Clinical & Payment Policies
Clinical Policies
Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information.
All policies found in the PA Health and Wellness Clinical Policy Manual apply to PA Health and Wellness members. Policies in the PA Health and Wellness Clinical Policy Manual may have either a PA Health and Wellness or a “Centene” heading. PA Health and Wellness utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a PA Health and 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 PA Health and Wellness. In addition, PA Health and 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 PA Health and Wellness.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
A-H
- Acupuncture PA.CP.MP.92 July 2023 (PDF)
- AHC Transplants SCA Thalassemia PA.CP.MP.108 October 2023 (PDF)
- Allergy Testing and Therapy PA.CP.MP.100 December 2022 (PDF)
- Articular Cartilage Defect Repairs PA.CP.MP.26 September 2023 (PDF)
- Bariatric Surgery PA.CP.MP.37 February 2023 (PDF)
- Biofeedback PA.CP.MP.168 v1.2024 (PDF)
- Bone-Anchored Hearing Aid PA.CP.MP.93 June 2023 (PDF)
- Bronchial Thermoplasty PA.CP.MP.110 April 2023 (PDF)
- Burn Surgery PA.CP.MP.186 November 2023 (PDF)
- Cardiac Biomarker Testing Annual PA.CP.MP.156 September 2023 (PDF)
- Caudal or Interlaminar ESIs PA.CP.MP.164 July 2023 (PDF)
- Clinical Trials PA.CP.MP.94 June 2023 (PDF)
- Cochlear Implant Replacements PA.CP.MP.14 July 2023 (PDF)
- Cosmetic and Reconstructive Surgery PA.CP.MP.31 October 2023 (PDF)
- DBP Recommended Payment Policy CG.CC.PP.01 (PDF)
- Dental Anesthesia PA.CP.MP.61 September 2023 (PDF)
- Dermatologic Testing CG.CP.MP.03 (PDF)
- Diaphragmatic Phernic Nerve Simulation PA.CP.MP.203 October 2023 (PDF)
- Disc Decompression Procedures PA.CP.MP.114 September 2022 (PDF)
- Discography PA.CP.MP.115 June 2023 (PDF)
- Digital EEG Analysis PA.CP.MP.105 November 2023 (PDF)
- DME Outpatient Criteria PA.CP.MP.107 October 2023 (PDF)
- Donor Lymphocyte Infusion PA.CP.MP.101 September 2023 (PDF)
- Drugs of Abuse - Definitive Testing PA.CP.MP.50 June 2023 (PDF)
- EEG Headache PA.CP.MP.155 September 2023 (PDF)
- Electric Tumor Treatment Fields PA.CP.MP.145 November 2023 (PDF)
- Endometrial Ablation PA.CP.MP.106 August 2023 (PDF)
- Evoked Potentials PA.CP.MP.134 September 2023 (PDF)
- Experimental Technologies PA.CP.MP.36 March 2024 (PDF)
- Facet Joint Interventions PA.CP.MP.171 July 2023 (PDF)
- Fecal Incontinence Treatments PA.CP.MP.137 July 2023 (PDF)
- Ferriscan R2 MRI PA.CP.MP.53 October 2023 (PDF)
- Fertility Preservation PA.CP.MP.130 v1.2024 (PDF)
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations PA.CP.MP.129 January 2024 (PDF)
- Functional MRI PA.CP.MP.43 March 2024 (PDF)
- Gastric Electrical Stimulation PA.CP.MP.40 August 2023 (PDF)
- Gastroenterologic Testing Policy CG.CP.MP.04 (PDF)
- Gender Affirming Surgery PA.CP.MP.95 v1. August 2023 (PDF)
- Heart Lung Transplant PA.CP.MP.132 November 2023 (PDF)
- Holter Monitors PA.CP.MP.113 June 2023 (PDF)
- Homocysteine Testing PA.CP.MP.121 March 2023 (PDF)
- Hospice Service PA.CP.MP.54 July 2023 (PDF)
- H Pylori Serology Testing PA.CP.MP.153 September 2023 (PDF)
- Hyperhidrosis Treatments PA.CP.MP.62 v1. January 2024 (PDF)
I-Q
- ID Genitourinary Testing CG.CP.MP.07 (PDF)
- ID Multisystem Testing CG.CP.MP.02 (PDF)
- ID Respiratory Testing CG.CP.MP.01 (PDF)
- Implantable Intrathecal Pain Pump PA.CP.MP.173 v1. January 2024 (PDF)
- ID Vector Borne and Tropical Disease Testing CG.CP.MP.06 (PDF)
- Implantable Loop Recorder PA.CP.MP.243 v1. January 2024 (PDF)
- Implantable Wireless PAP Monitoring PA.CP.MP.160 April 2023 (PDF)
- Intensity-Modulated Radiotherapy PA.CP.MP.69 September 2023 (PDF)
- Intestinal and Multivisceral Transplant PA.CP.MP.58 September 2023 (PDF)
- Intradiscal Steroid Injections PA.CP.MP.167 September 2023 (PDF)
- Laser Therapy for Skin Conditions PA.CP.MP.123 March 2023 (PDF)
- Long Term Care Placement PA.CP.MP.71 March 2024 (PDF)
- Low Frequency US Therapy for Wound Management PA.CP.MP.139 April 2023 (PDF)
- Lung Transplantation PA.CP.MP.57 August 2023 (PDF)
- Lysis of Epidural Lesions PA.CP.MP.116 September 2022 (PDF)
- Measurement of Serum 1,25 dihydroxyvitamin D PA.CP.MP.152 September 2023 (PDF)
- Mechanical Stretch Devices PA.CP.MP.144 November 2023 (PDF)
- Multiple Sleep Latency Testing PA.CP.MP.24 April 2023 (PDF)
- Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) PA.CP.MP.48 July 2023 (PDF)
- Nerve Blocks PA.CP.MP.170 September 2023 (PDF)
- Non-Invasive Home Ventilator PA.CP.MP.184 June 2023 (PDF)
- Nonmyeloablative Allogenic Stem Cell Transplants PA.CP.MP.141 February 2023 (PDF)
- Optic Nerve Decompression Surgery PA.CP.MP.128 v1. July 2023 (PDF)
- Outpatient Testing for DOA PA.CP.MP.50 v1. October 2023 (PDF)
- Pancreas Transplantation PA.CP.MP.102 September 2023 (PDF)
- Panniculectomy PA.CP.MP.109 October 2023 (PDF)
- Percutaneous LAA Device Stroke Prevention PA.CP.MP.147 February 2023 (PDF)
- Physical Occupational and Speech Therapy Services PA.CP.MP.49 June 2023 (PDF)
- Primary Care Preventative Testing CG.CP.MP.05 (PDF)
- Posterior Nerve Stimulation for Voiding Dysfunction PA.CP.MP.133 September 2023 (PDF)
- Proton and Neutron Beam Therapy PA.CP.MP.70 November 2023 (PDF)
- Pulmonary Function Testing PA.CP.MP.242 March 2023 (PDF)
R-Z
- Reduction Mammoplasty Gynecomastia Surgery PA.CP.MP.51 July 2023 (PDF)
- Sacroiliac Joint Fusion PA.CP.MP.126 June 2023 (PDF)
- Sacroiliac Joint Interventions PA.CP.MP.166 September 2023 (PDF)
- Sclerotherapy for Varicose Veins PA.CP.146 April 2023 (PDF)
- Selective Dorsal Rhizotomy for Spasticity PA.CP.MP.174 November 2023 (PDF)
- Selective Nerve Root Blocks and Transoraminal Epidural Steroid Injections PA.CP.MP.165 September 2023 (PDF)
- Short Inpatient Hospital Stay PA.CP.MP.182 October 2023 (PDF)
- Skin Substitutes for Chronic Wounds PA.CP.MP.185 April 2023 (PDF)
- Stereotactic Body Radiation Therapy PA.CP.MP.22 January 2024 (PDF)
- Spinal Cord Stimulation PA.CP.MP.117 January 2024 (PDF)
- Tandem Transplant PA.CP.MP.162 September 2023 (PDF)
- Total Artificial Heart PA.CP.MP.127 July 2023 (PDF)
- Total Par Nurtr Intradialytic PA.CP.MP.163 April 2023 (PDF)
- Transcatheter Closure of Patent Foramen Ovale PA.CP.MP.151 November 2023 (PDF)
- Trigger Point Injections PA.CP.MP.169 August 2023 (PDF)
- Ultrasound in Pregancy PA.CP.MP.38 February 2023 (PDF)
- Urinary Incontinence Devices Treatments PA.CP.MP.142 v1. 2024 (PDF)
- Urodynamic Testing PA.CP.MP.98 March 2023 (PDF)
- Vagus Nerve Stimulation PA.CP.MP.12 August 2023 (PDF)
- Ventricular Assist Devices PA.CP.MP.46 February 2023 (PDF)
- Wheelchair Seating PA.CP.MP.99 November 2023 (PDF)
- Wireless Motility Capsule PA.CP.MP.143 September 2023 (PDF)
A-H Policies
- 3 Day Payment Window Policy CC.PP.500 (PDF)
- 30 Day Readmission CC.PP.501 (PDF)
- Add on Policy CC.PP.030 (PDF)
- Assistant Surgeon CC.PP.029 (PDF)
- Bilateral Services CC.PP.037 (PDF)
- Cerumen Removal CC.PP.008 (PDF)
- Clean Claims CC.PP.021 Clean Claims (PDF)
- Clean Claim Reviews CC.PI.04 (PDF)
- Clean Claim - Cost to Charge Adjustments on Clean Claim Reviews CC.PI.06 (PDF)
- Clean Claim - Unbundling Adjustments on Clean Claim Reviews CC.PI.10 (PDF)
- CLIA CC.PP.022 (PDF)
- Clinic Facility Charge CC.PP.059 (PDF)
- Clinical Validation of Modifier 59 CC.PP.014 (PDF)
- Code Editing CC.PP.011 (PDF)
- Cosmetic Procedures CC.PP.024 (PDF)
- Distinct Procedural Modifiers CC.PP.020 (PDF)
- Duplicate Primary Code Billing CC.PP.044 (PDF)
- ED Facility EM Policy CC.PP.064 (PDF)
- EM Bundling with Labs and Radiology CC.PP.010 (PDF)
- EM Medical Decision Making CC.PP.051 (PDF)
- E&M Services Billed with Treatment Room Revenue Codes CC.PP.071 (PDF)
- EM Services Billed with Treatment Room Revenue Codes_Medicare Version CC.PP.072 (PDF)
- Hospital Visit Codes Billed with Labs CC.PP.023 (PDF)
I-Q Policies
- Inpatient Consultation CC.PP.038 (PDF)
- Inpatient Only Procedures CC.PP.018 (PDF)
- Intravenous Hydration CC.PP.012 (PDF)
- Leveling of Care ER CC.PP.053 (PDF)
- Leveling of Care Evaluation and Management Overcoding (NEW) CC.PP.066 (PDF)
- Leveling of Care Policy Professional CC.PP.058 (PDF)
- Maximum Units of Service CC.PP. 007 (PDF)
- Moderate Conscious Sedation CC.PP.015 (PDF)
- Modifier 25 CC.PP.013 (PDF)
- Modifier DOS Validation (CC.PP.034) (PDF)
- Modifier to Procedure Code Validation CC.PP.028 (PDF)
- MPPR for Ophthalmology CC.PP.069 (PDF)
- Multiple CPT Codes Replacement CC.PP.033 (PDF)
- Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (NEW) CC.PP.065 (PDF)
- Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services CC.PP.068 (PDF)
- NCCI Unbundling CC.PP.031 (PDF)
- Never Paid Events CC.PP.017 (PDF)
- New Patient CC.PP.036 (PDF)
- Non-obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds CC.PP.061 (PDF)
- Not Medically Necessary Inpatient Professional Services CC.PP.060 (PDF)
- Optum Comprehensive Payment Integrity (CPI) CC.PP.074 (PDF)
- Outpatient Consulation CC.PP.039 (PDF)
- Pelvic and Transabdominal Ultrasound CC.PP.061 (PDF)
- Physicians Consultation Services CC.PP.054 (PDF)
- Physicians Office Laboratory Testing CC.PP.055 (PDF)
- Place of Service Mismatch CC.PP.063 (PDF)
- Postoperative Visits CC.PP.042 (PDF)
- Preoperative Visits CC.PP.041 (PDF)
- Problem Oriented Visits with Preventative Services CC.PP.057 (PDF)
- Problem Oriented Visits with Surgical Procedures CC.PP.052 (PDF)
- Professional Component Modifier CC.PP.027 (PDF)
- Professional Services Billed with Labs CC.PP.019 (PDF)
- Pulse Oximetry with Office Visits CC.PP.025 (PDF)
R-Z Policies
- Renal Dialysis CC.PP.067 (PDF)
- Reporting the Global Maternity Package CC.PP.016 (PDF)
- Robotic Surgeries CC.PP.050 (PDF)
- Same Day Visits CC.PP.040 (PDF)
- Sepsis Diagnosis CC.PP.073 (PDF)
- Severe Malnutrition CC.PP.145 (PDF)
- Sleep Studies Place of Service CC.PP.035 (PDF)
- Status B Bundled Services CC.PP.046 (PDF)
- Status P Bundled Services CC.PP.049 (PDF)
- Supplies Same Day as Surgery CC.PP.032 (PDF)
- Transgender Related Services CC.PP.047 (PDF)
- Unbundled Professional Services CC.PP.043 (PDF)
- Unbundled Surgical Procedures CC.PP.045 (PDF)
- Unlisted Procedure Codes CC.PP.009 (PDF)
- Urine Specimen Validity Testing CC.PP.056 (PDF)
- Wheelchairs and Accessories CC.PP.502 (PDF)
Payment Policies
- PHW Provider Payment Policy Notification November 11, 2020 (PDF)
- PHW Provider Payment Policy Notification August 14, 2020 (PDF)
- PHW Provider Payment Policy Notification April 22, 2020 (PDF)
- PHW Provider Payment Policy Notification December 20, 2019 (PDF)
- PHW Provider Payment Policy Notification October 10, 2019 (PDF)
Pharmacy Policies
Pennsylvania Medical Assistance Program's Statewide Preferred Drug List (PDL) Pharmacy Policies
A
- Acne Agents, Oral v1.2024 (PDF)
- Acne Agents, Topical v1.2024 (PDF)
- Alcohol Use Disorder Agents v1.2024 (PDF)
- Alzheimers Agents v1.2024 (PDF)
- Analgesics Long-Acting Opioids v1. 2024 (PDF)
- Analgesics Non-Opioid Barbiturate Combinations v1.2024 (PDF)
- Analgesics, Opioid Short-Acting v1. 2024 (PDF)
- Androgenic Agents v1.2024 (PDF)
- Angiotensin Modulators v1.2024 (PDF)
- Angiotensin Modulator Combinations v1.2024 (PDF)
- Antianginal Agents v1.2024 (PDF)
- Antibiotics, Inhaled v1.2024 (PDF)
- Antibiotics, GI and Related Agents v1.2024 (PDF)
- Antibiotics, Topical v1.2024 (PDF)
- Anticoagulants v1.2024 (PDF)
- Anticonvulsants v1.2024 (PDF)
- Antidepressants, Other v1.2024 (PDF)
- Antidepressants, SSRIs (Selective Serotonin Reuptake Inhibitors) v1.2024 (PDF)
- Antiemetics Antivertigo Agents v1.2024 (PDF)
- Antifibrotics Respiratory Agents v1.2024 (PDF)
- Antifungals, Oral v1.2024 (PDF)
- Antifungals, Topical v1.2024 (PDF)
- Antihemophilia Agents v1.2024 (PDF)
- Antihistamines, Minimally Sedating v1.2024 (PDF)
- Antihypertensives, Sympatholytic v1.2024 (PDF)
- Antihyperuricemics v1.2024 (PDF)
- Antimalarials v1.2024 (PDF)
- Antimigraine Agents, Other v2.2020 (PDF)
- Antimigraine Agents, Triptans v2.2020 (PDF)
- Antiparasitics, Topical v1. 2024 (PDF)
- Antiparkinson's Agents v1.2024 (PDF)
- Antipsoriatics, Oral v2.2024 (PDF)
- Antipsoriatics, Topical v1.2024 (PDF)
- Antipsychotics v1.2024 (PDF)
- Antivirals, CMV v1.2024 (PDF)
- Antivirals, Herpes v1.2024 (PDF)
- Antivirals, Influenza v1.2024 (PDF)
- Anxiolytics v1.2024 (PDF)
B
- Beta-Blockers v1.2024 (PDF)
- Bile Salts v1.2024 (PDF)
- Bladder Relaxant Preparations v1.2024 (PDF)
- Blood Glucose Meters (Glucometers) and Test Strips v1.2024 (PDF)
- Bone Density Regulators v1.2024 (PDF)
- Botulinum Toxins v1.2024 (PDF)
- BPH (Benign Prostatic Hyperplasia) Treatments v1.2024 (PDF)
- Bronchodilators, Beta Agonist v1.2024 (PDF)
C
- Calcium Channel Blockers v1.2024 (PDF)
- Cephalosporins v1.2024 (PDF)
- Chronic Obstructive Pulmonary Disease (COPD) Agents v1.2024 (PDF)
- Colony Stimulating Factors v1.2024 (PDF)
- Continuous Glucose Monitoring Products v1.2024 (PDF)
- Contraceptives, Oral v2.2024 (PDF)
- Contraceptives, Other v2.2024 (PDF)
- Cytokine and CAM Antagonists v1.2024 (PDF)
D
E
- Enzyme Replacements, Gaucher Disease v1.2024 (PDF)
- Epinephrine, Self-Injected v1.2024 (PDF)
- Erythropoiesis Stimulating Agents v1.2024 (PDF)
- Estrogens v1.2024 (PDF)
F
G
- GI Motility, Chronic Agents v1.2024 (PDF)
- Glucocortoids, Inhaled v1.2024 (PDF)
- Glucocortoids, Oral v1.2024 (PDF)
- Growth Hormones v1.2024 (PDF)
H
- Hematopoietic Mixtures v1.2024 (PDF)
- Hepatitis B Agents v1.2024 (PDF)
- Hepatitis C Agents v1. 2024 (PDF)
- Hereditary Angiodema Treatments v1.2024 (PDF)
- Histamine 2 (H2) Receptor Blockers v1.2024 (PDF)
- HIV AIDS Antiretrovirals v1.2024 (PDF)
- H. Pylori Treatments v1.2024 (PDF)
- Hypoglycemia Treatments v1.2024 (PDF)
- Hypoglycemics, Alpha-Glucosidase Inhibitors v1.2024 (PDF)
- Hypglycemics, Incretin Mimetics, Enhancers v1.2024 (PDF)
- Hypoglycemics, Insulin and Related Agents v1.2024 (PDF)
- Hypoglycemics, Meglitinide v1.2024 (PDF)
- Hypoglycemics, Metformins v1.2024 (PDF)
- Hypoglycemics, SGLT2 Inhibitors v1.2024 (PDF)
- Hypoglycemics, Sulfonylureas v1.2024 (PDF)
- Hypoglycemics, TZD's v1.2024 (PDF)
I
- Immunomodulators, Atopic Dermatitis v1.2024 (PDF)
- Immunomodulators, Topical v1.2024 (PDF)
- Immunosuppresives, Oral v1.2024 (PDF)
- Intra-Articular Hyaluronates v1.2024 (PDF)
- Intranasal Rhinitis Agents v1.2024 (PDF)
- Iron Chelating Agents v1.2024 (PDF)
- Iron, Parenteral v1.2024 (PDF)
L
- Leukotriene Modifiers v1.2024 (PDF)
- Lipotropics, Other v1.2024 (PDF)
- Lipotropics, Statins v1.2024 (PDF)
- Local Anesthetics, Topical v1.2024 (PDF)
M
- Macrolides v1.2024 (PDF)
- Macular Degeneration Agents v1.2024 (PDF)
- Methotrexate v1.2024 (PDF)
- Migraine Acute Treatment Agents v1.2024 (PDF)
- Migraine Prevention Agents v1.2024 (PDF)
- Monoclonal Antibodies - Anti-II, ANti-IgE v1.2024 (PDF)
- Multiple Sclerosis Agents v1.2024 (PDF)
N
- Natalizumab Tysabri v1.2024 (PDF)
- Neuropathic Pain Agents v1.2024 (PDF)
- Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) v1.2024 (PDF)
O
- Obesity Treatment Agents v1.2024 (PDF)
- Oncology Agents, Breast Cancer v1.2024 (PDF)
- Oncology Agents, Oral v1.2024 (PDF)
- Opiod Dependence Treatments v1.2024 (PDF)
- Opiod Overdose Agents v1.2024 (PDF)
- Opioid Use Disorder Treatments v1. 2023 (PDF)
- Opthalmics, Allergic Conjunctivitis v1.2024 (PDF)
- Opthalmics, Antibiotics v1.2024 (PDF)
- Opthalmics, Antibiotic-Steroid Combination v1.2024 (PDF)
- Opthalmics, Anti-Inflammatories v1.2024 (PDF)
- Opthalmics, Glaucoma v1.2024 (PDF)
- Opthalmics, Immunomodulators v1.2022 (PDF)
- Otic Antibiotics v1.2024 (PDF)
P
- Pancreatic Enzymes v1.2024 (PDF)
- Penicillins v1.2024 (PDF)
- Phosphate Binders v1.2024 (PDF)
- Pituitary Suppressive Agents, LHRH v1.2024 (PDF)
- Platelet Aggregation Inhibitors v1.2024 (PDF)
- Potassium Removing Agents v1.2024 (PDF)
- Prenatal Vitamins v1.2024 (PDF)
- Progestational Agents v1.2024 (PDF)
- Proton Pump Inhibitors (PPI's) v1.2024 (PDF)
- Pulmonary Arterial Hypertension (PAH) Agents, Oral and Inhaled v1.2024 (PDF)
S
- Sedative Hypnotics v2.2024 (PDF)
- Sickle Cell Anemia Agents v1.2024 (PDF)
- Skeletal Muscle Relaxants v1.2024 (PDF)
- Smoking Cessation Products v1.2024 (PDF)
- Steroids, Topical v1.2024 (PDF)
- Stimulants and Related Agents v1.2024 (PDF)
T
- Tetracyclines v1.2024 (PDF)
- Thalidomide and Derivatives v1.2024 (PDF)
- Thrombopoietics v1.2024 (PDF)
- Thyroid Hormones v1.2024 (PDF)
- Tubeless Insulin Delivery Devices v1.2024 (PDF)
U
- Ulcerative Colitis Agents v1.2024 (PDF)
- Urea Cycle Disorder Agents v1.2024 (PDF)
- Urinary Anti-Infectives v1.2024 (PDF)
V
PHW Supplemental Drug List Pharmacy Policies
- ADAMTS13 Recombinant-krhn (Adzynma) v1.2024 (PDF)
- Ado-Trastuzumab (Kadcyla) V1.2023 (PDF)
- Aducanumab (Aduhelm) v1.2023 (PDF)
- Afamelanotide (Scenesse) v1.2024 (PDF)
- Agalsidase Beta (Fabrazyme) v1.2024 (PDF)
- Alglucosidase alfa (Lumizyme) v1.2024 (PDF)
- Allogenic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat_StrataGraft v1.2024 (PDF)
- Allogenic Processed Thymus Tissue - agdc (Rethymic) v1.2024 (PDF)
- Alpelisib (Vijoice) v1. August 2023 (PDF)
- Alpha - 1 Proteinase Inhibitors (Aralast NP, Glassia, ProlastinC, Zemaira) v1.2024 (PDF)
- Amifampridine (Firdapse, Ruzurgi) v1.2024 (PDF)
- Amisulpride (Barhemsys) v1.August 2023 (PDF)
- Amivantamab-vmjw (Rybrevant) v1. August 2023
- Anifrolumab-fnia (Saphnelo) v1.2023 (PDF)
- Antithrombin III (ATryn, Thrombate III) v1.2024 (PDF)
- Antithymocyte Globulion (Atgam, Thymoglobulin) v1.2023 (PDF)
- Apomorphine (Apokyn, Kynmobi) v1.2024 (PDF)
- Aprepitant (Aponvie) v2. August 2023 (PDF)
- Asfotase Alfa (Strensiq) v1.2023 (PDF)
- Atezolizumab (Tecentriq) v1.2024 (PDF)
- Avacopan (Tavenos) v1.2024 (PDF)
- Avalglucosidase alfa-ngpt (Nexviazyme) v1.2024 (PDF)
- Avelumab (Bavencio) v1.2024 (PDF)
- Axicabtagene Ciloleucel (Yescarta) v1.2024 (PDF)
- Azacitidine (Vidaza) v1.2023 (PDF)
B
- Bedaquiline (Siruro) v1.2024 (PDF)
- Belantamab Mafodotin (Blenrep) v1.2024 (PDF)
- Belatacept (Nulojix) v1.2023 (PDF)
- Belimumab (Benlysta) v1.2023 (PDF)
- Belinostat (Beleodaq) v1.2023 (PDF)
- Bendamustine (Bendeka, Treanda) v2.2023 (PDF)
- Benznidazole v1.2024 (PDF)
- Beremagene geperpavec-svdt (Vyjuvek) v1. August 2023 (PDF)
- Betaine (Cystadane) v1.2023 (PDF)
- Betibeglogene Autotemcel (Zynteglo) v2.August 2023 (PDF)
- Bevacizumab (Avastin, Mvasi, Zirabev) v1.2024 (PDF)
- Bexarontene (Targretin Capsules, Gel) v1.2024 (PDF)
- Birch Triterpenes (Filsuvez) v1.2024 (PDF)
- Blinatumomab (Blincyto) v1.2023 (PDF)
- Bortezomib (Velcade) v1.2024 (PDF)
- Brand Name Override for Medications Not on the Statewide PDL v1.2024 (PDF)
- Brentuximab Vedotin (adcetris) v2.2023 (PDF)
- Brexanolone (Zulresso) v2.2023 (PDF)
- Brexucabtagene autoleucel (Tecartus) v1.2024 (PDF)
- Brimonidine (Mirvaso) v1.2023 (PDF)
- Burosumab-twza (Crysvita) v1. August 2023 (PDF)
C
- Cabazitaxel (Jevtana) v1.2024 (PDF)
- Caplacizumab-yhdp (Cablivi) v1.2024 (PDF)
- Carfilzomib (Kyprolis) v2.2023 (PDF)
- Carglumic Acid (Carbaglu) v1.2024 (PDF)
- Casimersen (Amondys 45) v1.2024 (PDF)
- Cemiplimab-rwlc (Libtayo) v2.2023 (PDF)
- Cenegermin-bkbj (Oxervate) v1.2024 (PDF)
- Cerliponase Alfa (Brineura) v1. August 2023 (PDF)
- Cetuximab (Eritux) v2.2023 (PDF)
- Chlorambucil (Leukeran) v2.2023 (PDF)
- Chloramphenicol v2. 2023 (PDF)
- Ciltacabtagene Autoleucel (Carvykti) v2. 2023 (PDF)
- Cinacalcet (Sensipar) v1. August 2023 (PDF)
- Cipaglucosidase Alfa-atga + Miglustat _Pombiliti + Opfolda v1 v1. 2024 (PDF)
- Collagenase Clostridium Histolyticum (Xiaflex) v1. August 2023 (PDF)
- Coumponded Prescriptions v1. 2024 (PDF)
- Copanlisib (Aliqopa) v1.2023 (PDF)
- Corticotropin Injection (H.P. Acthar Gel, Purified Cortophin Gel) v1.2024 (PDF)
- Cosyntropin (Cortrosyn) v1.2024 (PDF)
- Cysteamine (Cystagon, Procysbi) v1.2023 (PDF)
- Cytomegalovirus Immune Globulin (Cytogam) v1. August 2023 (PDF)
- Cysteamine Ophthalmic (Cystaran, Cystadrops) v1 2024 (PDF)
D
- Daptomycin (Cubicin Cubicin RF) v2.2023 (PDF)
- Daprodustat (Jesduvroq) v1. October 2023 (PDF)
- Daratumumab (Darzalex, Darzalex Faspro) v1. 2023 (PDF)
- Daunorubicin Cytaribine (Vyxeos) v1.2023 (PDF)
- Decitabine-Cedazuridine (Inqovi) v1.2024 (PDF)
- Deferoxamine (Desferal) v2. August 2023 (PDF)
- Delandistrogene Moxeparvovec Rokl (Elevidys) v1 October 2023 (PDF)
- Desmopressin Acetate (DDAVP Injection ) v1.2024 (PDF)
- Dexrazoxane (Zinecard Totect) v1.2023 (PDF)
- Dextromethorphan-Quindine (Nuedexta) v1.2024 (PDF)
- Dichlorphenamide (Keveyis) v1.2024 (PDF)
- Dornase Alfa (Pulmozyme) v2. August 2023 (PDF)
- Dostarlimab-gxly (Jemperli) v2.2023 (PDF)
- Droxidopa (Northera) v2.2023 (PDF)
- Durvalumab (Imfinzi) v1.2023 (PDF)
E
- Eculizumab (Soliris) v2. August 2023 (PDF)
- Edaravone (Radicava) v1.2023 (PDF)
- Efgartigimod Alfa-fcab (Vyvgart) v1. 2024 (PDF)
- Elapegademase-lvlr (Revcovi) v1.2023 (PDF)
- Elexacaftor ivacaftor tezacaftor (Trikafta) v.2 August 2023 (PDF)
- Elivaldogene Autotemcel (Skysona) v1.2023 (PDF)
- Elosulfase Alfa (Vimizim) v1.2024 (PDF)
- Elranatamab-bcmm (Elrexfio) v1.2023 (PDF)
- Elotuzumab (Empliciti) v1.2023 (PDF)
- Emapalumab-Izsg (Gamifant) v1.2024 (PDF)
- Enfortumab Vedotin-ejfv (Padcev) v1 2024 (PDF)
- Epcoritamab-bysp (Epkinly) v1. August 2023 (PDF)
- Epoprostenol Sodium (Flolan Veletri) v1.2024 (PDF)
- Eribulin Mesylate (Halaven) v1.2023 (PDF)
- Erwinia Asparaginase (Erwinaze) v1.2024 (PDF)
- Etelcalcetide (Parsabiv) v1. August 2023 (PDF)
- Eteplirsen (Exondys 51) v1.2024 (PDF)
- Etranacogene Dezaparvovec-drlb Hemgenix v1.2024 (PDF)
F
- Factor XIII A-Subunit (Recombinant Tretten) V1.2024 (PDF)
- Factor XIII (Human Corifact) v1.2024 (PDF)
- Fam-trastuzumab deruxtecan-nxki (Enhertu) v1.2024 (PDF)
- Fecal Microbiota Live-jslm (Rebyota) v1. 2024 (PDF)
- Fecal Microbiota Spores Live-brpk (Vowst) v1. August 2023 (PDF)
- Ferric maltol (Accrufer) v1.2023 (PDF)
- Ferric Pyrophosphate (Triferic) v1 July 2023 (PDF)
- Fezolinetant Veozah v1 October 2023 (PDF)
- Fibrinogen Concentrate (human) (Fibryga, RiaSTAP) v1.2023 (PDF)
- Finerenone (Kerendia) v1.2023 (PDF)
- Fluorouracil Cream (Tolak) v1.2023 (PDF)
- Fosdenopterin (Nulibry) v1.2023 (PDF)
- Fulvestrant (Faslodex Injection) v1.2023 (PDF)
- Furosemide Furoscix v1.2024 (PDF)
G
- Galsulfase (Naglazyme) v1.2024 (PDF)
- Gemtuzumab (Mylotarg) v1.2023 (PDF)
- Givosiran (Givlaari) V1.2024 (PDF)
- Glofitamab-gxbm (Columvi) v1. 2023 (PDF)
- Glycopyrronium (Qbrexza) v1.2023 (PDF)
- Golodirsen (Vyondys 53) v1.2024 (PDF)
H
- Idecabtagene Vicleucel (Abecma) v1. 2023 (PDF)
- Idursulfase (Elaprase) v1.2024 (PDF)
- Immune Globulins v1. 2024 (PDF)
- Immunization Coverage v1. 2023 (PDF)
- Inebilizumab-cdon (Uplizna) v2. 2023 (PDF)
- Injectable Antibiotics Not on the Statewide Preferred Drug List v1. August 2023
- Interferon Gamma - 1b (Actimmune) v1.2024 (PDF)
- Intrathecal Baclofen (Gablofen, Lioresal Intrathecal) v1.2024 (PDF)
- Inotersen (Tegsedi) v1.2024 (PDF)
- Inotuzumab Ozogamicin (Besponsa) v1.2023 (PDF)
- Iobenguane l 131 (Azedra) v1.2024 (PDF)
- Ipilimumab (Yervoy) v1. July 2023 (PDF)
- Irinotecan Liposome Injection (Onivyde) v1.2023 (PDF)
- Isatuximab-irfc (Sarclisa) v1.2024 (PDF)
- Ivabradine (Corlanor) v1.2024 (PDF)
- Ivacaftor (Kalydeco) v2. August 2023 (PDF)
- Ivermectin Tablet (Stromectol) v1. November 2023 (PDF)
L
- Lactic acid-citric acid-potassium bitartrate (Phexxi) v2.2023 (PDF)
- Lanreotide (Somatuline Depot) v1.2023 (PDF)
- Laronidase (Aldurazyme) v1.2024 (PDF)
- Lecanemab-irmb (Leqembi) v1.2023 (PDF)
- Lefamulin (Xenleta) v2. August 2023 (PDF)
- Leniolisib (Joenja) v1.2024 (PDF)
- Leucovorin Injection v1.2023 (PDF)
- Levoketoconazole (Recorlev) v1.2023 (PDF)
- Levoleucovorin (Fusilev) v1.2023 (PDF)
- Linezolid (Zyvox) v2. August 2023 (PDF)
- Lisocabtagene Maraleucel (Breyanzi) v1. July 2023 (PDF)
- Lomustine (Gleostine) v1.2023 (PDF)
- Lonafarnib (Zokinvy) v1.2024 (PDF)
- Loncastuximab Tesirine-Ipyl (Zynlonta) v1. August 2023 (PDF)
- Lotilaner Xdemvy v1. 2023 (PDF)
- Lumacaftor-Ivacaftor (Orkambi) v2. August 2023 (PDF)
- Lumasiran (Oxlumo) v1.2024 (PDF)
- Lurbinectedin (Zepzelca) v1. August 2023 (PDF)
- Luspatercept-aamt (Reblozyl) v1.2024 (PDF)
- Lutetium Lu 177 Dotatate (Lutathera) v1. August 2023 (PDF)
- Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) v1. November 2023 (PDF)
M
- Mannitol (Bronchitol) v2. August 2023 (PDF)
- Maralixibat (Livmarli) v2. October 2023 (PDF)
- Margetuximab-cmkb (Margenza) v1.2024 (PDF)
- Mavacamten (Camzyos) v2.2023
- Mecamylamine (Vecamyl) v1. July 2023 (PDF)
- Mecasermin (Increlex) v1. August 2023 (PDF)
- Mechlorethamine (Valchlor) v1.2023 (PDF)
- Megestrol Acetate Oral Suspension (Megace ES) v1.2023 (PDF)
- Melphalan Flufenamide (Pepaxto) v2.2023 (PDF)
- Melphalan (Hepzato) v1.2023 (PDF)
- Metreleptin (Myalept) v1.2023 (PDF)
- Mercaptopurine (Purixan) v1.2023 (PDF)
- Migalastat (Galafold) v1.2023 (PDF)
- Mifepristone (Korlym) v1.2024 (PDF)
- Mirvetuximab Soravatansine Gynx (Elahere) v1. 2024 (PDF)
- Mitapivat (Pyrukynd) v1.2023 (PDF)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) v1. August 2023 (PDF)
- Mitoxantrone (Novantrone) v1.2023 (PDF)
- Mixed Pollens Allergen Extract (Oralair) v1 October 2023 (PDF)
- Mogamulizumab-kpkc (Poteligeo) v1.2023 (PDF)
- Mosunetuzumab axgb (Lunsumio) v1. 2024 (PDF)
- Motixafortide (Aphexda) v1.2024 (PDF)
- Moxetumomab Pasudotox-tdfk (Lumoxiti) v1.2023 (PDF)
N
- Nadofaragene Firadenovec-vncg (Adstiladrin) v1.2024 (PDF)
- Naxitamab-gqgk (Danyelza) v1.2024 (PDF)
- Necitumumab (Portrazza) v1.2023 (PDF)
- Nedosiran (Rivfloza) v1.2024 (PDF)
- Nifurtimox (Lampit) v1.2023 (PDF)
- Nitisinone (Orfadin, Nityr) v1.2023 (PDF)
- Nivolumab (Opdivo) v1. 2024 (PDF)
- Nivolumab and Relatlimab-rmbw (Opdualag) v1.2023 (PDF)
- No Coverage Criteria, Recent Label Changes Pending Update for Drug Not on Statewide PDL v1.2023 (PDF)
- Nusinersen (Spinraza) v1.2024 (PDF)
O
- Obinutuzumab (Gazyva) v1.2023 (PDF)
- Octreotide Acetate (Sandostatin Injection Sandostatin LAR Depot) v1.2024 (PDF)
- Odevixbat_Bylvay v2. October 2023 (PDF)
- Ofatumumab (Arzerra) v1.2023 (PDF)
- Off Label Use of Drug Not on the Statewide Preferred Drug List v2. July 2023 (PDF)
- Olaratumab (Lartruvo) v1.2023 (PDF)
- Olipudase Alfa-rpcp (Xenpozyme) v1. August 2023 (PDF)
- Omacetaxine (Synribo) v1.2024 (PDF)
- Omaveloxolone (Skyclarys) v1.2024 (PDF)
- Onasemnogene Abeparvovec (Zolgensma) v1. July 2023 (PDF)
- Ophthalmic Riboflavin (Photrexa Photrexa Viscous) v1. July 2023 (PDF)
- Osilodrostat (Isturisa) v1. August 2023 (PDF)
- Ospemifene (Osphena) v1.2023 (PDF)
- Oxymetazoline (Rhofade, Upneeq) v1. July 2023 (PDF)
P
- Paclitaxel Protein Bound (Abraxane) v1.2023 (PDF)
- Palivizumab (Synagis) v1.2023 (PDF)
- Panitumumab (Vectibix) v2.2023 (PDF)
- Parathyroid Hormone (Natpara) v1.2024 (PDF)
- Pasireotide (Signifor, Signifor LAR) v1.2023 (PDF)
- Patisiran (Onpattro) v1.2023 (PDF)
- Peanut Allergen Powder-dnfp_Palforzia v2. October 2023 (PDF)
- Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas) v1.2023 (PDF)
- Pegcetacoplan (Empaveli) v2. August 2023 (PDF)
- Pegunigalsidase Alfa-iwxj (Elfabrio) v1. August 2023 (PDF)
- Pegvaliase-pqpz (Palynziq) v1.2023 (PDF)
- Pegvisomant (Somavert) v1.2023 (PDF)
- Pembrolizuman (Keytruda) v2. 2023 (PDF)
- Pemetrexed (Alimta Pemfexy) v1.2024 (PDF)
- Pentosan Polysulfate Sodium (Elmiron) v1.2024 (PDF)
- Pertuzumab (Perjeta) v2.2023 (PDF)
- Pertuzumab (Phesgo) v1. August 2023 (PDF)
- Pegvaliase-pqpz (Palynziq) v2.2020 (PDF)
- Pembrolizumab (Keytruda) v1.2024 (PDF)
- Plasminogen (Ryplazim) v1.2023 (PDF)
- Plerixafor (Mozobil) v1. 2024 (PDF)
- Polatuzumab Vedotin-piiq (Polivy) v1.2023 (PDF)
- Pozelimab bbfg (Veopoz) v1.2024 (PDF)
- Pralatrexate (Folotyn) v1.2023 (PDF)
- Prasterone (Intrarosa) v1.2024 (PDF)
- Pretomanid v1.2024 (PDF)
- Protein C Concentrate, Human (Ceprotin) v1.2024 (PDF)
- Pyrimethamine (Daraprim) v1. October 2023 (PDF)
Q
R
- Ramucirumab (Cyramza) v1.2024 (PDF)
- Ravulizumab-cwvz (Ultomiris) v2.2023 (PDF)
- Request for Medically Necessary Drug Not on the Statewide Preferred Drug List v1. 2024 (PDF)
- Retifanlimab dlwr (Zynyz) v1. July 2023 (PDF)
- Rifabutin (Mycobutin) v1.2024 (PDF)
- Rifapentine (Priftin) v1.2024 (PDF)
- Risdiplam (Evrysdi) v1.2024 (PDF)
- Rituximab (Rituxan, Ruxience, Truxima, Rituxan Hycela) v3. August 2023 (PDF)
- Romidepsin (Istodax) v1.2023 (PDF)
- Ropeginterferon alfa-2b-njft (Besremi) v1.2024 (PDF)
- Rozanolixizumab-noli (Rystiggo) v1.2023 (PDF)
S
- Sacituzumab Govitecan-hziy (Trodelvy) v1.2023 (PDF)
- Sapropterin Dihydrochloride (Kuvan) v1.2023 (PDF)
- Satralizumab-mwge (Enspryng) v2.August 2023 (PDF)
- Sebelipase Alfa (Kanuma) v1.2023 (PDF)
- Setmelanotide (Imcivree) v1.2024 (PDF)
- Short Ragweed Pollen Allergen Extract Ragwitek v1. 2023 (PDF)
- Siltuximab (Sylvant) v1.2024 (PDF)
- Sipuleucel-T (Provenge) v1.2024 (PDF)
- Sirolimus Protein-Bound Particles (Fayarr, Topical Gel, Hyftor) v1.2024 (PDF)
- Sodium Oxybate (Xyrem) (Xywav) v1. 2024 (PDF)
- Sparsentan (Filspari) v1. July 2023 (PDF)
T
- Tafamidis (Vyndaqel, Vyndamax) v1. October 2023 (PDF)
- Tafasitamab-cxix (Monjuvi) v1.2023 (PDF)
- Talimogene Iaherparepvec (Imlygic) v2. August 2022 (PDF)
- Talquetamab-tgvs (Talvey) v1. 2023 (PDF)
- Tebentafusp-tebn (Kimmtrak) v1.2024 (PDF)
- Teclistamab-cqyv (Tecvayli) v1.2024 (PDF)
- Tedizolid (Sivextro) v2. August 2023 (PDF)
- Teduglutide (Gattex) v1.2024 (PDF)
- Telotristat Ethyl (Xermelo) v1. 2024 (PDF)
- Temsirolimus (Torisel) v1.2023 (PDF)
- Teplizumab-mzwv (Tzield) v1.2024 (PDF)
- Teprotumumab (Tepezza) v1.2024 (PDF)
- Tesamorelin (Egrifta SV) v1. August 2023 (PDF)
- Tezacaftor-Ivacaftor (Symdeko) v2.2023 (PDF)
- Thioguanine (Tabloid) v1.2023 (PDF)
- Thyrotropin Alfa (Thyrogen) v1.2023 (PDF)
- Timothy Grass Pollen Allergen Extract (Grastek) v1. October 2023 (PDF)
- Tisagenlecleucel (Kymriah) v1.2024 (PDF)
- Tisotumab Vedotin-tfv (Tivdak) v1.2023 (PDF)
- Tofersen Qalsody v1. August 2023 (PDF)
- Tolvaptan (Jynarque, Samsca) v1. August 2023 (PDF)
- Topotecan (Hycamtin) v1.2023 (PDF)
- Toripalimab-tpzi (Loqtorzi) v1.2024 (PDF)
- Trabectedin (Yondelis) v1.2024 (PDF)
- Tremelimbumab-actl (Imjudo) v1.2024 (PDF)
- Trastuzumab, Biosimilars, Trastuzumab-Hyaluronidase v1. July 2023 (PDF)
- Treprostinil (Remodulin) v1. November 2023 (PDF)
- Triamcinolone ER Injection (Zilretta) v1.2024 (PDF)
- Triheptanoin (Dojolvi) v1.2023 (PDF)
- Triclabendazole (Egaten) v1. August 2023 (PDF)
- Trientine (Syprine) v1.2023 (PDF)
- Trofineatide (Daybue) v1. July 2023 (PDF)
V
- Valoctocogene Roxaparvovec-rvox (Roctavian) v1. 2024 (PDF)
- Valrubicin (Valstar) v2.2023 (PDF)
- Velmanase Alfa tycv (Lamzede) v1. 2024 (PDF)
- Vestronidase Alfa-vjbk (Mepsevii) v1.2024 (PDF)
- Vincristine Sulfate Liposome Injection (Marqibo) v1.2023 (PDF)
- Vitolarsen (Viltepso) v1.2024 (PDF)
- Voretigene Neparvovec-rzyl (Luxturna) v1.2024 (PDF)
- Vosoritide (Voxzogo) v1.2024 (PDF)
- Vutrisiran (Amvuttra) v2.2023 (PDF)
Z
For Ambetter information, please visit our Ambetter website.
Archived Policies
- SNF Leveling PA.CP.MP.206 2022 (PDF)
- Ambulatory Surgery Center Optimization PA.CP.MP.158 October 2023 (PDF)
- Radial Head Implant PA.CP.MP.148 2022 (PDF)
- Tiludronate (Skelid) (CP.PM.106) (PDF)
- Mesalamine Oral Therapy (CP.PST.19) (PDF)
- Dipeptidyl Peptidase 4 (DPP 4) Inhibitors (CP.PST.18) (PDF)
- Daclizumab (Zinbryta) (CP.PHAR.269) (PDF)
- Glucagon-like Peptide 1 (GLP-1) Receptor Agents (CP.PST.14) (PDF)
- Sodium-Glucose-Co-Transporter 2 (SGLT2) Inhibitors (CP.PST.19) (PDF)
- Celecoxib (Celebrex) (CP.PPA.01) (PDF)
- Lisdexamfetamine (Vyvanse) (CP.PPA.03) (PDF)
- Itraconazole (Sporanox) (CP.PPA.07) (PDF)
- Colchicine (Colcrys) (CP.PPA.11) (PDF)
- Methylphenidate (CP.PMN.10) (PDF)
- Naltrexone (CP.PHAR.96) (PDF)
- Atomoxetine Strattera (CP.PMN.01) (PDF)
- Topical Immunomodulators (CP.PPA.05) (PDF)
- Glucagon-like Peptide 1 RA (CPPPA.21) (PDF)
- Rivastigmine (Exelon) (CP.PPA.22) (PDF)
- SGLT2 Inhibitors (CP.PPA.24) (PDF)
- Infertility and Fertilitiy Preservation (PA.CP.PHAR.131) (PDF)
- TPB IDPN (PA.CP.PHAR.205) (PDF)
- Aripiprazole LA Injections (Abilify Maintena, Aristada) (PA.CP.PHAR.205) (PDF)
- Paliperidone Injection (Invega Sustenna, Invega Trinza) (PA.CP.PHAR.291) (PDF)
- Olanzapine LA Injection (Zyprexa Relprevv) (PA.CP.PHAR.292) (PDF)
- Risperidone LA Injection (Risperdal Consta) (PA.CP.PHAR.293) (PDF)
- Gefitnib (Iressa) (PA.CP.PHAR.299) (PDF)
- Oral Antimetics (PA.CP.PMN.11) (PDF)
- Famciclovir (Famvir) (PA.CP.PMN.26) (PDF)
- Dexmethylphenidate ER (Focalin XR) (PA.CP.PMN.63) (PDF)
- Inhaled Combination LAA-LABA (PA.CP.PMN.69) (PDF)
- Ragweed Pollen (Ragwitek) (PA.CP.PMN.83) (PDF)
- Timothy Grass Pollen (Grastek) (PA.CP.PMN.84) (PDF)
- House Dust Mite (Odactra) (PA.CP.PMN. 111) (PDF)
- Betrixaban (Bevyxxa) (PA.CP.PMN.114) (PDF)
- Naloxone (Evzio) (PA.CP.PMN.139) (PDF)
- Epinephrine (Epipen Epipen JR) (PA.CP.PPA.09) (PDF)
- Toremifene (Fareston) (PA.CP.PPA.10) (PDF)
- Milnacipran (Savella) (PA.CP.PPA.15) (PDF)
- Vilazodone (Viibryd) (PA.CP.PPA.16) (PDF)
- Pimavanserin (Nuplazid) (PA.CP.PPA.19) (PDF)
- Anti-Allergy Ophthalmics (PA.CP.PST.03) (PDF)
- Exemestane (Aromasin) (PA.CP.PST.05) (PDF)
- Isotretinoin (PA.CP.PST.13) (PDF)
- Pramlintide (Symlin) (PA.CP.PST.13) (PDF)
- Sedative Hypnotics (PA.CP.PST.16) (PDF)
- Pediatric Heart Transplant (PA.CP.MP.1380 (PDF)
- Hyperbaric Oxygen Therapy Rev (PA.CP.MP.27) (PDF)
- Fecal Calprotectin Assay (PA.CP.MP.135) (PDF)
- EpiFix Wound Treatment (PA.CP.MP.140) (PDF)
- 2019 Novel Coronavirus Testing (PA.CP.MP.183) (PDF)
- NICU Apnea Bradycardia Guidelines (PA.CP.MP.82) (PDF)
- OB Home Health Programs (PA.CP.MP.91) (PDF)
- Neonatal Abstinence Syndrome Guidelines (PA.CP.MP.86) (PDF)
- Transcranial Magnetic Stimulaiton (PA.CP.MP.172) (PDF)
- Medical Necessity Criteria (PA.CP.MP.68) (PDF)
- Inhale Nitric Oxide (PA.CP.MP.87) (PDF)
- Injections for Pain Management (PA.CP.MP.118) (PDF)
- Home Sleep Testing (PA.CP.MP.75) (PDF)
- Zika Virus Testing (PA.CP.MP.111) (PDF)
- Monitored Anesthesia Care (PA.CP.MP.161) (PDF)
- Ventriculectomy Cardiomyoplasty (PA.CP.MP.56) (PDF)
- FeNo (PA.CP.MP.103) (PDF)
- DNA Analysis of Stool (PA.CP.MP.125) (PDF)
- Iron, Oral v2.2020 (PDF)
- Becaplermin (Regranex) v1.2021 (PDF)
- Continuous Insulin Delivery Systems (V-Go, Omnipod) v2.2020 (PDF)
- Crizanlizumab-tmca (Adakveo) v1.2020 (PDF)
- Hydroxyurea (Siklos) v2.2020 (PDF)
- Insulin Infusion Pump (Omnipod, Omnipod DASH) v1.2020 (PDF)
- L-glutamine (Endari) v2.2020 (PDF)
- Lasmiditan (Reyvow) v1.2020 (PDF)
- Moxidectin v1.2020 (PDF)
- Omadacycline (Nuzyra) v1.2020 (PDF)
- Ozenoxacin (Xepi) v1.2020 (PDF)
- Pegademase Bovine (Adagen) v2.2020 (PDF)
- Rifabutin (Mycobutin), Rifabutin, Omeprazole, Amoxicillin (Talicia) v1.2020 (PDF)
- Rituximab (Pituxan) v1.2020 (PDF)
- Ubrogepant (Ubrelvy) v1.2020 (PDF)
- Voxelotor (Oxbryta) v1.2020 (PDF)
- Carrier Screening in Pregnancy PA.CP.MP.83 v1.2021 (PDF)
- Cell-free Fetal DNA Testing PA.CP.MP.84 v2.2022 (PDF)
- Ambulatory EEG PA.CP.MP.96 v1.2021 (PDF)
- Balloon Sinus Ostial Dilation PA.CP.MP.119 v1.2021 (PDF)
- Testing for Rupture of Fetal Membranes PA.CP.MP.149 v1.2021 (PDF)
- Antithrombin III Atryn Thrombate PA.CP.MP.179 v1.2021 (PDF)
- PCR Respiratory Viral Panel Testing PA.CP.MP.181 v1.2021 (PDF)
- Sickle Cell Observation PA.CP.MP.88 v1.2021 (PDF)
- Genetic and Pharmacogenetic Testing PA.CP.MP.89 v1.2021 (PDF)
- Video EEG Monitoring PA.CP.MP.177 v1.2021 (PDF)
- ADHD Assessment and Treatment PA.CP.MP.124 v3.2022 (PDF)
- Essure Removal PA.CP.MP.131 v3.2023 (PDF)
- Hyperemesis Gravidarum Treatment PA.CP.MP.34 v2.2021 (PDF)