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Políticas clínicas y de pago
Clinical Policies
Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information.
All policies found in the Coordinated Care Clinical Policy Manual apply to Coordinated Care members. Policies in the Coordinated Care Clinical Policy Manual may have either a Coordinated Care or a “Centene” heading. Coordinated Care utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Coordinated Care clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Coordinated Care. In addition, Coordinated Care may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or InterQual®criteria is payable by Coordinated Care.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Ambetter Clinical Policies Listing
- ABA Therapy (PDF) (CP.BH.104)
- Acupuncture (PDF) (CP.MP.92)
- ADHD Assessment and Treatment (PDF) (CP.MP.124)
- Air Ambulance (PDF) (CP.MP.175)
- Allergy Testing (PDF) (CP.MP.100) Effective Through 2/28/21
- Allergy Testing and Therapy (PDF) (CP.MP.100) Revision Effective 3/1/21
- Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF) (CP.MP.108)
- Ambulatory EEG (PDF) (CP.MP.96)
- Antithrombin III (PDF) (CP.MP.179)
- Applied Behavioral Analysis (PDF) (CP.MP.104)
- Balloon sinus ostial dilation (PDF) (CP.MP.119)
- Biofeedback (PDF) (CP.MP.168)
- Bone-anchored Hearing Aid (PDF) (CP.MP.93)
- Bronchial Thermoplasty (PDF) (CP.MP.110)
- Burn Surgery (PDF) (CP.MP.186)
- Cardiac Biomarker Testing for Acute MI (PDF) (CP.MP.156)
- Carrier Screening in Pregnancy (PDF) (CP.MP.83)
- Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF)(CP.MP.164)
- Cell-free Fetal DNA Testing (PDF) (CP.MP.84)
- Clinical Trials (PDF) (CP.MP.94)
- Cochlear Implant Replacement (PDF) (CP.MP.14)
- Cosmetic and Reconstructive Surgery (PDF) (CP.MP.31)
- Dental Anesthesia (PDF) (CP.MP.61)
- Diagnostic Testing Guidelines for 2019-Novel Coronavirus (PDF) (CP.MP.183)
- Digital Analysis of EEG (PDF) (CP.MP.105)
- Discography (PDF) (CP.MP.115)
- DNA analysis of stool to screen for colorectal cancer (PDF) (CP.MP.125)
- Donor lymphocyte infusion (PDF) (CP.MP.101)
- Durable Medical Equipment (DME) (PDF) (CP.MP.107)
- Electric Tumor Treating Fields (PDF) (CP.MP.145)
- Electroencephalography in the evaluation of headache (PDF) (CP.MP.155)
- Endometrial ablation (PDF) (CP.MP.106)
- Essure Removal (PDF) (CP.MP.131)
- Evoked Potential Testing (PDF) (CP.MP.134)
- Experimental Technologies (PDF) (CP.MP.36)
- Facet Joint Intervention for Pain Management (PDF) (CP.MP.171)
- Fecal incontinence treatments (PDF) (CP.MP.137)
- Fetal surgery in utero for prenatally diagnosed malformations (PDF) (CP.MP.129)
- Fractional exhaled nitric oxide (PDF) (CP.MP.103)
- Gender-Affirming Procedures (PDF) (CP.MP.95)
- Genetic Testing (PDF) (CP.MP.89)
- H. Pylori serology testing (PDF) (CP.MP.153)
- Heart-Lung Transplant (PDF) (CP.MP.132)
- Holter Monitors (PDF) (CP.MP.113)
- Home Birth (PDF) (CP.MP.136)
- Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) (CP.MP.150)
- Home Ventilators (PDF) (CP.MP.184)
- Homocysteine testing (PDF) (CP.MP.121) Effective through 9/30/20
- Hospice Services (PDF) (CP.MP.54)
- Hyperemesis Gravidarum Treatment (PDF) (CP.MP.34)
- Hyperhidrosis Treatments (PDF) (CP.MP.62)
- Implantable Hypoglossal Nerve Stimulation (PDF) (CP.MP.180)
- Implantable Intrathecal Pain Pump (PDF) (CP.MP.173)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) (CP.MP.160)
- Inhaled Nitric Oxide (PDF) (CP.MP.87)
- Intensity-Modulated Radiotherapy (PDF) (CP.MP.69)
- Intestinal and Multivisceral Transplant (PDF) (CP.MP.58)
- Intradiscal Steroid Injections for Pain Management (PDF) (CP.MP.167)
- Laser therapy for skin conditions (PDF) (CP.MP.123)
- Low-frequency ultrasound therapy for wound management (PDF) (CP.MP.139) Effective through 1/31/21
- Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (CP.MP.139) Revision Effective 2/1/21
- Lung Transplantation (PDF) (CP.MP.57)
- Lysis of Epidural Lesions (PDF) (CP.MP.116)
- Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) (CP.MP.144)
- Medical Necessity Review (PDF) (WA.UM.02.01)
- Multiple Sleep Latency Testing (PDF) (CP.MP.24)
- Neonatal Abstinence Syndrome Guidelines (PDF) (CP.MP.86)
- Neonatal Sepsis Management Guidelines (PDF) (CP.MP.85)
- Nerve Blocks for Pain Management (PDF) (CP.MP.170)
- NICU Apnea Bradycardia Guidelines (PDF) (CP.MP.82)
- NICU Discharge Guidelines (PDF) (CP.MP.81)
- Non-invasive Home Ventilators (PDF) (CP.MP.184)
- Nonmyeloablative allogeneic SCT (PDF) (CP.MP.141)
- Obstetrical Home Health Care Programs (PDF) (CP.MP.91)
- Optic nerve decompression surgery (PDF) (CP.MP.128)
- Outpatient Cardiac Rehabilitation (PDF) (CP.MP.176)
- Outpatient Testing for Drugs of Abuse (PDF) (CP.MP.50)
- Oxygen Use and Concentrators (PDF) (CP.MP.190) Revision Effective 3/1/21
- Pancreas Transplant (PDF) (CP.MP.102)
- Panniculectomy (PDF) (CP.MP.109)
- Pediatric Heart Transplant (PDF) (CP.MP.138)
- Pediatric Liver Transplant (PDF) (CP.MP.120)
- Pediatric Oral Function Therapy (PDF) (CP.MP.188)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) (CP.MP.147)
- PT, OT, ST Services (PDF) (CP.MP.49) Effective through 03/31/21
- Physical, Occupational and Speech Therapy Services (PDF) (CP.MP.49) Revision Effective 04/01/2021
- Posterior tibial nerve stimulation for voiding dysfunction (PDF) (CP.MP.133)
- Proton and Neutron Beam Therapy (PDF) (CP.MP.70)
- Radiofrequency Ablation of Uterine Fibroids (PDF) (CP.MP.187)
- Reduction Mammoplasty and Gynecomastia Surgery (PDF) (CP.MP.51)
- Sacroiliac Joint Interventions for Pain Management (PDF) (CP.MP.166)
- Sclerotherapy for Varicose Veins (PDF) (CP.MP.146)
- Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF) (CP.MP.165)
- Short Inpatient Hospital Stay (PDF) (CP.MP.182)
- Sickle Cell Observation (PDF) (CP.MP.88)
- Skin Substitutes for Chronic Wounds (PDF) (CP.MP.185)
- Stereotactic Body Radiation Therapy (PDF) (CP.MP.22)
- Tandem Transplant (PDF) (CP.MP.162)
- Testing for rupture of fetal membranes (PDF) (CP.MP.149)
- Thymus Transplantation (PDF) (CP.MP.189)
- Thyroid hormones and insulin testing in pediatrics (PDF) (CP.MP.154)
- Total artificial heart (PDF) (CP.MP.127)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) (CP.MP.163)
- Transcatheter Closure of Patent Foramen Ovale (PDF) (CP.MP.151)
- Transcranial Magnetic Stimulation (PDF) (CP.BH.200)
- Trigger Point Injections for Pain Management (PDF) (CP.MP.169) Effective Through 12/31/20
- Trigger Point Injections for Pain Management (PDF) (CP.MP.169) Revision Effective 1/1/21
- Ultrasound in Pregnancy (PDF) (CP.MP.38)
- Urinary Incontinence Devices and Treatments (PDF) (CP.MP.142)
- Urodynamic testing (PDF) (CP.MP.98)
- Vagus Nerve Stimulation (PDF) (CP.MP.12)
- Ventricular Assist Devices (PDF) (CP.MP.46)
- Ventriculectomy and Cardiomyoplasty (PDF) (CP.MP.56)
- Video Electroencephalography (V-EEG) (PDF) (WA.CP.MP.177)
- Vitamin D Testing (PDF) (CP.MP.152)
- Vitamin D Testing in Children (PDF) (CP.MP.157)
- Wheelchair seating (PDF) (CP.MP.99)
- Wireless Motility Capsule (PDF) (CP.MP.143)
Ambetter Clinical Policies Listing
- ABA Therapy (PDF) (CP.BH.104)
- Acupuncture (PDF) (CP.MP.92)
- ADHD Assessment and Treatment (PDF) (CP.MP.124)
- Air Ambulance (PDF) (CP.MP.175)
- Allergy Testing (PDF) (CP.MP.100) Effective Through 2/28/21
- Allergy Testing and Therapy (PDF) (CP.MP.100) Revision Effective 3/1/21
- Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF) (CP.MP.108)
- Ambulatory EEG (PDF) (CP.MP.96)
- Antithrombin III (PDF) (CP.MP.179)
- Applied Behavioral Analysis (PDF) (CP.MP.104)
- Balloon sinus ostial dilation (PDF) (CP.MP.119)
- Biofeedback (PDF) (CP.MP.168)
- Bone-anchored Hearing Aid (PDF) (CP.MP.93)
- Bronchial Thermoplasty (PDF) (CP.MP.110)
- Burn Surgery (PDF) (CP.MP.186)
- Cardiac Biomarker Testing for Acute MI (PDF) (CP.MP.156)
- Carrier Screening in Pregnancy (PDF) (CP.MP.83)
- Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF)(CP.MP.164)
- Cell-free Fetal DNA Testing (PDF) (CP.MP.84)
- Clinical Trials (PDF) (CP.MP.94)
- Cochlear Implant Replacement (PDF) (CP.MP.14)
- Cosmetic and Reconstructive Surgery (PDF) (CP.MP.31)
- Dental Anesthesia (PDF) (CP.MP.61)
- Diagnostic Testing Guidelines for 2019-Novel Coronavirus (PDF) (CP.MP.183)
- Digital Analysis of EEG (PDF) (CP.MP.105)
- Discography (PDF) (CP.MP.115)
- DNA analysis of stool to screen for colorectal cancer (PDF) (CP.MP.125)
- Donor lymphocyte infusion (PDF) (CP.MP.101)
- Durable Medical Equipment (DME) (PDF) (CP.MP.107)
- Electric Tumor Treating Fields (PDF) (CP.MP.145)
- Electroencephalography in the evaluation of headache (PDF) (CP.MP.155)
- Endometrial ablation (PDF) (CP.MP.106)
- Essure Removal (PDF) (CP.MP.131)
- Evoked Potential Testing (PDF) (CP.MP.134)
- Experimental Technologies (PDF) (CP.MP.36)
- Facet Joint Intervention for Pain Management (PDF) (CP.MP.171)
- Fecal incontinence treatments (PDF) (CP.MP.137)
- Fetal surgery in utero for prenatally diagnosed malformations (PDF) (CP.MP.129)
- Fractional exhaled nitric oxide (PDF) (CP.MP.103)
- Gender-Affirming Procedures (PDF) (CP.MP.95)
- Genetic Testing (PDF) (CP.MP.89)
- H. Pylori serology testing (PDF) (CP.MP.153)
- Heart-Lung Transplant (PDF) (CP.MP.132)
- Holter Monitors (PDF) (CP.MP.113)
- Home Birth (PDF) (CP.MP.136)
- Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) (CP.MP.150)
- Home Ventilators (PDF) (CP.MP.184)
- Homocysteine testing (PDF) (CP.MP.121) Effective through 9/30/20
- Hospice Services (PDF) (CP.MP.54)
- Hyperemesis Gravidarum Treatment (PDF) (CP.MP.34)
- Hyperhidrosis Treatments (PDF) (CP.MP.62)
- Implantable Hypoglossal Nerve Stimulation (PDF) (CP.MP.180)
- Implantable Intrathecal Pain Pump (PDF) (CP.MP.173)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) (CP.MP.160)
- Inhaled Nitric Oxide (PDF) (CP.MP.87)
- Intensity-Modulated Radiotherapy (PDF) (CP.MP.69)
- Intestinal and Multivisceral Transplant (PDF) (CP.MP.58)
- Intradiscal Steroid Injections for Pain Management (PDF) (CP.MP.167)
- Laser therapy for skin conditions (PDF) (CP.MP.123)
- Low-frequency ultrasound therapy for wound management (PDF) (CP.MP.139) Effective through 1/31/21
- Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (CP.MP.139) Revision Effective 2/1/21
- Lung Transplantation (PDF) (CP.MP.57)
- Lysis of Epidural Lesions (PDF) (CP.MP.116)
- Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) (CP.MP.144)
- Medical Necessity Review (PDF) (WA.UM.02.01)
- Multiple Sleep Latency Testing (PDF) (CP.MP.24)
- Neonatal Abstinence Syndrome Guidelines (PDF) (CP.MP.86)
- Neonatal Sepsis Management Guidelines (PDF) (CP.MP.85)
- Nerve Blocks for Pain Management (PDF) (CP.MP.170)
- NICU Apnea Bradycardia Guidelines (PDF) (CP.MP.82)
- NICU Discharge Guidelines (PDF) (CP.MP.81)
- Non-invasive Home Ventilators (PDF) (CP.MP.184)
- Nonmyeloablative allogeneic SCT (PDF) (CP.MP.141)
- Obstetrical Home Health Care Programs (PDF) (CP.MP.91)
- Optic nerve decompression surgery (PDF) (CP.MP.128)
- Outpatient Cardiac Rehabilitation (PDF) (CP.MP.176)
- Outpatient Testing for Drugs of Abuse (PDF) (CP.MP.50)
- Oxygen Use and Concentrators (PDF) (CP.MP.190) Revision Effective 3/1/21
- Pancreas Transplant (PDF) (CP.MP.102)
- Panniculectomy (PDF) (CP.MP.109)
- Pediatric Heart Transplant (PDF) (CP.MP.138)
- Pediatric Liver Transplant (PDF) (CP.MP.120)
- Pediatric Oral Function Therapy (PDF) (CP.MP.188)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) (CP.MP.147)
- PT, OT, ST Services (PDF) (CP.MP.49) Effective through 03/31/21
- Physical, Occupational and Speech Therapy Services (PDF) (CP.MP.49) Revision Effective 04/01/2021
- Posterior tibial nerve stimulation for voiding dysfunction (PDF) (CP.MP.133)
- Proton and Neutron Beam Therapy (PDF) (CP.MP.70)
- Radiofrequency Ablation of Uterine Fibroids (PDF) (CP.MP.187)
- Reduction Mammoplasty and Gynecomastia Surgery (PDF) (CP.MP.51)
- Sacroiliac Joint Interventions for Pain Management (PDF) (CP.MP.166)
- Sclerotherapy for Varicose Veins (PDF) (CP.MP.146)
- Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF) (CP.MP.165)
- Short Inpatient Hospital Stay (PDF) (CP.MP.182)
- Sickle Cell Observation (PDF) (CP.MP.88)
- Skin Substitutes for Chronic Wounds (PDF) (CP.MP.185)
- Stereotactic Body Radiation Therapy (PDF) (CP.MP.22)
- Tandem Transplant (PDF) (CP.MP.162)
- Testing for rupture of fetal membranes (PDF) (CP.MP.149)
- Thymus Transplantation (PDF) (CP.MP.189)
- Thyroid hormones and insulin testing in pediatrics (PDF) (CP.MP.154)
- Total artificial heart (PDF) (CP.MP.127)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) (CP.MP.163)
- Transcatheter Closure of Patent Foramen Ovale (PDF) (CP.MP.151)
- Transcranial Magnetic Stimulation (PDF) (CP.BH.200)
- Trigger Point Injections for Pain Management (PDF) (CP.MP.169) Effective Through 12/31/20
- Trigger Point Injections for Pain Management (PDF) (CP.MP.169) Revision Effective 1/1/21
- Ultrasound in Pregnancy (PDF) (CP.MP.38)
- Urinary Incontinence Devices and Treatments (PDF) (CP.MP.142)
- Urodynamic testing (PDF) (CP.MP.98)
- Vagus Nerve Stimulation (PDF) (CP.MP.12)
- Ventricular Assist Devices (PDF) (CP.MP.46)
- Ventriculectomy and Cardiomyoplasty (PDF) (CP.MP.56)
- Video Electroencephalography (V-EEG) (PDF) (WA.CP.MP.177)
- Vitamin D Testing (PDF) (CP.MP.152)
- Vitamin D Testing in Children (PDF) (CP.MP.157)
- Wheelchair seating (PDF) (CP.MP.99)
- Wireless Motility Capsule (PDF) (CP.MP.143)
Ambetter Pharmacy Policies Listing
- Abaloparatide (Tymlos) (PDF) (CP.PHAR.345)
- Abametapir (Xeglyze) (PDF) (CP.PMN.253)
- Abemaciclib (Verzenio) (PDF) (CP.PHAR.355)
- Aclidinium/Formoterol (Duaklir Pressair) (PDF) (HIM.PA.151)
- Acyclovir Buccal Tablet (Sitavig), Ophthalmic Ointment (Avaclyr) (PDF) (CP.PMN.210)
- Afamelanotide (Scenesse) (PDF) (CP.PHAR.444)
- Abatacept (Orencia) (PDF) (CP.PHAR.241)
- Abiraterone (PDF) (CP.PHAR.84)
- AbobotulinumtoxinA (Dysport) (PDF) (CP.PHAR.230)
- Adefovir (Hepsera) (PDF) (CP.PHAR.142)
- Ado-Trastuzumab Emtansine (Kadcyla) (PDF) (CP.PHAR.229)
- Afatinib (Gilotrif) (PDF) (CP.PHAR.298)
- Afinitor (everolimus) (PDF) (CP.PHAR.63)
- Aflibercept (Eylea®) (PDF) (CP.PHAR.184)
- Agalsidase Beta (Fabrazyme) (PDF) (CP.PHAR.158)
- Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) (CP.PMN.138)
- Alectinib (Alecensa) (PDF) (CP.PHAR.369)
- Alemtuzumab (Lemtrada) (PDF) (CP.PHAR.243)
- Alendronate (Binosto, Fosamax plus D) (PDF) (CP.PMN.88)
- Alglucosidase Alfa (Lumizyme) (PDF) (CP.PHAR.160)
- Alpelisib (Piqray) (PDF) (CP.PHAR.430)
- Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF) (CP.PHAR.94)
- Ambrisentan (Letairis®) (PDF) (CP.PHAR.190)
- Amifampridine (Firdapse) (PDF) (CP.PHAR.411)
- Amikacin (Arikayce) (PDF) (CP.PHAR.401)
- Amisulpride (Barhemsys) (PDF) (CP.PMN.236)
- Anakinra (Kineret) (PDF) (CP.PHAR.244)
- Anti-Inhibitor Coagulant Complex (Feiba®) (PDF) (CP.PHAR.217)
- Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) (CP.PHAR.506)
- Apalutamide (Erleada) (PDF) (CP.PHAR.376)
- Apomorphine (Apokyn, Kynmobi) (PDF) (CP.PHAR.488)
- Apremilast (Otezla) (PDF) (CP.PHAR.245)
- aprepitant (PDF) (CP.PMN.19)
- Arformoterol Tartrate (Brovana) (PDF) (CP.PMN.201)
- Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF) (CP.PHAR.290)
- Armodafinil (Nuvigil) (PDF) (CP.PMN.35)
- Asenapine (Saphris) (PDF) (CP.PMN.15)
- Asfotase Alfa (Strensiq) (PDF) (CP.PHAR.328)
- Aspirin-dipyridamole (Aggrenox) (PDF) (CP.PMN.20)
- Atezolizumab (Tecentriq®) (PDF) (CP.PHAR.235)
- Avapritinib (Ayvakit) (PDF) (CP.PHAR.454)
- Avatrombopag (Doptelet) (PDF) (CP.PHAR.130)
- Avelumab (Bavencio®) (PDF) (CP.PHAR.333)
- Axicabtagene Ciloleucel (Yescarta®) (PDF) (CP.PHAR.362)
- Axitinib (Inlyta®) (PDF) (CP.PHAR.100)
- Azacitidine (Vidaza) (PDF) (CP.PHAR.387)
- Azelaic Acid (Finacea) (PDF) (HIM.PA.119)
- Aztreonam (Cayston®) (PDF) (CP.PHAR.209)
- Bedaquiline (Sirturo) (PDF) (CP.PMN.212)
- Belantamab Mafodotin (Blenrep) (PDF) (CP.PHAR.469)
- belatacept (Nulojix®) (PDF) (CP.PHAR.201)
- Belimumab (PDF) (CP.PHAR.88)
- belinostat (Beleodaq®) (PDF) (CP.PHAR.311)
- Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet) (PDF) (CP.PMN.237)
- bendamustine (Bendeka®, Treanda®) (PDF) (CP.PHAR.307)
- Benralizumab (Fasenra) (PDF) (CP.PHAR.373)
- Benznidazole (PDF) (CP.PMN.90)
- Betaine (Cystadane) (PDF) (CP.PHAR.143)
- Betamethasone Dipropionate Spray (Sernivo) (PDF) (CP.PMN.182)
- Bevacizumab (Avastin) (PDF) (CP.PHAR.93)
- Bexarotene (Targretin) (PDF) (CP.PHAR.75)
- Bezlotoxumab (Zinplava) (PDF) (CP.PHAR.300)
- Bimatoprost Implant (Durysta) (PDF) (CP.PHAR.486)
- Binimetinib (PDF) (CP.PHAR.50)
- Biologic DMARDs (PDF) (HIM.PA.SP60)
- Blinatumomab (PDF) (CP.PHAR.312)
- Bortezomib (Velcade) (PDF) (CP.PHAR.410)
- Bosentan (Tracleer®) (PDF) (CP.PHAR.191)
- Bosutinib (Bosulif) (PDF) (CP.PHAR.105)
- Brand Name Override and Non-Formulary Medications (PDF) (HIM.PA.103)
- Brentuximab (PDF) (CP.PHAR.303)
- Brexanolone (Zulresso) (PDF) (CP.PHAR.417)
- Brexpiprazole (Rexulti) (PDF) (CP.PMN.68)
- Brexucabtagene Autoleucel (Tecartus) (PDF) (CP.PHAR.472)
- Brigatinib (Alunbrig) (PDF) (CP.PHAR.342)
- Brimonidine Tartrate (Mirvaso) (PDF) (CP.PMN.192)
- Brinzolamide/Brimonidine (Simbrinza) (PDF) (HIM.PA.15)
- Brivaracetam (Briviact) (PDF) (CP.PCH.26)
- Brolucizumab-dbll (Beovu) (PDF) (CP.PHAR.445)
- Budesonide/Glycopyrrolate/Formoterol Fumarate (Breztri Aerosphere) (PDF) (HIM.PA.150)
- Budesonide (Uceris) (PDF) (CP.PCH.11)
- Budesonide Suspension (Pulmicort Respules) (PDF) (HIM.PA.48)
- buprenorphine and naloxone (Bunavail®, Suboxone®) (PDF) (HIM.PA.35)
- Buprenorphine (Subutex) (PDF) (CP.PMN.82)
- buprenorphine implant (Probuphine) (PDF) (CP.PHAR.289)
- Bupropion/Naltrexone (Contrave) (PDF) (CP.PCH.12)
- Burosumab-twza (Crysvita) (PDF) (CP.PHAR.11)
- Butorphanol Nasal Spray (PDF) (HIM.PA.46)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF) (CP.PHAR.202)
- Cabazitaxel (Jevtana®) (PDF) (CP.PHAR.316)
- Cabozantinib (Cometriq®, Cabometyx®) (PDF) (CP.PHAR.111)
- Calcifediol (Rayaldee) (PDF) (CP.PMN.76)
- Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) (PDF) (CP.PMN.181)
- Canakinumab (Ilaris) (PDF) (CP.PHAR.246)
- Cannabidiol (Epidiolex) (PDF) (CP.PMN.164)
- Capecitabine (Xeloda) (PDF) (CP.PHAR.60)
- Caplacizumab-yhdp (Cablivi) (PDF) (CP.PHAR.416)
- Capmatinib (Tabrecta) (PDF) (CP.PHAR.494)
- Carbidopa/Levodopa ER Capsules (Rytary) (PDF) (CP.PMN.238)
- carfilzomib (Kyprolis®) (PDF) (CP.PHAR.309)
- Carglumic Acid (Carbaglu) (PDF) (CP.PHAR.206)
- Celecoxib (Celebrex) (PDF) (CP.PMN.122)
- Cemiplimab-rwlc (Libtayo) (PDF) (CP.PHAR.397)
- Cenegermin-bkbj (Oxervate) (PDF) (CP.PMN.186)
- Cenobamate (Xcopri) (PDF) (CP.PMN.231)
- Ceritinib (Zykadia) (PDF) (CP.PHAR.349)
- Cerliponase alfa (PDF) (CP.PHAR.338)
- cetuximab (Erbitux®) (PDF) (CP.PHAR.317)
- Chenodiol (Chenodal) (PDF) (CP.PMN.239)
- Chlorambucil (Leukeran) (PDF) (HIM.PA.SP59)
- Chloramphenicol Sodium Succinate (PDF) (CP.PHAR.388)
- Cholic Acid (Cholbam) (PDF) (CP.PHAR.390)
- Ciclesonide (Alvesco) (PDF) (CP.PCH.35)
- Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) (CP.PMN.248)
- Ciprofloxacin/Fluocinolone (Otovel) (PDF) (CP.PMN.249)
- Cladribine (Mavenclad) (PDF) (CP.PHAR.422)
- Clobazam (PDF) (CP.PMN.54)
- CNS Stimulants (PDF) (CP.PMN.92)
- Cobimetinib (Cotellic) (PDF) (CP.PHAR.380)
- Colesevelam (Welchol) (PDF) (CP.PMN.250)
- Collagenase (PDF) (CP.PHAR.82)
- Colonoscopy Preparation Products (PDF) (HIM.PA.04)
- Compounded Medications (PDF) (CP.PCH.27)
- Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) (HIM.PA.140)
- Continuous Glucose Monitors (PDF) (CP.PMN.214)
- Continuous Insulin Delivery Systems (V-Go, Omnipod) (PDF) (CP.PHAR.505)
- copanlisib (Aliqopa®) (PDF) (CP.PHAR.357)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert) (PDF) (CP.PHAR.385)
- Cosyntropin (Cortrosyn®) (PDF) (CP.PHAR.203)
- Crisaborole (Eucrisa) (PDF) (CP.PMN.110)
- Crizanlizumab-tmca (Adakveo) (PDF) (CP.PHAR.449)
- Crizotinib (Xalkori) (PDF) (CP.PHAR.90)
- Cyclosporine (Restasis) (PDF) (CP.PMN.48)
- Cyramza® (PDF) (CP.PHAR.119)
- Cysteamine ophthalmic (Cystaran) (PDF) (CP.PMN.130)
- Cysteamine oral (Cystagon, Procysbi) (PDF) (CP.PHAR.155)
- Cytomegalovirus Immune Globulin (Cytogam) (PDF) (CP.PHAR.277)
- Dabrafenib (PDF) (CP.PHAR.239)
- Daclatasvir (Daklinza) (PDF) (HIM.PA.SP27)
- Dacomitinib (Vizimpro) (PDF) (CP.PHAR.399)
- Dalfampridine (Ampyra) (PDF) (CP.PHAR.248)
- Dalteparin (Fragmin) (PDF) (CP.PHAR.225)
- Daptomycin (Cubicin, Cubicin RF) (PDF) (CP.PHAR.351)
- Daratumumab (PDF) (CP.PHAR.310)
- Darbepoetin alfa (Aranesp) (PDF) (CP.PHAR.236)
- Darolutamide (Nubeqa) (PDF) (CP.PHAR.435)
- Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) (PDF) (HIM.PA.SP61)
- Dasatinib (Sprycel) (PDF) (CP.PHAR.72)
- Dapsone (Aczone Gel) (PDF) (CP.PCH.32)
- daunorubicin/cytarabine (Vyxeos®) (PDF) (CP.PHAR.352)
- Decitabine/Cedazuridine (Inqovi) (PDF) (CP.PHAR.479)
- deferasirox (PDF) (CP.PHAR.145)
- deferiprone (PDF) (CP.PHAR.147)
- Deferoxamine (Desferal) (PDF) (CP.PHAR.146)
- Deflazacort (Emflaza) (PDF) (CP.PHAR.331)
- degarelix acetate (Firmagon®) (PDF) (CP.PHAR.170)
- Delafloxacin (Baxdela) (PDF) (CP.PMN.115)
- Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (PDF) (CP.PHAR.214)
- Deutetrabenazine (Austedo) (PDF) (CP.PHAR.341)
- Dexlansoprazole (Dexilant) (PDF) (HIM.PA.05)
- Dexrazoxane (Zinecard, Totect) (PDF) (CP.PHAR.418)
- Dextromethorphan-Quinidine (Nuedexta) (PDF) (CP.PMN.93)
- Diazepam Nasal Spray (Valtoco) (PDF) (CP.PMN.216)
- Dichlorphenamide (Keveyis) (PDF) (CP.PCH.04)
- Diclofenac (Cambia, Flector, Licart, Pennsaid, Solaraze, Zipsor, Zorvolex) (PDF) (CP.PCH.28)
- diclofenac sodium topical gel (Solaraze, Voltaren®) (PDF) (HIM.PA.123)
- Dimethyl Fumarate (Tecfidera) (PDF) (CP.PHAR.249)
- Dipeptidyl Peptidase-4 Inhibitors (PDF) (HIM.PA.58)
- Dolasetron (Anzemet) (PDF) (CP.PMN.141)
- Dornase alfa (Pulmozyme) (PDF) (CP.PHAR.212)
- Doxepin Hydrochloride Cream (Prudoxin, Zonalon) (PDF) (HIM.PA.147)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF) (CP.PMN.79)
- Dupilumab (Dupixent) (PDF) (CP.PHAR.336)
- Durvalumab (Imfinzi) (PDF) (CP.PHAR.339)
- Duvelisib (Copiktra) (PDF) (CP.PHAR.400)
- Ecallantide (Kalbitor®) (PDF) (CP.PHAR.177)
- Eculizumab (Soliris®) (CP.PHAR.97)
- Edaravone (Radicava) (PDF) (CP.PHAR.343)
- Efinaconazole (Jublia) (PDF) (CP.PMN.25)
- Egrifta® (PDF) (CP.PHAR.109)
- Elagolix (Orilissa) (PDF) (CP.PHAR.136)
- Elapegademase-lvlr (Revcovi) (PDF) (CP.PHAR.419)
- Elbasvir/Grazoprevir (Zepatier) (PDF) (HIM.PA.SP62)
- Elexacaftor, tezacaftor (Trikafta) (PDF) (CP.PHAR.440)
- Eliglustat (Cerdelga) (PDF) (CP.PHAR.153)
- Elotuzumab (Empliciti®) (PDF) (CP.PHAR.308)
- Elosulfase alfa (PDF) (CP.PHAR.162)
- Eltrombopag (Promacta®) (PDF) (CP.PHAR.180)
- Eluxadoline (Viberzi) (PDF) (CP.PMN.170)
- Emapalumab-lzsg (Gamifant) (PDF) (CP.PHAR.402)
- Emicizumab-kxwh (Hemlibra) (PDF) (CP.PHAR.370)
- Emtricitabine/Tenofovir Alafenamide (Descovy) (PDF) (CP.PMN.235)
- Enasidenib (Idhifa) (PDF) (CP.PHAR.363)
- Encorafenib (PDF) (CP.PHAR.127)
- Enfortumab Vedotin-ejfv (Padcev) (PDF) (CP.PHAR.455)
- Enfuvirtide (PDF) (CP.PHAR.41)
- Entecavir (Baraclude) (PDF) (HIM.PA.08)
- Entrectinib (Rozlytrek) (PDF) (CP.PHAR.441)
- Enzalutamide (PDF) (CP.PHAR.106)
- Epoetin alfa (Epogen, Procrit), Epoetin alfa-epbx (Retacrit) (PDF) (CP.PHAR.237)
- Epoprostenol (Flolan®, Veletri®) (PDF) (CP.PHAR.192)
- Eptinezumab-jjmr (Vyepti) (PDF) (CP.PCH.29)
- Eptinezumab-jjmr (Vyepti) (PDF) (HIM.PA.SP64)
- Erdafitinib (Balversa) (PDF) (CP.PHAR.423)
- Eribulin Mesylate (Halaven®) (PDF) (CP.PHAR.318)
- Erlotinib (Tarceva) (PDF) (CP.PHAR.74)
- Erenumab-aaoe (Aimovig) (PDF) (HIM.PA.SP65)
- erwina asparaginase (Erwinaze®) (PDF) (CP.PHAR.301)
- Esketamine (Spravato) (PDF) (CP.PMN.199)
- Etanercept (Enbrel) (PDF) (CP.PHAR.250)
- Etelcalcetide (Parsabiv) (PDF) (CP.PHAR.379)
- Eteplirsen (Exondys 51) (PDF) (CP.PHAR.288)
- Evolocumab (PDF) (CP.PHAR.123)
- Factor IX (Human, Recombinant) (PDF) (CP.PHAR.218)
- Factor IX Complex Human (Bebulin®, Profilnine®) (PDF) (CP.PHAR.219)
- Factor VIIa, Recombinant (NovoSeven® RT) (PDF) (CP.PHAR.220)
- Factor VIII (Human Recombinant) (PDF) (CP.PHAR.215)
- Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF) (CP.PHAR.216)
- Factor XIII A-Subunit, Recombinant (Tretten®) (PDF) (CP.PHAR.222)
- Factor XIII, Human (Corifact®) (PDF) (CP.PHAR.221)
- Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) (CP.PHAR.456)
- Febuxostat (Uloric) (PDF) (CP.PMN.57)
- Fedratinib (Inrebic) (PDF) (CP.PHAR.442)
- Fenfluramine (Fintepla) (PDF) (CP.PMN.246)
- Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF) (CP.PMN.127)
- Ferric Carboxymaltose (Injectafer) (PDF) (CP.PHAR.234)
- Ferric Derisomaltose (Monoferric) (PDF) (CP.PHAR.480)
- Ferric gluconate (Ferrlecit®) (PDF) (CP.PHAR.166)
- Ferric Maltol (Accrufer) (PDF) (CP.PMN.213)
- Ferumoxytol (Feraheme®) (PDF) (CP.PHAR.165)
- Filgrastim (PDF) (CP.PHAR.297)
- Fingolimod (Gilenya) (PDF) (CP.PHAR.251)
- Fluorouracil Cream (Tolak) (PDF) (CP.PMN.165)
- Fluticasone Propionate (Xhance) (PDF) (CP.PMN.95)
- Fondaparinux (Arixtra) (PDF) (CP.PHAR.226)
- Formulary Medications Without Specific Guidelines (PDF) (HIM.PA.33)
- Fostamatinib (Tavalisse) (PDF) (CP.PHAR.24)
- Fremanezumab-vfrm (Ajovy) (PDF) (CP.PCH.17)
- Fremanezumab-vfrm (Ajovy) (PDF) (HIM.PA.SP66)
- Fulvestrant (Faslodex Injection) (PDF) (CP.PHAR.424)
- Gabapentin ER (Gralise, Horizant) (PDF) (CP.PMN.240)
- Galcanezumab-gnlm (Emgality) (PDF) (CP.PCH.24)
- Galcanezumab-gnlm (Emgality) (PDF) (HIM.PA.SP67)
- Galsulfase (Naglazyme) (PDF) (CP.PHAR.161)
- Gefitinib (Iressa) (PDF) (CP.PHAR.68)
- gemtuzumab ozogamicin (Mylotarg®) (PDF) (CP.PHAR.358)
- Gilteritinib (Xospata) (PDF) (CP.PHAR.412)
- Givosiran (Givlaari) (PDF) (CP.PHAR.457)
- Glasdegib (Daurismo) (PDF) (CP.PHAR.413)
- Glatiramer (Copaxone, Glatopa) (PDF) (CP.PHAR.252)
- Glecaprevir/Pibrentasvir (Mavyret) (PDF) (HIM.PA.SP36)
- Gleevec (imatinib mesylate) (PDF) (CP.PHAR.65)
- Glucagon-Like Peptide-1 Receptor Agonists (PDF) (HIM.PA.53)
- Glycerol phenylbutyrate (Ravicti®) (PDF) (CP.PHAR.207)
- Glycopyrronium (Qbrexza) (PDF) (CP.PMN.177)
- Golodirsen (Vyondys 53) (PDF) (CP.PHAR.453)
- goserelin acetate (Zoladex®) (PDF) (CP.PHAR.171)
- Granisetron (Kytril, Sancuso, Sustol) (PDF) (CP.PMN.74)
- Halcinonide (Halog) (PDF) (HIM.PA.20)
- Halobetasol Propionate/Tazarotene (Duobrii) (PDF) (CP.PMN.208)
- Hemin (Panhematin®) (PDF) (CP.PHAR.181)
- histrelin acetate (Vantas®, Supprelin LA®) (PDF) (CP.PHAR.172)
- Hyaluronate Derivatives (PDF) (CP.PHAR.05)
- Hydroxyprogesterone Caproate (Makena/compound) (PDF) (CP.PHAR.14)
- Ibalizumab-uiyk (PDF) (CP.PHAR.378)
- Ibandronate Injection (Boniva) (PDF) (CP.PHAR.189)
- Ibrutinib (PDF) (CP.PHAR.126)
- Ibuprofen/Famotidine (Duexis) (PDF) (CP.PMN.120)
- Icatibant (Firazyr®) (PDF) (CP.PHAR.178)
- Icosapent ethyl (Vascepa) (PDF) (CP.PMN.187)
- Idelalisib (Zydelig) (PDF) (CP.PHAR.133)
- Idursulfase (PDF) (CP.PHAR.156)
- Iloperidone (Fanapt) (PDF) (CP.PMN.32)
- Iloprost (Ventavis®) (PDF) (CP.PHAR.193)
- Imiglucerase (Cerezyme) (PDF) (CP.PHAR.154)
- Immune Globulins (PDF) (CP.PHAR.103)
- IncobotulinumtoxinA (Xeomin) (PDF) (CP.PHAR.231)
- Indacaterol/Glycopyrrolate (Utibron Neohaler) (PDF) (HIM.PA.102)
- Inebilizumab-cdon (Uplizna) (PDF) (CP.PHAR.458)
- Infertility and Fertility Preservation (PDF) (CP.PHAR.131)
- Infusion Therapy Site of Care Optimization (PDF) (CP.PHAR.493)
- Inotersen (Tegsedi) (PDF) (CP.PHAR.405)
- inotuzumab ozogamicin (Besponsa®) (PDF) (CP.PHAR.359)
- Insulin Degludec (Tresiba) (PDF) (HIM.PA.09)
- Interferon beta-1a (Avonex, Rebif) (PDF) (CP.PHAR.256)
- Interferon Beta-1a (Avonex, Rebif) (PDF) (CP.PHAR.255)
- Interferon Gamma- 1b (Actimmune) (PDF) (CP.PHAR.52)
- Intrathecal Baclofen (Gablofen, Lioresal) (PDF) (CP.PHAR.149)
- Iobenguane I-131 (Azedra) (PDF) (CP.PHAR.459)
- Ipilimumab (Yervoy) (PDF) (CP.PHAR.319)
- irinotecan Liposome (Onivyde®) (PDF) (CP.PHAR.304)
- Iron sucrose (Venofer®) (PDF) (CP.PHAR.167)
- Isatuximab-irfc (Sarclisa) (PDF) (CP.PHAR.482)
- isavuconazonium (Cresemba®) (PDF) (CP.PMN.154)
- Isotretinoin (PDF) (CP.PMN.143)
- Istradefylline (Nourianz) (PDF) (CP.PMN.217)
- Itraconazole (Sporanox, Onmel) (PDF) (CP.PMN.124)
- Ivabradine (Corlanor) (PDF) (CP.PMN.70)
- Ivacaftor (Kalydeco) (PDF) (CP.PHAR.210)
- ivermectin (Sklice®) (PDF) (HIM.PA.124)
- Ivosidenib (Tibsovo) (PDF) (CP.PHAR.137)
- Ixazomib (PDF) (CP.PHAR.302)
- Korlym (mifepristone) (PDF) (CP.PHAR.101)
- Kuvan (PDF) (CP.PHAR.43)
- Lacosamide (Vimpat) (PDF) (CP.PMN.155)
- Lactic Acid/Citric Acid/Potassium Bitartrate (Phexxi) (PDF) (CP.PMN.251)
- Lactitol (Pizensy) (PDF) (CP.PMN.241)
- Lanadelumab-fylo (Takhzyro) (PDF) (CP.PHAR.396)
- Lanreotide (Somatuline Depot) (PDF) (CP.PHAR.391)
- lapatinib (Tykerb®) (PDF) (CP.PHAR.79)
- Laronidase (Aldurazyme) (PDF) (CP.PHAR.152)
- Larotrectinib (Vitrakvi) (PDF) (CP.PHAR.414)
- Lasmiditan (Reyvow) (PDF) (CP.PMN.218)
- Ledipasvir/Sofosbuvir (Harvoni) (PDF) (HIM.PA.SP3)
- Lefamulin (Xenleta) (PDF) (CP.PMN.219)
- Lemborexant (Dayvigo) (PDF) (CP.PMN.233)
- Lenvatinib (Lenvima) (PDF) (CP.PHAR.138)
- Lesinurad (Zurampic), Lesinurad/Allopurinol (Duzallo) (PDF) (CP.PMN.150)
- Letermovir (Prevymis) (PDF) (CP.PHAR.367)
- levoleucovorin (Fusilev) (PDF) (CP.PHAR.151)
- Levomilnacipran (Fetzima) (PDF) (HIM.PA.125)
- Leucovorin Injection (PDF) (CP.PHAR.393)
- leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) (CP.PHAR.173)
- Levalbuterol (Xopenex) (PDF) (CP.PMN.07)
- L-glutamine (Endari) (PDF) (CP.PMN.116)
- lidocaine transdermal (Lidoderm, ZTlido) (PDF) (CP.PMN.08)
- Lifitegrast (Xiidra®) (PDF) (CP.PMN.73)
- Linaclotide (Linzess) (PDF) (CP.PMN.71)
- linezolid (Zyvox) (PDF) (CP.PMN.27)
- Lofexidine (Lucemyra) (PDF) (CP.PMN.152)
- Lomustine (Gleostine) (PDF) (CP.PHAR.507)
- Lorcaserin (Belviq®, Belviq XR) (PDF) (CP.PCH.03)
- Lorlatinib (Lorbrena) (PDF) (CP.PHAR.406)
- Lubiprostone (Amitiza) (PDF) (CP.PMN.142)
- Luliconazole Cream (Luzu) (PDF) (CP.PMN.166)
- Lumacaftor-ivacaftor (PDF) (CP.PHAR.213)
- Lumateperone (Caplyta) (PDF) (CP.PMN.232)
- Lurasidone (Latuda) (PDF) (CP.PMN.50)
- Lurbinectedin (Zepzelca) (PDF) (CP.PHAR.500)
- Luspatercept-aamt (Reblozyl) (PDF) (CP.PHAR.450)
- Lusutrombopag (Mulpleta) (PDF) (CP.PHAR.407)
- Lutetium Lu 177 Dotatate (Lutathera) (PDF) (CP.PHAR.384)
- Macitentan (Opsumit®) (PDF) (CP.PCH.31)
- Mecamylamine (Vecamyl) (PDF) (CP.PMN.136)
- Mecaserim (PDF) (CP.PHAR.150)
- Mechlorethamine Gel (Valchlor) (PDF) (CP.PHAR.381)
- Megestrol Acetate (Megace ES) (PDF) (CP.PMN.179)
- Memantine ER (Namenda XR), Memantine/Donepezil (Namzaric) (PDF) (CP.PCH.30)
- Mepolizumab (Nucala) (PDF) (CP.PHAR.200)
- Metformin ER (Fortamet, Glumetza) (PDF) (CP.PMN.72)
- Methotrexate (Otrexup, Rasuvo, Xatmep) (PDF) (CP.PHAR.134)
- Methoxsalen (Uvadex) (PDF) (HIM.PA.17)
- Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) (CP.PHAR.238)
- Methylnaltrexone Bromide (Relistor) (PDF) (CP.PMN.169)
- Metoclopramide (Gimoti) (PDF) (CP.PMN.252)
- Metreleptin (Myalept) (PDF) (CP.PHAR.425)
- Midazolam (Nayzilam) (PDF) (CP.PMN.211)
- Midostaurin (Rydapt) (PDF) (CP.PHAR.344)
- Migalastat (Galafold) (PDF) (CP.PHAR.394)
- Miglustat (Zavesca) (PDF) (CP.PHAR.164)
- Milnacipran (Savella) (PDF) (CP.PMN.125)
- Minocycline ER (Solodyn, Ximino, Minolira) and Microspheres (Arestin) (PDF) (CP.PMN.80)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF) (CP.PHAR.495)
- Mitoxantrone (Novantrone) (PDF) (CP.PHAR.258)
- Modafinil (Provigil) (PDF) (CP.PMN.39)
- Mogamulizumab-kpkc (Poteligeo) (PDF) (CP.PHAR.139)
- Mometasone (Asmanex) (PDF) (HIM.PA.01)
- Mometasone (Asmanex) (PDF) (CP.PCH.36)
- Mometasone (Nasonex) (PDF) (HIM.PA.93)
- Mometasone Furoate (Sinuva) (PDF) (CP.PHAR.448)
- Monomethyl Fumarate (Bafiertam) (PDF) (CP.PHAR.460)
- Montelukast oral granules (Singulair) (PDF) (HIM.PA.129)
- Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) (CP.PHAR.398)
- Nadofaragene Firadenovec (Instiladrin) (PDF) (CP.PHAR.461)
- nafarelin acetate (Synarel®) (PDF) (CP.PHAR.174)
- Naltrexone (Vivitrol®) (PDF) (CP.PHAR.96)
- Naproxen/Esomeprazole (Vimovo) (PDF) (CP.PMN.117)
- Naproxen oral suspension (Naprosyn) (PDF) (HIM.PA.130)
- Natalizumab (Tysabri) (PDF) (HIM.PA.SP17)
- Nebivolol (Bystolic) (PDF) (HIM.PA.131)
- necitumumab (Portrazza®) (PDF) (CP.PHAR.320)
- Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF) (CP.PMN.167)
- Neratinib (Nerlynx) (PDF) (CP.PHAR.365)
- Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan) (PDF) (CP.PMN.118)
- Netupitant and Palonosetron (Akynzeo) (PDF) (CP.PMN.158)
- Nifurtimox (Lampit) (PDF) (CP.PMN.256)
- Nilotinib (Tasigna) (PDF) (CP.PHAR.76)
- Nintedanib (Ofev) (PDF) (CP.PHAR.285)
- Nitisinone (Nityr, Orfadin) (PDF) (CP.PHAR.132)
- Nivolumab (PDF) (CP.PHAR.121)
- No Coverage Criteria (PDF) (CP.PMN.255)
- No Coverage Criteria/Off-Label Use Policy (PDF) (CP.PMN.53)
- Non-Formulary and Formulary Contraceptives (PDF) (HIM.PA.100)
- Non-Formulary Test Strips (PDF) (HIM.PA.34)
- Nusinersen (PDF) (CP.PHAR.327)
- Obeticholic Aacid (Ocaliva) (PDF) (CP.PHAR.287)
- obinutuzumab (Gazyva®) (PDF) (CP.PHAR.305)
- Ocrelizumab (Ocrevus) (PDF) (CP.PHAR.335)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot) (PDF) (CP.PHAR.40)
- ofatumumab (Arzerra®) (PDF) (CP.PHAR.306)
- Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) (CP.PHAR.292)
- Olaparib (Lynparza) (PDF) (CP.PHAR.360)
- olaratumab (Lartruvo®) (PDF) (CP.PHAR.326)
- Omacetaxine (Synribo) (PDF) (CP.PHAR.108)
- Omadacycline (Nuzyra) (PDF) (CP.PMN.188)
- omalizumab (PDF) (CP.PHAR.01)
- OnabotulinumtoxinA (Botox) (PDF) (CP.PHAR.232)
- Onasemnogene abeparvovec (Zolgensma) (PDF) (CP.PHAR.421)
- Ondansetron (Zuplenz) (PDF) (CP.PMN.45)
- Opioid Analgesics (PDF) (HIM.PA.139)
- Ophthalmic Corticosteroids (PDF) (HIM.PA.03)
- Osilodrostat (Isturisa) (PDF) (CP.PHAR.487)
- Osimertinib (Tagrisso) (PDF) (CP.PHAR.294)
- Ospemifene (Osphena) (PDF) (CP.PMN.168)
- Overactive Bladder Agents (PDF) (CP.PMN.198)
- Oxymetazoline (Rhofade, Upneeq) (PDF) (CP.PMN.86)
- Ozanimod (Zeposia) (PDF) (CP.PHAR.462)
- Ozenoxacin (Xepi) (PDF) (CP.PMN.119)
- Paclitaxel, protein bound (Abraxane) (PDF) (CP.PHAR.176)
- Palbociclib (Ibrance) (PDF) (CP.PHAR.125)
- Paliperidone Long-Acting Injections (Invega Sustenna, Invega Trinza) (PDF) (CP.PHAR.291)
- panitumumab (Vectibix®) (PDF) (CP.PHAR.321)
- Panobinostat (Farydak) (PDF) (CP.PHAR.382)
- Parathyroid Hormone (Natpara) (PDF) (CP.PHAR.282)
- Paricalcitrol Injection (PDF) (CP.PHAR.270)
- pasireotide (Signifor LAR®) (PDF) (CP.PHAR.332)
- Patisiran (Onpattro) (PDF) (CP.PHAR.395)
- Pazopanib (PDF) (CP.PHAR.81)
- Peanut Allergen Powder-dnfp (Palforzia) (PDF) (CP.PMN.220)
- Pegademase Bovine (Adagen) (PDF) (CP.PHAR.392)
- pegaspargase (Oncaspar®) (PDF) (CP.PHAR.353)
- Pegfilgrastim (PDF) (CP.PHAR.296)
- peginterferon beta-1a (Plegridy) (PDF) (CP.PHAR.271)
- Pegloticase (Krystexxa®) (PDF) (CP.PHAR.115)
- Pegvaliase-pqpz (Palynziq) (PDF) (CP.PHAR.140)
- Pegvisomant (Somavert) (PDF) (CP.PHAR.389)
- Pembrolizumab (Keytruda®) (PDF) (CP.PHAR.322)
- Pemetrexed (Alimta®) (PDF) (CP.PHAR.368)
- Pemigatinib (Pemazyre) (PDF) (CP.PHAR.496)
- Penicillamine (Cuprimine) (PDF) (CP.PCH.09)
- Perampanel (Fycompa) (PDF) (CP.PMN.156)
- Pertuzumab (Perjeta) (PDF) (CP.PHAR.227)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (PDF) (CP.PHAR.501)
- Pexidartinib (Turalio) (PDF) (CP.PHAR.436)
- Phendimetrazine IR (Bontril PDM) (PDF) (HIM.PA.114)
- Phentermine (Adipex-P, Lomaira) (PDF) (CP.PCH.13)
- Pimavanserin (Nuplazid) (PDF) (CP.PMN.140)
- Pirfenidone (Esbriet) (PDF) (CP.PHAR.286)
- Pitolisant (Wakix) (PDF) (CP.PMN.221)
- Plecanatide (Trulance) (PDF) (CP.PMN.87)
- Plerixafor (PDF) (CP.PHAR.323)
- Polatuzumab Vedotin-piiq (Polivy) (PDF) (CP.PHAR.433)
- Pomalyst (PDF) (CP.PHAR.116)
- Ponatinib (Iclusig) (PDF) (CP.PHAR.112)
- Potassium (Klor-Con) (PDF) (HIM.PA.143)
- pralatrexate (Folotyn®) (PDF) (CP.PHAR.313)
- Pralsetinib (Gavreto) (PDF) (CP.PHAR.514)
- Pramlintide (Symlin) (PDF) (CP.PMN.129)
- Pregabalin (Lyrica, Lyrica CR) (PDF) (CP.PMN.33)
- Pretomanid (PDF) (CP.PMN.222)
- Progesterone (Crinone, Endometrin, Milprosa) (PDF) (CP.PMN.243)
- Propranolol HCl Oral Solution (Hemangeol) (PDF) (CP.PMN.58)
- protein c concentrate, human (Ceprotin®) (PDF) (CP.PHAR.330)
- Prucalopride (Motegrity) (PDF) (CP.PMN.194)
- pyrimethamine (Daraprim®) (PDF) (CP.PMN.44)
- Quetiapine ER (Seroquel XR) (PDF) (CP.PMN.64)
- Quinine Sulfate (Qualaquin) (PDF) (CP.PCH.10)
- Ranibizumab (Lucentis®) (PDF) (CP.PHAR.186)
- rasagiline (Azilect®) (PDF) (HIM.PA.89)
- Ravulizumab-cwvz (Ultomiris) (PDF) (CP.PHAR.415)
- Regorafenib (Stivarga) (PDF) (CP.PHAR.107)
- Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) (CP.PHAR.168)
- Reslizumab (Cinqair) (PDF) (CP.PHAR.223)
- Revlimid (PDF) (CP.PHAR.71)
- Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF) (CP.PHAR.141)
- Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara) (PDF) (CP.PHAR.334)
- Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) (PDF) (CP.PMN.223)
- Rifamycin (Aemcolo) (PDF) (CP.PMN.196)
- Rilonacept (Arcalyst) (PDF) (CP.PHAR.266)
- RimabotulinumtoxinB (Myobloc) (PDF) (CP.PHAR.233)
- Riociguat (Adempas®) (PDF) (CP.PHAR.195)
- Ripretinib (Qinlock) (PDF) (CP.PHAR.502)
- Risdiplam (Evrysdi) (PDF) (CP.PHAR.477)
- Risedronate (Actonel, Atelvia) (PDF) (CP.PMN.100)
- Risperidone LA Inj (PDF) (CP.PHAR.293)
- rifaximin (PDF) (CP.PMN.47)
- Rituximab (Rituxan), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) (PDF) (CP.PHAR.260)
- Rivastigmine (Exelon®) (PDF) (CP.PMN.101)
- Rolapitant (Varubi) (PDF) (CP.PMN.102)
- romidepsin (Istodax®) (PDF) (CP.PHAR.314)
- Romiplostim (Nplate®) (PDF) (CP.PHAR.179)
- Romosozumab-aqqg (Evenity) (PDF) (CP.PHAR.428)
- Rucaparib (Rubraca®) (PDF) (CP.PHAR.350)
- Rufinamide (Banzel) (PDF) (CP.PMN.157)
- Ruxolitinib (Jakafi) (PDF) (CP.PHAR.98)
- Sacituzumab Govitecan-hziy (Trodelvy) (PDF) (CP.PHAR.475)
- Sacubitril/Valsartan (Entresto) (PDF) (CP.PMN.67)
- Safinamide (Xadago) (PDF) (CP.PMN.113)
- Sarecycline (Seysara) (PDF) (CP.PMN.189)
- Sargramostim (PDF) (CP.PHAR.295)
- Sarilumab (Kevzara) (PDF) (CP.PHAR.346)
- Sebelipase Alfa (Kanuma) (PDF) (CP.PHAR.159)
- Secnidazole (Solosec) (PDF) (CP.PMN.103)
- Selexipag (Uptravi®) (PDF) (CP.PHAR.196)
- Selinexor (Xpovio) (PDF) (CP.PHAR.431)
- Selpercatinib (LOXO-292) (PDF) (CP.PHAR.478)
- Selumetinib (PDF) (CP.PHAR.464)
- Semaglutide (Rybelsus) (PDF) (HIM.PA.02)
- Sensipar (PDF) (CP.PHAR.61)
- Short Ragweed Pollen Allergen Extract (Ragwitek) (PDF) (CP.PMN.83)
- Sildenafil (Revatio®) (PDF) (CP.PHAR.197)
- Sildenafil (Viagra) (PDF) (CP.PCH.07)
- Siponimod (Mayzent) (PDF) (CP.PHAR.427)
- Sipuleucel-T (Provenge) (PDF) (CP.PHAR.120)
- Siltuximab (Sylvant®) (PDF) (CP.PHAR.329)
- Sodium-Glucose Co-Transporter 2 Inhibitors (PDF) (HIM.PA.91)
- Sodium Oxybate (Xyrem) (PDF) (CP.PMN.42)
- Sodium Phenylbutyrate (Buphenyl) (PDF) (CP.PHAR.208)
- Sodium Zirconium Cyclosilicate (Lokelma) (PDF) (CP.PMN.163)
- Sofosbuvir (Sovaldi) (PDF) (HIM.PA.SP2)
- Sofosbuvir/Vepatasvir/Voxilaprevir (Vosevi) (PDF) (HIM.PA.SP63)
- Sofosbuvir-Velpatasvir (Epclusa) (PDF) (HIM.PA.SP1)
- Soliris (eculizumab) (PDF) (CP.PHAR.97)
- Solriamfetol (Sunosi) (PDF) (CP.PMN.209)
- Somatropin (Human Growth Hormone) (PDF) (CP.PCH.25)
- Sonidegib (Odomzo) (PDF) (CP.PHAR.272)
- Sorafenib (Nexavar) (PDF) (CP.PHAR.69)
- Spinosad (Natroba) (PDF) (HIM.PA.134)
- Step Therapy (PDF) (HIM.PA.109)
- Stiripentol (Diacomit) (PDF) (CP.PMN.184)
- sucroferric oxyhydoxide (Velphoro) (PDF) (HIM.PA.SP30)
- sunitinib (Sutent) (PDF) (CP.PHAR.73)
- Suvorexant (Belsomra®) (PDF) (CP.PMN.109)
- Sylatron (peginterferon alfa-2b) (PDF) (CP.PHAR.89)
- Synagis_palivizumab (PDF) (CP.PHAR.16)
- Tadalafil (Adcirca®) (PDF) (CP.PHAR.198)
- Tadafil BHP - ED (Cialis) (PDF) (CP.PMN.132)
- Tafamidis (Vyndaqel, Vyndamax) (PDF) (CP.PHAR.432)
- Tafasitamab-cxix (Monjuvi) (PDF) (CP.PHAR.508)
- Talazoparib (Talzenna) (PDF) (CP.PHAR.409)
- Taliglucerase Alfa (Elelyso) (PDF) (CP.PHAR.157)
- Tasimelteon (Hetlioz) (PDF) (CP.PMN.104)
- Tavaborole (Kerydin®) (PDF) (CP.PMN.105)
- Tazemetostat (PDF) (CP.PHAR.452)
- Tazarotene (Arazlo, Fabior, Tazorac) (PDF) (CP.PMN.244)
- Tedizolid (Sivextro) (PDF) (CP.PMN.62)
- Teduglutide (Gattex) (PDF) (CP.PHAR.114)
- Telotristat Ethyl (Xermelo) (PDF) (CP.PHAR.337)
- Temodar (PDF) (CP.PHAR.77)
- temsirolimus (Torisel®) (PDF) (CP.PHAR.324)
- Tenofovir Alafenamide Fumarate (Vemlidy) (PDF) (CP.PCH.33)
- Tenapanor (Ibsrela) (PDF) (CP.PMN.224)
- Teprotumumab (Tepezza) (PDF) (CP.PHAR.465)
- Teriparatide (Forteo®) (PDF) (CP.PHAR.188)
- Tesamorelin (PDF) (CP.PHAR.109)
- Testosterone (Testopel, Jatenzo) (PDF) (CP.PHAR.354)
- Thalomid (PDF) (CP.PHAR.78)
- Thioguanine (Tabloid) (PDF) (CP.PHAR.437)
- Thyrotropin alfa (PDF) (CP.PHAR.95)
- Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF) (CP.PHAR.377)
- Timothy Grass Pollen Allergen Extract (Grastek) (PDF) (CP.PMN.84)
- Tisagenlecleucel (PDF) (CP.PHAR.361)
- Tobramycin (Bethkis®, Kitabis Pak®, TOBI®, TOBI Podhaler®) (PDF) (CP.PHAR.211)
- Tolvaptan (Jynarque) (PDF) (CP.PHAR.27)
- Topical Acne Treatment (PDF) (HIM.PA.71)
- Topical Immunomodulators (PDF) (CP.PMN.107)
- topical testosterone (PDF) (HIM.PA.87)
- Topotecan (Hycamtin) (PDF) (CP.PHAR.64)
- Trabectedin (Yondelis®) (PDF) (CP.PHAR.204)
- Trametinib (PDF) (CP.PHAR.240)
- Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF) (CP.PHAR.228)
- Treprostinil (Orenitram®, Remodulin®, Tyvaso®) (PDF) (CP.PHAR.199)
- Triamcinolone ER Injection (Zilretta) (PDF) (CP.PHAR.371)
- Triclabendazole (Egaten) (PDF) (CP.PMN.207)
- Trientine (Syprine) (PDF) (CP.PHAR.438)
- Trifarotene (Aklief) (PDF) (CP.PMN.225)
- Trifluridine/Tipiracil (Lonsurf) (PDF) (CP.PHAR.383)
- Triheptanoin (Dojolvi) (PDF) (CP.PHAR.509)
- triptorelin pamoate (Trelstar®, Triptodur®) (PDF) (CP.PHAR.175)
- Tucatinib (Tukysa) (PDF) (CP.PHAR.497)
- Ubrogepant (Ubrelvy) (PDF) (CP.PHAR.476)
- Upadacitinib (Rinvoq) (PDF) (CP.PHAR.443)
- Uridine acetate (Vistogard) (PDF) (HIM.PA.SP55)
- Valbenazine (Ingrezza) (PDF) (CP.PHAR.340)
- valganciclovir (Valcyte) (PDF) (CP.PCH.06)
- Valproate Sodium for Intravenous Injection (Depacon) (PDF) (CP.PHAR.429)
- Valrubicin (Valstar) (PDF) (CP.PHAR.439)
- Vandetanib (Caprelsa®) (PDF) (CP.PHAR.80)
- Velaglucerase Alfa (VPRIV) (PDF) (CP.PHAR.163)
- Vemurafenib (Zelboraf®) (PDF) (CP.PHAR.91)
- Venetoclax (Venclexta) (PDF) (CP.PHAR.129)
- Vestronidase alfa-vjbk (Mepsevii) (PDF) (CP.PHAR.374)
- Vigabatrin (PDF) (CP.PHAR.169)
- Vilazodone (Viibryd) (PDF) (CP.PMN.145)
- Viltolarsen (Viltepso) (PDF) (CP.PHAR.484)
- vincristine sulfate liposome injection (Marqibo®) (PDF) (CP.PHAR.315)
- Vismodegib (Erivedge) (PDF) (CP.PHAR.273)
- Vorapaxar (Zontivity) (PDF) (HIM.PA.146)
- Voretigene neparvovec-rzyl (Luxturna) (PDF) (CP.PHAR.372)
- Vorinostat (Zolinza) (PDF) (CP.PHAR.83)
- Vortioxetine (Trintellix®) (PDF) (CP.PMN.65)
- Voxelotor (Oxbryta) (PDF) (CP.PHAR.451)
- Xenazine (tetrabenazine) (PDF) (CP.PHAR.92)
- Xgeva (PDF) (CP.PHAR.58)
- Xiaflex™ (PDF) (CP.PHAR.82)
- Xolair® (PDF) (CP.PHAR.01)
- Zanubrutinib (Brukinsa) (PDF) (CP.PHAR.467)
- ziv-aflibercept (Zaltrap®) (PDF) (CP.PHAR.325)
- Zometa (PDF) (CP.PHAR.59)
Payment Policies
Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.
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Ambetter Payment Policies
- 3-Day Payment Window (PDF) (CC.PP.500)
- 30-Day Readmission (PDF) (CC.PP.501)
- Add on Code Billed Without Primary Code (PDF) (CC.PP.030)
- Assistant Surgeon (PDF) (CC.PP.029)
- Bilateral Procedures (PDF) (CC.PP.037)
- Cerumen Removal (PDF) (CC.PP.008)
- Clean Claims (PDF) (CC.PP.021)
- Coding Overview (PDF) (CC.PP.011)
- Cosmetic Procedures (PDF) (CC.PP.024)
- Distinct Procedural Modifiers (PDF) (CC.PP.020)
- Duplicate Primary Code Billing (PDF) (CC.PP.044)
- E&M Medical Decision-Making (PDF) (CC.PP.051)
- EM Bundling Edits (PDF) (CC.PP.010)
- Global Maternity Billing (PDF) (CC.PP.016)
- Hospital Visit Codes Billed with Labs (PDF) (CC.PP.023)
- Inpatient Consultation (PDF) (CC.PP.038)
- Inpatient Only Procedures (PDF) (CC.PP.018)
- IV Hydration (PDF) (CC.PP.012)
- Leveling of Emergency Room Services (PDF) (CC.PP.053)
- Maximum Units (PDF) (CC.PP.007)
- Moderate Conscious Sedation (PDF) (CC.PP.015)
- Modifier -25 clinical validation (PDF) (CC.PP.013)
- Modifier -59 clinical validation (PDF) (CC.PP.014)
- Modifier DOS Validation (PDF) (CC.PP.034)
- Modifier to Procedure Code Validation (PDF) (CC.PP.028)
- Multiple CPT Code Replacement (PDF) (CC.PP.033)
- Multiple Diagnostic Cardiovascular Procedure (MDCP) (PDF) (CC.PP.065)
- Payment Reduction (MDCR)NCCI Unbundling (PDF) (CC.PP.031)
- Never Paid Events (PDF) (CC.PP.017)
- New Patient (PDF) (CC.PP.036)
- Not Medically Necessary IP Serv (PDF) (CC.PP.060)
- Outpatient Consultation (PDF) (CC.PP.039)
- Pelvic and Transabdominal US (PDF) (CC.PP.061)
- Physician's Consultation Services (PDF) (CC.PP.054)
- Physician Visit Codes Billed with Labs (PDF) (CC.PP.019)
- Physician's Office Lab Testing (PDF) (CC.PP.055)
- Place of Service Mismatch (PDF) (CC.PP.063)
- Post-Operative Visits (PDF) (CC.PP.042)
- Pre-Operative Visits (PDF) (CC.PP.041)
- Professional Component (PDF) (CC.PP.027)
- Pulse Oximetry (PDF) (CC.PP.025)
- Renal Hemodialysis (PDF) (CC.PP.067)
- Robotic Surgery (PDF) (CC.PP.050)
- Same Day Visits (PDF) (CC.PP.040)
- Sleep Studies Place of Services (PDF) (CC.PP.035)
- Status "B" Bundled Services (PDF) (CC.PP.046)
- Status P Bundled Services (PDF) (CC.PP.049)
- Supplies Billed on Same Day As Surgery (PDF) (CC.PP.032)
- Transgender Related Services (PDF) (CC.PP.047)
- Unbundled Surgical Procedures (PDF) (CC.PP.045)
- Unbundled Professional Services (PDF) (CC.PP.043)
- Unlisted Procedure Codes (PDF) (CC.PP.009)
- Wheelchair Accessories (PDF) (CC.PP.502)