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Clinical & Payment Policies

To easily search for a policy, use the Ctrl+F (Command+F on Mac) function on your keyboard to search by keyword, policy number or effective date.

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 including peer-reviewed medical literature, government agency/program approval status, evidence-based guidelines, 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 an 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 an 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

Ambetter from Arkansas Health and Wellness will be partnering with National Imaging Associates (NIA) beginning January 1, 2021, for prior authorization requests for the following services:

  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy
  • Spinal Epidural Injections
  • Paravertebral Facet Joint Injections or Blocks
  • Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis)
  • Sacroiliac Joint Injections

Clinical Policies for these procedures can be found at www.RadMD.com.

Clinical Policies for CT/CTA/CCTA, MRI, MRA, and Pet Scans can also be found at the NIA website (www.RADMD.com).

Policy Title Policy Number Effective Date
Acupuncture (PDF) CP.MP.92 October 1, 2021
ADHD Assessment and Treatment (PDF) CP.MP.124 May 1, 2022 - NEW
Air Ambulance (PDF) CP.MP.175 October 1, 2021
Allergy Testing (PDF) CP.MP.100 October 1, 2022 - NEW
Allergy Testing (PDF) CP.MP.100 Retire by October 1, 2022
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF) CP.MP.108 January 1, 2022
Ambulatory EEG (PDF) CP.MP.96 September 1, 2021
Amifampridine (Firdapse, Ruzurgi) (PDF) - NEW CP.PHAR.411 April 1, 2022
Antithrombin III (PDF) CP.MP.179 December 1, 2021
Articular Cartilage Defect Repairs (PDF) CP.MP.26 April 1, 2022
Assisted Reproductive Technology (PDF) CP.MP.55 February 1, 2022
Applied Behavioral Analysis (PDF) CP.BH.104 March 1, 2022
Biofeedback (PDF) CP.MP.168 February 1, 2022
Bone-Anchored Hearing Aid (PDF) AR.CP.MP.93 November 1, 2021
Bronchial Thermoplasty (PDF) CP.MP.110 July 1, 2022 - NEW
Burn Surgery (PDF) CP.MP.186 February 1, 2022
Cardiac Biomarker Testing for Acute MI (PDF) CP.MP.156 December 1, 2021
Caudal or Interlaminar Epidural Steroid Injections (PDF) CP.MP.164 November 1, 2021
Clinical Trials (PDF) CP.MP.94 August 1, 2021
Cochlear Implant Replacements (PDF) AR.CP.MP.14 September 1, 2020
Cosmetic Reconstructive Surgery (PDF) CP.MP.31 December 1, 2021
Dental Anesthesia (PDF) CP.MP.61 December 1, 2021
Deep Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder (PDF) CP.BH.201 September 1, 2022
Deep TMS for OCD (PDF) CP.BH.201 Retire by September 1, 2022
Diaphragmatic/Phrenic Nerve Stimulation (PDF) CP.MP.203 February 1, 2022
Digital Analysis of EEGs (PDF) CP.MP.105 December 1, 2021
Disc Decompression Procedures (PDF) CP.MP.114 October 1, 2022 - NEW
Disc Decompression Procedures (PDF) CP.MP.114 Retire by October 1, 2022
Discography (PDF) CP.MP.115 August 1, 2021
Donor Lymphocyte Infusion (PDF) CP.MP.101 December 1, 2021
Drugs of Abuse, Definitive Testing CP.MP.50 May 1, 2022 - NEW
Durable Medical Equipment (DME) (PDF) CP.MP.107 February 1, 2022
EEG in Evaluation of Headache (PDF) CP.MP.155 December 1, 2021
Electric Tumor Treatment Fields (PDF) CP.MP.145 February 1, 2022
Endometrial Ablation (PDF) CP.MP.106 June 1, 2022 - NEW
Endometrial Ablation (PDF) CP.MP.106 Retire by September 1, 2022
Essure Removal (PDF) CP.MP.131 December 1, 2021
Evoked Potentials (PDF) CP.MP.134 October 1, 2021
Experimental Technologies (PDF) CP.MP.36 April 1, 2022
Facet Joint Interventions (PDF) CP.MP.171 September 1, 2021
Fecal incontinence treatments (PDF) CP.MP.137 September 1, 2021
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) CP.MP.129 December 1, 2021
Ferriscan R2-MRI (PDF) CP.MP.53 December 1, 2021
Fertility Preservation (PDF) CP.MP.130 October 1, 2022 - NEW
Fertility Preservation (PDF) CP.MP.130 Retire by October 1, 2022
Gastric Electrical Stimulation (PDF) CP.MP.40 April 1, 2022
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) CP.MP.209 February 1, 2022
Gender Reassignment (PDF) CP.MP.95 January 1, 2022
GI Pathogen Nucleic Acid Detection Panel Testing CP.MP.209 May 1, 2022 - NEW
Heart-Lung Transplant (PDF) CP.MP.132 July 1, 2022 - NEW
H. Pylori Testing (PDF) CP.MP.153 December 1, 2021
Holter Monitors (PDF) CP.MP.113 February 1, 2022
Home Births (PDF) CP.MP.136 March 1, 2022
Homocysteine Testing (PDF) CP.MP.121 May 1, 2022 - NEW
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) CP.MP.150 December 1, 2021
Hospice (PDF) CP.MP.54 February 1, 2022
Hyperhidrosis Treatments (PDF) CP.MP.62 March 1, 2022
Hyperemesis Gravidarum Treatment (PDF) CP.MP.34 April 1, 2022
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) CP.MP.180 January 1, 2022
Implanable Intrathecal Pain Pump (PDF) CP.MP.173 June 1, 2022
Implantable Loop Recorder (PDF) CP.MP.243 September 1, 2022 - NEW
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 June 1, 2022 - NEW
Inhaled Nitric Oxide (PDF) CP.MP.87 June 1, 2022 - NEW 
Intensity Modulated Radiotherapy (PDF) CP.MP.69 February 1, 2022
Intestinal and Multivisceral Transplant (PDF) CP.MP.58 July 1, 2022 - NEW
Intradiscal Steroid Injections for Pain Management (PDF) CP.MP.167 October 1, 2021
Laser Therapy for Skin Conditions (PDF) CP.MP.123 May 1, 2022 - NEW
Liposuction for Lipedema (PDF) CP.MP.244 October 1, 2022 - NEW
Long- Term Care Placement Criteria (PDF) CP.MP.71 June 1, 2022 - NEW
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 May 1, 2022 - NEW
Lung Transplantation (PDF) CP.MP.57 April 1, 2022
Lysis of Epidural Lesions (PDF) CP.MP.116 July 1, 2022 - NEW
Measure Serum 1,25 Vitamin D (PDF) CP.MP.152 December 1, 2021
Mechanical Stretch Devices (PDF) CP.MP.144 February 1, 2022
Multiple Sleep Latency Testing (PDF) CP.MP.24 June 1, 2022 - NEW 
Neonatal Abstinence Syndrome Guidelines (PDF) CP.MP.86 November 1, 2021
Neonatal Sepsis Management Guidelines (PDF) CP.MP.85 December 1, 2021
Neurofeedback for Behavioral Health Disorders (PDF) CP.BH.300 August 1, 2021
Nerve Blocks for Pain Management (PDF) CP.MP.170 February 1, 2022
NICU Apnea Bradycardia Guidelines (PDF) CP.MP.82 August 1, 2021
NICU Discharge Guidelines (PDF) CP.MP.81 November 1, 2021
Non-Invasive Home Ventilator (PDF) CP.MP.184 October 1, 2021
Nonmyeloablative allogeneic stem cell transplant (PDF) CP.MP.141 April 1, 2021
OB Home Health Programs (PDF) CP.MP.91 February 1, 2022
Optic Nerve Decompression Surgery (PDF) CP.MP.128 October 1, 2021
Orthognathic Surgery (PDF) CP.MP.202  December 1, 2021
Osteogenic Stimulation (PDF) CP.MP.194 November 1, 2021
Outpatient Cardiac Rehabilitation (PDF) CP.MP.176 July 1, 2022 - NEW
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 May 1, 2022
Oxygen Use and Concentrators (PDF) CP.MP.190 March 1, 2022
Pancreas Transplantation (PDF) CP.MP.102 April 1, 2022
Panniculectomy (PDF) CP.MP.109 January 1, 2022
Pediatric Heart Transplant (PDF) CP.MP.138 February 1, 2022
Pediatric Liver Transplant (PDF) CP.MP.120 October 1, 2021
Pediatric Oral Function Therapy (PDF) CP.MP.188 July 1, 2022 - NEW
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) CP.MP.147 July 1, 2022 - NEW
Physical, Occupational, and Speech Therapy Services (PDF) CP.MP.49 August 1, 2021
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) CP.MP.181 May 1, 2022 - NEW
Post-Acute Care (PDF) CP.MP.213 April 1, 2022
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) CP.MP.133 October 1, 2021
PROM Testing (PDF) CP.MP.149 August 1, 2021
Proton and Neutron Beam Therapy (PDF) CP.MP.70 January 1, 2022
Radial Head Implant (PDF) CP.MP.148 July 1, 2022 - NEW
Radiofrequency Ablation of Uterine Fibroids (PDF) CP.MP.187 April 1, 2022
Reduction Mammoplasty and Gynecomastia Surgery (PDF) CP.MP.51 November 1, 2021
Repair of Nasal Valve Compromise (PDF) CP.MP.210 July 1, 2022 - NEW
Sacroiliac Joint Interventions for Pain Management (PDF) CP.MP.166 October 1, 2021
Sclerotherapy (PDF) CP.MP.146 Retire by September 1, 2022
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins (PDF) CP.MP.146 September 1, 2022 - NEW
Selective Dorsal Rhizotomy (PDF) CP.MP.174 January 1, 2022
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF) CP.MP.165 October 1, 2021
Skin Substitutes for Chronic Wounds (PDF) CP.MP.185 June 1, 2022 - NEW
Skilled Nursing Facility Leveling (PDF) CP.MP.206 April 1, 2022
Spinal Cord Stimulation (PDF) CP.MP.117 April 1, 2022
Stereotactic Body Radiation Therapy (PDF) CP.MP.22 March 1, 2022
SUD CP.BH.100 June 1, 2022
Tandem Transplant (PDF) CP.MP.162 April 1, 2022
Testing for Select Genitourinary Conditions (PDF) CP.MP.97 August 1, 2022 - NEW
Testing for Select Genitourinary Conditions (PDF) CP.MP.97 Retire by August 1, 2022
Thyroid Testing in Pediatrics (PDF) CP.MP.154 December 1, 2021
Total Artificial Heart (PDF) CP.MP.127 January 1, 2022
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 June 1, 2022 - NEW
Transcatheter Closure of Patent Foramen Ovale (PDF) CP.MP.151 January 1, 2022
Transcranial Magnetic Stimulation (PDF) CP.BH.200 September 1, 2022
TMS for Major Depressive Disorder (PDF) CP.BH.200 Retire by September 1, 2022
Trigger Point Injections for Pain Management (PDF) CP.MP.169 October 1, 2021
Ultrasound in Pregnancy (PDF) CP.MP.38 May 1, 2022 - NEW
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142 January 1, 2022
Urodynamic Testing (PDF) CP.MP.98 May 1, 2022 - NEW
Vagus Nerve Stimulation (PDF) CP.MP.12 October 1, 2021
Ventricular Assist Devices (PDF) CP.MP.46 April 1, 2022
Vitamin D Testing in Children (PDF) CP.MP.157 March 1, 2021
Wheelchair Seating (PDF) CP.MP.99 May 1, 2022 - NEW
Wireless Motility Capsule (PDF) CP.MP.143 December 1, 2021
Policy Title Policy Number Effective Date
3-Day Payment Window (PDF) CC.PP.500 July 1, 2014
Add-On Code Billed Without Primary Code (PDF) CC.PP.030 October 18, 2016
ADHD Assessment and Treatment (PDF) CP.MP.124 May 1, 2021
Ambulatory EEG (PDF) CP.MP.96 August 12, 2016
Ambulatory Surgery Center Optimization (PDF) CP.MP.158 June 1, 2021
Assistant Surgeon (PDF) CC.PP.029 February 7, 2017
Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF) CP.MP.124 July 1, 2022 - NEW
Bilateral Procedures (PDF) CC.PP.037 February 7, 2017
Bronchial Thermoplasty (PDF) CP.MP.110 April 1, 2017
Cardiac Biomarker Testing for Acute MI (PDF) CP.MP.156 March 1, 2021
Cerumen Removal (PDF) CC.PP.008 August 12, 2016
Clean Claims (PDF) CC.PP.021 October 18, 2016
Coding Overview (PDF) CC.PP.011 October 18, 2016
Cosmetic Procedures (PDF) CC.PP.024 October 18, 2016
Digital Analysis of EEGs (PDF) CP.MP.105 March 1, 2021
Distinct Procedural Modifiers (PDF) CC.PP.020 October 18, 2016
Duplicate Primary Code Billing (PDF) CC.PP.044 February 7, 2017
EEG in the Evaluation of Headache (PDF) CP.MP.155 July 1, 2022
E&M Medical Decision-Making (PDF) CC.PP.051 July 25, 2017
EM Bundling Edits (PDF) CC.PP.010 August 12, 2016
Endometrial Ablation (PDF) CP.MP.106 September 1, 2021
Functional MRI (PDF) CP.MP.43 April 1, 2022
Global Maternity Billing (PDF) CC.PP.016 October 18, 2016
H. Pylori Testing (PDF) CP.MP.153 May 21, 2018
Holter Monitors (PDF) CP.MP.113 April 1, 2017
Homocysteine Testing (PDF) CP.MP.121 May 1, 2021
Hospice Services (PDF) CP.MP.54 September 1, 2021
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 October 18, 2016
Inpatient Consultation (PDF) CC.PP.038 February 7, 2017
Inpatient Only Procedures (PDF) MP.PP.018 October 18, 2016
IV Hydration (PDF) CC.PP.012 October 18, 2016
Leveling of Care: Evaluation and Management Overcoding (PDF) CC.PP.066 March 15, 2021
Leveling of Emergency Room (PDF) CC.PP.053  January 1, 2019
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 November 1, 2017
Maximum Units (PDF) CC.PP.007 August 12, 2016
Measure Serum 1,25 Vitamin D (PDF) CP.MP.152 May 21, 2018
Moderate Conscious Sedation (PDF) CC.PP.015 October 18, 2016
Modifier -25 clinical validation (PDF) CC.PP.013 October 18, 2016
Modifier -59 clinical validation (PDF) CC.PP.014 October 18, 2016
Modifier DOS Validation (PDF) CC.PP.034 October 18, 2016
Modifier to Procedure Code Validation (PDF) CC.PP.028 October 18, 2016
Multiple CPT Code Replacement (PDF) CC.PP.033 October 18, 2016
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF) CC.PP.065 March 15, 2021
Multiple Procedure Reduction: Ophthalmology (PDF) CC.PP.069 March 15, 2021
Multiple Procedure Payment Reduction for Therapeutic Services (PDF) CC.PP.068 March 15, 2021
Multiple Sleep Latency Testing (PDF) CP.MP.24 June 1, 2022 - NEW
NCCI Unbundling (PDF) CC.PP.031 October 18, 2016
Neuromuscular Electrical Stimulation (PDF) CP.MP.48 June 1, 2022 - NEW
Never Paid Events (PDF) CC.PP.017 October 18, 2016
New Patient (PDF) CC.PP.036 February 7, 2017
Non-Obstetrical Pelvic and Transabdominal Ultrasound (PDF) CC.PP.061  March 15, 2021
Outpatient Consultation (PDF) CC.PP.039 February 7, 2017
Physician’s Consultation Services (PDF) CC.PP.054 September 1, 2018
Physician Visit Codes Billed with Labs (PDF) CC.PP.019 October 18, 2016
Place of Service Mismatch (PDF) CC.PP.063  December 15, 2018
Post-Operative Visits (PDF) CC.PP.042 February 7, 2017
Pre-Operative Visits (PDF) CC.PP.041 February 7, 2017
Problem Oriented Visits with Preventative Services (PDF) CC.PP.057 November 1, 2018
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 November 1, 2018
Professional Component (PDF) CC.PP.027 October 18, 2016
PROM Testing (PDF) CP.MP.149 November 8, 2017
Proton and Neutron Beam Therapy (PDF) CP.MP.70 June 1, 2019
Pulse Oximetry (PDF) CC.PP.025 October 18, 2016
Renal Hemodialysis (PDF) CC.PP.067 March 15, 2021
Robotic Surgery (PDF) CC.PP.050 November 1, 2017
Same Day Visits (PDF) CC.PP.040 February 7, 2017
Status "B" Bundled Services (PDF) CC.PP.046 February 7, 2017
Status P Bundled Services (PDF) CC.PP.049 June 17, 2017
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 October 18, 2016
Testing for Select Genitourinary Conditions (PDF) CP.MP.97 June 1, 2021
Thyroid Testing in Pediatrics (PDF) CP.MP.154 May 21, 2018
Transgender Related Services (PDF) CC.PP.047 February 22, 2017
Ultrasound in Pregnancy (PDF) CP.MP.38 February 10, 2017
Unbundled Professional Services (PDF) CC.PP.043 April 6, 2017
Unbundled Surgical Procedures (PDF) CC.PP.045 April 6, 2017
Unlisted Procedure Codes (PDF) CC.PP.009 August 12, 2016
Urine Specimen Validity Testing (PDF) CC.PP.056 November 8, 2017
Video Electroencephalographic (VEEG) Monitoring (PDF) CP.MP.177 November 1, 2021
Vitamin D Testing in Children (PDF) CP.MP.157 March 1, 2021
Wheelchair Accessories (PDF) CC.PP.502 August 12, 2016
Wireless Motility Capsule (PDF) CP.MP.143 March 1, 2021

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Policy Title Policy Number Effective Date
Abaloparatide (Tymlos) (PDF) CP.PHAR.345 June 1, 2022 - NEW 
Abametapir (Xeglyze) (PDF) CP.PMN.253 December 1, 2021
Abatacept (Orencia) (PDF) CP.PHAR.241 August 1, 2021
Abemaciclib (Verzenio) (PDF) CP.PHAR.355 December 1, 2021
Abiraterone (Zytiga) (PDF) CP.PHAR.84 March 1, 2022
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 June 1, 2022 - NEW
Acyclovir Buccal tab (Sitavig) (PDF) CP.PMN.210 December 1, 2021
Adefovir (Hepsera) (PDF) CP.PHAR.142 December 1, 2021
Ado-Trastuzumab Emtansine (Kadcyla) (PDF) CP.PHAR.229 June 1, 2022 - NEW 
Aducanumab (Aduhelm) (PDF) CP.PHAR.468 Retire by August 1, 2022
Aducanumab (Aduhelm) (PDF) CP.PHAR.468 August 1, 2022
Afamelanotide (Scenesse) (PDF) CP.PHAR.444 March 1, 2022
Afatinib (Gilotrif) (PDF) CP.PHAR.298 June 1, 2022 - NEW
Aflibercept (Eylea) (PDF) CP.PHAR.184 June 1, 2022 - NEW 
Agalsidase Beta (Fabrazyme) (PDF) CP.PHAR.158  June 1, 2022 - NEW
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) CP.PMN.138 June 1, 2022 - NEW
Alectinib (Alecensa) (PDF) CP.PHAR.369

Retire by August 1, 2022
Alectinib (Alecensa) (PDF) CP.PHAR.369 August 1, 2022 - NEW
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 June 1, 2022 - NEW
Alendronate (Binosto, Fosamax plus D) (PDF) CP.PMN.88 March 1, 2022
Alglucosidase (Lumizyme) (PDF) CP.PHAR.160 Retire by August 1, 2022
Alglucosidase (Lumizyme) (PDF) CP.PHAR.160 August 1, 2022 - NEW
Allogeneic cultured keratinocytes and dermal fibroblasts (StrataGraft) (PDF) CP.PHAR.562 March 1, 2022
Allogenic processed thymus tissue-agdc (Rethymic) (PDF) CP.PHAR.563 June 1, 2022 - NEW
Alpelisib (Piqray) (PDF) CP.PHAR.430 July 1, 2021
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF) CP.PHAR.94 March 1, 2022
Amantadine ER (Gocovri,Osmolex ER) (PDF) CP.PMN.89 March 1, 2022
Ambrisentan (Letairis®) (PDF) CP.PHAR.190 March 1, 2022
Amifampridine (Firdapse)(PDF)  - NEW CP.PHAR.411 April 1, 2022
Amikacin (Arikayce)(PDF)  CP.PHAR.401 April 1, 2022
Amivantamab-vmjw (Rybrevant) (PDF) CP.PHAR.544 October 1, 2021
Anifrolumab-fnia (Saphnelo) (PDF) CP.PHAR.551 December 1. 2021
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) CP.PHAR.217 June 1, 2022 - NEW
Antithymocyte Globulin (Thymoglobulin, Atgam) (PDF) CP.PHAR.506 December 1, 2021
Antithrombin III (ATryn, Thrombate III) (PDF) CP.PHAR.564 March 1, 2022
Apalutamide (Erleada) (PDF) CP.PHAR.376 June 1, 2022 - NEW
Apalutamide (Erleada) (PDF) CP.PCH.45 June 1, 2022 - NEW
Apomorphine (Apokyn) (PDF) CP.PHAR.488 July 1, 2021
Aprepitant (Emend®) (PDF) CP.PMN.19 March 1, 2022
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada)  (PDF) CP.PHAR.290 July 1, 2021
Aripiprazole ODT (Abilify) (PDF) CP.PCH.37 March 1, 2022
Armodafinil (Nuvigil) (PDF) CP.PMN.35 June 1, 2022 - NEW
Asciminib (Scemblix) (PDF) CP.PHAR.565 May 1, 2022
Asenapine (Saphris) (PDF) CP.PMN.15 March 1, 2022
Aspirin-dipyridamole (Aggrenox) (PDF) CP.PMN.20 March 1, 2022
Atezolizumab (Tecentriq) (PDF) CP.PHAR.235 April 1, 2022
Atogepant (Qulipta) (PDF) CP.PHAR.566 June 1, 2022 - NEW
Avacopan (Tavneos) (PDF) CP.PHAR.515 March 1, 2022
Avalglucosidase alfa-ngpt (Nexviazyme) (PDF) CP.PHAR.521 June 1, 2022 - NEW
Avapritinib (Ayvakit) (PDF) CP.PHAR.454 April 1, 2022
Avatrombopag (Doptelet) (PDF) CP.PHAR.130 March 1, 2022
Avelumab (Bavencio) (PDF) CP.PHAR.333 April 1, 2022
axicabtagene ciloleucel (Yescarta®) (PDF) CP.PHAR.362 March 1, 2022
Axitinib (Inlyta) (PDF) CP.PHAR.100 March 1, 2022
Azacitidine (Vidaza) (PDF) CP.PHAR.387 March 1, 2022
Azelaic Acid (Finacea) (PDF) HIM.PA.119 December 1, 2021
Aztreonam (Cayston) (PDF) CP.PHAR.209 March 1, 2022
Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispah, Ozobax)  - NEW CP.PHAR.149 April 1, 2022
Bamlanivimab-etesevimab (LY-CoV555-LY-CoV016) (PDF) CP.PHAR.532 Pending FDA Approval
Bedaquiline (Sirturo) (PDF) CP.PMN.212 March 1, 2022
Belatacept (Nulojix®)  (PDF) CP.PHAR.201 December 1, 2021
Belimumab (Benlysta) (PDF) CP.PHAR.88 June 1, 2022 - NEW
Belinostat (Beleodaq®) (PDF) CP.PHAR.311 December 1, 2021
Bempedoic acid (Nexletol), bempedoic acid-ezetimibe (Nexlizet) (PDF) CP.PMN.237 March 1, 2022
Bendamustine (Bendeka®, Treanda®) (PDF) CP.PHAR.307 February 1, 2022
Benralizumab (Fasenra) (PDF) CP.PHAR.373 March 1, 2022
Benznidazole (PDF) CP.PMN.90 March 1, 2022
Berotralstat (Orladeyo) (PDF) CP.PHAR.485 October 1, 2021
Betaine (Cystadane) (PDF) CP.PHAR.143 December 1, 2021
Betibeglogene autotemcel (PDF) CP.PHAR.545 Pending FDA Approval
Bevacizumab (PDF) CP.PHAR.93 February 1, 2022
Bexarotene (Targretin) (PDF) CP.PHAR.75 June 1, 2022 - NEW
Bezlotoxumab (Zinplava) (PDF) CP.PHAR.300 March 1, 2022
Belantamab mafodotin (Blenrep) (PDF) CP.PHAR.469 June 1, 2022 - NEW
Belumosudil (Rezurock) (PDF) CP.PHAR.552 December 1, 2021
Belzutifan (Welireg) (PDF) CP.PHAR.553 December 1, 2021
Bimatoprost Implant (Durysta) (PDF) CP.PHAR.486 June 1, 2022 - NEW
Binimetinib (Mektovi) (PDF) CP.PHAR.50 June 1, 2022 - NEW
Biologic DMARDs (PDF)
HIM.PA.SP60
Retire by August 1, 2022
Biologic DMARDs (PDF) HIM.PA.SP60 August 1, 2022 - NEW
Blinatumomab (Blincyto) (PDF) CP.PHAR.312 July 1, 2021
Bortezomib (Velcade) (PDF) CP.PHAR.410 March 1, 2022
Bosentan (Tracleer®) (PDF) CP.PHAR.191 March 1, 2022
Bosutinib (Bosulif) (PDF) CP.PHAR.105 June 1, 2022 - NEW 
Brand Name Override and Non-Formulary Medications (PDF) HIM.PA.103 December 1, 2021
Brentuximab Vedotin (Adcetris) (PDF) CP.PHAR.303 April 1, 2022
Brexanolone (Zulresso) (PDF) CP.PHAR.417 June 1, 2022 - NEW
Brexpiprazole (Rexulti) (PDF) CP.PMN.68 March 1, 2022
Brexucabtagene Autoleucel (Tecartus) (PDF) CP.PHAR.472 March 1, 2022
Brigatinib (Alunbrig) (PDF) CP.PHAR.342 Retire by August 1, 2022
Brigatinib (Alunbrig) (PDF) CP.PHAR.342 August 1, 2022 - NEW
Brolucizumab-dbll (Beovu) (PDF) CP.PHAR.445  March 1, 2022
Brimonidine Tartrate (Mirvaso) (PDF) CP.PMN.192 June 1, 2022 - NEW
Brinzolamide/Brimonidine (Simbrinza) (PDF) HIM.PA.15 December 1, 2021
Brivaracetam (Briviact) (PDF) CP.PCH.26 November 1, 2021
Budesonide (Uceris) (PDF) CP.PCH.11 December 1, 2021
Buprenorphine implant (Probuphine) (PDF) CP.PHAR.289 March 1, 2022
Bupropion/Naltrexone (Contr07e) (PDF) CP.PCH.12 June 1, 2022 - NEW
Burosumab-twza (Crysvita) (PDF) CP.PHAR.11 July 1, 2021
Burprenorphine (Brixadi) (PDF) CP.PHAR.498 Pending FDA Approval
Buprenorphine/Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF) CP.PMN.81 March 1, 2022
Buprenorphine (Subutex) CP.PMN.82 March 1, 2022
Butorphanol Nasal Spray (PDF) HIM.PA.46 June 1, 2022 - NEW
C1 Esterase Inhibitors (PDF) CP.PHAR.202 April 1, 2022
cabazitaxel (Jevtana®) (PDF) CP.PHAR.316 Retire by August 1, 2022
cabazitaxel (Jevtana®) (PDF) CP.PHAR.316 August 1, 2022 - NEW
Cabotegravir, Cabotegravir-Rilpivirine (Apretude Cabenuva) (PDF) CP.PHAR.573 May 1, 2022
Cabozantinib (Cometriq®, Cabometyx®) (PDF) CP.PHAR.111 March 1, 2022
Calcifediol (Rayaldee) (PDF) CP.PMN.76  July 1, 2021
Canakinumab (Ilaris) (PDF) CP.PHAR.246 June 1, 2022 - NEW 
Cannabidiol (Epidiolex) (PDF) CP.PMN.164 July 1, 2021
capecitabine (Xeloda) (PDF) CP.PHAR.60 June 1, 2022 - NEW
Caplacizumab-yhdp (Cablivi) (PDF) CP.PHAR.416 Retire by August 1, 2022
Caplacizumab-yhdp (Cablivi) (PDF) CP.PHAR.416 August 1, 2022 - NEW
Carbamazepine ER (Equetro) (PDF) CP.PMN.137 June 1, 2022 - NEW
Carbetocin (PDF) CP.PHAR.546 Pending FDA Approval
Carbidopa-Levodopa ER Capsules (Rytary), Enteral Suspension (Duopa) (PDF) CP.PMN.238 December 1, 2021
Carfilzomib (Kyprolis®) (PDF) CP.PHAR.309 December 1, 2021
Carglumic acid (Carbaglu®) (PDF) CP.PHAR.206  March 1, 2022
Casimersen (Amondys 45) (PDF) CP.PHAR.470 March 1, 2022
Casirivimab and imdevimab (REGEN-COV) (PDF) CP.PHAR.520 Retire by August 1, 2022
Casirivimab and imdevimab (REGEN-COV) (PDF) CP.PHAR.520 August 1, 2022 - NEW
Celecoxib (Celebrex) (PDF) CP.PMN.122 Retire by August 1, 2022
Celecoxib (Celebrex) (PDF) CP.PMN.122 August 1, 2022 - NEW
Cemiplimab-rwlc (Libtayo) (PDF) CP.PHAR.397 December 1, 2021
Cenegermin-bkbj (Oxervate)(PDF) CP.PMN.186 March 1, 2022
Cenobamate (Xcopri) (PDF) CP.PMN.231 March 1, 2022
Ceritinib (Zykadia) (PDF) CP.PHAR.349 Retire by August 1, 2022
Ceritinib (Zykadia) (PDF) CP.PHAR.349 August 1, 2022 - NEW
Cerliponase alfa (Brineura) (PDF) CP.PHAR.338 July 1, 2021
Cetuximab (Erbitux®) (PDF) CP.PHAR.317 December 1, 2021
Chlorambucil (Leukeran) (PDF) CP.PHAR.554 March 1, 2022
Chloramphenicol Sodium Succinate (PDF) CP.PHAR.388 March 1, 2022
Cholic Acid (Cholbam) (PDF) CP.PHAR.390 December 1, 2021
Ciclopirox (Penlac) (PDF) CP.PMN.24 April 1, 2022
Ciltacabtagene Autoleucel (Carvykti) (PDF) CP.PHAR.533 June 1, 2022 - NEW
Cinacalcet (Sensipar) (PDF) CP.PHAR.61 July 1, 2021
Cipaglucosidase alfa-miglustat (AT-GAA)  CP.PHAR.567 Pending FDA Approval
Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) CP.PMN.248 December 1, 2021
Ciprofloxacin/Fluocinolone (Otovel) (PDF) CP.PMN.249 December 1, 2021
Cladribine (Mavenclad) (PDF) CP.PHAR.422 June 1, 2022 - NEW
Clascoterone (Winlevi) (PDF) CP.PMN.257 March 1, 2022
Clinical Policy: Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) CP.PHAR.260 February 1, 2022
Clobazam (Onfi) (PDF) CP.PMN.54 December 1, 2021
CNS Stimulants (PDF) CP.PMN.92 May 1, 2022
Cobimetinib (Cotellic) (PDF) CP.PHAR.380 June 1, 2022 - NEW
Colchicine (Colcrys) (PDF) CP.PMN.123 March 1, 2022
Colesevelam (Welchol) (PDF) CP.PMN.250 December 1, 2021
Collagenase (Xiaflex) (PDF) CP.PHAR.82 July 1, 2021
Colonoscopy Preparation Products (PDF) CP.PCH.43 December 1, 2021
Compounded Medications (PDF) CP.PCH.27 December 1, 2021
Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) CP.PMN.258 March 1, 2022
Copanlisib (Aliqopa®)  (PDF) CP.PHAR.357 December 1, 2021
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) CP.PHAR.385 June 1, 2022 - NEW
Cosyntropin (Cortrosyn) (PDF) CP.PHAR.203 March 1, 2022
Crisaborole (Eucrisa) (PDF) CP.PMN.110 June 1, 2021 - NEW
Crizanlizumab-tmca (Adakveo) (PDF) CP.PHAR.449 March 1, 2022
Crizotinib (Xalkori) (PDF) CP.PHAR.90 Retire by August 1, 2022
Crizotinib (Xalkori) (PDF) CP.PHAR.90 August 1, 2022 - NEW
Cyclosporine (Restasis, Cequa) (PDF) CP.PMN.48 June 1, 2022 - NEW
Cysteamine ophthalmic (Cystaran) (PDF) CP.PMN.130 June 1, 2022 - NEW
Cysteamine oral (Cystagon, Procysbi) (PDF) CP.PHAR.155    June 1, 2022 - NEW
Cytomegalovirus Immune Globulin (Cytogam) (PDF) CP.PHAR.277 July 1, 2021
Dabrafenib (Tafinlar) (PDF) CP.PHAR.239 Retire by August 1, 2022 
Dabrafenib (Tafinlar) (PDF) CP.PHAR.239 August 1, 2022 
Dacomitinib (Vizimpro) (PDF) CP.PHAR.399 December 1, 2021
Dalfampridine (Ampyra) (PDF) CP.PHAR.248 June 1, 2022 - NEW
Deflazacort (Emflaza) (PDF) CP.PHAR.331 March 1, 2022
Dalteparin (Fragmin) (PDF) CP.PHAR.225 March 1, 2022
Daptomycin (Cubicin, Cubicin RF) (PDF) CP.PHAR.351 July 1, 2021
Dapsone (Aczone Gel) (PDF) CP.PCH.32 December 1, 2021
Daratumumab (Darzalex) (PDF) CP.PHAR.310 July 1, 2021
Darbepoetin alfa (Aranesp) (PDF) CP.PHAR.236 June 1, 2022 - NEW 
Darolutamide (Nubeqa) (PDF) CP.PHAR.435 December 1, 2021
Dasabuvir-Ombitasvir-Paritaprevir-Ritonavir (Viekira Pak) (PDF) HIM.PA.sp61 July 1, 2021
Dasatinib (Sprycel) (PDF) CP.PHAR.72 Retire by August 1, 2022
Dasatinib (Sprycel) (PDF) CP.PHAR.72 August 1, 2022  - NEW
Daunorubicin/cytarabine (Vyxeos®) (PDF) CP.PHAR.352 Deceber 1, 2021
Decitabine-Cedazuridine (Inqovi) (PDF) CP.PHAR.479 June 1, 2022 - NEW
Deferasirox (Exjade Jadenu) (PDF) CP.PHAR.145 July 1, 2021
Deferoxamine (Desferal) (PDF) CP.PHAR.146 July 1, 2021
Degarelix acetate (Firmagon®) (PDF) CP.PHAR.170 December 1, 2021
Delafloxacin (Baxdela) (PDF) CP.PMN.115 March 1, 2021
Denosumab (Prolia, Xgeva) (PDF) CP.PHAR.58 June 1, 2022 - NEW
Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF) CP.PHAR.214 March 1, 2022
Deutetrabenazine (Austedo) (PDF) CP.PCH.42 June 1, 2022 - NEW
Dexlansoprazole (Dexilant) (PDF) HIM.PA.05 February 2, 2022
Dexrazoxane (Zinecard, Totect) (PDF) CP.PHAR.418 June 1, 2022 - NEW
Dextromethorphan-Quinidine (Nuedexta) (PDF) CP.PMN.93 March 1, 2022
Diazepam Nasal Spray (Valtoco)(PDF) CP.PMN.216 December 1, 2021
Dichlorphenamide (Keveyis) (PDF) CP.PMN.261 March 1, 2022
diclofenac sodium topical gel (Solaraze, Voltaren®) (PDF) CP.PCH.28 December 1, 2021
Dimethyl fumarate (Tecfidera), diroximel fumarate (Vumerity), monomethyl fumarate (Bafiertam) (PDF) CP.PCH.41 June 1, 2022 - NEW
Dimethyl fumarate (Tecfidera), diroximel fumarate (Vumerity), monomethyl fumarate (Bafiertam) (PDF) CP.PHAR.41 June 1, 2021
Dipeptidyl Peptidase-4 Inhibitors (PDF) HIM.PA.58 March 1, 2022
Dolasetron (Anzemet) (PDF) CP.PMN.141 March 1, 2022
Donislecel (Lantidra)  CP.PHAR.569 Pending FDA Approval
Dornase alfa (Pulmozyme) (PDF) CP.PHAR.212 March 1, 2022
Dostarlimab-gxly (Jemperli) (PDF) CP.PHAR.540 November 1, 2021
Doxepin Hydrochloride Cream (Prudoxin, Zonalon) (PDF) HIM.PA.147 December 1, 2021
Doxycycline (Doryx, Oracea, Acticlate) (PDF) CP.PMN.79 June 1, 2022 - NEW
Dupilumab (Dupixent) (PDF) CP.PHAR.336 April 1, 2022
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 Retire by August 1, 2022
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 August 1, 2022 - NEW
Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn) (PDF) CP.PMN.128 June 1, 2022 - NEW
Duvelisib (Copiktra) (PDF) CP.PHAR.400 March 1, 2022
Ecallantide (Kalbitor) (PDF) CP.PHAR.177 April 1, 2022
Eculizumab (Soliris) (PDF) CP.PHAR.97 Retire by August 1, 2022
Eculizumab (Soliris) (PDF) CP.PHAR.97 August 1, 2022 - NEW
Edaravone (Radicava) (PDF) CP.PHAR.343 June 1, 2022 - NEW
Efgartigimod (ARGX-113) (PDF) CP.PHAR.555 December 1, 2021
Efinaconazole (Jublia) (PDF) CP.PMN.25 April 1, 2022
Elagolix (Orilissa), elagolix-estradiol-norethindrone (Oriahnn) (PDF) CP.PHAR.136 December 1, 2021
Elapegademase-lvlr (Revcovi) (PDF) CP.PHAR.419 June 1, 2022 - NEW
Elbasvir/Grazoprevir (Zepatier) (PDF) HIM.PA.SP62 March 1, 2022
Eliglustat (Cerdelga) (PDF) CP.PHAR.153 June 1, 2022 - NEW
Elexacaftor-ivacaftor-tezacaftor (Trikafta) (PDF) CP.PHAR.440 March 1, 2022
Elosulfase Alfa (Vimizim) (PDF) CP.PHAR.162  June 1, 2022 - NEW
Elotuzumab (Empliciti) (PDF) CP.PHAR.308 December 1, 2021
Eltrombopag (Promacta®) (PDF) CP.PHAR.180 March 1, 2022
Eluxadoline (Viberzi) (PDF) CP.PMN.170 December 1, 2021
Elivaldogene Autotemcel (PDF) CP.PHAR.556 Pending FDA Approval
Emapalumab-lzsg (Gamifant)(PDF) CP.PHAR.402 March 1, 2022
Emicizumab-kxwh (Hemlibra) (PDF) CP.PHAR.370 June 1, 2022 - NEW
Emtricitabine-tenofovir alafenamide (Descovy) (PDF) CP.PMN.235 June 1, 2022 - NEW
Enasidenib (Idhifa) (PDF) CP.PHAR.363 December 1, 2021
Encorafenib (Braftovi) (PDF) CP.PHAR.127 June 1, 2022 - NEW
Enfuvirtide (Fuzeon) (PDF) CP.PHAR.41    July 1, 2021
Enfortumab Vedotin-ejfv (Padcev) (PDF) CP.PHAR.455 March 1, 2022
Enoxaparin (Lovenox) (PDF) CP.PHAR.224 March 1, 2022
Entecavir (Baraclude) (PDF) HIM.PA.08 Retire by August 1, 2022
Entecavir (Baraclude) (PDF) HIM.PA.08 August 1, 2022 - NEW
Entrectinib (Rozlytrek) (PDF) CP.PHAR.441 December 1, 2021
Enzalutamide (Xtandi) (PDF) HIM.PA.164 March 1, 2022
Epoetin Alfa (Epogen® and Procrit) (PDF) CP.PHAR.237 June 1, 2022 - NEW
Epoprostenol (PDF) CP.PHAR.192 March 1, 2022
Eptinezumab-jjmr (Vyepti) (PDF) HIM.PA.SP64 March 1, 2022
Erdafitinib (Balversa) (PDF) CP.PHAR.423 July 1, 2021
Erenumab-aaoe (Aimovig) (PDF) HIM.PA.SP65 March 1, 2022
Eribulin Mesylate (Halaven®) (PDF) CP.PHAR.318 February 1, 2022
Erlotinib (Tarceva) (PDF) CP.PHAR.74 Retire by August 1, 2022
Erlotinib (Tarceva) (PDF) CP.PHAR.74 August 1, 2022 - NEW
Erwinia Asparaginase (Erwinaze) (PDF) CP.PHAR.301 April 1, 2022
Esketamine (Spravato) (PDF) CP.PMN.199 June 1, 2022 - NEW
Esomeprazole-Naproxen (Vimovo) (PDF) CP.PMN.117 Retire by August 1, 2022
Esomeprazole-Naproxen (Vimovo) (PDF) CP.PMN.117 August 1, 2022 - NEW
Etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 July 1, 2021
Eteplirsen  (Exondys 51) (PDF) CP.PHAR.288 March 1, 2022
Everolimus (Afinitor, Afinitor Disperz, Zortress)(PDF) CP.PHAR.63 March 1, 2022
Evinacumab-dgnb (Evkeeza) (PDF) CP.PHAR.511 March 1, 2022
Evolocumab (Repatha) (PDF) HIM.PA.156 March 1, 2022
Factor IX (Human, Recombinant) (PDF) CP.PHAR.218 June 1, 2022 - NEW
Factor IX Complex Human (Bebulin®, Profilnine®) (PDF) CP.PHAR.219 March 1, 2022
Factor VIIa, Recombinant (NovoSeven® RT) (PDF) CP.PHAR.220 March 1, 2022
Factor VIII (Human Recombinant) (PDF) CP.PHAR.215 June 1, 2022 - NEW
Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF) CP.PHAR.216 June 1, 2022 - NEW 
Factor XIII A-Subunit, Recombinant (Tretten®) CP.PHAR.222 June 1, 2022 - NEW
Factor XIII, Human (Corifact®) (PDF) CP.PHAR.221 June 1, 2022 - NEW
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) CP.PHAR.456 March 1, 2022
Famotidine-Ibuprofen (Duexis) (PDF) CP.PMN.120 June 1, 2022 - NEW
Febuxostat (Uloric) (PDF) CP.PMN.57 May 1, 2022
Fedratinib (Inrebic) (PDF) CP.PHAR.442 December 1, 2021
Fenfluramine (Fintepla) (PDF) CP.PMN.246 July 1, 2021
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF) CP.PMN.127 June 1, 2022 - NEW
Ferric Carboxymaltose (Injectafer) (PDF) CP.PHAR.234 March 1, 2022
Ferric Derisomaltose (Monoferric) (PDF) CP.PHAR.480 June 1, 2022 - NEW
Ferric gluconate (Ferrlecit®) (PDF) CP.PHAR.166 March 1, 2022
Ferric Maltol (Accrufer) (PDF) CP.PMN.213 December 1, 2021
Ferumoxytol (Feraheme®) (PDF) CP.PHAR.165 March 1, 2022
Flibanserin (Addyi) (PDF) CP.PHAR.446 February 1, 2022
Fibrinogen concentrate (human) (Fibryga, RiaSTAP) (PDF) CP.PHAR.526 June 1, 2022 - NEW
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) (PDF)  - NEW CP.PHAR.297 April 1, 2022
Finerenone (Kerendia) (PDF) CP.PMN.266 November 1, 2021
Fingolimod (Gilenya) (PDF) CP.PCH.38 June 1, 2022 - NEW
Fluorouracil Cream (Tolak) (PDF) CP.PMN.165 December 1, 2021
Fluticasone Propionate (Xhance) (PDF) CP.PMN.95 March 1, 2022
Fondaparinux (Arixtra) (PDF) CP.PHAR.226 March 1, 2022
Formulary Medications Without Specific Guidelines (PDF) HIM.PA.33 March 1, 2022
Fosdenopterin (Nulibry) (PDF) CP.PHAR.471 June 1, 2022 - NEW
Fostamatinib (Tavalisse) (PDF) CP.PHAR.24 March 1, 2022
Fostemsavir (Rukobia) (PDF) CP.PHAR.516 April 1, 2022
Fremanezumb-vfrm (PDF) HIM.PA.SP66 March 1, 2022
Fulvestrant (Faslodex Injection) (PDF) CP.PHAR.424 July 1, 2021
Galcanezumab-gnlm (Emgality) (PDF) HIM.PA.SP67 March 1, 2022
Galsulfase (Naglazyme) (PDF) CP.PHAR.161 June 1, 2022 - NEW
Gefitinib (Iressa) (PDF) CP.PHAR.68 Retire by August 1, 2022
Gefitinib (Iressa) (PDF) CP.PHAR.68 August 1, 2022 - NEW
gemtuzumab ozogamicin (Mylotarg®) (PDF) CP.PHAR.358 February 1, 2022
Gilteritinib (Xospata)(PDF) CP.PHAR.412 March 1, 2022
Givosiran (Givlaari) (PDF) CP.PHAR.457 April 1, 2022
Glasdegib (Daurismo)(PDF) CP.PHAR.413 March 1, 2022
Glatiramer (Copaxone, Glatopa) (PDF) HIM.PA.SP68 June 1, 2022 - NEW
Glecaprevir-Pibrentasvir (PDF) HIM.PA.SP36 July 1, 2021
Glucagon-Like Peptide-1 Receptor Agonists (PDF) HIM.PA.53 May 1, 2022
Glycerol phenylbutyrate (Ravicti®) (PDF) CP.PHAR.207 March 1, 2022
Golodirsen (Vyondys 53) (PDF) CP.PHAR.453 March 1, 2022
goserelin acetate (Zoladex®) (PDF) CP.PHAR.171 February 1, 2022
Granisetron (Kytril, Sancuso, Sustol) (PDF) CP.PMN.74 March 1, 2022
Halcinonide (Halog) (PDF) HIM.PA.20 December1, 2021
Halobetasol Propionate Lotion (Bryhali, Lexette, Ultravate) (PDF) CP.PMN.180 February 1, 2022
Halobetasol Propionate/Tazarotene (Duobrii) (PDF) CP.PMN.208 July 1, 2021
Hemin (Panhematin®) (PDF) CP.PHAR.181 March 1, 2022
histrelin acetate (Vantas®, Supprelin LA®) (PDF) CP.PHAR.172 December 1, 2020
House dust mite allergen extract (Odactra®) (PDF) CP.PMN.111  July 1, 2021
Human Growth Hormone (Somapacitan, Somatropin) (PDF) HIM.PA.161 April 1, 2022
Hyaluronate Derivatives (PDF) CP.PHAR.05 December 1, 2021
Hydroxyprogesterone Caproate (Makena) (PDF) CP.PHAR.14 March 1, 2022
Hydroxyurea (Siklos) (PDF) CP.PMN.193 June 1, 2022 - NEW
ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 June 1, 2022 - NEW
Ibandronate sodium (PDF) CP.PHAR.189 March 1, 2022
Ibrutinib (Imbruvica) (PDF) CP.PHAR.126 April 1, 2022
Icatibant (Firazyr®) (PDF) CP.PHAR.178  
Icosapent ethyl (Vascepa) (PDF) CP.PMN.187 March 1, 2022
Idecabtagene vicleucel (Abecma) (PDF) CP.PHAR.481 June 1, 2022 - NEW
Idelalisib (Zydelig) (PDF) CP.PHAR.133 February 1, 2022
Idursulfase (Elaprase) (PDF) CP.PHAR.156  June 1, 2022 - NEW
Iloperidone (Fanapt) (PDF) CP.PMN.32 March 1, 2022
Iloprost (Ventavis®) (PDF) CP.PHAR.193 March 1, 2023
Imatinib (Gleevec) (PDF) CP.PHAR.65 Retire by August 1, 2022
Imatinib (Gleevec) (PDF) CP.PHAR.65 August 1, 2022 - NEW
Imiglucerase (Cerezyme) (PDF) CP.PHAR.154  Retire by August 1, 2022
Imiglucerase (Cerezyme) (PDF) CP.PHAR.154  August 1, 2022 - NEW
Immune Globulins (PDF) CP.PHAR.103 March 1, 2022
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 June 1, 2022 - NEW
Inhaled Agents for Asthma and COPD (PDF) HIM.PA.153 March 1, 2022
Infertility and Fertility Preservation (PDF) CP.PHAR.131 December 1, 2021
Inclisiran (Leqvio) (PDF) CP.PHAR.568 March 1, 2022
Inebilizumab (PDF) CP.PHAR.458 Retire by August 1, 2022
Inebilizumab (PDF) CP.PHAR.458 August 1, 2022 - NEW
Infigratinib (Truseltiq) (PDF) CP.PHAR.547  
Inotersen (Tegsedi) (PDF) CP.PHAR.405 March 1, 2022
inotuzumab ozogamicin (Besponsa®) (PDF) CP.PHAR.359 December 1, 2021
Insulin Degludec (Tresiba) (PDF) HIM.PA.09 March 1, 2022
Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF) CP.PHAR.534 June 1, 2022 - NEW
Interferon Beta-1b (Betaseron, Extavia) (PDF) CP.PHAR.255 June 1, 2022 - NEW
Interferon beta-1b (Betaseron, Extavia) (PDF) CP.PCH.46 June 1, 2022 - NEW
Interferon Gamma- 1b (Actimmune) (PDF) CP.PHAR.52 March 1, 2022
Intrathecal Baclofen (Gablofen, Lioresal) (PDF) CP.PHAR.149 March 1, 2022
Iobenguane I-131 (Azedra) (PDF) CP.PHAR.459 March 1, 2022
Ipilimumab (Yervoy) (PDF) CP.PHAR.319 Retire by August 1, 2022
Ipilimumab (Yervoy) (PDF) CP.PHAR.319 August 1, 2022 - NEW
irinotecan Liposome (Onivyde®) (PDF) CP.PHAR.304 December 1, 2021
Iron sucrose (Venofer®) (PDF) CP.PHAR.167 March 1, 2022
Isatuximab-irfc (Sarclisa) (PDF) CP.PHAR.482 June 1, 2022 - NEW
isavuconazonium (Cresemba®) (PDF) CP.PMN.154 Retire by August 1, 2022
isavuconazonium (Cresemba®) (PDF) CP.PMN.154 August 1, 2022 - NEW
Isotretinoin (PDF) CP.PMN.143 December 1, 2021
Istradefylline (Nourianz) (PDF) CP.PMN.217 March 1, 2022
Itraconazole (Sporanox, Onmel) (PDF) CP.PMN.124 Retire by August 1, 2022
Itraconazole (Sporanox, Onmel) (PDF) CP.PMN.124 August 1, 2022 - NEW
Ivabradine (Corlanor) (PDF) CP.PMN.70 March 1, 2022
Ivacaftor (Kalydeco) (PDF) CP.PHAR.210 March 1, 2022
Ivermectin (Stromectol, Sklice) CP.PMN.269  February 1, 2022
Ivosidenib (Tibsovo) (PDF) CP.PHAR.137 December 1, 2021
Ixazomib (Ninlaro) (PDF) CP.PHAR.302 July 1, 2021
Lacosamide (Vimpat) (PDF) CP.PMN.155 July 1, 2021
Lactic acid-citric acid-potassium bitartrate (Phexxi) (PDF) CP.PMN.251 December 1, 2020
Lanadelumab-fylo (Takhzyro)(PDF) - NEW CP.PHAR.396 April 1, 2022
Lanreotide (Somatuline Depot) (PDF) CP.PHAR.391 December 1, 2021
lapatinib (Tykerb®) (PDF) CP.PHAR.79 February 1, 2022
Laronidase (Aldurazyme) (PDF) CP.PHAR.152 June 1, 2022 - NEW
Larotrectinib (Vitrakvi)(PDF) CP.PHAR.414 March 1, 2022
Lasmiditan (Reyvow) (PDF) CP.PMN.218 March 1, 2022
Latanoprostene Bunod (Vyzulta) (PDF) CP.PMN.108 March 1, 2022
Lefamulin (Xenleta) (PDF) CP.PMN.219 March 1, 2022
lenalidomide (Revlimid) (PDF) CP.PHAR.71 Retire by August 1, 2022 
lenalidomide (Revlimid) (PDF) CP.PHAR.71 August 1, 2022 - NEW
Lenvatinib (Lenvima) (PDF) CP.PHAR.138 December 1, 2021
Letermovir (Prevymis) (PDF) CP.PHAR.367 March 1, 2021
Levodopa Inhalation Powder (Inbrija) (PDF) CP.PMN.267 December 1, 2021
Levoleucovorin (Fusilev, Khapzory) (PDF) CP.PHAR.151 December 1, 2021
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) CP.PHAR.173 March 1, 2022
Levoketoconazole (Recorlev) (PDF) CP.PMN.275 June 1, 2022 - NEW
Levomilnacipran (Fetzima) (PDF) HIM.PA.125 July 1, 2021
lidocaine transdermal (Lidoderm®) (PDF) CP.PMN.08  September 1, 2020
Lifitegrast (Xiidra®) (PDF) CP.PMN.73 April 1, 2022
Linaclotide (Linzess) (PDF) CP.PMN.71 October 1, 2021
Lnezolid (Zyvox) (PDF) CP.PMN.27 March 1, 2022
Lisocabtagene maraleucel (Breyanzi) (PDF) CP.PHAR.483 June 1, 2022 - NEW
Lofexidine (Lucemyra) (PDF) CP.PMN.152 July 1, 2021
Lomustine (Gleostine) (PDF) CP.PHAR.507 February 1, 2022
Lonafarnib (Zokinvy) (PDF) CP.PHAR.499 March 1, 2022
Lorlatinib (Lorbrena)(PDF) CP.PHAR.406 Retire by August 1, 2022
Lorlatinib (Lorbrena)(PDF) CP.PHAR.406 August 1, 2022 - NEW
Loteprednol etabonate (Eysuvis) (PDF) CP.PMN.260 March 1, 2022
Lubiprostone (Amitiza) (PDF) CP.PMN.142 December 1, 2021
Luliconazole Cream (Luzu) (PDF) CP.PMN.166 March 1, 2022
Lumacaftor-Ivacaftor (Orkambi) (PDF) CP.PHAR.213 March 1, 2022
Lumasiran (Oxlumo) (PDF) CP.PHAR.473 March 1, 2022
Lumateperone (Caplyta) (PDF) CP.PMN.232 June 1, 2022 - NEW
Lurbinectedin (Zepzelca) (PDF) CP.PHAR.500 July 1, 2021
Lurasidone (Latuda) (PDF) CP.PMN.50 March 1, 2022
Luspatercept-aamt (Reblozyl) (PDF) CP.PHAR.450 March 1, 2022
Lusutrombopag (Mulpleta)(PDF) CP.PHAR.407 March 1, 2022
Lutetium Lu 177 Dotatate (Lutathera) (PDF) CP.PHAR.384 July 1, 2021
Macitentan (Opsumit®) (PDF) CP.PCH.31 March 1, 2022
Mannitol (Bronchitol) (PDF) CP.PHAR.518 March 1, 2021
Margetuximab-cmkb (Margenza) (PDF) CP.PHAR.522 March 1, 2022
Maribavir (Livtencity) (PDF) CP.PMN.271 March 1, 2022
Mavacamten (MYK-461)  CP.PMN.272 Pending FDA Approval
Mecamylamine (Vecamyl) (PDF) CP.PMN.136 June 1, 2022 - NEW
Mecasermin (Increlex) (PDF) CP.PHAR.150 July 1, 2021
Mechlorethamine Gel (Valchlor) (PDF) CP.PHAR.381 July 1, 2021
Megestrol Acetate 125 mg/mL Oral Suspension (Megace ES) (PDF) CP.PMN.179 December 1, 2021
Melphalan flufenamide (Pepaxto) (PDF) CP.PHAR.535 Retire by August 1, 2022
Melphalan flufenamide (Pepaxto) (PDF) CP.PHAR.535 August 1, 2022 - NEW
Mepolizumab (Nucala) (PDF) CP.PHAR.200 April 1, 2022
Mercaptopurine (Purixan) (PDF) CP.PHAR.447 June 1, 2022 - NEW
Metformin ER (Glumetza, Fortamet) (PDF) CP.PMN.72 March 1, 2022
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF) CP.PHAR.134 December 1, 2021
Methoxsalen (Uvadex) (PDF) HIM.PA.17 December 1, 2021
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) CP.PHAR.238 June 1, 2022 - NEW
Methylnaltrexone Bromide (Relistor) (PDF) CP.PMN.169 December 1, 2021
Metoclopramide (Gimoti) (PDF) CP.PMN.252 December 1, 2021
Metreleptin (Myalept) (PDF) CP.PHAR.425 July 1, 2021
Midazolam (Nayzilam) (PDF) CP.PMN.211 July 1, 2021
Midostaurin (Rydapt) (PDF) CP.PHAR.344 June 1, 2022 NEW
Mifepristone (Korlym) (PDF) CP.PHAR.101 March 1, 2022
Migalastat (Galafold) (PDF) CP.PHAR.394 December 1, 2021
Miglustat (Zavesca) (PDF) CP.PHAR.164  June 1, 2022 - NEW
Milnacipran (Savella) (PDF) CP.PMN.125 June 1, 2022 - NEW
Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) (PDF) CP.PMN.80 June 1, 2022 - NEW
Mitapivat (Pyrukynd) (PDF) CP.PHAR.558 June 1, 2022 - NEW
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 Retire by August 1, 2022
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 August 1, 2022 - NEW
modafinil (Provigil) (PDF) CP.PMN.39 June 1, 2022 - NEW
Mogamulizumab-kpkc (Poteligeo) (PDF) CP.PHAR.139 December 1, 2021
Mometasone (Nasonex) (PDF) HIM.PA.93 July 1, 2021
Mometasone Furoate (Sinuva) (PDF) CP.PHAR.448 April 1, 2022
Montelukast oral granules (Singulair) (PDF) HIM.PA.129 December  1, 2021
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) CP.PHAR.398 December 1, 2021
Nadofaragene Firadenovec (Instiladrin) CP.PHAR.461 Pending FDA Approval
nafarelin acetate (Synarel®) (PDF) CP.PHAR.174 December 1, 2021
Naltrexone (Vivitrol) (PDF) CP.PHAR.96 March 1, 2022
Naproxen oral suspension (Naprosyn) (PDF) HIM.PA.130 December 1, 2021
Narsoplimab (OMS721) (PDF) CP.PHAR.527 June 1, 2022 - NEW
Natalizumab (Tysabri) (PDF) CP.PHAR.259 June 1, 2022 - NEW
Naxitamab-gqgk (Danyelza)  CP.PHAR.523 March 1, 2022
necitumumab (Portrazza®) (PDF) CP.PHAR.320 December 1, 2021
Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF) CP.PMN.167 December 1, 2021
Neratinib (Nerlynx) (PDF) CP.PHAR.365 December 1, 2021
Netarsudil (Rhopressa), Netarsudil-Latanoprost (Rocklatan) (PDF) CP.PMN.118 June 1, 2022 - NEW
Netupitant and Palonosetron (Akynzeo) (PDF) CP.PMN.158 March 1, 2022
Nifurtimox (Lampit) ^ (PDF) CP.PMN.256 December 1, 2021
nilotinib (Tasigna) (PDF) CP.PHAR.76 Retire by August 1, 2022
nilotinib (Tasigna) (PDF) CP.PHAR.76 August 1, 2022 - NEW
Nintedanib (Ofev) (PDF) CP.PHAR.285 October 1, 2021
Nitisinone (Nityr, Orfadin) (PDF) CP.PHAR.132 February 1, 2022
Niraparib (Zejula) (PDF) CP.PHAR.408 March 1, 2022
Nitazoxanide (Alinia) (PDF) HIM.PA.152 March 1, 2022
Nivolumab (Opdivo) (PDF) CP.PHAR.121   April 1, 2022
Non-Calcium Phosphate Binders (PDF) CP.PMN.04 March 1, 2022
Non-Formulary and Formulary Contraceptives (PDF) HIM.PA.100 June 1, 2022 - NEW
Non-Formulary Test Strips (PDF) HIM.PA.34 March 1, 2022
Nusinersen (Spinraza®) (PDF) CP.PHAR.327 March 1, 2022
Obeticholic acid (Ocaliva) (PDF) CP.PHAR.287 March 1, 2022
obinutuzumab (Gazyva®) (PDF) CP.PHAR.305 February 1, 2022
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 Retire by August 1, 2022
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 August 1, 2022 - NEW
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF) CP.PHAR.40 March 1, 2022
Odevixibat (PDF) CP.PHAR.528 June 1, 2022 - NEW 
ofatumumab (Arzerra®) (PDF) CP.PHAR.306 June 1, 2022 - NEW
Off-label Policy (PDF) HIM.PA.154 June 1, 2022 - NEW
Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) CP.PHAR.292 July 1, 2021
olaparib (Lynparza) (PDF) CP.PHAR.360 June 1, 2022 - NEW
olaratumab (Lartruvo®) (PDF) CP.PHAR.326 December 1, 2021
Omacetaxine (Synribo) (PDF) CP.PHAR.108 June 1, 2022 - NEW 
Omadacycline (Nuzyra)(PDF) CP.PMN.188 March 1, 2022
Omalizumab (Xolair®) (PDF) CP.PHAR.01 March 1, 2022
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 June 1, 2022 - NEW
Onasemnogene abeparvovec (Zolgensma) (PDF) CP.PHAR.421 June 1, 2022 - NEW
Ophthalmic Corticosteroids (PDF) HIM.PA.03 December 1, 2021
Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF) CP.PHAR.536 June 1, 2022 - NEW
Opioid Analgesics (PDF) HIM.PA.139 March 1, 2022
Osimertinib (Tagrisso) (PDF) CP.PHAR.294 June 1, 2022 - NEW
Ospemifene (Osphena) (PDF) CP.PMN.168 December 1, 2021
Overactive Bladder Agents (PDF) CP.PMN.198 June 1, 2022 - NEW
Oxymetazoline (Rhofade) (PDF) CP.PMN.86 June 1, 2022 - NEW
Ozanimod (Zeposia) (PDF) CP.PHAR.462 June 1, 2022 - NEW
Ozenoxacin (Xepi) (PDF) CP.PMN.119 June 1, 2022 - NEW
Paclitaxel, protein-bound (Abraxane) (PDF) CP.PHAR.176  Retire by August 1, 2022
Paclitaxel, protein-bound (Abraxane) (PDF) CP.PHAR.176  August 1, 2022 - NEW
Palbociclib (Ibrance) (PDF) CP.PHAR.125 December 1, 2021
Paliperidone inj (Invega Sustenna, Invega Trinza, Invega Hafyera) (PDF) CP.PHAR.291 November 1, 2021
Palivizumab (Synagis) (PDF) CP.PHAR.16 June 1, 2022 - NEW
Palovarotene (PDF) CP.PHAR.548 Pending FDA Approval
Pancrelipase (Creon, Pancreaze, Pertyze, Viokace, Zenpep) (PDF) CP.PCH.44 March 1, 2022
panitumumab (Vectibix®) (PDF) CP.PHAR.321 December 1, 2021
Parathyroid Hormone (Natpara) (PDF) CP.PHAR.282 March 1, 2022
Paricalcitol Injection (Zemplar) (PDF) CP.PHAR.270 October 1, 2021
pasireotide (Signifor LAR®) (PDF) CP.PHAR.332 December 1, 2021
Patisiran (Onpattro) (PDF) CP.PHAR.395 February 1, 2022
Pazopanib (Votrient) (PDF) CP.PHAR.81 July 1, 2021
Peanut allergen powder (Palforzia) (PDF) CP.PMN.220 March 1, 2022
Pegaptanib (Macugen) (PDF) CP.PHAR.185 March 1, 2022
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF) CP.PHAR.353 February 1, 2022
Pegcetacoplan (Empaveli0 (PDF) CP.PHAR.524 March 1, 2022
Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) (PDF) CP.PHAR.296 March 1, 2022
Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) (PDF) CP.PHAR.89 July 1, 2021
Peginterferon beta-1a (Plegridy) (PDF) CP.PHAR.271 June 1, 2022 - NEW
Pegloticase (Krystexxa) (PDF) CP.PHAR.115 March 1, 2022
Pegvaliase-pqpz (Palynziq) (PDF) CP.PHAR.140 December 1, 2021
Pegvisomant (Somavert) (PDF) CP.PHAR.389 December 1, 2021
Pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 April 1, 2022
Pemetrexed (Alimta, Pemfexy) (PDF) CP.PHAR.368 April 1, 2022
Pemigatinib (Pemazyre) (PDF) CP.PHAR.496 November 1, 2021
Penicillamine (Cuprimine) (PDF) CP.PCH.09 December 1, 2021
Perampanel (Fycompa) (PDF) CP.PMN.156 July 1, 2021
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 June 1, 2022 - NEW
Pertuzumab-trastuzumab-hyaluronidase-zzxf (Phesgo) (PDF) CP.PHAR.501 July 1, 2021
Pexidartinib (Turalio)(PDF) CP.PHAR.436 December 1, 2021
Phendimetrazine (PDF) CP.PCH.47 June 1, 2022 - NEW
Phentermine (Adipex-P, Lomaira) (PDF) CP.PCH.13 June 1, 2022 - NEW
Pirfenidone (Esbriet) (PDF) CP.PHAR.286 July 1, 2021
Pitolisant (Wakix) (PDF) CP.PMN.221 June 1, 2022 - NEW
Plasminogen (Ryplazim) (PDF) CP.PHAR.513 Deceber 1, 2021
Plerixafor (Mozobil) (PDF) CP.PHAR.323 July 1, 2021
Polatuzumab Vedotin-piiq (Polivy) (PDF) CP.PHAR.433 July 1, 2021
Pomalidomide (Pomalyst) (PDF) CP.PHAR.116 Retire by August 1, 2022
Pomalidomide (Pomalyst) (PDF) CP.PHAR.116 August 1, 2022 - NEW
Ponatinib (Iclusig) (PDF) CP.PHAR.112 June 1, 2022 - NEW  
Ponesimod (Ponvory) (PDF) CP.PHAR.537 June 1, 2022 - NEW
Potassium (Klor-Con) (PDF) HIM.PA.143 March 1, 2022
pralatrexate (Folotyn®) (PDF) CP.PHAR.313 December 1, 2021
Pramlintide (Symlin) (PDF) CP.PMN.129 March 1, 2022
Prasterone (Intrarosa) (PDF) CP.PMN.99 March 1, 2022
pregabalin (Lyrica) (PDF) CP.PMN.33 June 1, 2022 - NEW
Pretomanid (PDF) CP.PMN.222 March 1, 2022
protein c concentrate, human (Ceprotin®) (PDF) CP.PHAR.330 March 1, 2022
propranolol HCL solution (Hemangeol) (PDF) CP.PMN.58 June 1, 2022 - NEW
Prucalopride (Motegrity) (PDF) HIM.PA.159 June 1, 2022 - NEW
Pyrimethamine (Daraprim®) (PDF) CP.PMN.44  April 1, 2022
Quetiapine ER (Seroquel XR) (PDF) CP.PMN.64 March 1, 2022
Quinine Sulfate (Qualaquin) (PDF) CP.PMN.262 Retire by August 1, 2022
Quinine Sulfate (Qualaquin) (PDF) CP.PMN.262 August 1, 2022 - NEW
Ondansetron (Zuplenz) (PDF) CP.PMN.45 April 1, 2022
Ramucirumab (Cyramza) (PDF) CP.PHAR.119 April 1, 2022
Ranibizumab (Lucentis) (PDF) CP.PHAR.186 June 1, 2022 - NEW
rasagiline (Azilect®) (PDF) HIM.PA.89 July 1, 2021
Ravulizumab-cwvz (Ultomiris) (PDF) CP.PHAR.415 April 1, 2022
Regorafenib (Stivarga) (PDF) CP.PHAR.107 June 1, 2022 - NEW
Relugolix (Orgovyx) (PDF) CP.PHAR.529 June 1, 2022 - NEW
Remestemcel-L (Ryoncil) (PDF) CP.PHAR.474 June 1, 2022 - NEW
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) CP.PHAR.168 December 1, 2021
Reslizumab (Cinqair) (PDF) CP.PHAR.223 March 1, 2022
Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF) CP.PHAR.141 December 1, 2021
Ribociclib (Kisqali, Kisqali Femara) (PDF) CP.PHAR.334 December 1, 2021
Rifabutin (Mycobutin) (PDF) - NEW CP.PMN.223 June 1, 2022 - NEW
Rifamycin (Aemcolo) (PDF) CP.PMN.196 June 1, 2022 - NEW
rifaximin (Xifaxan®) (PDF) CP.PMN.47 December 1, 2021
Rilonacept (Arcalyst) (PDF) CP.PHAR.266 June 1, 2022 - NEW 
Ripretinib (Qinlock) (PDF) CP.PHAR.502 July 1, 2021
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 June 1, 2022 - NEW
Rimegepant (Nurtec ODT) (PDF) CP.PHAR.490 April 1, 2022
Riociguat (Adempas®) (PDF) CP.PHAR.195 March 1, 2022
Risdiplam (Evrysdi) (PDF) CP.PHAR.477 March 1, 2022
Risedronate (Actonel, Atelvia) (PDF) CP.PMN.100 March 1, 2022
Risperidone Long-Acting Injection (Risperdal Consta) (PDF) CP.PHAR.293 July 1, 2021
Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) (PDF) CP.Phar.260 Retire by August 1, 2022
Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) (PDF) CP.Phar.260 August 1, 2022 - NEW
Rolapitant (Varubi) (PDF) CP.PMN.102 March 1, 2022
romidepsin (Istodax®) (PDF) CP.PHAR.314 February 1, 2022
Romiplostim (Nplate®) (PDF) CP.PHAR.179  March 1, 2021
Romosozumab-aqqg (Evenity) (PDF) CP.PHAR.428 June 1, 2022 - NEW
Ropeginterferon alfa-2b-njft (Besremi) (PDF) CP.PHAR.570 March 1, 2022
Rucaparib (Rubraca®) (PDF) CP.PHAR.350 March 1, 2022
Rufinamide (Banzel) (PDF) CP.PMN.157 March 1, 2022
Ruxolitinib (Jakafi) (PDF) CP.PHAR.98 May 1, 2022
Sacituzumab Govitecan-hziy (Trodelvy) (PDF) CP.PHAR.475 Retire by August 1, 2022
Sacituzumab Govitecan-hziy (Trodelvy) (PDF) CP.PHAR.475 August 1, 2022 - NEW
Sacubitril/Valsartan (Entresto) (PDF) CP.PMN.67 March 1, 2022
Safinamide (Xadago) (PDF) CP.PMN.113 March 1, 2022
Sapropterin (Kuvan) (PDF) CP.PHAR.43 June 1, 2022 - NEW
Sarecycline (Seysara) (PDF) CP.PMN.189 March 1, 2022
Sargramostim (Leukine) (PDF) CP.PHAR.295 December 1, 2021
Satralizumab-mwge (Enspryng) (PDF) CP.PHAR.463 March 1, 2022
Sebelipase Alfa (Kanuma) (PDF) CP.PHAR.159 June 1, 2022 - NEW
Secnidazole (Solosec) (PDF) CP.PMN.103 April 1, 2022
Selexipag (Uptravi®) (PDF) CP.PHAR.196 March 1, 2022
Selinexor (Xpovio) (PDF) CP.PHAR.431 March 1, 2022
Selpercatinib (Retevmo) (PDF) CP.PHAR.478 Retire August 1, 2022
Selpercatinib (Retevmo) (PDF) CP.PHAR.478 August 1, 2022 - NEW
Selumetinib (Koselugo) (PDF) CP.PHAR.464 March 1, 2022
Setmelanotide (Imcivree) (PDF) CP.PHAR.491 CP.PHAR.491
Sildenafil (Revatio®) (PDF) CP.PHAR.197 March 1, 2022
Sildenafil (Viagra) (PDF) CP.PCH.07 June 1, 2022 - NEW
Siponimod (Mayzent) (PDF) CP.PHAR.427 June 1, 2022 - NEW
Siltuximab (Sylvant) (PDF) CP.PHAR.329 March 1, 2022
sodium oxybate (Xyrem) (PDF) CP.PMN.42 June 1, 2022 - NEW
Sodium-Glucose Co-Transporter 2  Inhibitors (PDF) HIM.PA.91 June 1, 2022 - NEW
Sodium Phenylbutyrate (Buphenyl) (PDF) CP.PHAR.208 March 1, 2022
Sodium Zirconium Cyclosilicate (Lokelma) (PDF) CP.PMN.163 July 1, 2021
Sofosbuvir-Velpatasvir (Epclusa)  (PDF) HIM.PA.SP1 July 1, 2021
Sofosbuvir-Vepatasvir-Voxilaprevir (Vosevi) (PDF) Him.PA.SP63 July 1, 2021
Solriamfetol (Sunosi) (PDF) CP.PMN.209 June 1, 2022 - NEW
Sonidegib (Odomzo) (PDF) CP.PHAR.272 June 1, 2022 - NEW 
sorafenib (Nexavar) (PDF) CP.PHAR.69 June 1, 2022 - NEW 
Sotorasib (Lumakras) (PDF) CP.PHAR.549 October 1, 2021
Sotrovimab (VIR-7831)  CP.PHAR.541 Pending FDA Approval
Spinosad (Natroba) (PDF) HIM.PA.134 July 1, 2021
Step Therapy Criteria (PDF) HIM.PA.109 June 1, 2022 - NEW
Stiripentol (Diacomit) (PDF) CP.PMN.184 December 1, 2021
sunitinib (Sutent) (PDF) CP.PHAR.73 Retire by August 1, 2022
sunitinib (Sutent) (PDF) CP.PHAR.73 August 1, 2022 - NEW
Suvorexant (Belsomra®) (PDF) CP.PMN.109 December 1, 2021
Tadalafil (Adcirca®) (PDF) CP.PHAR.198 March 1, 2022
Tadalafil BHP - ED (Cialis) (PDF) CP.PMN.132 July 1, 2021
Tafamidis (Vyndaqel, Vyndamax) (PDF) CP.PHAR.432 July 1, 2021
Tafasitamab-cxix (Monjuvi) (PDF) CP.PHAR.508 December 1, 2021
Talazoparib (Talzenna)(PDF) CP.PHAR.409 March 1, 2022
Taliglucerase Alfa (Elelyso) (PDF) HIM.PA.162 Retire by August 1, 2022
Taliglucerase Alfa (Elelyso) (PDF) HIM.PA.162 August 1, 2022 - NEW
Tasimelteon (Hetlioz) (PDF) CP.PMN.104 March 1, 2022
Tavaborole (Kerydin®) (PDF) CP.PMN.105 April 1, 2022
Tazarotene (Arazlo, Fabior, Tazorac) (PDF) CP.PMN.244 December 1, 2021
Tazemetostat (PDF) CP.PHAR.452 March 1, 2022
Tebentafusp-tebn (Kimmtrak) (PDF) CP.PHAR.575 June 1, 2022 - NEW
Tedizolid (Sivextro) (PDF) CP.PMN.62 March 1, 2022
Teduglutide (Gattex) (PDF) CP.PHAR.114 April 1, 2022
Tegaserod (Zelnorm) (PDF) HIM.PA.160 June 1, 2022 - NEW
Telotristat ethyl (Xermelo) (PDF) CP.PHAR.337 June 1, 2022 NEW
Temozolomide (Temodar) (PDF) CP.PHAR.77 June 1, 2022 - NEW
temsirolimus (Torisel®) (PDF) CP.PHAR.324 December 1, 2021
Tenapanor (Ibsrela) (PDF) CP.PMN.224 April 1, 2022
Tenofovir Alafenamide Fumarate (Vemlidy) (PDF) CP.PMN.268 December 1, 2020
Tepotinib (Tepmetko) (PDF) CP.PHAR.530 June 1, 2022 - NEW
Teprotumumab (Tepezza) (PDF) CP.PHAR.465 March 1, 2022
Teriflunomide (Aubagio) (PDF) CP.PCH.40 June 1, 2022 - NEW
Teriparatide (Forteo®) (PDF) CP.PHAR.188 June 1, 2022 - NEW
Tesamorelin (Egrifta) (PDF) CP.PHAR.109 July 1, 2021
Testosterone (Androderm) (PDF) HIM.PA.87 December 1, 2021
Testosterone (Testopel, Jatenzo) (PDF) CP.PHAR.354 June 1, 2022 - NEW
tetrabenazine (Xenazine) (PDF) CP.PHAR.92 June 1, 2022 - NEW
Tezacaftor-Ivacaftor (Symdeko) (PDF) CP.PHAR.377 March 1, 2022
Tezepelumab (Tezspire) (PDF) CP.PHAR.576 June 1, 2022 - NEW
Thalidomide (Thalomid) (PDF) CP.PHAR.78 June 1, 2022 - NEW
Thioguanine (Tabloid) (PDF) CP.PHAR.437 February 1, 2022
Thyrotropin Alfa (Thyrogen) (PDF) CP.PHAR.95 July 1, 2021
Timothy grass pollen allergen extract (Grastek®) (PDF) CP.PMN.84  July 1, 2021
Tisagenlecleucel (Kymriah) (PDF) CP.PHAR.361 May 1, 2022
Tivozanib (Fotivda) (PDF) CP.PHAR.538 June 1, 2022 - NEW
Tobramycin (PDF) CP.PHAR.211 March 1, 2022
Tolvaptan (Jynarque) (PDF) CP.PHAR.27 July 1, 2021
Topical Acne Treatment (PDF) HIM.PA.71 December 1, 2021
Topotecan (Hycamtin) (PDF) CP.PHAR.64 Retire by August 1, 2022
Topotecan (Hycamtin) (PDF) CP.PHAR.64 August 1, 2022 - NEW
Topical Immunomodulators (PDF) CP.PMN.107 March 1, 2022
Trabectedin (Yondelis) (PDF) CP.PHAR.204 March 1, 2022
Tralokinumab-ldrm (Adbry) (PDF) CP.PHAR.577 June 1, 2022 - NEW
Trametinib (Mekinist) (PDF) CP.PHAR.240 June 1, 2022 - NEW 
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) CP.PHAR.228 June 1, 2022 - NEW
Treprostinil (Orenitram®, Remodulin®, Tyvaso®) (PDF) CP.PHAR.199  March 1, 2022
Triamcinolone ER Injection (Zilretta) (PDF) CP.PHAR.371 April 1, 2022
Triclabendazole (Egaten) (PDF) CP.PMN.207 July 1, 2021
Trientine (Syprine) (PDF) CP.PHAR.438 December 1, 2021
Trifarotene (Aklief) (PDF) CP.PMN.225 March 1, 2022
Trifluridine/Tipiracil (Lonsurf) (PDF) CP.PHAR.383 October 1, 2021
Triheptanoin (Dojolvi) ^ (PDF) CP.PHAR.509 December 1, 2021
triptorelin pamoate (Trelstar®, Triptodur®) (PDF) CP.PHAR.175 December 1, 2021
Ubrogepant (Ubrelvy) (PDF) CP.PHAR.476 March 1, 2022
Udenafil (PDF) CP.PHAR.557 Pending FDA Approval
Ulcer Therapy Combinations (Omeclamox Pak, Pylera, Talicia)(PDF) CP.PMN.277 June 1, 2022 - NEW
Umbralisib (Ukoniq) (PDF) CP.PHAR.531 June 1, 2022 - NEW
Uridine acetate (Vistogard) (PDF) HIM.PA.SP55 December 1, 2021
Valbenazine (Ingrezza) (PDF) CP.PHAR.340 June 1, 2022 - NEW
valganciclovir (Valcyte) (PDF) CP.PCH.06 March 1, 2022
Valoctocogene Roxaparvovec CP.PHAR.466 Pending FDA Approval
Valproate Sodium for Intravenous Injection (Depacon) (PDF) CP.PHAR.429 July 1, 2021
Valrubicin (Valstar) (PDF) CP.PHAR.439 December 1, 2021
Vandetanib (Caprelsa®) (PDF) CP.PHAR.80 April 1, 2022
Varenicline (Tyrvaya) (PDF) CP.PMN.273 March 1, 2022
Velaglucerase Alfa (VPRIV) (PDF) HIM.PA.163 June 1, 2002 - NEW
Vemurafenib (Zelboraf®) (PDF) CP.PHAR.91 March 1, 2022
Venetoclax (Venclexta) (PDF) CP.PHAR.129 February 1, 2022
Vestronidase alfa-vjbk (Mepsevii) (PDF) CP.PHAR.374 June 1, 2022 - NEW
Verteporfin (PDF) CP.PHAR.187 March 1, 2022
Vigabatrin (Sabril) (PDF) CP.PHAR.169  July 1, 2021
Vilazodone (Viibryd) (PDF) CP.PMN.145 July 1, 2021
Viloxazine (Qelbree) (PDF) CP.PMN.264 June 1, 2022 - NEW
Viltolarsen (Viltepso) (PDF) CP.PHAR.484 March 1, 2022
vincristine sulfate liposome injection (Marqibo®) (PDF) CP.PHAR.315 February 1, 2022
Vismodegib (Erivedge) (PDF) CP.PHAR.273 June 1, 2022 - NEW 
Vutrisiran (ALN-TTRsc02) CP.PHAR.550 December 1, 2021
Voclosporin (Lupkynis) (PDF) CP.PHAR.504 June 1, 2022 - NEW
Vorapaxar (Zontivity) (PDF) HIM.PA.146 March 1, 2022
Voretigene neparvovec-rzyl (Luxturna) (PDF) CP.PHAR.372 March 1, 2022
Vorinostat (Zolinza) (PDF) CP.PHAR.83 March 1, 2022
Vortioxetine (Trintellix®) (PDF) CP.PMN.65  July 1, 2021
Vosoritide (Voxzogo) (PDF) CP.PHAR.525 March 1, 2022
Voxelotor (Oxbryta) (PDF) CP.PHAR.451 March 1, 2022
Zanubrutinib (Brukinsa) (PDF) CP.PHAR.467 March 1, 2022
ziv-aflibercept (Zaltrap®) (PDF) CP.PHAR.325 December 1, 2021
Zoledronic acid (PDF) CP.PHAR.59 March 1, 2022
February 1, 2022
March 1, 2022

Wellcare by Allwell Policies

Policy Title Policy Number Effective Date
3-Day Payment Window (PDF) CC.PP.500 July 1, 2014
30 Day Readmission (PDF) CC.PP.501 October 1, 2021
Acupuncture (PDF) CP.MP.92 October 1, 2021
Adopted Clinical Practice and Preventive Health Guidelines (PDF)   June 1, 2020
Add on Code Billed Without Primary Code (PDF) CC.PP.030 October 18, 2016
ADHD Assessment and Treatment (PDF) CP.MP.124 May 1, 2021
Allergy Testing (PDF) CP.MP.100 Retire by October 1, 2022
Allergy Testing (PDF) CP.MP.100 October 1, 2022 - NEW
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF) CP.MP.108 January 1, 2021
Antithrombin III (Thrombate III, Atryn) (PDF) CP.MP.179 December 1, 2020
Articular Cartilage Defect Repairs (PDF) CP.MP.26 April 1, 2021
Applied Behavioral Analysis (PDF) CP.BH.104 July 24, 2020
Assistant Surgeon (PDF) CC.PP.029 February 7, 2017
Assisted Reproductive Technology (PDF) CP.MP.55 May 1, 2021
Bariatric Surgery (PDF) CP.MP.37 March 1, 2021
Balloon Sinus Ostial Dilation for Treatment of Chronic Sinusitis (PDF) CP.MP.119 November 1, 2020
Bevacizumab (PDF) CP.PHAR.93 February 10, 2017
Bilateral Procedures (PDF) CC.PP.037 February 7, 2017
Biofeedback (PDF) CP.MP.168 July 1, 2021
Bone-Anchored Hearing Aid (PDF) CP.MP.93 October 1, 2021
Bronchial Thermoplasty (PDF) CP.MP.110 July 1, 2022 - New
Burn Surgery (PDF) CP.MP.186 October 1, 2021
Cardiac Biomarker Testing for Acute MI (PDF) CP.MP.156 March 1, 2021
Carrier Screening in Pregnancy (PDF) CP.MP.83 July 1, 2020
Caudal or Interlaminar Epidural Steroid Injections (PDF) CP.MP.164 November 1, 2021
Cerumen Removal (PDF) CC.PP.008 August 12, 2016
Clean Claims (PDF) CC.PP.021 October 18, 2016
Clinical Trials (PDF) CP.MP.94 June 30, 2020
Cochlear Implant Replacements (PDF) CP.MP.14 September 1, 2021
Coding Overview (PDF) CC.PP.011 October 18, 2016
Cosmetic Reconstructive Surgery (PDF) CP.MP.31 January 1, 2022 
Cosmetic Procedures (PDF) CC.PP.024 October 18, 2016
Deep Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder (PDF) CP.BH.201 Retire by September 1, 2022
Deep Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder (PDF) CP.BH.201 June 1, 2021
Dental Anesthesia (PDF) CP.MP.61 May 1, 2021
Diagnosis of Vaginitis (PDF) CP.MP.97 Retire by May 1, 2022
Diaphragmatic/Phrenic Nerve Stimulation (PDF) CP.MP.203 May 1, 2021
Digital Analysis of EEGs (PDF) CP.MP.105 March 1, 2021
Disc Decompression Procedures (PDF) CP.MP.114 Retire by October 1, 2022
Disc Decompression Procedures (PDF) CP.MP.114 October 1, 2022 - NEW
Discography (PDF) CP.MP.115 June 30, 2020
Distinct Procedural Modifiers (PDF) CC.PP.020 October 18, 2016
Donor Lymphocyte Infusion (PDF) CP.MP.101 December 1, 2020
DNA Analysis of Stool (PDF) CP.MP.125 January 1, 2021
Drugs of Abuse: Presumptive Testing (PDF) CP.MP.208 December 1, 2021
Duplicate Primary Code Billing (PDF) CC.PP.044 February 7, 2017
Orthodics and Prosthetics Guidelines (PDF) CP.MP.107 January 1, 2022 
E&M Medical Decision-Making (PDF) CC.PP.051 July 25, 2017
EEG in Evaluation of Headache (PDF) CP.MP.155 July 1, 2021
Electric Tumor Treatment Fields (PDF) CP.MP.145 May 1, 2021
Electromyography and Nerve Conduction Studies (PDF) CP.MP.211 September 1, 2021
EM Bundling Edits (PDF) CC.PP.010 August 12, 2016
Endometrial Ablation (PDF) CP.MP.106 Retire by September 1, 2022
Endometrial Ablation (PDF) CP.MP.106 April 1, 2022
EpiFix Wound Treatment (PDF) CP.MP.140 November 1, 2017
Essure Removal (PDF) CP.MP.131 December 1, 2020
Evoked Potentials (PDF) CP.MP.134 October 1, 2021
Experimental Technologies (PDF) CP.MP.36 June 1, 2021
Facet Joint Interventions (PDF) CP.MP.171 September 1, 2021
Fecal Calprotectin Assay (PDF) CP.MP.135 June 17, 2017
Fecal Incontinence Treatments (PDF) CP.MP.137 September 1, 2021
Ferriscan R2-MRI (PDF) CP.MP.53 December 1, 2020
Fertility Preservation (PDF) CP.MP.130 Retire by October 1, 2022
Fertility Preservation (PDF) CP.MP.130 October 1, 2022 - NEW 
Fixed Wing Air Transportation (PDF) CP.MP.175 October 1, 2021
Functional MRI (PDF) CP.MP.43 November 1, 2021
Gastric Electrical Stimulation (PDF) CP.MP.40 November 1, 2021
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) CP.MP.209 May 1, 2022
Gender Reassignment (PDF) CP.MP.95 September 1, 2021
Genetic Testing (PDF) CP.MP.89 June 1, 2021
Global Maternity Billing (PDF) CC.PP.016 October 18, 2016
Heart-Lung Transplant (PDF) CP.MP.132 July 1, 2022 - NEW
H Pylori Testing (PDF) CP.MP.153 December 1, 2020
Holter Monitors (PDF) CP.MP.113 June 1, 2021
Home Births (PDF) CP.MP.136 November 1, 2021
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) CP.MP.150 March 1, 2021
Homocysteine Testing (PDF) CP.MP.121 May 1, 2022
Hospice (PDF) CP.MP.54 September 1, 2021
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 October 18, 2016
Hyperemesis Gravidarum Treatment (PDF) CP.MP.34 July 1, 2021
Hyperhidrosis Treatments (PDF) CP.MP.62 March 1, 2021
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) CP.MP.180 January 1, 2021
Implanable Intrathecal Pain Pump (PDF) CP.MP.173 March 1, 2021
Implantable Loop Recorder (PDF) CP.MP.243 September 1, 2022
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 June 1, 2022
Inhaled Nitric Oxide (PDF) CP.MP.87 June 1, 2022
Inpatient Only Procedures (PDF) MP.PP.018 October 18, 2016
Intensity Modulated Radiotherapy (PDF) CP.MP.69 February 1, 2021
Intestinal and Multivisceral Transplant (PDF) CP.MP.58 July 1, 2022 - NEW
Intradiscal Steroid Injections for Pain Management (PDF) CP.MP.167 October 1, 2021
Laser Skin Treatment (PDF) CP.MP.123 May 1, 2022
Leveling of Emergency Room (PDF) CC.PP.053  January 1, 2019
Liposuction for Lipedema (PDF) CP.MP.244 October 1, 2022 - NEW
Long Term Care Placement Criteria (PDF) CP.MP.71 June 1, 2022
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 May 1, 2022
Lung Transplantation (PDF) CP.MP.57 November 1, 2020
Lysis of Epidural Lesions (PDF) CP.MP.116 July 1, 2022 - NEW
Maximum Units (PDF) CC.PP.007 August 12, 2016
Measure Serum 1,25 Vitamin D (PDF) CP.MP.152 December 1, 2020
Mechanical Stretch Devices (PDF) CP.MP.144 June 1, 2021
Moderate Conscious Sedation (PDF) CC.PP.015 October 18, 2016
Modifier -25 clinical validation (PDF) CC.PP.013 October 18, 2016
Modifier -59 clinical validation (PDF) CC.PP.014 October 18, 2016
Modifier DOS Validation (PDF) CC.PP.034 October 18, 2016
Modifier to Procedure Code Validation (PDF) CC.PP.028 October 18, 2016
Monitored Anesthesia Care (PDF) CP.MP.161 December 15, 2018
Multiple CPT Code Replacement (PDF) CC.PP.033 October 18, 2016
Multiple Sleep Latency Testing (PDF) CP.MP.24 May 1, 2022
NCCI Unbundling (PDF) CC.PP.031 October 18, 2016
Neonatal Abstinence syndrome guideline (PDF) CP.MP.86 November 1, 2021
Neonatal Sepsis Management Guidelines (PDF) CP.MP.85 December 1, 2021
Nerve Blocks for Pain Management (PDF) CP.MP.170 November 1, 2022 
Neurofeedback for Behavioral Health Disorders (PDF) CP.BH.300 February 1, 2021
Neuromuscular Electrical Stimulation (PDF) CP.MP.48 November 1, 2021
Never Paid Events (PDF) CC.PP.017 October 18, 2016
New Patient (PDF) CC.PP.036 February 7, 2017
NICU Apnea Bradycardia Guidelines (PDF) CP.MP.82 July 1, 2021
Non-Invasive Home Ventilator (PDF) CP.MP.184 October 1, 2021
Non-Obstetrical Pelvic and Transabdominal Ultrasound (PDF) CC.PP.061  March 15, 2021
Nonmyeloablative allogeneic stem cell transplant (PDF) CP.MP.141 April 1, 2021
OB Home Health Programs (PDF) CP.MP.91 May 1, 2021
Optic Nerve Decompression Surgery (PDF) CP.MP.128 October 1, 2021
Osteogenic Stimulation (PDF) CP.MP.194 November 1, 2021
Outpatient Consultation (PDF) CC.PP.039 February 7, 2017
Outpatient Cardiac Rehabilitation (PDF) CP.MP.176 July 1, 2022 - NEW
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 May 1, 2022
Oxygen Use and Concentrators  (PDF) CP.MP.190 November 1, 2021
Paclitaxel (PDF) CP.PHAR.176 May 16, 2016
Pancreas Transplantation (PDF) CP.MP.102 October 1, 2021
Panniculectomy (PDF) CP.MP.109 August 1, 2021
Pediatric Hearing Amplification (PDF) CP.MP.192 November 1, 2021
Pediatric Liver Transplant (PDF) CP.MP.120 November 1, 2020
Pediatric Oral Function Therapy (PDF) CP.MP.188 July 1, 2022 - NEW
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) CP.MP.147 July 1, 2022 - NEW
Pediatric Continuous Positive Airway Pressure (CPAP) (PDF) CP.MP.197 November 1, 2021
Physician’s Consultation Services (PDF) CC.PP.054 September 1, 2018
Physician Visit Codes Billed with Labs (PDF) CC.PP.019 October 18, 2016
Physical, Occupational, and Speech Therapy Services (PDF) CP.MP.49 April 1, 2021
Place of Service Mismatch (PDF) CC.PP.063  December 15, 2018
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) CP.MP.181 May 1, 2022
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) CP.MP.133 October 1, 2021
Post-Acute Care (PDF) CP.MP.213 January 1, 2022 
Post-Operative Visits (PDF) CC.PP.042 February 7, 2017
Pre-Operative Visits (PDF) CC.PP.041 February 7, 2017
Problem Oriented Visits with Preventative Services (PDF) CC.PP.057 November 1, 2018
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 November 1, 2018
Professional Component (PDF) CC.PP.027 October 18, 2016
Proton and Neutron Beam Therapy (PDF) CP.MP.70 April 1, 2021
Pulse Oximetry (PDF) CC.PP.025 October 18, 2016
Radiofrequency Ablation of Uterine Fibroids (PDF) CP.MP.187 June 1, 2021
Radial Head Implant (PDF) CP.MP.148 July 1, 2022 - NEW
Reduction Mammoplasty and Gynecomastia Surgery (PDF) CP.MP.51 November 1, 2021
Repair of Nasal Valve Compromise (PDF) CP.MP.210 July 1, 2022 - NEW
Rituximab (PDF) CP.PHAR.260 February 10, 2017
Robotic Surgery (PDF) CC.PP.050 November 1, 2017
Sacroiliac Joint Interventions for Pain Management (PDF) CP.MP.166 October 1, 2021
Same Day Visits (PDF) CC.PP.040 February 7, 2017
Sacroiliac Joint Fusion (PDF) CP.MP.126 June 30, 2020
Sclerotherapy for Varicose Veins (PDF) CP.MP.146 Retired by September 1, 2022
Sclerotherapy for Varicose Veins (PDF) CP.MP.146 September 1, 2022
Selective Dorsal Rhizotomy (PDF) CP.MP.174 May 1, 2021
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF) CP.MP.165 October 1, 2021
Skilled Nursing Facility Leveling (PDF) CP.MP.206 October 1, 2021
Skin Substitutes for Chronic Wounds (PDF) CP.MP.185 June 1, 2022
Spinal Cord Stimulation (PDF) CP.MP.117 September 1, 2021
Status "B" Bundled Services (PDF) CC.PP.046 February 7, 2017
Status P Bundled Services (PDF) CC.PP.049 June 17, 2017
Stereotactic Body Radiation Therapy (PDF) CP.MP.22 March 1, 2021
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 October 18, 2016
Tandem Transplant (PDF) CP.MP.162 October 1, 2021
Total Artificial Heart (PDF) CP.MP.127 January 1, 2021
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 June 1, 2022
Thyroid Testing in Pediatrics (PDF) CP.MP.154 December 1, 2020
Transcatheter Closure of Patent Foramen Ovale (PDF) CP.MP.151 January 1, 2021
Transcranial Magnetic Stimulation (PDF) CP.BH.200 Retire by September 1, 2022
Transcranial Magnetic Stimulation (PDF) CP.BH.200 June 1, 2021
Transgender Related Services (PDF) CC.PP.047 February 22, 2017
Trigger Point Injections for Pain Management (PDF) CP.MP.169 October 1, 2021
Ultrasound in Pregnancy (PDF) CP.MP.38 May 1, 2022
Unbundled Professional Services (PDF) CC.PP.043 April 6, 2017
Unbundled Surgical Procedures (PDF) CC.PP.045 April 6, 2017
Unlisted Procedure Codes (PDF) CC.PP.009 August 12, 2016
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142 May 1, 2021
Urine Specimen Validity Testing (PDF) CC.PP.056 November 8, 2017
Urodynamic Testing (PDF) CP.MP.98 May 1, 2022
Vagus Nerve Stimulation (PDF) CP.MP.12 October 1, 2021
Ventricular Assist Devices (PDF) CP.MP.46 July 1, 2021
Vitamin D Testing in Children (PDF) CP.MP.157 March 1, 2021
Wheelchair Accessories (PDF) CC.PP.502 August 12, 2016
Wheelchair seating (PDF) CP.MP.99 May 1, 2022
Wireless Motility Capsule (PDF) CP.MP.143 March 1, 2021
Policy Title Policy Number Effective Date
3-Day Payment Window (PDF) CC.PP.500 July 1, 2014
Add on Code Billed Without Primary Code (PDF) CC.PP.030 October 18, 2016
Assistant Surgeon (PDF) CC.PP.029 February 7, 2017
Bevacizumab (PDF) CP.PHAR.93 February 10, 2017
Bilateral Procedures (PDF) CC.PP.037 February 7, 2017
Cardiac Biomarker Testing for Acute MI (PDF) CP.MP.156 March 1, 2021
Cerumen Removal (PDF) CC.PP.008 August 12, 2016
Clean Claims (PDF) CC.PP.021 October 18, 2016
Coding Overview (PDF) CC.PP.011 October 18, 2016
Cosmetic Procedures (PDF) CC.PP.024 October 18, 2016
Digital Analysis of EEGs (PDF) CP.MP.105 March 1, 2021
Distinct Procedural Modifiers (PDF) CC.PP.020 October 18, 2016
DNA Analysis of Stool (PDF) CP.MP.125 January 1, 2021
Drug Payment Reduction (PDF) CC.PP.070 August 1, 2021
Duplicate Primary Code Billing (PDF) CC.PP.044 February 7, 2017
E&M Medical Decision-Making (PDF) CC.PP.051 July 25, 2017
EEG in Evaluation of Headache (PDF) CP.MP.155 May 21, 2018
EM Bundling Edits (PDF) CC.PP.010 August 12, 2016
EpiFix Wound Treatment (PDF) CP.MP.140 November 1, 2017
Fecal Calprotectin Assay (PDF) CP.MP.135 June 17, 2017
FeNo Testing (PDF) CP.MP.103 April 1, 2017
Global Maternity Billing (PDF) CC.PP.016 October 18, 2016
H Pylori Testing (PDF) CP.MP.153 May 21, 2018
Holter Monitors (PDF) CP.MP.113 April 1, 2017
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 October 18, 2016
Inpatient Consultation (PDF) CC.PP.038 February 7, 2017
Inpatient Only Procedures (PDF) MP.PP.018 October 18, 2016
IV Hydration (PDF) CC.PP.012 October 18, 2016
Leveling of Care: Evaluation and Management Overcoding (PDF) CC.PP.066 March 15, 2021
Leveling of Emergency Room (PDF) CC.PP.053  January 1, 2019
Maximum Units (PDF) CC.PP.007 August 12, 2016
Measure Serum 1,25 Vitamin D (PDF) CP.MP.152 May 21, 2018
Mechanical Stretch Devices (PDF) CP.MP.144 November 1, 2017
Moderate Conscious Sedation (PDF) CC.PP.015 October 18, 2016
Modifier -25 clinical validation (PDF) CC.PP.013 October 18, 2016
Modifier -59 clinical validation (PDF) CC.PP.014 October 18, 2016
Modifier DOS Validation (PDF) CC.PP.034 October 18, 2016
Modifier to Procedure Code Validation (PDF) CC.PP.028 October 18, 2016
Monitored Anesthesia Care (PDF) CP.MP.161 December 15, 2018
Multiple CPT Code Replacement (PDF) CC.PP.033 October 18, 2016
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF) CC.PP.065 March 15, 2021
Multiple Procedure Reduction: Ophthalmology (PDF) CC.PP.069 March 15, 2021
Multiple Procedure Payment Reduction for Therapeutic Services (PDF) CC.PP.068 March 15, 2021
NCCI Unbundling (PDF) CC.PP.031 October 18, 2016
Never Paid Events (PDF) CC.PP.017 October 18, 2016
New Patient (PDF) CC.PP.036 February 7, 2017
Non-Obstetrical Pelvic and Transabdominal Ultrasound (PDF) CC.PP.061  March 15, 2021
Outpatient Consultation (PDF) CC.PP.039 February 7, 2017
Paclitaxel (PDF) CP.PHAR.176 May 16, 2016
Physician’s Consultation Services (PDF) CC.PP.054 September 1, 2018
Physician Visit Codes Billed with Labs (PDF) CC.PP.019 October 18, 2016
Place of Service Mismatch (PDF) CC.PP.063  December 15, 2018
Post-Operative Visits (PDF) CC.PP.042 February 7, 2017
Pre-Operative Visits (PDF) CC.PP.041 February 7, 2017
Problem Oriented Visits with Preventative Services (PDF) CC.PP.057 November 1, 2018
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 November 1, 2018
Professional Component (PDF) CC.PP.027 October 18, 2016
Proton and Neutron Beam Therapy (PDF) CP.MP.70 June 1, 2019
Pulse Oximetry (PDF) CC.PP.025 October 18, 2016
Renal Hemodialysis (PDF) CC.PP.067 March 15, 2021
Rituximab (PDF) CP.PHAR.260 February 10, 2017
Robotic Surgery (PDF) CC.PP.050 November 1, 2017
Same Day Visits (PDF) CC.PP.040 February 7, 2017
Status "B" Bundled Services (PDF) CC.PP.046 February 7, 2017
Status P Bundled Services (PDF) CC.PP.049 June 17, 2017
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 October 18, 2016
Thyroid Testing in Pediatrics (PDF) CP.MP.154 May 21, 2018
Transgender Related Services (PDF) CC.PP.047 February 22, 2017
Unbundled Professional Services (PDF) CC.PP.043 April 6, 2017
Unbundled Surgical Procedures (PDF) CC.PP.045 April 6, 2017
Unlisted Procedure Codes (PDF) CC.PP.009 August 12, 2016
Urine Specimen Validity Testing (PDF) CC.PP.056 November 8, 2017
Vitamin D Testing in Children (PDF) CP.MP.157 March 1, 2021
Wheelchair Accessories (PDF) CC.PP.502 August 12, 2016
Wireless Motility Capsule (PDF) CP.MP.143 March 1, 2021