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Texas Clinical Payment Policies | Ambetter from Superior HealthPlan
Clinical, Payment & Pharmacy 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 Superior HealthPlan Clinical Policy Manual apply to Superior HealthPlan members. Policies in the Superior HealthPlan Clinical Policy Manual may have either a Superior HealthPlan or a “Centene” heading. Superior HealthPlan utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Superior HealthPlan 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 Superior HealthPlan. In addition, Superior HealthPlan 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 Superior HealthPlan.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
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 Superior HealthPlan Payment Policy Manual apply with respect to Superior HealthPlan members. Policies in the Superior HealthPlan Payment Policy Manual may have either a Superior HealthPlan or a “Centene” heading. In addition, Superior HealthPlan 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 Superior HealthPlan.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Biopharmacy policies are used to help identify whether clinician administered drugs (CAD) are medically necessary. Pharmacy policies are used to help identify whether medications dispensed by pharmacies and billed through the pharmacy benefit are medically necessary. The criteria used are based on information found in generally accepted standards of medical and pharmacy 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 such as but not limited to the drug package insert. Pharmacy and biopharmacy policies are reviewed and approved by the Superior Pharmacy and Therapeutic (P&T) Committee prior to use. This webpage lists biopharmacy policies for Medicaid and biopharmacy and pharmacy policies for Ambetter.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Pharmacy department.If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Pharmacy department.
Effective Policies
Ambetter from Superior HealthPlan Policies
- Air Amulance (CP.MP.92) (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-Thalassemia (CP.MP.108) (PDF)
- Antithrombin III (Thrombate III, Atryn) (CP.MP.179) (PDF)
- Applied Behavioral Analysis for Autism - Effective 12/30/2020 (CP.MP.104) (PDF)
- Bone-anchored Hearing Aid (CP.MP.93) (PDF)
- Bronchial Thermoplasty - Effective 1/15/2017 (CP.MP.110) (PDF)
- Burn Surgery (CP.MP.186) (PDF)
- Carrier Screening in Pregnancy (CP.MP.83) (PDF)
- Caudal or Interlaminar Epidural Steroid Injections for Pain Management (CP.MP.164) (PDF)
- Cell-free Fetal DNA Testing (CP.MP.84) - Effective 12/30/2020 (PDF)
- Cochlear Implant Replacements (CP.MP.14) (PDF)
- Cosmetic and Reconstructive Procedures (CP.MP.31) - Effective 10/01/2020 (PDF)
- Cosmetic and Reconstructive Procedures (CP.MP.31) - Revision Effective 12/30/2020 (PDF)
- Dental Anesthesia (CP.MP.61) (PDF)
- DNA Analysis of Stool - Effective 5/1/2017 (CP.MP.125) (PDF)
- Donor Lymphocyte Infusion (CP.MP.101) (PDF)
- Donor Lymphocyte Infusion (CP.MP.101) - Revision Effective 02/15/2021 (PDF)
- Durable Medical Equipment (DME) (CP.MP.107) (PDF)
- Electric Tumor Treating Fields (Optune) (CP.MP.145) - Effective 9/01/2020 (PDF)
- Essure Removal (CP.MP.131) (PDF)
- Facet Joint Interventions for Pain Management (CP.MP.171) - Effective 10/01/2020 (PDF)
- Fecal Incontinence Treatments (CP.MP.137) - Effective 10/01/2020 (PDF)
- Fertility Preservation (CP.MP.130) (PDF)
- Fixed Wing Air Transportation (CP.MP.175) - Effective 07/15/2020 (PDF)
- Functional MRI (CP.MP.43) (PDF)
- Gastric Electrical Stimulation (CP.MP.40) (PDF)
- Gender-Affirming Procedures (CP.MP.95) (PDF)
- Genetic and Pharmacogenetic Testing (CP.MP.89) - Effective 9/01/2020 (PDF)
- Heart-Lung Transplant (CP.MP.132) - Effective 9/01/2020 (PDF)
- Home Births (CP.MP.136) - Effective 12/30/2020 (PDF)
- Home Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150) (PDF)
- Home Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150) - Revision Effective 02/15/2021 (PDF)
- Hospice Services (CP.MP.54) (PDF)
- Hyperemesis Gravidarum Treatment (CP.MP.34) (PDF)
- Hyperhidrosis Treatments (CP.MP.62) (PDF)
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (CP.MP.180) (PDF)
- Implantable Intrathecal Pain Pump (CP.MP.173) (PDF)
- Inhaled Nitric Oxide (CP.MP.87) - Effective 07/15/2020 (PDF)
- Intestinal and Multivisceral Transplant (CP.MP.58) - Effective 9/01/2020 (PDF)
- Intradiscal Steroid Injections for Pain Management (CP.MP.167) (PDF)
- Lung Transplantation (CP.MP.57) - Effective 9/01/2020 (PDF)
- Lysis of Epidural Lesions (CP.MP.116) (PDF)
- Mechanical Stretching Devices for Joint Stiffness (CP.MP.144)
- Multiple Sleep Latency Testing (CP.MP.24) (PDF)
- Neonatal Abstinence Syndrome Guidelines - Effective 12/30/20 (CP.MP.86) (PDF)
- Neonatal Sepsis Management Guidelines - Effective 10/01/2020 (CP.MP.85) (PDF)
- Nerve Blocks for Pain Management (CP.MP.170) (PDF)
- Non-Invasive Home Ventilator (CP.MP.184) - Effective 9/01/2020 (PDF)
- Non-myeloablative Allogeneic Stem Cell Transplants (CP.MP.141) (PDF)
- Obstetrical Home Health Care Programs (CP.MP.91) (PDF)
- Outpatient Cardiac Rehabilitation (CP.MP.176) (PDF)
- Outpatient Testing for Drugs of Abuse (CP.MP.50) - Effective 9/01/2020 (PDF)
- Outpatient Testing for Drugs of Abuse (CP.MP.50) - Revision Effective 02/15/2021 (PDF)
- Oxygen Use and Concentrators (CP.MP.190) - Effective 12/30/2020 (PDF)
- Pancreas Transplantation (CP.MP.102) - Effective 9/01/2020 (PDF)
- Panniculectomy (CP.MP.109) (PDF)
- Pediatric Heart Transplant (CP.MP.138) - Effective 9/01/2020 (PDF)
- Pediatric Liver Transplant (CP.MP.120) - Effective 9/01/2020 (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (CP.MP.133) (PDF)
- Private Duty Nursing (TX.CP.MP.520) (PDF)
- Proton and Neutron Beam Therapy - Effective 8/15/2016 (CP.MP.70) (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery - Effective 10/01/2020 (CP.MP.51) (PDF)
- Sacroiliac Joint Interventions for Pain Management (CP.MP.166) (PDF)
- Sclerotherapy for Varicose Veins (CP.MP.146) (PDF)
- Selective Dorsal Rhizotomy (CP.MP.174) (PDF)
- Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (CP.MP.165) (PDF)
- Short Inpatient Hospital Stay - Effective 9/15/2020 (CP.MP.182) (PDF)
- Sickle Cell Disease Observation (CP.MP.88) (PDF)
- Skin Substitutes for Chronic Wounds (CP.MP.185) - Effective 9/01/2020 (PDF)
- Spinal Cord Stimulation (CP.MP.117) (PDF)
- Tandem Transplant (CP.MP.162) (PDF)
- Therapy Services (PT/OT/ST) (CP.MP.49) (PDF)
- Thymus Transplantation (CP.MP.189) - Effective 9/01/2020 (PDF)
- Total Artificial Heart (CP.MP.127) (PDF)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (CP.MP.163) (PDF)
- Transcranial Magnetic Stimulation (CP.BH.200) - Effective 12/30/2020 (PDF)
- Trigger Point Injections for Pain Management – Effective 10/30/2020 (CP.MP.169) (PDF)
- Urinary Incontinence Devices and Treatments (CP.MP.142) (PDF)
- Vagus Nerve Stimulation –Effective 10/30/2020 (CP.MP.12) (PDF)
- Ventriculectomy and Cardiomyoplasty (CP.MP.56) (PDF)
- Wheelchair Seating - Effective 8/12/2016 (CP.MP.99) (PDF)
- Add on Code Billed Without Primary Code (CC.PP.030) (PDF)
- ADHD Assessment and Treatment - Effective 10/1/2020 (TX.CP.MP.124) (PDF)
- Allergy Testing (TX.CP.MP.100) (PDF)
- Ambulatory EEG - Effective 8/12/2016 (CP.MP.96) (PDF)
- Assistant Surgeon (CC.PP.029) (PDF)
- Bilateral Procedures (CC.PP.037) (PDF)
- Bronchial Thermoplasty - Effective 1/15/2017 (CP.MP.110) (PDF)
- Cardiac Biomarker Testing for Acute MI - Effective 8/1/2018 (CP.MP.156) (PDF)
- Cerumen Removal (CC.PP.008) (PDF)
- Clinical Validation of Modifier 25 (CC.PP.013) (PDF)
- Clinical Validation of Modifier 59 (CC.PP.014) (PDF)
- Code Editing Overview (CC.PP.011) (PDF)
- Cosmetic Procedures (CC.PP.024) (PDF)
- Diagnostic Testing Guidelines for 2019-Novel Coronavirus - Effective 4/1/2020 (CP.MP.183) (PDF)
- Digital Analysis of EEGs - Effective 8/15/2016 (CP.MP.105) (PDF)
- Distinct Procedural Modifiers (CC.PP.020) (PDF)
- Duplicate Primary Code Billing (CC.PP.044) (PDF)
- E&M Bundling with Lab-Radiology (CC.PP.010) (PDF)
- E&M Medical Decision-Making (CC.PP.051) (PDF)
- EEG in Evaluation of Headache - Effective 8/1/2018 (CP.MP.155) (PDF)
- Endometrial Ablation (EA) - Effective 8/15/2016 (CP.MP.106) (PDF)
- EpiFix Wound Treatment - Effective 9/1/2017 (CP.MP.140) (PDF)
- Evoked Potentials - Effective 5/1/2017 (CP.MP.134) (PDF)
- Global Maternity Billing (CC.PP.016) (PDF)
- H Pylori Testing - Effective 8/1/2018 (CP.MP.153) (PDF)
- Holter Monitors - Effective 11/1/2017 (CP.MP.113) (PDF)
- Homocysteine Testing - Effective 1/15/2017 (CP.MP.121) (PDF)
- Hospital Visit Codes Billed with Labs (CC.PP.023) (PDF)
- Inpatient Only Procedures (CC.PP.018) (PDF)
- Intravenous Hydration (CC.PP.012) (PDF)
- Laser Skin Treatment - Effective 1/15/2017 (CP.MP.123) (PDF)
- Leveling of Emergency Room Services - Professional (CC.PP.053) (PDF)
- Leveling of Emergency Room Services - Facility (CC.PP.064)
- Maximum Units of Service (CC.PP.007) (PDF)
- Measure Serum 1,25 Vitamin D - Effective 8/1/2018 (CP.MP.152) (PDF)
- Mechanical Stretch Devices - Effective 9/1/2017 (CP.MP.144) (PDF)
- Moderate Conscious Sedation (CC.PP.015) (PDF)
- Modifier DOS Validation (CC.PP.034) (PDF)
- Modifier to Procedure Code Validation (CC.PP.028) (PDF)
- Multiple CPT Code Replacement (CC.PP.033) (PDF)
- Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular Procedures (CC.PP.065) - Effective 1/15/2021 (PDF)
- NCCI Unbundling (CC.PP.031) (PDF)
- Never Paid Events (CC.PP.017) (PDF)
- New Patient (CC.PP.036) (PDF)
- Non-obstetrical Pelvic and Transvaginal Ultrasounds - Effective 1/15/19 (CC.PP.061) (PDF)
- Not Medically Necessary Inpatient Professional Services - Effective 1/15/19 (CC.PP.060) (PDF)
- Outpatient Consultation (CC.PP.039) (PDF)
- Physician Visit Codes Billed with Labs (CC.PP.019) (PDF)
- Place of Service Mismatch - Effective 1/15/19 (CC.PP.063) (PDF)
- Polymerase Chain Reaction (PCR) Testing - Effective 01/01/2020 (TX.PP.150) (PDF)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (CP.MP.181) - Effective 1/15 2021 (PDF)
- Post-Operative Visits (CC.PP.042) (PDF)
- Pre-Operative Visits (CC.PP.041) (PDF)
- Professional Component Modifier (CC.PP.027) (PDF)
- PROM Testing - Effective 12/15/2017 (CP.MP.149) (PDF)
- Pulse Oximetry with Office Visits (CC.PP.025) (PDF)
- Robotic Surgery - Effective 9/1/2017 (CC.PP.050) (PDF)
- Same Day Visits (CC.PP.040) (PDF)
- Sleep Studies Place of Services - Effective 5/1/2017 (CC.PP.035) (PDF)
- Status "B" Bundled Services (CC.PP.046) (PDF)
- Status "P" Bundled Services - Effective 4/1/2017 (CC.PP.049) (PDF)
- Supplies Billed on Same Day As Surgery (CC.PP.032) (PDF)
- Testing for Select Genitourinary Conditions (formerly Diagnosis of Vaginitis) - Effective 1/1/2018 (CP.MP.97) (PDF)
- Thyroid Testing in Pediatrics - Effective 8/1/2018 (CP.MP.154) (PDF)
- Transgender Related Services (CC.PP.047) (PDF)
- Ultrasound in Pregnancy - Effective 7/1/2017 (CP.MP.38) (PDF)
- Unbundled Professional Services (CC.PP.043) (PDF)
- Unbundled Surgical Procedures (CC.PP.045) (PDF)
- Unlisted Procedure Codes (CC.PP.009) (PDF)
- Urine Specimen Validity Testing - Effective 12/15/2017 (CC.PP.056) (PDF)
- Urodynamic Testing - Effective 1/1/2018 (CP.MP.98) (PDF)
- Vitamin D Testing in Children - Effective 8/1/2018 (CP.MP.157) (PDF)
- Wheelchair and Accessories - Effective 8/12/2016 (CC.PP.502) (PDF)
- Wireless Motility Capsule - Effective 9/1/2017 (CP.MP.143) (PDF)
- Abaloparatide (Tymlos) (CP.PHAR.345) - Effective 7/1/2017 (PDF)
- Abametapir (Xeglyze) (CP.PMN.253) - Effective 12/1/2020 (PDF)
- Abatacept (Orencia) (CP.PHAR.241) - Effective 6/1/2016 (PDF)
- Abiraterone (Zytiga, Yonsa) (CP.PHAR.84) - Effective 11/17/2020 (PDF)
- AbobotulinumtoxinA (Dysport) (CP.PHAR.230) - Effective 10/6/2020 (PDF)
- Aclidinium/Formoterol (Duaklir Pressair) (CP.PCH.23) - Effective 9/16/2020 (PDF)
- Adalimumab (Humira), Adalimumab-atto (Amjevita), Adalimumab-adbm (Cyltezo), Adalimumab-bwwd (Hadlima), Adalimumab-adaz (Hyrimoz) (CP.PHAR.242) - Effective 8/1/2016 (PDF)
- Adefovir (Hepsera) (CP.PHAR.142) - Effective 8/28/2018 (PDF)
- Ado-Trastuzumab Emtansine (Kadcyla) (CP.PHAR.229) - Effective 6/1/2016 (PDF)
- Afamelanotide (Scenesse) (CP.PHAR.444) - Effective 9/16/2020 (PDF)
- Afatinib (Gilotrif) (CP.PHAR.298) - Effective 1/1/2017 (PDF)
- Aflibercept (Eylea) (CP.PHAR.184) - Effective 3/1/2016 (PDF)
- Agalsidase Beta (Fabrazyme) (CP.PHAR.158) - Effective 2/1/2016 (PDF)
- Age Limit Override (Codeine, Tramadol, Hydrocodone) (CP.PMN.138) - Effective 3/13/2018 (PDF)
- Alectinib (Alecensa) (CP.PHAR.369) - Effective 11/16/2016 (PDF)
- Alemtuzumab (Lemtrada) (CP.PHAR.243) - Effective 11/17/2020 (PDF)
- Alendronate (Binosto, Fosamax Plus D) (CP.PMN.88) - Effective 3/1/2018 (PDF)
- Alglucosidase Alfa (Lumizyme) (CP.PHAR.160) - Effective 2/1/2016 (PDF)
- Alpelisib (Piqray) (CP.PHAR.430) - Effective 7/9/2019 (PDF)
- Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) - Effective 3/1/2012 (CP.PHAR.94) (PDF)
- Ambrisentan (Letairis) (CP.PHAR.190) - Effective 3/1/2016 (PDF)
- Amifampridine (Firdapse, Ruzurgi) (CP.PHAR.411) - Effective 1/22/2019 (PDF)
- Amikacin (Arikayce) - Effective 11/13/2018 (CP.PHAR.401) (PDF)
- Amisulpride (Barhemsys) (CP.PMN.236) - Effective 11/17/2020 (PDF)
- Anakinra (Kineret) - Effective 8/1/2016 (CP.PHAR.244) (PDF)
- Anti-inhibitor Coagulant Complex (Feiba) (CP.PHAR.217) - Effective 11/17/2020 (PDF)
- Antithymocyte Globulin (Atgam, Thymoglobulin) (CP.PHAR.506) - Effective 12/1/2020 (PDF)
- Apalutamide (Erleada) - Effective 6/1/2018 (CP.PHAR.376)
- Apomorphine (Apokyn) (CP.PHAR.488) - Effective 11/17/2020 (PDF)
- Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (CP.PMN.19) - Effective 11/1/2006 (PDF)
- Arformoterol tartrate (Brovana) (CP.PMN.201) - Effective 9/1/2018 (PDF)
- Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada, Aristada Initio) (CP.PHAR.290) - Effective 11/17/2020 (PDF)
- Armodafinil (Nuvigil) (CP.PMN.35) - Effective 12/1/2020 (PDF)
- Asenapine (Saphris, Secuado) (CP.PMN.15) - Effective 12/1/2014 (PDF)
- Asfotase Alfa (Strensiq) (CP.PHAR.328) - Effective 3/1/2017 (PDF)
- Aspirin/Dipyridamole (Aggrenox) (CP.PMN.20) - Effective 9/1/2006 (PDF)
- Atezolizumab (Tecentriq®) (CP.PHAR.235) - Effective 10/6/2020 (PDF)
- Avapritinib (Ayvakit) (CP.PHAR.454) - Effective 3/1/2020 (PDF)
- Avatrombopag (Doptelet) (CP.PHAR.130) - Effective 11/17/2020 (PDF)
- Avelumab (Bavencio) (CP.PHAR.333) - Effective 10/6/2020 (PDF)
- Axicabtagene Ciloleucel (Yescarta) (CP.PHAR.362) - Effective 12/1/2017 (PDF)
- Axitinib (Inlyta) (CP.PHAR.100) - Effective 5/1/2012 (PDF)
- Azacitidine (Vidaza) (CP.PHAR.387) - Effective 8/28/2018 (PDF)
- Azelaic Acid (Finacea Topical Gel) (HIM.PA.119) - Effective 12/1/2017 (PDF)
- Aztreonam (Cayston) (CP.PHAR.209) - Effective 5/1/2016 (PDF)
- Baclofen (Gablofen, Lioresal, Ozobax) (CP.PHAR.149) - Effective 12/1/2015 (PDF)
- Baricitinib (Olumiant) (CP.PHAR.135) - Effective 7/24/2018 (PDF)
- Bedaquiline (Sirturo) (CP.PMN.212) - Effective 9/4/2018 (PDF)
- Belantamab Mafodotin (Blenrep) (CP.PHAR.469) - Effective 12/1/2020 (PDF)
- Belatacept (Nulojix) (CP.PHAR.201) - Effective 3/1/2016 (PDF)
- Belimumab (Benlysta) (CP.PHAR.88) - Effective 11/17/2020 (PDF)
- Belinostat (Beleodaq) (CP.PHAR.311) - Effective 12/1/2020 (PDF)
- Bempedoic acid (Nexletol), bempedoic acid-ezetimibe (Nexlizet) (CP.PMN.237) - Effective 11/17/2020 (PDF)
- Bendamustine (Bendeka, Treanda) (CP.PHAR.307) - Effective 2/1/2017 (PDF)
- Benralizumab (Fasenra) (CP.PHAR.373) - Effective 6/1/2018 (PDF)
- Benznidazole (CP.PMN.90) - Effective 12/1/2020 (PDF)
- Betaine (Cystadane) (CP.PHAR.143) - Effective 8/28/2018 (PDF)
- Bevacizumab (Avastin, Mvasi, Zirabev) (CP.PHAR.93) - Effective 12/1/2011 (PDF)
- Bexarotene (Targretin Capsules, Gel) (CP.PHAR.75) - Effective 9/1/2011 (PDF)
- Bezlotoxumab (Zinplava) (CP.PHAR.300) - Effective 11/16/2016 (PDF)
- Bimatoprost Implant (Durysta) - Effective 6/1/2020 (CP.PHAR.486)
- Binimetinib (Mektovi) (CP.PHAR.50) - Effective 9/1/2018 (PDF)
- Biologic DMARDs (HIM.PA.SP60) - Effective 1/15/2021 (PDF)
- Blinatumomab (Blincyto) (CP.PHAR.312) - Effective 9/16/2020 (PDF)
- Bortezomib (Velcade) (CP.PHAR.410) - Effective 12/11/2018 (PDF)
- Bosentan (Tracleer) (CP.PHAR.191) - Effective 3/1/2016 (PDF)
- Bosutinib (Bosulif) (CP.PHAR.105) - Effective 10/1/2012 (PDF)
- Brand Name Override and Non-Formulary Medications (HIM.PA.103) - Effective 12/1/2014 (PDF)
- Bremelanotide (Vyleesi) (CP.PHAR.434) - Effective 8/7/2019 (PDF)
- Brentuximab (Adcetris) (CP.PHAR.303) - Effective 11/17/2020 (PDF)
- Brexanolone (Zulresso) (CP.PHAR.417) - Effective 6/1/2019 (PDF)
- Brexpiprazole (Rexulti) (CP.PMN.68) - Effective 9/16/2020 (PDF)
- Brigatinib (Alunbrig) (CP.PHAR.342) - Effective 7/7/2017 (PDF)
- Brimonidine Tartrate (Mirvaso) (CP.PMN.192) - Effective 11/16/2016 (PDF)
- Brinzolamide/Brimonidine (Simbrinza) (HIM.PA.15) - Effective 9/4/2018 (PDF)
- Brivaracetam (Briviact) (CP.PCH.26) - Effective 11/17/2020 (PDF)
- Brodalumab (Siliq) (CP.PHAR.375) - Effective 6/1/2018 (PDF)
- Brolucizumab-dbll (Beovu) (CP.PHAR.445) - Effective 3/1/2020 (PDF)
- Budesonide/Glycopyrrolate/Formoterol Fumarate (Breztri Aerosphere) (HIM.PA.150) - Effective 12/1/2020 (PDF)
- Budesonide (Pulmicort Respules) (HIM.PA.48) - Effective 9/1/2018 (PDF)
- Budesonide (Uceris) (CP.PCH.11) (PDF)
- Buprenorphine (Subutex) (CP.PMN.82) - Effective 9/1/2017 (PDF)
- Buprenorphine Implant/Injection (Probuphine/Sublocade) (CP.PHAR.289) - Effective 12/1/2016 (PDF)
- Buprenorphine Injection (Brixadi) (CP.PHAR.498) - Effective 11/17/2020 (PDF)
- Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone) (HIM.PA.35) - Effective 2/1/2017 (PDF)
- Bupropion-naltrexone (Contrave) (CP.PCH.12) - Effective 11/17/2020 (PDF)
- Burosumab-twza (Crysvita) (CP.PHAR.11) - Effective 12/1/2020 (PDF)
- Butorphanol Nasal Spray (HIM.PA.46) - Effective 12/1/2014 (PDF)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (CP.PHAR.202) - Effective 3/1/2016 (PDF)
- Cabazitaxel (Jevtana) (CP.PHAR.316) - Effective 3/1/2017 (PDF)
- Cabozantinib (Cabometyx, Cometriq) (CP.PHAR.111) - Effective 6/1/2013 (PDF)
- Calcifediol (Rayaldee) (CP.PMN.76) - Effective 11/17/2020 (PDF)
- Canakinumab (Ilaris) (CP.PHAR.246) - Effective 12/1/2020 (PDF)
- Cannabidiol (Epidiolex) (CP.PMN.164) - Effective 12/1/2020 (PDF)
- Capecitabeine (Xeloda) (CP.PHAR.60) - Effective 5/1/2011 (PDF)
- Caplacizumab-yhdp (Cablivi) (CP.PHAR.416) - Effective 3/12/2019 (PDF)
- Capmatinib (Tabrecta) (CP.PHAR.494) - Effective 11/17/2020 (PDF)
- Carbidopa-Levodopa ER Capsules (Rytary) (CP.PMN.238) - Effective 11/17/2020 (PDF)
- Carfilzomib (Kyprolis) (CP.PHAR.309) - Effective 12/1/2020 (PDF)
- Carglumic Acid (Carbaglu) (CP.PHAR.206) - Effective 5/1/2016 (PDF)
- Celecoxib (Celebrex, Elyxyb) (CP.PMN.122) - Effective 1/1/2007 (PDF)
- Cemiplimab-rwlc (Libtayo) (CP.PHAR.397) - Effective 10/16/2018 (PDF)
- Cenegermin-bkbj (Oxervate) (CP.PMN.186) - Effective 3/1/2019 (PDF)
- Cenobamate (Xcopri) (CP.PMN.231) - Effective 3/1/2020 (PDF)
- Ceritinib (Zykadia) (CP.PHAR.349) - Effective 7/1/2017 (PDF)
- Cerliponase alfa (Brineura) (CP.PHAR.338) - Effective 7/1/2017 (PDF)
- Certolizumab (Cimzia) (CP.PHAR.247) - Effective 8/1/2016 (PDF)
- Cetuximab (Erbitux) (CP.PHAR.317) - Effective 12/1/2020 (PDF)
- Chenodiol (Chenodal) (CP.PMN.239) - Effective 11/17/2020 (PDF)
- Chlorambucil (Leukeran) (HIM.PA.SP59) - Effective 8/28/2018 (PDF)
- Chloramphenicol Sodium Succinate (CP.PHAR.388) - Effective 12/1/2018 (PDF)
- Cholic Acid (Cholbam) (CP.PHAR.390) - Effective 12/1/2018 (PDF)
- Ciclesonide (Alvesco) (HIM.PA.65) - Effective 11/17/2020 (PDF)
- Cinacalcet (Sensipar) (CP.PHAR.61) - Effective 9/16/2020 (PDF)
- Ciprofloxacin/Dexamethasone (Ciprodex) (CP.PMN.248) - Effective 12/1/2020 (PDF)
- Ciprofloxacin/Fluocinolone (Otovel) (CP.PMN.249) - Effective 12/1/2020 (PDF)
- Cladribine (Mavenclad) (CP.PHAR.422) - Effective 11/17/2020 (PDF)
- Clobazam (Onfi, Sympazan) (CP.PMN.54) - Effective 12/1/2012 (PDF)
- Colesevelam (Welchol) (CP.PMN.250) - Effective 12/1/2020 (PDF)
- CNS Stimulants (CP.PMN.92) - Effective 3/1/2018 (PDF)
- Cobimetinib (Cotellic) (CP.PHAR.380) - Effective 11/16/2016 (PDF)
- Collagenase Clostridium Histolyticum (Xiaflex) (CP.PHAR.82) - Effective 11/17/2020 (PDF)
- Colonoscopy Preparation Products (HIM.PA.04) - Effective 1/15/2021 (PDF)
- Compounded Medications (CP.PCH.27) - Effective 11/17/2020 (PDF)
- Conjugated Estrogens/Bazedoxifene (Duavee) (HIM.PA.140) - Effective 10/24/2017 (PDF)
- Continuous Glucose Monitors (CP.PMN.214) - Effective 9/3/2019 (PDF)
- Continuous Insulin Delivery Systems (V-Go, Omnipod) (CP.PHAR.505) - Effective 12/1/2020 (PDF)
- Copanlisib (Aliqopa) (CP.PHAR.357) - Effective 10/17/2017 (PDF)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (CP.PHAR.385) - Effective 12/1/2020 (PDF)
- Corticotropin (H.P. Acthar) (CP.PHAR.168) - Effective 11/17/2020 (PDF)
- Cosyntropin (Cortrosyn) (CP.PHAR.203) - Effective 4/1/2016 (PDF)
- Crisaborole (Eucrisa) (CP.PMN.110) - Effective 2/21/2017 (PDF)
- Crizanlizumab-tmca (Adakveo) (CP.PHAR.449) - Effective 3/1/2020 (PDF)
- Crizotinib (Xalkori) (CP.PHAR.90) - Effective 11/1/2011 (PDF)
- Cyclosprine (Cequa, Restasis) (CP.PMN.48) - Effective 5/1/2012 (PDF)
- Cysteamine ophthalmic (Cystaran) (CP.PMN.130) - Effective 8/1/2017 (PDF)
- Cysteamine oral (Cystagon, Procysbi) (CP.PHAR.155) - Effective 2/1/2016 (PDF)
- Cytomegalovirus Immune Globulin (CytoGam) (CP.PHAR.277) - Effective 11/17/2020 (PDF)
- Dabrafenib (Tafinlar) (CP.PHAR.239) - Effective 11/16/2016 (PDF)
- Dacomitinib (Vizimpro) (CP.PHAR.399) - Effective 10/16/2018 (PDF)
- Daclatasvir (Daklinza) (HIM.PA.SP27) - Effective 11/17/2020 (PDF)
- Dalfampridine (Ampyra) (CP.PHAR.248) - Effective 8/1/2016 (PDF)
- Dalteparin (Fragmin) (CP.PHAR.225) - Effective 5/1/2016 (PDF)
- Dapsone (Aczone Gel) (CP.PCH.32) - Effective 12/1/2020 (PDF)
- Daptomycin (Cubicin, Cubicin RF) (CP.PHAR.351) - Effective 11/17/2020 (PDF)
- Daratumumab, Daratumumab-Hyaluronidase-fihj (Darzalex, Darzalex Faspro) (CP.PHAR.310) - Effective 10/6/2020 (PDF)
- Darbepoetin Alfa (Aranesp) (CP.PHAR.236) - Effective 11/17/2020 (PDF)
- Darolutamide (Nubeqa) (CP.PHAR.435) - Effective 9/3/2019 (PDF)
- Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) (HIM.PA.SP61) - Effective 11/17/2020 (PDF)
- Dasatinib (Sprycel) (CP.PHAR.72) - Effective 6/1/2012 (PDF)
- Daunorubicin-cytarabine (Vyxeos) (CP.PHAR.352) - Effective 12/1/2017 (PDF)
- Decitabine/Cedazuridine (Inqovi) (CP.PHAR.479) - Effective 12/1/2020 (PDF)
- Deferasirox (Exjade, Jadenu) (CP.PHAR.145) - Effective 11/17/2020 (PDF)
- Deferoxamine (Desferal) (CP.PHAR.146) - Effective 9/16/2020 (PDF)
- Deflazacort (Emflaza) (CP.PHAR.331) - Effective 4/1/2017 (PDF)
- Degarelix Acetate (Firmagon) (CP.PHAR.170) - Effective 10/1/2016 (PDF)
- Delafloxacin (Baxdela) (CP.PMN.115) - Effective 12/1/2017 (PDF)
- Denosumab (Prolia, Xgeva) (CP.PHAR.58) - Effective 3/1/2011 (PDF)
- Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (CP.PHAR.214) - Effective 5/1/2016 (PDF)
- Deutetrabenazine (Austedo) (CP.PHAR.341) - Effective 11/17/2020 (PDF)
- Dexlansoprazole (Dexilant) (HIM.PA.05) - Effective 1/1/2020 (PDF)
- Dexrazoxane (Zinecard, Totect) (CP.PHAR.418) - Effective 3/19/2019 (PDF)
- Dextromethorphan-Quinidine (Nuedexta) (CP.PMN.93) - Effective 12/5/2017 (PDF)
- Diazepam Nasal Spray (Valtoco) (CP.PMN.216) - Effective 12/1/2019 (PDF)
- Dichlorphenamide (Keveyis) (CP.PCH.04) - Effective 9/16/2020 (PDF)
- Diclofenac (Cambia, Flector, Pennsaid, Solaraze, Zipsor, Zorvolex) (CP.PCH.28) - Effective 11/17/2020 (PDF)
- Dimethyl fumarate (Tecfidera), diroximel fumarate (Vumerity) (CP.PHAR.249) - Effective 11/17/2020 (PDF)
- Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (HIM.PA.58) - Effective 1/1/2021 (PDF)
- Dolasetron (Anzemet) (CP.PMN.141) - Effective 9/1/2006 (PDF)
- Dornase alfa (Pulmozyme) (CP.PHAR.212) - Effective 11/17/2020 (PDF)
- Doxepin (Silenor, Prudoxin, Zonalon) (HIM.PA.147) - Effective 11/17/2017 (PDF)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (CP.PMN.79) - Effective 6/1/2017 (PDF)
- Dupilumab (Dupixent) (CP.PHAR.336) - Effective 11/17/2020 (PDF)
- Durvalumab (Imfinzi) (CP.PHAR.339) - Effective 7/1/2017 (PDF)
- Duvelisib (Copiktra) (CP.PHAR.400) - Effective 10/16/2018 (PDF)
- Ecallantide (Kalbitor) (CP.PHAR.177) - Effective 3/1/2016 (PDF)
- Eculizumab (Soliris) (CP.PHAR.97) - Effective 3/1/2012 (PDF)
- Edaravone (Radicava) (CP.PHAR.343) - Effective 7/1/2017 (PDF)
- Efinaconazole (Jublia) (CP.PMN.25) - Effective 8/1/2016 (PDF)
- Elagolix (Orilissa) (CP.PHAR.136) - Effective 8/28/2018 (PDF)
- Elapegademase-lvlr (Revcovi) (CP.PHAR.419) - Effective 4/23/2019 (PDF)
- Elbasvir/Grazoprevir (Zepatier) (HIM.PA.SP62) - Effective 11/17/2020 (PDF)
- Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (CP.PHAR.440) - Effective 9/16/2020 (PDF)
- Eliglustat (Cerdelga) (CP.PHAR.153) - Effective 2/1/2016 (PDF)
- Elosulfase Alfa (Vimizim) (CP.PHAR.162) - Effective 2/1/2016 (PDF)
- Elotuzumab (Empliciti) (CP.PHAR.308) - Effective 2/1/2017 (PDF)
- Eltrombopag (Promacta) (CP.PHAR.180) - Effective 11/17/2020 (PDF)
- Emapalumab-lzsg (Gamifant) (CP.PHAR.402) - Effective 12/11/2018 (PDF)
- Emicizumab-kxwh (Hemlibra) (CP.PHAR.370) - Effective 11/17/2020 (PDF)
- Emtricitabine/Tenofovir Alafenamide (Descovy) (CP.PMN.235) - Effective 11/17/2020 (PDF)
- Enasidenib (Idhifa) (CP.PHAR.363) - Effective 9/5/2017 (PDF)
- Encorafenib (Braftovi) (CP.PHAR.127) - Effective 9/1/2018 (PDF)
- Enfortumab Vedotin-ejfv (Padcev) (CP.PHAR.455) - Effective 3/1/2020 (PDF)
- Enfuvirtide (Fuzeon) (CP.PHAR.41) - Effective 6/1/2010 (PDF)
- Entecavir (Baraclude) (HIM.PA.08) - Effective 6/1/2019 (PDF)
- Entrectinib (Rozlytrek) (CP.PHAR.441) - Effective 9/16/2020 (PDF)
- Enzalutamide (Xtandi) (CP.PHAR.106) - Effective 10/1/2012 (PDF)
- Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) (CP.PHAR.237) - Effective 10/6/2020 (PDF)
- Epoprostenol (Flolan, Veletri) (CP.PHAR.192) - Effective 3/1/2016 (PDF)
- Eptinezumab-jjmr (Vyepti) (HIM.PA.SP64) - Effective 1/1/2021 (PDF)
- Erdafitinib (Balversa) (CP.PHAR.423) - Effective 9/16/2020 (PDF)
- Erenumab-aaoe (Aimovig) (HIM.PA.SP65) - Effective 10/1/2020 (PDF)
- Eribulin Mesylate (Halaven) (CP.PHAR.318) - Effective 3/1/2017 (PDF)
- Erlotinib (Tarceva) (CP.PHAR.74) - Effective 9/16/2020 (PDF)
- Erwinia Asparaginase (Erwinaze) (CP.PHAR.301) - Effective 2/1/2017 (PDF)
- Esketamine (Spravato) (CP.PMN.199) - Effective 11/17/2020 (PDF)
- Etelcalcetide (Parsabiv) (CP.PHAR.379) - Effective 11/17/2020 (PDF)
- Eteplirsen (Exondys 51) (CP.PHAR.288) - Effective 1/1/2017 (PDF)
- Everolimus (Afinitor, Afinitor Disperz, Zortress) (CP.PHAR.63) - Effective 9/16/2020 (PDF)
- Evolocumab (Repatha) (CP.PHAR.123) - Effective 10/1/2015 (PDF)
- Factor IX Human Recombinant (CP.PHAR.218) - Effective 11/17/2020 (PDF)
- Factor IX Complex, Human (Profilnine) (CP.PHAR.219) - Effective 5/1/2016 (PDF)
- Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (CP.PHAR.220) (PDF) - Effective 5/1/2016 (PDF)
- Factor VIII (CP.PHAR.215) - Effective 10/6/2020 (PDF)
- Factor VIII-von Willebrand (Alphanate, Humate-P, Vonvendi, Wilate) (CP.PHAR.216) - Effective 11/17/2020 (PDF)
- Factor XIIIa Recombinant (Tretten) (CP.PHAR.222) - Effective 11/17/2020 (PDF)
- Factor XIII Human (Corifact) (CP.PHAR.221) - Effective 11/17/2020 (PDF)
- Fam-trastuzumab Deruxtecan-nxki (Enhertu) (CP.PHAR.456) - Effective 3/1/2020 (PDF)
- Febuxostat (Uloric) (CP.PMN.57) - Effective 8/1/2013 (PDF)
- Fedratinib (Inrebic) (CP.PHAR.442) - Effective 1/1/2021 (PDF)
- Fenfluramine (Fintepla) (CP.PMN.246) - Effective 11/17/2020 (PDF)
- Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (CP.PMN.127) - Effective 6/1/2015 (PDF)
- Ferric Carboxymaltose (Injectafer) (CP.PHAR.234) - Effective 6/1/2016 (PDF)
- Ferric Derisomaltose (Monoferric) (CP.PHAR.480) - Effective 6/1/2020 (PDF)
- Ferric Gluconate (Ferrlecit) (CP.PHAR.166) - Effective 3/1/2016 (PDF)
- Ferric Maltol (Accrufer) (CP.PMN.213) - Effective 9/3/2019 (PDF)
- Ferumoxytol (Feraheme) (CP.PHAR.165) - Effective 3/1/2016 (PDF)
- Filgrastim (Neupogen, Zarxio, Granix, Nivestym) (CP.PHAR.297) - Effective 10/6/2020 (PDF)
- Fingolimod (Gilenya) (CP.PHAR.251) - Effective 11/17/2020 (PDF)
- Fluorouracil Cream (Tolak) (CP.PMN.165) - Effective 12/1/2018 (PDF)
- Fluticasone Propionate (Xhance) (CP.PMN.95) - Effective 3/1/2018 (PDF)
- Fondaparinux (Arixtra) (CP.PHAR.226) - Effective 5/1/2016 (PDF)
- Formulary Medications without Specific Guidelines (HIM.PA.33) - Effective 12/1/2020 (PDF)
- Fostamatinib (Tavalisse) (CP.PHAR.24) - Effective 6/5/2018 (PDF)
- Fremanezumab-vfrm (Ajovy) (HIM.PA.SP66) - Effective 1/1/2021 (PDF)
- Fulvestrant (Faslodex Injection) (CP.PHAR.424) - Effective 9/16/2020 (PDF)
- Gabapentin ER (Gralise, Horizant) (CP.PMN.240) - Effective 11/17/2020 (PDF)
- Galcanezumab-gnlm (Emgality) (HIM.PA.SP67) - Effective 10/6/2020 (PDF)
- Galsulfase (Naglazyme) (CP.PHAR.161) - Effective 2/1/2016 (PDF)
- Gefitinib (Iressa) (CP.PHAR.68) - Effective 11/16/2016 (PDF)
- Gemtuzumab Ozogamicin (Mylotarg) (CP.PHAR.358) - Effective 12/1/2020 (PDF)
- Gilteritinib (Xospata) (CP.PHAR.412) - Effective 1/15/2019 (PDF)
- Givosiran (Givlaari) (CP.PHAR.457) - Effective 9/16/2020 (PDF)
- Glasdegib (Daurismo) (CP.PHAR.413) - Effective 1/8/2019 (PDF)
- Glatiramer (Copaxone, Glatopa) (CP.PHAR.252) - Effective 11/17/2020 (PDF)
- Glecaprevir/Pibrentasvir (Mavyret) (HIM.PA.SP36) - Effective 9/16/2020 (PDF)
- GLP-1 receptor agonists (HIM.PA.53) - Effective 11/17/2020 (PDF)
- Glycerol Phenylbutyrate (Ravicti) (CP.PHAR.207) - Effective 5/1/2016 (PDF)
- Golimumab (Simponi, Simponi Aria) (CP.PHAR.253) - Effective 7/1/2016 (PDF)
- Golodirsen (Vyondys 53) (CP.PHAR.453) - Effective 3/1/2020 (PDF)
- Goserelin Acetate (Zoladex) (CP.PHAR.171) - Effective 10/1/2016 (PDF)
- Granisetron (Kytril, Sancuso, Sustol) (CP.PMN.74) - Effective 11/1/2016 (PDF)
- Guselkumab (Tremfya) (CP.PHAR.364) - Effective 12/1/2020 (PDF)
- Halcinonide (Halog) (HIM.PA.20) - Effective 8/28/2018 (PDF)
- Halobetasol-Tazarotene (Duobrii) (CP.PMN.208) - Effective 11/17/2020 (PDF)
- Hemin (Panhematin) (CP.PHAR.181) - Effective 2/1/2016 (PDF)
- Histrelin Acetate (Vantas, Supprelin LA) (CP.PHAR.172) - Effective 10/1/2016 (PDF)
- House Dust Mite Allergen Extract (Odactra) (CP.PMN.111) - Effective 11/17/2020 (PDF)
- Hyaluronate Derivatives (CP.PHAR.05) - Effective 12/1/2020 (PDF)
- Hydroxyprogesterone caproate (Makena) (CP.PHAR.14) - Effective 11/17/2020 (PDF)
- Hydroxyurea (Siklos) (CP.PMN.193) - Effective 2/19/2019 (PDF)
- Ibalizumab-uiyk (Trogarzo) (CP.PHAR.378) - Effective 6/1/2018 (PDF)
- Ibandronate Injection (Boniva) (CP.PHAR.189) - Effective 11/15/2017 (PDF)
- Ibrutinib (Imbruvica) (CP.PHAR.126) - Effective 10/1/2015 (PDF)
- Ibuprofen/Famotidine (Duexis) (CP.PMN.120) - Effective 6/1/2018 (PDF)
- Icatibant (Firazyr) (CP.PHAR.178) - Effective 3/1/2016 (PDF)
- Icosapent Ethyl (Vascepa) (CP.PMN.187) - Effective 3/1/2019 (PDF)
- Idelalisib (Zydelig) (CP.PHAR.133) - Effective 12/1/2018 (PDF)
- Idursulfase (Elaprase) (CP.PHAR.156) - Effective 2/1/2016 (PDF)
- Iloperidone (Fanapt) (CP.PMN.32) - Effective 9/1/2015 (PDF)
- Iloprost (Ventavis) (CP.PHAR.193) - Effective 3/1/2016 (PDF)
- Imatinib (Gleevec) (CP.PHAR.65) - Effective 6/1/2011 (PDF)
- Imiglucerase (Cerezyme) (CP.PHAR.154) - Effective 2/1/2016 (PDF)
- Immune Globulins (CP.PHAR.103) - Effective 11/17/2020 (PDF)
- IncobotulinumtoxinA (Xeomin) (CP.PHAR.231) - Effective 7/1/2016 (PDF)
- Indacaterol (Arcapta Neohaler) (CP.PMN.203) - Effective 1/1/2021 (PDF)
- Indacaterol/Glycopyrrolate (Utibron Neohaler) (HIM.PA.102) - Effective 1/1/2021 (PDF)
- Inebilizumab (CP.PHAR.458) - Effective 11/17/2020 (PDF)
- Infertility and Fertility Preservation (CP.PHAR.131) - Effective 11/17/2020 (PDF)
- Infliximab (Remicade), Infliximab-axxq (Avsola), Infliximab-dyyb (Inflectra), and Infliximab-abda (Renflexis) (CP.PHAR.254) - Effective 1/15/2021 (PDF)
- Inotersen (Tegsedi) (CP.PHAR.405) - Effective 11/20/2018 (PDF)
- Inotuzumab Ozogamicin (Besponsa) (CP.PHAR.359) - Effective 9/26/2017 (PDF)
- Insulin Degludec (Tresiba), Insulin Glargine (Semglee) (HIM.PA.09) - Effective 12/1/2020 (PDF)
- Interferon beta-1a (Avonex, Rebif) (CP.PHAR.255) - Effective 11/17/2020 (PDF)
- Interferon beta-1b (Betaseron, Extavia) (CP.PHAR.256) - Effective 11/17/2020 (PDF)
- Interferon Gamma-1b (Actimmune) (CP.PHAR.52) - Effective 6/1/2010 (PDF)
- Iobenguane I-131 (Azedra) (CP.PHAR.459) - Effective 3/1/2020 (PDF)
- Ipilimumab (Yervoy) (CP.PHAR.319) - Effective 9/16/2020 (PDF)
- Irinotecan Liposome (Onivyde) (CP.PHAR.304) - Effective 2/1/2017 (PDF)
- Isavuconazonium (Cresemba) (CP.PMN.154) - Effective 11/16/2016 (PDF)
- Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (CP.PMN.143) - Effective 12/1/2014 (PDF)
- Istradefylline (Nourianz) (CP.PMN.217) - Effective 3/1/2020 (PDF)
- Itraconazole (Sporanox ,Onmel, Tolsura) (CP.PMN.124) - Effective 11/17/2020 (PDF)
- Ivabradine (Corlanor) (CP.PMN.70) - Effective 11/1/2015 (PDF)
- Ivacaftor (Kalydeco) (CP.PHAR.210) - Effective 11/10/2020 (PDF)
- Ivermectin (Sklice) (HIM.PA.124) - Effective 12/1/2017 (PDF)
- Ivosidenib (Tibsovo) (CP.PHAR.137) - Effective 12/1/2020 (PDF)
- Ixazomib (Ninlaro) (CP.PHAR.302) - Effective 9/16/2020 (PDF)
- Ixekizumab (Taltz) (CP.PHAR.257) - Effective 12/1/2020 (PDF)
- KTE-X19 (Tecartus) (CP.PHAR.472) - Effective 11/17/2020 (PDF)
- Lactic Acid/Citric Acid/Potassium Bitartrate (Phexxi) (CP.PMN.251) - Effective 12/1/2020 (PDF)
- Lactitol (Pizensy) (CP.PMN.241) - Effective 11/17/2020 (PDF)
- Lacosamide (Vimpat) (CP.PMN.155) - Effective 12/1/2014 (PDF)
- Lanadelumab-fylo (Takhzyro) (CP.PHAR.396) - Effective 9/25/2018 (PDF)
- Lanreotide (Somatuline Depot) (CP.PHAR.391) - Effective 12/1/2020 (PDF)
- Lapatinib (Tykerb) (CP.PHAR.79) - Effective 10/1/2011 (PDF)
- Laronidase (Aldurazyme) (CP.PHAR.152) - Effective 2/1/2016 (PDF)
- Larotrectinib (Vitrakvi) (CP.PHAR.414) - Effective 1/1/2020 (PDF)
- Lasmiditan (Reyvow) (CP.PMN.218) - Effective 3/1/2020 (PDF)
- Ledipasvir/Sofosbuvir (Harvoni) (HIM.PA.SP3) - Effective 11/17/2020 (PDF)
- Lefamulin (Xenleta) (CP.PMN.219) - Effective 3/1/2020 (PDF)
- Lemborexant (Dayvigo) (CP.PMN.233) - Effective 6/1/2020 (PDF)
- Lenalidomide (Revlimid) (CP.PHAR.71) - Effective 7/1/2011 (PDF)
- Lenvatinib (Lenvima) (CP.PHAR.138) - Effective 12/1/2018 (PDF)
- Lenvatinib (Lenvima) (CP.PHAR.128) - Effective 12/1/2020 (PDF)
- Lesinurad (Zurampic), Duzallo (CP.PMN.150) - Effective 11/16/2016 (PDF)
- Letermovir (Prevymis) (CP.PHAR.367) - Effective 3/1/2018 (PDF)
- Leucovorin Injection (CP.PHAR.393) - Effective 12/1/2018 (PDF)
- Leuprolide Acetate (CP.PHAR.173) - Effective 9/16/2020 (PDF)
- Levalbuterol (Xopenex HFA/Inhalation Solution) (CP.PMN.07) - Effective 9/1/2006 (PDF)
- Levoleucovorin (Fusilev) (CP.PHAR.151) - Effective 12/1/2020 (PDF)
- Levomilnacipran (Fetzima) (HIM.PA.125) - Effective 12/1/2017 (PDF)
- Lidocaine Transdermal (Lidoderm, ZTlido) (CP.PMN.08) - Effective 9/16/2020 (PDF)
- Lifitegrast (Xiidra) (CP.PMN.73) - Effective 11/1/2016 (PDF)
- Linaclotide (Linzess) (CP.PMN.71) - Effective 11/1/2015 (PDF)
- Linezolid (Zyvox) (CP.PMN.27) - Effective 11/01/2020 (PDF)
- Lofexidine (Lucemyra) (CP.PMN.152) - Effective 7/31/2018 (PDF)
- Lomustine (Gleostine) (CP.PHAR.507) - Effective 12/1/2020 (PDF)
- Lonafarnib (Zokinvy) (CP.PHAR.499) - Effective 11/17/2020 (PDF)
- Lorcaserin (Belviq, Belviq XR) (CP.PCH.03) - Effective 11/17/2020 (PDF)
- Lorlatinib (Lorbrena) (CP.PHAR.406) - Effective 12/11/2018 (PDF)
- Lubiprostone (Amitiza) (CP.PMN.142) - Effective 12/1/2014 (PDF)
- Luliconazole Cream (Luzu) (CP.PMN.166) - Effective 8/28/2018 (PDF)
- Lumacaftor-ivacaftor (Orkambi) (CP.PHAR.213) - Effective 11/17/2020 (PDF)
- Lumateperone (Caplyta) (CP.PMN.232) - Effective 3/1/2020 (PDF)
- Lurasidone (Latuda) (CP.PMN.50) - Effective 9/1/2015 (PDF)
- Lurbinectedin (Zepzelca) (CP.PHAR.500) - Effective 11/17/2020 (PDF)
- Luspatercept-aamt (Reblozyl) (CP.PHAR.450) - Effective 9/16/2020 (PDF)
- Lusutrombopag (Mulpleta) (CP.PHAR.407) - Effective 9/18/2018 (PDF)
- Lutetium Lu 177 dotatate (Lutathera) (CP.PHAR.384) - Effective 11/17/2020 (PDF)
- Mecamylamine (Vecamyl) (CP.PMN.136) - Effective 6/1/2017 (PDF)
- Mecasermin (Increlex) (CP.PHAR.150) - Effective 11/17/2020 (PDF)
- Mechlorethamine (Valchlor) (CP.PHAR.381) - Effective 11/17/2020 (PDF)
- Mecitentan (Opsumit) (CP.PCH.31) - Effective 3/1/2016 (PDF)
- Megestrol Acetate (Megace ES) (CP.PMN.179) - Effective 12/1/2018 (PDF)
- Memantine (Namenda XR, Namzaric) (CP.PCH.30) - Effective 11/17/2020 (PDF)
- Mepolizumab (Nucala) (CP.PHAR.200) - Effective 5/1/2016 (PDF)
- Metformin ER (Fortamet, Glumetza) (CP.PMN.72) - Effective 12/1/2015 (PDF)
- Methotrexate (Otrexup, Rasuvo, Reditrex, Xatmep) (CP.PHAR.134) - Effective 12/1/2018 (PDF)
- Methoxsalen (Uvadex) (HIM.PA.17) - Effective 9/4/2018 (PDF)
- Methoxy polyethylene glycol-epoetin beta (Mircera) (CP.PHAR.238) - Effective 11/17/2020 (PDF)
- Methylnaltrexone Bromide (Relistor) (CP.PMN.169) - Effective 12/1/2018 (PDF)
- Metoclopramide (Gimoti) (CP.PMN.252) - Effective 12/1/2020 (PDF)
- Metreleptin (Myalept) (CP.PHAR.425) - Effective 11/16/2016 (PDF)
- Midazolam (Nayzilam) (CP.PMN.211) - Effective 6/25/2019 (PDF)
- Midostaurin (Rydapt) (CP.PHAR.344) - Effective 6/1/2017 (PDF)
- Mifepristone (Korlym) (CP.PHAR.101) - Effective 5/1/2012 (PDF)
- Migalastat (Galafold) (CP.PHAR.394) - Effective 9/11/2018 (PDF)
- Miglustat (Zavesca) (CP.PHAR.164) - Effective 2/1/2016 (PDF)
- Milnacipran (Savella) (CP.PMN.125) - Effective 8/1/2012 (PDF)
- Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) (CP.PMN.80) - Effective 12/1/2020 (PDF)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) (CP.PHAR.495) - Effective 11/17/2020 (PDF)
- Mitoxantrone (Novantrone) (CP.PHAR.258) - Effective 11/17/2020 (PDF)
- Modafinil (Provigil) (CP.PMN.39) - Effective 12/1/2020 (PDF)
- Mogamulizumab-kpkc (Poteligeo) (CP.PHAR.139) - Effective 9/4/2018 (PDF)
- Mometasone (Nasonex) (HIM.PA.93) - Effective 11/17/2020 (PDF)
- Mometasone Furoate (Sinuva) (CP.PHAR.448) - Effective 3/1/2020 (PDF)
- Monomethyl fumarate (Bafiertam) (CP.PHAR.460) - Effective 11/17/2020 (PDF)
- Montelukast Oral Granules (Singulair) (HIM.PA.129) - Effective 12/1/2017 (PDF)
- Moxetumomab Pasudotox-tdfk (Lumoxiti) (CP.PHAR.398) - Effective 10/16/2018 (PDF)
- Nafarelin Acetate (Synarel) (CP.PHAR.174) - Effective 10/1/2016 (PDF)
- Naloxone (Evzio) (CP.PMN.139) - Effective 11/16/2016 (PDF)
- Naltrexone (Vivitrol) (CP.PHAR.96) - Effective 3/1/2012 (PDF)
- Naproxen Oral Suspension (Naprosyn) (HIM.PA.130) - Effective 12/1/2017 (PDF)
- Naproxen/Esomeprazole (Vimovo) (CP.PMN.117) - Effective 6/1/2018 (PDF)
- Natalizumab (Tysabri) (HIM.PA.SP17) - Effective 11/17/2020 (PDF)
- Nebivolol (Bystolic) (HIM.PA.131) - Effective 1/15/2021 (PDF)
- Necitumumab (Portrazza) (CP.PHAR.320) - Effective 3/1/2017 (PDF)
- Neomycin/Fluocinolone Cream (Neo-Synalar) (CP.PMN.167) - Effective 8/28/2018 (PDF)
- Neratinib (Nerlynx) (CP.PHAR.365) - Effective 9/16/2020 (PDF)
- Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan) (CP.PMN.118) - Effective 2/13/2018 (PDF)
- Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (CP.PMN.158) - Effective 9/16/2020 (PDF)
- Nifurtimox (Lampit) (CP.PMN.256) - Effective 12/1/2020 (PDF)
- Nilotinib (Tasigna) (CP.PHAR.76) - Effective 9/1/2011 (PDF)
- Nintedanib (Ofev) (CP.PHAR.285) - Effective 9/16/2020 (PDF)
- Nitisinone (Nityr, Orfadin) (CP.PHAR.132) - Effective 8/28/2018 (PDF)
- Nivolumab (Opdivo) (CP.PHAR.121) - Effective 9/16/2020 (PDF)
- No Coverage Criteria (CP.PMN.255) - Effective 12/1/2020 (PDF)
- Non-Formulary and Formulary Contraceptives (HIM.PA.100) - Effective 5/1/2015 (PDF)
- Non-Formulary Test Strips (HIM.PA.34) - Effective 2/1/2016 (PDF)
- Nusinersen (Spinraza) (CP.PHAR.327) - Effective 11/17/2020 (PDF)
- Off-Label Use (CP.PMN.53) - Effective 12/1/2020 (PDF)
- Obeticholic Aacid (Ocaliva) (CP.PHAR.287) - Effective 9/16/2020 (PDF)
- Obinutuzumab (Gazyva) (CP.PHAR.305) - Effective 2/1/2017 (PDF)
- Ocrelizumab (Ocrevus) (CP.PHAR.335) - Effective 11/17/2020 (PDF)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (CP.PHAR.40) - Effective 9/16/2020 (PDF)
- Ofatumumab (Arzerra) (CP.PHAR.306) - Effective 2/1/2017 (PDF)
- Olanzapine Long-Acting Injection (Zyprexa Relprevv) (CP.PHAR.292) - Effective 11/17/2020 (PDF)
- Olaparib (Lynparza) (CP.PHAR.360) - Effective 9/16/2020 (PDF)
- Olaratumab (Lartruvo) (CP.PHAR.326) - Effective 3/1/2017 (PDF)
- Omadacycline (Nuzyra) (CP.PMN.188) - Effective 3/1/2019 (PDF)
- Omalizumab (Xolair) (CP.PHAR.01) - Effective 10/1/2008 (PDF)
- Omecetaxine (Synribo) (CP.PHAR.108) - Effective 1/0/1900 (PDF)
- OnabotulinumtoxinA (Botox) (CP.PHAR.232) - Effective 12/1/2020 (PDF)
- Onasemnogene Abeparvovec (Zolgensma) (CP.PHAR.421) - Effective 11/17/2020 (PDF)
- Ondansetron (Zuplenz) (CP.PMN.45) - Effective 9/1/2006 (PDF)
- Ophthalmic Corticosteroids (HIM.PA.03) - Effective 1/1/2020 (PDF)
- Opicapone (Ongentys) (CP.PMN.245) - Effective 11/17/2020 (PDF)
- Opioid Analgesics* (HIM.PA.139) - Effective 1/15/2021 (PDF)
- Osilodrostat (Isturisa) (CP.PHAR.487) - Effective 11/17/2020 (PDF)
- Osimertinib (Tagrisso) (CP.PHAR.294) - Effective 12/1/2016 (PDF)
- Ospemifene (Osphena) (CP.PMN.168) - Effective 8/28/2018 (PDF)
- Overactive Bladder Agents (CP.PMN.198) - Effective 11/17/2020 (PDF)
- Ozanimod (Zeposia) (CP.PHAR.462) - Effective 11/17/2020 (PDF)
- Ozenoxacin (Xepi) (CP.PMN.119) - Effective 6/1/2018 (PDF)
- Paclitaxel, Protein-Bound (Abraxane) (CP.PHAR.176) - Effective 7/1/2015 (PDF)
- Palbociclib (Ibrance) (CP.PHAR.125) - Effective 9/16/2020 (PDF)
- Paliperidone Long-Acting Injections (Invega Sustenna, Invega Trinza) (CP.PHAR.291) - Effective 11/17/2020 (PDF)
- Palivizumab (Synagis) (CP.PHAR.16) - Effective 9/16/2020 (PDF)
- Panitumumab (Vectibix) (CP.PHAR.321) - Effective 12/1/2020 (PDF)
- Panobinostat (Farydak) (CP.PHAR.382) - Effective 11/17/2020 (PDF)
- Parathyroid Hormone (Natpara) (CP.PHAR.282) - Effective 11/16/2016 (PDF)
- Paricalcitol Injection (Zemplar) (CP.PHAR.270) - Effective 9/16/2020 (PDF)
- Pasireotide (Signifor, Signifor LAR) (CP.PHAR.332) - Effective 3/1/2017 (PDF)
- Patisiran (Onpattro) (CP.PHAR.395) - Effective 9/11/2018 (PDF)
- Pazopanib (Votrient) (CP.PHAR.81) - Effective 11/17/2020 (PDF)
- Peanut Allergen Powder-dnfp (Palforzia) (CP.PMN.220) - Effective 3/1/2020 (PDF)
- Pegademase Bovine (Adagen) (CP.PHAR.392) - Effective 8/28/2018 (PDF)
- Pegaptanib (Macugen) (CP.PHAR.185) - Effective 3/1/2016 (PDF)
- Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (CP.PHAR.353) - Effective 12/1/2020 (PDF)
- Pegfilgrastim (Neulasta), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo), Pegfilgrastin-apgf (Nyvepria) (CP.PHAR.296) - Effective 01/01/2021 (PDF)
- Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) (CP.PHAR.89) - Effective 11/17/2020 (PDF)
- Peginterferon beta-1a (Plegridy) (CP.PHAR.271) - Effective 11/17/2020 (PDF)
- Pegloticase (Krystexxa) (CP.PHAR.115) - Effective 6/1/2013 (PDF)
- Pegvaliase-pqpz (Palynziq) (CP.PHAR.140) - Effective 7/31/2018 (PDF)
- Pegvisomant (Somavert) (CP.PHAR.389) - Effective 12/1/2018 (PDF)
- Pembrolizumab (Keytruda) (CP.PHAR.322) - Effective 1/15/2021 (PDF)
- Pemetrexed (Alimta, Pemfexy) (CP.PHAR.368) - Effective 10/31/2017 (PDF)
- Pemigatinib (Pemazyre)(CP.PHAR.496) - Effective 11/17/2020 (PDF)
- Penicillamine (Cuprimine) (CP.PCH.09) - Effective 12/1/2018 (PDF)
- Perampanel (Fycompa) (CP.PMN.156) - Effective 11/16/2016 (PDF)
- Pertuzumab (Perjeta) (CP.PHAR.227) - Effective 6/1/2016 (PDF)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (CP.PHAR.501) - Effective 11/17/2020 (PDF)
- Pexidartinib (Turalio) (CP.PHAR.436) - Effective 9/3/2019 (PDF)
- Phendimetrazine (Bontril PDM) (HIM.PA.114) - Effective 11/17/2020 (PDF)
- Phentermine (Adipex-P, Lomaira) (CP.PCH.13) - Effective 11/17/2020 (PDF)
- Pimavanserin (Nuplazid) (CP.PMN.140) - Effective 11/17/2020 (PDF)
- Pirfenidone (Esbriet) (CP.PHAR.286) - Effective 11/17/2020 (PDF)
- Pitolisant (Wakix) (CP.PMN.221) - Effective 12/1/2020 (PDF)
- Plerixafor (Mozobil) (CP.PHAR.323) - Effective 3/1/2017 (PDF)
- Polatuzumab vedotin-piiq (Polivy) (CP.PHAR.433) - Effective 1/15/2021 (PDF)
- Pomalidomide (Pomalyst) (CP.PHAR.116) - Effective 9/16/2020 (PDF)
- Ponatinib (Iclusig) (CP.PHAR.112) - Effective 6/1/2013 (PDF)
- Potassium Chloride for Oral Solution (Klor-Con Powder) (HIM.PA.143) - Effective 10/31/2017 (PDF)
- Pralatrexate (Folotyn) (CP.PHAR.313) - Effective 2/1/2017 (PDF)
- Pramlintide (Symlin) (CP.PMN.129) - Effective 6/1/2018 (PDF)
- Pregabalin (Lyrica, Lyrica CR) (CP.PMN.33) - Effective 1/1/2007 (PDF)
- Pretomanid (CP.PMN.222) - Effective 3/1/2020 (PDF)
- Progesterone (Crinone, Endometrin, Milprosa) (CP.PMN.243) - Effective 11/17/2020 (PDF)
- Propranolol HCl Oral Solution (Hemangeol) (CP.PMN.58) - Effective 5/1/2014 (PDF)
- Protein C Concentrate, Human (Ceprotin) (CP.PHAR.330) - Effective 3/1/2017 (PDF)
- Prucalopride (Motegrity) (CP.PMN.194) - Effective 1/29/2019 (PDF)
- Pyrimethamine (Daraprim) (CP.PMN.44) - Effective 11/17/2020 (PDF)
- Quetiapine Extended-Release (Seroquel XR) (CP.PMN.64) - Effective 9/16/2020 (PDF)
- Quinine (Qualaquin) (CP.PCH.10) - Effective 12/1/2018 (PDF)
- Ramucirumab (Cyramza) (CP.PHAR.119) - Effective 12/1/2020 (PDF)
- Ranibizumab (Lucentis) (CP.PHAR.186) - Effective 3/1/2016 (PDF)
- Rasagiline (Azilect) (HIM.PA.89) - Effective 12/1/2014 (PDF)
- Ravulizumab-cwvz (Ultomiris) (CP.PHAR.415) - Effective 6/1/2019 (PDF)
- Regorafenib (Stivarga) (CP.PHAR.107) - Effective 12/1/2012 (PDF)
- Reslizumab (Cinqair) (CP.PHAR.223) - Effective 6/1/2016 (PDF)
- Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (CP.PHAR.141) - Effective 12/1/2020 (PDF)
- Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) (CP.PMN.223) - Effective 3/1/2020 (PDF)
- Rifamycin (Aemcolo) (CP.PMN.196) - Effective 6/1/2019 (PDF)
- Rifaximin (Xifaxan) (CP.PMN.47) - Effective 11/1/2011 (PDF)
- Rilonacept (Arcalyst) (CP.PHAR.266) - Effective 11/16/2016 (PDF)
- RimabotulinumtoxinB (Myobloc) (CP.PHAR.233) - Effective 7/1/2016 (PDF)
- Rimegepant (Nurtec ODT) (CP.PHAR.490) - Effective 11/17/2020 (PDF)
- Riociguat (Adempas) (CP.PHAR.195) - Effective 3/1/2016 (PDF)
- Ripretinib (Qinlock) (CP.PHAR.502) - Effective 11/17/2020 (PDF)
- Risankizumab-rzaa (Skyrizi) (CP.PHAR.426) - Effective 6/4/2019 (PDF)
- Risdiplam (Evrysdi) (CP.PHAR.477) - Effective 11/17/2020 (PDF)
- Risedronate (Actonel, Atelvia) (CP.PMN.100) - Effective 3/1/2018 (PDF)
- Risperidone LA Injection (Risperdal Consta, Perseris) (CP.PHAR.293) - Effective 12/1/2016Risankizumab-rzaa (Skyrizi) (CP.PHAR.426) - Effective 6/4/2019 (PDF)
- Rituximab (Rituxan, Ruxience, Truxima, Rituxan Hycela) (CP.PHAR.260) - Effective 11/17/2020 (PDF)
- Rolapitant (Varubi) (CP.PMN.102) - Effective 2/1/2017 (PDF)
- Romidepsin (Istodax) (CP.PHAR.314) - Effective 1/1/2017 (PDF)
- Romiplostim (Nplate) (CP.PHAR.179) - Effective 11/17/2020 (PDF)
- Romosozumab-aqqg (Evenity) (CP.PHAR.428) - Effective 5/21/2019 (PDF)
- Rucaparib (Rubraca) (CP.PHAR.350) - Effective 9/16/2020 (PDF)
- Rufinamide (Banzel) (CP.PMN.157) - Effective 12/1/2014 (PDF)
- Ruxolitinib (Jakafi) (CP.PHAR.98) - Effective 3/1/2012 (PDF)
- Sacituzumab govitecan-hziy (Trodelvy) (CP.PHAR.475) - Effective 11/17/2020 (PDF)
- Sacubitril/Valsartan (Entresto) (CP.PMN.67) - Effective 11/1/2015 (PDF)
- Safinamide (Xadago) (CP.PMN.113) - Effective 7/1/2017 (PDF)
- Sapropterin Dihydrochloride (Kuvan) (CP.PHAR.43) - Effective 2/1/2010 (PDF)
- Sarecycline (Seysara) (CP.PMN.189) - Effective 3/1/2019 (PDF)
- Sargramostim (Leukine) (CP.PHAR.295) - Effective 9/16/2020 (PDF)
- Sarilumab (Kevzara) (CP.PHAR.346) - Effective 7/28/2017 (PDF)
- Sebelipase Alfa (Kanuma) (CP.PHAR.159) - Effective 2/1/2016 (PDF)
- Secnidazole (Solosec) (CP.PMN.103) - Effective 3/1/2018 (PDF)
- Secukinumab (Cosentyx) (CP.PHAR.261) - Effective 12/1/2020 (PDF)
- Selexipag (Uptravi®) (CP.PHAR.196) - Effective 3/1/2016 (PDF)
- Selinexor (Xpovio) (CP.PHAR.431) - Effective 9/16/2020 (PDF)
- Selpercatinib (Retevmo) (CP.PHAR.478) - Effective 11/17/2020 (PDF)
- Selumetinib (Koselugo) (CP.PHAR.464) - Effective 4/10/2020 (PDF)
- Semaglutide (Rybelsus) (HIM.PA.02) - Effective 3/1/2020 (PDF)
- Setmelanotide (RM-493) (CP.PHAR.491) - Effective 11/17/2020 (PDF)
- Sildenafil (Revatio) (CP.PHAR.197) - Effective 3/1/2016 (PDF)
- Sildenafil for ED (Viagra) (CP.PCH.07) - Effective 6/1/2018 (PDF)
- Siltuximab (Sylvant) (CP.PHAR.329) - Effective 3/1/2017 (PDF)
- Siponimod (Mayzent) (CP.PHAR.427) - Effective 11/17/2020 (PDF)
- Sipuleucel-T (Provenge) (CP.PHAR.120) - Effective 7/1/2015 (PDF)
- Short Ragweed Pollen Allergen Extract (Ragwitek) (CP.PMN.83) - Effective 11/17/2020 (PDF)
- Sodium Oxybate (Xyrem) (CP.PMN.42) - Effective 12/1/2020 (PDF)
- Sodium phenylbutyrate (Buphenyl) (CP.PHAR.208) - Effective 5/1/2016 (PDF)
- Sodium-Glucose Co-Transporter 2 (SGLT2) inhibitors (HIM.PA.91) - Effective 1/1/2021 (PDF)
- Sofosbuvir (Sovaldi) (HIM.PA.SP2) - Effective 11/17/2020 (PDF)
- Sofosbuvir/Velpatasvir (Epclusa) (HIM.PA.SP1) - Effective 9/16/2020 (PDF)
- Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (HIM.PA.SP63) - Effective 9/16/2020 (PDF)
- Solriamfetol (Sunosi) (CP.PMN.209) - Effective 12/1/2020 (PDF)
- Somatropin (Human Growth Hormone_HGH) (CP.PCH.25) - Effective 11/17/2020 (PDF)
- Sonidegib (Odomzo) (CP.PHAR.272) - Effective 5/1/2012 (PDF)
- Sorafenib (Nexavar) (CP.PHAR.69) - Effective 7/1/2011 (PDF)
- Spinosad (Natroba) (HIM.PA.134) - Effective 12/1/2017 (PDF)
- Step Therapy (HIM.PA.109) - Effective 1/1/2021 (PDF)
- Stiripentol (Diacomit) (CP.PMN.184) - Effective 9/25/2018 (PDF)
- Sucroferric Oxyhydroxide (Velphoro) (HIM.PA.SP30) - Effective 5/1/2017 (PDF)
- Sunitinib (Sutent) (CP.PHAR.73) - Effective 9/1/2011 (PDF)
- Suvorexant (Belsomra) (CP.PMN.109) - Effective 2/1/2017 (PDF)
- Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair) (CP.PMN.85) - Effective 11/16/2016 (PDF)
- Tadalafil (Adcirca, Alyq) (CP.PHAR.198) - Effective 3/1/2016 (PDF)
- Tadalafil BPH - ED (Cialis) (CP.PMN.132) - Effective 9/16/2020 (PDF)
- Tafamidis (Vyndaqel, Vyndamax) (CP.PHAR.432) - Effective 9/1/2019 (PDF)
- Tafasitamab-cxix (Monjuvi) (CP.PHAR.508) - Effective 12/1/2020 (PDF)
- Talazoparib (Talzenna) (CP.PHAR.409) - Effective 11/17/2020 (PDF)
- Taliglucerase Alfa (Elelyso) (CP.PHAR.157) - Effective 1/15/2021 (PDF)
- Tazarotene (Arazlo, Fabior, Tazorac) (CP.PMN.244) - Effective 12/1/2020 (PDF)
- Tasimelteon (Hetlioz) (CP.PMN.104) - Effective 3/1/2017 (PDF)
- Tavaborole (Kerydin) (CP.PMN.105) - Effective 3/1/2018 (PDF)
- Tazarotene (Arazlo, Fabior, Tazorac) (CP.PMN.244) - Effective 11/17/2020 (PDF)
- Tazemetostat (Tazverik) (CP.PHAR.452) - Effective 9/16/2020 (PDF)
- Tedizolid (Sivextro) (CP.PMN.62) - Effective 11/01/2020 (PDF)
- Teduglutide (Gattex) (CP.PHAR.114) - Effective 5/1/2013 (PDF)
- Telotristat Ethyl (Xermelo) (CP.PHAR.337) - Effective 6/1/2017 (PDF)
- Temozolomide (Temodar) (CP.PHAR.77) - Effective 9/1/2011 (PDF)
- Temsirolimus (Torisel) (CP.PHAR.324) - Effective 3/1/2017 (PDF)
- Tenapanor (Ibsrela) (CP.PMN.224) - Effective 3/1/2020 (PDF)
- Tenofovir Alafenamide Fumarate (Vemlidy) (CP.PCH.33) - Effective 12/1/2020 (PDF)
- Teplizumab (PRV-031) (CP.PHAR.492) - Effective 11/17/2020 (PDF)
- Teprotumumab (Tepezza) (CP.PHAR.465) - Effective 9/16/2020 (PDF)
- Teriflunomide (Aubagio) (CP.PHAR.262) - Effective 11/17/2020 (PDF)
- Teriparatide (Forteo) (CP.PHAR.188) - Effective 11/15/2017 (PDF)
- Tesamorelin (Egrifta) (CP.PHAR.109) - Effective 9/16/2020 (PDF)
- Testosterone (Androderm) (HIM.PA.87) - Effective 12/1/2014 (PDF)
- Testosterone (Testopel, Jatenzo) (CP.PHAR.354) - Effective 12/1/2020 (PDF)
- Tetrabenazine (Xenazine) (CP.PHAR.92) - Effective 11/17/2020 (PDF)
- Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (CP.PHAR.377) - Effective 4/3/2018 (PDF)
- Thalidomide (Thalomid) (CP.PHAR.78) - Effective 12/1/2020 (PDF)
- Thioguanine (Tabloid) (CP.PHAR.437) - Effective 9/4/2018 (PDF)
- Thyrotropin Alfa (Thyrogen) (CP.PHAR.95) - Effective 11/17/2020 (PDF)
- Tildrakizumab-asmn (Ilumya) (CP.PHAR.386) - Effective 5/1/2018 (PDF)
- Timothy Grass Pollen Allergen Extract (Grastek) (CP.PMN.84) - Effective 11/16/2016 (PDF)
- Tisagenlecleucel (Kymriah) (CP.PHAR.361) - Effective 12/1/2017 (PDF)
- Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (CP.PHAR.211) - Effective 5/1/2016 (PDF)
- Tocilizumab (Actemra) (CP.PHAR.263) - Effective 7/1/2016 (PDF)
- Tofacitinib (Xeljanz, Xeljanz XR) (CP.PHAR.267) - Effective 1/30/2018 (PDF)
- Tolvaptan (Jynarque, Samsca) (CP.PHAR.27) - Effective 9/16/2020 (PDF)
- Topical Acne Treatment (HIM.PA.71) - Effective 12/1/2020 (PDF)
- Topical Immunomodulators (CP.PMN.107) - Effective 9/1/2006 (PDF)
- Topotecan (Hycamtin) (CP.PHAR.64) - Effective 6/1/2011 (PDF)
- Trabectedin (Yondelis) (CP.PHAR.204) - Effective 5/1/2016 (PDF)
- Trametinib (Mekinist) (CP.PHAR.240) - Effective 7/1/2016 (PDF)
- Trastuzumab, Biosimilars, Trastuzumab-Hyaluronidase (CP.PHAR.228) - Effective 6/1/2016 (PDF)
- Treprostinil (Orenitram, Remodulin, Tyvaso) (CP.PHAR.199) - Effective 11/17/2020 (PDF)
- Triamcinolone ER Injection (Zilretta) (CP.PHAR.371) - Effective 12/11/2018 (PDF)
- Triclabendazole (Egaten) (CP.PMN.207) - Effective 4/2/2019 (PDF)
- Trientine (Syprine) (CP.PHAR.438) - Effective 12/1/2018 (PDF)
- Trifarotene (Aklief) (CP.PMN.225) - Effective 9/16/2020 (PDF)
- Trifluridine-tipiracil (Lonsurf) (CP.PHAR.383) - Effective 11/17/2020 (PDF)
- Triheptanoin (Dojolvi) (CP.PHAR.509) - Effective 12/1/2020 (PDF)
- Triptorelin pamoate (Trelstar, Triptodur) (CP.PHAR.175) - Effective 10/1/2016 (PDF)
- Tucatinib (Tukysa) (CP.PHAR.497) - Effective 11/17/2020 (PDF)
- Ubrogepant (Ubrelvy) (CP.PHAR.476) - Effective 9/16/2020 (PDF)
- Umeclidinium/Vilanterol (Anoro Ellipta) (CP.PMN.149) - Effective 12/1/2020 (PDF)
- Unoprostone Isopropyl (Rescula) (HIM.PA.11) - Effective 9/4/2018 (PDF)
- Uridine triacetate (Vistogard) (HIM.PA.SP55) - Effective 12/1/2017 (PDF)
- Ustekinumab (Stelara) (CP.PHAR.264) - Effective 10/6/2020 (PDF)
- Valganciclovir (Valcyte) (CP.PCH.06) - Effective 12/1/2017 (PDF)
- Valproate (Depacon) (CP.PHAR.429) - Effective 6/4/2019 (PDF)
- Valrubicin (Valstar) (CP.PHAR.439) - Effective 12/1/2020 (PDF)
- Vandetanib (Caprelsa) (CP.PHAR.80) - Effective 10/1/2011 (PDF)
- Vedolizumab (Entyvio) (CP.PHAR.265) - Effective 7/1/2016 (PDF)
- Velaglucerase Alfa (VPRIV) (CP.PHAR.163) - Effective 2/1/2016 (PDF)
- Vemurafenib (Zelboraf) (CP.PHAR.91) - Effective 11/1/2011 (PDF)
- Venetoclax (Venclexta) (CP.PHAR.129) - Effective 12/1/2020 (PDF)
- Verteporfin (Visudyne) (CP.PHAR.187) - Effective 3/1/2016 (PDF)
- Vestronidase alfa-vjbk (Mepsevii) (CP.PHAR.374) - Effective 1/9/2018 (PDF)
- Vigabatrin (Sabril) (CP.PHAR.169) - Effective 9/16/2020 (PDF)
- Vilazodone (Viibryd) (CP.PMN.145) - Effective 8/1/2012 (PDF)
- Viltolarsen(Viltepso) (CP.PHAR.484) - Effective 11/17/2020 (PDF)
- Vincristine Sulfate Liposome Injection (Marqibo) - Effective 12/1/2020 (PDF)
- Vismodegib (Erivedge) (CP.PHAR.273) - Effective 8/1/2016 (PDF)
- Vorapaxar (Zontivity) (HIM.PA.146) - Effective 10/31/2017 (PDF)
- Voretigene Neparvovec-rzyl (Luxturna) (CP.PHAR.372) - Effective 3/1/2018 (PDF)
- Vorinostat (Zolinza) (CP.PHAR.83) - Effective 9/16/2020 (PDF)
- Vortioxetine (Trintellix) (CP.PMN.65) - Effective 9/16/2020 (PDF)
- Voxelotor (Oxbryta) (CP.PHAR.451) - Effective 3/1/2020 (PDF)
- Zanubrutinib (Brukinsa) (CP.PHAR.467) - Effective 3/1/2020 (PDF)
- Ziv-aflibercept (Zaltrap) (CP.PHAR.325) - Effective 3/1/2017 (PDF)
- Zoledronic Acid (Reclast, Zometa) (CP.PHAR.59) - Effective 3/1/2011 (PDF)
Archived Policies
- Eptinezumab (Vyepti) (CP.PCH.29) - Effective 6/1/2011 (PDF) – RETIRED (Ambetter 1/1/2021)
- Fremanezumab-vfrm (Ajovy) (CP.PCH.17) - Effective 3/1/2020 (PDF) – RETIRED (Ambetter 1/1/2021)
- Applied Behavioral Analysis for Autism (CP.MP.104) (PDF) – RETIRED (Ambetter 12/30/2020)
- Cell-free Fetal DNA Testing (CP.MP.84) (PDF) – RETIRED (Ambetter 12/30/2020)
- Neonatal Abstinence Syndrome Guidelines (CP.MP.86) (PDF) – RETIRED (Ambetter 12/30/2020)
- Genetic Testing (TX.CP.MP.531) (PDF) – RETIRED (Medicaid and CHIP 12/30/2020)
- Enteral Nutrition (TX.CP.MP.550) (PDF) – RETIRED (Medicaid and CHIP 12/30/2020)
- Magnetoencephalography (TX.CP.MP.570) – RETIRED (Medicaid and CHIP 12/30/2020)
- Antithymocyte Globulin (Thymoglobulin, Atgam) (HIM.PA.16) - RETIRED (Ambetter - 12/1/2020)
- Ciprofloxacin/Dexamethasone (Ciprodex) (HIM.PA.120) - Effective 12/1/2017 (PDF) - RETIRED (Ambetter - 12/1/2020)
- Ciprofloxacin/Fluocinolone (Otovel) (HIM.PA.14) - Effective 9/4/2018 (PDF) - RETIRED (Ambetter - 12/1/2020)
- Clindamycin (Evoclin) (HIM.PA.21) - Effective 8/28/2018 (PDF) - RETIRED (Ambetter - 12/1/2020)
- Clindamycin Phosphate/Benzoyl Peroxide (BenzaClin) (HIM.PA.31) - Effective 12/1/2018 (PDF) - RETIRED (Ambetter - 12/1/2020)
- Colesevelam (WelChol) (HIM.PA.121) - Effective 12/1/2017 (PDF) - RETIRED (Ambetter - 12/1/2020)
- Insulin Infusion Pump (Omnipod, Omnipod DASH) (CP.PHAR.420) - Effective 4/23/2019 (PDF) - RETIRED (Ambetter - 12/1/2020)
- Lomustine (Gleostine) (HIM.PA.19) - Effective 8/28/2018 (PDF) - RETIRED (Ambetter - 12/1/2020)
- Mesalamine (Apriso) (HIM.PA.42) - Effective 9/4/2018 (PDF) - RETIRED (Ambetter - 12/1/2020)
- Topical Diclofenac (Solaraze, Flector) (HIM.PA.123) (PDF) - RETIRED (Ambetter - 12/1/2020)
- Apomorphine (Apokyn) (CP.PCH.14) (PDF) - RETIRED (Ambetter - 11/17/2020)
- Brivaracetam (Briviact) (HIM.PA.07) (PDF) - RETIRED (Ambetter - 11/17/2020)
- Daclatasvir (Daklinza) (CP.PCH.15) (PDF) - RETIRED (Ambetter - 11/17/2020)
- Elbasvir/Grazoprevir (Zepatier) (CP.PCH.16) (PDF) - RETIRED (Ambetter - 11/17/2020)
- Ledipasvir/Sofosbuvir (Harvoni) (CP.PCH.19) (PDF) - RETIRED (Ambetter - 11/17/2020)
- Sofosbuvir (Sovaldi) (CP.PCH.20) (PDF) - RETIRED (Ambetter - 11/17/2020)
- Topical Diclofenac (Solaraze, Flector) (HIM.PA.123) (PDF) - RETIRED (Ambetter - 11/17/2020)
- Trigger Point Injections for Pain Management (CP.MP.169) (PDF) - RETIRED (Ambetter - 10/30/2020)
- Vagus Nerve Stimulation (CP.MP.12) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 10/30/2020)
- Facet Joint Interventions for Pain Management (CP.MP.171) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 10/1/2020)
- Fecal Incontinence Treatments (CP.MP.137) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 10/1/2020)
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 10/1/2020)
- Neonatal Sepsis Management Guidelines (CP.MP.85) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 10/1/2020)
- Physician’s Office Lab Testing (CC.PP.055) (PDF) – IMPLEMENTATION CANCELLED
- Monitored Anesthesia Care for Gastrointestinal Endoscopy - Effective 1/15/19 (CP.MP.161) PDF) - RETIRED (Medicaid and CHIP - 7/18/2019, Medicare - 7/22/2019, MarketPlace - 7/22/2019)
- Rituximab - Effective 11/1/2017 (CP.PHAR.260) (PDF) - RETIRED (Medicaid and CHIP, Medicare, Ambetter - 1/1/ 2019)
- Alpelisib (Piqray) (CP.PHAR.430) (PDF) - RETIRED
- Rivastigmine (Exelon) (CP.PMN.101) (PDF) - RETIRED
- Segesterone-Ethinyl Estradiol (Annovera) (CP.PMN.190) (PDF - RETIRED)
- Siponimod (Mayzent) (HIM.PA.SP37) (PDF) - RETIRED
- Somatropin (Human Growth Hormone) (HIM.PA.SP39) (PDF) - RETIRED
- Tafenoquine (Arakoda, Krintafel) (CP.PMN.178) (PDF) - RETIRED
- Enoxaparin (Lovenox) (CP.PHAR.224) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Halobetasol-Tazarotene (Duobrii) (CP.PMN.208) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Isavuconazonium (Cresemba) (HIM.PA.108) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Ixekizumab (Taltz) (CP.PHAR.257) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Naloxone (Evzio) (CP.PMN.139) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Olodaterol (Striverdi Respimat) (CP.PMN.204) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Peginterferon Beta-1a (Plegridy) (HIM.PA.SP18) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Revefenacin (Yupelri) (CP.PMN.195) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Sodium Zirconium Cyclosilicate (Lokelma) (CP.PMN.163) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Tegaserod (Zelnorm) (CP.PMN.206) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Teriflunomide (Aubagio) (CP.PCH.02) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Umeclidinium-vilanterol (Anoro Ellipta) (HIM.PA.106) (PDF) - RETIRED (Ambetter - 6/1/2020)
- Digital Breast Tomosynthesis (DBT) (CP.MP.90) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 10/5/2018)
- Fecal Calprotectin Assay (CP.MP.135) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 12/14/2018)
- Assertive Community Treatment (TX.CP.MP.548) (PDF) - RETIRED (Medicaid and CHIP - 3/20/2020)
- Home Telemonitoring Services (TX.CP.MP.547) (PDF) - RETIRED (Medicaid and CHIP - 3/18/2020)
- Standard Manual Wheelchair or Standard Power Wheeled Mobility Systems (TX.CP.MP.519) (PDF) - RETIRED (Medicaid and CHIP - 4/15/2020)
- Emtricitabine-Tenofovir (Truvada) (HIM.PA.78) - RETIRED (Ambetter - 9/16/2020)
- Glecaprevir/Pibrentasvir (Mavyret) (CP.PCH.18) - RETIRED (Ambetter - 9/16/2020)
- Sofosbuvir/Velpatasvir (Epclusa) (CP.PCH.21) - RETIRED (Ambetter - 9/16/2020)
- Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (CP.PCH.22) - RETIRED (Ambetter - 9/16/2020)
- Erenumab-aaoe (Aimovig) (CP.PHAR.128) - Effective 7/10/2018 (PDF) - RETIRED (Ambetter - 10/6/2020)
- Galcanezumab-gnlm (Emgality) (CP.PCH.24) - Effective 1/1/2020 (PDF) - RETIRED (Ambetter - 10/6/2020)