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.

 

POLICY TITLE POLICY NUMBER EFFECTIVE DATE
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
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
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

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

Attachment (PDF)

GA.MP.11 11/17/2014
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 Tumor Treating Fields (PDF) CP.MP.145 05/31/2017
Electroencephalography in the Evaluation of Headache (PDF) CP.MP.155 12/29/2017
Emergency Air Ambulance Services (PDF) GA.MP.12 06/27/2012
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 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
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 (PDF) GA.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
Medical Necessity for Infant Apnea Monitors (PDF) GA.MP.06 11/18/2015
Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF) CP.MP.161 05/31/2018
Multiple Sleep Latency Testing (PDF) CP.MP.24 10/31/2008
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-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 Testing for Drugs of Abuse (PDF) CP.MP.50 09/30/2012
Pancreas Transplant (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
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.MP.05 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
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 Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF) CP.MP.165 08/31/2018
Sclerotherapy for Varicose Veins (PDF)   06/30/2017
Sickle Cell Disease Observation (PDF) CP.MP.88 09/30/2013
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
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
Wheelchair Seating (PDF) CP.MP.99 10/31/2015
Wireless Motility Capsule (PDF) CP.MP.143 04/30/2017
Zika Virus Testing (PDF) CP.MP.111 06/30/2016

 

POLICY TITLE POLICY NUMBER EFFECTIVE DATE
72 Hour Supply of Medication (PDF) GA.PHAR.07 06/01/2006
abatacept (Orencia) (PDF) CP.PHAR.241 08/01/2016
Abiraterone (Zytiga) (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
Ado-Trastuzumab Emtansine (Kadcyla) (PDF) CP.PHAR.229 06/01/2016
Aflibercept (Eylea®) (PDF) CP.PHAR.184 03/01/2016
Agalsidase Beta (Fabrazyme) (PDF) CP.PHAR.158 02/01/2016
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 08/01/2016
Alglucosidase Alfa (Lumizyme) (PDF) CP.PHAR.160 02/01/2016
Alirocumab (Praluent) (PDF) CP.PHAR.124 10/01/2015
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
Anakinra (Kineret) (PDF) CP.PHAR.244 08/01/2016
Apremilast (Otezla) (PDF) CP.PHAR.245 08/01/2016

Appropriate Use and Safety Edits (PDF)

Appropriate Use and Safety Edits: Attachment A (PDF)

GA.PMN.01 05/01/2012
asfotase alfa (Strensiq®) (PDF) CP.PHAR.328 03/01/2017
Axitinib (Inlyta®) (PDF) CP.PHAR.100 05/01/2012
belatacept (Nulojix®) (PDF) CP.PHAR.201 11/09/2017
Belimumab (Benlysta) (PDF) CP.PHAR.88 10/01/2011
Bendamustine (Bendeka®, Treanda®) (PDF) CP.PHAR.307 06/01/2010
Bexarotene (Targretin) (PDF) CP.PHAR.75 09/01/2011
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
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
Buprenorphine implant (Probuphine) (PDF) CP.PHAR.289 11/16/2016
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (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
capecitabine (Xeloda) (PDF) CP.PHAR.60 05/01/2011
carfilzomib (Kyprolis®) (PDF) CP.PHAR.309 02/01/2017
Carglumic acid (Carbaglu®) (PDF) CP.PHAR.206 05/01/2016
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
Cinacalcet (Sensipar) (PDF) CP.PHAR.61 05/01/2011
Collagenase (Xiaflex) (PDF) CP.PHAR.82 10/01/2011
Crizotinib (Xalkori) (PDF) CP.PHAR.90 11/01/2011
Dalteparin (Fragmin) (PDF) CP.PHAR.225 05/01/2016
Daratumumab (Darzalex) (PDF) CP.PHAR.310 07/01/2017
Dasatinib (Sprycel) (PDF) CP.PHAR.72 06/01/2012
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
Degarelix acetate (Firmagon®) (PDF) CP.PHAR.170 11/09/2017
Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF) CP.PHAR.214 05/01/2016
Dornase alfa (Pulmozyme) (PDF) CP.PHAR.212 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
Dupilumab (Dupixent) (PDF) CP.PHAR.336 05/01/2017
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 07/01/2017
Eculizumab (Soliris®) (PDF) CP.PHAR.97 03/01/2012
Elosulfase Alfa (Vimizim) (PDF) CP.PHAR.162 02/01/2016
Eltrombopag (Promacta®) (PDF) CP.PHAR.180 03/01/2016
Enfuvirtide (Fuzeon) (PDF) CP.PHAR.41 06/01/2010
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
Eribulin Mesylate (Halaven®) (PDF) CP.PHAR.318 03/01/2017
Erlotinib (Tarceva) (PDF) CP.PHAR.74 09/01/2011
Etanercept (Enbrel) (PDF) CP.PHAR.250 08/01/2016
Eteplirsen (PDF) CP.PHAR.288 12/01/2016
Evolocumab (Repatha) (PDF) CP.PHAR.123 10/01/2015
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
Galsulfase (Naglazyme) (PDF) CP.PHAR.161 02/01/2016
Glatiramer (Copaxone, Glatopa) (PDF) CP.PHAR.252 08/01/2016
Golimumab (Simponi, Simponi Aria) (PDF) CP.PHAR.253 07/01/2016
histrelin acetate (Vantas®, Supprelin LA®) (PDF) CP.PHAR.172 11/09/2017
Hydroxyprogesterone Caproate (Makena®) (PDF) CP.PHAR.14 11/20/2017
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
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
Infliximab (Remicade, Inflectra, Renflexis) (PDF) CP.PHAR.254 07/01/2016
Interferon Gamma- 1b (Actimmune) (PDF) CP.PHAR.52 06/01/2010
Intrathecal Baclofen (Gablofen, Lioresal) (PDF) CP.PHAR.149 11/09/2017
Ipilimumab (Yervoy) (PDF) CP.PHAR.319 04/17/2018
irinotecan Liposome (Onivyde®) (PDF) CP.PHAR.304 02/01/2017
Ivacaftor (Kalydeco) (PDF) CP.PHAR.210 05/01/2016
Ixazomib (Ninlaro) (PDF) CP.PHAR.302 02/01/2017
lapatinib (Tykerb®) (PDF) CP.PHAR.79 11/09/2017
Lenalidomide (Revlimid) (PDF) CP.PHAR.71 07/01/2011
Levoleucovorin (Fusilev®) (PDF) CP.PHAR.151 11/09/2017
Lost, Stolen, Spilled or Broken Medications (PDF) GA.PHAR.10 04/01/2007
Lumacaftor-Ivacaftor (Orkambi) (PDF) CP.PHAR.213 05/01/2016
Mecasermin (Increlex) (PDF) CP.PHAR.150 03/01/2011
Medication Safety Policy (PDF) GA.PMN.22 07/01/2017
Mepolizumab (Nucala) (PDF) CP.PHAR.200 04/01/2016
Miglustat (Zavesca) (PDF) CP.PHAR.164 02/01/2016
nafarelin acetate (Synarel®) (PDF) CP.PHAR.174 11/09/2017
Necitumumab (Portrazza®) (PDF) CP.PHAR.320 03/01/2017
nilotinib (Tasigna) (PDF) CP.PHAR.76 09/01/2011 
Nivolumab (Opdivo) (PDF) CP.PHAR.121 07/01/2015
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
Octreotide (Sandostatin, Sandostatin LAR) (PDF) CP.PHAR.40 03/01/2010
olaratumab (Lartruvo®) (PDF) CP.PHAR.326 03/01/2017
Omacetaxine (Synribo) (PDF) CP.PHAR.108 04/01/2013
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 07/01/2016
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
Paricalcitol Injection (Zemplar) (PDF) CP.PHAR.270 08/01/2016
Pasireotide (Signifor LAR®) (PDF) CP.PHAR.332 03/01/2017
Pazopanib (Votrient) (PDF) CP.PHAR.81 10/01/2011
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
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
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
Plerixafor (Mozobil) (PDF) CP.PHAR.323 03/01/2017
Pomalidomide (Pomalyst) (PDF) CP.PHAR.116 07/01/2013
Ponatinib (Iclusig) (PDF) CP.PHAR.112 06/01/2013
Pralatrexate (Folotyn®) (PDF) CP.PHAR.313 02/01/2017
Progesterone (Crinone, Endometrin) (PDF) CP.CPA.03 11/16/2016
Regorafenib (Stivarga) (PDF) CP.PHAR.107 12/01/2012
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) CP.PHAR.168 03/01/2016
Reslizumab (Cinqair) (PDF) CP.PHAR.223 05/01/2016
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 07/01/2016
Riociguat (Adempas®) (PDF) CP.PHAR.195 03/01/2016
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
romidepsin (Istodax®) (PDF) CP.PHAR.314 01/01/2017
Sargramostim (Leukine) (PDF) CP.PHAR.295 12/01/2016
Sebelipase Alfa (Kanuma) (PDF) CP.PHAR.159 02/01/2016
Sildenafil (Revatio®) (PDF) CP.PHAR.197 03/01/2016
Sipuleucel-T (Provenge) (PDF) CP.PHAR.120 06/01/2015
sodium oxybate (Xyrem) (PDF) CP.PMN.42 05/01/2011
Somatropin (Growth Hormone) (PDF) CP.PHAR.55 03/01/2011
Somatropin (HGH) (PDF) CP.CPA.84 11/16/2016
sorafenib (Nexavar) (PDF) CP.PHAR.69 07/01/2011
Step Therapy (PDF) HIM.PA.109 08/01/2017
sunitinib (Sutent) (PDF) CP.PHAR.73 09/01/2011
Tadalafil (Adcirca®) (PDF) CP.PHAR.198 03/01/2016
Taliglucerase Alfa (Elelyso) (PDF) CP.PHAR.157 02/01/2016
Tedizolid (Sivextro) (PDF) CP.PMN.62 03/01/2015
Teduglutide (Gattex) (PDF) CP.PHAR.114 05/01/2013
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
Teriparatide (Forteo®) (PDF) CP.PHAR.188 11/15/2017
Tesamorelin (Egrifta) (PDF) CP.PHAR.109 03/01/2014
tetrabenazine (Xenazine) (PDF) CP.PHAR.92 12/01/2011
Thalidomide (Thalomid) (PDF) CP.PHAR.78 09/01/2011
Thyrotropin Alfa (Thyrogen) (PDF)  CP.PHAR.95 03/01/2012
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
Topotecan (Hycamtin)(PDF) CP.PHAR.64 06/01/2011
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) CP.PHAR.228 06/01/2016
triptorelin pamoate (Trelstar®, Triptodur®) (PDF) CP.PHAR.175 11/09/2017
Ustekinumab (Stelara) (PDF) CP.PHAR.264 08/01/2016
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
Vigabatrin (Sabril) (PDF) CP.PHAR.169 02/01/2016
vincristine sulfate liposome injection (Marqibo®) (PDF) CP.PHAR.315 02/01/2017
Vorinostat (Zolinza) (PDF) CP.PHAR.83 12/01/2012
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
abatacept (Orencia) (PDF) CP.PHAR.241 08/01/2016
Abiraterone (Zytiga) (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
Aflibercept (Eylea®) (PDF) CP.PHAR.184 03/01/2016
Agalsidase Beta (Fabrazyme) (PDF) CP.PHAR.158 02/01/2016
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 08/01/2016
Alglucosidase Alfa (Lumizyme) (PDF) CP.PHAR.160 02/01/2016
Alirocumab (Praluent) (PDF) CP.PHAR.124 10/01/2015
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
Anakinra (Kineret) (PDF) CP.PHAR.244 08/01/2016

Appropriate Use and Safety Edits (PDF)

Appropriate Use and Safety Edits: Attachment A (PDF)

GA.PMN.01 05/01/2012
Approval of Brand Name Override (PDF) GA.PHAR.09 04/01/2007
Apremilast (Otezla) (PDF) CP.PHAR.245 08/01/2016
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF) CP.PHAR.290 12/01/2016
asfotase alfa (Strensiq®) (PDF) CP.PHAR.328 03/01/2017
atezolizumab (Tecentrip®) (PDF) CP.PHAR.235 06/01/2016
Axitinib (Inlyta®) (PDF) CP.PHAR.100 05/01/2012
Aztreonam (Cayston®) (PDF) CP.PHAR.209 05/01/2016
belatacept (Nulojix®) (PDF) CP.PHAR.201 11/09/2017
Belimumab (Benlysta) (PDF) CP.PHAR.88 10/01/2011
Bendamustine (Bendeka®, Treanda®) (PDF) CP.PHAR.307 02/01/2017
Benznidazole (PDF) CP.PMN.90 10/17/2017
Bexarotene (Targretin) (PDF) CP.PHAR.75 09/01/2011
Bezlotoxumab (Zinplava) (PDF) CP.PHAR.300 11/16/2016
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
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
Buprenorphine implant (Probuphine) (PDF) CP.PHAR.289 11/16/2016
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (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
capecitabine (Xeloda) (PDF) CP.PHAR.60 05/01/2011
carfilzomib (Kyprolis®) (PDF) CP.PHAR.309 02/01/2017
Carglumic acid (Carbaglu®) (PDF) CP.PHAR.206 05/01/2016
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
Cinacalcet (Sensipar) (PDF) CP.PHAR.61 05/01/2011
Collagenase (Xiaflex) (PDF) CP.PHAR.82 10/01/2011
Cosyntropin (Cortrosyn®) (PDF) CP.PHAR.203 04/01/2016
Crizotinib (Xalkori) (PDF) CP.PHAR.90 11/01/2011
Cysteamine oral (Cystagon, Procysbi) (PDF) CP.PHAR.155 02/01/2016
Daclatasvir (Daklinza) (PDF) GA.PMN.15 12/01/2016
Daclizumab (Zinbryta) (PDF) CP.PHAR.269 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
Dasabuvir Ombitasvir Paritaprevir Ritonavir (Viekira XR, Viekira Pak) (PDF) GA.PMN.12 12/01/2016
Dasatinib (Sprycel) (PDF) CP.PHAR.72 06/01/2012
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
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
Dornase alfa (Pulmozyme) (PDF) CP.PHAR.212 05/01/2016
Dose Escalation of Biologics (PDF) GA.PMN.21 09/01/2017
droxidopa (Northera®) (PDF) CP.PMN.17 11/09/2017
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
Eculizumab (Soliris®) (PDF) CP.PHAR.97 03/01/2012
Elbasvir Grazoprevir (Zepatier) (PDF) GA.PMN.16 12/01/2016
Elosulfase Alfa (Vimizim) (PDF) CP.PHAR.162 02/01/2016
Eltrombopag (Promacta®) (PDF) CP.PHAR.180 03/01/2016
Enfuvirtide (Fuzeon) (PDF) CP.PHAR.41 06/01/2010
Enoxaparin (Lovenox) (PDF) CP.PHAR.224 05/01/2016
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
Eribulin Mesylate (Halaven®) (PDF) CP.PHAR.318 03/01/2017
Erlotinib (Tarceva) (PDF) CP.PHAR.74 09/01/2011
Erwina asparaginase (Erwinaze®) (PDF) CP.PHAR.301 02/01/2017
Etanercept (Enbrel) (PDF) CP.PHAR.250 08/01/2016
Eteplirsen (PDF) CP.PHAR.288 12/01/2016
Evolocumab (Repatha) (PDF) CP.PHAR.123 10/01/2015
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 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
ferric carboxymaltose (Injectafer®) (PDF) CP.PHAR.234 06/01/2016
Ferric gluconate (Ferrlecit®) (PDF) CP.PHAR.166 03/01/2016
Ferumoxytol (Feraheme®) (PDF) CP.PHAR.165 03/01/2016
Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF) CP.PHAR.297 12/01/2016
Fingolimod (Gilenya) (PDF) CP.PHAR.251 08/01/2016
Galsulfase (Naglazyme) (PDF) CP.PHAR.161 02/01/2016
Glatiramer (Copaxone, Glatopa) (PDF) CP.PHAR.252 08/01/2016
Glecaprevir/Pibrentasvir (Mavyret) (PDF) GA.PMN.24 09/01/2017
Golimumab (Simponi, Simponi Aria) (PDF) CP.PHAR.253 07/01/2016
goserelin acetate (Zoladex®) (PDF) CP.PHAR.171 11/09/2017
Hemin (Panhematin®) (PDF) CP.PHAR.181 02/01/2016
histrelin acetate (Vantas®, Supprelin LA®) (PDF) CP.PHAR.172 11/09/2017
Hydroxyprogesterone Caproate (Makena®) (PDF) CP.PHAR.14 11/20/2017
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
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
Infliximab (Remicade, Inflectra, Renflexis) (PDF) CP.PHAR.254 07/01/2016
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
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
Ivacaftor (Kalydeco) (PDF) CP.PHAR.210 05/01/2016
Ixazomib (Ninlaro) (PDF) CP.PHAR.302 02/01/2017
Ixekizumab (Taltz) (PDF) CP.PHAR.257 08/01/2016
lapatinib (Tykerb®) (PDF) CP.PHAR.79 11/09/2017
Ledipasvir Sofosbuvir (Harvoni) (PDF) GA.PMN.13 12/01/2016
Lenalidomide (Revlimid) (PDF) CP.PHAR.71 07/01/2011
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) CP.PHAR.173 11/09/2017
Levoleucovorin (Fusilev®) (PDF) CP.PHAR.151 11/09/2017
Levofloxacin (Levaquin) in Pediatric Community Acquired Pneumonia (PDF) GA.PMN.05 03/01/2016
Lomitapide (Juxtapid) (PDF) CP.PHAR.283 10/01/2016
Lost, Stolen, Spilled or Broken Medications (PDF) GA.PHAR.10 04/01/20117
Lumacaftor-Ivacaftor (Orkambi) (PDF) CP.PHAR.213 05/01/2016
Mecasermin (Increlex) (PDF) CP.PHAR.150 03/01/2011
Medication Safety Policy (PDF) GA.PMN.22 07/01/2017
Mepolizumab (Nucala) (PDF) CP.PHAR.200 04/01/2016
Mifepristone (Korlym) (PDF) CP.PHAR.101 05/01/2012
Miglustat (Zavesca) (PDF) CP.PHAR.164 02/01/2016
Mipomersen (Kynamro) (PDF) CP.PHAR.284 10/01/2016
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 08/01/2016
nafarelin acetate (Synarel®) (PDF) CP.PHAR.174 11/09/2017
Naltrexone (Vivitrol®) (PDF) CP.PHAR.96 03/01/2012
Natalizumab (Tysabri) (PDF) CP.PHAR.259 07/01/2016
Necitumumab (Portrazza®) (PDF) CP.PHAR.320 03/01/2017
nilotinib (Tasigna) (PDF) CP.PHAR.76 09/01/2011
Nivolumab (Opdivo) (PDF) CP.PHAR.121 07/01/2015
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
Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) CP.PHAR.292 12/01/2016
olaratumab (Lartruvo®) (PDF) CP.PHAR.326 03/01/2017
Omacetaxine (Synribo) (PDF) CP.PHAR.108 04/01/2013
Ombitasvir Paritaprevir Ritonavir (Technivie) (PDF) GA.PMN.14 12/01/2016
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 07/01/2016
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
Paricalcitol Injection (Zemplar) (PDF) CP.PHAR.270 08/01/2016
Pasireotide (Signifor LAR®) (PDF) CP.PHAR.332 03/01/2017
Pazopanib (Votrient) (PDF) CP.PHAR.81 10/01/2011

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

Attachment A (PDF)

GA.PHAR.11 04/01/2007
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
Pegaptanib (Macugen®) (PDF) CP.PHAR.185 03/01/2016
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
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
Pharmaceutical Management (PDF) GA.PHAR.03 02/01/2003
Pharmacy and Therapeutics Committee (PDF) GA.PHAR.17 08/09/2011

Pharmacy Lock-In Program (PDF)

Lock-In Letter (PDF)

Lock-In Release Letter (PDF)

GA.PHAR.06 07/01/2006
Pharmacy Prior Authorization and Medical Necessity Criteria (PDF) GA.PHAR.16 07/09/2010
Plerixafor (Mozobil) (PDF) CP.PHAR.323 03/01/2017
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
Protein c concentrate, human (Ceprotin®) (PDF) CP.PHAR.330 03/01/2017
Psychotropic Medication Continuity of Care (COC) (PDF) GA.PMN.10 12/01/2016
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
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) CP.PHAR.168 03/01/2016
Reslizumab (Cinqair) (PDF) CP.PHAR.223 05/01/2016
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.223 07/01/2016
Riociguat (Adempas®) (PDF) CP.PHAR.195 03/01/2016
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
romidepsin (Istodax®) (PDF) CP.PHAR.314 01/01/2017
Sapropterin Dihydrochloride (Kuvan®) (PDF) CP.PHAR.43 02/01/2010
Sargramostim (Leukine) (PDF) CP.PHAR.295 12/01/2016
Sebelipase Alfa (Kanuma) (PDF) CP.PHAR.159 02/01/2016
Sildenafil (Revatio®) (PDF) CP.PHAR.197 03/01/2016
siltuximab (Sylvant®) (PDF) CP.PHAR.329 03/01/2017
Simpeprevir (Olysio) (PDF) GA.PMN.18 12/01/2016
Sipuleucel-T (Provenge) (PDF) CP.PHAR.120 06/01/2015
sodium oxybate (Xyrem) (PDF) CP.PMN.42 05/01/2011
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
Somatropin (Growth Hormone) (PDF) CP.PHAR.55 03/01/2011
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
sunitinib (Sutent) (PDF) CP.PHAR.73 09/01/2011
Tadalafil (Adcirca®) (PDF) CP.PHAR.198 03/01/2016
Taliglucerase Alfa (Elelyso) (PDF) CP.PHAR.157 02/01/2016
Tedizolid (Sivextro) (PDF) CP.PMN.62 03/01/2015
Teduglutide (Gattex) (PDF) CP.PHAR.114 05/01/2013
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
Teriparatide (Forteo®) (PDF) CP.PHAR.188 11/15/2017
Tesamorelin (Egrifta) (PDF) CP.PHAR.109 03/01/2014
tetrabenazine (Xenazine) (PDF) CP.PHAR.92 12/01/2011
Thalidomide (Thalomid) (PDF) CP.PHAR.78 09/01/2011
Thyrotropin Alfa (Thyrogen) (PDF)  CP.PHAR.95 03/01/2012
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
Topical Tretinoin in Adult Acne Vulgaris (PDF) GA.PMN.06 03/01/2016
Topotecan (Hycamtin)(PDF) CP.PHAR.64 06/01/2011
Trabectedin (Yondelis®) (PDF) CP.PHAR.204 05/01/2016
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) CP.PHAR.228 06/01/2016
triptorelin pamoate (Trelstar®, Triptodur®) (PDF) CP.PHAR.175 11/09/2017
Ustekinumab (Stelara) (PDF) CP.PHAR.264 08/01/2016
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
Vigabatrin (Sabril) (PDF) CP.PHAR.169 02/01/2016
vincristine sulfate liposome injection (Marqibo®) (PDF) CP.PHAR.315 02/01/2017
Vorinostat (Zolinza) (PDF) CP.PHAR.83 12/01/2012
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
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 Visit Codes Billed with Labs (PDF) CC.PP.055 01/01/2013
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 10/01/2017
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.CP.053 11/05/2018
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
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 Visit Codes Billed with Labs (PDF) CC.PP.055 01/01/2013
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 10/01/2017
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 Laboratory Improvement Amendments (CLIA) (PDF) CC.PP.022 01/01/2016
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
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 Visit Codes Billed with Labs (PDF) CC.PP.055 01/01/2013
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 10/01/2017
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