Ambetter Archived Policies
| Policy Number | Policy Title | Effective Date Start | Retire Date |
| CP.MP.151 | Transcatheter Closure of Patent Foramen Ovale (PDF) | Janurary 1, 2018 | December 1, 2024 |
| CP.MP.206 | SNF Leveling (PDF) | Janurary 1, 2018 | December 1, 2024 |
| CP.MP.53 | Ferriscan R2-MRI (PDF) | Janurary 1, 2018 | October 1, 2024 |
| Policy Number | Policy Title | Effective Date Start | Retire Date |
| CP.PCH.48 | Valbenazine (Ingrezza, Ingrezza Sprinkle) (PDF) | September 1, 2022 | January 1, 2026 |
| CP.PHAR.103 | Immune Globulins (PDF) | August 1, 2012 | February 1, 2026 |
| CP.PCH.52 | Sacubitril-Valsartan (Entresto) (PDF) | September 1, 2024 | March 1, 2026 |
| CP.PHAR.578 | Abrocitinib (Cibinqo) (PDF) | June 1, 2022 | March 1, 2026 |
| CP.PHAR.704 | Lebrikizumab (Ebglyss) (PDF) | January 1, 2025 | March 1, 2026 |
| CP.PHAR.703 | Nemolizumab-ito (Nemluvio) (PDF) | December 1, 2024 | March 1, 2026 |
| CP.PHAR.577 | Tralokinumab-ldrm (Adbry) (PDF) | June 1, 2022 | March 1, 2026 |
| CP.PMN.248 | Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) | December 1, 2020 | March 1, 2026 |
| HIM.PA.15 | Brinzolamide/Brimonidine (Simbrinza) (PDF) | September 4, 2018 | March 1, 2026 |
| CP.PHAR.576 | Tezepelumab (Tezspire) (PDF) | June 1, 2022 | March 1, 2026 |
| HIM.PA.93 | Mometasone (Nasonex) (PDF) | December 1, 2014 | March 1, 2026 |
| Policy Number | Policy Title | Effective Date Start | Retire Date |