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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

Ambetter from Arkansas Health and Wellness will be partnering with National Imaging Associates 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
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
Allergy Testing (PDF) CP.MP.100 May 1, 2021
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
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
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
Testing for Select Genitourinary Conditions (PDF) CP.MP.97 June 1, 2021
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 June 17, 2017
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
Endometrial Ablation (PDF) CP.MP.106 December 10, 2018
EpiFix Wound Treatment (PDF) CP.MP.140 November 1, 2017
Evoked Potentials (PDF) CP.MP.134 May 1, 2021
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
Homocysteine Testing (PDF) CP.MP.121 May 1, 2021
Hospice Services (PDF) CP.MP.54 June 1, 2020
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
Laser Skin Treatment (PDF) CP.MP.123 April 1, 2017
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
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
Multiple Sleep Latency Testing (PDF) CP.MP.24 June 1, 2020
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
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 July 1, 2021 - NEW
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
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) CP.MP.181 March 15, 2021
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
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
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 June 1, 2020
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
Policy Title Policy Number Effective Date
3-Day Payment Window (PDF) CC.PP.500 July 1, 2014
Acupuncture (PDF) CP.MP.92 February 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 March 1, 2021
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF) CP.MP.108 January 1, 2021
Ambulatory EEG (PDF) CP.MP.96 August 12, 2016
Articular Cartilage Defect Repairs (PDF) CP.MP.26 April 1, 2021
Assistant Surgeon (PDF) CC.PP.029 February 7, 2017
Assisted Reproductive Technology (PDF) CP.MP.55 May 1, 2021
Applied Behavioral Analysis (PDF) CP.BH.104 July 24, 2020
Bariatric Surgery (PDF) CP.MP.37 March 1, 2021
Bevacizumab (PDF) CP.PHAR.93 February 10, 2017
Bilateral Procedures (PDF) CC.PP.037 February 7, 2017
Bone-Anchored Hearing Aid (PDF) CP.MP.93 October 1, 2020
Bronchial Thermoplasty (PDF) CP.MP.110 April 1, 2017
Burn Surgery (PDF) CP.MP.186 September 1, 2020
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 July 31, 2020
Cell-Free Fetal DNA Testing (PDF) CP.MP.84 March 31, 2020
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 July 31, 2020
Coding Overview (PDF) CC.PP.011 October 18, 2016
Cosmetic Reconstructive Surgery (PDF) CP.MP.31 March 1, 2021
Cosmetic Procedures (PDF) CC.PP.024 October 18, 2016
Dental Anesthesia (PDF) CP.MP.61 March 31, 2020
Testing for Select Genitourinary Conditions (PDF) CP.MP.97 June 1, 2021 - NEW
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 September 1, 2020
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 July 1, 2021 - NEW
Duplicate Primary Code Billing (PDF) CC.PP.044 February 7, 2017
Durable Medical Equipment (DME) (PDF) CP.MP.107 May 1, 2021
E&M Medical Decision-Making (PDF) CC.PP.051 July 25, 2017
EEG in Evaluation of Headache (PDF) CP.MP.155 December 1, 2020
Electric Tumor Treatment Fields (PDF) CP.MP.145 July 1, 2020
EM Bundling Edits (PDF) CC.PP.010 August 12, 2016
Endometrial Ablation (PDF) CP.MP.106 December 10, 2018
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 May 1, 2021
Experimental Technologies (PDF) CP.MP.36 June 30, 2020
Facet Joint Interventions (PDF) CP.MP.171 March 4, 2020
Fecal Calprotectin Assay (PDF) CP.MP.135 June 17, 2017
Fecal incontinence treatments (PDF) CP.MP.137 July 31, 2020
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) CP.MP.129 July 31, 2020
FeNo Testing (PDF) CP.MP.103 January 1, 2021
Ferriscan R2-MRI (PDF) CP.MP.53 December 1, 2020
Fertility Preservation (PDF) CP.MP.130 November 1, 2020
Fixed Wing Air Transportation (PDF) CP.MP.175 February 1, 2021
Gender Reassignment (PDF) CP.MP.95 February 1, 2021
Genetic Testing (PDF) CP.MP.89 March 31, 2020
Global Maternity Billing (PDF) CC.PP.016 October 18, 2016
Heart-Lung Transplant (PDF) CP.MP.132 June 1, 2020
H Pylori Testing (PDF) CP.MP.153 December 1, 2020
Holter Monitors (PDF) CP.MP.113 April 1, 2017
Home Births (PDF) CP.MP.136 February 1, 2021
Homocysteine Testing (PDF) CP.MP.121 May 1, 2021
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) CP.MP.150 March 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 - NEW
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 Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 June 1, 2020
Inhaled Nitric Oxide (PDF) CP.MP.87 January 1, 2021
Inpatient Consultation (PDF) CC.PP.038 February 7, 2017
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, 2020
Intradiscal Steroid Injections for Pain Management (PDF) CP.MP.167 October 1, 2020
IV Hydration (PDF) CC.PP.012 October 18, 2016
Laser Skin Treatment (PDF) CP.MP.123 April 1, 2017
Leveling of Emergency Room (PDF) CC.PP.053  January 1, 2019
Long Term Care Placement Criteria (PDF) CP.MP.71 March 16, 2017
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 February 1, 2021
Lung Transplantation (PDF) CP.MP.57 July 1, 2020
Lysis of Epidural Lesions (PDF) CP.MP.116 November 1, 2020
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 October 1, 2020
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
NCCI Unbundling (PDF) CC.PP.031 October 18, 2016
Neonatal Sepsis Management Guidelines (PDF) CP.MP.85 July 31, 2020
Neurofeedback for Behavioral Health Disorders (PDF) CP.BH.300 February 1, 2021
Nerve Blocks for Pain Management (PDF) CP.MP.170 February 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, 2020
NICU Discharge Guidelines (PDF) CP.MP.81 June 30, 2020
Non-Invasive Home Ventilator (PDF) CP.MP.184 December 1, 2020
Non-Obstetrical Pelvic and Transabdominal Ultrasound (PDF) CC.PP.061  December 15, 2018
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, 2020
Outpatient Cardiac Rehabilitation (PDF) CP.MP.176 July 1, 2020
Outpatient Consultation (PDF) CC.PP.039 February 7, 2017
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 July 1, 2021 - NEW
Oxygen Use and Concentrators (PDF) CP.MP.190 January 1, 2021
Paclitaxel (PDF) CP.PHAR.176 May 16, 2016
Pancreas Transplantation (PDF) CP.MP.102 April 1, 2021
Panniculectomy (PDF) CP.MP.109 July 1, 2020
Pediatric Heart Transplant (PDF) CP.MP.138 May 1, 2021
Pediatric Liver Transplant (PDF) CP.MP.120 March 1, 2021
Reduction Mammoplasty and Gynecomastia Surgery (PDF) CP.MP.51 July 31, 2020
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) CP.MP.147 July 1, 2020
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 February 1, 2021
Post-Operative Visits (PDF) CC.PP.042 February 7, 2017
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) CP.MP.133 October 1, 2020
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 April 1, 2021
Pulse Oximetry (PDF) CC.PP.025 October 18, 2016
Radial Head Implant (PDF) CP.MP.148 July 1, 2020
Radiofrequency Ablation of Uterine Fibroids (PDF) CP.MP.187 June 1, 2020
Rituximab (PDF) CP.PHAR.260 February 10, 2017
Robotic Surgery (PDF) CC.PP.050 November 1, 2017
Sacroiliac Joint Fusion (PDF) CP.MP.126 June 30, 2020
Sacroiliac Joint Interventions for Pain Management (PDF) CP.MP.166 October 1, 2020
Same Day Visits (PDF) CC.PP.040 February 7, 2017
Selective Dorsal Rhizotomy (PDF) CP.MP.174 March 31, 2020
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF) CP.MP.165 October 1, 2020
Sickle Cell Disease Observation (PDF) CP.MP.88 March 16, 2017
Skin Substitutes for Chronic Wounds (PDF) CP.MP.185 October 1, 2020
Skilled Nursing Facility Leveling (PDF) CP.MP.206 March 1, 2021
Spinal Cord Stimulation (PDF) CP.MP.117 March 31, 2020
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 July 31, 2020
Thymus Transplantation (PDF) CP.MP.189 October 1, 2020
Thyroid Testing in Pediatrics (PDF) CP.MP.154 December 1, 2020
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 June 1, 2020
Transcatheter Closure of Patent Foramen Ovale (PDF) CP.MP.151 January 1, 2021
Transcranial Magnetic Stimulation (PDF) CP.BH.200 February 1, 2021
Transgender Related Services (PDF) CC.PP.047 February 22, 2017
Trigger Point Injections for Pain Management (PDF) CP.MP.169 February 1, 2021
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
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142 July 1, 2020
Urine Specimen Validity Testing (PDF) CC.PP.056 November 8, 2017
Urodynamic Testing (PDF) CP.MP.98 March 1, 2021
Vagus Nerve Stimulation (PDF) CP.MP.12 February 1, 2021
Ventricular Assist Devices (PDF) CP.MP.46 July 1, 2021 - NEW
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
Policy Title Policy Number Effective Date
Abaloparatide (Tymlos) (PDF) CP.PHAR.345 November 7, 2017
Abametapir (Xeglyze) (PDF) CP.PMN.253 December 1, 2020
Abiraterone (Zytiga) (PDF) CP.PHAR.84 July 24, 2015
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 November 1, 2020
Aclidinium/Formoterol (Duaklir Pressair) (PDF) HIM.PA.151 March 1, 2021
Adefovir (Hepsera) (PDF) CP.PHAR.142 June 1, 2019
Ado-Trastuzumab Emtansine (Kadcyla) (PDF) CP.PHAR.229 June 1, 2019
Afamelanotide (Scenesse) (PDF) CP.PHAR.444 March 1, 2020
afatinib (Gilotrif) (PDF) CP.PHAR.298 June 1, 2019
Aflibercept (Eylea) (PDF) CP.PHAR.184 July 1, 2016
Agalsidase Beta (Fabrazyme) (PDF) CP.PHAR.158  June 1, 2019
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) CP.PMN.138 June 1, 2019
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 December 8, 2017
Alendronate (Binosto, Fosamax plus D) (PDF) CP.PMN.88 June 1, 2019
Alglucosidase Alfa (Lumizyme) (PDF) CP.PHAR.160 June 1, 2019
Alpelisib (Piqray) (PDF) CP.PHAR.430 December 1, 2019
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF) CP.PHAR.94 July 24, 2015
Amantadine ER (Gocovri,Osmolex ER) (PDF) CP.PMN.89 March 1, 2021
Ambrisentan (Letairis®) (PDF) CP.PHAR.190 July 1, 2016
Amifampridine (Firdapse)(PDF) CP.PHAR.411 March 1, 2019
Amikacin (Arikayce)(PDF)  CP.PHAR.401 March 1, 2019
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) CP.PHAR.217 December 1, 2020
Antithrombin III (PDF) CP.MP.179 December 1, 2020
Antithymocyte Globulin (Thymoglobulin, Atgam) (PDF) CP.PHAR.506 December 1, 2020
Apomorphine (Apokyn) (PDF) CP.PHAR.488 March 1, 2020
aprepitant (Emend®) (PDF) CP.PMN.19 March 1, 2016
Arformoterol Tartrate (Brovana) (PDF) CP.PMN.201 June 1, 2019
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada)  (PDF) CP.PHAR.290 January 1, 2020
Aripiprazole ODT (Abilify) (PDF) CP.PCH.37 March 1, 2021
armodafinil (Nuvigil) (PDF) CP.PMN.35 June 1, 2019
Asenapine (Saphris) (PDF) CP.PMN.15 June 1, 2019
Aspirin-dipyridamole (Aggrenox) (PDF) CP.PMN.20 June 1, 2019
Atezolizumab (Tecentriq) (PDF) CP.PHAR.235 November 1, 2020
Avapritinib (Ayvakit) (PDF) CP.PHAR.454 March 1, 2020
Avatrombopag (Doptelet) (PDF) CP.PHAR.130 March 1, 2019
Avelumab (Bavencio) (PDF) CP.PHAR.333 October 1, 2020
axicabtagene ciloleucel (Yescarta®) (PDF) CP.PHAR.362 June 1, 2019
Axitinib (Inlyta) (PDF) CP.PHAR.100 September 8, 2017
Azacitidine (Vidaza) (PDF) CP.PHAR.387 June 1, 2019
Azelaic Acid (Finacea) (PDF) HIM.PA.119 June 1, 2019
Aztreonam (Cayston) (PDF) CP.PHAR.209 September 8, 2017
Bedaquiline (Sirturo) (PDF) CP.PMN.212 June 1, 2019
belatacept (Nulojix®)  (PDF) CP.PHAR.201 June 1, 2019
Belimumab (Benlysta) (PDF) CP.PHAR.88 July 24, 2015
belinostat (Beleodaq®) (PDF) CP.PHAR.311 June 1, 2019
Bempedoic acid (Nexletol), bempedoic acid-ezetimibe (Nexlizet) (PDF) CP.PMN.237 March 1, 2021
bendamustine (Bendeka®, Treanda®) (PDF) CP.PHAR.307 June 1, 2019
Benralizumab (Fasenra) (PDF) CP.PHAR.373 June 1, 2019
Benznidazole (PDF) CP.PMN.90 March 1, 2021
Betaine (Cystadane) (PDF) CP.PHAR.143 June 1, 2019
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) CP.PHAR.93 March 1, 2021
Bexarotene (Targretin) (PDF) CP.PHAR.75 November 7, 2017
Bezlotoxumab (Zinplava) (PDF) CP.PHAR.300 July 15, 2019
Biologic DMARDs (PDF) HIM.PA.SP60 January 1, 2021
Binimetinib (Mektovi) (PDF) CP.PHAR.50 June 1, 2019
Belantamab mafodotin (Blenrep) (PDF) CP.PHAR.469 December 1, 2020
Blinatumomab (Blincyto) (PDF) CP.PHAR.312 June 1, 2019
Bortezomib (Velcade) (PDF) CP.PHAR.410 July 15, 2019
Bosentan (Tracleer®) (PDF) CP.PHAR.191 July 1, 2016
Bosutinib (Bosulif) (PDF) CP.PHAR.105 March 1, 2016
Brand Name Override and Non-Formulary Medications (PDF) HIM.PA.103 March 1, 2016
Brentuximab Vedotin (Adcetris) (PDF) CP.PHAR.303 June 1, 2019
Brexanolone (Zulresso) (PDF) CP.PHAR.417 June 1, 2019
Brexpiprazole (Rexulti) (PDF) CP.PMN.68 June 1, 2019
Brexucabtagene Autoleucel (Tecartus) (PDF) CP.PHAR.472 September 1, 2020
Brigatinib (Alunbrig) (PDF) CP.PHAR.342 July 1, 2020
Brolucizumab-dbll (Beovu) (PDF) CP.PHAR.445  March 1, 2021
Oxymetazoline (Rhofade)(PDF) CP.PMN.86 June 1, 2019
Brimonidine Tartrate (Mirvaso) (PDF) CP.PMN.192 June 1, 2019
Brinzolamide/Brimonidine (Simbrinza) (PDF) HIM.PA.15 June 1, 2019
Brivaracetam (Briviact) (PDF) CP.PCH.26 January 1, 2020
Budesonide (Uceris) (PDF) CP.PCH.11 June 1, 2019
Budesonide-glycopyrrolate-formoterol fumarate (Breztri Aerosphere) (PDF) HIM.PA.150 December 1, 2020
Budesonide Suspension (Pulmicort Respules) (PDF) HIM.PA.48 June 1, 2019
buprenorphine implant (Probuphine) (PDF) CP.PHAR.289 June 1, 2019
Bupropion/Naltrexone (Contrave) (PDF) CP.PCH.12 July 15, 2019
Burosumab-twza (Crysvita) (PDF) CP.PHAR.11 June 1, 2019
Butorphanol Nasal Spray (PDF) HIM.PA.46 March 1, 2016
C1 Esterase Inhibitors (PDF) CP.PHAR.202 July 1, 2016
cabazitaxel (Jevtana®) (PDF) CP.PHAR.316 June 1, 2019
Cabozantinib (Cometriq®, Cabometyx®) (PDF) CP.PHAR.111 September 8, 2017
Calcifediol (Rayaldee) (PDF) CP.PMN.76  September 1, 2020
Canakinumab (Ilaris) (PDF) CP.PHAR.246 June 1, 2019
Cannabidiol (Epidiolex) (PDF) CP.PMN.164 July 1, 2019
capecitabine (Xeloda) (PDF) CP.PHAR.60 November 7, 2017
Caplacizumab-yhdp (Cablivi) (PDF) CP.PHAR.416 June 1, 2019
carfilzomib (Kyprolis®) (PDF) CP.PHAR.309 June 1, 2019
Carglumic acid (Carbaglu®) (PDF) CP.PHAR.206  September 8, 2017
Celecoxib (Celebrex) (PDF) CP.PMN.122 June 1, 2019
Cemiplimab-rwlc (Libtayo) (PDF) CP.PHAR.397 June 1, 2019
Cenegermin-bkbj (Oxervate)(PDF) CP.PMN.186 March 1, 2019
Cenobamate (Xcopri) (PDF) CP.PMN.231 March 1, 2021
Ceritinib (Zykadia) (PDF) CP.PHAR.349 June 1, 2019
Cerliponase alfa (Brineura) (PDF) CP.PHAR.338 November 7, 2017
cetuximab (Erbitux®) (PDF) CP.PHAR.317 June 1, 2019
Chlorambucil (Leukeran) (PDF) HIM.PA.SP59 June 1, 2019
Chloramphenicol Sodium Succinate (PDF) CP.PHAR.388 June 1, 2019
Cholic Acid (Cholbam) (PDF) CP.PHAR.390 June 1, 2019
Ciclesonide (Alvesco) (PDF)  CP.PCH.35 March 1, 2021
Ciclopirox (Penlac) (PDF) CP.PMN.24 March 1, 2021
Cinacalcet (Sensipar) (PDF) CP.PHAR.61 September 8, 2017
Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) CP.PMN.248 December 1, 2020
Ciprofloxacin/Fluocinolone (Otovel) (PDF) CP.PMN.249 December 1, 2020
Cladribine (Mavenclad) (PDF) CP.PHAR.422 January 1, 2020
Clascoterone (Winlevi) (PDF) CP.PMN.257 March 1, 2021
Clinical Policy: Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) CP.PHAR.260 June 1, 2019
Clobazam (Onfi) (PDF) CP.PMN.54 June 1, 2019
CNS Stimulants (PDF) CP.PMN.92 March 1, 2020
Colchicine (Colcrys) (PDF) CP.PMN.123 March 1, 2021
Colesevelam (Welchol) (PDF) CP.PMN.250 December 1, 2020
Collagenase (Xiaflex) (PDF) CP.PHAR.82 July 24, 2015
Colonoscopy Preparation Products (PDF) HIM.PA.04 June 1, 2020
Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) CP.PMN.258 March 1, 2021
Continuous Insulin Delivery Systems (V-Go, Omnipod) (PDF) CP.PHAR.505 December 1, 2020
Continuous Glucose Monitors (PDF) CP.PMN.214 March 1, 2020
copanlisib (Aliqopa®)  (PDF) CP.PHAR.357 June 1, 2019
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) CP.PHAR.385 October 19, 2018
Cosyntropin (Cortrosyn) (PDF) CP.PHAR.203 March 1, 2021
Crisaborole (Eucrisa) (PDF) CP.PMN.110 June 1, 2019
Crizanlizumab-tmca (Adakveo) (PDF) CP.PHAR.449 June 1, 2020
Crizotinib (Xalkori) (PDF) CP.PHAR.90 December 8, 2017
Cyclosporine (Restasis, Cequa) (PDF) CP.PMN.48 June 1, 2019
Cysteamine ophthalmic (Cystaran) (PDF) CP.PMN.130 June 1, 2019
Cysteamine oral (Cystagon, Procysbi) (PDF) CP.PHAR.155    December 1, 2020
Cytomegalovirus Immune Globulin (Cytogam) (PDF) CP.PHAR.277 January 1, 2020
Dabrafenib (Tafinlar) (PDF) CP.PHAR.239 November 7, 2017
Daclatasvir (Daklinza) (PDF) HIM.PA.SP27 November 1, 2020
Dacomitinib (Vizimpro) (PDF) CP.PHAR.399 June 1, 2019
Dalfampridine (Ampyra) (PDF) CP.PHAR.248 December 8, 2017
Deflazacort (Emflaza) (PDF) CP.PHAR.331 July 15, 2019
Dalteparin (Fragmin) (PDF) CP.PHAR.225 September 8, 2017
Daptomycin (Cubicin, Cubicin RF) (PDF) CP.PHAR.351 January 1, 2020
Dapsone (Aczone Gel) (PDF) CP.PCH.32 December 1, 2020
Daratumumab (Darzalex) (PDF) CP.PHAR.310 March, 1, 2021
Darbepoetin alfa (Aranesp) (PDF) CP.PHAR.236 October 30, 2016
Darolutamide (Nubeqa) (PDF) CP.PHAR.435 December 1, 2019
Dasabuvir-Ombitasvir-Paritaprevir-Ritonavir (Viekira Pak) (PDF) HIM.PA.SP61 November 1, 2020
Dasatinib (Sprycel) (PDF) CP.PHAR.72 November 7, 2017
daunorubicin/cytarabine (Vyxeos®) (PDF) CP.PHAR.352 June 1, 2019
Decitabine-Cedazuridine (Inqovi) (PDF) CP.PHAR.479 December 1, 2020
deferasirox (Exjade Jadenu) (PDF) CP.PHAR.145 March 1, 2016
Deferoxamine (Desferal) (PDF) CP.PHAR.146 September 1, 2020
degarelix acetate (Firmagon®) (PDF) CP.PHAR.170 June 1, 2019
Delafloxacin (Baxdela) (PDF) CP.PMN.115 January 1, 2020
Denosumab (Prolia, Xgeva) (PDF) CP.PHAR.58 December 8, 2017
Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF) CP.PHAR.214 September 8, 2017
Deutetrabenazine (Austedo) (PDF) CP.PHAR.341 November 7, 2017
Dexlansoprazole (Dexilant) (PDF) HIM.PA.05 June 1, 2020
Dexrazoxane (Zinecard, Totect) (PDF) CP.PHAR.418 June 1, 2019
Dextromethorphan-Quinidine (Nuedexta) (PDF) CP.PMN.93 March 1, 2021
Diazepam Nasal Spray (Valtoco)(PDF) CP.PMN.216 December 1, 2019
Dichlorphenamide (Keveyis) (PDF) CP.PMN.261 March 1, 2021
diclofenac sodium topical gel (Solaraze, Voltaren®) (PDF) CP.PCH.28 June 1, 2019
Dimethyl Fumarate (Tecfidera) (PDF) CP.PHAR.249 December 8, 2017
Dipeptidyl Peptidase-4 Inhibitors (PDF) HIM.PA.58 March 1, 2016
Dolasetron (Anzemet) (PDF) CP.PMN.141 March 1, 2016
Dornase alfa (Pulmozyme) (PDF) CP.PHAR.212 September 8, 2017
Doxepin Hydrochloride Cream (Prudoxin, Zonalon) (PDF) HIM.PA.147 June 1, 2019
Dupilumab (Dupixent) (PDF) CP.PHAR.336 September 8, 2017
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 November 7, 2017
Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn) (PDF) CP.PMN.128 March 1, 2020
Duvelisib (Copiktra) (PDF) CP.PHAR.400 July 15, 2019
Ecallantide (Kalbitor) (PDF) CP.PHAR.177 July 1, 2016
Eculizumab (Soliris) (PDF) CP.PHAR.97 September 8, 2017
Edaravone (Radicava) (PDF) CP.PHAR.343 November 7, 2017
Efinaconazole (Jublia) (PDF) CP.PMN.25 June 1, 2019
Elagolix (Orilissa), elagolix-estradiol-norethindrone (Oriahnn) (PDF) CP.PHAR.136 March 1, 2021
Elapegademase-lvlr (Revcovi) (PDF) CP.PHAR.419 June 1, 2019
Elbasvir/Grazoprevir (Zepatier) (PDF) HIM.PA.SP62 November 1, 2020
Eliglustat (Cerdelga) (PDF) CP.PHAR.153 June 1, 2019
Elexacaftor-ivacaftor-tezacaftor (Trikafta) (PDF) CP.PHAR.440 December 1, 2019
Elosulfase Alfa (Vimizim) (PDF) CP.PHAR.162  June 1, 2019
Elotuzumab (Empliciti) (PDF) CP.PHAR.308 December 1, 2020
Eltrombopag (Promacta®) (PDF) CP.PHAR.180 July 1, 2016
Eluxadoline (Viberzi) (PDF) CP.PMN.170 June 1, 2019
Emapalumab-lzsg (Gamifant)(PDF) CP.PHAR.402 March 1, 2019
Emicizumab-kxwh (Hemlibra) (PDF) CP.PHAR.370 June 1, 2019
Encorafenib (Braftovi) (PDF) CP.PHAR.127 June 1, 2019
Enfuvirtide (Fuzeon) (PDF) CP.PHAR.41    July 24, 2015
Enfortumab Vedotin-ejfv (Padcev) (PDF) CP.PHAR.455 March 1, 2020
Entecavir (Baraclude) (PDF) HIM.PA.08 June 1, 2019
Entrectinib (Rozlytrek) (PDF) CP.PHAR.441 December 1, 2019
Enzalutamide (Xtandi) (PDF) CP.PHAR.106 March 1, 2016
Epoetin Alfa (Epogen® and Procrit) (PDF) CP.PHAR.237 February 1, 2020
Epoprostenol (PDF) CP.PHAR.192 July 1, 2016
Eptinezumab-jjmr (Vyepti) (PDF) HIM.PA.SP64 February 1, 2021
Erdafitinib (Balversa) (PDF) CP.PHAR.423 January 1, 2020
Erenumab-aaoe (Aimovig) (PDF) HIM.PA.SP65 October 1, 2021
eribulin Mesylate (Halaven®) (PDF) CP.PHAR.318 June 1, 2019
Erlotinib (Tarceva) (PDF) CP.PHAR.74 July 24, 2015
Erwinia Asparaginase (Erwinaze) (PDF) CP.PHAR.301 March 1, 2020
Esketamine (Spravato) (PDF) CP.PMN.199 June 1, 2019
Etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 June 1, 2019
Eteplirsen  (Exondys 51) (PDF) CP.PHAR.288 October 1, 2020
Etidronate (Didronel) (PDF) CP.PMN.94 March 1, 2021
Everolimus (Afinitor, Afinitor Disperz, Zortress)(PDF) CP.PHAR.63 September 8, 2017
Evolocumab (Repatha) (PDF) CP.PHAR.123 March 1, 2016
Factor IX (Human, Recombinant) (PDF) CP.PHAR.218 December 1, 2020
Factor IX Complex Human (Bebulin®, Profilnine®) (PDF) CP.PHAR.219 June 1, 2019
Factor VIIa, Recombinant (NovoSeven® RT) (PDF) CP.PHAR.220 June 1, 2019
Factor VIII (Human Recombinant) (PDF) CP.PHAR.215 November 1, 2020
Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF) CP.PHAR.216 September 8, 2017
Factor XIII A-Subunit, Recombinant (Tretten®) CP.PHAR.222 June 1, 2019
Factor XIII, Human (Corifact®) (PDF) CP.PHAR.221 June 1, 2019
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) CP.PHAR.456 March 1, 2020
febuxostat (Uloric) (PDF) CP.PMN.57 June 1, 2019
Fedratinib (Inrebic) (PDF) CP.PHAR.442 December 1, 2019
Fenfluramine (Fintepla) (PDF) CP.PMN.246 December 1, 2020
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF) CP.PMN.127 June 1, 2019
Ferric Carboxymaltose (Injectafer) (PDF) CP.PHAR.234 March 1, 2020
Ferric gluconate (Ferrlecit®) (PDF) CP.PHAR.166 March 1, 2020
Ferric Maltol (Accrufer) (PDF) CP.PMN.213 December 1, 2019
Ferumoxytol (Feraheme®) (PDF) CP.PHAR.165 March 1, 2020
Flibanserin (Addyi) (PDF) CP.PHAR.446 March 1, 2021
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) (PDF) CP.PHAR.297 March 1, 2021
Fingolimod (Gilenya) (PDF) CP.PCH.38 March 1, 2021
Fluorouracil Cream (Tolak) (PDF) CP.PMN.165 June 1, 2019
Fluticasone Propionate (Xhance) (PDF) CP.PMN.95 May 1, 2019
Fondaparinux (Arixtra) (PDF) CP.PHAR.226 September 8, 2017
Formulary Medications Without Specific Guidelines (PDF) HIM.PA.33 June 1, 2019
Fostamatinib (Tavalisse) (PDF) CP.PHAR.24 June 1, 2019
Fostemsavir (Rukobia) (PDF) CP.PHAR.516 March 1, 2021
Fremanezumb-vfrm (PDF) HIM.PA.SP66 February 1, 2021
Fulvestrant (Faslodex Injection) (PDF) CP.PHAR.424 January 1, 2020
Galcanezumab-gnlm (Emgality) (PDF) HIM.PA.SP67 October 1, 2020
Galsulfase (Naglazyme) (PDF) CP.PHAR.161   June 1, 2019
Gefitinib (Iressa) (PDF) CP.PHAR.68 June 1, 2019
gemtuzumab ozogamicin (Mylotarg®) (PDF) CP.PHAR.358 June 1, 2019
Gilteritinib (Xospata)(PDF) CP.PHAR.412 March 1, 2019
Givosiran (Givlaari) (PDF) CP.PHAR.457 March 1, 2020
Glasdegib (Daurismo)(PDF) CP.PHAR.413 March 1, 2019
Glatiramer (Copaxone, Glatopa) (PDF) HIM.PA.SP68 March 1, 2021
Glecaprevir-Pibrentasvir (PDF) HIM.PA.SP36 August 1, 2020
Glucagon-Like Peptide-1 Receptor Agonists (PDF) HIM.PA.53 June 1, 2019
Glycerol phenylbutyrate (Ravicti®) (PDF) CP.PHAR.207 March 1, 2020
Golodirsen (Vyondys 53) (PDF) CP.PHAR.453 March 1, 2020
goserelin acetate (Zoladex®) (PDF) CP.PHAR.171 June 1, 2019
Halcinonide (Halog) (PDF) HIM.PA.20 June 1, 2019
Halobetasol Propionate/Tazarotene (Duobrii) (PDF) CP.PMN.208 September 1, 2020
Hemin (Panhematin®) (PDF) CP.PHAR.181 March 1, 2020
histrelin acetate (Vantas®, Supprelin LA®) (PDF) CP.PHAR.172 June 1, 2019
House dust mite allergen extract (Odactra®) (PDF) CP.PMN.111  June 1, 2019
Human Growth Hormone (Somapacitan, Somatropin) (PDF) CP.PCH.39 March 1, 2021
Hyaluronate Derivatives (PDF) CP.PHAR.05 December 8, 2017
Hydroxyprogesterone Caproate (Makena) (PDF) CP.PHAR.14 March 1, 2016
Hyperhidrosis Treatments (PDF) CP.MP.62 March 1, 2021
ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 June 1, 2019
Ibandronate sodium (PDF) CP.PHAR.189 July 1, 2016
Ibrutinib (Imbruvica) (PDF) CP.PHAR.126 June 1, 2019
Icatibant (Firazyr®) (PDF) CP.PHAR.178 July 1, 2016
Icosapent ethyl (Vascepa) (PDF) CP.PMN.187 June 1, 2019
Idelalisib (Zydelig) (PDF) CP.PHAR.133 June 1, 2019
Idursulfase (Elaprase) (PDF) CP.PHAR.156  June 1, 2019
lesinurad (Zurampic), lesinurad-allopurinol (Duzallo) (PDF) CP.PMN.150 January 1, 2020
Iloperidone (Fanapt) (PDF) CP.PMN.32 June 1, 2019
Iloprost (Ventavis®) (PDF) CP.PHAR.193 July 1, 2016
Imatinib (Gleevec) (PDF) CP.PHAR.65 November 7, 2017
Imiglucerase (Cerezyme) (PDF) CP.PHAR.154  June 1, 2019
Immune Globulins (PDF) CP.PHAR.103 March 1, 2016
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 March 1, 2021
Infertility and Fertility Preservation (PDF) CP.PHAR.131 June 1, 2019
Inebilizumab (PDF) CP.PHAR.458 March 1, 2020
Inotersen (Tegsedi) (PDF) CP.PHAR.405 March 1, 2019
inotuzumab ozogamicin (Besponsa®) (PDF) CP.PHAR.359 October 1, 2020
Interferon Beta-1b (Betaseron, Extavia) (PDF) CP.PHAR.256 February 1, 2020
Insulin Degludec (Tresiba) (PDF) HIM.PA.09 July 15, 2019
interferon beta-1a (Avonex, Rebif) (PDF) CP.PHAR.255 December 8, 2017
Interferon Gamma- 1b (Actimmune) (PDF) CP.PHAR.52 September 8, 2017
Intrathecal Baclofen (Gablofen, Lioresal) (PDF) CP.PHAR.149 June 1, 2019
Iobenguane I-131 (Azedra) (PDF) CP.PHAR.459 March 1, 2020
Ipilimumab (Yervoy) (PDF) CP.PHAR.319 June 1, 2019
irinotecan Liposome (Onivyde®) (PDF) CP.PHAR.304 June 1, 2019
Iron sucrose (Venofer®) (PDF) CP.PHAR.167 March 1, 2020
isavuconazonium (Cresemba®) (PDF) CP.PMN.154 June 1, 2019
Isotretinoin (PDF) CP.PMN.143 March 1, 2016
Istradefylline (Nourianz) (PDF) CP.PMN.217 March 1, 2021
Itraconazole (Sporanox, Onmel) (PDF) CP.PMN.124 June 1, 2019
Ivabradine (Corlanor) (PDF) CP.PMN.70 March 1, 2021
Ivacaftor (Kalydeco) (PDF) CP.PHAR.210 September 8, 2017
ivermectin (Sklice®) (PDF) HIM.PA.124  June 1, 2019
Ivosidenib (Tibsovo) (PDF) CP.PHAR.137 July 15, 2019
Ixazomib (Ninlaro) (PDF) CP.PHAR.302 June 1, 2019
Lacosamide (Vimpat) (PDF) CP.PMN.155 September 8, 2017
Lactic acid-citric acid-potassium bitartrate (Phexxi) (PDF) CP.PMN.251 December 1, 2020
Lanadelumab-fylo (Takhzyro)(PDF) CP.PHAR.396 March 1, 2019
Lanreotide (Somatuline Depot) (PDF) CP.PHAR.391 June 1, 2019
lapatinib (Tykerb®) (PDF) CP.PHAR.79 July 24, 2015
Laronidase (Aldurazyme) (PDF) CP.PHAR.152 June 1, 2019
Larotrectinib (Vitrakvi)(PDF) CP.PHAR.414 March 1, 2019
Lasmiditan (Reyvow) (PDF) CP.PMN.218 March 1, 2021
Latanoprostene Bunod (Vyzulta) (PDF) CP.PMN.108 May 1, 2021
ledipasvir sofosbuvir (Harvoni) (PDF) HIM.PA.SP3 November 1, 2020
Lefamulin (Xenleta) (PDF) CP.PMN.219 March 1, 2021
lenalidomide (Revlimid) (PDF) CP.PHAR.71 October 30, 2016
Lenvatinib (Lenvima) (PDF) CP.PHAR.138 June 1, 2019
Letermovir (Prevymis) (PDF) CP.PHAR.367 June 1, 2019
Levoleucovorin (Fusilev, Khapzory) (PDF) CP.PHAR.151 December 1, 2020
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) CP.PHAR.173 March 1, 2021
Levalbuterol (Xopenex) (PDF) CP.PMN.07 June 1, 2019
Levomilnacipran (Fetzima) (PDF) HIM.PA.125 June 1, 2019
lidocaine transdermal (Lidoderm®) (PDF) CP.PMN.08  June 1, 2019
Lifitegrast (Xiidra®) (PDF) CP.PMN.73 March 1, 2020
Linaclotide (Linzess) (PDF) CP.PMN.71 June 1, 2019
linezolid (Zyvox) (PDF) CP.PMN.27 June 1, 2019
Lofexidine (Lucemyra) (PDF) CP.PMN.152 July 15, 2019
Lomustine (Gleostine) (PDF) CP.PHAR.507 December 1, 2020
Lorcaserin (Belviq®, Belviq XR) (PDF) CP.PCH.03 June 1, 2019
Lorlatinib (Lorbrena)(PDF) CP.PHAR.406 March 1, 2019
Loteprednol etabonate (Eysuvis) (PDF) CP.PMN.260 March 1, 2021
Lubiprostone (Amitiza) (PDF) CP.PMN.142 March 1, 2016
Luliconazole Cream (Luzu) (PDF) CP.PMN.166 June 1, 2019
Lumacaftor-Ivacaftor (Orkambi) (PDF) CP.PHAR.213 March 1, 2019
Lumateperone (Caplyta) (PDF) CP.PMN.232 March 1, 2021
Lurbinectedin (Zepzelca) (PDF) CP.PHAR.500 December 1, 2020
Lurasidone (Latuda) (PDF) CP.PMN.50 June 1, 2019
Luspatercept-aamt (Reblozyl) (PDF) CP.PHAR.450 June 1, 2020
Lusutrombopag (Mulpleta)(PDF) CP.PHAR.407 July 1, 2019
Lutetium Lu 177 Dotatate (Lutathera) (PDF) CP.PHAR.384 June 1, 2019
Macitentan (Opsumit®) (PDF) CP.PCH.31 March 1, 2021
Mannitol (Bronchitol) (PDF) CP.PHAR.518 March 1, 2021
Mecamylamine (Vecamyl) (PDF) CP.PMN.136 June 1, 2019
Mecasermin (Increlex) (PDF) CP.PHAR.150 December 1, 2020
Mechlorethamine Gel (Valchlor) (PDF) CP.PHAR.381 September 1, 2020
Megestrol Acetate 125 mg/mL Oral Suspension (Megace ES) (PDF) CP.PMN.179 June 1, 2019
Mepolizumab (Nucala) (PDF) CP.PHAR.200 September 8, 2017
Metformin ER (Glumetza, Fortamet) (PDF) CP.PMN.72 March 1, 2021
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF) CP.PHAR.134 July 1, 2020
Methoxsalen (Uvadex) (PDF) HIM.PA.17 June 1, 2019
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) CP.PHAR.238 June 1, 2019
Methylnaltrexone Bromide (Relistor) (PDF) CP.PMN.169 June 1, 2019
Metoclopramide (Gimoti) (PDF) CP.PMN.252 December 1, 2020
Metreleptin (Myalept) (PDF) CP.PHAR.425 June 1, 2019
Midazolam (Nayzilam) (PDF) CP.PMN.211 January 1, 2020
Mifepristone (Korlym) (PDF) CP.PHAR.101 March 1, 2020
Migalastat (Galafold) (PDF) CP.PHAR.394 July 15, 2019
Miglustat (Zavesca) (PDF) CP.PHAR.164  June 1, 2019
Milnacipran (Savella) (PDF) CP.PMN.125 June 1, 2019
Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) (PDF) CP.PMN.80 December 1, 2020
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 June 1, 2021 - NEW
modafinil (Provigil) (PDF) CP.PMN.39 June 1, 2019
Mogamulizumab-kpkc (Poteligeo) (PDF) CP.PHAR.139 June 1, 2019
Mometasone (Nasonex) (PDF) HIM.PA.93 March 1, 2016
Mometasone (Asmanex) (PDF) CP.PCH.36 March 1, 2021
Mometasone Furoate (Sinuva) (PDF) CP.PHAR.448 March 1, 2020
Montelukast oral granules (Singulair) (PDF) HIM.PA.129 June 1, 2019
Monomethyl Fumarate (Bafiertam) (PDF) CP.PHAR.460 March 1, 2020
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) CP.PHAR.398 June 1, 2019
Moxidectin (PDF) CP.PMN.162 June 1, 2019
nafarelin acetate (Synarel®) (PDF) CP.PHAR.174 June 1, 2019
Naltrexone (Vivitrol) (PDF) CP.PHAR.96 November 1, 2020
Naproxen oral suspension (Naprosyn) (PDF) HIM.PA.130 June 1, 2019
natalizumab (Tysabri) (PDF) HIM.PA.SP17 June 1, 2021 - NEW
Nebivolol (Bystolic) (PDF) HIM.PA.131 June 1, 2019
necitumumab (Portrazza®) (PDF) CP.PHAR.320 June 1, 2019
Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF) CP.PMN.167 June 1, 2019
Neratinib (Nerlynx) (PDF) CP.PHAR.365 September 1, 2020
Netupitant and Palonosetron (Akynzeo) (PDF) CP.PMN.158 September 1, 2020
Nifurtimox (Lampit) ^ (PDF) CP.PMN.256 December 1, 2020
nilotinib (Tasigna) (PDF) CP.PHAR.76 November 7, 2017
Nintedanib (Ofev) (PDF) CP.PHAR.285 July 15, 2019
Nitisinone (Nityr, Orfadin) (PDF) CP.PHAR.132 June 1, 2019
Nivolumab (Opdivo) (PDF) CP.PHAR.121   September 8, 2017
No Coverage Criteria (PDF) CP.PMN.255 December 1, 2020
No Coverage Criteria/Off-Label Use Policy (PDF) CP.PMN.53 June 1, 2019
Non-Formulary and Formulary Contraceptives (PDF) HIM.PA.100 July 25, 2015
Non-Formulary Test Strips (PDF) HIM.PA.34 June 1, 2019
nusinersen (Spinraza®) (PDF) CP.PHAR.327 June 1, 2019
obinutuzumab (Gazyva®) (PDF) CP.PHAR.305 June 1, 2019
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 June 1, 2019
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF) CP.PHAR.40 September 1, 2020
ofatumumab (Arzerra®) (PDF) CP.PHAR.306 June 1, 2021 - NEW
Off-label Policy (PDF) HIM.PA.154 February 1, 2020
Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) CP.PHAR.292 January 1, 2020
olaparib (Lynparza) (PDF) CP.PHAR.360 June 1, 2019
olaratumab (Lartruvo®) (PDF) CP.PHAR.326 June 1, 2019
Omacetaxine (Synribo) (PDF) CP.PHAR.108 April 1, 2016
Omadacycline (Nuzyra)(PDF) CP.PMN.188 March 1, 2019
Omalizumab (Xolair®) (PDF) CP.PHAR.01 November 7, 2017
Omega-3-Acid Ethyl Esters (Lovaza) (PDF) CP.PMN.52 May 1, 2021
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 March 1, 2021
Onasemnogene abeparvovec (Zolgensma) (PDF) CP.PHAR.421 December 1, 2020
Ophthalmic Corticosteroids (PDF) HIM.PA.03 June 1, 2020
Opioid Analgesics (PDF) HIM.PA.139 January 1, 2018
Ospemifene (Osphena) (PDF) CP.PMN.168 June 1, 2019
Overactive Bladder Agents (PDF) CP.PMN.198 July 15, 2019
Ozanimod (Zeposia) (PDF) CP.PHAR.462 September 1, 2020
Paclitaxel, protein-bound (Abraxane) (PDF) CP.PHAR.176  June 1, 2019
Palbociclib (Ibrance) (PDF) CP.PHAR.125 September 1, 2020
Paliperidone (Invega) (PDF) CP.PMN.30 June 1, 2019
Palivizumab (Synagis) (PDF) CP.PHAR.16 December 8, 2017
panitumumab (Vectibix®) (PDF) CP.PHAR.321 June 1, 2019
Parathyroid Hormone (Natpara) (PDF) CP.PHAR.282 March 1, 2020
Paricalcitol Injection (Zemplar) (PDF) CP.PHAR.270 December 8, 2017
pasireotide (Signifor LAR®) (PDF) CP.PHAR.332 June 1, 2019
Patisiran (Onpattro) (PDF) CP.PHAR.395 June 1, 2019
Pazopanib (Votrient) (PDF) CP.PHAR.81 July 24, 2015
Peanut allergen powder (Palforzia) (PDF) CP.PMN.220 March 1, 2021
Pegademase Bovine (Adagen) (PDF) CP.PHAR.392 June 1, 2019
Pegaptanib (Macugen) (PDF) CP.PHAR.185 July 1, 2016
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF) CP.PHAR.353 June 1, 2019
Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) (PDF) CP.PHAR.296 May 1, 2021
Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) (PDF) CP.PHAR.89 July 24, 2015
peginterferon beta-1a (Plegridy) (PDF) CP.PHAR.271 December 1, 2020
Pegloticase (Krystexxa) (PDF) CP.PHAR.115 June 1, 2013
Pegvaliase-pqpz (Palynziq) (PDF) CP.PHAR.140 July 15, 2019
Pegvisomant (Somavert) (PDF) CP.PHAR.389 June 1, 2019
pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 January 1, 2021
Pemetrexed (Alimta, Pemfexy) (PDF) CP.PHAR.368 October 31, 2017
Penicillamine (Cuprimine) (PDF) CP.PCH.09 June 1, 2019
Perampanel (Fycompa) (PDF) CP.PMN.156 June 1, 2019
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 October 30, 2016
Pertuzumab-trastuzumab-hyaluronidase-zzxf (Phesgo) (PDF) CP.PHAR.501 December 1, 2020
Pexidartinib (Turalio)(PDF) CP.PHAR.436 December 1, 2019
Phendimetrazine IR (Bontril PDM) (PDF) HIM.PA.114 June 1, 2019
Phentermine (Adipex-P, Lomaira) (PDF) CP.PCH.13 July 15, 2019
Pimecrolimus (Elidel) (PDF) CP.PMN.98 June 1, 2019
Pirfenidone (Esbriet) (PDF) CP.PHAR.286 December 1, 2020
Pitolisant (Wakix) (PDF) CP.PMN.221 May 1, 2019
Plerixafor (Mozobil) (PDF) CP.PHAR.323 June 1, 2019
Polatuzumab Vedotin-piiq (Polivy) (PDF) CP.PHAR.433 January 1, 2021
Pomalidomide (Pomalyst) (PDF) CP.PHAR.116 April 1, 2016
Potassium (Klor-Con) (PDF) HIM.PA.143 June 1, 2019
pralatrexate (Folotyn®) (PDF) CP.PHAR.313 June 1, 2019
Pralsetinib (Gavreto) (PDF) CP.PHAR.514 February 1, 2020
Pramlintide (Symlin) (PDF) CP.PMN.129 June 1, 2019
Prasterone (Intrarosa) (PDF) CP.PMN.99 March 1, 2021
pregabalin (Lyrica) (PDF) CP.PMN.33 June 1, 2019
Pretomanid (PDF) CP.PMN.222 March 1, 2021
protein c concentrate, human (Ceprotin®) (PDF) CP.PHAR.330 July 15, 2019
propranolol HCL solution (Hemangeol) (PDF) CP.PMN.58 June 1, 2019
Prucalopride (Motegrity) (PDF) CP.PMN.194 September 1, 2019
pyrimethamine (Daraprim®) (PDF) CP.PMN.44  June 1, 2019
Quetiapine ER (Seroquel XR) (PDF) CP.PMN.64 June 1, 2019
Ondansetron (Zuplenz) (PDF) CP.PMN.45 March 1, 2020
Quinine Sulfate (Qualaquin) (PDF) HIM.PA.144 June 1, 2019
Quinine Sulfate (Qualaquin) (PDF) CP.PCH.10 June 1, 2019
Ramelteon (Rozerem) (PDF) CP.PMN.173 June 1, 2019
Ramucirumab (Cyramza) (PDF) CP.PHAR.119 September 8, 2017
Ranibizumab (Lucentis) (PDF) CP.PHAR.186 November 1, 2020
rasagiline (Azilect®) (PDF) HIM.PA.89 March 1, 2016
Ravulizumab-cwvz (Ultomiris) (PDF) CP.PHAR.415 June 1, 2019
Regorafenib (Stivarga) (PDF) CP.PHAR.107 March 1, 2016
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) CP.PHAR.168 September 8, 2017
Reslizumab (Cinqair) (PDF) CP.PHAR.223 September 8, 2017
Revefenacin (Yupelri) (PDF) CP.PMN.195 September 1, 2019
Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF) CP.PHAR.141 June 1, 2019
Rifabutin (Mycobutin) (PDF) CP.PMN.223 May 1, 2021 
rifaximin (Xifaxan®) (PDF) CP.PMN.47 March 1, 2016
Rilonacept (Arcalyst) (PDF) CP.PHAR.266 November 7, 2017
Ripretinib (Qinlock) (PDF) CP.PHAR.502 December 1, 2020
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 November 7, 2017
Riociguat (Adempas®) (PDF) CP.PHAR.195 July 1, 2016
Risdiplam (Evrysdi) (PDF) CP.PHAR.477 September 1, 2020
Risedronate (Actonel, Atelvia) (PDF) CP.PMN.100 June 1, 2019
Risperidone Long-Acting Injection (Risperdal Consta) (PDF) CP.PHAR.293 March 1, 2016
Rolapitant (Varubi) (PDF) CP.PMN.102 June 1, 2019
romidepsin (Istodax®) (PDF) CP.PHAR.314 June 1, 2019
Romiplostim (Nplate®) (PDF) CP.PHAR.179  March 1, 2021
Romosozumab-aqqg (Evenity) (PDF) CP.PHAR.428 January 1, 2020
Rucaparib (Rubraca®) (PDF) CP.PHAR.350 March 1, 2020
Rufinamide (Banzel) (PDF) CP.PMN.157 March 1, 2016
Ruxolitinib (Jakafi) (PDF) CP.PHAR.98 September 8, 2017
Sacituzumab Govitecan-hziy (Trodelvy) (PDF) CP.PHAR.475 March 1, 2021
Sacubitril/Valsartan (Entresto) (PDF) CP.PMN.67 June 1, 2019
Safinamide (Xadago) (PDF) CP.PMN.113 March 1, 2020
Sapropterin (Kuvan) (PDF) CP.PHAR.43 September 8, 2017
Sarecycline (Seysara) (PDF) CP.PMN.189 March 1, 2020
Sargramostim (Leukine) (PDF) CP.PHAR.295 June 1, 2019
Satralizumab-mwge (Enspryng) (PDF) CP.PHAR.463 May 1, 2021
Sebelipase Alfa (Kanuma) (PDF) CP.PHAR.159 June 1, 2019
Secnidazole (Solosec) (PDF) CP.PMN.103 June 1, 2019
Segesterone acetate/Ethinyl estradiol (Annovera) (PDF) CP.PMN.190 July 15, 2019
Selexipag (Uptravi®) (PDF) CP.PHAR.196 March 1, 2020
Selinexor (Xpovio) (PDF) CP.PHAR.431 January 1, 2020
Selpercatinib (Retevmo) (PDF) CP.PHAR.478 September 1, 2020
Selumetinib (Koselugo) (PDF) CP.PHAR.464 March 1, 2021
Sildenafil (Revatio®) (PDF) CP.PHAR.197 July 1, 2016
Sildenafil (Viagra) (PDF) CP.PCH.07 June 1, 2019
Siponimod (Mayzent) (PDF) CP.PHAR.427 January 1, 2020
Sipuleucel-T (Provenge) (PDF) CP.PHAR.120 April 1, 2016
Siltuximab (Sylvant) (PDF) CP.PHAR.329 March 1, 2021
sodium oxybate (Xyrem) (PDF) CP.PMN.42 May 1, 2019
Sodium-Glucose Co-Transporter 2  Inhibitors (PDF) HIM.PA.91 June 1, 2019
Sodium Phenylbutyrate (Buphenyl) (PDF) CP.PHAR.208 March 1, 2020
Sodium Zirconium Cyclosilicate (Lokelma) (PDF) CP.PMN.163 March 1, 2020
Sofosbuvir (Sovaldi) (PDF) HIM.PA.SP2 November 1, 2020
Sofosbuvir-Velpatasvir (Epclusa)  (PDF) HIM.PA.SP1 August 1, 2020
Sofosbuvir-Vepatasvir-Voxilaprevir (Vosevi) (PDF) HIM.PA.SP63 August 1, 2020
Solriamfetol (Sunosi) (PDF) CP.PMN.209 January 1, 2020
Somatropin (Growth Hormone) (PDF) CP.PCH.25 November 7, 2017
Sonidegib (Odomzo) (PDF) CP.PHAR.272 December 8, 2017
sorafenib (Nexavar) (PDF) CP.PHAR.69 October 30, 2016
Spinosad (Natroba) (PDF) HIM.PA.134 June 1, 2019
Step Therapy (PDF) HIM.PA.109 June 1, 2019
Stiripentol (Diacomit) (PDF) CP.PMN.184 March 1, 2020
sucroferric oxyhydoxide (Velphoro) (PDF) HIM.PA.SP30 June 1, 2019
Sulfacetamide Sodium Sulfur (Sumadan) (PDF) HIM.PA.145 June 1, 2019
sunitinib (Sutent) (PDF) CP.PHAR.73 December 8, 2017
Suvorexant (Belsomra®) (PDF) CP.PMN.109 June 1, 2019
Tadalafil (Adcirca®) (PDF) CP.PHAR.198 July 1, 2016
Tadalafil BHP - ED (Cialis) (PDF) CP.PMN.132 June 1, 2019
Tafamidis (Vyndaqel, Vyndamax) (PDF) CP.PHAR.432 January 1, 2020
Tafasitamab-cxix (Monjuvi) (PDF) CP.PHAR.508 December 1, 2020
Tafenoquine (Krintafel) (PDF) CP.PMN.178 June 1, 2019
Talazoparib (Talzenna)(PDF) CP.PHAR.409 March 1, 2019
Taliglucerase Alfa (Elelyso) (PDF) CP.PHAR.157 January 1, 2021
Tasimelteon (Hetlioz) (PDF) CP.PMN.104 June 1, 2019
tavaborole (Kerydin®) (PDF) CP.PMN.105 June 1, 2019
Tazarotene (Arazlo, Fabior, Tazorac) (PDF) CP.PMN.244 November 1, 2020
Tazemetostat (PDF) CP.PHAR.452 June 1, 2020
Tedizolid (Sivextro) (PDF) CP.PMN.62 June 1, 2019
Teduglutide (Gattex) (PDF) CP.PHAR.114 September 8, 2017
Tegaserod (Zelnorm) (PDF) CP.PMN.206 January 1, 2020
Temozolomide (Temodar) (PDF) CP.PHAR.77 December 8, 2017
temsirolimus (Torisel®) (PDF) CP.PHAR.324 June 1, 2019
Tenapanor (Ibsrela) (PDF) CP.PMN.224 March 1, 2021
Tenofovir Alafenamide Fumarate (Vemlidy) (PDF) CP.PCH.33 December 1, 2020
Teprotumumab (Tepezza) (PDF) CP.PHAR.465 December 1, 2020
Teriflunomide (Aubagio) (PDF) CP.PCH.40 March 1, 2021
Teriparatide (Forteo®) (PDF) CP.PHAR.188 July 1, 2016
Tesamorelin (Egrifta) (PDF) CP.PHAR.109 April 1, 2016
Testosterone (Androderm) (PDF) HIM.PA.87 March 1, 2016
Testosterone (Testopel, Jatenzo) (PDF) CP.PHAR.354 March 1, 2020
tetrabenazine (Xenazine) (PDF) CP.PHAR.92 July 24, 2015
Tezacaftor-Ivacaftor (Symdeko) (PDF) CP.PHAR.377 March 1, 2021
Thalidomide (Thalomid) (PDF) CP.PHAR.78 October 30, 2016
Thioguanine (Tabloid) (PDF) CP.PHAR.437 June 1, 2019
Thyrotropin Alfa (Thyrogen) (PDF) CP.PHAR.95 July 24, 2015
Timothy grass pollen allergen extract (Grastek®) (PDF) CP.PMN.84  June 1, 2019
Tisagenlecleucel (Kymriah) (PDF) CP.PHAR.361 June 1, 2019
Tobramycin (PDF) CP.PHAR.211 September 8, 2017
Tolvaptan (Jynarque) (PDF) CP.PHAR.27 June 1, 2019
Topical Acne Treatment (PDF) HIM.PA.71 March 1, 2016
Topotecan (Hycamtin) (PDF) CP.PHAR.64 October 30, 2016
Topical Immunomodulators (PDF) CP.PMN.107 July 15, 2019
Trabectedin (Yondelis) (PDF) CP.PHAR.204 September 8, 2017
Trametinib (Mekinist) (PDF) CP.PHAR.240 November 7, 2017
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) CP.PHAR.228 March 1, 2021
Treprostinil (Orenitram®, Remodulin®, Tyvaso®) (PDF) CP.PHAR.199  July 1, 2016
Triamcinolone ER Injection (Zilretta) (PDF) CP.PHAR.371 June 1, 2019
Triclabendazole (Egaten) (PDF) CP.PMN.207 January 1, 2020
Trientine (Syprine) (PDF) CP.PHAR.438 June 1, 2019
Trifarotene (Aklief) (PDF) CP.PMN.225 August 1, 2020
Trifluridine/Tipiracil (Lonsurf) (PDF) CP.PHAR.383 September 1, 2020
Triheptanoin (Dojolvi) ^ (PDF) CP.PHAR.509 December 1, 2020
triptorelin pamoate (Trelstar®, Triptodur®) (PDF) CP.PHAR.175 June 1, 2019
Ubrogepant (Ubrelvy) (PDF) CP.PHAR.476 September 1, 2020
Unoprostone Isopropyl (Rescula) (PDF) HIM.PA.11 June 1, 2019
Uridine acetate (Vistogard) (PDF) HIM.PA.SP55 June 1, 2019
valganciclovir (Valcyte) (PDF) CP.PCH.06 June 1, 2019
Valproate Sodium for Intravenous Injection (Depacon) (PDF) CP.PHAR.429 January 1, 2020
Valrubicin (Valstar) (PDF) CP.PHAR.439 June 1, 2019
Vandetanib (Caprelsa®) (PDF) CP.PHAR.80 July 24, 2015
Vedolizumab (Entyvio) (PDF) CP.PHAR.265 November 7, 2017
Velaglucerase Alfa (VPRIV) (PDF) CP.PHAR.163 June 1, 2019
Vemurafenib (Zelboraf®) (PDF) CP.PHAR.91 July 24, 2015
Vestronidase alfa-vjbk (Mepsevii) (PDF) CP.PHAR.374 June 1, 2019
Verteporfin (PDF) CP.PHAR.187 July 1, 2016
Vigabatrin (Sabril) (PDF) CP.PHAR.169  June 1, 2019
Vilazodone (Viibryd) (PDF) CP.PMN.145 June 1, 2019
Viltolarsen (Viltepso) (PDF) CP.PHAR.484 September 1, 2020
vincristine sulfate liposome injection (Marqibo®) (PDF) CP.PHAR.315 June 1, 2019
Vismodegib (Erivedge) (PDF) CP.PHAR.273 December 8, 2017
Vorapaxar (Zontivity) (PDF) HIM.PA.146 June 1, 2019
Voretigene neparvovec-rzyl (Luxturna) (PDF) CP.PHAR.372 June 1, 2019
Vortioxetine (Trintellix®) (PDF) CP.PMN.65  June 1, 2019
Voxelotor (Oxbryta) (PDF) CP.PHAR.451 June 1, 2020
Zanubrutinib (Brukinsa) (PDF) CP.PHAR.467 March 1, 2021
ziv-aflibercept (Zaltrap®) (PDF) CP.PHAR.325 June 1, 2019
Zoledronic acid (PDF) CP.PHAR.59 July 1, 2016
Vorinostat (Zolinza) (PDF) CP.PHAR.83 July 24, 2015

Allwell Policies

Policy Title Policy Number Effective Date
3-Day Payment Window (PDF) CC.PP.500 July 1, 2014
Acupuncture (PDF) CP.MP.92 February 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 March 1, 2020
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF) CP.MP.108 January 1, 2021
Ambulatory EEG (PDF) CP.MP.96 August 12, 2016
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, 2020
Bone-Anchored Hearing Aid (PDF) CP.MP.93 October 1, 2020
Bronchial Thermoplasty (PDF) CP.MP.110 April 1, 2017
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 July 31, 2020
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 July 31, 2020
Coding Overview (PDF) CC.PP.011 October 18, 2016
Cosmetic Reconstructive Surgery (PDF) CP.MP.31 March 1, 2021
Cosmetic Procedures (PDF) CC.PP.024 October 18, 2016
Dental Anesthesia (PDF) CP.MP.61 March 31, 2020
Diagnosis of Vaginitis (PDF) CP.MP.97 June 1, 2021
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 September 1, 2020
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
Duplicate Primary Code Billing (PDF) CC.PP.044 February 7, 2017
Durable Medical Equipment (DME) (PDF) CP.MP.107 May 1, 2021
E&M Medical Decision-Making (PDF) CC.PP.051 July 25, 2017
EEG in Evaluation of Headache (PDF) CP.MP.155 December 1, 2020
Electric Tumor Treatment Fields (PDF) CP.MP.145 July 1, 2020
EM Bundling Edits (PDF) CC.PP.010 August 12, 2016
Endometrial Ablation (PDF) CP.MP.106 December 10, 2018
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 May 1, 2021
Experimental Technologies (PDF) CP.MP.36 June 30, 2020
Facet Joint Interventions (PDF) CP.MP.171 March 4, 2020
Fecal Calprotectin Assay (PDF) CP.MP.135 June 17, 2017
Fecal Incontinence Treatments (PDF) CP.MP.137 July 31, 2020
FeNo Testing (PDF) CP.MP.103 January 1, 2021
Ferriscan R2-MRI (PDF) CP.MP.53 December 1, 2020
Fertility Preservation (PDF) CP.MP.130 November 1, 2020
Fixed Wing Air Transportation (PDF) CP.MP.175 February 1, 2021
Gender Reassignment (PDF) CP.MP.95 February 1, 2021
Genetic Testing (PDF) CP.MP.89 March 31, 2020
Global Maternity Billing (PDF) CC.PP.016 October 18, 2016
Heart-Lung Transplant (PDF) CP.MP.132 June 1, 2020
H Pylori Testing (PDF) CP.MP.153 December 1, 2020
Holter Monitors (PDF) CP.MP.113 April 1, 2017
Home Births (PDF) CP.MP.136 February 1, 2021
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) CP.MP.150 March 1, 2021
Homocysteine Testing (PDF) CP.MP.121 May 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 - NEW
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 Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 June 1, 2020
Inhaled Nitric Oxide (PDF) CP.MP.87 January 1, 2021
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, 2020
Intradiscal Steroid Injections for Pain Management (PDF) CP.MP.167 October 1, 2020
Laser Skin Treatment (PDF) CP.MP.123 April 1, 2017
Leveling of Emergency Room (PDF) CC.PP.053  January 1, 2019
Long Term Care Placement Criteria (PDF) CP.MP.71 March 16, 2017
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 February 1, 2021
Lung Transplantation (PDF) CP.MP.57 July 1, 2020
Lysis of Epidural Lesions (PDF) CP.MP.116 November 1, 2020
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 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 Sleep Latency Testing (PDF) CP.MP.24 June 1, 2020
NCCI Unbundling (PDF) CC.PP.031 October 18, 2016
Nerve Blocks for Pain Management (PDF) CP.MP.170 February 1, 2021
Neurofeedback for Behavioral Health Disorders (PDF) CP.BH.300 February 1, 2021
Never Paid Events (PDF) CC.PP.017 October 18, 2016
New Patient (PDF) CC.PP.036 February 7, 2017
Non-Invasive Home Ventilator (PDF) CP.MP.184 December 1, 2020
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, 2020
Outpatient Consultation (PDF) CC.PP.039 February 7, 2017
Outpatient Cardiac Rehabilitation (PDF) CP.MP.176 July 1, 2020
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 July 1, 2021 - NEW
Oxygen Use and Concentrators  (PDF) CP.MP.190 January 1, 2021
Paclitaxel (PDF) CP.PHAR.176 May 16, 2016
Pancreas Transplantation (PDF) CP.MP.102 April 1, 2021
Panniculectomy (PDF) CP.MP.109 July 1, 2020
Pediatric Liver Transplant (PDF) CP.MP.120 November 1, 2020
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) CP.MP.147 July 1, 2020
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 March 15, 2021
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) CP.MP.133 October 1, 2020
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 April 1, 2021
Pulse Oximetry (PDF) CC.PP.025 October 18, 2016
Radiofrequency Ablation of Uterine Fibroids (PDF) CP.MP.187 June 1, 2020
Radial Head Implant (PDF) CP.MP.148 July 1, 2020
Reduction Mammoplasty and Gynecomastia Surgery (PDF) CP.MP.51 July 31, 2020
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, 2020
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 October 1, 2020
Selective Dorsal Rhizotomy (PDF) CP.MP.174 March 31, 2020
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF) CP.MP.165 October 1, 2020
Sickle Cell Disease Observation (PDF) CP.MP.88 March 16, 2017
Skilled Nursing Facility Leveling (PDF) CP.MP.206 March 1, 2021
Skin Substitutes for Chronic Wounds (PDF) CP.MP.185 June 1, 2020
Spinal Cord Stimulation (PDF) CP.MP.117 March 31, 2020
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 July 31, 2020
Total Artificial Heart (PDF) CP.MP.127 January 1, 2021
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 June 1, 2020
Thymus Transplantation (PDF) CP.MP.189 October 1, 2020
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 August 1, 2021
Transgender Related Services (PDF) CC.PP.047 February 22, 2017
Trigger Point Injections for Pain Management (PDF) CP.MP.169 February 1, 2021
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
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142 July 1, 2020
Urine Specimen Validity Testing (PDF) CC.PP.056 November 8, 2017
Urodynamic Testing (PDF) CP.MP.98 March 1, 2021
Vagus Nerve Stimulation (PDF) CP.MP.12 February 1, 2021
Ventricular Assist Devices (PDF) CP.MP.46 July 1, 2021 - NEW
Video Electroencephalographic (VEEG) Monitoring (PDF) CP.MP.177 June 1, 2020
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
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
Allergy Testing (PDF) CP.MP.100 May 1, 2021
Ambulatory EEG (PDF) CP.MP.96 August 12, 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
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
Diagnosis of Vaginitis (PDF) CP.MP.97 June 1, 2021 - NEW
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 - NEW
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
Endometrial Ablation (PDF) CP.MP.106 December 10, 2018
EpiFix Wound Treatment (PDF) CP.MP.140 November 1, 2017
Evoked Potentials (PDF) CP.MP.134 May 1, 2021
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
Homocysteine Testing (PDF) CP.MP.121 May 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
Laser Skin Treatment (PDF) CP.MP.123 April 1, 2017
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
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
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 March 15, 2021
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
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) CP.MP.181 March 15, 2021
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
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
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
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