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Clinical & Payment 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 Arkansas Health & Wellness Clinical Policy Manual apply to Arkansas Health & Wellness members. Policies in the Arkansas Health & Wellness Clinical Policy Manual may have either a Arkansas Health & Wellness or a “Centene” heading.  Arkansas Health & Wellness utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Arkansas Health & Wellness 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 Arkansas Health & Wellness. In addition, Arkansas Health & Wellness 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 Arkansas Health & Wellness. 

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

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

All policies found in the Arkansas Health & Wellness Payment Policy Manual apply with respect to Arkansas Health & Wellness members. Policies in the Arkansas Health & Wellness Payment Policy Manual may have either a Arkansas Health & Wellness or a “Centene” heading.  In addition, Arkansas Health & Wellness 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 Arkansas Health & Wellness. 

Ambetter Policies

Policy Title Policy Number Effective Date
2019 Novel Coronavirus testing (PDF) CP.MP.183 3/16/2020
3-Day Payment Window (PDF) CC.PP.500 7/1/2014
Acupuncture (PDF) CP.MP.92 3/17/2017
Adopted Clinical Practice and Preventive Health Guidelines (PDF)   6/1/2020
Add on Code Billed Without Primary Code (PDF) CC.PP.030 10/18/2016
ADHD Assessment and Treatment (PDF) CP.MP.124 9/1/2020
Allergy Testing (PDF) CP.MP.100 5/1/2019
Ambulatory EEG (PDF) CP.MP.96 8/12/2016
Articular Cartilage Defect Repairs (PDF) CP.MP.26 3/31/20
Assistant Surgeon (PDF) CC.PP.029 2/7/2017
Bariatric Surgery (PDF) CP.MP.37 10/1/2020
Bevacizumab (PDF) CP.PHAR.93 2/10/2017
Bilateral Procedures (PDF) CC.PP.037 2/7/2017
Bronchial Thermoplasty (PDF) CP.MP.110 4/1/2017
Burn Surgery (PDF) CP.MP.186 9/1/2020
Cardiac Biomarker Testing for Acute MI (PDF) CP.MP.156 5/21/2018
Carrier Screening in Pregnancy (PDF) CP.MP.83 7/1/2020
Cell-Free Fetal DNA Testing (PDF) CP.MP.84 03/31/20
Cerumen Removal (PDF) CC.PP.008 8/12/2016
Clean Claims (PDF) CC.PP.021 10/18/2016
Clinical Trials (PDF) CP.MP.94 6/30/2020
Coding Overview (PDF) CC.PP.011 10/18/2016
Cosmetic Reconstructive Surgery (PDF) CP.MP.31 7/1/2020
Cosmetic Procedures (PDF) CC.PP.024 10/18/2016
Dental Anesthesia (PDF) CP.MP.61 03/31/20
Diagnosis of Vaginitis (PDF) CP.MP.97 4/1/2017
Digital Analysis of EEGs (PDF) CP.MP.105 2/10/2017
Disc Decompression Procedures (PDF) CP.MP.114 9/1/2020
Discography (PDF) CP.MP.115 6/30/2020
Distinct Procedural Modifiers (PDF) CC.PP.020 10/18/2016
DNA Analysis of Stool (PDF) CP.MP.125 6/17/2017
Duplicate Primary Code Billing (PDF) CC.PP.044 2/7/2017
Durable Medical Equipment (DME) (PDF) CP.MP.107 6/1/2020
E&M Medical Decision-Making (PDF) CC.PP.051 7/25/2017
EEG in Evaluation of Headache (PDF) CP.MP.155 5/21/2018
Electric Tumor Treatment Fields (PDF) CP.MP.145 7/1/2020
EM Bundling Edits (PDF) CC.PP.010 8/12/2016
Endometrial Ablation (PDF) CP.MP.106 12/10/2018
EpiFix Wound Treatment (PDF) CP.MP.140 11/1/2017
Evoked Potentials (PDF) CP.MP.134 6/17/2017
Experimental Technologies (PDF) CP.MP.36 6/30/2020
Facet Joint Interventions (PDF) CP.MP.171 3/4/2020
Fecal Calprotectin Assay (PDF) CP.MP.135 6/17/2017
FeNo Testing (PDF) CP.MP.103 4/1/2017
Fertility Preservation (PDF) CP.MP.130 6/1/2020
Fixed Wing Air Transportation (PDF) CP.MP.175 3/31/2020
Gender Reassignment (PDF) CP.MP.95 6/1/2020
Genetic Testing (PDF) CP.MP.89
03/31/20
Global Maternity Billing (PDF) CC.PP.016 10/18/2016
Heart-Lung Transplant (PDF) CP.MP.132 6/1/2020
H Pylori Testing (PDF) CP.MP.153 5/21/2018
Holter Monitors (PDF) CP.MP.113 4/1/2017
Homocysteine Testing (PDF) CP.MP.121 9/1/2020
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 10/18/2016
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 6/1/2020
Inhaled Nitric Oxide (PDF) CP.MP.87 7/1/2020
Inpatient Consultation (PDF) CC.PP.038 2/7/2017
Inpatient Only Procedures (PDF) MP.PP.018 10/18/2016
Intestinal and Multivisceral Transplant (PDF) CP.MP.58 7/1/2020
IV Hydration (PDF) CC.PP.012 10/18/2016
Laser Skin Treatment (PDF) CP.MP.123 4/1/2017
Leveling of Emergency Room (PDF) CC.PP.053  1/1/2019
Long Term Care Placement Criteria (PDF) CP.MP.71 3/16/2017
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 11/1/2017
Lung Transplantation (PDF) CP.MP.57 7/1/2020
Lysis of Epidural Lesions (PDF) CP.MP.116 7/1/2020
Maximum Units (PDF) CC.PP.007 8/12/2016
Measure Serum 1,25 Vitamin D (PDF) CP.MP.152 5/21/2018
Mechanical Stretch Devices (PDF) CP.MP.144 10/1/2020
Moderate Conscious Sedation (PDF) CC.PP.015 10/18/2016
Modifier -25 clinical validation (PDF) CC.PP.013 10/18/2016
Modifier -59 clinical validation (PDF) CC.PP.014 10/18/2016
Modifier DOS Validation (PDF) CC.PP.034 10/18/2016
Modifier to Procedure Code Validation (PDF) CC.PP.028 10/18/2016
Monitored Anesthesia Care (PDF) CP.MP.161 12/15/18
Multiple CPT Code Replacement (PDF) CC.PP.033 10/18/2016
NCCI Unbundling (PDF) CC.PP.031 10/18/2016
Never Paid Events (PDF) CC.PP.017 10/18/2016
New Patient (PDF) CC.PP.036 2/7/2017
NICU Apnea Bradycardia Guidelines (PDF) CP.MP.82 7/1/2020
NICU Discharge Guidelines (PDF) CP.MP.81 6/30/2020
Non-Invasive Home Ventilator (PDF) CP.MP.184 7/1/2020
Non-Obstetrical Pelvic and Transabdominal Ultrasound (PDF) CC.PP.061  12/15/2018
Nonmyeloablative allogeneic stem cell transplant (PDF) CP.MP.141
6/1/2020
OB Home Health Programs (PDF) CP.MP.91 6/1/2020
Outpatient Cardiac Rehabilitation (PDF) CP.MP.176 7/1/2020
Outpatient Consultation (PDF) CC.PP.039 2/7/2017
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 10/1/2020
Paclitaxel (PDF) CP.PHAR.176 5/16/2016
Pancreas Transplantation (PDF) CP.MP.102 7/1/2020
Panniculectomy (PDF) CP.MP.109 7/1/2020
Pediatric Heart Transplant (PDF) CP.MP.138 7/1/2020
Pediatric Liver Transplant (PDF) CP.MP.120 7/1/2020
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) CP.MP.147 7/1/2020
Physician’s Consultation Services (PDF) CC.PP.054 9/1/2018
Physician Visit Codes Billed with Labs (PDF) CC.PP.019 10/18/2016
Physical, Occupational, and Speech Therapy Services (PDF) CP.MP.49 6/30/2020
Place of Service Mismatch (PDF) CC.PP.063  12/15/2018
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) CP.MP.181 6/1/2020
Post-Operative Visits (PDF) CC.PP.042 2/7/2017
Pre-Operative Visits (PDF) CC.PP.041 2/7/2017
Problem Oriented Visits with Preventative Services (PDF) CC.PP.057 11/1/2018
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 11/1/2018
Professional Component (PDF) CC.PP.027 10/18/2016
PROM Testing (PDF) CP.MP.149 11/8/2017
Proton and Neutron Beam Therapy (PDF) CP.MP.70 6/1/2019
Pulse Oximetry (PDF) CC.PP.025 10/18/2016
Radial Head Implant (PDF) CP.MP.148 7/1/2020
Radiofrequency Ablation of Uterine Fibroids (PDF) CP.MP.187 6/1/2020
Rituximab (PDF) CP.PHAR.260 2/10/2017
Robotic Surgery (PDF) CC.PP.050 11/1/2017
Sacroiliac Joint Fusion (PDF) CP.MP.126 6/30/2020
Sacroiliac Joint Interventions for Pain Management (PDF) CP.MP.166 6/1/2020
Same Day Visits (PDF) CC.PP.040 2/7/2017
Selective Dorsal Rhizotomy (PDF) CP.MP.174 3/31/2020
Sickle Cell Disease Observation (PDF) CP.MP.88 3/16/2017
Skin Substitutes for Chronic Wounds (PDF) CP.MP.185 10/1/2020
Spinal Cord Stimulation (PDF) CP.MP.117 3/31/2020
Status "B" Bundled Services (PDF) CC.PP.046 2/7/2017
Status P Bundled Services (PDF) CC.PP.049 6/17/2017
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 10/18/2016
Thymus Transplantation (PDF) CP.MP.189 10/1/2020
Thyroid Testing in Pediatrics (PDF) CP.MP.154 5/21/2018
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 6/1/2020
Transgender Related Services (PDF) CC.PP.047 2/22/2017
Trigger Point Injections for Pain Management (PDF) CP.MP.169 6/1/2020
Ultrasound in Pregnancy (PDF) CP.MP.38 2/10/2017
Unbundled Professional Services (PDF) CC.PP.043 4/6/2017
Unbundled Surgical Procedures (PDF) CC.PP.045 4/6/2017
Unlisted Procedure Codes (PDF) CC.PP.009 8/12/2016
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142
7/1/20
Urine Specimen Validity Testing (PDF) CC.PP.056 11/8/2017
Urodynamic Testing (PDF) CP.MP.98 8/12/2016
Vitamin D Testing in Children (PDF) CP.MP.157 5/21/2018
Wheelchair Accessories (PDF) CC.PP.502 8/12/2016
Wireless Motility Capsule (PDF) CP.MP.143 11/1/2017
Policy Title Policy Number Effective Date
3-Day Payment Window (PDF) CC.PP.500 7/1/2014
Add on Code Billed Without Primary Code (PDF) CC.PP.030 10/18/2016
Allergy Testing (PDF) CP.MP.100 5/1/2019
Ambulatory EEG (PDF) CP.MP.96 8/12/2016
Assistant Surgeon (PDF) CC.PP.029 2/7/2017
Balloon Sinus Ostial Dilation for Treatment of Chronic Sinusitis (PDF) CP.MP.119 6/1/2020
Bevacizumab (PDF) CP.PHAR.93 2/10/2017
Bilateral Procedures (PDF) CC.PP.037 2/7/2017
Bronchial Thermoplasty (PDF) CP.MP.110 4/1/2017
Cardiac Biomarker Testing for Acute MI (PDF) CP.MP.156 5/21/2018
Cerumen Removal (PDF) CC.PP.008 8/12/2016
Clean Claims (PDF) CC.PP.021 10/18/2016
Coding Overview (PDF) CC.PP.011 10/18/2016
Cosmetic Procedures (PDF) CC.PP.024 10/18/2016
Diagnosis of Vaginitis (PDF) CP.MP.97 4/1/2017
Digital Analysis of EEGs (PDF) CP.MP.105 2/10/2017
Distinct Procedural Modifiers (PDF) CC.PP.020 10/18/2016
DNA Analysis of Stool (PDF) CP.MP.125 6/17/2017
Duplicate Primary Code Billing (PDF) CC.PP.044 2/7/2017
E&M Medical Decision-Making (PDF) CC.PP.051 7/25/2017
EEG in Evaluation of Headache (PDF) CP.MP.155 5/21/2018
EM Bundling Edits (PDF) CC.PP.010 8/12/2016
Endometrial Ablation (PDF) CP.MP.106 12/10/2018
EpiFix Wound Treatment (PDF) CP.MP.140 11/1/2017
Evoked Potentials (PDF) CP.MP.134 6/17/2017
Fecal Calprotectin Assay (PDF) CP.MP.135 6/17/2017
FeNo Testing (PDF) CP.MP.103 4/1/2017
Global Maternity Billing (PDF) CC.PP.016 10/18/2016
H Pylori Testing (PDF) CP.MP.153 5/21/2018
Holter Monitors (PDF) CP.MP.113 4/1/2017
Homocysteine Testing (PDF) CP.MP.121 4/1/2017
Hospice Services (PDF) CP.MP.54 6/1/2020
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 10/18/2016
Inpatient Consultation (PDF) CC.PP.038 2/7/2017
Inpatient Only Procedures (PDF) MP.PP.018 10/18/2016
IV Hydration (PDF) CC.PP.012 10/18/2016
Laser Skin Treatment (PDF) CP.MP.123 4/1/2017
Leveling of Emergency Room (PDF) CC.PP.053  1/1/2019
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 11/1/2017
Maximum Units (PDF) CC.PP.007 8/12/2016
Measure Serum 1,25 Vitamin D (PDF) CP.MP.152 5/21/2018
Moderate Conscious Sedation (PDF) CC.PP.015 10/18/2016
Modifier -25 clinical validation (PDF) CC.PP.013 10/18/2016
Modifier -59 clinical validation (PDF) CC.PP.014 10/18/2016
Modifier DOS Validation (PDF) CC.PP.034 10/18/2016
Modifier to Procedure Code Validation (PDF) CC.PP.028 10/18/2016
Monitored Anesthesia Care (PDF) CP.MP.161 12/15/18
Multiple CPT Code Replacement (PDF) CC.PP.033 10/18/2016
Multiple Sleep Latency Testing (PDF) CP.MP.24 6/1/2020
NCCI Unbundling (PDF) CC.PP.031 10/18/2016
Never Paid Events (PDF) CC.PP.017 10/18/2016
New Patient (PDF) CC.PP.036 2/7/2017
Non-Obstetrical Pelvic and Transabdominal Ultrasound (PDF) CC.PP.061  12/15/2018
Outpatient Consultation (PDF) CC.PP.039 2/7/2017
Paclitaxel (PDF) CP.PHAR.176 5/16/2016
Physician’s Consultation Services (PDF) CC.PP.054 9/1/2018
Physician Visit Codes Billed with Labs (PDF) CC.PP.019 10/18/2016
Place of Service Mismatch (PDF) CC.PP.063  12/15/2018
Post-Operative Visits (PDF) CC.PP.042 2/7/2017
Pre-Operative Visits (PDF) CC.PP.041 2/7/2017
Problem Oriented Visits with Preventative Services (PDF) CC.PP.057 11/1/2018
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 11/1/2018
Professional Component (PDF) CC.PP.027 10/18/2016
PROM Testing (PDF) CP.MP.149 11/8/2017
Proton and Neutron Beam Therapy (PDF) CP.MP.70 6/1/2019
Pulse Oximetry (PDF) CC.PP.025 10/18/2016
Rituximab (PDF) CP.PHAR.260 2/10/2017
Robotic Surgery (PDF) CC.PP.050 11/1/2017
Same Day Visits (PDF) CC.PP.040 2/7/2017
Status "B" Bundled Services (PDF) CC.PP.046 2/7/2017
Status P Bundled Services (PDF) CC.PP.049 6/17/2017
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 10/18/2016
Thyroid Testing in Pediatrics (PDF) CP.MP.154 5/21/2018
Transgender Related Services (PDF) CC.PP.047 2/22/2017
Ultrasound in Pregnancy (PDF) CP.MP.38 2/10/2017
Unbundled Professional Services (PDF) CC.PP.043 4/6/2017
Unbundled Surgical Procedures (PDF) CC.PP.045 4/6/2017
Unlisted Procedure Codes (PDF) CC.PP.009 8/12/2016
Urine Specimen Validity Testing (PDF) CC.PP.056 11/8/2017
Urodynamic Testing (PDF) CP.MP.98 8/12/2016
Ventriculectomy and Cardiomyoplasty (PDF) CP.MP.56 6/1/2020
Video Electroencephalographic (VEEG) Monitoring (PDF) CP.MP.177 6/1/2020
Vitamin D Testing in Children (PDF) CP.MP.157 5/21/2018
Wheelchair Accessories (PDF) CC.PP.502 8/12/2016
Wireless Motility Capsule (PDF) CP.MP.143 11/1/2017
Policy Title Policy Number Effective Date
Abaloparatide (Tymlos) (PDF) CP.PHAR.345 11/7/2017
Abiraterone (Zytiga) (PDF) CP.PHAR.84 7/24/2015
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 11/7/2017
Aclidinium/Formoterol (Duaklir Pressair) (PDF) CP.PCH.23 1/1/2020
Adefovir (Hepsera) (PDF) CP.PHAR.142 6/1/2019
Ado-Trastuzumab Emtansine (Kadcyla) (PDF) CP.PHAR.229 6/1/2019
Afamelanotide (Scenesse) (PDF) CP.PHAR.444 3/1/2020
afatinib (Gilotrif) (PDF) CP.PHAR.298 6/1/2019
Aflibercept (Eylea) (PDF) CP.PHAR.184 7/1/2016
Agalsidase Beta (Fabrazyme) (PDF) CP.PHAR.158  6/1/2019
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) CP.PMN.138 6/1/2019
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 12/8/2017
Alendronate (Binosto, Fosamax plus D) (PDF) CP.PMN.88 6/1/2019
Alglucosidase Alfa (Lumizyme) (PDF) CP.PHAR.160 6/1/2019
Alpelisib (Piqray) (PDF) CP.PHAR.430 12/1/2019
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF) CP.PHAR.94 7/24/15
Ambrisentan (Letairis®) (PDF) CP.PHAR.190 7/1/2016
Amifampridine (Firdapse)(PDF) CP.PHAR.411 3/1/2019
Amikacin (Arikayce)(PDF)  CP.PHAR.401 3/1/2019
Antithrombin III (PDF) CP.MP.179 03/01/20
Antithymocyte Globulin (Thymoglobulin, Atgam) (PDF) HIM.PA.16 6/1/2019
Apomorphine (Apokyn) (PDF) CP.PCH.14 1/1/2020
aprepitant (Emend®) (PDF) CP.PMN.19 3/1/2016
Arformoterol Tartrate (Brovana) (PDF) CP.PMN.201 6/1/2019
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada)  (PDF) CP.PHAR.290 1/1/2020
armodafinil (Nuvigil) (PDF) CP.PMN.35 6/1/2019
Asenapine (Saphris) (PDF) CP.PMN.15 6/1/2019
Aspirin-dipyridamole (Aggrenox) (PDF) CP.PMN.20 6/1/2019
Atezolizumab (Tecentriq) (PDF) CP.PHAR.235 9/8/2017
Avapritinib (Ayvakit) (PDF) CP.PHAR.454 3/1/2020
Avatrombopag (Doptelet) (PDF) CP.PHAR.130 3/1/19
Avelumab (Bavencio) (PDF) CP.PHAR.333 9/8/2017
axicabtagene ciloleucel (Yescarta®) (PDF) CP.PHAR.362 6/1/2019
Axitinib (Inlyta) (PDF) CP.PHAR.100 9/8/2017
Azacitidine (Vidaza) (PDF) CP.PHAR.387 6/1/2019
Azelaic Acid (Finacea) (PDF) HIM.PA.119 6/1/2019
Aztreonam (Cayston) (PDF) CP.PHAR.209 9/8/2017
Bedaquiline (Sirturo) (PDF) CP.PMN.212 6/1/2019
belatacept (Nulojix®)  (PDF) CP.PHAR.201 6/1/2019
Belimumab (Benlysta) (PDF) CP.PHAR.88 7/24/2015
belinostat (Beleodaq®) (PDF) CP.PHAR.311 6/1/2019
bendamustine (Bendeka®, Treanda®) (PDF) CP.PHAR.307 6/1/2019
Benralizumab (Fasenra) (PDF) CP.PHAR.373 6/1/2019
Betaine (Cystadane) (PDF) CP.PHAR.143 6/1/2019
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) CP.PHAR.93 6/1/2020
Bexarotene (Targretin) (PDF) CP.PHAR.75 11/7/2017
Bezlotoxumab (Zinplava) (PDF) CP.PHAR.300 7/15/2019
Biologic DMARDs (PDF) HIM.PA.SP60 6/1/2020
Binimetinib (Mektovi) (PDF) CP.PHAR.50 6/1/2019
Blinatumomab (Blincyto) (PDF) CP.PHAR.312 6/1/2019
Bortezomib (Velcade) (PDF) CP.PHAR.410 7/15/2019
Bosentan (Tracleer®) (PDF) CP.PHAR.191 7/1/2016
Bosutinib (Bosulif) (PDF) CP.PHAR.105 3/1/2016
Brand Name Override and Non-Formulary Medications (PDF) HIM.PA.103 3/1/2016
Brentuximab Vedotin (Adcetris) (PDF) CP.PHAR.303 6/1/2019
Brexanolone (Zulresso) (PDF) CP.PHAR.417 6/1/2019
Brexpiprazole (Rexulti) (PDF) CP.PMN.68 6/1/2019
Brigatinib (Alunbrig) (PDF) CP.PHAR.342 7/1/2020
Brolucizumab-dbll (Beovu) (PDF) CP.PHAR.445  3/1/2020
Oxymetazoline (Rhofade)(PDF) CP.PMN.86 6/1/2019
Brimonidine Tartrate (Mirvaso) (PDF) CP.PMN.192 6/1/2019
Brinzolamide/Brimonidine (Simbrinza) (PDF) HIM.PA.15 6/1/2019
Brivaracetam (Briviact) (PDF) HIM.PA.07 1/1/2020
Budesonide (Uceris) (PDF) CP.PCH.11 6/1/2019
Budesonide Suspension (Pulmicort Respules) (PDF) HIM.PA.48 6/1/2019
buprenorphine implant (Probuphine) (PDF) CP.PHAR.289 6/1/2019
Bupropion/Naltrexone (Contrave) (PDF) CP.PCH.12 7/15/2019
Burosumab-twza (Crysvita) (PDF) CP.PHAR.11 6/1/2019
Butorphanol Nasal Spray (PDF) HIM.PA.46 3/1/2016
C1 Esterase Inhibitors (PDF) CP.PHAR.202 7/1/2016
cabazitaxel (Jevtana®) (PDF) CP.PHAR.316 6/1/2019
Cabozantinib (Cometriq®, Cabometyx®) (PDF) CP.PHAR.111 9/8/2017
Canakinumab (Ilaris) (PDF) CP.PHAR.246 6/1/2019
Cannabidiol (Epidiolex) (PDF) CP.PMN.164 7/1/19
capecitabine (Xeloda) (PDF) CP.PHAR.60 11/7/2017
Caplacizumab-yhdp (Cablivi) (PDF) CP.PHAR.416 6/1/2019
carfilzomib (Kyprolis®) (PDF) CP.PHAR.309 6/1/2019
Carglumic acid (Carbaglu®) (PDF) CP.PHAR.206  9/8/2017
Celecoxib (Celebrex) (PDF) CP.PMN.122 6/1/2019
Cemiplimab-rwlc (Libtayo) (PDF) CP.PHAR.397 6/1/2019
Cenegermin-bkbj (Oxervate)(PDF) CP.PMN.186 3/1/2019
Ceritinib (Zykadia) (PDF) CP.PHAR.349 6/1/2019
Cerliponase alfa (Brineura) (PDF) CP.PHAR.338 11/7/2017
cetuximab (Erbitux®) (PDF) CP.PHAR.317 6/1/2019
Chlorambucil (Leukeran) (PDF) HIM.PA.SP59 6/1/2019
Chloramphenicol Sodium Succinate (PDF) CP.PHAR.388 6/1/2019
Cholic Acid (Cholbam) (PDF) CP.PHAR.390 6/1/2019
Ciclesonide (Alvesco) (PDF) HIM.PA.65 6/1/2019
Cinacalcet (Sensipar) (PDF) CP.PHAR.61 9/8/2017
Ciprofloxacin/Fluocinolone (Otovel) (PDF) HIM.PA.14 6/1/2019
Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) HIM.PA.120 6/1/2019
Cladribine (Mavenclad) (PDF) CP.PHAR.422 1/1/2020
Clindamycin (Evoclin) (PDF) HIM.PA.21 6/1/2019
Clindamycin Phosphate/Benzoyl Peroxide (BenzaClin) (PDF) HIM.PA.31 6/1/2019
Clinical Policy: Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) CP.PHAR.260 6/1/2019
Clobazam (Onfi) (PDF) CP.PMN.54 6/1/2019
CNS Stimulants (PDF) CP.PMN.92 3/1/2020
Colesevelam (Welchol) (PDF) HIM.PA.121 6/1/2019
Collagenase (Xiaflex) (PDF) CP.PHAR.82 7/24/2015
Colonoscopy Preparation Products (PDF) HIM.PA.04 6/1/2020
Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) HIM.PA.140 6/1/2019
Continuous Glucose Monitors (PDF) CP.PMN.214 3/1/2020
copanlisib (Aliqopa®)  (PDF) CP.PHAR.357 6/1/2019
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) CP.PHAR.385 10/19/2018
Crisaborole (Eucrisa) (PDF) CP.PMN.110 6/1/2019
Crizanlizumab-tmca (Adakveo) (PDF) CP.PHAR.449 6/1/2020
Crizotinib (Xalkori) (PDF) CP.PHAR.90 12/8/2017
Cyclosporine (Restasis, Cequa) (PDF) CP.PMN.48 6/1/2019
Cysteamine ophthalmic (Cystaran) (PDF) CP.PMN.130 6/1/2019
Cysteamine oral (Cystagon, Procysbi) (PDF) CP.PHAR.155    6/1/2019
Cytomegalovirus Immune Globulin (Cytogam) (PDF) CP.PHAR.277 1/1/2020
Dabrafenib (Tafinlar) (PDF) CP.PHAR.239 11/7/2017
Daclatasvir (Daklinza) (PDF) CP.PCH.15 12/8/2017
Dacomitinib (Vizimpro) (PDF) CP.PHAR.399 6/1/2019
Dalfampridine (Ampyra) (PDF) CP.PHAR.248 12/8/2017
Deflazacort (Emflaza) (PDF) CP.PHAR.331 7/15/2019
Dalteparin (Fragmin) (PDF) CP.PHAR.225 9/8/2017
Daptomycin (Cubicin, Cubicin RF) (PDF) CP.PHAR.351 1/1/2020
Daratumumab (Darzalex) (PDF) CP.PHAR.310 6/1/2019
Darbepoetin alfa (Aranesp) (PDF) CP.PHAR.236 10/30/2016
Darolutamide (Nubeqa) (PDF) CP.PHAR.435 12/1/2019
Dasatinib (Sprycel) (PDF) CP.PHAR.72 11/7/2017
daunorubicin/cytarabine (Vyxeos®) (PDF) CP.PHAR.352 6/1/2019
deferasirox (Exjade Jadenu) (PDF) CP.PHAR.145 3/1/2016
Deferoxamine (Desferal) (PDF) CP.PHAR.146 1/1/2020
degarelix acetate (Firmagon®) (PDF) CP.PHAR.170 6/1/2019
Delafloxacin (Baxdela) (PDF) CP.PMN.115 1/1/2020
Denosumab (Prolia, Xgeva) (PDF) CP.PHAR.58 12/8/2017
Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF) CP.PHAR.214 9/8/2017
Deutetrabenazine (Austedo) (PDF) CP.PHAR.341 11/7/2017
Dexlansoprazole (Dexilant) (PDF) HIM.PA.05 6/1/2020
Dexrazoxane (Zinecard, Totect) (PDF) CP.PHAR.418 6/1/2019
Diazepam Nasal Spray (Valtoco)(PDF) CP.PMN.216 12/1/2019
Dichlorphenamide (Keveyis) (PDF) CP.PCH.04 6/1/2019
diclofenac sodium topical gel (Solaraze, Voltaren®) (PDF) HIM.PA.123  6/1/2019
Dimethyl Fumarate (Tecfidera) (PDF) CP.PHAR.249 12/8/2017
Dipeptidyl Peptidase-4 Inhibitors (PDF) HIM.PA.58 3/1/2016
Dolasetron (Anzemet) (PDF) CP.PMN.141 3/1/2016
Dornase alfa (Pulmozyme) (PDF) CP.PHAR.212 9/8/2017
Doxepin Hydrochloride Cream (Prudoxin, Zonalon) (PDF) HIM.PA.147 6/1/2019
Dupilumab (Dupixent) (PDF) CP.PHAR.336 9/8/2017
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 11/7/2017
Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn) (PDF) CP.PMN.128 3/1/2020
Duvelisib (Copiktra) (PDF) CP.PHAR.400 7/15/2019
Ecallantide (Kalbitor) (PDF) CP.PHAR.177 7/1/2016
Eculizumab (Soliris) (PDF) CP.PHAR.97 9/8/2017
Edaravone (Radicava) (PDF) CP.PHAR.343 11/7/2017
Efinaconazole (Jublia) (PDF) CP.PMN.25 6/1/2019
Elapegademase-lvlr (Revcovi) (PDF) CP.PHAR.419 6/1/2019
Elbasvir/Grazoprevir (Zepatier) (PDF) CP.PCH.16 6/1/2020
Eliglustat (Cerdelga) (PDF) CP.PHAR.153 6/1/2019
Elexacaftor-ivacaftor-tezacaftor (Trikafta) (PDF) CP.PHAR.440 12/1/2019
Elosulfase Alfa (Vimizim) (PDF) CP.PHAR.162  6/1/2019
Eltrombopag (Promacta®) (PDF) CP.PHAR.180 7/1/2016
Eluxadoline (Viberzi) (PDF) CP.PMN.170 6/1/2019
Emapalumab-lzsg (Gamifant)(PDF) CP.PHAR.402 3/1/2019
Emicizumab-kxwh (Hemlibra) (PDF) CP.PHAR.370 6/1/2019
Emtricitabine/Tenofovir (Truvada®) (PDF) HIM.PA.78 3/1/2016
Encorafenib (Braftovi) (PDF) CP.PHAR.127 6/1/2019
Enfuvirtide (Fuzeon) (PDF) CP.PHAR.41    7/24/2015
Enfortumab Vedotin-ejfv (Padcev) (PDF) CP.PHAR.455 3/1/2020
Enoxaparin (Lovenox) (PDF) CP.PHAR.224 9/8/2017
Entecavir (Baraclude) (PDF) HIM.PA.08 6/1/2019
Entrectinib (Rozlytrek) (PDF) CP.PHAR.441 12/1/2019
Enzalutamide (Xtandi) (PDF) CP.PHAR.106 3/1/2016
Epoetin Alfa (Epogen® and Procrit) (PDF) CP.PHAR.237 7/1/2016
Epoprostenol (PDF) CP.PHAR.192 7/1/2016
Erdafitinib (Balversa) (PDF) CP.PHAR.423 1/1/2020
Erenumab-aaoe (Aimovig) (PDF) CP.PHAR.128 3/1/2020
eribulin Mesylate (Halaven®) (PDF) CP.PHAR.318 6/1/2019
Erlotinib (Tarceva) (PDF) CP.PHAR.74 7/24/2015
Erwinia Asparaginase (Erwinaze) (PDF) CP.PHAR.301 3/1/2020
Esketamine (Spravato) (PDF) CP.PMN.199 6/1/2019
Etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 6/1/2019
Eteplirsen  (Exondys 51) (PDF) CP.PHAR.288 6/1/2019
Everolimus (Afinitor, Afinitor Disperz, Zortress)(PDF) CP.PHAR.63 9/8/2017
Evolocumab (Repatha) (PDF) CP.PHAR.123 3/1/2016
Factor IX (Human, Recombinant) (PDF) CP.PHAR.218 6/1/2019
Factor IX Complex Human (Bebulin®, Profilnine®) (PDF) CP.PHAR.219 6/1/2019
Factor VIIa, Recombinant (NovoSeven® RT) (PDF) CP.PHAR.220 6/1/2019
Factor VIII (Human Recombinant) (PDF) CP.PHAR.215 9/8/2017
Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF) CP.PHAR.216 9/8/2017
Factor XIII A-Subunit, Recombinant (Tretten®) CP.PHAR.222 6/1/2019
Factor XIII, Human (Corifact®) (PDF) CP.PHAR.221 6/1/2019
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) CP.PHAR.456 3/1/2020
febuxostat (Uloric) (PDF) CP.PMN.57 6/1/2019
Fedratinib (Inrebic) (PDF) CP.PHAR.442 12/1/2019
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF) CP.PMN.127 6/1/2019
Ferric Carboxymaltose (Injectafer) (PDF) CP.PHAR.234 3/1/2020
Ferric gluconate (Ferrlecit®) (PDF) CP.PHAR.166 3/1/2020
Ferric Maltol (Accrufer) (PDF) CP.PMN.213 12/1/2019
Ferumoxytol (Feraheme®) (PDF) CP.PHAR.165 3/1/2020
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) (PDF) CP.PHAR.297 6/1/2019
Fingolimod (Gilenya) (PDF) CP.PHAR.251 12/8/2017
Fluorouracil Cream (Tolak) (PDF) CP.PMN.165 6/1/2019
Fluticasone Propionate (Xhance) (PDF) CP.PMN.95 5/1/2019
Fondaparinux (Arixtra) (PDF) CP.PHAR.226 9/8/2017
Formulary Medications Without Specific Guidelines (PDF) HIM.PA.33 6/1/2019
Fostamatinib (Tavalisse) (PDF) CP.PHAR.24 6/1/2019
Fulvestrant (Faslodex Injection) (PDF) CP.PHAR.424 1/1/2020
Galcanezumab-gnlm (Emgality) (PDF) CP.PCH.24 3/1/2019
Galsulfase (Naglazyme) (PDF) CP.PHAR.161   6/1/2019
Gefitinib (Iressa) (PDF) CP.PHAR.68 6/1/2019
gemtuzumab ozogamicin (Mylotarg®) (PDF) CP.PHAR.358 6/1/2019
Gilteritinib (Xospata)(PDF) CP.PHAR.412 3/1/2019
Givosiran (Givlaari) (PDF) CP.PHAR.457 3/1/2020
Glasdegib (Daurismo)(PDF) CP.PHAR.413 3/1/2019
Glatiramer (Copaxone, Glatopa) (PDF) CP.PHAR.252 12/8/2017
Glecaprevir-Pibrentasvir (PDF) CP.PCH.18 12/8/2017
Glucagon-Like Peptide-1 Receptor Agonists (PDF) HIM.PA.53 6/1/2019
Glycerol phenylbutyrate (Ravicti®) (PDF) CP.PHAR.207 3/1/2020
Golodirsen (Vyondys 53) (PDF) CP.PHAR.453 3/1/2020
goserelin acetate (Zoladex®) (PDF) CP.PHAR.171 6/1/2019
Halcinonide (Halog) (PDF) HIM.PA.20 6/1/2019
Hemin (Panhematin®) (PDF) CP.PHAR.181 3/1/2020
histrelin acetate (Vantas®, Supprelin LA®) (PDF) CP.PHAR.172 6/1/2019
House dust mite allergen extract (Odactra®) (PDF) CP.PMN.111  6/1/2019
Hyaluronate Derivatives (PDF) CP.PHAR.05 12/8/2017
Hydrocodone-chlorpheniramine (Vituz) (PDF) HIM.PA.141 6/1/2019
Hydroxyprogesterone Caproate (Makena) (PDF) CP.PHAR.14 3/1/2016
ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 6/1/2019
Ibandronate sodium (PDF) CP.PHAR.189 7/1/2016
Ibrutinib (Imbruvica) (PDF) CP.PHAR.126 6/1/2019
Icatibant (Firazyr®) (PDF) CP.PHAR.178 7/1/2016
Icosapent ethyl (Vascepa) (PDF) CP.PMN.187 6/1/2019
Idelalisib (Zydelig) (PDF) CP.PHAR.133 6/1/2019
Idursulfase (Elaprase) (PDF) CP.PHAR.156  6/1/2019
lesinurad (Zurampic), lesinurad-allopurinol (Duzallo) (PDF) CP.PMN.150 1/1/2020
Iloperidone (Fanapt) (PDF) CP.PMN.32 6/1/2019
Iloprost (Ventavis®) (PDF) CP.PHAR.193 7/1/2016
Imatinib (Gleevec) (PDF) CP.PHAR.65 11/7/2017
Imiglucerase (Cerezyme) (PDF) CP.PHAR.154  6/1/2019
Immune Globulins (PDF) CP.PHAR.103 3/1/2016
Immunization Coverage (PDF) CP.PHAR.28 7/24/2015
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 11/7/2017
Indacaterol/Glycopyrrolate (Utibron Neohaler) (PDF) HIM.PA.102 6/1/2019
Infertility and Fertility Preservation (PDF) CP.PHAR.131 6/1/2019
Infliximab (Remicade, Inflectra, Renflexis) (PDF) CP.PHAR.254 5/1/2019
Inebilizumab (PDF) CP.PHAR.458 3/1/2020
Inotersen (Tegsedi) (PDF) CP.PHAR.405 3/1/2019
inotuzumab ozogamicin (Besponsa®) (PDF) CP.PHAR.359 6/1/2019
Insulin Degludec (Tresiba) (PDF) HIM.PA.09 7/15/2019
Insulin Infusion Pump (Omnipod, Omnipod DASH) (PDF) CP.PHAR.420 6/1/2019
interferon beta-1a (Avonex, Rebif) (PDF) HIM.PA.SP14 12/8/2017
interferon beta-1b (Betasero, Extavia) (PDF) HIM.PA.SP15 12/8/2017
Interferon Gamma- 1b (Actimmune) (PDF) CP.PHAR.52 9/8/2017
Intrathecal Baclofen (Gablofen, Lioresal) (PDF) CP.PHAR.149 6/1/2019
Iobenguane I-131 (Azedra) (PDF) CP.PHAR.459 3/1/2020
Ipilimumab (Yervoy) (PDF) CP.PHAR.319 6/1/2019
irinotecan Liposome (Onivyde®) (PDF) CP.PHAR.304 6/1/2019
Iron sucrose (Venofer®) (PDF) CP.PHAR.167 3/1/2020
isavuconazonium (Cresemba®) (PDF) HIM.PA.108  6/1/2019
Isotretinoin (PDF) CP.PMN.143 3/1/2016
Itraconazole (Sporanox, Onmel) (PDF) CP.PMN.124 6/1/2019
Ivacaftor (Kalydeco) (PDF) CP.PHAR.210 9/8/2017
ivermectin (Sklice®) (PDF) HIM.PA.124  6/1/2019
Ivosidenib (Tibsovo) (PDF) CP.PHAR.137 7/15/2019
Ixazomib (Ninlaro) (PDF) CP.PHAR.302 6/1/2019
Lacosamide (Vimpat) (PDF) CP.PMN.155 9/8/2017
Lanadelumab-fylo (Takhzyro)(PDF) CP.PHAR.396 3/1/2019
Lanreotide (Somatuline Depot) (PDF) CP.PHAR.391 6/1/2019
lapatinib (Tykerb®) (PDF) CP.PHAR.79 7/24/2015
Laronidase (Aldurazyme) (PDF) CP.PHAR.152 6/1/2019
Larotrectinib (Vitrakvi)(PDF) CP.PHAR.414 3/1/2019
ledipasvir sofosbuvir (Harvoni) (PDF) CP.PCH.19 9/8/2017
lenalidomide (Revlimid) (PDF) CP.PHAR.71 10/30/2016
Lenvatinib (Lenvima) (PDF) CP.PHAR.138 6/1/2019
Letermovir (Prevymis) (PDF) CP.PHAR.367 6/1/2019
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) CP.PHAR.173 6/1/2019
Levalbuterol (Xopenex) (PDF) CP.PMN.07 6/1/2019
Levomilnacipran (Fetzima) (PDF) HIM.PA.125 6/1/2019
lidocaine transdermal (Lidoderm®) (PDF) CP.PMN.08  6/1/2019
Lifitegrast (Xiidra®) (PDF) CP.PMN.73 3/1/2020
Linaclotide (Linzess) (PDF) CP.PMN.71 6/1/2019
linezolid (Zyvox) (PDF) CP.PMN.27 6/1/2019
Lofexidine (Lucemyra) (PDF) CP.PMN.152 7/15/2019
Lomustine (Gleostine) (PDF) HIM.PA.19 6/1/2019
Lorcaserin (Belviq®, Belviq XR) (PDF) CP.PCH.03 6/1/2019
Lorlatinib (Lorbrena)(PDF) CP.PHAR.406 3/1/2019
Lubiprostone (Amitiza) (PDF) CP.PMN.142 3/1/2016
Luliconazole Cream (Luzu) (PDF) CP.PMN.166 6/1/2019
Lumacaftor-Ivacaftor (Orkambi) (PDF) CP.PHAR.213 3/1/2019
Lurasidone (Latuda) (PDF) CP.PMN.50 6/1/2019
Luspatercept-aamt (Reblozyl) (PDF) CP.PHAR.450 6/1/2020
Lusutrombopag (Mulpleta)(PDF) CP.PHAR.407 7/1/2019
Lutetium Lu 177 Dotatate (Lutathera) (PDF) CP.PHAR.384 6/1/2019
Macitentan (Opsumit®) (PDF) CP.PHAR.194 7/1/2016
Mecamylamine (Vecamyl) (PDF) CP.PMN.136 6/1/2019
Mecasermin (Increlex) (PDF) CP.PHAR.150 6/1/2019
Megestrol Acetate 125 mg/mL Oral Suspension (Megace ES) (PDF) CP.PMN.179 6/1/2019
Mepolizumab (Nucala) (PDF) CP.PHAR.200 9/8/2017
Mesalamine (Apriso) (PDF) HIM.PA.42 6/1/2019
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF) CP.PHAR.134 7/1/2020
Methoxsalen (Uvadex) (PDF) HIM.PA.17 6/1/2019
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) CP.PHAR.238 6/1/2019
Methylnaltrexone Bromide (Relistor) (PDF) CP.PMN.169 6/1/2019
Metreleptin (Myalept) (PDF) CP.PHAR.425 6/1/2019
Midazolam (Nayzilam) (PDF) CP.PMN.211 1/1/2020
Mifepristone (Korlym) (PDF) CP.PHAR.101 3/1/2020
Migalastat (Galafold) (PDF) CP.PHAR.394 7/15/2019
Miglustat (Zavesca) (PDF) CP.PHAR.164  6/1/2019
Milnacipran (Savella) (PDF) CP.PMN.125 6/1/2019
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 12/8/2017
modafinil (Provigil) (PDF) CP.PMN.39 6/1/2019
Mogamulizumab-kpkc (Poteligeo) (PDF) CP.PHAR.139 6/1/2019
Mometasone (Nasonex) (PDF) HIM.PA.93 3/1/2016
Mometasone Furoate (Sinuva) (PDF) CP.PHAR.448 3/1/2020
Montelukast oral granules (Singulair) (PDF) HIM.PA.129 6/1/2019
Monomethyl Fumarate (Bafiertam) (PDF) CP.PHAR.460 3/1/2/20
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) CP.PHAR.398 6/1/2019
Moxidectin (PDF) CP.PMN.162 6/1/2019
nafarelin acetate (Synarel®) (PDF) CP.PHAR.174 6/1/2019
Naltrexone (Vivitrol) (PDF) CP.PHAR.96 7/1/2016
Naproxen oral suspension (Naprosyn) (PDF) HIM.PA.130 6/1/2019
natalizumab (Tysabri) (PDF) HIM.PA.SP17 11/7/2017
Nebivolol (Bystolic) (PDF) HIM.PA.131 6/1/2019
necitumumab (Portrazza®) (PDF) CP.PHAR.320 6/1/2019
Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF) CP.PMN.167 6/1/2019
Netupitant and Palonosetron (Akynzeo) (PDF) CP.PMN.158 6/1/2019
nilotinib (Tasigna) (PDF) CP.PHAR.76 11/7/2017
Nintedanib (Ofev) (PDF) CP.PHAR.285 7/15/2019
Nitisinone (Nityr, Orfadin) (PDF) CP.PHAR.132 6/1/2019
Nivolumab (Opdivo) (PDF) CP.PHAR.121   9/8/2017
No Coverage Criteria/Off-Label Use Policy (PDF) CP.PMN.53 6/1/2019
Non-Formulary and Formulary Contraceptives (PDF) HIM.PA.100 7/25/2015
Non-Formulary Test Strips (PDF) HIM.PA.34 6/1/2019
nusinersen (Spinraza®) (PDF) CP.PHAR.327 6/1/2019
obinutuzumab (Gazyva®) (PDF) CP.PHAR.305 6/1/2019
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 6/1/2019
Ocreotide acetate (PDF) CP.PHAR.40 7/24/2015
ofatumumab (Arzerra®) (PDF) CP.PHAR.306 6/1/2019
Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) CP.PHAR.292 1/1/2020
olaparib (Lynparza) (PDF) CP.PHAR.360 6/1/2019
olaratumab (Lartruvo®) (PDF) CP.PHAR.326 6/1/2019
Omacetaxine (Synribo) (PDF) CP.PHAR.108 4/1/2016
Omadacycline (Nuzyra)(PDF) CP.PMN.188 3/1/2019
Omalizumab (Xolair®) (PDF) CP.PHAR.01 11/7/2017
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 11/7/2017
Onasemnogene abeparvovec (Zolgensma) (PDF) CP.PHAR.421 7/15/2019
Ophthalmic Corticosteroids (PDF) HIM.PA.03 6/1/2020
Opioid Analgesics (PDF) HIM.PA.139 1/1/2018
Ospemifene (Osphena) (PDF) CP.PMN.168 6/1/2019
Overactive Bladder Agents (PDF) CP.PMN.198 7/15/2019
Paclitaxel, protein-bound (Abraxane) (PDF) CP.PHAR.176  6/1/2019
Paliperidone (Invega) (PDF) CP.PMN.30 6/1/2019
Palivizumab (Synagis) (PDF) CP.PHAR.16 12/8/2017
panitumumab (Vectibix®) (PDF) CP.PHAR.321 6/1/2019
Parathyroid Hormone (Natpara) (PDF) CP.PHAR.282 3/1/2020
Paricalcitol Injection (Zemplar) (PDF) CP.PHAR.270 12/8/2017
pasireotide (Signifor LAR®) (PDF) CP.PHAR.332 6/1/2019
Patisiran (Onpattro) (PDF) CP.PHAR.395 6/1/2019
Pazopanib (Votrient) (PDF) CP.PHAR.81 7/24/2015
Pegademase Bovine (Adagen) (PDF) CP.PHAR.392 6/1/2019
Pegaptanib (Macugen) (PDF) CP.PHAR.185 7/1/2016
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF) CP.PHAR.353 6/1/2019
Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) (PDF) CP.PHAR.296 7/1/2020
Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) (PDF) CP.PHAR.89 7/24/2015
peginterferon beta-1a (Plegridy) (PDF) HIM.PA.SP18 12/8/2017
Pegloticase (Krystexxa) (PDF) CP.PHAR.115 6/1/2013
Pegvaliase-pqpz (Palynziq) (PDF) CP.PHAR.140 7/15/2019
Pegvisomant (Somavert) (PDF) CP.PHAR.389 6/1/2019
pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 6/1/2019
Pemetrexed (Alimta, Pemfexy) (PDF) CP.PHAR.368 10/31/2017
Penicillamine (Cuprimine) (PDF) CP.PCH.09 6/1/2019
Perampanel (Fycompa) (PDF) CP.PMN.156 6/1/2019
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 10/30/2016
Pexidartinib (Turalio)(PDF) CP.PHAR.436 12/1/2019
Phendimetrazine IR (Bontril PDM) (PDF) HIM.PA.114 6/1/2019
Phentermine (Adipex-P, Lomaira) (PDF) CP.PCH.13 7/15/2019
Pimecrolimus (Elidel) (PDF) CP.PMN.98 6/1/2019
Pitolisant (Wakix) (PDF) CP.PMN.221 5/1/2019
Plerixafor (Mozobil) (PDF) CP.PHAR.323 6/1/2019
Polatuzumab Vedotin-piiq (Polivy) (PDF) CP.PHAR.433 1/1/2020
Pomalidomide (Pomalyst) (PDF) CP.PHAR.116 4/1/2016
Potassium (Klor-Con) (PDF) HIM.PA.143 6/1/2019
pralatrexate (Folotyn®) (PDF) CP.PHAR.313 6/1/2019
Pramlintide (Symlin) (PDF) CP.PMN.129 6/1/2019
pregabalin (Lyrica) (PDF) CP.PMN.33 6/1/2019
protein c concentrate, human (Ceprotin®) (PDF) CP.PHAR.330 7/15/2019
propranolol HCL solution (Hemangeol) (PDF) CP.PMN.58 6/1/2019
Prucalopride (Motegrity) (PDF) CP.PMN.194 9/1/2019
pyrimethamine (Daraprim®) (PDF) CP.PMN.44  6/1/2019
Quetiapine ER (Seroquel XR) (PDF) CP.PMN.64 6/1/2019
Ondansetron (Zuplenz) (PDF) CP.PMN.45 3/1/2020
Quinine Sulfate (Qualaquin) (PDF) HIM.PA.144 6/1/2019
Quinine Sulfate (Qualaquin) (PDF) CP.PCH.10 6/1/2019
Ramelteon (Rozerem) (PDF) CP.PMN.173 6/1/2019
Ramucirumab (Cyramza) (PDF) CP.PHAR.119 9/8/2017
Ranibizumab (Lucentis) (PDF) CP.PHAR.186 7/1/2016
rasagiline (Azilect®) (PDF) HIM.PA.89 3/1/2016
Ravulizumab-cwvz (Ultomiris) (PDF) CP.PHAR.415 6/1/2019
Regorafenib (Stivarga) (PDF) CP.PHAR.107 3/1/2016
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) CP.PHAR.168 9/8/2017
Reslizumab (Cinqair) (PDF) CP.PHAR.223 9/8/2017
Revefenacin (Yupelri) (PDF) CP.PMN.195 9/1/2019
Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF) CP.PHAR.141 6/1/2019
Rifabutin (Mycobutin) (PDF) HIM.PA.12 6/1/2019
rifaximin (Xifaxan®) (PDF) CP.PMN.47 3/1/2016
Rilonacept (Arcalyst) (PDF) CP.PHAR.266 11/7/2017
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 11/7/2017
Riociguat (Adempas®) (PDF) CP.PHAR.195 7/1/2016
Risedronate (Actonel, Atelvia) (PDF) CP.PMN.100 6/1/2019
Risperidone Long-Acting Injection (Risperdal Consta) (PDF) CP.PHAR.293 3/1/2016
Rolapitant (Varubi) (PDF) CP.PMN.102 6/1/2019
romidepsin (Istodax®) (PDF) CP.PHAR.314 6/1/2019
Romiplostim (Nplate®) (PDF) CP.PHAR.179  7/1/2016
Romosozumab-aqqg (Evenity) (PDF) CP.PHAR.428 1/1/2020
Rucaparib (Rubraca®) (PDF) CP.PHAR.350 3/1/2020
Rufinamide (Banzel) (PDF) CP.PMN.157 3/1/2016
Ruxolitinib (Jakafi) (PDF) CP.PHAR.98 9/8/2017
Sacubitril/Valsartan (Entresto) (PDF) CP.PMN.67 6/1/2019
Safinamide (Xadago) (PDF) CP.PMN.113 3/1/2020
Sapropterin (Kuvan) (PDF) CP.PHAR.43 9/8/2017
Sarecycline (Seysara) (PDF) CP.PMN.189 3/1/2020
Sargramostim (Leukine) (PDF) CP.PHAR.295 6/1/2019
Sebelipase Alfa (Kanuma) (PDF) CP.PHAR.159 6/1/2019
Secnidazole (Solosec) (PDF) CP.PMN.103 6/1/2019
Segesterone acetate/Ethinyl estradiol (Annovera) (PDF) CP.PMN.190 7/15/2019
Selexipag (Uptravi®) (PDF) CP.PHAR.196 3/1/2020
Selinexor (Xpovio) (PDF) CP.PHAR.431 1/1/2020
Sildenafil (Revatio®) (PDF) CP.PHAR.197 7/1/2016
Sildenafil (Viagra) (PDF) CP.PCH.07 6/1/2019
Siponimod (Mayzent) (PDF) CP.PHAR.427 1/1/2020
Sipuleucel-T (Provenge) (PDF) CP.PHAR.120 4/1/2016
sodium oxybate (Xyrem) (PDF) CP.PMN.42 5/1/2019
Sodium-Glucose Co-Transporter 2  Inhibitors (PDF) HIM.PA.91 6/1/2019
Sodium Phenylbutyrate (Buphenyl) (PDF) CP.PHAR.208 3/1/2020
Sodium Zirconium Cyclosilicate (Lokelma) (PDF) CP.PMN.163 3/1/2020
Sofosbuvir (Sovaldi) (PDF) CP.PCH.20 9/8/2017
Sofosbuvir-Velpatasvir (Epclusa)  (PDF) CP.PCH.21 12/8/2017
Sofosbuvir-Vepatasvir-Voxilaprevir (Vosevi) (PDF) CP.PCH.22 6/1/2020
Solriamfetol (Sunosi) (PDF) CP.PMN.209 1/1/2020
Somatropin (Growth Hormone) (PDF) CP.PCH.25 11/7/2017
Sonidegib (Odomzo) (PDF) CP.PHAR.272 12/8/2017
sorafenib (Nexavar) (PDF) CP.PHAR.69 10/30/2016
Spinosad (Natroba) (PDF) HIM.PA.134 6/1/2019
Step Therapy (PDF) HIM.PA.109 6/1/2019
Stiripentol (Diacomit) (PDF) CP.PMN.184 3/1/2020
sucroferric oxyhydoxide (Velphoro) (PDF) HIM.PA.SP30 6/1/2019
Sulfacetamide Sodium Sulfur (Sumadan) (PDF) HIM.PA.145 6/1/2019
sunitinib (Sutent) (PDF) CP.PHAR.73 12/8/2017
Suvorexant (Belsomra®) (PDF) CP.PMN.109 6/1/2019
Tadalafil (Adcirca®) (PDF) CP.PHAR.198 7/1/2016
Tadalafil BHP - ED (Cialis) (PDF) CP.PMN.132 6/1/2019
Tafamidis (Vyndaqel, Vyndamax) (PDF) CP.PHAR.432 1/1/2020
Tafenoquine (Krintafel) (PDF) CP.PMN.178 6/1/2019
Talazoparib (Talzenna)(PDF) CP.PHAR.409 3/1/2019
Taliglucerase Alfa (Elelyso) (PDF) CP.PHAR.157 6/1/2019
Tasimelteon (Hetlioz) (PDF) CP.PMN.104 6/1/2019
tavaborole (Kerydin®) (PDF) CP.PMN.105 6/1/2019
Tazemetostat (PDF) CP.PHAR.452 6/1/2020
Tedizolid (Sivextro) (PDF) CP.PMN.62 6/1/2019
Teduglutide (Gattex) (PDF) CP.PHAR.114 9/8/2017
Tegaserod (Zelnorm) (PDF) CP.PMN.206 1/1/2020
Temozolomide (Temodar) (PDF) CP.PHAR.77 12/8/2017
temsirolimus (Torisel®) (PDF) CP.PHAR.324 6/1/2019
Teriflunomide (Aubagio) (PDF) CP.PCH.02 12/8/2017
Teriparatide (Forteo®) (PDF) CP.PHAR.188 7/1/2016
Tesamorelin (Egrifta) (PDF) CP.PHAR.109 4/1/2016
Testosterone (Androderm) (PDF) HIM.PA.87 3/1/2016
Testosterone (Testopel, Jatenzo) (PDF) CP.PHAR.354 03/01/20
tetrabenazine (Xenazine) (PDF) CP.PHAR.92 7/24/2015
Thalidomide (Thalomid) (PDF) CP.PHAR.78 10/30/2016
Thioguanine (Tabloid) (PDF) CP.PHAR.437 6/1/2019
Thyrotropin Alfa (Thyrogen) (PDF) CP.PHAR.95 7/24/2015
Timothy grass pollen allergen extract (Grastek®) (PDF) CP.PMN.84  6/1/2019
Tisagenlecleucel (Kymriah) (PDF) CP.PHAR.361 6/1/2019
Tobramycin (PDF) CP.PHAR.211 9/8/2017
Tolvaptan (Jynarque) (PDF) CP.PHAR.27 6/1/2019
Topical Acne Treatment (PDF) HIM.PA.71 3/1/2016
Topotecan (Hycamtin) (PDF) CP.PHAR.64 10/30/2016
Topical Immunomodulators (PDF) CP.PMN.107 7/15/2019
Trabectedin (Yondelis) (PDF) CP.PHAR.204 9/8/2017
Trametinib (Mekinist) (PDF) CP.PHAR.240 11/7/2017
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) CP.PHAR.228 6/1/2019
Treprostinil (Orenitram®, Remodulin®, Tyvaso®) (PDF) CP.PHAR.199  7/1/2016
Triamcinolone ER Injection (Zilretta) (PDF) CP.PHAR.371 6/1/2019
Triclabendazole (Egaten) (PDF) CP.PMN.207 1/1/2020
Trientine (Syprine) (PDF) CP.PHAR.438 6/1/2019
triptorelin pamoate (Trelstar®, Triptodur®) (PDF) CP.PHAR.175 6/1/2019
Umeclidinium/Vilanterol (Anoro Ellipta) (PDF) HIM.PA.106 6/1/2019
Unoprostone Isopropyl (Rescula) (PDF) HIM.PA.11 6/1/2019
Uridine acetate (Vistogard) (PDF) HIM.PA.SP55 6/1/2019
valganciclovir (Valcyte) (PDF) CP.PCH.06 6/1/2019
Valproate Sodium for Intravenous Injection (Depacon) (PDF) CP.PHAR.429 1/1/2020
Valrubicin (Valstar) (PDF) CP.PHAR.439 6/1/2019
Vandetanib (Caprelsa®) (PDF) CP.PHAR.80 7/24/2015
Vedolizumab (Entyvio) (PDF) CP.PHAR.265 11/7/2017
Velaglucerase Alfa (VPRIV) (PDF) CP.PHAR.163 6/1/2019
Vemurafenib (Zelboraf®) (PDF) CP.PHAR.91 7/24/2015
Vestronidase alfa-vjbk (Mepsevii) (PDF) CP.PHAR.374 6/1/2019
Verteporfin (PDF) CP.PHAR.187 7/1/2016
Vigabatrin (Sabril) (PDF) CP.PHAR.169  6/1/2019
Vilazodone (Viibryd) (PDF) CP.PMN.145 6/1/2019
vincristine sulfate liposome injection (Marqibo®) (PDF) CP.PHAR.315 6/1/2019
Vismodegib (Erivedge) (PDF) CP.PHAR.273 12/8/2017
Vorapaxar (Zontivity) (PDF) HIM.PA.146 6/1/2019
Voretigene neparvovec-rzyl (Luxturna) (PDF) CP.PHAR.372 6/1/2019
Vortioxetine (Trintellix®) (PDF) CP.PMN.65  6/1/2019
Voxelotor (Oxbryta) (PDF) CP.PHAR.451 6/1/2020
ziv-aflibercept (Zaltrap®) (PDF) CP.PHAR.325 6/1/2019
Zoledronic acid (PDF) CP.PHAR.59 7/1/2016
Vorinostat (Zolinza) (PDF) CP.PHAR.83 7/24/2015

Allwell Policies

Policy Title Policy Number Effective Date
2019 Novel Coronavirus testing (PDF) CP.MP.183 3/16/2020
3-Day Payment Window (PDF) CC.PP.500 7/1/2014
Acupuncture (PDF) CP.MP.92 3/17/2017
Adopted Clinical Practice and Preventive Health Guidelines (PDF)   6/1/2020
Add on Code Billed Without Primary Code (PDF) CC.PP.030 10/18/2016
ADHD Assessment and Treatment (PDF) CP.MP.124 7/1/2020
Allergy Testing (PDF) CP.MP.100 5/1/2019
Ambulatory EEG (PDF) CP.MP.96 8/12/2016
Articular Cartilage Defect Repairs (PDF) CP.MP.26 3/31/20
Assistant Surgeon (PDF) CC.PP.029 2/7/2017
Bariatric Surgery (PDF) CP.MP.37 8/6/2019
Balloon Sinus Ostial Dilation for Treatment of Chronic Sinusitis (PDF) CP.MP.119 6/1/2020
Bevacizumab (PDF) CP.PHAR.93 2/10/2017
Bilateral Procedures (PDF) CC.PP.037 2/7/2017
Biofeedback (PDF) CP.MP.168 7/1/2020
Bronchial Thermoplasty (PDF) CP.MP.110 4/1/2017
Cardiac Biomarker Testing for Acute MI (PDF) CP.MP.156 5/21/2018
Carrier Screening in Pregnancy (PDF) CP.MP.83 7/1/2020
Cerumen Removal (PDF) CC.PP.008 8/12/2016
Clean Claims (PDF) CC.PP.021 10/18/2016
Clinical Trials (PDF) CP.MP.94 6/30/2020
Coding Overview (PDF) CC.PP.011 10/18/2016
Cosmetic Reconstructive Surgery (PDF) CP.MP.31 07/1/20
Cosmetic Procedures (PDF) CC.PP.024 10/18/2016
Dental Anesthesia (PDF) CP.MP.61 03/31/20
Diagnosis of Vaginitis (PDF) CP.MP.97 4/1/2017
Digital Analysis of EEGs (PDF) CP.MP.105 2/10/2017
Disc Decompression Procedures (PDF) CP.MP.114 9/1/2020
Discography (PDF) CP.MP.115 6/30/2020
Distinct Procedural Modifiers (PDF) CC.PP.020 10/18/2016
DNA Analysis of Stool (PDF) CP.MP.125 6/17/2017
Duplicate Primary Code Billing (PDF) CC.PP.044 2/7/2017
Durable Medical Equipment (DME) (PDF) CP.MP.107 6/1/2020
E&M Medical Decision-Making (PDF) CC.PP.051 7/25/2017
EEG in Evaluation of Headache (PDF) CP.MP.155 5/21/2018
Electric Tumor Treatment Fields (PDF) CP.MP.145 7/1/2020
EM Bundling Edits (PDF) CC.PP.010 8/12/2016
Endometrial Ablation (PDF) CP.MP.106 12/10/2018
EpiFix Wound Treatment (PDF) CP.MP.140 11/1/2017
Evoked Potentials (PDF) CP.MP.134 6/17/2017
Experimental Technologies (PDF) CP.MP.36 6/30/2020
Facet Joint Interventions (PDF) CP.MP.171 3/4/2020
Fecal Calprotectin Assay (PDF) CP.MP.135 6/17/2017
FeNo Testing (PDF) CP.MP.103 4/1/2017
Fertility Preservation (PDF) CP.MP.130 6/1/2020
Fixed Wing Air Transportation (PDF) CP.MP.175 3/31/2020
Gender Reassignment (PDF) CP.MP.95 6/1/2020
Genetic Testing (PDF) CP.MP.89
03/31/20
Global Maternity Billing (PDF) CC.PP.016 10/18/2016
Heart-Lung Transplant (PDF) CP.MP.132 6/1/2020
H Pylori Testing (PDF) CP.MP.153 5/21/2018
Holter Monitors (PDF) CP.MP.113 4/1/2017
Homocysteine Testing (PDF) CP.MP.121 9/1/2020
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 10/18/2016
Hyperhidrosis Treatments (PDF) CP.MP.62 6/1/2020
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 6/1/2020
Inhaled Nitric Oxide (PDF) CP.MP.87 7/1/2020
Inpatient Only Procedures (PDF) MP.PP.018 10/18/2016
Intestinal and Multivisceral Transplant (PDF) CP.MP.58 7/1/2020
Laser Skin Treatment (PDF) CP.MP.123 4/1/2017
Leveling of Emergency Room (PDF) CC.PP.053  1/1/2019
Long Term Care Placement Criteria (PDF) CP.MP.71 3/16/2017
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 11/1/2017
Lung Transplantation (PDF) CP.MP.57 7/1/2020
Maximum Units (PDF) CC.PP.007 8/12/2016
Measure Serum 1,25 Vitamin D (PDF) CP.MP.152 5/21/2018
Mechanical Stretch Devices (PDF) CP.MP.144 11/1/2017
Moderate Conscious Sedation (PDF) CC.PP.015 10/18/2016
Modifier -25 clinical validation (PDF) CC.PP.013 10/18/2016
Modifier -59 clinical validation (PDF) CC.PP.014 10/18/2016
Modifier DOS Validation (PDF) CC.PP.034 10/18/2016
Modifier to Procedure Code Validation (PDF) CC.PP.028 10/18/2016
Monitored Anesthesia Care (PDF) CP.MP.161 12/15/18
Multiple CPT Code Replacement (PDF) CC.PP.033 10/18/2016
Multiple Sleep Latency Testing (PDF) CP.MP.24 6/1/2020
NCCI Unbundling (PDF) CC.PP.031 10/18/2016
Never Paid Events (PDF) CC.PP.017 10/18/2016
New Patient (PDF) CC.PP.036 2/7/2017
Non-Invasive Home Ventilator (PDF) CP.MP.184 7/1/2020
Non-Obstetrical Pelvic and Transabdominal Ultrasound (PDF) CC.PP.061  12/15/2018
Nonmyeloablative allogeneic stem cell transplant (PDF) CP.MP.141
6/1/2020
OB Home Health Programs (PDF) CP.MP.91 6/1/2020
Outpatient Consultation (PDF) CC.PP.039 2/7/2017
Outpatient Cardiac Rehabilitation (PDF) CP.MP.176 7/1/2020
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 10/1/2020
Paclitaxel (PDF) CP.PHAR.176 5/16/2016
Pancreas Transplantation (PDF) CP.MP.102 7/1/2020
Panniculectomy (PDF) CP.MP.109 7/1/2020
Pediatric Liver Transplant (PDF) CP.MP.120 7/1/2020
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) CP.MP.147 7/1/2020
Physician’s Consultation Services (PDF) CC.PP.054 9/1/2018
Physician Visit Codes Billed with Labs (PDF) CC.PP.019 10/18/2016
Physical, Occupational, and Speech Therapy Services (PDF) CP.MP.49 6/30/2020
Place of Service Mismatch (PDF) CC.PP.063  12/15/2018
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) CP.MP.181 6/1/2020
Post-Operative Visits (PDF) CC.PP.042 2/7/2017
Pre-Operative Visits (PDF) CC.PP.041 2/7/2017
Problem Oriented Visits with Preventative Services (PDF) CC.PP.057 11/1/2018
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 11/1/2018
Professional Component (PDF) CC.PP.027 10/18/2016
PROM Testing (PDF) CP.MP.149 11/8/2017
Proton and Neutron Beam Therapy (PDF) CP.MP.70 6/1/2019
Pulse Oximetry (PDF) CC.PP.025 10/18/2016
Radiofrequency Ablation of Uterine Fibroids (PDF) CP.MP.187 6/1/2020
Radial Head Implant (PDF) CP.MP.148 7/1/2020
Rituximab (PDF) CP.PHAR.260 2/10/2017
Robotic Surgery (PDF) CC.PP.050 11/1/2017
Sacroiliac Joint Interventions for Pain Management (PDF) CP.MP.166 6/1/2020
Same Day Visits (PDF) CC.PP.040 2/7/2017
Sacroiliac Joint Fusion (PDF) CP.MP.126 6/30/2020
Sclerotherapy for Varicose Veins (PDF) CP.MP.146 7/1/2020
Selective Dorsal Rhizotomy (PDF) CP.MP.174 3/31/2020
Sickle Cell Disease Observation (PDF) CP.MP.88 3/16/2017
Skin Substitutes for Chronic Wounds (PDF) CP.MP.185 6/1/2-2-
Spinal Cord Stimulation (PDF) CP.MP.117 3/31/2020
Status "B" Bundled Services (PDF) CC.PP.046 2/7/2017
Status P Bundled Services (PDF) CC.PP.049 6/17/2017
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 10/18/2016
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 6/1/2020
Thymus Transplantation (PDF) CP.MP.189 10/1/2020
Thyroid Testing in Pediatrics (PDF) CP.MP.154 5/21/2018
Transgender Related Services (PDF) CC.PP.047 2/22/2017
Trigger Point Injections for Pain Management (PDF) CP.MP.169 6/1/2020
Ultrasound in Pregnancy (PDF) CP.MP.38 2/10/2017
Unbundled Professional Services (PDF) CC.PP.043 4/6/2017
Unbundled Surgical Procedures (PDF) CC.PP.045 4/6/2017
Unlisted Procedure Codes (PDF) CC.PP.009 8/12/2016
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142
7/1/20
Urine Specimen Validity Testing (PDF) CC.PP.056 11/8/2017
Urodynamic Testing (PDF) CP.MP.98 8/12/2016
Ventriculectomy and Cardiomyoplasty (PDF) CP.MP.56 6/1/2020
Video Electroencephalographic (VEEG) Monitoring (PDF) CP.MP.177 6/1/2020
Vitamin D Testing in Children (PDF) CP.MP.157 5/21/2018
Wheelchair Accessories (PDF) CC.PP.502 8/12/2016
Wireless Motility Capsule (PDF) CP.MP.143 11/1/2017
Policy Title Policy Number Effective Date
3-Day Payment Window (PDF) CC.PP.500 7/1/2014
Add on Code Billed Without Primary Code (PDF) CC.PP.030 10/18/2016
ADHD Assessment and Treatment (PDF) CP.MP.124 4/1/2017
Allergy Testing (PDF) CP.MP.100 5/1/2019
Ambulatory EEG (PDF) CP.MP.96 8/12/2016
Assistant Surgeon (PDF) CC.PP.029 2/7/2017
Bevacizumab (PDF) CP.PHAR.93 2/10/2017
Bilateral Procedures (PDF) CC.PP.037 2/7/2017
Bronchial Thermoplasty (PDF) CP.MP.110 4/1/2017
Cardiac Biomarker Testing for Acute MI (PDF) CP.MP.156 5/21/2018
Cerumen Removal (PDF) CC.PP.008 8/12/2016
Clean Claims (PDF) CC.PP.021 10/18/2016
Coding Overview (PDF) CC.PP.011 10/18/2016
Cosmetic Procedures (PDF) CC.PP.024 10/18/2016
Diagnosis of Vaginitis (PDF) CP.MP.97 4/1/2017
Digital Analysis of EEGs (PDF) CP.MP.105 2/10/2017
Distinct Procedural Modifiers (PDF) CC.PP.020 10/18/2016
DNA Analysis of Stool (PDF) CP.MP.125 6/17/2017
Duplicate Primary Code Billing (PDF) CC.PP.044 2/7/2017
E&M Medical Decision-Making (PDF) CC.PP.051 7/25/2017
EEG in Evaluation of Headache (PDF) CP.MP.155 5/21/2018
EM Bundling Edits (PDF) CC.PP.010 8/12/2016
Endometrial Ablation (PDF) CP.MP.106 12/10/2018
EpiFix Wound Treatment (PDF) CP.MP.140 11/1/2017
Evoked Potentials (PDF) CP.MP.134 6/17/2017
Fecal Calprotectin Assay (PDF) CP.MP.135 6/17/2017
FeNo Testing (PDF) CP.MP.103 4/1/2017
Global Maternity Billing (PDF) CC.PP.016 10/18/2016
H Pylori Testing (PDF) CP.MP.153 5/21/2018
Holter Monitors (PDF) CP.MP.113 4/1/2017
Homocysteine Testing (PDF) CP.MP.121 4/1/2017
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 10/18/2016
Inpatient Consultation (PDF) CC.PP.038 2/7/2017
Inpatient Only Procedures (PDF) MP.PP.018 10/18/2016
IV Hydration (PDF) CC.PP.012 10/18/2016
Laser Skin Treatment (PDF) CP.MP.123 4/1/2017
Leveling of Emergency Room (PDF) CC.PP.053  1/1/2019
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 11/1/2017
Maximum Units (PDF) CC.PP.007 8/12/2016
Measure Serum 1,25 Vitamin D (PDF) CP.MP.152 5/21/2018
Mechanical Stretch Devices (PDF) CP.MP.144 11/1/2017
Moderate Conscious Sedation (PDF) CC.PP.015 10/18/2016
Modifier -25 clinical validation (PDF) CC.PP.013 10/18/2016
Modifier -59 clinical validation (PDF) CC.PP.014 10/18/2016
Modifier DOS Validation (PDF) CC.PP.034 10/18/2016
Modifier to Procedure Code Validation (PDF) CC.PP.028 10/18/2016
Monitored Anesthesia Care (PDF) CP.MP.161 12/15/18
Multiple CPT Code Replacement (PDF) CC.PP.033 10/18/2016
NCCI Unbundling (PDF) CC.PP.031 10/18/2016
Never Paid Events (PDF) CC.PP.017 10/18/2016
New Patient (PDF) CC.PP.036 2/7/2017
Non-Obstetrical Pelvic and Transabdominal Ultrasound (PDF) CC.PP.061  12/15/2018
Outpatient Consultation (PDF) CC.PP.039 2/7/2017
Paclitaxel (PDF) CP.PHAR.176 5/16/2016
Physician’s Consultation Services (PDF) CC.PP.054 9/1/2018
Physician Visit Codes Billed with Labs (PDF) CC.PP.019 10/18/2016
Place of Service Mismatch (PDF) CC.PP.063  12/15/2018
Post-Operative Visits (PDF) CC.PP.042 2/7/2017
Pre-Operative Visits (PDF) CC.PP.041 2/7/2017
Problem Oriented Visits with Preventative Services (PDF) CC.PP.057 11/1/2018
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 11/1/2018
Professional Component (PDF) CC.PP.027 10/18/2016
PROM Testing (PDF) CP.MP.149 11/8/2017
Proton and Neutron Beam Therapy (PDF) CP.MP.70 6/1/2019
Pulse Oximetry (PDF) CC.PP.025 10/18/2016
Rituximab (PDF) CP.PHAR.260 2/10/2017
Robotic Surgery (PDF) CC.PP.050 11/1/2017
Same Day Visits (PDF) CC.PP.040 2/7/2017
Status "B" Bundled Services (PDF) CC.PP.046 2/7/2017
Status P Bundled Services (PDF) CC.PP.049 6/17/2017
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 10/18/2016
Thyroid Testing in Pediatrics (PDF) CP.MP.154 5/21/2018
Transgender Related Services (PDF) CC.PP.047 2/22/2017
Ultrasound in Pregnancy (PDF) CP.MP.38 2/10/2017
Unbundled Professional Services (PDF) CC.PP.043 4/6/2017
Unbundled Surgical Procedures (PDF) CC.PP.045 4/6/2017
Unlisted Procedure Codes (PDF) CC.PP.009 8/12/2016
Urine Specimen Validity Testing (PDF) CC.PP.056 11/8/2017
Urodynamic Testing (PDF) CP.MP.98 8/12/2016
Vitamin D Testing in Children (PDF) CP.MP.157 5/21/2018
Wheelchair Accessories (PDF) CC.PP.502 8/12/2016
Wireless Motility Capsule (PDF) CP.MP.143 11/1/2017