Georgia Clinical Payment Policies | Ambetter from Peach State Health Plan

 

Clinical & Payment Policies

Clinical Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules.  They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies.  Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

All policies found in the Peach State Health Plan Clinical Policy Manual apply to Peach State Health Plan members. Policies in the Peach State Health Plan Clinical Policy Manual may have either a Peach State Health Plan or a “Centene” heading.  Peach State Health Plan utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Peach State Health Plan clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Peach State Health Plan. In addition, Peach State Health Plan may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or  InterQual®criteria is payable by Peach State Health Plan.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

 

POLICY TITLE POLICY NUMBER EFFECTIVE DATE
25-Hydroxyvitamin D Testing in Children and Adolescents (PDF) CP.MP.157 December 29, 2017
Acupuncture (PDF) CP.MP.92 December 31, 2013
ADHD Assessment and Treatment (PDF) CP.MP.124 December 31, 2013
Air Ambulance (PDF) CP.MP.175 April 30, 2019
Allergy Testing and Therapy (PDF) CP.MP.100 August 31, 2016
Allogeneic Hematopoietic Cell Transplants for Sickle Cell (PDF) CP.MP.108 March 31, 2016
Ambulatory EEG (PDF) CP.MP.96 September 30, 2015
Ambulatory Surgery Center Optimization (PDF) CP.MP.158 February 16, 2018
Antithrombin III (Thrombate III, Atryn) (PDF) CP.MP.179 October 31, 2020
Articular Cartilage Defect Repairs (PDF) CP.MP.26 October 31, 2008
Assisted Reproductive Technology (PDF) CP.MP.55 March 31, 2014
Balloon Sinus Ostial Dilation (PDF) CP.MP.119 July 29, 2016
Bariatric Surgery (PDF) CP.MP.37 June 11, 2009
Biofeedback (PDF) CP.MP.168 July 31, 2017
Bone-Anchored Hearing Aid (PDF) CP.MP.93 December 31, 2013
Bronchial Thermoplasty (PDF) CP.MP.110 May 31, 2016
Burn Surgery (PDF) CP.MP.186 May 31, 2020
Cardiac Biomarker Testing (PDF) CP.MP.156 December 29, 2017
Carrier Screening in Pregnancy (PDF) CP.MP.83 July 31, 2013
Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF) CP.MP.164 August 31, 2018
Cell-Free Fetal DNA Testing (PDF) CP.MP.84 August 31, 2013
Clinical Trials (PDF) CP.MP.94 January 27, 2014
Cochlear Implant Replacements (PDF) CP.MP.14 March 20, 2009
Cosmetic and Reconstructive Surgery (PDF) CP.MP.31 March 31, 2009
Dental Anesthesia (PDF) CP.MP.61 June 1, 2013
Diaphragmatic/Phrenic Nerve Stimulation (PDF) CP.MP.203 December 31, 2020
Digital EEG Spike Analysis (PDF) CP.MP.105 January 15, 2016
Disc Decompression Procedures (PDF) CP.MP.114 July 31, 2016
Discography (PDF) CP.MP.115 August 30, 2016
DNA Analysis of Stool (PDF) CP.MP.125 September 30, 2016
Donor Lymphocyte Infusion (PDF) CP.MP.101 December 1, 2015
Drugs of Abuse:  Definitive Testing (PDF) CP.MP.50 February 28, 2021
Drugs of Abuse:  Presumptive Testing (PDF) CP.MP.208 February 28, 2021
Durable Medical Equipment (DME) (PDF) CP.MP.107 June 30, 2009
Electric Breast Pumps (PDF) GA.CP.MP.500 April 1, 2020
Electric Tumor Treating Fields (PDF) CP.MP.145 May 31, 2017
EEG in the Evaluation of Headache (PDF) CP.MP.155 December 29, 2017
Endometrial Ablation (PDF) CP.MP.106 March 1, 2016
EpiFix Wound Treatment (PDF) CP.MP.140 April 30, 2017
Essure Removal (PDF) CP.MP.131 November 30, 2016
Evoked Potential Testing (PDF) CP.MP.134 November 30, 2016
Experimental Technologies (PDF) CP.MP.36 June 30, 2009
Facet Joint Interventions for Pain Management (PDF) CP.MP.171 September 14, 2018
Fecal Incontinence Treatments (PDF) CP.MP.137 December 30, 2016
Ferriscan R2-MRI (PDF) CP.MP.53 November 14, 2012
Fertility Preservation (PDF) CP.MP.130 October 30, 2016
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) CP.MP.129 October 30, 2016
Fractionated Exhaled Nitric Oxide (PDF) CP.MP.103 January 27, 2016
Functional MRI (PDF) CP.MP.43 September 23, 2009
Gastric Electrical Stimulation (PDF) CP.MP.40 July 30, 2009
Gender Affirming Procedures (PDF) CP.MP.95 November 28, 2014
Gender Reassignment Surgery (PDF) CP.MP.95 November 28, 2014
Genetic Testing (PDF) CP.MP.89 November 30, 2013
Helicobacter Pylori Serology Testing (PDF) CP.MP.153 December 29, 2017
Heart-Lung Transplant (PDF) CP.MP.132 June 30, 2017
Holter Monitors (PDF) CP.MP.113 August 30, 2016
Home Birth (PDF) CP.MP.136 December 30, 2016
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) CP.MP.150 December 21, 2017
Homocysteine Testing (PDF) CP.MP.121 August 30, 2016
Hospice Services (PDF) CP.MP.54 July 30, 2014
Hyperbaric Oxygen Therapy (PDF) CP.MP.27 Juen 30, 2009
Hyperemesis Gravidarum Treatment (PDF) CP.MP.34 March 31, 2009
Hyperhidrosis Treatments (PDF) CP.MP.62 May 16, 2013
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) CP.MP.180 November 30, 2020
Implantable Intrathecal Pain Pump (PDF) CP.MP.173 February 28, 2019
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 April 30, 2018
Incontinence and Ostomy Supplies (PDF) GA.CP.MP.07 Novmeber 18, 2015
Infant Apnea Monitors (PDF) GA.CP.MP.06 November 20, 2015
Inhaled Nitric Oxide (PDF) CP.MP.87 August 30, 2013
Insulin Testing in Pediatrics (PDF) GA.CP.MP.154 July 1, 2018
Intensity-Modulated Radiotherapy (PDF) CP.MP.69 March 31, 2014
Intestinal and Multivisceral Transplant (PDF) CP.MP.58 February 28, 2014
Intradiscal Steroid Injections for Pain Management (PDF) CP.MP.167 August 31, 2018
Laser Therapy for Skin Conditions (PDF) CP.MP.123 August 30, 2016
Long Acting Reversible Contraception (LARC) (PDF) GA.CP.MP.10 September 17, 2017
Long Term Care Placement Criteria (PDF) CP.MP.71 July 11, 2018
Low-Frequency Ultrasound Therapy for Wound Management (PDF) CP.MP.139 February 28, 2017
Lung Transplantation (PDF) CP.MP.57 February 28, 2014
Lysis of Epidural Lesions (PDF) CP.MP.116 July 31, 2018
Measurement of Serum 1,25-dihydroxyvitamin D (PDF) CP.MP.152 December 29, 2017
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) CP.MP.144 April 30, 2017
Medical Necessity for Authorizing Incontinence Supplies (PDF) GA.MP.07 November 18, 2015
Multiple Sleep Latency Testing (PDF) CP.MP.24 October 31, 2008
Nebulizer with Compressor (PDF) GA.CP.MP.501 April 29, 2020
Neonatal Abstinence Syndrome Guidelines (PDF) CP.MP.86 October 30, 2013
Neonatal Sepsis Management (PDF) CP.MP.85 August 30, 2013
Nerve Blocks for Pain Management (PDF) CP.MP.170 August 31, 2018
NICU Apnea Bradycardia Guidelines (PDF) CP.MP.82 June 30, 2013
NICU Discharge Guidelines (PDF) CP.MP.81 June 30, 2013
Non-Invasive Home Ventilator (PDF) CP.MP.184 May 31, 2020
Non-myeloablative Allogeneic Stem Cell Transplants (PDF) CP.MP.141 April 28, 2017
Obstetrical Home Care Programs (PDF) CP.MP.91 January 27, 2014
Optic Nerve Decompression Surgery (PDF) CP.MP.128 September 30, 2016
Outpatient Cardiac Rehabilitation (PDF) CP.MP.176 May 31, 2019
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 September 30, 2012
Oxygen Use and Concentrators (PDF) CP.MP.190 December 2, 2020
Pancreas Transplantation (PDF) CP.MP.102 April 29, 2016
Panniculectomy (PDF) CP.MP.109 April 30, 2016
Pediatric Heart Transplant (PDF) CP.MP.138 January 31, 2017
Pediatric Liver Transplant (PDF) CP.MP.120 April 30, 2018
Pediatric Oral Function Therapy (PDF) CP.MP.188 May 31, 2020
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) CP.MP.147 July 31, 2017
Physical, Occupational, Speech, and/or Feeding Therapy (PDF) GA.CP.MP.49 March 23, 2009
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) CP.MP.181 December 2, 2020
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) CP.MP.133 October 30, 2016
Proton and Neutron Beam Therapy (PDF) CP.MP.70 March 31, 2014
Radial Head Implant (PDF) CP.MP.148 August 31, 2017
Radiofrequency Ablation of Uterine Fibroids (PDF) CP.MP.187 April 30, 2020
Reduction Mammaplasty (PDF) CP.MP.51 July 31, 2012
Sacroiliac Joint Fusion (PDF) CP.MP.126 September 30, 2016
Sacroiliac Joint Interventions for Pain Management (PDF) CP.MP.166 August 31, 2018
Selective Dorsal Rhizotomy (PDF) CP.MP.174 March 31, 2019
Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF) CP.MP.165 August 31, 2018
Sclerotherapy for Varicose Veins (PDF) CP.MP.146 June 30, 2017
Short Inpatient Hospital Stay (PDF) CP.MP.182 May 29, 2020
Sickle Cell Disease Observation (PDF) CP.MP.88 September 30, 2013
Skilled Nursing Facility Leveling (PDF) CP.MP.206 December 31, 2020
Skin Substitutes for Chronic Wounds (PDF) CP.MP.185 April 20, 2020
Spinal Cord Stimulation (PDF) CP.MP.117 July 31, 2016
Stereotactic Body Radiation Therapy (PDF) CP.MP.22 December 30, 2008
Tandem Transplant (PDF) CP.MP.162 July 31, 2018
Testing of Rupture of Fetal Membranes (PDF) CP.MP.149 August 30, 2017
Testing for Select Genitourinary Conditions (PDF) CP.MP.97 June 15, 2016
Thymus Transplantation (PDF) CP.MP.189 June 30, 2020
Thyroid and Insulin Testing in Pediatrics (PDF) CP.MP.154 October 31, 2020
Total Artificial Heart (PDF) CP.MP.127 December 30, 2016
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 May 31, 2016
Transcather Closer of Patent Foramen Ovale (PDF) CP.MP.151 December 29, 2017
Trigger Point Injections for Pain Management (PDF) CP.MP.169 August 31, 2018
Ultrasound in Pregnancy (PDF) CP.MP.38 January 31, 2011
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142 April 30, 2017
Urodynamic Testing (PDF) CP.MP.98 October 30, 2015
Vagus Nerve Stimulation (PDF) CP.MP.12 September 30, 2008
Ventricular Assist Devices (PDF) CP.MP.46 December 31, 2009
Video Electroencephalographic (VEEG) Monitoring (PDF) CP.MP.177 October 31, 2019
Wheelchair Seating (PDF) CP.MP.99 October 31, 2015
Wireless Motility Capsule (PDF) CP.MP.143 April 30, 2017
POLICY TITLE POLICY NUMBER EFFECTIVE DATE
Applied Behavioral Analysis (PDF) CP.BH.104 August 31, 2009
Neurofeedback for Behavioral Health Disorders (PDF) CP.BH.300 August 7, 2020
Transcranial Magnetic Stimulation (PDF) CP.BH.200 January 8, 2019
POLICY TITLE POLICY NUMBER EFFECTIVE DATE
Adjacent Tissue Transfer Grafts involving Eyelid (PDF) CP.VP.01 January 1, 2017
Age Related Macular Degeneration (PDF) CP.VP.02 October 1, 2017
Amblyopia (PDF) CP.VP.03 January 1, 2017
Anterior Segment Photography with FA (PDF) CP.VP.67 October 1, 2017
Aqueous Shunt (PDF) CP.VP.05 January 1, 2016
Blepharoplasty, Ptosis and Canthoplasty (PDF) CP.VP.07 January 1, 2017
B-Scan (PDF) CP.VP.68 January 1, 2018
Cataract Extraction (PDF) CP.VP.08 January 1, 2017
Chemodenervation (PDF) CP.VP.10 January 1, 2017
Complex Cataract (PDF) CP.VP.12 January 1, 2017
Corneal Hysteresis (PDF) CP.VP.17 January 1, 2016
Corneal Pachymetry (PDF) CP.VP.16 January 1, 2017
Corneal Topography (PDF) CP.VP.18 Janury 1, 2017
Dark Adaptation and Color Vision Examinations (92283/92284) (PDF) CP.VP.23 January 1, 2017
Destruction of a Localized Lesion of the Retina (PDF) CP.VP.21 January 1, 2017
Destruction of Localized Lesion of Choroid (PDF) CP.VP.20 January 2,2015
Destruction of Retinopathy (PDF) CP.VP.19 January 1, 2018
Dilation Protocol (PDF) CPG.VP.24 January 1, 2016
Ectropion and Entropion Repair (PDF) CP.VP.25 October 1, 2017
Examination Guidelines for Diabetic Patients (PDF) CPG.VP.22 January 1, 2018
Extended Ophthalmoscopy (PDF) CP.VP.26 January 1, 2018
External Ocular Photography (PDF) CP.VP.43 October 1, 2016
Fluorescein Angiography (PDF) CP.VP.28 January 1, 2018
Fundus Photography (PDF) CP.VP.29 January 1, 2018
Glaucoma (PDF) CPG.VP.30 January 1, 2017
Gonioscopy (PDF) CP.VP.31 October 1, 2016
Indocyanine Green (ICG) Angiography (PDF) CP.VP.32 January 1, 2017
Infracture of the Inferior Turbinate (PDF) CP.VP.33 January 2, 2016
Iris Coloboma (PDF) CP.VP.34 January 1, 2018
Keratoplasty (PDF) CP.VP.36 January 1, 2016
Laser Iridotomy and Iridectomy for Glaucoma (PDF) CP.VP.37 January 1, 2018
Laser Trabeculoplasty for POAG (PDF) CP.VP.38 January 1, 2018
Ocular Prosthesis (PDF) CP.VP.44 January 1, 2017
Ophthalmic Biometry (PDF) CP.VP.45 January 1, 2017
Photodynamic and Intravitreal Therapies and Pharmaceuticals (PDF) CP.VP.40 September 1, 2017
Prophylaxis of Retinal Detachment (PDF) CP.VP.53 January 1, 2016
Recurrent Erosion Syndrome and PTK (PDF) CP.VP.49 January 1, 2016
Refractive Surgery (PDF) CP.VP.52 January 1, 2016
Refraction (PDF) CP.VP.35 December 1, 2019
Repair of Retinal Detachment (PDF) CP.VP.54 January 1, 2016
Secondary IOL (PDF) CP.VP.48 January 1, 2016
Sensorimotor Examination (PDF) CP.VP.55 January 1, 2017
Specular Microscopy (PDF) CP.VP.66 January 1, 2018
Strabismus Surgeries (PDF) CP.VP.57 January 1, 2016
Teleretinal Screening for Diabetic Retinopathy (PDF) CP.VP.88 January 1, 2017
Trabeculetomy Ab Externo (PDF) CP.VP.61 January 1, 2016
Visual Field Testing (PDF) CP.VP.63 January 1, 2018
Visual Therapy (PDF) CP.VP.46 January 1, 2018
Vitrectomy (PDF) CP.VP.64 January 1, 2017
YAG Laser Capsulotomy (PDF) CP.VP.65 January 1, 2017

 

POLICY TITLE POLICY NUMBER EFFECTIVE DATE
72 Hour Supply of Medication (PDF) GA.PHAR.07 June 1, 2006
Abaloparatide (Tymlos) (PDF) CP.PHAR.345 July 1, 2017
abatacept (Orencia) (PDF) CP.PHAR.241 August 1, 2016
Abiraterone (Zytiga) (PDF) CP.PHAR.84 October 1, 2011
Abiraterone (Zytiga, Yonsa) (PDF) CP.PHAR.84 October 1, 2011
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 July 1, 2016
Adalimumab (Humira) (PDF) CP.PHAR.242 August 1, 2016
Adefovir (Hepsera) (PDF) CP.PHAR.142 August 28, 2018
Ado-Trastuzumab Emtansine (Kadcyla) (PDF) CP.PHAR.229 June 1, 2016
Aducanumab (PDF)
CP.PHAR.468 June 1, 2020
Afatinib (Gilotrif) (PDF) CP.PHAR.298 June1/2017
Aflibercept (Eylea®) (PDF) CP.PHAR.184 March 1, 2016
Agalsidase Beta (Fabrazyme) (PDF) CP.PHAR.158 February 1, 2016
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) CP.PMN.138 March 13, 2018
Alectinib (Alecensa) (PDF) CP.PHAR.369 November 16, 2016
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 August 1, 2016
Alendronate (Binosto, Fosamax plus D) (PDF) CP.PMN.88 March 1, 2018
Alglucosidase Alfa (Lumizyme) (PDF) CP.PHAR.160 February 1, 2016
Alirocumab (Praluent) (PDF) CP.PHAR.124 October 1, 2015
Alpelisib (Piqray) (PDF) CP.PHAR.430 September 1, 2019
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF) CP.PHAR.94 March 1, 2012
Ambrisentan (Letairis®) (PDF) CP.PHAR.190 March 1, 2016
Amifampridine (Firdapse, Ruzurgi) (PDF) CP.PHAR.411 January 22, 2019
Amikacin (Arikayce) (PDF) CP.PHAR.401 November 13, 2018
Antithymocyte Globulin (Thymoglobulin, Atgam) (PDF) HIM.PA.16 September 1, 2018
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) CP.PHAR.217 May 1, 2016
Anakinra (Kineret) (PDF) CP.PHAR.244 August 1, 2016
Apalutamide (Erleada) (PDF) CP.PHAR.376 June 1, 2018
Apremilast (Otezla) (PDF) CP.PHAR.245 August 1, 2016
Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF) CP.PMN.19 November 30, 2016

Appropriate Use and Safety Edits (PDF)

Appropriate Use and Safety Edits: Attachment A (PDF)

GA.PMN.01 May 1, 2012
Arformoterol Tartrate (Brovana) (PDF) CP.PMN.201 September 1, 2019
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF) CP.PHAR.290 December 1, 2016
Armodafinil (Nuvigil) (PDF) CP.PMN.35 August 1, 2009
Asenapine (Saphris, Secuado) (PDF) CP.PMN.15 December 1, 2014
asfotase alfa (Strensiq®) (PDF) CP.PHAR.328 March 1, 2017
Aspirin-dipyridamole (Aggrenox) (PDF) CP.PMN.20 September 1, 2006
Atezolizumab (Tecentriq®) (PDF) CP.PHAR.235 June 1, 2016
Avapritinib (Ayvakit) (PDF) CP.PHAR.454 March 1, 2020
Avatrombopag (Doptelet) (PDF) CP.PHAR.130 July 17, 2018
Avelumab (Bavencio®) (PDF) CP.PHAR.333 May 1, 2017
Axicabtagene Ciloleucel (Yescarta) (PDF) CP.PHAR.362 October 31, 2017
Axitinib (Inlyta®) (PDF) CP.PHAR.100 May 1, 2012
Azacitidine (Vidaza) (PDF) CP.PHAR.387 August 28, 2017
Azelaic Acid (Finacea) (PDF) HIM.PA.119 November 9, 2017
Aztreonam (Cayston®) (PDF) CP.PHAR.209 May 1, 2016
Baclofen (Gablofen, Lioresal, Ozobax) (PDF) CP.PHAR.149 November 9, 2017
Baloxavir Marboxil (Xofluza) (PDF) CP.PMN.185 October 30, 2018
Bedaquiline (Sirturo) (PDF) CP.PMN.212 December 1, 2019
Belantamab Mafodotin (PDF) CP.PHAR.469 June 1, 2020
belatacept (Nulojix®) (PDF) CP.PHAR.201 November 9, 2017
Belimumab (Benlysta) (PDF) CP.PHAR.88 October 1, 2011
belinostat (Beleodaq®) (PDF) CP.PHAR.311 February 1, 2017
Bendamustine (Bendeka®, Treanda®) (PDF) CP.PHAR.307 June 1, 2010
Benralizumab (Fasenra) (PDF) CP.PHAR.373 January 16, 2018
Benznidazole (PDF) CP.PMN.90 October 17, 2017
Berotralstat (PDF) CP.PHAR.485 June 1, 2020
Betaine (Cystadane) (PDF) CP.PHAR.143 August 28, 2018
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) CP.PHAR.93 November 1, 2011
Bexarotene (Targretin) (PDF) CP.PHAR.75 September 1, 2011
Bezlotoxumab (Zinplava) (PDF) CP.PHAR.300 November 16, 2016
Bimatoprost Implant (Durysta) (PDF) CP.PHAR.486 June 1, 2020
Binimetinib (Mektovi) (PDF) CP.PHAR.50 July 24, 2018
Biologic DMARDs (PDF) HIM.PA.SP60 January 1, 2020
Blinatumomab (Blincyto) (PDF) CP.PHAR.312 February 1, 2017
Blocking Adjudication of Controlled Substance Prescriptions for Selected Prescribers (PDF) GA.PHAR.19 November 1, 2001
Bortezomib (Velcade) (PDF) CP.PHAR.410 December 11, 2018
Bosentan (Tracleer®) (PDF) CP.PHAR.191 March 1, 2016
Bosutinib (Bosulif) (PDF) CP.PHAR.105 October 1, 2012
Brand Name Override and Non-Formulary Medications (PDF) HIM.PA.103 December 1, 2014
Brentuximab Vedotin (Adcetris) (PDF) CP.PHAR.303 February 1, 2017
Brexanolone (Zulresso) (PDF) CP.PHAR.417 April 16, 2019
Brexpiprazole (Rexulti) (PDF) CP.PMN.68 November 5, 2015
Brexucabtagene Autoleucel (Tecartus) (PDF)
CP.PHAR.472 June 1, 2020
Brigatinib (Alunbrig) (PDF) CP.PHAR.342 July 17, 2017
Brimonidine Tartrate (Mirvaso) (PDF) CP.PMN.192 November 16, 2016
Brinzolamide/Brimonidine (Simbrinza) (PDF) HIM.PA.15 September 4, 2018
Brivaracetam (Briviact) (PDF) HIM.PA.07 September 1, 2019
Brolucizumab-dbll (Beovu) (PDF) CP.PHAR.445 March 1, 2020
Budesonide Suspension (Pulmicort Respules) (PDF) HIM.PA.48 September 1, 2018
Buprenorphine Implant/Injection (Probuphine, Sublocade) (PDF) CP.PHAR.289 November 16, 2016
Buprenorphine implant (Probuphine) (PDF) CP.PHAR.289 November 16, 2016
Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone) (PDF) HIM.PA.35 February 1, 2017
Buprenorphine (Subutex) (PDF) CP.PMN.82 September 1, 2017
Burosumab-twza (Crysvita)(PDF) CP.PHAR.11 May 8, 2018
Butorphanol Nasal Spray (PDF) HIM.PA.46 December 1, 2014
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF) CP.PHAR.202 March 1, 2016
C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF) CP.PHAR.202 March 1, 2016
cabazitaxel (Jevtana® (PDF) CP.PHAR.316 February 1, 2017
Cabozantinib (Cometriq®, Cabometyx®) (PDF) CP.PHAR.111 June 1, 2013
Canakinumab (Ilaris) (PDF) CP.PHAR.246 August 1, 2016
Cannabidiol (Epidiolex) (PDF) CP.PMN.164 July 17, 2018
capecitabine (Xeloda) (PDF) CP.PHAR.60 May 1, 2011
Caplacizumab-yhdp (Cablivi) (PDF) CP.PHAR.416 March 12, 2019
carfilzomib (Kyprolis®) (PDF) CP.PHAR.309 February 1, 2017
Carglumic acid (Carbaglu®) (PDF) CP.PHAR.206 May 1, 2016
Casimersen (PDF) CP.PHAR.470 June 1, 2020
Cedazuridine/Decitabine (ASTX-727) (PDF) CP.PHAR.479 June 1, 2020
Celecoxib (Celebrex, Elyxyb) (PDF) CP.PMN.122 January 1, 2007
Cemiplimab-rwlc (Libtayo) (PDF) CP.PHAR.397 October 16, 2018
Cenegermin-bkbj (Oxervate) (PDF) CP.PMN.186 October 9, 2018
Cenobamate (Xcopri) (PDF) CP.PMN.231 March 1, 2020
Ceritinib (Zykadia) (PDF) CP.PHAR.349 July 1, 2017
Cerliponase alfa (Brineura) (PDF) CP.PHAR.338 July 1, 2017
Certolizumab (Cimzia) (PDF) CP.PHAR.247 August 1, 2016
Cetuximab (Erbitux®) (PDF) CP.PHAR.317 February 1, 2017
Chlorambucil (Leukeran) (PDF) HIM.PA.SP59 August 28, 2018
Chloramphenicol Sodium Succinate (PDF) CP.PHAR.388 December 1, 2018
Cholic Acid (Cholbam) (PDF) CP.PHAR.390 December 1, 2018
Ciclesonide (Alvesco) (PDF) HIM.PA.65 September 1, 2018
Cinacalcet (Sensipar) (PDF) CP.PHAR.61 May 1, 2011
Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) HIM.PA.120 November 9, 2017
Ciprofloxacin/Fluocinolone (Otovel) (PDF) HIM.PA.14 September 4, 2018
Cladribine (Mavenclad) (PDF) CP.PHAR.422 September 1, 2019
Clindamycin (Evoclin) (PDF) HIM.PA.21 August 28, 2018
Clindamycin Phosphate/Benzoyl Peroxide (BenzaClin) (PDF) HIM.PA.31 December 1, 2018
Clobazam (Onfi) (PDF) CP.PMN.54 November 1, 2012
CNS Stimulants (PDF) CP.PMN.92 March 1, 2018
Cobimetinib (Cotellic) (PDF) CP.PHAR.380 November 16, 2016
Colesevelam (Welchol) (PDF) HIM.PA.121 November 9, 2017
Collagenase (Xiaflex) (PDF) CP.PHAR.82 October 1, 2011
Colonoscopy Preparation Products (PDF) HIM.PA.04 January 1, 2020
Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) HIM.PA.140 October 24, 2017
Continuous Glucose Monitors (PDF) CP.PMN.214 December 1, 2019
copanlisib (Aliqopa®) (PDF) CP.PHAR.357 October 17, 2017
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) CP.PHAR.385 May 29, 2018
Cosyntropin (Cortrosyn®) (PDF) CP.PHAR.203 April 1, 2016
Crisaborole (Eucrisa) (PDF) CP.PMN.110 February 21, 2017
Crizanlizumab-tmca (Adakveo) (PDF) CP.PHAR.449 March 1, 2020
Crizotinib (Xalkori) (PDF) CP.PHAR.90 November 1, 2011
Cyclosporine (Cequa, Restasis) (PDF) CP.PMN.48 May 1, 2012
Cysteamine ophthalmic (Cystaran) (PDF) CP.PMN.130 August 1, 2017
Cysteamine oral (Cystagon, Procysbi) (PDF) CP.PHAR.155 Februay 1, 2016
Cytomegalovirus Immune Globulin (Cytogam)(PDF) CP.PHAR.277 September 1, 2018
Dabrafenib (Tafinlar) (PDF) CP.PHAR.239 November 16, 2016
Dacomitinib (Vizimpro) (PDF) CP.PHAR.399 October 16, 2018
Dalfampridine (Ampyra) (PDF) CP.PHAR.248 August 1, 2016
Dalteparin (Fragmin) (PDF) CP.PHAR.225 May 1, 2016
Daptomycin (Cubicin, Cubicin RF)(PDF) CP.PHAR.351 November 30, 2017
Daratumumab (Darzalex) (PDF) CP.PHAR.310 July 1, 2017
Darbepoetin Alfa (Aranesp) (PDF) CP.PHAR.236 June 1, 2016
Darolutamide (Nubeqa) (PDF) CP.PHAR.435 December 1, 2019
Dasatinib (Sprycel) (PDF) CP.PHAR.72 June 1, 2012
daunorubicin/cytarabine (Vyxeos®) (PDF) CP.PHAR.352 December 1, 2017
Deferasirox (Exjade Jadenu) (PDF) CP.PHAR.145 November 1, 2015
Deferiprone (Ferriprox) (PDF) CP.PHAR.147 November 1, 2015
Deferoxamine (Desferal) (PDF) CP.PHAR.146 November 1, 2015
Deflazacort (Emflaza) (PDF) CP.PHAR.331 March 1, 2017
Degarelix acetate (Firmagon®) (PDF) CP.PHAR.170 November 9, 2017
Delafloxacin (Baxdela) (PDF) CP.PMN.115 November 9, 2017
Denosumab (Prolia, Xgeva) (PDF) CP.PHAR.58 March 1, 2011
Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF) CP.PHAR.214 May 1, 2016
Deutetrabenazine (Austedo) (PDF) CP.PHAR.341 June 13, 2017
Dexlansoprazole (Dexilant) (PDF) HIM.PA.05 January 1, 2020
Dexrazoxane (Zinecard, Totect) (PDF) CP.PHAR.418 March 19, 2019
Dextromethorphan-Quinidine (Nuedexta) (PDF) CP.PMN.93 March 1, 2018
Diazepam Nasal Spray (Valtoco) (PDF) CP.PMN.216 December 1, 2019
Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity) (PDF) CP.PHAR.249 August 1, 2016
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF) HIM.PA.58 March 1, 2018
Dolasetron (Anzemet) (PDF) CP.PMN.141 September 1, 2006
Dornase alfa (Pulmozyme) (PDF) CP.PHAR.212 May 1, 2016
Dose Escalation of Biologics (PDF) GA.PMN.21 September 1, 2017
Doxepin (Silenor, Prudoxin, Zonalon) (PDF) HIM.PA.147 November 17, 2017
Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF) CP.PMN.79 May 1, 2017
Drug Recall Notification Process (PDF) GA.PHAR.08 July 1, 2008
Drug Utilization Review (PDF) GA.PHAR.13 April 1, 2007
Dupilumab (Dupixent) (PDF) CP.PHAR.336 May 1, 2017
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 July 1, 2017
Duvelisib (Copiktra) (PDF) CP.PHAR.400 October 16, 2018
Early and Periodic Screening, Diagnostic, and Treatment Benefit for Pediatric Members (PDF) CP.PMN.234 June 1, 2020
Ecallantide (Kalbitor®) (PDF) CP.PHAR.177 March 1, 2016
Eculizumab (Soliris®) (PDF) CP.PHAR.97 March 1, 2012
Edaravone (Radicava) (PDF) CP.PHAR.343 July 1, 2017
Efinaconazole (Jublia) (PDF) CP.PMN.25 August 1, 2016
Elagolix (Orilissa) (PDF) CP.PHAR.136 August 28, 2018
Elapegademase-lvlr (Revcovi) (PDF) CP.PHAR.419 April 23, 2019
Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (PDF) CP.PHAR.440 December 1, 2019
Eliglustat (Cerdelga) (PDF) CP.PHAR.153 February 1, 2016
Elosulfase Alfa (Vimizim) (PDF) CP.PHAR.162 February 1, 2016
Elotuzumab (Empliciti®) (PDF) CP.PHAR.308 February 1, 2017
Eltrombopag (Promacta®) (PDF) CP.PHAR.180 March 1, 2016
Emapalumab-lzsg (Gamifant) (PDF) CP.PHAR.402 December 11, 2018
Emicizumab-kxwh (Hemlibra) (PDF) CP.PHAR.370 March 1, 2018
Emtricitabine/Tenofovir Alafenamide (Descovy)(PDF) CP.PMN.235 June 1, 2020
Emtricitabine/Tenofovir (Truvada®) (PDF) HIM.PA.78 December 1, 2014
Enasidenib (Idhifa) (PDF) CP.PHAR.363 September 5, 2017
Encorafenib (Braftovi) (PDF) CP.PHAR.127 July 24, 2018
Enfortumab Vedotin-ejfv (Padcev) (PDF) CP.PHAR.455 March 1, 2020
Enfuvirtide (Fuzeon) (PDF) CP.PHAR.41 June 1, 2010
Entecavir (Baraclude) (PDF) HIM.PA.08 February 19, 2019
Entrectinib (Rozlytrek) (PDF) CP.PHAR.441 December 1, 2019
Enzalutamide (Xtandi) (PDF) CP.PHAR.106 October 1, 2012
Epoetin Alfa (Epogen® and Procrit) (PDF) CP.PHAR.237 June 1, 2016
Epoprostenol (Flolan®), Veletri®) (PDF) CP.PHAR.192 March 1, 2016
Erdafitinib (Balversa)(PDF) CP.PHAR.423 September 1, 2019
Erenumab-aaoe (Aimovig) (PDF) CP.PHAR.128 July 10, 2018
Eribulin Mesylate (Halaven®) (PDF) CP.PHAR.318 March 1, 2017
Erlotinib (Tarceva) (PDF) CP.PHAR.74 September 1, 2011
Erwinia Asparaginase (Erwinaze) (PDF) CP.PHAR.301 February 1, 2017
Esketamine (Spravato) (PDF) CP.PMN.199 March 12, 2019
Etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 March 20, 2018
Etanercept (Enbrel) (PDF) CP.PHAR.250 August 1, 2016
Eteplirsen (Exondys 51) (PDF) CP.PHAR.288 December 1, 2016
Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF) CP.PHAR.63 June 1, 2011
Evolocumab (Repatha) (PDF) CP.PHAR.123 October 1, 2015
Factor IX (Human, Recombinant) (PDF) CP.PHAR.218 May 1, 2016
Factor IX Complex, Human (Profilnine) (PDF) CP.PHAR.219 May 1, 2016
Factor VIII (Human Recombinant) (PDF) CP.PHAR.215 May 1, 2016
Factor VIIa, Recombinant (NovoSeven® RT) (PDF) CP.PHAR.220 May 1, 2016
Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (PDF) CP.PHAR.220 May 1, 2016
Factor VIII/von Willebrand Factor Complex (Human - Alphanate, Humate-P, Wilate) (PDF) CP.PHAR.216 May 1, 2016
Factor XIII A-Subunit, Recombinant (Tretten®) (PDF) CP.PHAR.222 May 1, 2016
Factor XIII, Human (Corifact®) (PDF) CP.PHAR.221 May 1, 2016
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) CP.PHAR.456 March 1, 2020
Febuxostat (Uloric) (PDF) CP.PMN.57 August 1, 2013
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF) CP.PMN.127 June 1, 2015
Ferumoxytol (Feraheme®) (PDF) CP.PHAR.165 March 1, 2016
Ferric Carboxymaltose (Injectafer) (PDF) CP.PHAR.234 June 1, 2016
Ferric Derisomaltose (Monoferric) (PDF) CP.PHAR.480 June 1, 2020
Ferric gluconate (Ferrlecit®) (PDF) CP.PHAR.166 March 1, 2016
Filgrastim (Neupogen, Zarxio) (PDF) CP.CPA.129 November 16, 2016
Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF) CP.PHAR.297 December 1, 2016
Fingolimod (Gilenya) (PDF) CP.PHAR.251 August 1, 2016
Fondaparinux (Arixtra) (PDF) CP.PHAR.226 May 1, 2016
Formulary Medications without Specific Guidelines (PDF) HIM.PA.33 May 1, 2016
Fosdenopterin (PDF) CP.PHAR.471 June 1, 2020
Fostamatinib (Tavalisse) (PDF) CP.PHAR.24 June 5, 2018
Fluorouracil Cream (Tolak)(PDF) CP.PMN.165 December 1, 2018
Fluticasone Propionate (Xhance) (PDF) CP.PMN.95 October 24, 2017
Fulvestrant (Faslodex Injection)(PDF) CP.PHAR.424 September 1, 2019
Galsulfase (Naglazyme) (PDF) CP.PHAR.161 February 1, 2016
Gefitinib (Iressa) (PDF) CP.PHAR.68 November 16, 2016
gemtuzumab ozogamicin (Mylotarg®) (PDF) CP.PHAR.358 October 3, 2017
Gilteritinib (Xospata) (PDF) CP.PHAR.412 January 15, 2019
Givosiran (Givlaari) (PDF) CP.PHAR.457 March 1, 2020
Glasdegib (Daurismo) (PDF) CP.PHAR.413 January 8, 2019
Glatiramer (Copaxone, Glatopa) (PDF) CP.PHAR.252 August 1, 2016
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF) CP.CPA.16 November 16, 2016
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF) HIM.PA.53 March 1, 2018
Glycerol phenylbutyrate (Ravicti®) (PDF) CP.PHAR.207 May 1, 2016
Golimumab (Simponi, Simponi Aria) (PDF) CP.PHAR.253 July 1, 2016
Golodirsen (Vyondys 53) (PDF) CP.PHAR.453 March 1, 2020
goserelin acetate (Zoladex®) (PDF) CP.PHAR.171 November 9, 2017
Granisetron (Kytril, Sancuso, Sustol) (PDF) CP.PMN.74 November 1, 2016
Halcinonide (Halog) (PDF) HIM.PA.20 August 28, 2018
Hemin (Panhematin®) (PDF) CP.PHAR.181 February 1, 2016
histrelin acetate (Vantas®, Supprelin LA®) (PDF) CP.PHAR.172 November 9, 2017
Hyaluronate Derivatives (PDF) CP.PHAR.05 October 1, 2008
Hydroxyprogesterone Caproate (Makena/compound) CP.PHAR.14 November 20, 2017
Hydroxyurea (Siklos) (PDF) CP.PMN.193 February 19, 2019
Ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 April 17, 2018
Ibandronate sodium (Boniva®) (PDF) CP.PHAR.189 November 15, 2017
Ibrutinib (Imbruvica) (PDF) CP.PHAR.126 October 1, 2015
Ibuprofen/Famotidine (Duexis) (PDF) CP.PMN.120 June 1, 2018
Icatibant (Firazyr) (PDF) CP.PHAR.178 March 1, 2016
Icosapent ethyl (Vascepa) (PDF) CP.PMN.187 November 20, 2018
Idelalisib (Zydelig) (PDF) CP.PHAR.133 December 1, 2018
Idecabtagene Vicleucel (BB2121) (PDF) CP.PHAR.481 June 1, 2020
Idursulfase (Elaprase) (PDF) CP.PHAR.156 February 1, 2016
Iloperidone (Fanapt) (PDF) CP.PMN.32 December 1, 2014
Iloprost (Ventavis®) (PDF) CP.PHAR.193 March 1, 2016
Imatinib (Gleevec) (PDF) CP.PHAR.65 June 1, 2011
Imiglucerase (Cerezyme) (PDF) CP.PHAR.154 February 1, 2016
Immune Globulins (PDF) CP.PHAR.103 August 1, 2012
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 July 1, 2016
Indacaterol/Glycopyrrolate (Utibron Neohaler) (PDF) HIM.PA.102 September 1, 2018
Inebilizumab (PDF) CP.PHAR.458 March 1, 2020
Infertility and Fertility Preservation (PDF) CP.PHAR.131 November 16, 2016
Infliximab (Remicade, Inflectra, Renflexis) (PDF) CP.PHAR.254 July 1, 2016
Inotersen (Tegsedi) (PDF) CP.PHAR.405 November 20, 2018
inotuzumab ozogamicin (Besponsa®) (PDF) CP.PHAR.359 September 26, 2017
Insulin Infusion Pump (Omnipod, Omnipod DASH) (PDF) CP.PHAR.420 April 23, 2019
Insulin Degludec (Tresiba) (PDF) HIM.PA.09 March 1, 2019
Interferon beta-1a (Avonex, Rebif) (PDF) CP.PHAR.255 August 1, 2016
Interferon beta-1b (Betaseron, Extavia) (PDF) CP.PHAR.256 August 1, 2016
Interferon Gamma- 1b (Actimmune) (PDF) CP.PHAR.52 June 1, 2010
Intrathecal Baclofen (Gablofen, Lioresal) (PDF) CP.PHAR.149 November 9, 2017
Iobenguane I-131 (Azedra) (PDF) CP.PHAR.459 March 1, 2020
Ipilimumab (Yervoy) (PDF) CP.PHAR.319 April 17, 2018
irinotecan Liposome (Onivyde®) (PDF) CP.PHAR.304 February 1, 2017
Iron sucrose (Venofer®) (PDF) CP.PHAR.167 March 1, 2016
Isatuximab-irfc (Sarclisa)(PDF) CP.PHAR.482 June 1, 2020
Isavuconazonium (Cresemba) (PDF) CP.PMN.154 November 16, 2016
Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (PDF) CP.PMN.143 December 1, 2014
Istradefylline (Nourianz) (PDF) CP.PMN.217 March 1, 2020
Itraconazole (Sporanox, Onmel, Tolsura) (PDF) CP.PMN.124 November 1, 2006
Ivabradine (Corlanor) (PDF) CP.PMN.70 November 1, 2015
Ivacaftor (Kalydeco) (PDF) CP.PHAR.210 May 1, 2016
Ivermectin (Sklice®) (PDF) HIM.PA.124 December 1, 2017
Ivosidenib (Tibsovo) (PDF) CP.PHAR.137 August 21, 2018
Ixazomib (Ninlaro) (PDF) CP.PHAR.302 February 1, 2017
Lacosamide (Vimpat) (PDF) CP.PMN.155 December 1, 2014
Lanadelumab-fylo (Takhzyro) (PDF) CP.PHAR.396 September 25, 2018
Lanreotide (Somatuline Depot) (PDF) CP.PHAR.391 August 14, 2018
lapatinib (Tykerb®) (PDF) CP.PHAR.79 November 9, 2017
Laronidase (Aldurazyme) (PDF) CP.PHAR.152 February 1, 2016
Larotrectinib (Vitrakvi) (PDF) CP.PHAR.414 January 15, 2018
Lasmiditan (Reyvow) (PDF) CP.PMN.218 March 1, 2020
Lefamulin (Xenleta) (PDF) CP.PMN.219 March 1, 2020
Lemborexant (Dayvigo)(PDF) CP.PMN.233 June 1, 2020
Lenalidomide (Revlimid) (PDF) CP.PHAR.71 July 1, 2011
Lenvatinib (Lenvima) (PDF) CP.PHAR.138 December 1, 2018
Lesinurad (Zurampic), Lesinurad/Allopurinol (Duzallo) (PDF) CP.PMN.150 November 16, 2016
Letermovir (Prevymis) (PDF) CP.PHAR.367 March 1, 2018
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) CP.PHAR.173 November 9, 2017
Levalbuterol (Xopenex HFA/Inhalation Solution) (PDF) CP.PMN.07 September 1, 2006
Levoleucovorin (Fusilev®) (PDF) CP.PHAR.151 November 9, 2017
Levomilnacipran (Fetzima) (PDF) HIM.PA.125 November 9, 2017
Lidocaine Transdermal (Lidoderm, ZTlido) (PDF) CP.PMN.08 September 1, 2006
Lifitegrast (Xiidra®) (PDF) CP.PMN.73 November 9, 2017
Linaclotide (Linzess) (PDF) CP.PMN.71 November 1, 2015
Linezolid (Zyvox) (PDF) CP.PMN.27 September 1, 2016
Lofexidine (Lucemyra) (PDF) CP.PMN.152 August 1, 2018
Lomustine (Gleostine) (PDF) HIM.PA.19 August 28, 2018
Lorlatinib (Lorbrena) (PDF) CP.PHAR.406 December 11, 2018
Lumacaftor-Ivacaftor (Orkambi) (PDF) CP.PHAR.213 May 1, 2016
Lumateperone (Caplyta) (PDF) CP.PMN.232 March 1, 2020
Lubiprostone (Amitiza) (PDF) CP.PMN.142 December 1, 2014
Luliconazole Cream (Luzu) (PDF) CP.PMN.166 August 28, 2018
Lumasiran (ALN-GO1) (PDF) CP.PHAR.473 June 1, 2020
Luspatercept-aamt (Reblozyl) (PDF) CP.PHAR.450 March 1, 2020
Lusutrombopag (Mulpleta) (PDF) CP.PHAR.407 September 18, 2018
Lutetium Lu 177 Dotatate (Lutathera)(PDF) CP.PHAR.384 May 22, 2018
Lurasidone (Latuda) (PDF) CP.PMN.50 December 1, 2014
Macitentan (Opsumit) (PDF) CP.PCH.31 September 1, 2020
Macitentan (Opsumit®) (PDF) CP.PHAR.194 March 1, 2016
Mecamylamine (Vecamyl) (PDF) CP.PMN.136 May 1, 2017
Mecasermin (Increlex) (PDF) CP.PHAR.150 March 1, 2011
Medication Safety Policy (PDF) GA.PMN.22 July 1, 2017
Megestrol Acetate (Megace ES) (PDF) CP.PMN.179 December 1, 2018
Mepolizumab (Nucala) (PDF) CP.PHAR.200 April 1, 2016
Methoxsalen (Uvadex) (PDF) HIM.PA.17 September 4, 2018
Mometasone Furoate (Sinuva) (PDF) CP.PHAR.448 March 1, 2020
Monomethyl Fumarate (Bafiertam) (PDF) CP.PHAR.460 March 1, 2020
Montelukast oral granules (Singulair) (PDF) HIM.PA.129 November 9, 2017
Mepolizumab (Nucala) (PDF) CP.PHAR.200 April 1, 2016
Mesalamine (Apriso) (PDF) HIM.PA.42 September 4, 2018
Metformin ER (Fortamet, Glumetza) (PDF) CP.PMN.72 November 1, 2015
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF) CP.PHAR.134 December 1, 2018
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) CP.PHAR.238 June 1, 2016
Methylnaltrexone Bromide (Relistor) (PDF) CP.PMN.169 December 1, 2018
Metreleptin (Myalept) (PDF) CP.PHAR.425 September 1, 2019
Midazolam (Nayzilam) (PDF) CP.PMN.211 September 1, 2019
Midostaurin (Rydapt) (PDF) CP.PHAR.344 June 1, 2017
Mifepristone (Korlym) (PDF) CP.PHAR.101 May 1, 2012
Migalastat (Galafold) (PDF) CP.PHAR.394 September 11, 2018
Miglustat (Zavesca) (PDF) CP.PHAR.164 February 1, 2016
Milnacipran (Savella) (PDF) CP.PMN.125 August 1, 2012
Minocycline ER (Solodyn, Ximino, Minolira) and Microspheres (Arestin) (PDF) CP.PMN.80 May 1, 2017
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 August 1, 2016
Modafinil (Provigil) (PDF) CP.PMN.39 May 1, 2008
Mogamulizumab-kpkc (Poteligeo) (PDF) CP.PHAR.139 September 4, 2018
Mometasone (Nasonex) (PDF) HIM.PA.93 12/01/2014
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) CP.PHAR.398 October 16, 2018
Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF) CC.PP.068 December 16, 2020
Nadofaragene Firadenovec (Instiladrin) (PDF) CP.PHAR.461 March 1, 2020
nafarelin acetate (Synarel®) (PDF) CP.PHAR.174 November 9, 2017
Naltrexone (Vivitrol®) (PDF) CP.PHAR.96 March 1, 2012
Naproxen/Esomeprazole (Vimovo) (PDF) CP.PMN.117 June 1, 2018
Naproxen oral suspension (Naprosyn) (PDF) HIM.PA.130 November 9, 2017
Natalizumab (Tysabri) (PDF) HIM.PA.SP17 May 1, 2017
Nebivolol (Bystolic) (PDF) HIM.PA.131 November 9, 2017
Necitumumab (Portrazza®) (PDF) CP.PHAR.320 March 1, 2017
Neomycin/Fluocinolone Cream (Neo-Synalar)_(PDF) CP.PMN.167 August 28, 2018
Neratinib (Nerlynx) (PDF) CP.PHAR.365 September 5, 2017
Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan)  (PDF) CP.PMN.118 February 13, 2018
Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (PDF) CP.PMN.158 September 1, 2006
nilotinib (Tasigna) (PDF) CP.PHAR.76 September 1, 2011 
Nintedanib (Ofev) (PDF) CP.PHAR.285 October 1, 2016
Nitisinone (Nityr, Orfadin) (PDF) CP.PHAR.132 August 28, 2018
Nivolumab (Opdivo) (PDF) CP.PHAR.121 July 1, 2015
No Coverage Criteria/Off-Label Use Policy (PDF) CP.PMN.53 September 12, 2017
Non-Formulary and Formulary Contraceptives (PDF) HIM.PA.100 May 1, 2015
Non-Formulary Test Strips (PDF) HIM.PA.34 February 1, 2016
Nusinersen (Spinraza®)(PDF) CP.PHAR.327 November 28, 2017
Obeticholic (Ocaliva) (PDF) CP.PHAR.287 November 1, 2016
Obinutuzumab (Gazyva®) (PDF) CP.PHAR.305 February 1, 2017
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 April 1, 2017
Octreotide (Sandostatin, Sandostatin LAR) (PDF) CP.PHAR.40 March 1, 2010
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia) (PDF) CP.PHAR.40 March 1, 2010
ofatumumab (Arzerra®) (PDF) CP.PHAR.306 February 1, 2017
Olanzapine Long-Acting Injection (Zyprexa Relprevv)(PDF) CP.PHAR.292 December 1, 2016
Olaparib (Lynparza) (PDF) CP.PHAR.360 October 3, 2017
olaratumab (Lartruvo®) (PDF) CP.PHAR.326 March 1, 2017
Omadacycline (Nuzyra) (PDF) CP.PMN.188 November 20, 2018
Omacetaxine (Synribo) (PDF) CP.PHAR.108 April 1, 2013
Omalizumab (Xolair®) (PDF) CP.PHAR.01 October 1, 2008
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 July 1, 2016
Onasemnogene Abeparvovec (Zolgensma) (PDF) CP.PHAR.421 June 7, 2019
Ondansetron (Zuplenz) (PDF) CP.PMN.45 September 1, 2006
Ophthalmic Corticosteroids (PDF) HIM.PA.03 January 1, 2020
Osimertinib (Tagrisso) (PDF) CP.PHAR.294 December 1, 2016
Ospemifene (Osphena) (PDF) CP.PMN.168 August 28, 2018
Overactive Bladder Agents (PDF) CP.PMN.198 May 1, 2016
Ozanimod (PDF) CP.PHAR.462 March 1, 2020
Ozenoxacin (Xepi) (PDF) CP.PMN.119 January 30, 2018
Paclitaxel, Protein-Bound (Abraxane) (PDF) CP.PHAR.176 July 1, 2015
Palbociclib (Ibrance®) (PDF) CP.PHAR.125 October 1, 2015
Palivizumab (Synagis) (PDF) CP.PHAR.16 August 1, 2009
panitumumab (Vectibix®) (PDF) CP.PHAR.321 March 1, 2017
Parathyroid Hormone (Natpara) (PDF) CP.PHAR.282 November 16, 2016
Paricalcitol Injection (Zemplar) (PDF) CP.PHAR.270 August 1, 2016
Pasireotide (Signifor LAR®) (PDF) CP.PHAR.332 March 1, 2017
Patisiran (Onpattro) (PDF) CP.PHAR.395 September 11, 2018
Pazopanib (Votrient) (PDF) CP.PHAR.81 October 1, 2011
Peanut Allergen Powder-dnfp (Palforzia) (PDF) CP.PMN.220 March 1, 2020
Pegademase Bovine (Adagen) (PDF) CP.PHAR.392 August 28, 2018
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF) CP.PHAR.353 September 5, 2017
Pegfilgrastim (Neulasta) (PDF) CP.PHAR.296 December 1, 2016
peginterferon alfa-2b (PegIntron, Sylatron®) (PDF) CP.PHAR.89 October 1, 2011
Peginterferon beta-1a (Plegridy) (PDF) CP.PHAR.271 August 1, 2016
Pegloticase (Krystexxa®) (PDF) CP.PHAR.115 June 1, 2013
Pegvaliase-pqpz (Palynziq) (PDF) CP.PHAR.140 July 31, 2018
Pegvisomant (Somavert) (PDF) CP.PHAR.389 December 1, 2018
pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 March 1, 2017
Pemetrexed (Alimta, Pemfexy) (PDF) CP.PHAR.368 October 31, 2017
Perampanel (Fycompa) (PDF) CP.PMN.156 November 16, 2016
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 June 1, 2016
Pexidartinib (Turalio) (PDF) CP.PHAR.436 December 1, 2019
Pharmaceutical Management (PDF) GA.PHAR.03 February 1, 2003
Pharmacy and Therapeutics Committee (PDF) GA.PHAR.17 August 19, 2011
Pharmacy Prior Authorization and Medical Necessity Criteria (PDF) GA.PHAR.16 July 9, 2010
Phendimetrazine IR (Bontril PDM) (PDF) HIM.PA.114 May 1, 2017
Pitolisant (Wakix) (PDF) CP.PMN.221 March 1, 2020
Plerixafor (Mozobil) (PDF) CP.PHAR.323 March 1, 2017
Polatuzumab Vedotin-piiq (Polivy) (PDF) CP.PHAR.433 September 1, 2019
Pomalidomide (Pomalyst) (PDF) CP.PHAR.116 July 1, 2013
Ponatinib (Iclusig) (PDF) CP.PHAR.112 June 1, 2013
Potassium Chloride for Oral Solution (Klor-Con Powder) (PDF) HIM.PA.143 October 31, 2017
Pralatrexate (Folotyn®) (PDF) CP.PHAR.313 February 1, 2017
Pramlintide (Symlin) (PDF) CP.PMN.129 June 1, 2018
Pregabalin (Lyrica, Lyrica CR) (PDF) CP.PMN.33 January 1, 2007
Pretomanid (PDF) CP.PMN.222 March 1, 2020
Progesterone (Crinone, Endometrin) (PDF) CP.CPA.03 November 16, 2016
Propranolol HCl Oral Solution (Hemangeol) (PDF) CP.PMN.58 May 1, 2014
Protein C Concentrate, Human (Ceprotin) (PDF) CP.PHAR.330 March 1, 2017
Prucalopride (Motegrity) (PDF) CP.PMN.194 January 29, 2019
pyrimethamine (Daraprim®) (PDF) CP.PMN.44 November 1, 2015
Quetiapine ER (Seroquel XR) (PDF) CP.PMN.64 December 1, 2014
Ramucirumab (Cyramza®) (PDF) CP.PHAR.119 May 1, 2015
Ranibizumab (Lucentis®) (PDF) CP.PHAR.186 March 1, 2016
Rasagiline (Azilect®) (PDF) HIM.PA.89 December 1, 2014
Regorafenib (Stivarga) (PDF) CP.PHAR.107 December 1, 2012
Remestemcel-L (Prochymal) (PDF) CP.PHAR.474 June 1, 2020
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) CP.PHAR.168 March 1, 2016
Reslizumab (Cinqair) (PDF) CP.PHAR.223 May 1, 2016
Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF) CP.PHAR.141 November 16, 2016
Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) (PDF) CP.PMN.223 March 1, 2020
Rifamycin (Aemcolo) (PDF) CP.PMN.196 January 8, 2019
rifaximin (Xifaxan®)(PDF) CP.PMN.47 November 1, 2011
Rilonacept (Arcalyst) (PDF) CP.PHAR.266 November 16, 2016
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 July 1, 2016
Riociguat (Adempas®) (PDF) CP.PHAR.195 March 1, 2016
Risdiplam (PDF) CP.PHAR.477 June 1, 2020
Risedronate (Actonel, Atelvia) (PDF) CP.PMN.100 March 1, 2018
Risperidone Long-Acting Injection (Risperdal Consta) (PDF) CP.PHAR.293 December 1, 2016
Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) CP.PHAR.260 July 1, 2016
Rolapitant (Varubi) (PDF) CP.PMN.102 February 1, 2017
romidepsin (Istodax®) (PDF) CP.PHAR.314 January 1, 2017
Romiplostim (Nplate®) (PDF) CP.PHAR.179 March 1, 2016
Romosozumab-aqqg (Evenity) (PDF) CP.PHAR.428 September 1, 2019
Rucaparib (Rubraca®) (PDF) CP.PHAR.350 Septemner 1, 2017
Rufinamide (Banzel) (PDF) CP.PMN.157 December 1, 2014
Sacubitril/Valsartan (Entresto) (PDF) CP.PMN.67 November 1, 2015
Sacitizumab Govitecan (PDF) CP.PHAR.475 June 1, 2020
Safinamide (Xadago) (PDF) CP.PMN.113 July 1, 2017
Sarecycline (Seysara) (PDF) CP.PMN.189 November 13, 2018
Sargramostim (Leukine) (PDF) CP.PHAR.295 December 1, 2016
Sapropterin Dihydrochloride (Kuvan) (PDF) CP.PHAR.43 February 1, 2010
Satralizumab (PDF) CP.PHAR.463 March 1, 2020
Secnidazole (Solosec) (PDF) CP.PMN.103 October 24, 2017
Sebelipase Alfa (Kanuma) (PDF) CP.PHAR.159 February 1, 2016
Selexipag (Uptravi®) (PDF) CP.PHAR.196 March 1, 2016
Selinexor (Xpovio) (PDF) CP.PHAR.431 September 1, 2019
Selpercatinib (LOXO-292) (PDF) CP.PHAR.478 June 1, 2020
Selumetinib (Koselugo) (PDF) CP.PHAR.464 March 1, 2020
Semaglutide (Rybelsus) (PDF) HIM.PA.02 March 1, 2020
Sildenafil (Revatio®) (PDF) CP.PHAR.197 March 1, 2016
Siltuximab (Sylvant®) (PDF) CP.PHAR.329 March 1, 2017
Siponimod (Mayzent) (PDF) CP.PHAR.427 September 1, 2019
Sipuleucel-T (Provenge) (PDF) CP.PHAR.120 June 1, 2015
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF) HIM.PA.91 January 1, 2015
sodium oxybate (Xyrem) (PDF) CP.PMN.42 May 1, 2011
Sodium Phenylbutyrate (Buphenyl) (PDF) CP.PHAR.208 May 1, 2016
Solriamfetol (Sunosi) (PDF) CP.PMN.209 September 1, 2019
Somatropin (Growth Hormone) (PDF) CP.PHAR.55 March 1, 2011
Somatropin (HGH) (PDF) CP.CPA.84 November 16, 2016
Sonidegib (Odomzo) (PDF) CP.PHAR.272 May 1, 2012
sorafenib (Nexavar) (PDF) CP.PHAR.69 July 1, 2011
Spinosad (Natroba) (PDF) HIM.PA.134 November 9, 2017
Step Therapy (PDF) HIM.PA.109 August 1, 2017
Stiripentol (Diacomit) (PDF) CP.PMN.184 September 25, 2018
Sucroferric Oxyhydroxide (Velphoro) (PDF) HIM.PA.SP30 January 1, 2015
sunitinib (Sutent) (PDF) CP.PHAR.73 September 1, 2011
Suvorexant (Belsomra®) (PDF) CP.PMN.109 February 1, 2017
Tadalafil (Adcirca®) (PDF) CP.PHAR.198 March 1, 2016
Tadalafil BHP - ED (Cialis) (PDF) CP.PMN.132 June 1, 2018
Tafamidis (Vyndaqel, Vyndamax) (PDF) CP.PHAR.432 September 1, 2019
Talazoparib (Talzenna) (PDF) CP.PHAR.409 November 27, 2018
Taliglucerase Alfa (Elelyso) (PDF) CP.PHAR.157 February 1, 2016
Tasimelteon (Hetlioz) (PDF) CP.PMN.104 February 1, 2017
Tavaborole (Kerydin) (PDF) CP.PMN.105 March 1, 2018
Tazemetostat (Tazverik) (PDF) CP.PHAR.452 March 1, 2020
Tedizolid (Sivextro) (PDF) CP.PMN.62 March 1, 2015
Teduglutide (Gattex) (PDF) CP.PHAR.114 May 1, 2013
Tegaserod (Zelnorm) (PDF) CP.PMN.206 September 1, 2019
Telotristat Ethyl (Xermelo) (PDF) CP.PHAR.337 June 1, 2017
Temozolomide (Temodar) (PDF) CP.PHAR.77 September 1, 2011
temsirolimus (Torisel®) (PDF) CP.PHAR.324 March 1, 2017
Tenapanor (Ibsrela) (PDF) CP.PMN.224 March 1, 2020
Teprotumumab (Tepezza) (PDF) CP.PHAR.465 January 21, 2020
Teriparatide (Forteo®) (PDF) CP.PHAR.188 November 15, 2017
Tesamorelin (Egrifta) (PDF) CP.PHAR.109 March 1, 2014
Testosterone (Androderm) (PDF) HIM.PA.87 December 1, 2014
Testosterone (Testopel, Jatenzo) (PDF) CP.PHAR.354 August 1, 2017
tetrabenazine (Xenazine) (PDF) CP.PHAR.92 December 1, 2011
Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF) CP.PHAR.377 April 3, 2018
Thalidomide (Thalomid) (PDF) CP.PHAR.78 September 1, 2011
Thioguanine (Tabloid) (PDF) CP.PHAR.437 December 1, 2019
Thyrotropin Alfa (Thyrogen) (PDF)  CP.PHAR.95 March 1, 2012
Timothy grass pollen allergen extract (Grastek®) (PDF) CP.PMN.84 August 31, 2017
Tisagenlecleucel (Kymriah) (PDF) CP.PHAR.361 September 26, 2017
Tobramycin (Bethkis®, Kitabis Pak®, TOBI®, TOBI Podhaler®) (PDF) CP.PHAR.211 May 1, 2016
Tocilizumab (Actemra) (PDF) CP.PHAR.263 July 1, 2016
Tofacitinib (Xeljanz, Xeljanz Poor girl.XR) (PDF) CP.PHAR.267 January 30, 2018
Tolvaptan (Jynarque) (PDF) CP.PHAR.27 June 5, 2018
Topical Acne Treatment (PDF) HIM.PA.71 December 1, 2014
Topical Diclofenac (Solaraze, Flector) (PDF) HIM.PA.123 December 1, 2017
Topical Immunomodulators (PDF) CP.PMN.107 September 1, 2006
Topotecan (Hycamtin)(PDF) CP.PHAR.64 June 1, 2011
Trabectedin (Yondelis®) (PDF) CP.PHAR.204 May 1, 2016
Trametinib (Mekinist) (PDF) CP.PHAR.240 July 1, 2016
Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF) CP.PHAR.228 June 1, 2016
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF) CP.PHAR.199 June 1, 2016
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF) CP.PHAR.199  March 1, 2016
Triamcinolone ER Injection (Zilretta) (PDF) CP.PHAR.371 March 1, 2018
Trientine (Syprine) (PDF) CP.PHAR.438 December 1, 2019
Triptans (PDF) CP.CPA.217 November 16, 2016
triptorelin pamoate (Trelstar®, Triptodur®) (PDF) CP.PHAR.175 November 9, 2017
Ubrogepant (Ubrelvy) (PDF) CP.PHAR.476 June 1, 2020
Unoprostone Isopropyl (Rescula) (PDF) HIM.PA.11 September 4, 2018
Uridine acetate (Vistogard) (PDF) HIM.PA.SP55 November 9, 2017
Ustekinumab (Stelara) (PDF) CP.PHAR.264 August 1, 2016
Valoctocogene Roxaparvovec (PDF) CP.PHAR.466 March 1, 2020
Valproate Sodium for Intravenous Injection (Depacon) (PDF) CP.PHAR.429 September 1, 2019
Valrubicin (Valstar) (PDF) CP.PHAR.439 December 1, 2019
Vandetanib (Caprelsa®) (PDF) CP.PHAR.80 October 1, 2011
Velaglucerase Alfa (VPRIV) (PDF) CP.PHAR.163 February 1, 2016
Vemurafenib (Zelboraf®) (PDF) CP.PHAR.91 November 1, 2011
Verteporfin (Visudyne®) (PDF) CP.PHAR.187 March 1, 2016
Vestronidase alfa-vjbk (Mepsevii) (PDF) CP.PHAR.374 January 19, 2018
Vigabatrin (Sabril) (PDF) CP.PHAR.169 February 1, 2016
Vilazodone (Viibryd) (PDF) CP.PMN.145 August 1, 2012
Viltolarsen (PDF) CP.PHAR.484 June 1, 2020
vincristine sulfate liposome injection (Marqibo®) (PDF) CP.PHAR.315 February 1, 2017
Vismodegib (Erivedge) (PDF) CP.PHAR.273 August 1, 2016
Vorapaxar (Zontivity) (PDF) HIM.PA.146 October 31, 2017
Voretigene neparvovec-rzyl (Luxturna) (PDF) CP.PHAR.372 March 1, 2018
Vorinostat (Zolinza) (PDF) CP.PHAR.83 December 1, 2012
Vortioxetine (Trintellix®) (PDF) CP.PMN.65 May 31, 2017
Voxelotor (Oxbryta) (PDF) CP.PHAR.451 March 1, 2020
Zanubrutinib (Brukinsa) (PDF) CP.PHAR.467 March 1, 2020
ziv-aflibercept (Zaltrap®) (PDF) CP.PHAR.325 March 1, 2017
Zoledronic acid (Reclast, Zometa) (PDF) CP.PHAR.59 March 1, 2011

 

POLICY TITLE POLICY NUMBER EFFECTIVE DATE
340B Shared Savings Model (PDF) GA.PHAR.20 April 1, 2017
72 Hour Supply of Medication (PDF) GA.PHAR.07 June 1, 2006
Abaloparatide (Tymlos) (PDF) CP.PHAR.345 July 1, 2017
abatacept (Orencia) (PDF) CP.PHAR.241 August 1, 2016
Abiraterone (Zytiga) (PDF) CP.PHAR.84 October 1, 2011
Abiraterone (Zytiga, Yonsa) (PDF) CP.PHAR.84 October 1/2011
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 July 1, 2016
Adalimumab (Humira) (PDF) CP.PHAR.242 August 1, 2016
Adefovir (Hepsera) (PDF) CP.PHAR.142 August 28, 2018
Aducanumab (PDF) CP.PHAR.468 June 1, 2020
Afatinib (Gilotrif) (PDF) CP.PHAR.298 January 1, 2017
Aflibercept (Eylea®) (PDF) CP.PHAR.184 March 1, 2016
Agalsidase Beta (Fabrazyme) (PDF) CP.PHAR.158 February 1, 2016
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) CP.PMN.138 March 13, 2018
Age Limit for Tazarotene (Tazorac, Arazlo) (PDF) CP.PMN.75 November 9, 2017
Alectinib (Alecensa) (PDF) CP.PHAR.369 November 16, 2016
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 August 1, 2016
Alendronate (Binosto, Fosamax plus D) (PDF) CP.PMN.88 March 1, 2018
Alglucosidase Alfa (Lumizyme) (PDF) CP.PHAR.160 February 1, 2016
Alirocumab (Praluent) (PDF) CP.PHAR.124 October 1, 2015
Alpelisib (Piqray) (PDF) CP.PHAR.430 September 1, 2019
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF) CP.PHAR.94 March 1, 2012
Ambrisentan (Letairis®) (PDF) CP.PHAR.190 March 1, 2016
Amifampridine (Firdapse, Ruzurgi) (PDF) CP.PHAR.411 January 22, 2019
Amikacin (Arikayce) (PDF) CP.PHAR.401 November 13, 2018
Anakinra (Kineret) (PDF) CP.PHAR.244 August 1, 2016
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) CP.PHAR.217 May 1, 2016
Apalutamide (Erleada) (PDF) CP.PHAR.376 June 1, 2018

Appropriate Use and Safety Edits (PDF)

Appropriate Use and Safety Edits: Attachment A (PDF)

GA.PMN.01 May 1, 2012
Apremilast (Otezla) (PDF) CP.PHAR.245 August 1, 2016
Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF) CP.PMN.19 November 30, 2016
Arformoterol Tartrate (Brovana) (PDF) CP.PMN.201 September 1, 2019
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF) CP.PHAR.290 December 1, 2016
Armodafinil (Nuvigil) (PDF) CP.PMN.35 August 1, 2009
Asenapine (Saphris, Secuado) (PDF) CP.PMN.15 December 1, 2014
asfotase alfa (Strensiq®) (PDF) CP.PHAR.328 March 1, 2017
Aspirin-dipyridamole (Aggrenox) (PDF) CP.PMN.20 Septembre 1, 2006
Atezolizumab (Tecentriq®) (PDF) CP.PHAR.235 June 1, 2016
Avapritinib (Ayvakit) (PDF) CP.PHAR.454 March 1, 2020
Avatrombopag (Doptelet) (PDF) CP.PHAR.130 July 17, 2018
Avelumab (Bavencio®) (PDF) CP.PHAR.333 May 1, 2017
Axicabtagene Ciloleucel (Yescarta) (PDF) CP.PHAR.362 October 31, 2017
Axitinib (Inlyta®) (PDF) CP.PHAR.100 May 1, 2012
Azacitidine (Vidaza) (PDF) CP.PHAR.387 August 28, 2017
Aztreonam (Cayston®) (PDF) CP.PHAR.209 May 1, 2016
Baclofen (Gablofen, Lioresal, Ozobax) (PDF) CP.PHAR.149 November 9, 2017
Baloxavir Marboxil (Xofluza) (PDF) CP.PMN.185 October 30, 2018
Bedaquiline (Sirturo) (PDF) CP.PMN.212 December 1, 2019
belatacept (Nulojix®) (PDF) CP.PHAR.201 November 9, 2017
Belantamab Mafodotin (PDF) CP.PHAR.469 June 1, 2020
Belimumab (Benlysta) (PDF) CP.PHAR.88 October 1, 2011
belinostat (Beleodaq®) (PDF) CP.PHAR.311 February 1, 2017
Bendamustine (Bendeka®, Treanda®) (PDF) CP.PHAR.307 February 1, 2017
Benralizumab (Fasenra) (PDF) CP.PHAR.373 January 16, 2018
Benzodiazepine Use in Pediatric Seizure Disorders (PDF) GA.PMN.08 March 1, 2016
Benznidazole (PDF) CP.PMN.90 October 17, 2017
Berotralstat (PDF) CP.PHAR.485 June 1, 2020
Betaine (Cystadane) (PDF) CP.PHAR.143 August 28, 2018
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) CP.PHAR.93 November 1, 2011
Bexarotene (Targretin) (PDF) CP.PHAR.75 September 1, 2011
Bezlotoxumab (Zinplava) (PDF) CP.PHAR.300 November 16, 2016
Bimatoprost Implant (Durysta) (PDF) CP.PHAR.486 June 1, 2020
Binimetinib (Mektovi) (PDF) CP.PHAR.50 July 24, 2018
Biologic Drug Dose Escalation (PDF) GA.PMN.21 September 1, 2017
Blinatumomab (Blincyto) (PDF) CP.PHAR.312 February 1, 2017
Blocking Adjudication of Controlled Substance Prescriptions for Selected Prescribers (PDF) GA.PHAR.19 November 1, 2001
Bortezomib (Velcade) (PDF) CP.PHAR.410 December 11, 2018
Bosentan (Tracleer®) (PDF) CP.PHAR.191 March 1, 2016
Bosutinib (Bosulif) (PDF) CP.PHAR.105 October 1, 2012
Brentuximab Vedotin (Adcetris) (PDF) CP.PHAR.303 February 1, 2017
Brexanolone (Zulresso) (PDF) CP.PHAR.417 April 16, 2019
Brexpiprazole (Rexulti) (PDF) CP.PMN.68 November 5, 2015
Brexucabtagene Autoleucel (Tecartus) (PDF)
CP.PHAR.472 June 1, 2020
Brigatinib (Alunbrig) (PDF) CP.PHAR.342 July 17, 2017
Brimonidine Tartrate (Mirvaso) (PDF) CP.PMN.192 November 16, 2016
Brivaracetam (Briviact) (PDF) HIM.PA.07 September 1, 2019
Brolucizumab-dbll (Beovu) (PDF) CP.PHAR.445 March 1, 2020
Buprenorphine Implant/Injection (Probuphine, Sublocade) (PDF) CP.PHAR.289 November 16, 2016
Buprenorphine implant (Probuphine) (PDF) CP.PHAR.289 November 16, 2016
Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF) CP.PMN.81 September 1, 2017
Buprenorphine (Subutex) (PDF) CP.PMN.82 September 1, 2017
Burosumab-twza (Crysvita)(PDF) CP.PHAR.11 May 8, 2018
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF) CP.PHAR.202 March 1, 2016
C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF) CP.PHAR.202 March 1, 2016
cabazitaxel (Jevtana® (PDF) CP.PHAR.316 February 1, 2017
Cabozantinib (Cometriq®, Cabometyx®) (PDF) CP.PHAR.111 June 1, 2013
Cannabidiol (Epidiolex) (PDF) CP.PMN.164 July 17, 2018
Canakinumab (Ilaris) (PDF) CP.PHAR.246 August 1, 2016
capecitabine (Xeloda) (PDF) CP.PHAR.60 May 1, 2011
Caplacizumab-yhdp (Cablivi) (PDF) CP.PHAR.416 March 12, 2019
carfilzomib (Kyprolis®) (PDF) CP.PHAR.309 February 1, 2017
Carglumic acid (Carbaglu®) (PDF) CP.PHAR.206 May 1, 2016
Casimersen (PDF) CP.PHAR.470 June 1, 2020
Cedazuridine/Decitabine (ASTX-727) (PDF) CP.PHAR.479 June 1, 2020
Celecoxib (Celebrex, Elyxyb) (PDF) CP.PMN.122 January 1, 2007
Cenegermin-bkbj (Oxervate) (PDF) CP.PMN.186 October 9, 2018
Cenobamate (Xcopri) (PDF) CP.PMN.231 March 1, 2020
Cemiplimab-rwlc (Libtayo) (PDF) CP.PHAR.397 October 16, 2018
Ceritinib (Zykadia) (PDF) CP.PHAR.349 July 1, 2017
Cerliponase alfa (Brineura) (PDF) CP.PHAR.338 July 1, 2017
Certolizumab (Cimzia) (PDF) CP.PHAR.247 August 1, 2016
Cetuximab (Erbitux®) (PDF) CP.PHAR.317 February 1, 2017
Chloramphenicol Sodium Succinate (PDF) CP.PHAR.388 December 1, 2018
Cholic Acid (Cholbam) (PDF) CP.PHAR.390 December 1, 2018
Cinacalcet (Sensipar) (PDF) CP.PHAR.61 May 1, 2011
Cladribine (Mavenclad) (PDF) CP.PHAR.422 September 1, 2019
Clobazam (Onfi) (PDF) CP.PMN.54 November 1, 2012
CNS Stimulants (PDF) CP.PMN.92 March 1, 2018
Cobimetinib (Cotellic) (PDF) CP.PHAR.380 November 16, 2016
Collagenase (Xiaflex) (PDF) CP.PHAR.82 October 1, 2011
Continuous Glucose Monitors (PDF) CP.PMN.214 December 1, 2019
copanlisib (Aliqopa®) (PDF) CP.PHAR.357 October 17, 2017
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) CP.PHAR.385 May 29, 2018
Cosyntropin (Cortrosyn®) (PDF) CP.PHAR.203 April 1, 2016
Crisaborole (Eucrisa) (PDF) CP.PMN.110 February 21, 2017
Crizanlizumab-tmca (Adakveo) (PDF) CP.PHAR.449 March 1, 2020
Crizotinib (Xalkori) (PDF) CP.PHAR.90 November 1, 2011
Cyclosporine (Cequa, Restasis) (PDF) CP.PMN.48 May 1, 2012
Cysteamine ophthalmic (Cystaran) (PDF) CP.PMN.130 August 1, 2017
Cysteamine oral (Cystagon, Procysbi) (PDF) CP.PHAR.155 February 1, 2016
Cytomegalovirus Immune Globulin (Cytogam)(PDF) CP.PHAR.277 September 1, 2018
Dabrafenib (Tafinlar) (PDF) CP.PHAR.239 November 16, 2016
Daclatasvir (Daklinza) (PDF) CP.PHAR.278 September 1, 2016
Daclizumab (Zinbryta) (PDF) CP.PHAR.269 August 1, 2016
Dacomitinib (Vizimpro) (PDF) CP.PHAR.399 October 16, 2018
Dalfampridine (Ampyra) (PDF) CP.PHAR.248 August 1, 2016
Dalteparin (Fragmin) (PDF) CP.PHAR.225 May 1, 2016
Daptomycin (Cubicin, Cubicin RF) (PDF) CP.PHAR.351 November 30, 2017
Daratumumab (Darzalex) (PDF) CP.PHAR.310 July 1, 2017
Darbepoetin Alfa (Aranesp) (PDF) CP.PHAR.236 June 1, 2016
Darolutamide (Nubeqa) (PDF)
CP.PHAR.435 December 1, 2019
Dasabuvir Ombitasvir Paritaprevir Ritonavir (Viekira XR, Viekira Pak) (PDF) GA.PMN.12 December 1, 2016
Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira XR, Viekira Pak) (PDF) CP.PHAR.278 September 1, 2016
Dasatinib (Sprycel) (PDF) CP.PHAR.72 June 1, 2012
daunorubicin/cytarabine (Vyxeos®) (PDF) CP.PHAR.352 December 1, 2017
Deferasirox (Exjade Jadenu) (PDF) CP.PHAR.145 November 1, 2015
Deferiprone (Ferriprox) (PDF) CP.PHAR.147 November 1, 2015
Deferoxamine (Desferal) (PDF) CP.PHAR.146 November 1, 2015
Deflazacort (Emflaza) (PDF) CP.PHAR.331 March 1, 2017
Degarelix acetate (Firmagon®) (PDF) CP.PHAR.170 November 9, 2017
Denosumab (Prolia, Xgeva) (PDF) CP.PHAR.58 March 1, 2011
Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF) CP.PHAR.214 May 1, 2016
Deutetrabenazine (Austedo) (PDF) CP.PHAR.341 June 13, 2017
Dexrazoxane (Zinecard, Totect) (PDF) CP.PHAR.418 March 19, 2019
Dextromethorphan-Quinidine (Nuedexta) (PDF) CP.PMN.93 March 1, 2018
Diazepam Nasal Spray (Valtoco) (PDF) CP.PMN.216 December 1, 2019
Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity) (PDF) CP.PHAR.249 August 1, 2016
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF) CP.PMN.03 September 19, 2018
Dolasetron (Anzemet) (PDF) CP.PMN.141 September 1, 2006
Dornase alfa (Pulmozyme) (PDF) CP.PHAR.212 May 1, 2016
Dose Escalation of Biologics (PDF) GA.PMN.21 September 1, 2017
Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF) CP.PMN.79 May 1, 2017
droxidopa (Northera®) (PDF) CP.PMN.17 November 9, 2017
Dupilumab (Dupixent) (PDF) CP.PHAR.336 May 1, 2017
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 July 1, 2017
Duvelisib (Copiktra) (PDF) CP.PHAR.400 October 16, 2018
Early and Periodic Screening, Diagnostic, and Treatment Benefit for Pediatric Members (PDF) CP.PMN.234 June 1, 2020
Ecallantide (Kalbitor®) (PDF) CP.PHAR.177 March 1, 2016
Eculizumab (Soliris®) (PDF) CP.PHAR.97 March 1, 2012
Edaravone (Radicava) (PDF) CP.PHAR.343 July 1, 2017
Efinaconazole (Jublia) (PDF) CP.PMN.25 August 1, 2016
Elagolix (Orilissa) (PDF) CP.PHAR.136 August 28, 2018
Elapegademase-lvlr (Revcovi) (PDF) CP.PHAR.419 April 23, 2019
Elbasvir/Grazoprevir (Zepatier) (PDF) GA.PMN.16 December 1, 2016
Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (PDF) CP.PHAR.440 December 1, 2019
Eliglustat (Cerdelga) (PDF) CP.PHAR.153 February 1, 2016
Elosulfase Alfa (Vimizim) (PDF) CP.PHAR.162 February 1, 2016
Elotuzumab (Empliciti®) CP.PHAR.308 February 1, 2017
Eltrombopag (Promacta®) (PDF) CP.PHAR.180 March 1, 2016
Emapalumab-lzsg (Gamifant) (PDF) CP.PHAR.402 December 11, 2018
Emicizumab-kxwh (Hemlibra) (PDF) CP.PHAR.370 March 1, 2018
Emtricitabine/Tenofovir Alafenamide (Descovy)(PDF) CP.PMN.235 June 1, 2020
Enasidenib (Idhifa) (PDF) CP.PHAR.363 September 5, 2017
Encorafenib (Braftovi) (PDF) CP.PHAR.127 July 24, 2018
Enfortumab Vedotin-ejfv (Padcev) (PDF) CP.PHAR.455 March 1, 2020
Enfuvirtide (Fuzeon) (PDF) CP.PHAR.41 June 1, 2010
Enoxaparin (Lovenox) (PDF) CP.PHAR.224 May 1, 2016
Entrectinib (Rozlytrek) (PDF) CP.PHAR.441 December 1, 2019
Enzalutamide (Xtandi) (PDF) CP.PHAR.106 October 1, 2012
EoE (PDF) GA.PMN.11 September 1, 2016
Epinephrine Injection Device - Quantity Limit Override (PDF) GA.PMN.03 March 1, 2015
Epoetin Alfa (Epogen® and Procrit) (PDF) CP.PHAR.237 June 1, 2016
Epoprostenol (Flolan®), Veletri®) (PDF) CP.PHAR.192 March 1, 2016
Erdafitinib (Balversa)(PDF) CP.PHAR.423 September 1, 2019
Erenumab-aaoe (Aimovig) (PDF) CP.PHAR.128 July 10, 2018
Eribulin Mesylate (Halaven®) (PDF) CP.PHAR.318 March 1, 2017
Erlotinib (Tarceva) (PDF) CP.PHAR.74 September 1, 2011
Erwinia Asparaginase (Erwinaze) (PDF) CP.PHAR.301 February 1, 2017
Esketamine (Spravato) (PDF) CP.PMN.199 March 12, 2019
Etanercept (Enbrel) (PDF) CP.PHAR.250 August 1, 2016
Etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 March 20, 2018
Eteplirsen (Exondys 51) (PDF) CP.PHAR.288 December 1, 2016
Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF) CP.PHAR.63 June 1, 2011
Evolocumab (Repatha) (PDF) CP.PHAR.123 October 1, 2015
Factor IX (Human, Recombinant) (PDF) CP.PHAR.218 May 1, 2016
Factor IX Complex, Human (Profilnine) (PDF) CP.PHAR.219 May 1, 2016
Factor IX Complex Human (Bebulin®, Profilnine®) (PDF) CP.PHAR.219 May 1, 2016
Factor VIII (Human Recombinant) (PDF) CP.PHAR.215 May 1, 2016
Factor VIII/von Willebrand Factor Complex (Human - Alphanate, Humate-P, Wilate) (PDF) CP.PHAR.216 May 1, 2016
Factor VIIa, Recombinant (NovoSeven® RT) (PDF) CP.PHAR.220 May 1, 2016
Factor XIII A-Subunit, Recombinant (Tretten®) (PDF) CP.PHAR.222 May 1, 2016
Factor XIII, Human (Corifact®) (PDF) CP.PHAR.221 May 1, 2016
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) CP.PHAR.456 March 1, 2020
Febuxostat (Uloric) (PDF) CP.PMN.57 August 1, 2013
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF) CP.PMN.127 June 1, 2015
Ferric Carboxymaltose (Injectafer) (PDF) CP.PHAR.234 June 1, 2016
Ferric Derisomaltose (Monoferric) (PDF) CP.PHAR.280 June 1, 2020
Ferric gluconate (Ferrlecit®) (PDF) CP.PHAR.166 March 1, 2016
Ferumoxytol (Feraheme®) (PDF) CP.PHAR.165 March 1, 2016
Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF) CP.PHAR.297 December 1, 2016
Fingolimod (Gilenya) (PDF) CP.PHAR.251 August 1, 2016
Fondaparinux (Arixtra) (PDF) CP.PHAR.226 May 1, 2016
Fosdenopterin (PDF) CP.PHAR.471 June 1, 2020
Fostamatinib (Tavalisse) (PDF) CP.PHAR.24 June 5, 2018
Fluorouracil Cream (Tolak(PDF) CP.PMN.165 December 1, 2018
Fluticasone Propionate (Xhance) (PDF) CP.PMN.95 October 24, 2017
Fluticasone/Vilanterol (Breo Ellipta) (PDF) CP.PMN.229 March 1, 2020
Fremanezumab-vfrm (Ajovy) (PDF) CP.PHAR.403 October 30, 2018
Fulvestrant (Faslodex Injection)(PDF) CP.PHAR.424 September 1, 2019
Galcanezumab-gnlm (Emgality) (PDF) CP.PHAR.404 November 13, 2018
Galsulfase (Naglazyme) (PDF) CP.PHAR.161 February 1, 2016
Gefitinib (Iressa) (PDF) CP.PHAR.68 November 16, 2016
gemtuzumab ozogamicin (Mylotarg®) (PDF) C.PHAR.358 October 3, 2017
Gilteritinib (Xospata) (PDF) CP.PHAR.412 January 15, 2019
Givosiran (Givlaari) (PDF) CP.PHAR.457 March 1, 2020
Glasdegib (Daurismo) (PDF) CP.PHAR.413 January 8, 2019
Glatiramer (Copaxone, Glatopa) (PDF) CP.PHAR.252 Augustt 1, 2016
Glecaprevir/pibrentasvir (Mavyret) (PDF) GA.PMN.24 September 1, 2017
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF) CP.PMN.183 September 19, 2018
Glycerol phenylbutyrate (Ravicti®) (PDF) CP.PHAR.207 May 1, 2016
Golimumab (Simponi, Simponi Aria) (PDF) CP.PHAR.253 July 1, 2016
Golodirsen (Vyondys 53) (PDF) CP.PHAR.453 March 1, 2020
goserelin acetate (Zoladex®) (PDF) CP.PHAR.171 November 9, 2017
Granisetron (Kytril, Sancuso, Sustol) (PDF) CP.PMN.74 November 1, 2016
Hemin (Panhematin®) (PDF) CP.PHAR.181 Februay 1, 2016
histrelin acetate (Vantas®, Supprelin LA®) (PDF) CP.PHAR.172 November 9, 2017
Hyaluronate Derivatives (PDF) CP.PHAR.05 October 1, 2008
Hydroxyprogesterone Caproate (Makena/compound) CP.PHAR.14 November 20, 2017
Hydroxyurea (Siklos) (PDF) CP.PMN.193 February 19, 2019
Ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 April 17, 2018
Ibandronate sodium (Boniva®) (PDF) CP.PHAR.189 November 15, 2017
Ibrutinib (Imbruvica) (PDF) CP.PHAR.126 October 1, 2015
Ibuprofen/Famotidine (Duexis) (PDF) CP.PMN.120 June 1, 2018
Icatibant (Firazyr) (PDF) CP.PHAR.178 March 1, 2016
Icosapent ethyl (Vascepa) (PDF) CP.PMN.187 November 20, 2018
Idecabtagene Vicleucel (BB2121) (PDF) CP.PHAR.481 June 1, 2020
Idelalisib (Zydelig) (PDF) CP.PHAR.133 December 1, 2018
Idursulfase (Elaprase) (PDF) CP.PHAR.156 February 1, 2016
Iloperidone (Fanapt) (PDF) CP.PMN.32 December 1, 2014
Iloprost (Ventavis®) (PDF) CP.PHAR.193 March 1, 2016
Imatinib (Gleevec) (PDF) CP.PHAR.65 June 1, 2011
Imiglucerase (Cerezyme) (PDF) CP.PHAR.154 February 1, 2016
Immune Globulins (PDF) CP.PHAR.103 August 1, 2012
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 July 1, 2016
Indacaterol/Glycopyrrolate (Utibron Neohaler) (PDF) HIM.PA.102 September 1, 2018
Inebilizumab (PDF) CP.PHAR.458 March 1, 2020
Infertility and Fertility Preservation (PDF) CP.PHAR.131 November 16, 2016
Infliximab (Remicade, Inflectra, Renflexis) (PDF) CP.PHAR.254 July 1, 2016
Inotersen (Tegsedi) (PDF) CP.PHAR.405 November 20, 2018
inotuzumab ozogamicin (Besponsa®) (PDF) CP.PHAR.359 September 26, 2017
Insulin Infusion Pump (Omnipod, Omnipod DASH) (PDF) CP.PHAR.420 April 23, 2019
Interferon beta-1a (Avonex, Rebif) (PDF) CP.PHAR.255 August 1, 2016
Interferon beta-1b (Betaseron, Extavia) (PDF) CP.PHAR.256 August 1, 2016
Interferon Gamma- 1b (Actimmune) (PDF) CP.PHAR.52 June 1, 2010
Itraconazole (Sporanox, Onmel, Tolsura) (PDF) CP.PMN.124 November 1, 2006
Intrathecal Baclofen (Gablofen, Lioresal) (PDF) CP.PHAR.149 November 9, 2017
Iobenguane I-131 (Azedra) (PDF) CP.PHAR.459 March 1, 2020
Ipilimumab (Yervoy) (PDF) CP.PHAR.319 April 17, 2018
irinotecan Liposome (Onivyde®) (PDF) CP.PHAR.304 February 1, 2017
Iron sucrose (Venofer®) (PDF) CP.PHAR.167 March 1, 2016
Isatuximab-irfc (Sarclisa)(PDF) CP.PHAR.482 June 1, 2020
Isavuconazonium (Cresemba) (PDF) CP.PMN.154 November 16, 2016
Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (PDF) CP.PMN.143 December 1, 2014
Istradefylline (Nourianz) (PDF) CP.PMN.217 March 1, 2020
Ivabradine (Corlanor) (PDF) CP.PMN.70 November 1, 2015
Ivacaftor (Kalydeco) (PDF) CP.PHAR.210 May 1, 2016
Ivosidenib (Tibsovo) (PDF)
CP.PHAR.137 August 21, 2018
Ixazomib (Ninlaro) (PDF) CP.PHAR.302 February 1, 2017
Ixekizumab (Taltz) (PDF) CP.PHAR.257 August 1, 2016
Lacosamide (Vimpat) (PDF) CP.PMN.155 December 1, 2014
Lanadelumab-fylo (Takhzyro) (PDF) CP.PHAR.396 September 25, 2018
Lanreotide (Somatuline Depot) (PDF) CP.PHAR.391 August 28, 2018
lapatinib (Tykerb®) (PDF) CP.PHAR.79 November 9, 2017
Laronidase (Aldurazyme) (PDF) CP.PHAR.152 February 1, 2016
Larotrectinib (Vitrakvi) (PDF) CP.PHAR.414 January 15, 2018
Lasmiditan (Reyvow) (PDF) CP.PMN.218 March 1, 2020
Ledipasvir/Sofosbuvir (Harvoni) (PDF) CP.PHAR.279 September 1, 2016
Lefamulin (Xenleta) (PDF) CP.PMN.219 March 1, 2020
Lemborexant (Dayvigo)(PDF) CP.PMN.233 June 1, 2020
Lenalidomide (Revlimid) (PDF) CP.PHAR.71 July 1, 2011
Lenvatinib (Lenvima) (PDF) CP.PHAR.138 December 1, 2018
Letermovir (Prevymis) (PDF) CP.PHAR.367 March 1, 2018
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) CP.PHAR.173 November 9, 2017
Levalbuterol (Xopenex HFA/Inhalation Solution) (PDF) CP.PMN.07 September 1, 2006
Levoleucovorin (Fusilev®) (PDF) CP.PHAR.151 November 9, 2017
Levofloxacin (Levaquin) in Pediatric Community Acquired Pneumonia (PDF) GA.PMN.05 March 1, 2016
Lidocaine Transdermal (Lidoderm, ZTlido) (PDF) CP.PMN.08 September 1, 2006
Linaclotide (Linzess) (PDF) CP.PMN.71 November 1, 2015
Linezolid (Zyvox) (PDF) CP.PMN.27 September 1, 2016
Lifitegrast (Xiidra®) (PDF) CP.PMN.73 November 9, 2017
Lofexidine (Lucemyra) (PDF) CP.PMN.152 August 1, 2018
Lomitapide (Juxtapid) (PDF) CP.PHAR.283 October 1, 2016
Lorlatinib (Lorbrena) (PDF) CP.PHAR.406 December 11, 2018
Lubiprostone (Amitiza) (PDF) CP.PMN.142 December 1, 2014
Luliconazole Cream (Luzu) (PDF) CP.PMN.166 August 28, 2018
Lumacaftor-Ivacaftor (Orkambi) (PDF) CP.PHAR.213 May 1, 2016
Lumasiran (ALN-GO1) (PDF) CP.PHAR.473 June 1, 2020
Lumateperone (Caplyta) (PDF) CP.PMN.232 March 1, 2020
Lurasidone (Latuda) (PDF) CP.PMN.50 December 1, 2014
Luspatercept-aamt (Reblozyl) (PDF) CP.PHAR.450 March 1, 2020
Lusutrombopag (Mulpleta) (PDF) CP.PHAR.407 September 18, 2018
Lutetium Lu 177 Dotatate (Lutathera)(PDF) CP.PHAR.384 May 22, 2018
Macitentan (Opsumit®) (PDF) CP.PHAR.194 March 1, 2016
Maximum Allowable Cost Requirement (PDF) GA.PHAR.21 July 1, 2017
Mecasermin (Increlex) (PDF) CP.PHAR.150 March 1, 2011
Mecamylamine (Vecamyl) (PDF) CP.PMN.136 May 1, 2017
Medication Safety Policy (PDF) GA.PMN.22 July 1, 2017
Megestrol Acetate (Megace ES) (PDF) CP.PMN.179 December 1, 2018
Mepolizumab (Nucala) (PDF) CP.PHAR.200 April 1, 2016
Metformin ER (Fortamet, Glumetza) (PDF) CP.PMN.72 November 1, 2015
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF) CP.PHAR.134 December 1, 2018
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) CP.PHAR.238 June 1, 2016
Methylnaltrexone Bromide (Relistor) (PDF) CP.PMN.169 December 1, 2018
Metreleptin (Myalept) (PDF) CP.PHAR.425 September 1, 2019
Midazolam (Nayzilam) (PDF) CP.PMN.211 September 1, 2019
Midostaurin (Rydapt) (PDF) CP.PHAR.344 June 1, 2017
Mifepristone (Korlym) (PDF) CP.PHAR.101 May 1, 2012
Migalastat (Galafold) (PDF) CP.PHAR.394 September 11, 2018
Miglustat (Zavesca) (PDF) CP.PHAR.164 February 1, 2016
Milnacipran (Savella) (PDF) CP.PMN.125 August 1, 2012
Mipomersen (Kynamro) (PDF) CP.PHAR.284 October 1, 2016
Minocycline ER (Solodyn, Ximino, Minolira) and Microspheres (Arestin) (PDF) CP.PMN.80 May 1, 2017
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 August 1, 2016
Modafinil (Provigil) (PDF) CP.PMN.39 May 1, 2008
Mogamulizumab-kpkc (Poteligeo) (PDF) CP.PHAR.139 September 4, 2018
Mometasone/Formoterol (Dulera) (PDF) CP.PMN.230 March 1, 2020
Mometasone Furoate (Sinuva) (PDF) CP.PHAR.448 March 1, 2020
Monomethyl Fumarate (Bafiertam) (PDF) CP.PHAR.460 March 1, 2020
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) CP.PHAR.398 10/16/2018
Nadofaragene Firadenovec (Instiladrin) (PDF) CP.PHAR.461 March 1, 2020
nafarelin acetate (Synarel®) (PDF) CP.PHAR.174 11/09/2017
Naproxen/Esomeprazole (Vimovo) (PDF) CP.PMN.117 06/01/2018
Natalizumab (Tysabri) (PDF) CP.PHAR.259 07/01/2016
Necitumumab (Portrazza®) (PDF) CP.PHAR.320 March 1, 2017
Neomycin/Fluocinolone Cream (Neo-Synalar)_(PDF) CP.PMN.167 August 28, 2018
Neratinib (Nerlynx) (PDF) CP.PHAR.365 September 5, 2017
Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan)  (PDF) CP.PMN.118 February 13, 2018
Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (PDF) CP.PMN.158 September 1, 2006
nilotinib (Tasigna) (PDF) CP.PHAR.76 September 1, 2011
Nintedanib (Ofev) (PDF) CP.PHAR.285 October 1, 2016
Nitisinone (Nityr, Orfadin) (PDF) CP.PHAR.132 August 28, 2018
Nivolumab (Opdivo) (PDF) CP.PHAR.121 July 1, 2015
No Coverage Criteria/Off-Label Use Policy (PDF) CP.PMN.53 September 12, 2017
Nusinersen (Spinraza®)(PDF) CP.PHAR.327 November 28, 2017
Obeticholic (Ocaliva) (PDF) CP.PHAR.287 November 1, 2016
Obinutuzumab (Gazyva®) (PDF) CP.PHAR.305 Februay 1, 2017
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 April 1, 2017
Octreotide (Sandostatin, Sandostatin LAR) (PDF) CP.PHAR.40 March 1, 2010
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia) (PDF) CP.PHAR.40 March 1, 2010
ofatumumab (Arzerra®) (PDF) CP.PHAR.306 February 1, 2017
Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) CP.PHAR.292 December 1, 2016
Olaparib (Lynparza) (PDF) CP.PHAR.360 October 3, 2017
olaratumab (Lartruvo®) (PDF) CP.PHAR.326 March 1, 2017
Omadacycline (Nuzyra) (PDF) CP.PMN.188 November 20, 2018
Omacetaxine (Synribo) (PDF) CP.PHAR.108 April 1, 2013
Omalizumab (Xolair®) (PDF) CP.PHAR.01 October 1, 2008
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 July 1, 2016
Onasemnogene Abeparvovec (Zolgensma) (PDF) CP.PHAR.421 June 7, 2019
Ondansetron (Zuplenz) (PDF) CP.PMN.45 September 1, 2006
Opioid Analgesics (PDF) GA.PMN.26 October 1, 2019
Osimertinib (Tagrisso) (PDF) CP.PHAR.294 December 1, 2016
Ospemifene (Osphena) (PDF) CP.PMN.168 August 28, 2018
Overactive Bladder Agents (PDF) CP.PMN.198 May 1, 2016
Ozanimod (PDF) CP.PHAR.462 March 1, 2020
Ozenoxacin (Xepi) (PDF) CP.PMN.119 January 30, 2018
Paclitaxel, Protein-Bound (Abraxane) (PDF) CP.PHAR.176 July 1, 2015
Palbociclib (Ibrance®) (PDF) CP.PHAR.125 October 1, 2015
Palivizumab (Synagis) (PDF) CP.PHAR.16 August 1, 2009
panitumumab (Vectibix®) (PDF) CP.PHAR.321 March 1, 2017
Parathyroid Hormone (Natpara) (PDF) CP.PHAR.282 November 16, 2016
Paricalcitol Injection (Zemplar) (PDF) CP.PHAR.270 August 1, 2016
Pasireotide (Signifor LAR®) (PDF) CP.PHAR.332 March 1, 2017
Patisiran (Onpattro) (PDF) CP.PHAR.395 September 11, 2018
Pazopanib (Votrient) (PDF) CP.PHAR.81 October 1, 2011
Peanut Allergen Powder-dnfp (Palforzia) (PDF) CP.PMN.220 March 1, 2020
Pediatric Benzodiazepine Use in Chemotherapy Induced Nausea and Vomiting CINV (PDF) GA.PMN.07 August 1, 2016
Pediatric BZD Seizures (PDF) GA.PMN.08 March 1, 2016
Pegademase Bovine (Adagen) (PDF) CP.PHAR.392 August 28, 2018
Pegaptanib (Macugen®) (PDF) CP.PHAR.185 March 1, 2016
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF) CP.PHAR.353 September 5, 2017
Pegfilgrastim (Neulasta) (PDF) CP.PHAR.296 December 1, 2016
peginterferon alfa-2b (PegIntron, Sylatron®) (PDF) CP.PHAR.89 October 1, 2011
Peginterferon beta-1a (Plegridy) (PDF) CP.PHAR.271 August 1, 2016
Pegloticase (Krystexxa®) (PDF) CP.PHAR.115 June 1, 2013
Pegvaliase-pqpz (Palynziq) (PDF) CP.PHAR.140 July 31, 2018
Pegvisomant (Somavert) (PDF) CP.PHAR.389 December 1, 2018
Pemetrexed (Alimta, Pemfexy) (PDF) CP.PHAR.368 October 31, 2017
pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 March 1, 2017
Perampanel (Fycompa) (PDF) CP.PMN.156 November 16, 2016
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 June 1, 2016
Pexidartinib (Turalio) (PDF) CP.PHAR.436 December 1, 2019

Pharmacy Lock-In Program (PDF)

Lock-In Letter (PDF)

Lock-In Release Letter (PDF)

GA.PHAR.06 July 1, 2006
Pharmacy Program (PDF) GA.PHAR.01 October 1, 2006
Pitolisant (Wakix) (PDF) CP.PMN.221 March 1, 2020
Plerixafor (Mozobil) (PDF) CP.PHAR.323 March 1, 2017
Polatuzumab Vedotin-piiq (Polivy) (PDF) CP.PHAR.433 September 1, 2019
Pomalidomide (Pomalyst) (PDF) CO.PHAR.116 July 1, 2013
Ponatinib (Iclusig) (PDF) CO.PHAR.112 June 1, 2013
Pralatrexate (Folotyn®) (PDF) CP.PHAR.313 February 1, 2017
Pramlintide (Symlin) (PDF) CP.PMN.129 June 1, 2018
Pregabalin (Lyrica, Lyrica CR) (PDF) CP.PMN.33 January 1, 2007
Pretomanid (PDF) CP.PMN.222 March 1, 2020
Protein C Concentrate, Human (Ceprotin) (PDF) CP.PHAR.330 March 1, 2017
Propranolol HCl Oral Solution (Hemangeol) (PDF) CP.PMN.58 May 1, 2014
Prucalopride (Motegrity) (PDF) CP.PMN.194 January 29, 2019
Psychotropic Medication Continuity of Care (COC) (PDF) GA.PMN.10 December 1, 2016
pyrimethamine (Daraprim®) (PDF) CP.PMN.44 November 1, 2015
Quetiapine ER (Seroquel XR) (PDF) CP.PMN.64 December 1, 2014
Ramucirumab (Cyramza®) (PDF) CP.PHAR.119 May 1, 2015
Ranibizumab (Lucentis®) (PDF) CP.PHAR.186 March 1, 2016
Regorafenib (Stivarga) (PDF) CP.PHAR.107 December 1, 2012
Remestemcel-L (Prochymal) (PDF) CP.PHAR.474 June 1, 2020
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) CP.PHAR.168 March 1, 2016
Request for Medically Necessary Drug Not on the PDL (PDF) CP.PMN.16 November 9, 2017
Reslizumab (Cinqair) (PDF) CP.PHAR.223 May 1, 2016
Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF) CP.PHAR.141 November 16, 2016
Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) (PDF) CP.PMN.223 March 1, 2020
Rifamycin (Aemcolo) (PDF) CP.PMN.196 January 8, 2019
rifaximin (Xifaxan®)(PDF) CP.PMN.47 November 1, 2011
Rilonacept (Arcalyst) (PDF) CP.PHAR.266 November 16, 2016
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 July 1, 2016
Riociguat (Adempas®) (PDF) CP.PHAR.195 March 1, 2016
Risdiplam (PDF) CP.PHAR.477 June 1, 2020
Risedronate (Actonel, Atelvia) (PDF) CP.PMN.100 March 1, 2018
Risperidone Long-Acting Injection (Risperdal Consta) (PDF) CP.PHAR.293 December 1, 2016
Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) CP.PHAR.260 July 1, 2016
Rolapitant (Varubi) (PDF) CP.PMN.102 February 1, 2017
romidepsin (Istodax®) (PDF) CP.PHAR.314 January 1, 2017
Romiplostim (Nplate®) (PDF) CP.PHAR.179 March 1, 2016
Rucaparib (Rubraca®) (PDF) CP.PHAR.350 September 1, 2017
Rufinamide (Banzel) (PDF) CP.PMN.157 December 1, 2014
Sacubitril/Valsartan (Entresto) (PDF) CP.PMN.67 November 1, 2015
Sacitizumab Govitecan (PDF) CP.PHAR.475 June 1, 2020
Safinamide (Xadago) (PDF) CP.PMN.113 July 1, 2017
Sapropterin Dihydrochloride (Kuvan) (PDF) CP.PHAR.43 February 1, 2010
Sarecycline (Seysara) (PDF) CP.PMN.189 November 13, 2018
Sargramostim (Leukine) (PDF) CP.PHAR.295 December 1, 2016
Satralizumab (PDF) CP.PHAR.463 March 1, 2020
Sebelipase Alfa (Kanuma) (PDF) CP.PHAR.159 February 1, 2016
Secnidazole (Solosec) (PDF) CP.PMN.103 October 24, 2017
Selexipag (Uptravi®) (PDF) CP.PHAR.196 March 1, 2016
Selinexor (Xpovio) (PDF) CP.PHAR.431 September 1, 2019
Selpercatinib (LOXO-292) (PDF) CP.PHAR.478 June 1, 2020
Selumetinib (Koselugo) (PDF) CP.PHAR.464 March 1, 2020
Sildenafil (Revatio®) (PDF) CP.PHAR.197 March 1, 2016
Siltuximab (Sylvant®) (PDF) CP.PHAR.329 March 1, 2017
Simeprevir (Olysio) (PDF) CP.PHAR.280 September 1, 2016
Siponimod (Mayzent) (PDF) CP.PHAR.427 September 1, 2019
Sipuleucel-T (Provenge) (PDF) CP.PHAR.120 June 1, 2015
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF) CP.PMN.14 September 18, 2018
sodium oxybate (Xyrem) (PDF) CP.PMN.42 May 1, 2011
Sodium Phenylbutyrate (Buphenyl) (PDF) CP.PHAR.208 May 1, 2016
Sofosbuvir/Ledipasvir (Harvoni) (PDF) GA.PMN.13 December 1, 2016
Sofosbuvir (Sovaldi) (PDF) CP.PHAR.281 September 1, 2016
Sofosbuvir (Sovaldi) (PDF) GA.PMN.17 December 1, 2016
Sofosbuvir/Velpatasvir (Epclusa) (PDF) GA.PMN.06 December 1, 2016
Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (PDF) GA.PMN.25 September 1, 2017
Solriamfetol (Sunosi) (PDF) CP.PMN.209 September 1, 2019
Somatropin (Growth Hormone) (PDF) CP.PHAR.55 March 1, 2011
Sonidegib (Odomzo) (PDF) CP.PHAR.272 May 1, 2012
sorafenib (Nexavar) (PDF) CP.PHAR.69 July 1, 2011
Specialty Drug Classification (PDF) GA.PHAR.15 March 12, 2000
Specialty Pharmacy Program (PDF) GA.PHAR.18 March 12, 2014
Step Therapy (PDF) CP.PST.01 December 28, 2017
Stiripentol (Diacomit) (PDF) CP.PMN.184 September 25, 2018
sunitinib (Sutent) (PDF) CP.PHAR.73 September 1, 2011
Suvorexant (Belsomra®) (PDF) CP.PMN.109 February 1, 2017
Tadalafil (Adcirca®) (PDF) CP.PHAR.198 March 1, 2016
Tadalafil BHP - ED (Cialis) (PDF) CP.PMN.132 June 1, 2018
Tafamidis (Vyndaqel, Vyndamax) (PDF) CP.PHAR.432 September 1, 2019  
Talazoparib (Talzenna) (PDF) CP.PHAR.409 November 27, 2018  
Taliglucerase Alfa (Elelyso) (PDF) CP.PHAR.157 February 1, 2016
Tasimelteon (Hetlioz) (PDF) CP.PMN.104 Februray 1, 2017
Tavaborole (Kerydin) (PDF) CP.PMN.105 March 1, 2018
Tazemetostat (Tazverik) (PDF) CP.PHAR.452 March 1, 2020
Tedizolid (Sivextro) (PDF) CP.PMN.62 March 1, 2015
Teduglutide (Gattex) (PDF) CP.PHAR.114 May 1, 2013
Tegaserod (Zelnorm) (PDF) CP.PMN.206 September 1, 2019
Telotristat Ethyl (Xermelo) (PDF) CP.PHAR.337 June 1, 2017
Temozolomide (Temodar) (PDF) CP.PHAR.77 September 1, 2011
temsirolimus (Torisel®) (PDF) CP.PHAR.324 March 1, 2017
Tenapanor (Ibsrela) (PDF) CP.PMN.224 March 1, 2020
Teprotumumab (Tepezza) (PDF) CP.PHAR.465 January 21, 2020
Teriflunomide (Aubagio) (PDF) CP.PHAR.262 August 1, 2016
Teriparatide (Forteo®) (PDF) CP.PHAR.188 Novembe 15, 2017
Tesamorelin (Egrifta) (PDF) CP.PHAR.109 March 1, 2014
Testosterone (Testopel, Jatenzo) (PDF) CP.PHAR.354 August 1, 2017
tetrabenazine (Xenazine) (PDF) CP.PHAR.92 December 1, 2011
Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF) CP.PHAR.377 April 3, 2018
Thalidomide (Thalomid) (PDF) CP.PHAR.78 September 1, 2011
Thioguanine (Tabloid) (PDF) CP.PHAR.437 December 1, 2019
Thyrotropin Alfa (Thyrogen) (PDF)  CP.PHAR.95 March 1, 2012
Timothy grass pollen allergen extract (Grastek®) (PDF) CP.PMN.84 August 31, 2017
Tisagenlecleucel (Kymriah) (PDF) CP.PHAR.361 September 26, 2017
Tobramycin (Bethkis®, Kitabis Pak®, TOBI®, TOBI Podhaler®) (PDF) CP.PHAR.211 May 1, 2016
Tocilizumab (Actemra) (PDF) CP.PHAR.263 July 1, 2016
Tofacitinib (Xeljanz, Xeljanz XR) (PDF) CP.PHAR.267 January 30, 2018
Tolvaptan (Jynarque) (PDF) CP.PHAR.27 June 5, 2018
Topical Immunomodulators (PDF) CP.PMN.107 September 1, 2006
Topical Steroid Use For Eosinophilic Esophagitis (PDF) GA.PMN.11 September 1, 2016
Topical Tretinoin in Adult Acne Vulgaris (PDF) GA.PMN.09 March 1, 2016
Topotecan (Hycamtin)(PDF) CP.PHAR.64 June 1, 2011
Trabectedin (Yondelis®) (PDF) CP.PHAR.204 May 1, 2016
Trametinib (Mekinist) (PDF) CP.PHAR.240 July 1, 2016
Transition of Care (PDF) GA.PHAR.02 October 1, 2020
Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF) CP.PHAR.228 June 1, 2016
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF) CP.PHAR.199 March 1, 2016
Triamcinolone ER Injection (Zilretta) (PDF) CP.PHAR.371 March 1, 2018
Trientine (Syprine) (PDF) CP.PHAR.438 December 1, 2019
triptorelin pamoate (Trelstar®, Triptodur®) (PDF) CP.PHAR.175 November 9, 2017
Ubrogepant (Ubrelvy) (PDF) CP.PHAR.475 June 1, 2020
Upadacitinib (Rinvoq) (PDF) CP.PHAR.443 December 1, 2019
Ustekinumab (Stelara) (PDF) CP.PHAR.264 August 1, 2016
Valoctocogene Roxaparvovec (PDF) CP.PHAR.466 March 1, 2020
Valproate Sodium for Intravenous Injection (Depacon) (PDF) CP.PHAR.429 September 1, 2019
Valrubicin (Valstar) (PDF) CP.PHAR.439 December 1, 2019
Vandetanib (Caprelsa®) (PDF) CP.PHAR.80 October 1, 2011
Varenicline (Chantix) (PDF) GA.PMN.16 January 1, 2017
Vedolizumab (Entyvio) (PDF) CP.PHAR.265 July 1, 2016
Velaglucerase Alfa (VPRIV) (PDF) CP.PHAR.163 February 1, 2016
Vemurafenib (Zelboraf®) (PDF) CP.PHAR.91 November 1, 2011
Verteporfin (Visudyne®) (PDF) CP.PHAR.187 March 1, 2016
Vestronidase alfa-vjbk (Mepsevii) (PDF) CP.PHAR.374 January 19, 2018
Vigabatrin (Sabril) (PDF) CP.PHAR.169 February 1, 2016
Vilazodone (Viibryd) (PDF) CP.PMN.145 August 1, 2012
Viltolarsen (PDF) CP.PHAR.484 June 1, 2020
vincristine sulfate liposome injection (Marqibo®) (PDF) CP.PHAR.315 February 1, 2017
Vismodegib (Erivedge) (PDF) CP.PHAR.273 August 1, 2016
Voretigene neparvovec-rzyl (Luxturna) (PDF) CP.PHAR.372 March 1, 2018
Vorinostat (Zolinza) (PDF) CP.PHAR.83 December 1, 2012
Vortioxetine (Trintellix®) (PDF) CP.PMN.65 May 31, 2017
Voxelotor (Oxbryta) (PDF) CP.PHAR.451 March 1, 2020
Zanubrutinib (Brukinsa) (PDF) CP.PHAR.467 March 1, 2020
ziv-aflibercept (Zaltrap®) (PDF) CP.PHAR.325 March 1, 2017
Zoledronic acid (Reclast, Zometa) (PDF) CP.PHAR.59 March 1, 2011

 

POLICY TITLE POLICY NUMBER EFFECTIVE DATE
72 Hour Supply of Medication (PDF) GA.PHAR.07 June 1, 2006
Ado-Trastuzumab Emtansine (Kadcyla) (PDF) CP.PHAR.229 June 1, 2016
Aflibercept (Eylea®) (PDF) CP.PHAR.184 March 1, 2016
Alglucosidase Alfa (Lumizyme) (PDF) CP.PHAR.160 February 1, 2016
Anakinra (Kineret) (PDF) CP.PHAR.244 August 1, 2016
Ambrisentan (Letairis®) (PDF) CP.PHAR.190 March 1, 2016

Appropriate Use and Safety Edits (PDF)

Appropriate Use and Safety Edits: Attachment A (PDF)

GA.PMN.01 May 1, 2012
Benznidazole (PDF) CP.PMN.90 October 17, 2017
Blocking Adjudication of Controlled Substance Prescriptions for Selected Prescribers (PDF) GA.PHAR.19 November 1, 2001
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF) CP.PHAR.202 March 1, 2016
Cabozantinib (Cometriq®, Cabometyx®) (PDF) CP.PHAR.111 June 1, 2013
Carglumic acid (Carbaglu®) (PDF) CP.PHAR.206 May 1, 2016
Dose Escalation of Biologics (PDF) GA.PMN.21 September 1, 2017
Drug Recall Notification Process (PDF) GA.PHAR.08 July 1, 2008
Drug Utilization Review (PDF) GA.PHAR.13 April 1, 2007
Enoxaparin (Lovenox) (PDF) CP.PHAR.224 May 1, 2016
Epoprostenol (Flolan®), Veletri®) (PDF) CP.PHAR.192 March 1, 2016
Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF) CP.PHAR.297 December 1, 2016
Hydroxyprogesterone Caproate (Makena®) (PDF) CP.PHAR.14 November 20, 2017
Ibandronate sodium (Boniva®) (PDF) CP.PHAR.189 November 15, 2017
Ibrutinib (Imbruvica) (PDF) CP.PHAR.126 October 1, 2015
Iloprost (Ventavis®) (PDF) CP.PHAR.193 March 1, 2016
Ivacaftor (Kalydeco) (PDF) CP.PHAR.210 May 1, 2016
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) CP.PHAR.173 November 9, 2017
Lomitapide (Juxtapid) (PDF) CP.PHAR.283 October 1, 2016
Lost, Stolen, Spilled or Broken Medications (PDF) GA.PHAR.10 April 1, 2007
Maximum Allowable Cost (MAC) Requirement (PDF) GA.PHAR.21 July 1, 2017
Mecasermin (Increlex) (PDF) CP.PHAR.150 March 1, 2011
Medication Safety Policy (PDF) GA.PMN.22 July 1, 2017
Mifepristone (Korlym) (PDF) CP.PHAR.101 May 1, 2012
Mipomersen (Kynamro) (PDF) CP.PHAR.284 October 1, 2016
Pegaptanib (Macugen®) (PDF) CP.PHAR.185 March 1, 2016
Pegloticase (Krystexxa®) (PDF) CP.PHAR.115 June 1, 2013
pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 March 1, 2017
Pharmacy and Therapeutics Committee (PDF) GA.PHAR.17 August 9, 2011
Pharmaceutical Management (PDF) GA.PHAR.03 February 1, 2003
Pharmacy Prior Authorization and Medical Necessity Criteria (PDF) GA.PHAR.16 July 9, 2010
Plerixafor (Mozobil) (PDF) CP.PHAR.323 March 1, 2017
Ranibizumab (Lucentis®) (PDF) CP.PHAR.186 March 1, 2016
Riociguat (Adempas®) (PDF) CP.PHAR.195 March 1, 2016
Tadalafil (Adcirca®) (PDF) CP.PHAR.198 March 1, 2016
Vandetanib (Caprelsa®) (PDF) CP.PHAR.80 October 1, 2011
vincristine sulfate liposome injection (Marqibo®) (PDF) CP.PHAR.315 February 1, 2017

 

 

Payment Policies

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding.  They are used to help identify whether health care services are correctly coded for reimbursement.  Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for  physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the Peach State Health Plan Payment Policy Manual apply with respect to Peach State Health Plan members. Policies in the Peach State Health Plan Payment Policy Manual may have either a Peach State Health Plan or a “Centene” heading.  In addition, Peach State Health Plan may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Peach State Health Plan.     

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

 

POLICY TITLE POLICY NUMBER EFFECTIVE DATE
3 Day Payment Window (PDF) CC.PP.500 July 1, 2014
30 Day Readmission (PDF) CC.PP.501 January 1, 2015
Add On Policy (PDF) CC.PP.030 January 1, 2013
Assistant Surgeon (PDF) CC.PP.029 January 1, 2014
Bilateral Procedures (PDF) CC.PP.037 January 1, 2014
Cerumen Removal Policy (PDF) CC.PP.008 January 1, 2014
Clean Claims Policy (PDF) CC.PP.021 January 1, 2013
Clinical Validation of Modifier 25 (PDF) CC.PP.013 January 1, 2013
Clinical Validation of Modifier 59 (PDF) CC.PP.014 January 1, 2013
Code Editing Overview (PDF) CC.PP.011 January 1, 2013
Cosmetic Procedures (PDF) CC.PP.024 January 1, 2014
Distinct Procedure Modifiers Policy (PDF) CC.PP.020 January 1, 2013
Duplicate Primary Code Billing (PDF) CC.PP.044 January 1, 2014
EM Medical Decision Making (PDF) CC.PP.051 June 1, 2017
E&M Bundling with Labs and Radiology (PDF) CC.PP.010 January 1, 2013
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 January 1, 2016
Inpatient Consultation (PDF) CC.PP.038 January 1, 2014
Inpatient Only Procedures Policy (PDF) CC.PP.018 January 1, 2018
IV Hydration Policy (PDF) CC.PP.012 January 1, 2013
Leveling of Care: Evaluation and Management Overcoding (PDF) CC.PP.066 February 6, 2020
Leveling of Emergency Room Services (PDF) GA.PP.506 December 16, 2020
Max Units Payment Policy (PDF) CC.PP.007 January 1, 2013
Moderate Conscious Sedation (PDF) CC.PP.015 January 1, 2013
Modifier DOS Validation (PDF) CC.PP.034 Janaury 1, 2015
Modifier to Procedure Code Validation (PDF) CC.PP.028 January 1, 2013
Multiple CPT Code Replace (PDF) CC.PP.033 January 1, 2013
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF) CC.PP.065 February 6, 2020
Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF) CC.PP.068 December 16, 2020
Multiple Procedure Reduction: Ophthalmology (PDF) CC.PP.069 August 18, 2020
NCCI Unbundling (PDF) CC.PP.031 January 1, 2013
New Patient (PDF) CC.PP.036 January 1, 2014
Never Paid Events (PDF) CC.PP.017 January 1, 2013
Non-obstectrical Pelvic and Transvaginal Ultrasounds (PDF) CC.PP.061 June 1, 2018
Not Medically Necessary Inpatient Service (PDF) CC.PP.060 June 1, 2018
Outpatient Consultation (PDF) CC.PP.039 January 1, 2014
Physicians Consultation Services (PDF) CC.PP.054 October 1, 2017
Physician's Office Lab Testing (PDF) CC.PP.055 December 1, 2019
Place of Service Mismatch (PDF) CC.PP.063 September 1, 2018
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) CP.MP.181 August 1, 2020
Postoperative Visits (PDF) CC.PP.042 January 1, 2014
Preoperative Visits (PDF) CC.PP.041 January 1, 2014
Problem Oriented Visits with Preventative Services (PDF) CC.PP.057 October 1, 2017
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 November 1, 2017
Professional Component Modifier (PDF) CC.PP.027 January 1, 2013
Pulse Oximetry w Office Visits (PDF) CC.PP.025 January 1, 2013
Robotic Surgeries (PDF) CC.PP.050 August 1, 2017
Renal Hemodialysis (PDF) CC.PP.067 March 1, 2021
Same Day Visits (PDF) CC.PP.040 January 1, 2014
Status B Bundled Services (PDF) CC.PP.046 January 1, 2014
Status P Bundled Services (PDF) CC.PP.049 January 1, 2014
Supplies Same Day as Surgery (PDF) CC.PP.032 January 1, 2013
Transgender Related Services (PDF) CC.PP.047 January 1, 2017
Ultrasound in Pregnancy (PDF) CP.MP.38 January 31, 2011
Unbundled Professional Services (PDF) CC.PP.043 March 15, 2017
Unbundled Surgical Procedures (PDF) CC.PP.045 March 15, 2017
Unlisted Procedure Codes Policy (PDF) CC.PP.009 January 1, 2013
Urine Specimen Validity Testing (PDF) CC.PP.056 October 1, 2017
Wheelchairs and Accessories (PDF) CC.PP.052 October 1, 2015

 

POLICY TITLE POLICY NUMBER EFFECTIVE DATE
3 Day Payment Window (PDF) CC.PP.500 July 1, 2014
30 Day Readmission (PDF) CC.PP.501 January 1, 2015
Add On Policy (PDF) CC.PP.030 January 1, 2013
Assistant Surgeon (PDF) CC.PP.029 January 1, 2014
Bilateral Procedures (PDF) CC.PP.037 January 1, 2014
Cerumen Removal Policy (PDF) CC.PP.008 January 1, 2014
Clean Claims Policy (PDF) CC.PP.021 January 1, 2013
Clinical Validation of Modifier 25 (PDF) CC.PP.013 January 1, 2013
Clinical Validation of Modifier 59 (PDF) CC.PP.014 January 1, 2013
Code Editing Overview (PDF) CC.PP.011 January 1, 2013
Cosmetic Procedures (PDF) CC.PP.024 January 1, 2014
Distinct Procedure Modifiers Policy (PDF) CC.PP.020 January 1, 2013
Duplicate Primary Code Billing (PDF) CC.PP.044 January 1, 2014
E&M Bundling with Labs and Radiology (PDF) CC.PP.010 January 1, 2013
EM Medical Decision Making (PDF) CC.PP.051 June 1, 2017
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 January 1, 2016
Inpatient Consultation (PDF) CC.PP.038 January 1, 2014
Inpatient Only Procedures Policy (PDF) CC.PP.018 January 1, 2018
IV Hydration Policy (PDF) CC.PP.012 January 1, 2013
Leveling of Care: Evaluation and Management Overcoding (PDF) CC.PP.066 February 6, 2020
Leveling Professional Fees for Emergency Room Services (PDF) GA.PP.053 December 16, 2020
Max Units Payment Policy (PDF CC.PP.007 January 1, 2013
Moderate Conscious Sedation (PDF) CC.PP.015 January 1, 2013
Modifier DOS Validation (PDF) CC.PP.034 January 1, 2015
Modifier to Procedure Code Validation (PDF) CC.PP.028 January 1, 2013
Multiple CPT Code Replace (PDF) CC.PP.033 January 1, 2013
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF) CC.PP.065 February 6, 2020
Multiple Procedure Reduction: Ophthalmology (PDF) CC.PP.069 August 18, 2020
Multiple Procedure Payment Reduction: Therapeutic Services (PDF) CC.PP.068 July 1, 2021
NCCI Unbundling (PDF) CC.PP.031 January 1, 2013
Never Paid Events (PDF) CC.PP.017 January 1, 2013
New Patient (PDF) CC.PP.036 January 1, 2014
Non-obstectrical Pelvic and Transvaginal Ultrasounds (PDF) CC.PP.061 June 1, 2018
Not Medically Necessary Inpatient Service (PDF) CC.PP.060 June 1, 2018
Outpatient Consultation (PDF) CC.PP.039 January 1, 2014
Physician's Office Lab Testing (PDF) CC.PP.055 December 1, 2019
Place of Service Mismatch (PDF) CC.PP.063 September 1, 2018
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) CP.MP.181 August 1, 2020
Postoperative Visits (PDF) CC.PP.042 January 1, 2014
Preoperative Visits (PDF) CC.PP.041 January 1, 2014
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 November 1, 2017
Professional Component Modifier (PDF) CC.PP.027 January 1, 2013
Pulse Oximetry w Office Visits (PDF) CC.PP.025 January 1, 2013
Renal Hemodialysis (PDF) CC.PP.067 March 1, 2021
Reporting the Global Maternity Package (PDF) GA.PP.016 January 1, 2013
Robotic Surgeries (PDF) CC.PP.050 August 1, 2017
Same Day Visits (PDF) CC.PP.040 January 1, 2014
Sleep Studies POS (PDF) CC.PP.035 June 15, 2017
Status B Bundled Services (PDF) CC.PP.046 January 1, 2014
Status P Bundled Services (PDF) CC.PP.049 January 1, 2014
Supplies Same Day as Surgery (PDF) CC.PP.032 January 1, 2013
Transgender Related Services (PDF) CC.PP.047 January 1, 2017
Ultrasound in Pregnancy (PDF) CP.MP.38 January 31, 2011
Unbundled Professional Services (PDF) CC.PP.043 March 15, 2017
Unbundled Surgical Procedures (PDF) CC.PP.045 March 15, 2017
Unlisted Procedure Codes Policy (PDF) OC.UM.CP.0014 January 1, 2017
Wheelchairs and Accessories (PDF) CC.PP.502 October 1, 2015

 

POLICY TITLE POLICY NUMBER EFFECTIVE DATE
3 Day Payment Window (PDF) CC.PP.500 July 1, 2014
30 Day Readmission (PDF) CC.PP.501 January 1, 2015
340B Drug Payment Reduction (PDF) CC.PP.070 July 1, 2021
Add On Policy (PDF) CC.PP.030 January 1, 2013
Assistant Surgeon (PDF) CC.PP.029 January 1, 2014
Bilateral Procedures (PDF) CC.PP.037 January 1, 2014
Cerumen Removal Policy (PDF) CC.PP.008 January 1, 2014
Clean Claims Policy (PDF) CC.PP.021 January 1, 2013
Clinical Validation of Modifier 25 (PDF) CC.PP.013 January 1, 2013
Clinical Validation of Modifier 59 (PDF) CC.PP.014 January 1, 2013
Code Editing Overview (PDF) CC.PP.011 January 1, 2013
Cosmetic Procedures (PDF) CC.PP.024 January 1, 2014
Distinct Procedure Modifiers Policy (PDF) CC.PP.020 January 1, 2013
Duplicate Primary Code Billing (PDF) CC.PP.044 January 1, 2014
E&M Bundling with Labs and Radiology (PDF) CC.PP.010 January 1, 2013
EM Medical Decision Making (PDF) CC.PP.051 June 1, 2017
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 January 1, 2016
Inpatient Consultation (PDF) CC.PP.038 January 1, 2014
Inpatient Only Procedures Policy (PDF) CC.PP.018 January 1, 2018
IV Hydration Policy (PDF) CC.PP.012 January 1, 2013
Leveling of Care: Evaluation and Management Overcoding (PDF) CC.PP.066 February 6, 2020
Leveling of Emergency Room Services (PDF) GA.PP.506 December 16, 2020
Maximum Units (PDF) CC.PP.007 January 1, 2013
Moderate Conscious Sedation (PDF) CC.PP.015 January 1, 2013
Modifier DOS Validation (PDF) CC.PP.034 January 1, 2015
Modifier to Procedure Code Validation (PDF) CC.PP.028 January 1, 2013
Multiple CPT Code Replace (PDF) CC.PP.033 January 1, 2013
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF) CC.PP.065 February 6, 2020
Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF) CC.PP.068 December 16, 2020
Multiple Procedure Reduction: Ophthalmology (PDF) CC.PP.069 August 18, 2020
NCCI Unbundling (PDF) CC.PP.031 January 1, 2013
Never Paid Events (PDF) CC.PP.017 January 1, 2013
New Patient (PDF) CC.PP.036 January 1, 2014
Non-obstectrical Pelvic and Transvaginal Ultrasounds (PDF) CC.PP.061 June 1, 2018
Not Medically Necessary Inpatient Service (PDF) CC.PP.060 June 1, 2018
Outpatient Consultation (PDF) CC.PP.039 January 1, 2014
Physician's Office Lab Testing (PDF) CC.PP.055 December 16, 2020
Place of Service Mismatch (PDF) CC.PP.063 September 1, 2018
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) CP.MP.181 August 1, 2020
Postoperative Visits (PDF) CC.PP.042 January 1, 2014
Preoperative Visits (PDF) CC.PP.041 January 1, 2014
Problem Oriented Visits with Preventative Services (PDF) CC.PP.057 October 1, 2017
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 November 1, 2017
Professional Component Modifier (PDF) CC.PP.027 January 1, 2013
Pulse Oximetry w Office Visits (PDF) CC.PP.025 January 1, 2013
Renal Hemodialysis (PDF) CC.PP.067 March 1, 2021
Same Day Visits (PDF) CC.PP.040 January 1, 2014
Sleep Studies POS (PDF) CC.PP.035 June 15, 2017
Status B Bundled Services (PDF) CC.PP.046 January 1, 2014
Status P Bundled Services (PDF) CC.PP.049 January 1, 2014
Supplies Same Day as Surgery (PDF) CC.PP.032 January 1, 2013
Transgender Related Services (PDF) CC.PP.047 January 1, 2017
Ultrasound in Pregnancy (PDF) CP.MP.38 January 31, 2011
Unbundled Professional Services (PDF) CC.PP.043 March 15, 2017
Unbundled Surgical Procedures (PDF) CC.PP.045 March 15, 2017
Unlisted Procedure Codes Policy (PDF) CC.PP.009 January 1, 2013
Urine Specimen Validity Testing (PDF) CC.PP.056 October 1, 2017
Wheelchairs and Accessories (PDF) CC.PP.502 October 1, 2015