (PDF) CP.PHAR.245 08/01/2016
Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF) CP.PMN.19 11/30/2016
Arformoterol Tartrate (Brovana) (PDF) CP.PMN.201 09/01/2019
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF) CP.PHAR.290 12/01/2016
Armodafinil (Nuvigil) (PDF) CP.PMN.35 08/01/2009
Asenapine (Saphris, Secuado) (PDF) CP.PMN.15 12/01/2014
asfotase alfa (Strensiq®) (PDF) CP.PHAR.328 03/01/2017
Aspirin-dipyridamole (Aggrenox) (PDF) CP.PMN.20 09/01/2006
Atezolizumab (Tecentriq®) (PDF) CP.PHAR.235 06/01/2016
Avapritinib (Ayvakit) (PDF) CP.PHAR.454 03/01/2020
Avatrombopag (Doptelet) (PDF) CP.PHAR.130 07/17/2018
Avelumab (Bavencio®) (PDF) CP.PHAR.333 05/01/2017
Axicabtagene Ciloleucel (Yescarta) (PDF) CP.PHAR.362 10/31/2017
Axitinib (Inlyta®) (PDF) CP.PHAR.100 05/01/2012
Azacitidine (Vidaza) (PDF) CP.PHAR.387 08/28/2017
Aztreonam (Cayston®) (PDF) CP.PHAR.209 05/01/2016
Baclofen (Gablofen, Lioresal, Ozobax) (PDF) CP.PHAR.149 11/09/2017
Baloxavir Marboxil (Xofluza) (PDF) CP.PMN.185 10/30/2018
Bedaquiline (Sirturo) (PDF) CP.PMN.212 12/01/2019
belatacept (Nulojix®) (PDF) CP.PHAR.201 11/09/2017
Belantamab Mafodotin (PDF) CP.PHAR.469 06/01/2020
Belimumab (Benlysta) (PDF) CP.PHAR.88 10/01/2011
belinostat (Beleodaq®) (PDF) CP.PHAR.311 02/01/2017
Bendamustine (Bendeka®, Treanda®) (PDF) CP.PHAR.307 02/01/2017
Benralizumab (Fasenra) (PDF) CP.PHAR.373 01/16/2018
Benzodiazepine Use in Pediatric Seizure Disorders (PDF) GA.PMN.08 03/01/2016
Benznidazole (PDF) CP.PMN.90 10/17/2017
Berotralstat (PDF) CP.PHAR.485 06/01/2020
Betaine (Cystadane) (PDF) CP.PHAR.143 08/28/2018
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) CP.PHAR.93 11/01/2011
Bexarotene (Targretin) (PDF) CP.PHAR.75 09/01/2011
Bezlotoxumab (Zinplava) (PDF) CP.PHAR.300 11/16/2016
Bimatoprost Implant (Durysta) (PDF) CP.PHAR.486 06/01/2020
Binimetinib (Mektovi) (PDF) CP.PHAR.50 07/24/2018
Biologic Drug Dose Escalation (PDF) GA.PMN.21 09/01/2017
Blinatumomab (Blincyto) (PDF) CP.PHAR.312 02/01/2017
Blocking Adjudication of Controlled Substance Prescriptions for Selected Prescribers (PDF) GA.PHAR.19 11/01/2001
Bortezomib (Velcade) (PDF) CP.PHAR.410 12/11/2018
Bosentan (Tracleer®) (PDF) CP.PHAR.191 03/01/2016
Bosutinib (Bosulif) (PDF) CP.PHAR.105 10/01/2012
Brentuximab Vedotin (Adcetris) (PDF) CP.PHAR.303 02/01/2017
Brexanolone (Zulresso) (PDF) CP.PHAR.417 04/16/2019
Brexpiprazole (Rexulti) (PDF) CP.PMN.68 11/05/2015
Brigatinib (Alunbrig) (PDF) CP.PHAR.342 07/17/2017
Brimonidine Tartrate (Mirvaso) (PDF) CP.PMN.192 11/16/2016
Brivaracetam (Briviact) (PDF) HIM.PA.07 09/01/2019
Brolucizumab-dbll (Beovu) (PDF) CP.PHAR.445 03/01/2020
Buprenorphine Implant/Injection (Probuphine, Sublocade) (PDF) CP.PHAR.289 11/16/2016
Buprenorphine implant (Probuphine) (PDF) CP.PHAR.289 11/16/2016
Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF) CP.PMN.81 09/01/2017
Buprenorphine (Subutex) (PDF) CP.PMN.82 09/01/2017
Burosumab-twza (Crysvita)(PDF) CP.PHAR.11 05/08/2018
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF) CP.PHAR.202 03/01/2016
C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF) CP.PHAR.202 03/01/2016
cabazitaxel (Jevtana® (PDF) CP.PHAR.316 02/01/2017
Cabozantinib (Cometriq®, Cabometyx®) (PDF) CP.PHAR.111 06/01/2013
Cannabidiol (Epidiolex) (PDF) CP.PMN.164 07/17/2018
Canakinumab (Ilaris) (PDF) CP.PHAR.246 08/01/2016
capecitabine (Xeloda) (PDF) CP.PHAR.60 05/01/2011
Caplacizumab-yhdp (Cablivi) (PDF) CP.PHAR.416 03/12/2019
carfilzomib (Kyprolis®) (PDF) CP.PHAR.309 02/01/2017
Carglumic acid (Carbaglu®) (PDF) CP.PHAR.206 05/01/2016
Casimersen (PDF) CP.PHAR.470 06/01/2020
Cedazuridine/Decitabine (ASTX-727) (PDF) CP.PHAR.479 06/01/2020
Celecoxib (Celebrex, Elyxyb) (PDF) CP.PMN.122 01/01/2007
Cenegermin-bkbj (Oxervate) (PDF) CP.PMN.186 10/09/2018
Cenobamate (Xcopri) (PDF) CP.PMN.231 03/01/2020
Cemiplimab-rwlc (Libtayo) (PDF) CP.PHAR.397 10/16/2018
Ceritinib (Zykadia) (PDF) CP.PHAR.349 07/01/2017
Cerliponase alfa (Brineura) (PDF) CP.PHAR.338 07/01/2017
Certolizumab (Cimzia) (PDF) CP.PHAR.247 08/01/2016
Cetuximab (Erbitux®) (PDF) CP.PHAR.317 02/01/2017
Chloramphenicol Sodium Succinate (PDF) CP.PHAR.388 12/01/2018
Cholic Acid (Cholbam) (PDF) CP.PHAR.390 12/01/2018
Cinacalcet (Sensipar) (PDF) CP.PHAR.61 05/01/2011
Cladribine (Mavenclad) (PDF) CP.PHAR.422 09/01/2019
Clobazam (Onfi) (PDF) CP.PMN.54 11/1/2012
CNS Stimulants (PDF) CP.PMN.92 03/01/2018
Cobimetinib (Cotellic) (PDF) CP.PHAR.380 11/16/2016
Collagenase (Xiaflex) (PDF) CP.PHAR.82 10/01/2011
Continuous Glucose Monitors (PDF) CP.PMN.214 12/01/2019
copanlisib (Aliqopa®) (PDF) CP.PHAR.357 10/17/2017
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) CP.PHAR.385 05/29/2018
Cosyntropin (Cortrosyn®) (PDF) CP.PHAR.203 04/01/2016
Crisaborole (Eucrisa) (PDF) CP.PMN.110 02/21/2017
Crizanlizumab-tmca (Adakveo) (PDF) CP.PHAR.449 03/01/2020
Crizotinib (Xalkori) (PDF) CP.PHAR.90 11/01/2011
Cyclosporine (Cequa, Restasis) (PDF) CP.PMN.48 05/01/2012
Cysteamine ophthalmic (Cystaran) (PDF) CP.PMN.130 08/01/2017
Cysteamine oral (Cystagon, Procysbi) (PDF) CP.PHAR.155 02/01/2016
Cytomegalovirus Immune Globulin (Cytogam)(PDF) CP.PHAR.277 09/01/2018
Dabrafenib (Tafinlar) (PDF) CP.PHAR.239 11/16/2016
Daclatasvir (Daklinza) (PDF) CP.PHAR.278 09/01/2016
Daclizumab (Zinbryta) (PDF) CP.PHAR.269 08/01/2016
Dacomitinib (Vizimpro) (PDF) CP.PHAR.399 10/16/2018
Dalfampridine (Ampyra) (PDF) CP.PHAR.248 08/01/2016
Dalteparin (Fragmin) (PDF) CP.PHAR.225 05/01/2016
Daptomycin (Cubicin, Cubicin RF) (PDF) CP.PHAR.351 11/30/2017
Daratumumab (Darzalex) (PDF) CP.PHAR.310 07/01/2017
Darbepoetin Alfa (Aranesp) (PDF) CP.PHAR.236 06/01/2016
Darolutamide (Nubeqa) (PDF)
CP.PHAR.435 12/01/2019
Dasabuvir Ombitasvir Paritaprevir Ritonavir (Viekira XR, Viekira Pak) (PDF) GA.PMN.12 12/01/2016
Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira XR, Viekira Pak) (PDF) CP.PHAR.278 09/01/2016
Dasatinib (Sprycel) (PDF) CP.PHAR.72 06/01/2012
daunorubicin/cytarabine (Vyxeos®) (PDF) CP.PHAR.352 12/01/2017
Deferasirox (Exjade Jadenu) (PDF) CP.PHAR.145 11/01/2015
Deferiprone (Ferriprox) (PDF) CP.PHAR.147 11/01/2015
Deferoxamine (Desferal) (PDF) CP.PHAR.146 11/01/2015
Deflazacort (Emflaza) (PDF) CP.PHAR.331 03/01/2017
Degarelix acetate (Firmagon®) (PDF) CP.PHAR.170 11/09/2017
Denosumab (Prolia, Xgeva) (PDF) CP.PHAR.58 03/01/2011
Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF) CP.PHAR.214 05/01/2016
Deutetrabenazine (Austedo) (PDF) CP.PHAR.341 06/13/2017
Dexrazoxane (Zinecard, Totect) (PDF) CP.PHAR.418 03/19/2019
Dextromethorphan-Quinidine (Nuedexta) (PDF) CP.PMN.93 03/01/2018
Diazepam Nasal Spray (Valtoco) (PDF) CP.PMN.216 12/01/2019
Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity) (PDF) CP.PHAR.249 08/01/2016
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF) CP.PMN.03 09/19/2018
Dolasetron (Anzemet) (PDF) CP.PMN.141 09/01/2006
Dornase alfa (Pulmozyme) (PDF) CP.PHAR.212 05/01/2016
Dose Escalation of Biologics (PDF) GA.PMN.21 09/01/2017
Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF) CP.PMN.79 05/01/2017
droxidopa (Northera®) (PDF) CP.PMN.17 11/09/2017
Dupilumab (Dupixent) (PDF) CP.PHAR.336 05/01/2017
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 07/01/2017
Duvelisib (Copiktra) (PDF) CP.PHAR.400 10/16/2018
Early and Periodic Screening, Diagnostic, and Treatment Benefit for Pediatric Members (PDF) CP.PMN.234 06/01/2020
Ecallantide (Kalbitor®) (PDF) CP.PHAR.177 03/01/2016
Eculizumab (Soliris®) (PDF) CP.PHAR.97 03/01/2012
Edaravone (Radicava) (PDF) CP.PHAR.343 07/01/2017
Efinaconazole (Jublia) (PDF) CP.PMN.25 08/01/2016
Elagolix (Orilissa) (PDF) CP.PHAR.136 08/28/2018
Elapegademase-lvlr (Revcovi) (PDF) CP.PHAR.419 04/23/2019
Elbasvir/Grazoprevir (Zepatier) (PDF) GA.PMN.16 12/01/2016
Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (PDF) CP.PHAR.440 12/01/2019
Eliglustat (Cerdelga) (PDF) CP.PHAR.153 02/01/2016
Elosulfase Alfa (Vimizim) (PDF) CP.PHAR.162 02/01/2016
Elotuzumab (Empliciti®) CP.PHAR.308 02/01/2017
Eltrombopag (Promacta®) (PDF) CP.PHAR.180 03/01/2016
Emapalumab-lzsg (Gamifant) (PDF) CP.PHAR.402 12/11/2018
Emicizumab-kxwh (Hemlibra) (PDF) CP.PHAR.370 03/01/2018
Emtricitabine/Tenofovir Alafenamide (Descovy)(PDF) CP.PMN.235 06/01/2020
Enasidenib (Idhifa) (PDF) CP.PHAR.363 09/05/2017
Encorafenib (Braftovi) (PDF) CP.PHAR.127 07/24/2018
Enfortumab Vedotin-ejfv (Padcev) (PDF) CP.PHAR.455 03/01/2020
Enfuvirtide (Fuzeon) (PDF) CP.PHAR.41 06/01/2010
Enoxaparin (Lovenox) (PDF) CP.PHAR.224 05/01/2016
Entrectinib (Rozlytrek) (PDF) CP.PHAR.441 12/01/2019
Enzalutamide (Xtandi) (PDF) CP.PHAR.106 10/01/2012
EoE (PDF) GA.PMN.11 09/01/2016
Epinephrine Injection Device - Quantity Limit Override (PDF) GA.PMN.03 03/01/2015
Epoetin Alfa (Epogen® and Procrit) (PDF) CP.PHAR.237 06/01/2016
Epoprostenol (Flolan®), Veletri®) (PDF) CP.PHAR.192 03/01/2016
Erdafitinib (Balversa)(PDF) CP.PHAR.423 09/01/2019
Erenumab-aaoe (Aimovig) (PDF) CP.PHAR.128 07/10/2018
Eribulin Mesylate (Halaven®) (PDF) CP.PHAR.318 03/01/2017
Erlotinib (Tarceva) (PDF) CP.PHAR.74 09/01/2011
Erwinia Asparaginase (Erwinaze) (PDF) CP.PHAR.301 02/01/2017
Esketamine (Spravato) (PDF) CP.PMN.199 03/12/2019
Etanercept (Enbrel) (PDF) CP.PHAR.250 08/01/2016
Etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 03/20/2018
Eteplirsen (Exondys 51) (PDF) CP.PHAR.288 12/01/2016
Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF) CP.PHAR.63 06/01/2011
Evolocumab (Repatha) (PDF) CP.PHAR.123 10/01/2015
Factor IX (Human, Recombinant) (PDF) CP.PHAR.218 05/01/2016
Factor IX Complex, Human (Profilnine) (PDF) CP.PHAR.219 05/01/2016
Factor IX Complex Human (Bebulin®, Profilnine®) (PDF) CP.PHAR.219 05/01/2016
Factor VIII (Human Recombinant) (PDF) CP.PHAR.215 05/01/2016
Factor VIII/von Willebrand Factor Complex (Human - Alphanate, Humate-P, Wilate) (PDF) CP.PHAR.216 05/01/2016
Factor VIIa, Recombinant (NovoSeven® RT) (PDF) CP.PHAR.220 05/01/2016
Factor XIII A-Subunit, Recombinant (Tretten®) (PDF) CP.PHAR.222 05/01/2016
Factor XIII, Human (Corifact®) (PDF) CP.PHAR.221 05/01/2016
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) CP.PHAR.456 03/01/2020
Febuxostat (Uloric) (PDF) CP.PMN.57 08/01/2013
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF) CP.PMN.127 06/01/2015
Ferric Carboxymaltose (Injectafer) (PDF) CP.PHAR.234 06/01/2016
Ferric Derisomaltose (Monoferric) (PDF) CP.PHAR.280 06/01/2020
Ferric gluconate (Ferrlecit®) (PDF) CP.PHAR.166 3/1/2016
Ferumoxytol (Feraheme®) (PDF) CP.PHAR.165 3/1/2016
Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF) CP.PHAR.297 12/01/2016
Fingolimod (Gilenya) (PDF) CP.PHAR.251 08/01/2016
Fondaparinux (Arixtra) (PDF) CP.PHAR.226 05/01/2016
Fosdenopterin (PDF) CP.PHAR.471 06/01/2020
Fostamatinib (Tavalisse) (PDF) CP.PHAR.24 06/05/2018
Fluorouracil Cream (Tolak(PDF) CP.PMN.165 12/1/2018
Fluticasone Propionate (Xhance) (PDF) CP.PMN.95 10/24/2017
Fluticasone/Vilanterol (Breo Ellipta) (PDF) CP.PMN.229 03/01/2020
Fremanezumab-vfrm (Ajovy) (PDF) CP.PHAR.403 10/30/2018
Fulvestrant (Faslodex Injection)(PDF) CP.PHAR.424 09/01/2019
Galcanezumab-gnlm (Emgality) (PDF) CP.PHAR.404 11/13/2018
Galsulfase (Naglazyme) (PDF) CP.PHAR.161 02/01/2016
Gefitinib (Iressa) (PDF) CP.PHAR.68 11/16/2016
gemtuzumab ozogamicin (Mylotarg®) (PDF) C.PHAR.358 10/03/2017
Gilteritinib (Xospata) (PDF) CP.PHAR.412 01/15/2019
Givosiran (Givlaari) (PDF) CP.PHAR.457 03/01/2020
Glasdegib (Daurismo) (PDF) CP.PHAR.413 01/08/2019
Glatiramer (Copaxone, Glatopa) (PDF) CP.PHAR.252 08/01/2016
Glecaprevir/pibrentasvir (Mavyret) (PDF) GA.PMN.24 09/01/2017
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF) CP.PMN.183 09/19/2018
Glycerol phenylbutyrate (Ravicti®) (PDF) CP.PHAR.207 05/01/2016
Golimumab (Simponi, Simponi Aria) (PDF) CP.PHAR.253 07/01/2016
Golodirsen (Vyondys 53) (PDF) CP.PHAR.453 03/01/2020
goserelin acetate (Zoladex®) (PDF) CP.PHAR.171 11/09/2017
Granisetron (Kytril, Sancuso, Sustol) (PDF) CP.PMN.74 11/01/2016
Hemin (Panhematin®) (PDF) CP.PHAR.181 02/01/2016
histrelin acetate (Vantas®, Supprelin LA®) (PDF) CP.PHAR.172 11/09/2017
Hyaluronate Derivatives (PDF) CP.PHAR.05 10/01/2008
Hydroxyprogesterone Caproate (Makena/compound) CP.PHAR.14 11/20/2017
Hydroxyurea (Siklos) (PDF) CP.PMN.193 02/19/2019
Ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 04/17/2018
Ibandronate sodium (Boniva®) (PDF) CP.PHAR.189 11/15/2017
Ibrutinib (Imbruvica) (PDF) CP.PHAR.126 10/01/2015
Ibuprofen/Famotidine (Duexis) (PDF) CP.PMN.120 06/01/2018
Icatibant (Firazyr) (PDF) CP.PHAR.178 03/01/2016
Icosapent ethyl (Vascepa) (PDF) CP.PMN.187 11/20/2018
Idecabtagene Vicleucel (BB2121) (PDF) CP.PHAR.481 06/01/2020
Idelalisib (Zydelig) (PDF) CP.PHAR.133 12/01/2018
Idursulfase (Elaprase) (PDF) CP.PHAR.156 02/01/2016
Iloperidone (Fanapt) (PDF) CP.PMN.32 12/01/2014
Iloprost (Ventavis®) (PDF) CP.PHAR.193 03/01/2016
Imatinib (Gleevec) (PDF) CP.PHAR.65 06/01/2011
Imiglucerase (Cerezyme) (PDF) CP.PHAR.154 02/01/2016
Immune Globulins (PDF) CP.PHAR.103 08/01/2012
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 07/01/2016
Indacaterol/Glycopyrrolate (Utibron Neohaler) (PDF) HIM.PA.102 09/01/2018
Inebilizumab (PDF) CP.PHAR.458 03/01/2020
Infertility and Fertility Preservation (PDF) CP.PHAR.131 11/16/2016
Infliximab (Remicade, Inflectra, Renflexis) (PDF) CP.PHAR.254 07/01/2016
Inotersen (Tegsedi) (PDF) CP.PHAR.405 11/20/2018
inotuzumab ozogamicin (Besponsa®) (PDF) CP.PHAR.359 09/26/2017
Insulin Infusion Pump (Omnipod, Omnipod DASH) (PDF) CP.PHAR.420 04/23/2019
Interferon beta-1a (Avonex, Rebif) (PDF) CP.PHAR.255 08/01/2016
Interferon beta-1b (Betaseron, Extavia) (PDF) CP.PHAR.256 08/01/2016
Interferon Gamma- 1b (Actimmune) (PDF) CP.PHAR.52 06/01/2010
Itraconazole (Sporanox, Onmel, Tolsura) (PDF) CP.PMN.124 11/01/2006
Intrathecal Baclofen (Gablofen, Lioresal) (PDF) CP.PHAR.149 11/09/2017
Iobenguane I-131 (Azedra) (PDF) CP.PHAR.459 03/01/2020
Ipilimumab (Yervoy) (PDF) CP.PHAR.319 04/17/2018
irinotecan Liposome (Onivyde®) (PDF) CP.PHAR.304 02/01/2017
Iron sucrose (Venofer®) (PDF) CP.PHAR.167 03/01/2016
Isatuximab-irfc (Sarclisa)(PDF) CP.PHAR.482 06/01/2020
Isavuconazonium (Cresemba) (PDF) CP.PMN.154 11/16/2016
Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (PDF) CP.PMN.143 12/01/2014
Istradefylline (Nourianz) (PDF) CP.PMN.217 03/01/2020
Ivabradine (Corlanor) (PDF) CP.PMN.70 11/01/2015
Ivacaftor (Kalydeco) (PDF) CP.PHAR.210 05/01/2016
Ivosidenib (Tibsovo) (PDF)
CP.PHAR.137 08/21/2018
Ixazomib (Ninlaro) (PDF) CP.PHAR.302 02/01/2017
Ixekizumab (Taltz) (PDF) CP.PHAR.257 08/01/2016
KTE-X19 (PDF) CP.PHAR.472 06/01/2020
Lacosamide (Vimpat) (PDF) CP.PMN.155 12/01/2014
Lanadelumab-fylo (Takhzyro) (PDF) CP.PHAR.396 09/25/2018
Lanreotide (Somatuline Depot) (PDF) CP.PHAR.391 08/28/2018
lapatinib (Tykerb®) (PDF) CP.PHAR.79 11/09/2017
Laronidase (Aldurazyme) (PDF) CP.PHAR.152 02/01/2016
Larotrectinib (Vitrakvi) (PDF) CP.PHAR.414 01/15/2018
Lasmiditan (Reyvow) (PDF) CP.PMN.218 03/01/2020
Ledipasvir/Sofosbuvir (Harvoni) (PDF) CP.PHAR.279 09/01/2016
Lefamulin (Xenleta) (PDF) CP.PMN.219 03/01/2020
Lemborexant (Dayvigo)(PDF) CP.PMN.233 06/01/2020
Lenalidomide (Revlimid) (PDF) CP.PHAR.71 07/01/2011
Lenvatinib (Lenvima) (PDF) CP.PHAR.138 12/01/2018
Letermovir (Prevymis) (PDF) CP.PHAR.367 03/01/2018
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) CP.PHAR.173 11/09/2017
Levalbuterol (Xopenex HFA/Inhalation Solution) (PDF) CP.PMN.07 09/01/2006
Levoleucovorin (Fusilev®) (PDF) CP.PHAR.151 11/09/2017
Levofloxacin (Levaquin) in Pediatric Community Acquired Pneumonia (PDF) GA.PMN.05 03/01/2016
Lidocaine Transdermal (Lidoderm, ZTlido) (PDF) CP.PMN.08 09/01/2006
Linaclotide (Linzess) (PDF) CP.PMN.71 11/01/2015
Linezolid (Zyvox) (PDF) CP.PMN.27 09/01/2016
Lifitegrast (Xiidra®) (PDF) CP.PMN.73 11/09/2017
Lisocabtagene Maraleucel (JCAR017) (PDF) CP.PHAR.483 06/01/2020
Lofexidine (Lucemyra) (PDF) CP.PMN.152 08/01/2018
Lomitapide (Juxtapid) (PDF) CP.PHAR.283 10/01/2016
Lorlatinib (Lorbrena) (PDF) CP.PHAR.406 12/11/2018
Lubiprostone (Amitiza) (PDF) CP.PMN.142 12/01/2014
Luliconazole Cream (Luzu) (PDF) CP.PMN.166 08/28/2018
Lumacaftor-Ivacaftor (Orkambi) (PDF) CP.PHAR.213 05/01/2016
Lumasiran (ALN-GO1) (PDF) CP.PHAR.473 06/01/2020
Lumateperone (Caplyta) (PDF) CP.PMN.232 03/01/2020
Lurasidone (Latuda) (PDF) CP.PMN.50 12/01/2014
Luspatercept-aamt (Reblozyl) (PDF) CP.PHAR.450 03/01/2020
Lusutrombopag (Mulpleta) (PDF) CP.PHAR.407 09/18/2018
Lutetium Lu 177 Dotatate (Lutathera)(PDF) CP.PHAR.384 05/22/2018
Macitentan (Opsumit®) (PDF) CP.PHAR.194 03/01/2016
Maximum Allowable Cost Requirement (PDF) GA.PHAR.21 07/01/2017
Mecasermin (Increlex) (PDF) CP.PHAR.150 03/01/2011
Mecamylamine (Vecamyl) (PDF) CP.PMN.136 05/01/2017
Medication Safety Policy (PDF) GA.PMN.22 07/01/2017
Megestrol Acetate (Megace ES) (PDF) CP.PMN.179 12/01/2018
Mepolizumab (Nucala) (PDF) CP.PHAR.200 04/01/2016
Metformin ER (Fortamet, Glumetza) (PDF) CP.PMN.72 11/01/2015
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF) CP.PHAR.134 12/01/2018
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) CP.PHAR.238 06/01/2016
Methylnaltrexone Bromide (Relistor) (PDF) CP.PMN.169 12/01/2018
Metreleptin (Myalept) (PDF) CP.PHAR.425 09/01/2019
Midazolam (Nayzilam) (PDF) CP.PMN.211 09/01/2019
Midostaurin (Rydapt) (PDF) CP.PHAR.344 06/01/2017
Mifepristone (Korlym) (PDF) CP.PHAR.101 05/01/2012
Migalastat (Galafold) (PDF) CP.PHAR.394 09/11/2018
Miglustat (Zavesca) (PDF) CP.PHAR.164 02/01/2016
Milnacipran (Savella) (PDF) CP.PMN.125 08/01/2012
Mipomersen (Kynamro) (PDF) CP.PHAR.284 10/01/2016
Minocycline ER (Solodyn, Ximino, Minolira) and Microspheres (Arestin) (PDF) CP.PMN.80 05/01/2017
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 08/01/2016
Modafinil (Provigil) (PDF) CP.PMN.39 05/01/2008
Mogamulizumab-kpkc (Poteligeo) (PDF) CP.PHAR.139 09/04/2018
Mometasone/Formoterol (Dulera) (PDF) CP.PMN.230 03/01/2020
Mometasone Furoate (Sinuva) (PDF) CP.PHAR.448 03/01/2020
Monomethyl Fumarate (Bafiertam) (PDF) CP.PHAR.460 03/01/2020
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) CP.PHAR.398 10/16/2018
Nadofaragene Firadenovec (Instiladrin) (PDF) CP.PHAR.461 03/01/2020
nafarelin acetate (Synarel®) (PDF) CP.PHAR.174 11/09/2017
Naproxen/Esomeprazole (Vimovo) (PDF) CP.PMN.117 06/01/2018
Natalizumab (Tysabri) (PDF) CP.PHAR.259 07/01/2016
Necitumumab (Portrazza®) (PDF) CP.PHAR.320 03/01/2017
Neomycin/Fluocinolone Cream (Neo-Synalar)_(PDF) CP.PMN.167 08/28/2018
Neratinib (Nerlynx) (PDF) CP.PHAR.365 09/05/2017
Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan)  (PDF) CP.PMN.118 02/13/2018
Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (PDF) CP.PMN.158 09/01/2006
nilotinib (Tasigna) (PDF) CP.PHAR.76 09/01/2011
Nintedanib (Ofev) (PDF) CP.PHAR.285 10/01/2016
Nitisinone (Nityr, Orfadin) (PDF) CP.PHAR.132 08/28/2018
Nivolumab (Opdivo) (PDF) CP.PHAR.121 07/01/2015
No Coverage Criteria/Off-Label Use Policy (PDF) CP.PMN.53 09/12/2017
Nusinersen (Spinraza®)(PDF) CP.PHAR.327 11/28/2017
Obeticholic (Ocaliva) (PDF) CP.PHAR.287 11/01/2016
Obinutuzumab (Gazyva®) (PDF) CP.PHAR.305 02/01/2017
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 04/01/2017
Octreotide (Sandostatin, Sandostatin LAR) (PDF) CP.PHAR.40 03/01/2010
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia) (PDF) CP.PHAR.40 03/01/2010
ofatumumab (Arzerra®) (PDF) CP.PHAR.306 02/01/2017
Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) CP.PHAR.292 12/01/2016
Olaparib (Lynparza) (PDF) CP.PHAR.360 10/03/2017
olaratumab (Lartruvo®) (PDF) CP.PHAR.326 03/01/2017
Omadacycline (Nuzyra) (PDF) CP.PMN.188 11/20/2018
Omacetaxine (Synribo) (PDF) CP.PHAR.108 04/01/2013
Omalizumab (Xolair®) (PDF) CP.PHAR.01 10/1/2008
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 07/01/2016
Onasemnogene Abeparvovec (Zolgensma) (PDF) CP.PHAR.421 06/07/2019
Ondansetron (Zuplenz) (PDF) CP.PMN.45 09/01/2006
Opioid Analgesics (PDF) GA.PMN.26 10/01/2019
Osimertinib (Tagrisso) (PDF) CP.PHAR.294 12/01/2016
Ospemifene (Osphena) (PDF) CP.PMN.168 08/28/2018
Overactive Bladder Agents (PDF) CP.PMN.198 05/01/2016
Ozanimod (PDF) CP.PHAR.462 03/01/2020
Ozenoxacin (Xepi) (PDF) CP.PMN.119 01/30/2018
Paclitaxel, Protein-Bound (Abraxane) (PDF) CP.PHAR.176 07/01/2015
Palbociclib (Ibrance®) (PDF) CP.PHAR.125 10/01/2015
Palivizumab (Synagis) (PDF) CP.PHAR.16 08/01/2009
panitumumab (Vectibix®) (PDF) CP.PHAR.321 03/01/2017
Parathyroid Hormone (Natpara) (PDF) CP.PHAR.282 11/16/2016
Paricalcitol Injection (Zemplar) (PDF) CP.PHAR.270 08/01/2016
Pasireotide (Signifor LAR®) (PDF) CP.PHAR.332 03/01/2017
Patisiran (Onpattro) (PDF) CP.PHAR.395 09/11/2018
Pazopanib (Votrient) (PDF) CP.PHAR.81 10/01/2011
Peanut Allergen Powder-dnfp (Palforzia) (PDF) CP.PMN.220 03/01/2020
Pediatric Benzodiazepine Use in Chemotherapy Induced Nausea and Vomiting CINV (PDF) GA.PMN.07 08/01/2016
Pediatric BZD Seizures (PDF) GA.PMN.08 03/01/2016
Pegademase Bovine (Adagen) (PDF) CP.PHAR.392 08/28/2018
Pegaptanib (Macugen®) (PDF) CP.PHAR.185 03/01/2016
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF) CP.PHAR.353 09/05/2017
Pegfilgrastim (Neulasta) (PDF) CP.PHAR.296 12/01/2016
peginterferon alfa-2b (PegIntron, Sylatron®) (PDF) CP.PHAR.89 10/01/2011
Peginterferon beta-1a (Plegridy) (PDF) CP.PHAR.271 08/01/2016
Pegloticase (Krystexxa®) (PDF) CP.PHAR.115 6/1/2013
Pegvaliase-pqpz (Palynziq) (PDF) CP.PHAR.140 07/31/2018
Pegvisomant (Somavert) (PDF) CP.PHAR.389 12/01/2018
Pemetrexed (Alimta, Pemfexy) (PDF) CP.PHAR.368 10/31/2017
pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 03/01/2017
Perampanel (Fycompa) (PDF) CP.PMN.156 11/16/2016
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 06/01/2016
Pexidartinib (Turalio) (PDF) CP.PHAR.436 12/01/2019

Pharmacy Lock-In Program (PDF)

Lock-In Letter (PDF)

Lock-In Release Letter (PDF)

GA.PHAR.06 07/01/2006
Pharmacy Program (PDF) GA.PHAR.01 10/01/2006
Pitolisant (Wakix) (PDF) CP.PMN.221 03/01/2020
Plerixafor (Mozobil) (PDF) CP.PHAR.323 03/01/2017
Polatuzumab Vedotin-piiq (Polivy) (PDF) CP.PHAR.433 09/01/2019
Pomalidomide (Pomalyst) (PDF) CO.PHAR.116 07/01/2013
Ponatinib (Iclusig) (PDF) CO.PHAR.112 06/01/2013
Pralatrexate (Folotyn®) (PDF) CP.PHAR.313 02/01/2017
Pramlintide (Symlin) (PDF) CP.PMN.129 06/01/2018
Pregabalin (Lyrica, Lyrica CR) (PDF) CP.PMN.33 01/01/2007
Pretomanid (PDF) CP.PMN.222 03/01/2020
Protein C Concentrate, Human (Ceprotin) (PDF) CP.PHAR.330 03/01/2017
Propranolol HCl Oral Solution (Hemangeol) (PDF) CP.PMN.58 05/01/2014
Prucalopride (Motegrity) (PDF) CP.PMN.194 01/29/2019
Psychotropic Medication Continuity of Care (COC) (PDF) GA.PMN.10 12/01/2016
pyrimethamine (Daraprim®) (PDF) CP.PMN.44 11/01/2015
Quetiapine ER (Seroquel XR) (PDF) CP.PMN.64 12/01/2014
Ramucirumab (Cyramza®) (PDF) CP.PHAR.119 05/01/2015
Ranibizumab (Lucentis®) (PDF) CP.PHAR.186 03/01/2016
Regorafenib (Stivarga) (PDF) CP.PHAR.107 12/01/2012
Remestemcel-L (Prochymal) (PDF) CP.PHAR.474 06/01/2020
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) CP.PHAR.168 03/01/2016
Request for Medically Necessary Drug Not on the PDL (PDF) CP.PMN.16 11/09/2017
Reslizumab (Cinqair) (PDF) CP.PHAR.223 05/01/2016
Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF) CP.PHAR.141 11/16/2016
Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) (PDF) CP.PMN.223 03/01/2020
Rifamycin (Aemcolo) (PDF) CP.PMN.196 01/08/2019
rifaximin (Xifaxan®)(PDF) CP.PMN.47 11/01/2011
Rilonacept (Arcalyst) (PDF) CP.PHAR.266 11/16/2016
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 07/01/2016
Riociguat (Adempas®) (PDF) CP.PHAR.195 03/01/2016
Risdiplam (PDF) CP.PHAR.477 06/01/2020
Risedronate (Actonel, Atelvia) (PDF) CP.PMN.100 03/01/2018
Risperidone Long-Acting Injection (Risperdal Consta) (PDF) CP.PHAR.293 12/01/2016
Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) CP.PHAR.260 07/01/2016
Rolapitant (Varubi) (PDF) CP.PMN.102 02/01/2017
romidepsin (Istodax®) (PDF) CP.PHAR.314 01/01/2017
Romiplostim (Nplate®) (PDF) CP.PHAR.179 03/01/2016
Rucaparib (Rubraca®) (PDF) CP.PHAR.350 09/01/2017
Rufinamide (Banzel) (PDF) CP.PMN.157 12/01/2014
Sacubitril/Valsartan (Entresto) (PDF) CP.PMN.67 11/01/2015
Sacitizumab Govitecan (PDF) CP.PHAR.475 06/01/2020
Safinamide (Xadago) (PDF) CP.PMN.113 07/01/2017
Sapropterin Dihydrochloride (Kuvan) (PDF) CP.PHAR.43 02/01/2010
Sarecycline (Seysara) (PDF) CP.PMN.189 11/13/2018
Sargramostim (Leukine) (PDF) CP.PHAR.295 12/01/2016
Satralizumab (PDF) CP.PHAR.463 03/01/2020
Sebelipase Alfa (Kanuma) (PDF) CP.PHAR.159 02/01/2016
Secnidazole (Solosec) (PDF) CP.PMN.103 10/24/2017
Selexipag (Uptravi®) (PDF) CP.PHAR.196 03/01/2016
Selinexor (Xpovio) (PDF) CP.PHAR.431 09/01/2019
Selpercatinib (LOXO-292) (PDF) CP.PHAR.478 06/01/2020
Selumetinib (Koselugo) (PDF) CP.PHAR.464 03/01/2020
Sildenafil (Revatio®) (PDF) CP.PHAR.197 03/01/2016
Siltuximab (Sylvant®) (PDF) CP.PHAR.329 03/01/2017
Simeprevir (Olysio) (PDF) CP.PHAR.280 09/01/2016
Siponimod (Mayzent) (PDF) CP.PHAR.427 09/01/2019
Sipuleucel-T (Provenge) (PDF) CP.PHAR.120 06/01/2015
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF) CP.PMN.14 09/18/2018
sodium oxybate (Xyrem) (PDF) CP.PMN.42 05/01/2011
Sodium Phenylbutyrate (Buphenyl) (PDF) CP.PHAR.208 05/01/2016
Sofosbuvir/Ledipasvir (Harvoni) (PDF) GA.PMN.13 12/01/2016
Sofosbuvir (Sovaldi) (PDF) CP.PHAR.281 09/01/2016
Sofosbuvir (Sovaldi) (PDF) GA.PMN.17 12/01/2016
Sofosbuvir/Velpatasvir (Epclusa) (PDF) GA.PMN.06 12/01/2016
Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (PDF) GA.PMN.25 09/01/2017
Solriamfetol (Sunosi) (PDF) CP.PMN.209 09/01/2019
Somatropin (Growth Hormone) (PDF) CP.PHAR.55 03/01/2011
Sonidegib (Odomzo) (PDF) CP.PHAR.272 05/01/2012
sorafenib (Nexavar) (PDF) CP.PHAR.69 07/01/2011
Specialty Drug Classification (PDF) GA.PHAR.15 03/12/2000
Specialty Pharmacy Program (PDF) GA.PHAR.18 03/12/2014
Step Therapy (PDF) CP.PST.01 12/28/2017
Stiripentol (Diacomit) (PDF) CP.PMN.184 09/25/2018
sunitinib (Sutent) (PDF) CP.PHAR.73 09/01/2011
Suvorexant (Belsomra®) (PDF) CP.PMN.109 02/01/2017
Tadalafil (Adcirca®) (PDF) CP.PHAR.198 03/01/2016
Tadalafil BHP - ED (Cialis) (PDF) CP.PMN.132 06/01/2018
Tafamidis (Vyndaqel, Vyndamax) (PDF) CP.PHAR.432 09/01/2019  
Talazoparib (Talzenna) (PDF) CP.PHAR.409 11/27/2018  
Taliglucerase Alfa (Elelyso) (PDF) CP.PHAR.157 02/01/2016
Tasimelteon (Hetlioz) (PDF) CP.PMN.104 02/01/2017
Tavaborole (Kerydin) (PDF) CP.PMN.105 03/01/2018
Tazemetostat (Tazverik) (PDF) CP.PHAR.452 03/01/2020
Tedizolid (Sivextro) (PDF) CP.PMN.62 03/01/2015
Teduglutide (Gattex) (PDF) CP.PHAR.114 05/01/2013
Tegaserod (Zelnorm) (PDF) CP.PMN.206 09/01/2019
Telotristat Ethyl (Xermelo) (PDF) CP.PHAR.337 06/01/2017
Temozolomide (Temodar) (PDF) CP.PHAR.77 09/01/2011
temsirolimus (Torisel®) (PDF) CP.PHAR.324 03/01/2017
Tenapanor (Ibsrela) (PDF) CP.PMN.224 03/01/2020
Teprotumumab (Tepezza) (PDF) CP.PHAR.465 01/21/2020
Teriflunomide (Aubagio) (PDF) CP.PHAR.262 08/01/2016
Teriparatide (Forteo®) (PDF) CP.PHAR.188 11/15/2017
Tesamorelin (Egrifta) (PDF) CP.PHAR.109 03/01/2014
Testosterone (Testopel, Jatenzo) (PDF) CP.PHAR.354 08/01/2017
tetrabenazine (Xenazine) (PDF) CP.PHAR.92 12/01/2011
Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF) CP.PHAR.377 04/03/2018
Thalidomide (Thalomid) (PDF) CP.PHAR.78 09/01/2011
Thioguanine (Tabloid) (PDF) CP.PHAR.437 12/01/2019
Thyrotropin Alfa (Thyrogen) (PDF)  CP.PHAR.95 03/01/2012
Timothy grass pollen allergen extract (Grastek®) (PDF) CP.PMN.84 08/31/2017
Tisagenlecleucel (Kymriah) (PDF) CP.PHAR.361 09/26/2017
Tobramycin (Bethkis®, Kitabis Pak®, TOBI®, TOBI Podhaler®) (PDF) CP.PHAR.211 05/01/2016
Tocilizumab (Actemra) (PDF) CP.PHAR.263 07/01/2016
Tofacitinib (Xeljanz, Xeljanz XR) (PDF) CP.PHAR.267 01/30/2018
Tolvaptan (Jynarque) (PDF) CP.PHAR.27 06/05/2018
Topical Immunomodulators (PDF) CP.PMN.107 09/01/2006
Topical Steroid Use For Eosinophilic Esophagitis (PDF) GA.PMN.11 09/01/2016
Topical Tretinoin in Adult Acne Vulgaris (PDF) GA.PMN.09 03/01/2016
Topotecan (Hycamtin)(PDF) CP.PHAR.64 06/01/2011
Trabectedin (Yondelis®) (PDF) CP.PHAR.204 05/01/2016
Trametinib (Mekinist) (PDF) CP.PHAR.240 07/01/2016
Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF) CP.PHAR.228 06/01/2016
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF) CP.PHAR.199 03/01/2016
Triamcinolone ER Injection (Zilretta) (PDF) CP.PHAR.371 03/01/2018
Trientine (Syprine) (PDF) CP.PHAR.438 12/01/2019
triptorelin pamoate (Trelstar®, Triptodur®) (PDF) CP.PHAR.175 11/09/2017
Ubrogepant (Ubrelvy) (PDF) CP.PHAR.475 06/01/2020
Upadacitinib (Rinvoq) (PDF) CP.PHAR.443 12/01/2019
Ustekinumab (Stelara) (PDF) CP.PHAR.264 08/01/2016
Valoctocogene Roxaparvovec (PDF) CP.PHAR.466 03/01/2020
Valproate Sodium for Intravenous Injection (Depacon) (PDF) CP.PHAR.429 09/01/2019
Valrubicin (Valstar) (PDF) CP.PHAR.439 12/01/2019
Vandetanib (Caprelsa®) (PDF) CP.PHAR.80 10/01/2011
Varenicline (Chantix) (PDF) GA.PMN.16 01/01/2017
Vedolizumab (Entyvio) (PDF) CP.PHAR.265 07/01/2016
Velaglucerase Alfa (VPRIV) (PDF) CP.PHAR.163 02/01/2016
Vemurafenib (Zelboraf®) (PDF) CP.PHAR.91 11/01/2011
Verteporfin (Visudyne®) (PDF) CP.PHAR.187 03/01/2016
Vestronidase alfa-vjbk (Mepsevii) (PDF) CP.PHAR.374 01/19/2018
Vigabatrin (Sabril) (PDF) CP.PHAR.169 02/01/2016
Vilazodone (Viibryd) (PDF) CP.PMN.145 08/01/2012
Viltolarsen (PDF) CP.PHAR.484 06/01/2020
vincristine sulfate liposome injection (Marqibo®) (PDF) CP.PHAR.315 02/01/2017
Vismodegib (Erivedge) (PDF) CP.PHAR.273 08/01/2016
Voretigene neparvovec-rzyl (Luxturna) (PDF) CP.PHAR.372 03/01/2018
Vorinostat (Zolinza) (PDF) CP.PHAR.83 12/01/2012
Vortioxetine (Trintellix®) (PDF) CP.PMN.65 05/31/2017
Voxelotor (Oxbryta) (PDF) CP.PHAR.451 03/01/2020
Zanubrutinib (Brukinsa) (PDF) CP.PHAR.467 03/01/2020
ziv-aflibercept (Zaltrap®) (PDF) CP.PHAR.325 03/01/2017
Zoledronic acid (Reclast, Zometa) (PDF) CP.PHAR.59 03/01/2011

 

POLICY TITLE POLICY NUMBER EFFECTIVE DATE
72 Hour Supply of Medication (PDF) GA.PHAR.07 06/01/2006
Ado-Trastuzumab Emtansine (Kadcyla) (PDF) CP.PHAR.229 06/01/2016
Aflibercept (Eylea®) (PDF) CP.PHAR.184 03/01/2016
Alglucosidase Alfa (Lumizyme) (PDF) CP.PHAR.160 02/01/2016
Anakinra (Kineret) (PDF) CP.PHAR.244 08/01/2016
Ambrisentan (Letairis®) (PDF) CP.PHAR.190 03/01/2016

Appropriate Use and Safety Edits (PDF)

Appropriate Use and Safety Edits: Attachment A (PDF)

GA.PMN.01 05/01/2012
Benznidazole (PDF) CP.PMN.90 10/17/2017
Blocking Adjudication of Controlled Substance Prescriptions for Selected Prescribers (PDF) GA.PHAR.19 11/01/2001
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF) CP.PHAR.202 03/01/2016
Cabozantinib (Cometriq®, Cabometyx®) (PDF) CP.PHAR.111 06/01/2013
Carglumic acid (Carbaglu®) (PDF) CP.PHAR.206 05/01/2016
Dose Escalation of Biologics (PDF) GA.PMN.21 09/01/2017
Drug Recall Notification Process (PDF) GA.PHAR.08 07/01/2008
Drug Utilization Review (PDF) GA.PHAR.13 04/01/2007
Enoxaparin (Lovenox) (PDF) CP.PHAR.224 05/01/2016
Epoprostenol (Flolan®), Veletri®) (PDF) CP.PHAR.192 03/01/2016
Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF) CP.PHAR.297 12/01/2016
Hydroxyprogesterone Caproate (Makena®) (PDF) CP.PHAR.14 11/20/2017
Ibandronate sodium (Boniva®) (PDF) CP.PHAR.189 11/15/2017
Ibrutinib (Imbruvica) (PDF) CP.PHAR.126 10/01/2015
Iloprost (Ventavis®) (PDF) CP.PHAR.193 03/01/2016
Ivacaftor (Kalydeco) (PDF) CP.PHAR.210 05/01/2016
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) CP.PHAR.173 11/09/2017
Lomitapide (Juxtapid) (PDF) CP.PHAR.283 10/01/2016
Lost, Stolen, Spilled or Broken Medications (PDF) GA.PHAR.10 04/01/2007
Maximum Allowable Cost (MAC) Requirement (PDF) GA.PHAR.21 07/01/2017
Mecasermin (Increlex) (PDF) CP.PHAR.150 03/01/2011
Medication Safety Policy (PDF) GA.PMN.22 07/01/2017
Mifepristone (Korlym) (PDF) CP.PHAR.101 05/01/2012
Mipomersen (Kynamro) (PDF) CP.PHAR.284 10/01/2016
Pegaptanib (Macugen®) (PDF) CP.PHAR.185 03/01/2016
Pegloticase (Krystexxa®) (PDF) CP.PHAR.115 06/01/2013
pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 03/01/2017
Pharmacy and Therapeutics Committee (PDF) GA.PHAR.17 08/09/2011
Pharmaceutical Management (PDF) GA.PHAR.03 02/01/2003
Pharmacy Prior Authorization and Medical Necessity Criteria (PDF) GA.PHAR.16 07/09/2010
Plerixafor (Mozobil) (PDF) CP.PHAR.323 03/01/2017
Ranibizumab (Lucentis®) (PDF) CP.PHAR.186 03/01/2016
Riociguat (Adempas®) (PDF) CP.PHAR.195 03/01/2016
Tadalafil (Adcirca®) (PDF) CP.PHAR.198 03/01/2016
Vandetanib (Caprelsa®) (PDF) CP.PHAR.80 10/01/2011
vincristine sulfate liposome injection (Marqibo®) (PDF) CP.PHAR.315 02/01/2017

 

 

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.

 

POLICY TITLE POLICY NUMBER EFFECTIVE DATE
3 Day Payment Window (PDF) CC.PP.500 07/01/2014
30 Day Readmission (PDF) CC.PP.501 01/01/2015
Add On Policy (PDF) CC.PP.030 01/01/2013
Assistant Surgeon (PDF) CC.PP.029 01/01/2014
Bilateral Procedures (PDF) CC.PP.037 01/01/2014
Cerumen Removal Policy (PDF) CC.PP.008 01/01/2014
Clean Claims Policy (PDF) CC.PP.021 01/01/2013
Clinical Validation of Modifier 25 (PDF) CC.PP.013 01/01/2013
Clinical Validation of Modifier 59 (PDF) CC.PP.014 01/01/2013
Code Editing Overview (PDF) CC.PP.011 01/01/2013
Cosmetic Procedures (PDF) CC.PP.024 01/01/2014
Distinct Procedure Modifiers Policy (PDF) CC.PP.020 01/01/2013
Duplicate Primary Code Billing (PDF) CC.PP.044 01/01/2014
EM Medical Decision Making (PDF) CC.PP.051 06/01/2017
E&M Bundling with Labs and Radiology (PDF) CC.PP.010 01/01/2013
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 01/01/2016
Inpatient Consultation (PDF) CC.PP.038 01/01/2014
Inpatient Only Procedures Policy (PDF) CC.PP.018 01/01/2018
IV Hydration Policy (PDF) CC.PP.012 01/01/2013
Max Units Payment Policy (PDF) CC.PP.007 01/01/2013
Moderate Conscious Sedation (PDF) CC.PP.015 01/01/2013
Modifier DOS Validation (PDF) CC.PP.034 01/01/2015
Modifier to Procedure Code Validation (PDF) CC.PP.028 01/01/2013
Multiple CPT Code Replace (PDF) CC.PP.033 01/01/2013
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF) CC.PP.065 02/06/2020
NCCI Unbundling (PDF) CC.PP.031 01/01/2013
New Patient (PDF) CC.PP.036 01/01/2014
Never Paid Events (PDF) CC.PP.017 01/01/2013
Non-obstectrical Pelvic and Transvaginal Ultrasounds (PDF) CC.PP.061 06/01/2018
Not Medically Necessary Inpatient Service (PDF) CC.PP.060 06/01/2018
Outpatient Consultation (PDF) CC.PP.039 01/01/2014
Physicians Consultation Services (PDF) CC.PP.054 10/01/2017
Physician's Office Lab Testing (PDF) GA.PP.055 12/01/2019
Place of Service Mismatch (PDF) CC.PP.063 09/01/2018
Postoperative Visits (PDF) CC.PP.042 01/01/2014
Preoperative Visits (PDF) CC.PP.041 01/01/2014
Problem Oriented Visits with Preventative Services (PDF) CC.PP.057 10/01/2017
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 11/01/2017
Professional Component Modifier (PDF) CC.PP.027 01/01/2013
Pulse Oximetry w Office Visits (PDF) CC.PP.025 01/01/2013
Robotic Surgeries (PDF) CC.PP.050 08/01/2017
Same Day Visits (PDF) CC.PP.040 01/01/2014
Status B Bundled Services (PDF) CC.PP.046 01/01/2014
Status P Bundled Services (PDF) CC.PP.049 01/01/2014
Supplies Same Day as Surgery (PDF) CC.PP.032 01/01/2013
Transgender Related Services (PDF) CC.PP.047 01/01/2017
Ultrasound in Pregnancy (PDF) CP.MP.38 01/31/2011
Unbundled Professional Services (PDF) CC.PP.043 03/15/2017
Unbundled Surgical Procedures (PDF) CC.PP.045 03/15/2017
Unlisted Procedure Codes Policy (PDF) CC.PP.009 01/01/2013
Urine Specimen Validity Testing (PDF) CC.PP.056 10/01/2017
Visual Field Testing (PDF) OC.UM.CP.0063 01/01/2017
Wheelchairs and Accessories (PDF) CC.PP.052 10/01/2015

 

POLICY TITLE POLICY NUMBER EFFECTIVE DATE
3 Day Payment Window (PDF) CC.PP.500 07/01/2014
30 Day Readmission (PDF) CC.PP.501 01/01/2015
Add On Policy (PDF) CC.PP.030 01/01/2013
Assistant Surgeon (PDF) CC.PP.029 01/01/2014
Bilateral Procedures (PDF) CC.PP.037 01/01/2014
Cerumen Removal Policy (PDF) CC.PP.008 01/01/2014
Clean Claims Policy (PDF) CC.PP.021 01/01/2013
Clinical Validation of Modifier 25 (PDF) CC.PP.013 01/01/2013
Clinical Validation of Modifier 59 (PDF) CC.PP.014 01/01/2013
Code Editing Overview (PDF) CC.PP.011 01/01/2013
Cosmetic Procedures (PDF) CC.PP.024 01/01/2014
Distinct Procedure Modifiers Policy (PDF) CC.PP.020 01/01/2013
Duplicate Primary Code Billing (PDF) CC.PP.044 01/01/2014
E&M Bundling with Labs and Radiology (PDF) CC.PP.010 01/01/2013
EM Medical Decision Making (PDF) CC.PP.051 06/01/2017
External Ocular Photography (PDF) OC.UM.CP.0043 01/01/2017
Extended Ophthalmoscopy (PDF) OC.UM.CP.0026 01/01/2017
Fluorescein Angiography (PDF) OC.UM.CP.0028 01/01/2017
Fundus Photography (PDF) OC.UM.CP.0029 01/01/2017
Gonioscopy (PDF) OC.UM.CP.0031 10/01/2016
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 01/01/2016
Inpatient Consultation (PDF) CC.PP.038 01/01/2014
Inpatient Only Procedures Policy (PDF) CC.PP.018 01/01/2018
IV Hydration Policy (PDF) CC.PP.012 01/01/2013
Leveling Professional Fees for Emergency Room Services (PDF) GA.PP.053 10/02/2018
Max Units Payment Policy (PDF CC.PP.007 01/01/2013
Moderate Conscious Sedation (PDF) CC.PP.015 01/01/2013
Modifier DOS Validation (PDF) CC.PP.034 01/01/2015
Modifier to Procedure Code Validation (PDF) CC.PP.028 01/01/2013
Multiple CPT Code Replace (PDF) CC.PP.033 01/01/2013
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF) CC.PP.065 02/06/2020
NCCI Unbundling (PDF) CC.PP.031 01/01/2013
Never Paid Events (PDF) CC.PP.017 01/01/2013
New Patient (PDF) CC.PP.036 01/01/2014
Non-obstectrical Pelvic and Transvaginal Ultrasounds (PDF) CC.PP.061 06/01/2018
Not Medically Necessary Inpatient Service (PDF) CC.PP.060 06/01/2018
Outpatient Consultation (PDF) CC.PP.039 01/01/2014
Place of Service Mismatch (PDF) CC.PP.063 09/01/2018
Postoperative Visits (PDF) CC.PP.042 01/01/2014
Preoperative Visits (PDF) CC.PP.041 01/01/2014
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 11/01/2017
Professional Component Modifier (PDF) CC.PP.027 01/01/2013
Pulse Oximetry w Office Visits (PDF) CC.PP.025 01/01/2013
Reporting the Global Maternity Package (PDF) GA.PP.016 01/01/2013
Robotic Surgeries (PDF) CC.PP.050 08/01/2017
Same Day Visits (PDF) CC.PP.040 01/01/2014
Scan Comp Oph Diag Imaging OC.UM.CP.0014 01/01/2017
Sleep Studies POS (PDF) CC.PP.035 06/15/2017
Status B Bundled Services (PDF) CC.PP.046 01/01/2014
Status P Bundled Services (PDF) CC.PP.049 01/01/2014
Supplies Same Day as Surgery (PDF) CC.PP.032 01/01/2013
Transgender Related Services (PDF) CC.PP.047 01/01/2017
Ultrasound in Pregnancy (PDF) CP.MP.38 01/31/2011
Unbundled Professional Services (PDF) CC.PP.043 03/15/2017
Unbundled Surgical Procedures (PDF) CC.PP.045 03/15/2017
Unlisted Procedure Codes Policy OC.UM.CP.0014 01/01/2017
Visual Field Testing OC.UM.CP.0063 01/01/2017
Wheelchairs and Accessories (PDF) CC.PP.502 10/01/2015

 

POLICY TITLE POLICY NUMBER EFFECTIVE DATE
3 Day Payment Window (PDF) CC.PP.500 07/01/2014
30 Day Readmission (PDF) CC.PP.501 01/01/2015
Add On Policy (PDF) CC.PP.030 01/01/2013
Assistant Surgeon (PDF) CC.PP.029 01/01/2014
Bilateral Procedures (PDF) CC.PP.037 01/01/2014
Cerumen Removal Policy (PDF) CC.PP.008 01/01/2014
Clean Claims Policy (PDF) CC.PP.021 01/01/2013
Clinical Validation of Modifier 25 (PDF) CC.PP.013 01/01/2013
Clinical Validation of Modifier 59 (PDF) CC.PP.014 01/01/2013
Code Editing Overview (PDF) CC.PP.011 01/01/2013
Cosmetic Procedures (PDF) CC.PP.024 01/01/2014
Distinct Procedure Modifiers Policy (PDF) CC.PP.020 01/01/2013
Duplicate Primary Code Billing (PDF) CC.PP.044 01/01/2014
E&M Bundling with Labs and Radiology (PDF) CC.PP.010 01/01/2013
EM Medical Decision Making (PDF) CC.PP.051 06/01/2017
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 01/01/2016
Inpatient Consultation (PDF) CC.PP.038 01/01/2014
Inpatient Only Procedures Policy (PDF) CC.PP.018 01/01/2018
IV Hydration Policy (PDF) CC.PP.012 01/01/2013
Maximum Units (PDF) CC.PP.007 01/01/2013
Moderate Conscious Sedation (PDF) CC.PP.015 01/01/2013
Modifier DOS Validation (PDF) CC.PP.034 01/01/2015
Modifier to Procedure Code Validation (PDF) CC.PP.028 01/01/2013
Multiple CPT Code Replace (PDF) CC.PP.033 01/01/2013
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF) CC.PP.065 02/06/2020
NCCI Unbundling (PDF) CC.PP.031 01/01/2013
Never Paid Events (PDF) CC.PP.017 01/01/2013
New Patient (PDF) CC.PP.036 01/01/2014
Non-obstectrical Pelvic and Transvaginal Ultrasounds (PDF) CC.PP.061 06/01/2018
Not Medically Necessary Inpatient Service (PDF) CC.PP.060 06/01/2018
Outpatient Consultation (PDF) CC.PP.039 01/01/2014
Physician's Office Lab Testing (PDF) GA.PP.055 12/1/2019
Place of Service Mismatch (PDF) CC.PP.063 09/01/2018
Postoperative Visits (PDF) CC.PP.042 01/01/2014
Preoperative Visits (PDF) CC.PP.041 01/01/2014
Problem Oriented Visits with Preventative Services (PDF) CC.PP.057 10/01/2017
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 11/01/2017
Professional Component Modifier (PDF) CC.PP.027 01/01/2013
Pulse Oximetry w Office Visits (PDF) CC.PP.025 01/01/2013
Same Day Visits (PDF) CC.PP.040 01/01/2014
Sleep Studies POS (PDF) CC.PP.035 06/15/2017
Status B Bundled Services (PDF) CC.PP.046 01/01/2014
Status P Bundled Services (PDF) CC.PP.049 01/01/2014
Supplies Same Day as Surgery (PDF) CC.PP.032 01/01/2013
Transgender Related Services (PDF) CC.PP.047 01/01/2017
Ultrasound in Pregnancy (PDF) CP.MP.38 01/31/2011
Unbundled Professional Services (PDF) CC.PP.043 03/15/2017
Unbundled Surgical Procedures (PDF) CC.PP.045 03/15/2017
Unlisted Procedure Codes Policy CC.PP.009 01/01/2013
Urine Specimen Validity Testing (PDF) CC.PP.056 10/01/2017
Wheelchairs and Accessories (PDF) CC.PP.502 10/01/2015