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Clinical & Payment Policies

Provider billing guidance for COVID-19

For information regarding Provider billing guidance for COVID-19 testing please refer to our COVID-19 resources page.

Clinical Policies

Important Notice

The Clinical Policies do not constitute medical advice.  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 Clinical Policy Manual apply to health plan members. The health plan utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which health plan clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  In addition, the health plan 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 the health plan.   

The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine. The health plan reserves the right to amend the Policies without notice to providers or Members.

Policies specifically developed to assist the health plan in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service, or supply for Medicare or Medicaid Members shall not be construed to apply to any other health plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation.

The Clinical Policy Manuals may be accessed through the links below.

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

 
Policy Title Policy Number Effective Date
2019-Novel Coronavirus Testing (PDF) CP.MP.183 03/06/2020
25-Hydroxyvitamin D Testing in Children and Adolescents (PDF) CP.MP.157 12/29/2017
Acupuncture (PDF) CP.MP.92 12/31/2013
ADHD Assessment and Treatment (PDF) CP.MP.124 12/31/2013
Air Ambulance (PDF) CP.MP.175 04/30/2019
Allergy Testing and Therapy (PDF) CP.MP.100 08/31/2016
Allogeneic Hematopoietic Cell Transplants for Sickle Cell (PDF) CP.MP.108 03/31/2016
Ambulatory EEG (PDF) CP.MP.96 09/30/2015
Ambulatory Surgery Center Optimization (PDF) CP.MP.158 02/16/2018
Antithrombin III (Thrombate III, Atryn) (PDF) CP.MP.179 10/31/2020
Articular Cartilage Defect Repairs (PDF) CP.MP.26 10/31/2008
Assisted Reproductive Technology (PDF) CP.MP.55 03/31/2014
Balloon Sinus Ostial Dilation (PDF) CP.MP.119 07/29/2016
Bariatric Surgery (PDF) CP.MP.37 06/11/2009
Biofeedback (PDF) CP.MP.168 07/31/2017
Bone-Anchored Hearing Aid (PDF) CP.MP.93 12/31/2013
Bronchial Thermoplasty (PDF) CP.MP.110 05/31/2016
Burn Surgery (PDF) CP.MP.186 05/31/2020
Cardiac Biomarker Testing (PDF) CP.MP.156 12/29/2017
Carrier Screening in Pregnancy (PDF) CP.MP.83 07/31/2013
Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF) CP.MP.164 08/31/2018
Cell-Free Fetal DNA Testing (PDF) CP.MP.84 08/31/2013
Clinical Trials (PDF) CP.MP.94 01/27/2014
Cochlear Implant Replacements (PDF) CP.MP.14 03/20/2009
Cosmetic and Reconstructive Surgery (PDF) CP.MP.31 03/31/2009
Dental Anesthesia (PDF) CP.MP.61 06/01/2013
Digital EEG Spike Analysis (PDF) CP.MP.105 01/15/2016
Disc Decompression Procedures (PDF) CP.MP.114 07/31/2016
Discography (PDF) CP.MP.115 08/30/2016
DNA Analysis of Stool to Screen for Colorectal Cancer (PDF) CP.MP.125 09/30/2016
Donor Lymphocyte Infusion (PDF) CP.MP.101 12/01/2015
Durable Medical Equipment (DME) (PDF) CP.MP.107 06/30/2009
Electric Tumor Treating Fields (PDF) CP.MP.145 05/31/2017
EEG in the Evaluation of Headache (PDF) CP.MP.155 12/29/2017
Endometrial Ablation (PDF) CP.MP.106 03/01/2016
EpiFix Wound Treatment (PDF) CP.MP.140 04/30/2017
Essure Removal (PDF) CP.MP.131 11/30/2016
Evoked Potential Testing (PDF) CP.MP.134 11/30/2016
Experimental Technologies (PDF) CP.MP.36 06/30/2009
Facet Joint Interventions for Pain Management (PDF) CP.MP.171 09/14/2018
Fecal Incontinence Treatments (PDF) CP.MP.137 12/30/2016
Ferriscan R2-MRI (PDF) CP.MP.53 11/14/2012
Fertility Preservation (PDF) CP.MP.130 10/30/2016
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) CP.MP.129 10/30/2016
Fractionated Exhaled Nitric Oxide (FeNO) measurement (PDF) CP.MP.103 01/27/2016
Functional MRI (PDF) CP.MP.43 09/23/2009
Gastric Electrical Stimulation (PDF) CP.MP.40 07/30/2009
Gender Affirming Procedures (PDF) CP.MP.95 11/28/2014
Gender Reassignment Surgery (PDF) CP.MP.95 11/28/2014
Genetic Testing (PDF) CP.MP.89 11/30/2013
Helicobacter Pylori Serology Testing (PDF) CP.MP.153 12/29/2017
Heart-Lung Transplant (PDF) CP.MP.132 06/30/2017
Holter Monitors (PDF) CP.MP.113 08/30/2016
Home Birth (PDF) CP.MP.136 12/30/2016
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) CP.MP.150 12/21/2017
Homocysteine Testing (PDF) CP.MP.121 08/30/2016
Hospice Services (PDF) CP.MP.54 07/30/2014
Hyperbaric Oxygen Therapy (PDF) CP.MP.27 06/30/2009
Hyperemesis Gravidarum Treatment (PDF) CP.MP.34 03/31/2009
Hyperhidrosis Treatments (PDF) CP.MP.62 05/16/2013
Implantable Intrathecal Pain Pump (PDF) CP.MP.173 02/28/2019
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 04/30/2018
Inhaled Nitric Oxide (PDF) CP.MP.87 08/30/2013
Intensity-Modulated Radiotherapy (PDF) CP.MP.69 03/31/2014
Intestinal and Multivisceral Transplant (PDF) CP.MP.58 02/28/2014
Intradiscal Steroid Injections for Pain Management (PDF) CP.MP.167 08/31/2018
Laser Therapy for Skin Conditions (PDF) CP.MP.123 08/30/2016
Long Term Care Placement Criteria (PDF) CP.MP.71 07/11/2018
Low-Frequency Ultrasound Therapy for Wound Management (PDF) CP.MP.139 02/28/2017
Lung Transplantation (PDF) CP.MP.57 02/28/2014
Lysis of Epidural Lesions (PDF) CP.MP.116 07/31/2018
Measurement of Serum 1,25-dihydroxyvitamin D (PDF) CP.MP.152 12/29/2017
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) CP.MP.144 04/30/2017
Multiple Sleep Latency Testing (PDF) CP.MP.24 10/31/2008
Neonatal Abstinence Syndrome Guidelines (PDF) CP.MP.86 10/30/2013
Neonatal Sepsis Management (PDF) CP.MP.85 08/30/2013
Nerve Blocks for Pain Management (PDF) CP.MP.170 08/31/2018
NICU Apnea Bradycardia Guidelines (PDF) CP.MP.82 06/30/2013
NICU Discharge Guidelines (PDF) CP.MP.81 06/30/2013
Non-Invasive Home Ventilator (PDF) CP.MP.184 05/31/2020
Non-myeloablative Allogeneic Stem Cell Transplants (PDF) CP.MP.141 04/28/2017
OB Home Health Programs (PDF) CP.MP.91 01/27/2014
Optic Nerve Decompression Surgery (PDF) CP.MP.128 09/30/2016
Outpatient Cardiac Rehabilitation (PDF) CP.MP.176 05/31/2019
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 09/30/2012
Pancreas Transplantation (PDF) CP.MP.102 04/29/2016
Panniculectomy (PDF) CP.MP.109 04/30/2016
Pediatric Heart Transplant (PDF) CP.MP.138 01/31/2017
Pediatric Liver Transplant (PDF) CP.MP.120 04/30/2018
Pediatric Oral Function Therapy (PDF) CP.MP.188 05/31/2020
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) CP.MP.147 07/31/2017
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) CP.MP.133 10/30/2016
Proton and Neutron Beam Therapy (PDF) CP.MP.70 03/31/2014
Radial Head Implant (PDF) CP.MP.148 08/31/2017
Radiofrequency Ablation of Uterine Fibroids (PDF) CP.MP.187 04/30/2020
Reduction Mammaplasty (PDF) CP.MP.51 07/31/2012
Sacroiliac Joint Fusion (PDF) CP.MP.126 09/30/2016
Sacroiliac Joint Interventions for Pain Management (PDF) CP.MP.166 08/31/2018
Selective Dorsal Rhizotomy (PDF) CP.MP.174 03/31/2019
Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF) CP.MP.165 08/31/2018
Sclerotherapy for Varicose Veins (PDF) CP.MP.146 06/30/2017
Short Inpatient Hospital Stay (PDF) CP.MP.182 05/29/2020
Sickle Cell Disease Observation (PDF) CP.MP.88 09/30/2013
Skin Substitutes for Chronic Wounds (PDF) CP.MP.185 04/20/2020
Spinal Cord Stimulation (PDF) CP.MP.117 07/31/2016
Stereotactic Body Radiation Therapy (PDF) CP.MP.22 12/30/2008
Tandem Transplant (PDF) CP.MP.162 07/31/2018
Testing of Rupture of Fetal Membranes (PDF) CP.MP.149 08/30/17
Testing for Select Genitourinary Conditions (PDF) CP.MP.97 06/15/2016
Thymus Transplantation (PDF) CP.MP.189 06/30/2020
Thyroid and Insulin Testing in Pediatrics (PDF) CP.MP.154 10/31/2020
Total Artificial Heart (PDF) CP.MP.127 12/30/2016
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 05/31/2016
Transcather Closer of Patent Foramen Ovale (PDF) CP.MP.151 12/29/2017
Trigger Point Injections for Pain Management (PDF) CP.MP.169 08/31/2018
Ultrasound in Pregnancy (PDF) CP.MP.38 01/31/2011
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142 04/30/2017
Urodynamic Testing (PDF) CP.MP.98 10/30/2015
Vagus Nerve Stimulation (PDF) CP.MP.12 09/30/2008
Ventricular Assist Devices (PDF) CP.MP.46 12/31/2009
Ventriculectomy and Cardiomyoplasty (PDF) CP.MP.56 05/06/2013
Video Electroencephalographic (VEEG) Monitoring (PDF) CP.MP.177 10/31/2019
Visual Field Testing (PDF) OC.UM.CP.0063  
Wheelchair Seating (PDF) CP.MP.99 10/31/2015
Wireless Motility Capsule (PDF) CP.MP.143 04/30/2017
POLICY TITLE POLICY NUMBER EFFECTIVE DATE
Buprenorphine (Probuphine, Sublocade) (PDF) AZ.CP.PHAR.289 02/2021
Cariprazine (Vraylar) (PDF) AZ.CP.PMN.91 01/2020
Concomitant Antidepressant (PDF) AZ.CP.PMN.11 02/2021
Cytokine and CAM Antagonists (PDF) AZ.CP.PHAR.06 02/2021
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF) AZ.CP.PMN.43 02/2021
Edoxaban (Savaysa) (PDF) AZ.CP.PMN.227 02/2021
Endothelin Receptor Antagonists-ETRA (Letairis, Opsumit, Tracleer) (PDF) AZ.CP.PHAR.1012 02/2021
Esketamine (Spravato) (PDF) AZ.CP.PMN.199 02/2021
Extended Release Opioid Analgesics (PDF) AZ.CP.PHAR.97b 02/2021
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF) AZ.CP.PMN.183 02/2021
Human Growth Hormone (Norditropin, Genotropin, Humatrope, Nutropin, NuSpin, Omnitrope, Saizen, Serostim, Sogroya, Zomacton, Zorbtive) (PDF) AZ.CP.PHAR.517 02/2021
Iloperidone (Fanapt) (PDF) AZ.CP.PMN.32 02/2021
Immediate Release Opioid Analgesics (PDF) AZ.CP.PHAR.97a 02/2021
Istradefylline (Nourianz) (PDF) AZ.CP.PMN.217 02/2021
Maraviroc (Selzentry) (PDF) AZ.CP.PHAR.32 02/2021
Memantine_Donepezil (Namenda, Namzaric) (PDF) AZ.CP.PHAR.29 08/2020
Migraine Products - Monoclonal Antibodies - (Aimovig, Ajovy, Emgality) (PDF) AZ.CP.PHAR.1010 02/2021
Multiple Sclerosis Drugs (PDF) AZ.CP.PHAR.1020 02/2021
Non-Calcium Phosphate Binders (Auryxia, Fosrenol, Renvela, Renagel, Velphoro) (PDF) AZ.CP.PMN.04 02/2021
Non-preferred drugs and Brand Name override (PDF) AZ.CP.PMN.16 02/2021
Paliperidone (Invega) (PDF) AZ.CP.PMN.30 08/2020
Pegfilgrastim (Neulasta), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo) (PDF) AZ.CP.PHAR.296 11/2020
Phosphodiesterase-5 inhibitors (PDE-5) (Adcirca, Revatio) (PDF) AZ.CP.PHAR.1013 02/2021
Proton Pump Inhibitors (PDF) AZ.CP.PMN.1002 02/2021
Rifapentine (Priftin) (PDF) AZ.CP.PMN.05 02/2021
Rituximab (Rituxan), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela)  (PDF) AZ.CP.PHAR.260 02/2021
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF) AZ.CP.PMN.14 02/2021
Step Therapy (PDF) AZ.CP.PST.01 02/2021
Tenapanor (Ibsrela) (PDF) AZ.CP.PMN.224 02/2021
teriparatide (Forteo) (PDF) AZ.CP.PHAR.188 02/2021
Thrombopoiesis stimulating agents (PDF) AZ.CP.PHAR.1019 02/2021
Tobramycin (Bethkis, Kitabis, TOBI, TOBI podhaler) (PDF) AZ.CP.PHAR.211 02/2021
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF) AZ.CP.PHAR.199 02/2021
Vancomycin Oral (Vancocin) (PDF) AZ.CP.PMN.166 02/2021
Voriconazole (Vfend) (PDF) AZ.CP.PMN.1003 02/2021
POLICY TITLE POLICY NUMBER EFFECTIVE DATE
Abaloparatide (Tymlos) (PDF) CP.PHAR.345 07/01/2017
abatacept (Orencia) (PDF) CP.PHAR.241 08/01/2016
Abiraterone (Zytiga) (PDF) CP.PHAR.84 10/01/2011
Abiraterone (Zytiga, Yonsa) (PDF) CP.PHAR.84 10/01/2011
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 07/01/2016
Adalimumab (Humira) (PDF) CP.PHAR.242 08/01/2016
Adefovir (Hepsera) (PDF) CP.PHAR.142 08/28/2018
Aducanumab (PDF) CP.PHAR.468 06/01/2020
Afatinib (Gilotrif) (PDF) CP.PHAR.298 01/01/2017
Aflibercept (Eylea®) (PDF) CP.PHAR.184 03/01/2016
Agalsidase Beta (Fabrazyme) (PDF) CP.PHAR.158 02/01/2016
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) CP.PMN.138 03/13/2018
Age Limit for Tazarotene (Tazorac, Arazlo) (PDF) CP.PMN.75 11/09/2017
Alectinib (Alecensa) (PDF) CP.PHAR.369 11/16/2016
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 08/01/2016
Alendronate (Binosto, Fosamax plus D) (PDF) CP.PMN.88 03/01/2018
Alglucosidase Alfa (Lumizyme) (PDF) CP.PHAR.160 02/01/2016
Alirocumab (Praluent) (PDF) CP.PHAR.124 10/01/2015
Alpelisib (Piqray) (PDF) CP.PHAR.430 09/01/2019
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF) CP.PHAR.94 03/01/2012
Ambrisentan (Letairis®) (PDF) CP.PHAR.190 03/01/2016
Amifampridine (Firdapse, Ruzurgi) (PDF) CP.PHAR.411 01/22/2019
Amikacin (Arikayce) (PDF) CP.PHAR.401 11/13/2018
Anakinra (Kineret) (PDF) CP.PHAR.244 08/01/2016
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) CP.PHAR.217 05/01/2016
Apalutamide (Erleada) (PDF) CP.PHAR.376 06/01/2018
Apremilast (Otezla) (PDF) CP.PHAR.245 08/01/2016
Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF) CP.PMN.19 11/30/2016
Arformoterol Tartrate (Brovana) (PDF) CP.PMN.201 09/01/2019
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF) CP.PHAR.290 12/01/2016
Armodafinil (Nuvigil) (PDF) CP.PMN.35 08/01/2009
Asenapine (Saphris, Secuado) (PDF) CP.PMN.15 12/01/2014
asfotase alfa (Strensiq®) (PDF) CP.PHAR.328 03/01/2017
Aspirin-dipyridamole (Aggrenox) (PDF) CP.PMN.20 09/01/2006
Atezolizumab (Tecentriq®) (PDF) CP.PHAR.235 06/01/2016
Avapritinib (Ayvakit) (PDF) CP.PHAR.454 03/01/2020
Avatrombopag (Doptelet) (PDF) CP.PHAR.130 07/17/2018
Avelumab (Bavencio®) (PDF) CP.PHAR.333 05/01/2017
Axicabtagene Ciloleucel (Yescarta) (PDF) CP.PHAR.362 10/31/2017
Axitinib (Inlyta®) (PDF) CP.PHAR.100 05/01/2012
Azacitidine (Vidaza) (PDF) CP.PHAR.387 08/28/2017
Aztreonam (Cayston®) (PDF) CP.PHAR.209 05/01/2016
Baclofen (Gablofen, Lioresal, Ozobax) (PDF) CP.PHAR.149 11/09/2017
Baloxavir Marboxil (Xofluza) (PDF) CP.PMN.185 10/30/2018
Bedaquiline (Sirturo) (PDF) CP.PMN.212 12/01/2019
belatacept (Nulojix®) (PDF) CP.PHAR.201 11/09/2017
Belantamab Mafodotin (PDF) CP.PHAR.469 06/01/2020
Belimumab (Benlysta) (PDF) CP.PHAR.88 10/01/2011
belinostat (Beleodaq®) (PDF) CP.PHAR.311 02/01/2017
Bendamustine (Bendeka®, Treanda®) (PDF) CP.PHAR.307 02/01/2017
Benralizumab (Fasenra) (PDF) CP.PHAR.373 01/16/2018
Benznidazole (PDF) CP.PMN.90 10/17/2017
Berotralstat (PDF) CP.PHAR.485 06/01/2020
Betaine (Cystadane) (PDF) CP.PHAR.143 08/28/2018
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) CP.PHAR.93 11/01/2011
Bexarotene (Targretin) (PDF) CP.PHAR.75 09/01/2011
Bezlotoxumab (Zinplava) (PDF) CP.PHAR.300 11/16/2016
Bimatoprost Implant (Durysta) (PDF) CP.PHAR.486 06/01/2020
Binimetinib (Mektovi) (PDF) CP.PHAR.50 07/24/2018
Blinatumomab (Blincyto) (PDF) CP.PHAR.312 02/01/2017
Bortezomib (Velcade) (PDF) CP.PHAR.410 12/11/2018
Bosentan (Tracleer®) (PDF) CP.PHAR.191 03/01/2016
Bosutinib (Bosulif) (PDF) CP.PHAR.105 10/01/2012
Brentuximab Vedotin (Adcetris) (PDF) CP.PHAR.303 02/01/2017
Brexanolone (Zulresso) (PDF) CP.PHAR.417 04/16/2019
Brexpiprazole (Rexulti) (PDF) CP.PMN.68 11/05/2015
Brexucabtagene Autoleucel (Tecartus) (PDF)
CP.PHAR.472 06/01/2020
Brigatinib (Alunbrig) (PDF) CP.PHAR.342 07/17/2017
Brimonidine Tartrate (Mirvaso) (PDF) CP.PMN.192 11/16/2016
Brivaracetam (Briviact) (PDF) HIM.PA.07 09/01/2019
Brolucizumab-dbll (Beovu) (PDF) CP.PHAR.445 03/01/2020
Buprenorphine Implant/Injection (Probuphine, Sublocade) (PDF) CP.PHAR.289 11/16/2016
Buprenorphine implant (Probuphine) (PDF) CP.PHAR.289 11/16/2016
Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF) CP.PMN.81 09/01/2017
Buprenorphine (Subutex) (PDF) CP.PMN.82 09/01/2017
Burosumab-twza (Crysvita)(PDF) CP.PHAR.11 05/08/2018
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF) CP.PHAR.202 03/01/2016
C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF) CP.PHAR.202 03/01/2016
cabazitaxel (Jevtana® (PDF) CP.PHAR.316 02/01/2017
Cabozantinib (Cometriq®, Cabometyx®) (PDF) CP.PHAR.111 06/01/2013
Cannabidiol (Epidiolex) (PDF) CP.PMN.164 07/17/2018
Canakinumab (Ilaris) (PDF) CP.PHAR.246 08/01/2016
capecitabine (Xeloda) (PDF) CP.PHAR.60 05/01/2011
Caplacizumab-yhdp (Cablivi) (PDF) CP.PHAR.416 03/12/2019
carfilzomib (Kyprolis®) (PDF) CP.PHAR.309 02/01/2017
Carglumic acid (Carbaglu®) (PDF) CP.PHAR.206 05/01/2016
Casimersen (PDF) CP.PHAR.470 06/01/2020
Cedazuridine/Decitabine (ASTX-727) (PDF) CP.PHAR.479 06/01/2020
Celecoxib (Celebrex, Elyxyb) (PDF) CP.PMN.122 01/01/2007
Cenegermin-bkbj (Oxervate) (PDF) CP.PMN.186 10/09/2018
Cenobamate (Xcopri) (PDF) CP.PMN.231 03/01/2020
Cemiplimab-rwlc (Libtayo) (PDF) CP.PHAR.397 10/16/2018
Ceritinib (Zykadia) (PDF) CP.PHAR.349 07/01/2017
Cerliponase alfa (Brineura) (PDF) CP.PHAR.338 07/01/2017
Certolizumab (Cimzia) (PDF) CP.PHAR.247 08/01/2016
Cetuximab (Erbitux®) (PDF) CP.PHAR.317 02/01/2017
Chloramphenicol Sodium Succinate (PDF) CP.PHAR.388 12/01/2018
Cholic Acid (Cholbam) (PDF) CP.PHAR.390 12/01/2018
Cinacalcet (Sensipar) (PDF) CP.PHAR.61 05/01/2011
Cladribine (Mavenclad) (PDF) CP.PHAR.422 09/01/2019
Clobazam (Onfi) (PDF) CP.PMN.54 11/1/2012
CNS Stimulants (PDF) CP.PMN.92 03/01/2018
Cobimetinib (Cotellic) (PDF) CP.PHAR.380 11/16/2016
Collagenase (Xiaflex) (PDF) CP.PHAR.82 10/01/2011
Continuous Glucose Monitors (PDF) CP.PMN.214 12/01/2019
copanlisib (Aliqopa®) (PDF) CP.PHAR.357 10/17/2017
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) CP.PHAR.385 05/29/2018
Cosyntropin (Cortrosyn®) (PDF) CP.PHAR.203 04/01/2016
Crisaborole (Eucrisa) (PDF) CP.PMN.110 02/21/2017
Crizanlizumab-tmca (Adakveo) (PDF) CP.PHAR.449 03/01/2020
Crizotinib (Xalkori) (PDF) CP.PHAR.90 11/01/2011
Cyclosporine (Cequa, Restasis) (PDF) CP.PMN.48 05/01/2012
Cysteamine ophthalmic (Cystaran) (PDF) CP.PMN.130 08/01/2017
Cysteamine oral (Cystagon, Procysbi) (PDF) CP.PHAR.155 02/01/2016
Cytomegalovirus Immune Globulin (Cytogam)(PDF) CP.PHAR.277 09/01/2018
Dabrafenib (Tafinlar) (PDF) CP.PHAR.239 11/16/2016
Daclatasvir (Daklinza) (PDF) CP.PHAR.278 09/01/2016
Daclizumab (Zinbryta) (PDF) CP.PHAR.269 08/01/2016
Dacomitinib (Vizimpro) (PDF) CP.PHAR.399 10/16/2018
Dalfampridine (Ampyra) (PDF) CP.PHAR.248 08/01/2016
Dalteparin (Fragmin) (PDF) CP.PHAR.225 05/01/2016
Daptomycin (Cubicin, Cubicin RF) (PDF) CP.PHAR.351 11/30/2017
Daratumumab (Darzalex) (PDF) CP.PHAR.310 07/01/2017
Darbepoetin Alfa (Aranesp) (PDF) CP.PHAR.236 06/01/2016
Darolutamide (Nubeqa) (PDF)
CP.PHAR.435 12/01/2019
Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira XR, Viekira Pak) (PDF) CP.PHAR.278 09/01/2016
Dasatinib (Sprycel) (PDF) CP.PHAR.72 06/01/2012
daunorubicin/cytarabine (Vyxeos®) (PDF) CP.PHAR.352 12/01/2017
Deferasirox (Exjade Jadenu) (PDF) CP.PHAR.145 11/01/2015
Deferiprone (Ferriprox) (PDF) CP.PHAR.147 11/01/2015
Deferoxamine (Desferal) (PDF) CP.PHAR.146 11/01/2015
Deflazacort (Emflaza) (PDF) CP.PHAR.331 03/01/2017
Degarelix acetate (Firmagon®) (PDF) CP.PHAR.170 11/09/2017
Denosumab (Prolia, Xgeva) (PDF) CP.PHAR.58 03/01/2011
Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF) CP.PHAR.214 05/01/2016
Deutetrabenazine (Austedo) (PDF) CP.PHAR.341 06/13/2017
Dexrazoxane (Zinecard, Totect) (PDF) CP.PHAR.418 03/19/2019
Dextromethorphan-Quinidine (Nuedexta) (PDF) CP.PMN.93 03/01/2018
Diazepam Nasal Spray (Valtoco) (PDF) CP.PMN.216 12/01/2019
Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity) (PDF) CP.PHAR.249 08/01/2016
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF) CP.PMN.03 09/19/2018
Dolasetron (Anzemet) (PDF) CP.PMN.141 09/01/2006
Dornase alfa (Pulmozyme) (PDF) CP.PHAR.212 05/01/2016
Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF) CP.PMN.79 05/01/2017
droxidopa (Northera®) (PDF) CP.PMN.17 11/09/2017
Dupilumab (Dupixent) (PDF) CP.PHAR.336 05/01/2017
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 07/01/2017
Duvelisib (Copiktra) (PDF) CP.PHAR.400 10/16/2018
Early and Periodic Screening, Diagnostic, and Treatment Benefit for Pediatric Members (PDF) CP.PMN.234 06/01/2020
Ecallantide (Kalbitor®) (PDF) CP.PHAR.177 03/01/2016
Eculizumab (Soliris®) (PDF) CP.PHAR.97 03/01/2012
Edaravone (Radicava) (PDF) CP.PHAR.343 07/01/2017
Efinaconazole (Jublia) (PDF) CP.PMN.25 08/01/2016
Elagolix (Orilissa) (PDF) CP.PHAR.136 08/28/2018
Elapegademase-lvlr (Revcovi) (PDF) CP.PHAR.419 04/23/2019
Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (PDF) CP.PHAR.440 12/01/2019
Eliglustat (Cerdelga) (PDF) CP.PHAR.153 02/01/2016
Elosulfase Alfa (Vimizim) (PDF) CP.PHAR.162 02/01/2016
Elotuzumab (Empliciti®) CP.PHAR.308 02/01/2017
Eltrombopag (Promacta®) (PDF) CP.PHAR.180 03/01/2016
Emapalumab-lzsg (Gamifant) (PDF) CP.PHAR.402 12/11/2018
Emicizumab-kxwh (Hemlibra) (PDF) CP.PHAR.370 03/01/2018
Emtricitabine/Tenofovir Alafenamide (Descovy)(PDF) CP.PMN.235 06/01/2020
Enasidenib (Idhifa) (PDF) CP.PHAR.363 09/05/2017
Encorafenib (Braftovi) (PDF) CP.PHAR.127 07/24/2018
Enfortumab Vedotin-ejfv (Padcev) (PDF) CP.PHAR.455 03/01/2020
Enfuvirtide (Fuzeon) (PDF) CP.PHAR.41 06/01/2010
Enoxaparin (Lovenox) (PDF) CP.PHAR.224 05/01/2016
Entrectinib (Rozlytrek) (PDF) CP.PHAR.441 12/01/2019
Enzalutamide (Xtandi) (PDF) CP.PHAR.106 10/01/2012
Epoetin Alfa (Epogen® and Procrit) (PDF) CP.PHAR.237 06/01/2016
Epoprostenol (Flolan®), Veletri®) (PDF) CP.PHAR.192 03/01/2016
Erdafitinib (Balversa)(PDF) CP.PHAR.423 09/01/2019
Erenumab-aaoe (Aimovig) (PDF) CP.PHAR.128 07/10/2018
Eribulin Mesylate (Halaven®) (PDF) CP.PHAR.318 03/01/2017
Erlotinib (Tarceva) (PDF) CP.PHAR.74 09/01/2011
Erwinia Asparaginase (Erwinaze) (PDF) CP.PHAR.301 02/01/2017
Esketamine (Spravato) (PDF) CP.PMN.199 03/12/2019
Etanercept (Enbrel) (PDF) CP.PHAR.250 08/01/2016
Etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 03/20/2018
Eteplirsen (Exondys 51) (PDF) CP.PHAR.288 12/01/2016
Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF) CP.PHAR.63 06/01/2011
Evolocumab (Repatha) (PDF) CP.PHAR.123 10/01/2015
Factor IX (Human, Recombinant) (PDF) CP.PHAR.218 05/01/2016
Factor IX Complex, Human (Profilnine) (PDF) CP.PHAR.219 05/01/2016
Factor IX Complex Human (Bebulin®, Profilnine®) (PDF) CP.PHAR.219 05/01/2016
Factor VIII (Human Recombinant) (PDF) CP.PHAR.215 05/01/2016
Factor VIII/von Willebrand Factor Complex (Human - Alphanate, Humate-P, Wilate) (PDF) CP.PHAR.216 05/01/2016
Factor VIIa, Recombinant (NovoSeven® RT) (PDF) CP.PHAR.220 05/01/2016
Factor XIII A-Subunit, Recombinant (Tretten®) (PDF) CP.PHAR.222 05/01/2016
Factor XIII, Human (Corifact®) (PDF) CP.PHAR.221 05/01/2016
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) CP.PHAR.456 03/01/2020
Febuxostat (Uloric) (PDF) CP.PMN.57 08/01/2013
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF) CP.PMN.127 06/01/2015
Ferric Carboxymaltose (Injectafer) (PDF) CP.PHAR.234 06/01/2016
Ferric Derisomaltose (Monoferric) (PDF) CP.PHAR.280 06/01/2020
Ferric gluconate (Ferrlecit®) (PDF) CP.PHAR.166 3/1/2016
Ferumoxytol (Feraheme®) (PDF) CP.PHAR.165 3/1/2016
Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF) CP.PHAR.297 12/01/2016
Fingolimod (Gilenya) (PDF) CP.PHAR.251 08/01/2016
Fondaparinux (Arixtra) (PDF) CP.PHAR.226 05/01/2016
Fosdenopterin (PDF) CP.PHAR.471 06/01/2020
Fostamatinib (Tavalisse) (PDF) CP.PHAR.24 06/05/2018
Fluorouracil Cream (Tolak(PDF) CP.PMN.165 12/1/2018
Fluticasone Propionate (Xhance) (PDF) CP.PMN.95 10/24/2017
Fluticasone/Vilanterol (Breo Ellipta) (PDF) CP.PMN.229 03/01/2020
Fremanezumab-vfrm (Ajovy) (PDF) CP.PHAR.403 10/30/2018
Fulvestrant (Faslodex Injection)(PDF) CP.PHAR.424 09/01/2019
Galcanezumab-gnlm (Emgality) (PDF) CP.PHAR.404 11/13/2018
Galsulfase (Naglazyme) (PDF) CP.PHAR.161 02/01/2016
Gefitinib (Iressa) (PDF) CP.PHAR.68 11/16/2016
gemtuzumab ozogamicin (Mylotarg®) (PDF) C.PHAR.358 10/03/2017
Gilteritinib (Xospata) (PDF) CP.PHAR.412 01/15/2019
Givosiran (Givlaari) (PDF) CP.PHAR.457 03/01/2020
Glasdegib (Daurismo) (PDF) CP.PHAR.413 01/08/2019
Glatiramer (Copaxone, Glatopa) (PDF) CP.PHAR.252 08/01/2016
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF) CP.PMN.183 09/19/2018
Glycerol phenylbutyrate (Ravicti®) (PDF) CP.PHAR.207 05/01/2016
Golimumab (Simponi, Simponi Aria) (PDF) CP.PHAR.253 07/01/2016
Golodirsen (Vyondys 53) (PDF) CP.PHAR.453 03/01/2020
goserelin acetate (Zoladex®) (PDF) CP.PHAR.171 11/09/2017
Granisetron (Kytril, Sancuso, Sustol) (PDF) CP.PMN.74 11/01/2016
Hemin (Panhematin®) (PDF) CP.PHAR.181 02/01/2016
histrelin acetate (Vantas®, Supprelin LA®) (PDF) CP.PHAR.172 11/09/2017
Hyaluronate Derivatives (PDF) CP.PHAR.05 10/01/2008
Hydroxyprogesterone Caproate (Makena/compound) CP.PHAR.14 11/20/2017
Hydroxyurea (Siklos) (PDF) CP.PMN.193 02/19/2019
Ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 04/17/2018
Ibandronate sodium (Boniva®) (PDF) CP.PHAR.189 11/15/2017
Ibrutinib (Imbruvica) (PDF) CP.PHAR.126 10/01/2015
Ibuprofen/Famotidine (Duexis) (PDF) CP.PMN.120 06/01/2018
Icatibant (Firazyr) (PDF) CP.PHAR.178 03/01/2016
Icosapent ethyl (Vascepa) (PDF) CP.PMN.187 11/20/2018
Idecabtagene Vicleucel (BB2121) (PDF) CP.PHAR.481 06/01/2020
Idelalisib (Zydelig) (PDF) CP.PHAR.133 12/01/2018
Idursulfase (Elaprase) (PDF) CP.PHAR.156 02/01/2016
Iloperidone (Fanapt) (PDF) CP.PMN.32 12/01/2014
Iloprost (Ventavis®) (PDF) CP.PHAR.193 03/01/2016
Imatinib (Gleevec) (PDF) CP.PHAR.65 06/01/2011
Imiglucerase (Cerezyme) (PDF) CP.PHAR.154 02/01/2016
Immune Globulins (PDF) CP.PHAR.103 08/01/2012
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 07/01/2016
Indacaterol/Glycopyrrolate (Utibron Neohaler) (PDF) HIM.PA.102 09/01/2018
Inebilizumab (PDF) CP.PHAR.458 03/01/2020
Infertility and Fertility Preservation (PDF) CP.PHAR.131 11/16/2016
Infliximab (Remicade, Inflectra, Renflexis) (PDF) CP.PHAR.254 07/01/2016
Inotersen (Tegsedi) (PDF) CP.PHAR.405 11/20/2018
inotuzumab ozogamicin (Besponsa®) (PDF) CP.PHAR.359 09/26/2017
Insulin Infusion Pump (Omnipod, Omnipod DASH) (PDF) CP.PHAR.420 04/23/2019
Interferon beta-1a (Avonex, Rebif) (PDF) CP.PHAR.255 08/01/2016
Interferon beta-1b (Betaseron, Extavia) (PDF) CP.PHAR.256 08/01/2016
Interferon Gamma- 1b (Actimmune) (PDF) CP.PHAR.52 06/01/2010
Itraconazole (Sporanox, Onmel, Tolsura) (PDF) CP.PMN.124 11/01/2006
Intrathecal Baclofen (Gablofen, Lioresal) (PDF) CP.PHAR.149 11/09/2017
Iobenguane I-131 (Azedra) (PDF) CP.PHAR.459 03/01/2020
Ipilimumab (Yervoy) (PDF) CP.PHAR.319 04/17/2018
irinotecan Liposome (Onivyde®) (PDF) CP.PHAR.304 02/01/2017
Iron sucrose (Venofer®) (PDF) CP.PHAR.167 03/01/2016
Isatuximab-irfc (Sarclisa)(PDF) CP.PHAR.482 06/01/2020
Isavuconazonium (Cresemba) (PDF) CP.PMN.154 11/16/2016
Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (PDF) CP.PMN.143 12/01/2014
Istradefylline (Nourianz) (PDF) CP.PMN.217 03/01/2020
Ivabradine (Corlanor) (PDF) CP.PMN.70 11/01/2015
Ivacaftor (Kalydeco) (PDF) CP.PHAR.210 05/01/2016
Ivosidenib (Tibsovo) (PDF)
CP.PHAR.137 08/21/2018
Ixazomib (Ninlaro) (PDF) CP.PHAR.302 02/01/2017
Ixekizumab (Taltz) (PDF) CP.PHAR.257 08/01/2016
Lacosamide (Vimpat) (PDF) CP.PMN.155 12/01/2014
Lanadelumab-fylo (Takhzyro) (PDF) CP.PHAR.396 09/25/2018
Lanreotide (Somatuline Depot) (PDF) CP.PHAR.391 08/28/2018
lapatinib (Tykerb®) (PDF) CP.PHAR.79 11/09/2017
Laronidase (Aldurazyme) (PDF) CP.PHAR.152 02/01/2016
Larotrectinib (Vitrakvi) (PDF) CP.PHAR.414 01/15/2018
Lasmiditan (Reyvow) (PDF) CP.PMN.218 03/01/2020
Ledipasvir/Sofosbuvir (Harvoni) (PDF) CP.PHAR.279 09/01/2016
Lefamulin (Xenleta) (PDF) CP.PMN.219 03/01/2020
Lemborexant (Dayvigo)(PDF) CP.PMN.233 06/01/2020
Lenalidomide (Revlimid) (PDF) CP.PHAR.71 07/01/2011
Lenvatinib (Lenvima) (PDF) CP.PHAR.138 12/01/2018
Letermovir (Prevymis) (PDF) CP.PHAR.367 03/01/2018
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) CP.PHAR.173 11/09/2017
Levalbuterol (Xopenex HFA/Inhalation Solution) (PDF) CP.PMN.07 09/01/2006
Levoleucovorin (Fusilev®) (PDF) CP.PHAR.151 11/09/2017
Lidocaine Transdermal (Lidoderm, ZTlido) (PDF) CP.PMN.08 09/01/2006
Linaclotide (Linzess) (PDF) CP.PMN.71 11/01/2015
Linezolid (Zyvox) (PDF) CP.PMN.27 09/01/2016
Lifitegrast (Xiidra®) (PDF) CP.PMN.73 11/09/2017
Lisocabtagene Maraleucel (JCAR017) (PDF) CP.PHAR.483 06/01/2020
Lofexidine (Lucemyra) (PDF) CP.PMN.152 08/01/2018
Lomitapide (Juxtapid) (PDF) CP.PHAR.283 10/01/2016
Lorlatinib (Lorbrena) (PDF) CP.PHAR.406 12/11/2018
Lubiprostone (Amitiza) (PDF) CP.PMN.142 12/01/2014
Luliconazole Cream (Luzu) (PDF) CP.PMN.166 08/28/2018
Lumacaftor-Ivacaftor (Orkambi) (PDF) CP.PHAR.213 05/01/2016
Lumasiran (ALN-GO1) (PDF) CP.PHAR.473 06/01/2020
Lumateperone (Caplyta) (PDF) CP.PMN.232 03/01/2020
Lurasidone (Latuda) (PDF) CP.PMN.50 12/01/2014
Luspatercept-aamt (Reblozyl) (PDF) CP.PHAR.450 03/01/2020
Lusutrombopag (Mulpleta) (PDF) CP.PHAR.407 09/18/2018
Lutetium Lu 177 Dotatate (Lutathera)(PDF) CP.PHAR.384 05/22/2018
Macitentan (Opsumit®) (PDF) CP.PHAR.194 03/01/2016
Mecasermin (Increlex) (PDF) CP.PHAR.150 03/01/2011
Mecamylamine (Vecamyl) (PDF) CP.PMN.136 05/01/2017
Megestrol Acetate (Megace ES) (PDF) CP.PMN.179 12/01/2018
Mepolizumab (Nucala) (PDF) CP.PHAR.200 04/01/2016
Metformin ER (Fortamet, Glumetza) (PDF) CP.PMN.72 11/01/2015
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF) CP.PHAR.134 12/01/2018
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) CP.PHAR.238 06/01/2016
Methylnaltrexone Bromide (Relistor) (PDF) CP.PMN.169 12/01/2018
Metreleptin (Myalept) (PDF) CP.PHAR.425 09/01/2019
Midazolam (Nayzilam) (PDF) CP.PMN.211 09/01/2019
Midostaurin (Rydapt) (PDF) CP.PHAR.344 06/01/2017
Mifepristone (Korlym) (PDF) CP.PHAR.101 05/01/2012
Migalastat (Galafold) (PDF) CP.PHAR.394 09/11/2018
Miglustat (Zavesca) (PDF) CP.PHAR.164 02/01/2016
Milnacipran (Savella) (PDF) CP.PMN.125 08/01/2012
Mipomersen (Kynamro) (PDF) CP.PHAR.284 10/01/2016
Minocycline ER (Solodyn, Ximino, Minolira) and Microspheres (Arestin) (PDF) CP.PMN.80 05/01/2017
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 08/01/2016
Modafinil (Provigil) (PDF) CP.PMN.39 05/01/2008
Mogamulizumab-kpkc (Poteligeo) (PDF) CP.PHAR.139 09/04/2018
Mometasone/Formoterol (Dulera) (PDF) CP.PMN.230 03/01/2020
Mometasone Furoate (Sinuva) (PDF) CP.PHAR.448 03/01/2020
Monomethyl Fumarate (Bafiertam) (PDF) CP.PHAR.460 03/01/2020
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) CP.PHAR.398 10/16/2018
Nadofaragene Firadenovec (Instiladrin) (PDF) CP.PHAR.461 03/01/2020
nafarelin acetate (Synarel®) (PDF) CP.PHAR.174 11/09/2017
Naproxen/Esomeprazole (Vimovo) (PDF) CP.PMN.117 06/01/2018
Natalizumab (Tysabri) (PDF) CP.PHAR.259 07/01/2016
Necitumumab (Portrazza®) (PDF) CP.PHAR.320 03/01/2017
Neomycin/Fluocinolone Cream (Neo-Synalar)_(PDF) CP.PMN.167 08/28/2018
Neratinib (Nerlynx) (PDF) CP.PHAR.365 09/05/2017
Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan)  (PDF) CP.PMN.118 02/13/2018
Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (PDF) CP.PMN.158 09/01/2006
nilotinib (Tasigna) (PDF) CP.PHAR.76 09/01/2011
Nintedanib (Ofev) (PDF) CP.PHAR.285 10/01/2016
Nitisinone (Nityr, Orfadin) (PDF) CP.PHAR.132 08/28/2018
Nivolumab (Opdivo) (PDF) CP.PHAR.121 07/01/2015
No Coverage Criteria/Off-Label Use Policy (PDF) CP.PMN.53 09/12/2017
Nusinersen (Spinraza®)(PDF) CP.PHAR.327 11/28/2017
Obeticholic (Ocaliva) (PDF) CP.PHAR.287 11/01/2016
Obinutuzumab (Gazyva®) (PDF) CP.PHAR.305 02/01/2017
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 04/01/2017
Octreotide (Sandostatin, Sandostatin LAR) (PDF) CP.PHAR.40 03/01/2010
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia) (PDF) CP.PHAR.40 03/01/2010
ofatumumab (Arzerra®) (PDF) CP.PHAR.306 02/01/2017
Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) CP.PHAR.292 12/01/2016
Olaparib (Lynparza) (PDF) CP.PHAR.360 10/03/2017
olaratumab (Lartruvo®) (PDF) CP.PHAR.326 03/01/2017
Omadacycline (Nuzyra) (PDF) CP.PMN.188 11/20/2018
Omacetaxine (Synribo) (PDF) CP.PHAR.108 04/01/2013
Omalizumab (Xolair®) (PDF) CP.PHAR.01 10/1/2008
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 07/01/2016
Onasemnogene Abeparvovec (Zolgensma) (PDF) CP.PHAR.421 06/07/2019
Ondansetron (Zuplenz) (PDF) CP.PMN.45 09/01/2006
Osimertinib (Tagrisso) (PDF) CP.PHAR.294 12/01/2016
Ospemifene (Osphena) (PDF) CP.PMN.168 08/28/2018
Overactive Bladder Agents (PDF) CP.PMN.198 05/01/2016
Ozanimod (PDF) CP.PHAR.462 03/01/2020
Ozenoxacin (Xepi) (PDF) CP.PMN.119 01/30/2018
Paclitaxel, Protein-Bound (Abraxane) (PDF) CP.PHAR.176 07/01/2015
Palbociclib (Ibrance®) (PDF) CP.PHAR.125 10/01/2015
Palivizumab (Synagis) (PDF) CP.PHAR.16 08/01/2009
panitumumab (Vectibix®) (PDF) CP.PHAR.321 03/01/2017
Parathyroid Hormone (Natpara) (PDF) CP.PHAR.282 11/16/2016
Paricalcitol Injection (Zemplar) (PDF) CP.PHAR.270 08/01/2016
Pasireotide (Signifor LAR®) (PDF) CP.PHAR.332 03/01/2017
Patisiran (Onpattro) (PDF) CP.PHAR.395 09/11/2018
Pazopanib (Votrient) (PDF) CP.PHAR.81 10/01/2011
Peanut Allergen Powder-dnfp (Palforzia) (PDF) CP.PMN.220 03/01/2020
Pegademase Bovine (Adagen) (PDF) CP.PHAR.392 08/28/2018
Pegaptanib (Macugen®) (PDF) CP.PHAR.185 03/01/2016
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF) CP.PHAR.353 09/05/2017
Pegfilgrastim (Neulasta) (PDF) CP.PHAR.296 12/01/2016
peginterferon alfa-2b (PegIntron, Sylatron®) (PDF) CP.PHAR.89 10/01/2011
Peginterferon beta-1a (Plegridy) (PDF) CP.PHAR.271 08/01/2016
Pegloticase (Krystexxa®) (PDF) CP.PHAR.115 6/1/2013
Pegvaliase-pqpz (Palynziq) (PDF) CP.PHAR.140 07/31/2018
Pegvisomant (Somavert) (PDF) CP.PHAR.389 12/01/2018
Pemetrexed (Alimta, Pemfexy) (PDF) CP.PHAR.368 10/31/2017
pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 03/01/2017
Perampanel (Fycompa) (PDF) CP.PMN.156 11/16/2016
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 06/01/2016
Pexidartinib (Turalio) (PDF) CP.PHAR.436 12/01/2019
Pitolisant (Wakix) (PDF) CP.PMN.221 03/01/2020
Plerixafor (Mozobil) (PDF) CP.PHAR.323 03/01/2017
Polatuzumab Vedotin-piiq (Polivy) (PDF) CP.PHAR.433 09/01/2019
Pomalidomide (Pomalyst) (PDF) CO.PHAR.116 07/01/2013
Ponatinib (Iclusig) (PDF) CO.PHAR.112 06/01/2013
Pralatrexate (Folotyn®) (PDF) CP.PHAR.313 02/01/2017
Pramlintide (Symlin) (PDF) CP.PMN.129 06/01/2018
Pregabalin (Lyrica, Lyrica CR) (PDF) CP.PMN.33 01/01/2007
Pretomanid (PDF) CP.PMN.222 03/01/2020
Protein C Concentrate, Human (Ceprotin) (PDF) CP.PHAR.330 03/01/2017
Propranolol HCl Oral Solution (Hemangeol) (PDF) CP.PMN.58 05/01/2014
Prucalopride (Motegrity) (PDF) CP.PMN.194 01/29/2019
pyrimethamine (Daraprim®) (PDF) CP.PMN.44 11/01/2015
Quetiapine ER (Seroquel XR) (PDF) CP.PMN.64 12/01/2014
Ramucirumab (Cyramza®) (PDF) CP.PHAR.119 05/01/2015
Ranibizumab (Lucentis®) (PDF) CP.PHAR.186 03/01/2016
Regorafenib (Stivarga) (PDF) CP.PHAR.107 12/01/2012
Remestemcel-L (Prochymal) (PDF) CP.PHAR.474 06/01/2020
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) CP.PHAR.168 03/01/2016
Request for Medically Necessary Drug Not on the PDL (PDF) CP.PMN.16 11/09/2017
Reslizumab (Cinqair) (PDF) CP.PHAR.223 05/01/2016
Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF) CP.PHAR.141 11/16/2016
Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) (PDF) CP.PMN.223 03/01/2020
Rifamycin (Aemcolo) (PDF) CP.PMN.196 01/08/2019
rifaximin (Xifaxan®)(PDF) CP.PMN.47 11/01/2011
Rilonacept (Arcalyst) (PDF) CP.PHAR.266 11/16/2016
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 07/01/2016
Riociguat (Adempas®) (PDF) CP.PHAR.195 03/01/2016
Risdiplam (PDF) CP.PHAR.477 06/01/2020
Risedronate (Actonel, Atelvia) (PDF) CP.PMN.100 03/01/2018
Risperidone Long-Acting Injection (Risperdal Consta) (PDF) CP.PHAR.293 12/01/2016
Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) CP.PHAR.260 07/01/2016
Rolapitant (Varubi) (PDF) CP.PMN.102 02/01/2017
romidepsin (Istodax®) (PDF) CP.PHAR.314 01/01/2017
Romiplostim (Nplate®) (PDF) CP.PHAR.179 03/01/2016
Rucaparib (Rubraca®) (PDF) CP.PHAR.350 09/01/2017
Rufinamide (Banzel) (PDF) CP.PMN.157 12/01/2014
Sacubitril/Valsartan (Entresto) (PDF) CP.PMN.67 11/01/2015
Sacitizumab Govitecan (PDF) CP.PHAR.475 06/01/2020
Safinamide (Xadago) (PDF) CP.PMN.113 07/01/2017
Sapropterin Dihydrochloride (Kuvan) (PDF) CP.PHAR.43 02/01/2010
Sarecycline (Seysara) (PDF) CP.PMN.189 11/13/2018
Sargramostim (Leukine) (PDF) CP.PHAR.295 12/01/2016
Satralizumab (PDF) CP.PHAR.463 03/01/2020
Sebelipase Alfa (Kanuma) (PDF) CP.PHAR.159 02/01/2016
Secnidazole (Solosec) (PDF) CP.PMN.103 10/24/2017
Selexipag (Uptravi®) (PDF) CP.PHAR.196 03/01/2016
Selinexor (Xpovio) (PDF) CP.PHAR.431 09/01/2019
Selpercatinib (LOXO-292) (PDF) CP.PHAR.478 06/01/2020
Selumetinib (Koselugo) (PDF) CP.PHAR.464 03/01/2020
Sildenafil (Revatio®) (PDF) CP.PHAR.197 03/01/2016
Siltuximab (Sylvant®) (PDF) CP.PHAR.329 03/01/2017
Simeprevir (Olysio) (PDF) CP.PHAR.280 09/01/2016
Siponimod (Mayzent) (PDF) CP.PHAR.427 09/01/2019
Sipuleucel-T (Provenge) (PDF) CP.PHAR.120 06/01/2015
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF) CP.PMN.14 09/18/2018
sodium oxybate (Xyrem) (PDF) CP.PMN.42 05/01/2011
Sodium Phenylbutyrate (Buphenyl) (PDF) CP.PHAR.208 05/01/2016
Sofosbuvir (Sovaldi) (PDF) CP.PHAR.281 09/01/2016
Solriamfetol (Sunosi) (PDF) CP.PMN.209 09/01/2019
Somatropin (Growth Hormone) (PDF) CP.PHAR.55 03/01/2011
Sonidegib (Odomzo) (PDF) CP.PHAR.272 05/01/2012
sorafenib (Nexavar) (PDF) CP.PHAR.69 07/01/2011
Step Therapy (PDF) CP.PST.01 12/28/2017
Stiripentol (Diacomit) (PDF) CP.PMN.184 09/25/2018
sunitinib (Sutent) (PDF) CP.PHAR.73 09/01/2011
Suvorexant (Belsomra®) (PDF) CP.PMN.109 02/01/2017
Tadalafil (Adcirca®) (PDF) CP.PHAR.198 03/01/2016
Tadalafil BHP - ED (Cialis) (PDF) CP.PMN.132 06/01/2018
Tafamidis (Vyndaqel, Vyndamax) (PDF) CP.PHAR.432 09/01/2019
Talazoparib (Talzenna) (PDF) CP.PHAR.409 11/27/2018
Taliglucerase Alfa (Elelyso) (PDF) CP.PHAR.157 02/01/2016
Tasimelteon (Hetlioz) (PDF) CP.PMN.104 02/01/2017
Tavaborole (Kerydin) (PDF) CP.PMN.105 03/01/2018
Tazemetostat (Tazverik) (PDF) CP.PHAR.452 03/01/2020
Tedizolid (Sivextro) (PDF) CP.PMN.62 03/01/2015
Teduglutide (Gattex) (PDF) CP.PHAR.114 05/01/2013
Tegaserod (Zelnorm) (PDF) CP.PMN.206 09/01/2019
Telotristat Ethyl (Xermelo) (PDF) CP.PHAR.337 06/01/2017
Temozolomide (Temodar) (PDF) CP.PHAR.77 09/01/2011
temsirolimus (Torisel®) (PDF) CP.PHAR.324 03/01/2017
Tenapanor (Ibsrela) (PDF) CP.PMN.224 03/01/2020
Teprotumumab (Tepezza) (PDF) CP.PHAR.465 01/21/2020
Teriflunomide (Aubagio) (PDF) CP.PHAR.262 08/01/2016
Teriparatide (Forteo®) (PDF) CP.PHAR.188 11/15/2017
Tesamorelin (Egrifta) (PDF) CP.PHAR.109 03/01/2014
Testosterone (Testopel, Jatenzo) (PDF) CP.PHAR.354 08/01/2017
tetrabenazine (Xenazine) (PDF) CP.PHAR.92 12/01/2011
Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF) CP.PHAR.377 04/03/2018
Thalidomide (Thalomid) (PDF) CP.PHAR.78 09/01/2011
Thioguanine (Tabloid) (PDF) CP.PHAR.437 12/01/2019
Thyrotropin Alfa (Thyrogen) (PDF)  CP.PHAR.95 03/01/2012
Timothy grass pollen allergen extract (Grastek®) (PDF) CP.PMN.84 08/31/2017
Tisagenlecleucel (Kymriah) (PDF) CP.PHAR.361 09/26/2017
Tobramycin (Bethkis®, Kitabis Pak®, TOBI®, TOBI Podhaler®) (PDF) CP.PHAR.211 05/01/2016
Tocilizumab (Actemra) (PDF) CP.PHAR.263 07/01/2016
Tofacitinib (Xeljanz, Xeljanz XR) (PDF) CP.PHAR.267 01/30/2018
Tolvaptan (Jynarque) (PDF) CP.PHAR.27 06/05/2018
Topical Immunomodulators (PDF) CP.PMN.107 09/01/2006
Topotecan (Hycamtin)(PDF) CP.PHAR.64 06/01/2011
Trabectedin (Yondelis®) (PDF) CP.PHAR.204 05/01/2016
Trametinib (Mekinist) (PDF) CP.PHAR.240 07/01/2016
Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF) CP.PHAR.228 06/01/2016
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF) CP.PHAR.199 03/01/2016
Triamcinolone ER Injection (Zilretta) (PDF) CP.PHAR.371 03/01/2018
Trientine (Syprine) (PDF) CP.PHAR.438 12/01/2019
triptorelin pamoate (Trelstar®, Triptodur®) (PDF) CP.PHAR.175 11/09/2017
Ubrogepant (Ubrelvy) (PDF) CP.PHAR.475 06/01/2020
Upadacitinib (Rinvoq) (PDF) CP.PHAR.443 12/01/2019
Ustekinumab (Stelara) (PDF) CP.PHAR.264 08/01/2016
Valoctocogene Roxaparvovec (PDF) CP.PHAR.466 03/01/2020
Valproate Sodium for Intravenous Injection (Depacon) (PDF) CP.PHAR.429 09/01/2019
Valrubicin (Valstar) (PDF) CP.PHAR.439 12/01/2019
Vandetanib (Caprelsa®) (PDF) CP.PHAR.80 10/01/2011
Vedolizumab (Entyvio) (PDF) CP.PHAR.265 07/01/2016
Velaglucerase Alfa (VPRIV) (PDF) CP.PHAR.163 02/01/2016
Vemurafenib (Zelboraf®) (PDF) CP.PHAR.91 11/01/2011
Verteporfin (Visudyne®) (PDF) CP.PHAR.187 03/01/2016
Vestronidase alfa-vjbk (Mepsevii) (PDF) CP.PHAR.374 01/19/2018
Vigabatrin (Sabril) (PDF) CP.PHAR.169 02/01/2016
Vilazodone (Viibryd) (PDF) CP.PMN.145 08/01/2012
Viltolarsen (PDF) CP.PHAR.484 06/01/2020
vincristine sulfate liposome injection (Marqibo®) (PDF) CP.PHAR.315 02/01/2017
Vismodegib (Erivedge) (PDF) CP.PHAR.273 08/01/2016
Voretigene neparvovec-rzyl (Luxturna) (PDF) CP.PHAR.372 03/01/2018
Vorinostat (Zolinza) (PDF) CP.PHAR.83 12/01/2012
Vortioxetine (Trintellix®) (PDF) CP.PMN.65 05/31/2017
Voxelotor (Oxbryta) (PDF) CP.PHAR.451 03/01/2020
Zanubrutinib (Brukinsa) (PDF) CP.PHAR.467 03/01/2020
ziv-aflibercept (Zaltrap®) (PDF) CP.PHAR.325 03/01/2017
Zoledronic acid (Reclast, Zometa) (PDF) CP.PHAR.59 03/01/2011
POLICY TITLE POLICY NUMBER EFFECTIVE DATE
Abaloparatide (Tymlos) (PDF) CP.PHAR.345 07/01/2017
abatacept (Orencia) (PDF) CP.PHAR.241 08/01/2016
Abiraterone (Zytiga) (PDF) CP.PHAR.84 10/01/2011
Abiraterone (Zytiga, Yonsa) (PDF) CP.PHAR.84 10/01/2011
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 07/01/2016
Adalimumab (Humira) (PDF) CP.PHAR.242 08/01/2016
Adefovir (Hepsera) (PDF) CP.PHAR.142 08/28/2018
Aducanumab (PDF) CP.PHAR.468 06/01/2020
Afatinib (Gilotrif) (PDF) CP.PHAR.298 01/01/2017
Aflibercept (Eylea®) (PDF) CP.PHAR.184 03/01/2016
Agalsidase Beta (Fabrazyme) (PDF) CP.PHAR.158 02/01/2016
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) CP.PMN.138 03/13/2018
Age Limit for Tazarotene (Tazorac, Arazlo) (PDF) CP.PMN.75 11/09/2017
Alectinib (Alecensa) (PDF) CP.PHAR.369 11/16/2016
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 08/01/2016
Alendronate (Binosto, Fosamax plus D) (PDF) CP.PMN.88 03/01/2018
Alglucosidase Alfa (Lumizyme) (PDF) CP.PHAR.160 02/01/2016
Alirocumab (Praluent) (PDF) CP.PHAR.124 10/01/2015
Alpelisib (Piqray) (PDF) CP.PHAR.430 09/01/2019
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF) CP.PHAR.94 03/01/2012
Ambrisentan (Letairis®) (PDF) CP.PHAR.190 03/01/2016
Amifampridine (Firdapse, Ruzurgi) (PDF) CP.PHAR.411 01/22/2019
Amikacin (Arikayce) (PDF) CP.PHAR.401 11/13/2018
Anakinra (Kineret) (PDF) CP.PHAR.244 08/01/2016
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) CP.PHAR.217 05/01/2016
Apalutamide (Erleada) (PDF) CP.PHAR.376 06/01/2018
Apremilast (Otezla) (PDF) CP.PHAR.245 08/01/2016
Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF) CP.PMN.19 11/30/2016
Arformoterol Tartrate (Brovana) (PDF) CP.PMN.201 09/01/2019
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF) CP.PHAR.290 12/01/2016
Armodafinil (Nuvigil) (PDF) CP.PMN.35 08/01/2009
Asenapine (Saphris, Secuado) (PDF) CP.PMN.15 12/01/2014
asfotase alfa (Strensiq®) (PDF) CP.PHAR.328 03/01/2017
Aspirin-dipyridamole (Aggrenox) (PDF) CP.PMN.20 09/01/2006
Atezolizumab (Tecentriq®) (PDF) CP.PHAR.235 06/01/2016
Avapritinib (Ayvakit) (PDF) CP.PHAR.454 03/01/2020
Avatrombopag (Doptelet) (PDF) CP.PHAR.130 07/17/2018
Avelumab (Bavencio®) (PDF) CP.PHAR.333 05/01/2017
Axicabtagene Ciloleucel (Yescarta) (PDF) CP.PHAR.362 10/31/2017
Axitinib (Inlyta®) (PDF) CP.PHAR.100 05/01/2012
Azacitidine (Vidaza) (PDF) CP.PHAR.387 08/28/2017
Aztreonam (Cayston®) (PDF) CP.PHAR.209 05/01/2016
Baclofen (Gablofen, Lioresal, Ozobax) (PDF) CP.PHAR.149 11/09/2017
Baloxavir Marboxil (Xofluza) (PDF) CP.PMN.185 10/30/2018
Bedaquiline (Sirturo) (PDF) CP.PMN.212 12/01/2019
belatacept (Nulojix®) (PDF) CP.PHAR.201 11/09/2017
Belantamab Mafodotin (PDF) CP.PHAR.469 06/01/2020
Belimumab (Benlysta) (PDF) CP.PHAR.88 10/01/2011
belinostat (Beleodaq®) (PDF) CP.PHAR.311 02/01/2017
Bendamustine (Bendeka®, Treanda®) (PDF) CP.PHAR.307 02/01/2017
Benralizumab (Fasenra) (PDF) CP.PHAR.373 01/16/2018
Benznidazole (PDF) CP.PMN.90 10/17/2017
Berotralstat (PDF) CP.PHAR.485 06/01/2020
Betaine (Cystadane) (PDF) CP.PHAR.143 08/28/2018
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) CP.PHAR.93 11/01/2011
Bexarotene (Targretin) (PDF) CP.PHAR.75 09/01/2011
Bezlotoxumab (Zinplava) (PDF) CP.PHAR.300 11/16/2016
Bimatoprost Implant (Durysta) (PDF) CP.PHAR.486 06/01/2020
Binimetinib (Mektovi) (PDF) CP.PHAR.50 07/24/2018
Blinatumomab (Blincyto) (PDF) CP.PHAR.312 02/01/2017
Bortezomib (Velcade) (PDF) CP.PHAR.410 12/11/2018
Bosentan (Tracleer®) (PDF) CP.PHAR.191 03/01/2016
Bosutinib (Bosulif) (PDF) CP.PHAR.105 10/01/2012
Brentuximab Vedotin (Adcetris) (PDF) CP.PHAR.303 02/01/2017
Brexanolone (Zulresso) (PDF) CP.PHAR.417 04/16/2019
Brexpiprazole (Rexulti) (PDF) CP.PMN.68 11/05/2015
Brexucabtagene Autoleucel (Tecartus) (PDF)
CP.PHAR.472 06/01/2020
Brigatinib (Alunbrig) (PDF) CP.PHAR.342 07/17/2017
Brimonidine Tartrate (Mirvaso) (PDF) CP.PMN.192 11/16/2016
Brivaracetam (Briviact) (PDF) HIM.PA.07 09/01/2019
Brolucizumab-dbll (Beovu) (PDF) CP.PHAR.445 03/01/2020
Buprenorphine Implant/Injection (Probuphine, Sublocade) (PDF) CP.PHAR.289 11/16/2016
Buprenorphine implant (Probuphine) (PDF) CP.PHAR.289 11/16/2016
Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF) CP.PMN.81 09/01/2017
Buprenorphine (Subutex) (PDF) CP.PMN.82 09/01/2017
Burosumab-twza (Crysvita)(PDF) CP.PHAR.11 05/08/2018
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF) CP.PHAR.202 03/01/2016
C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF) CP.PHAR.202 03/01/2016
cabazitaxel (Jevtana® (PDF) CP.PHAR.316 02/01/2017
Cabozantinib (Cometriq®, Cabometyx®) (PDF) CP.PHAR.111 06/01/2013
Cannabidiol (Epidiolex) (PDF) CP.PMN.164 07/17/2018
Canakinumab (Ilaris) (PDF) CP.PHAR.246 08/01/2016
capecitabine (Xeloda) (PDF) CP.PHAR.60 05/01/2011
Caplacizumab-yhdp (Cablivi) (PDF) CP.PHAR.416 03/12/2019
carfilzomib (Kyprolis®) (PDF) CP.PHAR.309 02/01/2017
Carglumic acid (Carbaglu®) (PDF) CP.PHAR.206 05/01/2016
Casimersen (PDF) CP.PHAR.470 06/01/2020
Cedazuridine/Decitabine (ASTX-727) (PDF) CP.PHAR.479 06/01/2020
Celecoxib (Celebrex, Elyxyb) (PDF) CP.PMN.122 01/01/2007
Cenegermin-bkbj (Oxervate) (PDF) CP.PMN.186 10/09/2018
Cenobamate (Xcopri) (PDF) CP.PMN.231 03/01/2020
Cemiplimab-rwlc (Libtayo) (PDF) CP.PHAR.397 10/16/2018
Ceritinib (Zykadia) (PDF) CP.PHAR.349 07/01/2017
Cerliponase alfa (Brineura) (PDF) CP.PHAR.338 07/01/2017
Certolizumab (Cimzia) (PDF) CP.PHAR.247 08/01/2016
Cetuximab (Erbitux®) (PDF) CP.PHAR.317 02/01/2017
Chloramphenicol Sodium Succinate (PDF) CP.PHAR.388 12/01/2018
Cholic Acid (Cholbam) (PDF) CP.PHAR.390 12/01/2018
Cinacalcet (Sensipar) (PDF) CP.PHAR.61 05/01/2011
Cladribine (Mavenclad) (PDF) CP.PHAR.422 09/01/2019
Clobazam (Onfi) (PDF) CP.PMN.54 11/1/2012
CNS Stimulants (PDF) CP.PMN.92 03/01/2018
Cobimetinib (Cotellic) (PDF) CP.PHAR.380 11/16/2016
Collagenase (Xiaflex) (PDF) CP.PHAR.82 10/01/2011
Continuous Glucose Monitors (PDF) CP.PMN.214 12/01/2019
copanlisib (Aliqopa®) (PDF) CP.PHAR.357 10/17/2017
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) CP.PHAR.385 05/29/2018
Cosyntropin (Cortrosyn®) (PDF) CP.PHAR.203 04/01/2016
Crisaborole (Eucrisa) (PDF) CP.PMN.110 02/21/2017
Crizanlizumab-tmca (Adakveo) (PDF) CP.PHAR.449 03/01/2020
Crizotinib (Xalkori) (PDF) CP.PHAR.90 11/01/2011
Cyclosporine (Cequa, Restasis) (PDF) CP.PMN.48 05/01/2012
Cysteamine ophthalmic (Cystaran) (PDF) CP.PMN.130 08/01/2017
Cysteamine oral (Cystagon, Procysbi) (PDF) CP.PHAR.155 02/01/2016
Cytomegalovirus Immune Globulin (Cytogam)(PDF) CP.PHAR.277 09/01/2018
Dabrafenib (Tafinlar) (PDF) CP.PHAR.239 11/16/2016
Daclatasvir (Daklinza) (PDF) CP.PHAR.278 09/01/2016
Daclizumab (Zinbryta) (PDF) CP.PHAR.269 08/01/2016
Dacomitinib (Vizimpro) (PDF) CP.PHAR.399 10/16/2018
Dalfampridine (Ampyra) (PDF) CP.PHAR.248 08/01/2016
Dalteparin (Fragmin) (PDF) CP.PHAR.225 05/01/2016
Daptomycin (Cubicin, Cubicin RF) (PDF) CP.PHAR.351 11/30/2017
Daratumumab (Darzalex) (PDF) CP.PHAR.310 07/01/2017
Darbepoetin Alfa (Aranesp) (PDF) CP.PHAR.236 06/01/2016
Darolutamide (Nubeqa) (PDF)
CP.PHAR.435 12/01/2019
Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira XR, Viekira Pak) (PDF) CP.PHAR.278 09/01/2016
Dasatinib (Sprycel) (PDF) CP.PHAR.72 06/01/2012
daunorubicin/cytarabine (Vyxeos®) (PDF) CP.PHAR.352 12/01/2017
Deferasirox (Exjade Jadenu) (PDF) CP.PHAR.145 11/01/2015
Deferiprone (Ferriprox) (PDF) CP.PHAR.147 11/01/2015
Deferoxamine (Desferal) (PDF) CP.PHAR.146 11/01/2015
Deflazacort (Emflaza) (PDF) CP.PHAR.331 03/01/2017
Degarelix acetate (Firmagon®) (PDF) CP.PHAR.170 11/09/2017
Denosumab (Prolia, Xgeva) (PDF) CP.PHAR.58 03/01/2011
Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF) CP.PHAR.214 05/01/2016
Deutetrabenazine (Austedo) (PDF) CP.PHAR.341 06/13/2017
Dexrazoxane (Zinecard, Totect) (PDF) CP.PHAR.418 03/19/2019
Dextromethorphan-Quinidine (Nuedexta) (PDF) CP.PMN.93 03/01/2018
Diazepam Nasal Spray (Valtoco) (PDF) CP.PMN.216 12/01/2019
Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity) (PDF) CP.PHAR.249 08/01/2016
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF) CP.PMN.03 09/19/2018
Dolasetron (Anzemet) (PDF) CP.PMN.141 09/01/2006
Dornase alfa (Pulmozyme) (PDF) CP.PHAR.212 05/01/2016
Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF) CP.PMN.79 05/01/2017
droxidopa (Northera®) (PDF) CP.PMN.17 11/09/2017
Dupilumab (Dupixent) (PDF) CP.PHAR.336 05/01/2017
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 07/01/2017
Duvelisib (Copiktra) (PDF) CP.PHAR.400 10/16/2018
Early and Periodic Screening, Diagnostic, and Treatment Benefit for Pediatric Members (PDF) CP.PMN.234 06/01/2020
Ecallantide (Kalbitor®) (PDF) CP.PHAR.177 03/01/2016
Eculizumab (Soliris®) (PDF) CP.PHAR.97 03/01/2012
Edaravone (Radicava) (PDF) CP.PHAR.343 07/01/2017
Efinaconazole (Jublia) (PDF) CP.PMN.25 08/01/2016
Elagolix (Orilissa) (PDF) CP.PHAR.136 08/28/2018
Elapegademase-lvlr (Revcovi) (PDF) CP.PHAR.419 04/23/2019
Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (PDF) CP.PHAR.440 12/01/2019
Eliglustat (Cerdelga) (PDF) CP.PHAR.153 02/01/2016
Elosulfase Alfa (Vimizim) (PDF) CP.PHAR.162 02/01/2016
Elotuzumab (Empliciti®) CP.PHAR.308 02/01/2017
Eltrombopag (Promacta®) (PDF) CP.PHAR.180 03/01/2016
Emapalumab-lzsg (Gamifant) (PDF) CP.PHAR.402 12/11/2018
Emicizumab-kxwh (Hemlibra) (PDF) CP.PHAR.370 03/01/2018
Emtricitabine/Tenofovir Alafenamide (Descovy)(PDF) CP.PMN.235 06/01/2020
Enasidenib (Idhifa) (PDF) CP.PHAR.363 09/05/2017
Encorafenib (Braftovi) (PDF) CP.PHAR.127 07/24/2018
Enfortumab Vedotin-ejfv (Padcev) (PDF) CP.PHAR.455 03/01/2020
Enfuvirtide (Fuzeon) (PDF) CP.PHAR.41 06/01/2010
Enoxaparin (Lovenox) (PDF) CP.PHAR.224 05/01/2016
Entrectinib (Rozlytrek) (PDF) CP.PHAR.441 12/01/2019
Enzalutamide (Xtandi) (PDF) CP.PHAR.106 10/01/2012
Epoetin Alfa (Epogen® and Procrit) (PDF) CP.PHAR.237 06/01/2016
Epoprostenol (Flolan®), Veletri®) (PDF) CP.PHAR.192 03/01/2016
Erdafitinib (Balversa)(PDF) CP.PHAR.423 09/01/2019
Erenumab-aaoe (Aimovig) (PDF) CP.PHAR.128 07/10/2018
Eribulin Mesylate (Halaven®) (PDF) CP.PHAR.318 03/01/2017
Erlotinib (Tarceva) (PDF) CP.PHAR.74 09/01/2011
Erwinia Asparaginase (Erwinaze) (PDF) CP.PHAR.301 02/01/2017
Esketamine (Spravato) (PDF) CP.PMN.199 03/12/2019
Etanercept (Enbrel) (PDF) CP.PHAR.250 08/01/2016
Etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 03/20/2018
Eteplirsen (Exondys 51) (PDF) CP.PHAR.288 12/01/2016
Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF) CP.PHAR.63 06/01/2011
Evolocumab (Repatha) (PDF) CP.PHAR.123 10/01/2015
Factor IX (Human, Recombinant) (PDF) CP.PHAR.218 05/01/2016
Factor IX Complex, Human (Profilnine) (PDF) CP.PHAR.219 05/01/2016
Factor IX Complex Human (Bebulin®, Profilnine®) (PDF) CP.PHAR.219 05/01/2016
Factor VIII (Human Recombinant) (PDF) CP.PHAR.215 05/01/2016
Factor VIII/von Willebrand Factor Complex (Human - Alphanate, Humate-P, Wilate) (PDF) CP.PHAR.216 05/01/2016
Factor VIIa, Recombinant (NovoSeven® RT) (PDF) CP.PHAR.220 05/01/2016
Factor XIII A-Subunit, Recombinant (Tretten®) (PDF) CP.PHAR.222 05/01/2016
Factor XIII, Human (Corifact®) (PDF) CP.PHAR.221 05/01/2016
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) CP.PHAR.456 03/01/2020
Febuxostat (Uloric) (PDF) CP.PMN.57 08/01/2013
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF) CP.PMN.127 06/01/2015
Ferric Carboxymaltose (Injectafer) (PDF) CP.PHAR.234 06/01/2016
Ferric Derisomaltose (Monoferric) (PDF) CP.PHAR.280 06/01/2020
Ferric gluconate (Ferrlecit®) (PDF) CP.PHAR.166 3/1/2016
Ferumoxytol (Feraheme®) (PDF) CP.PHAR.165 3/1/2016
Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF) CP.PHAR.297 12/01/2016
Fingolimod (Gilenya) (PDF) CP.PHAR.251 08/01/2016
Fondaparinux (Arixtra) (PDF) CP.PHAR.226 05/01/2016
Fosdenopterin (PDF) CP.PHAR.471 06/01/2020
Fostamatinib (Tavalisse) (PDF) CP.PHAR.24 06/05/2018
Fluorouracil Cream (Tolak(PDF) CP.PMN.165 12/1/2018
Fluticasone Propionate (Xhance) (PDF) CP.PMN.95 10/24/2017
Fluticasone/Vilanterol (Breo Ellipta) (PDF) CP.PMN.229 03/01/2020
Fremanezumab-vfrm (Ajovy) (PDF) CP.PHAR.403 10/30/2018
Fulvestrant (Faslodex Injection)(PDF) CP.PHAR.424 09/01/2019
Galcanezumab-gnlm (Emgality) (PDF) CP.PHAR.404 11/13/2018
Galsulfase (Naglazyme) (PDF) CP.PHAR.161 02/01/2016
Gefitinib (Iressa) (PDF) CP.PHAR.68 11/16/2016
gemtuzumab ozogamicin (Mylotarg®) (PDF) C.PHAR.358 10/03/2017
Gilteritinib (Xospata) (PDF) CP.PHAR.412 01/15/2019
Givosiran (Givlaari) (PDF) CP.PHAR.457 03/01/2020
Glasdegib (Daurismo) (PDF) CP.PHAR.413 01/08/2019
Glatiramer (Copaxone, Glatopa) (PDF) CP.PHAR.252 08/01/2016
Glycerol phenylbutyrate (Ravicti®) (PDF) CP.PHAR.207 05/01/2016
Golimumab (Simponi, Simponi Aria) (PDF) CP.PHAR.253 07/01/2016
Golodirsen (Vyondys 53) (PDF) CP.PHAR.453 03/01/2020
goserelin acetate (Zoladex®) (PDF) CP.PHAR.171 11/09/2017
Granisetron (Kytril, Sancuso, Sustol) (PDF) CP.PMN.74 11/01/2016
Hemin (Panhematin®) (PDF) CP.PHAR.181 02/01/2016
histrelin acetate (Vantas®, Supprelin LA®) (PDF) CP.PHAR.172 11/09/2017
Hyaluronate Derivatives (PDF) CP.PHAR.05 10/01/2008
Hydroxyprogesterone Caproate (Makena/compound) CP.PHAR.14 11/20/2017
Hydroxyurea (Siklos) (PDF) CP.PMN.193 02/19/2019
Ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 04/17/2018
Ibandronate sodium (Boniva®) (PDF) CP.PHAR.189 11/15/2017
Ibrutinib (Imbruvica) (PDF) CP.PHAR.126 10/01/2015
Ibuprofen/Famotidine (Duexis) (PDF) CP.PMN.120 06/01/2018
Icatibant (Firazyr) (PDF) CP.PHAR.178 03/01/2016
Icosapent ethyl (Vascepa) (PDF) CP.PMN.187 11/20/2018
Idecabtagene Vicleucel (BB2121) (PDF) CP.PHAR.481 06/01/2020
Idelalisib (Zydelig) (PDF) CP.PHAR.133 12/01/2018
Idursulfase (Elaprase) (PDF) CP.PHAR.156 02/01/2016
Iloperidone (Fanapt) (PDF) CP.PMN.32 12/01/2014
Iloprost (Ventavis®) (PDF) CP.PHAR.193 03/01/2016
Imatinib (Gleevec) (PDF) CP.PHAR.65 06/01/2011
Imiglucerase (Cerezyme) (PDF) CP.PHAR.154 02/01/2016
Immune Globulins (PDF) CP.PHAR.103 08/01/2012
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 07/01/2016
Indacaterol/Glycopyrrolate (Utibron Neohaler) (PDF) HIM.PA.102 09/01/2018
Inebilizumab (PDF) CP.PHAR.458 03/01/2020
Infertility and Fertility Preservation (PDF) CP.PHAR.131 11/16/2016
Infliximab (Remicade, Inflectra, Renflexis) (PDF) CP.PHAR.254 07/01/2016
Inotersen (Tegsedi) (PDF) CP.PHAR.405 11/20/2018
inotuzumab ozogamicin (Besponsa®) (PDF) CP.PHAR.359 09/26/2017
Insulin Infusion Pump (Omnipod, Omnipod DASH) (PDF) CP.PHAR.420 04/23/2019
Interferon beta-1a (Avonex, Rebif) (PDF) CP.PHAR.255 08/01/2016
Interferon beta-1b (Betaseron, Extavia) (PDF) CP.PHAR.256 08/01/2016
Interferon Gamma- 1b (Actimmune) (PDF) CP.PHAR.52 06/01/2010
Itraconazole (Sporanox, Onmel, Tolsura) (PDF) CP.PMN.124 11/01/2006
Intrathecal Baclofen (Gablofen, Lioresal) (PDF) CP.PHAR.149 11/09/2017
Iobenguane I-131 (Azedra) (PDF) CP.PHAR.459 03/01/2020
Ipilimumab (Yervoy) (PDF) CP.PHAR.319 04/17/2018
irinotecan Liposome (Onivyde®) (PDF) CP.PHAR.304 02/01/2017
Iron sucrose (Venofer®) (PDF) CP.PHAR.167 03/01/2016
Isatuximab-irfc (Sarclisa)(PDF) CP.PHAR.482 06/01/2020
Isavuconazonium (Cresemba) (PDF) CP.PMN.154 11/16/2016
Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (PDF) CP.PMN.143 12/01/2014
Istradefylline (Nourianz) (PDF) CP.PMN.217 03/01/2020
Ivabradine (Corlanor) (PDF) CP.PMN.70 11/01/2015
Ivacaftor (Kalydeco) (PDF) CP.PHAR.210 05/01/2016
Ivosidenib (Tibsovo) (PDF)
CP.PHAR.137 08/21/2018
Ixazomib (Ninlaro) (PDF) CP.PHAR.302 02/01/2017
Ixekizumab (Taltz) (PDF) CP.PHAR.257 08/01/2016
Lacosamide (Vimpat) (PDF) CP.PMN.155 12/01/2014
Lanadelumab-fylo (Takhzyro) (PDF) CP.PHAR.396 09/25/2018
Lanreotide (Somatuline Depot) (PDF) CP.PHAR.391 08/28/2018
lapatinib (Tykerb®) (PDF) CP.PHAR.79 11/09/2017
Laronidase (Aldurazyme) (PDF) CP.PHAR.152 02/01/2016
Larotrectinib (Vitrakvi) (PDF) CP.PHAR.414 01/15/2018
Lasmiditan (Reyvow) (PDF) CP.PMN.218 03/01/2020
Ledipasvir/Sofosbuvir (Harvoni) (PDF) CP.PHAR.279 09/01/2016
Lefamulin (Xenleta) (PDF) CP.PMN.219 03/01/2020
Lemborexant (Dayvigo)(PDF) CP.PMN.233 06/01/2020
Lenalidomide (Revlimid) (PDF) CP.PHAR.71 07/01/2011
Lenvatinib (Lenvima) (PDF) CP.PHAR.138 12/01/2018
Letermovir (Prevymis) (PDF) CP.PHAR.367 03/01/2018
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) CP.PHAR.173 11/09/2017
Levalbuterol (Xopenex HFA/Inhalation Solution) (PDF) CP.PMN.07 09/01/2006
Levoleucovorin (Fusilev®) (PDF) CP.PHAR.151 11/09/2017
Lidocaine Transdermal (Lidoderm, ZTlido) (PDF) CP.PMN.08 09/01/2006
Linaclotide (Linzess) (PDF) CP.PMN.71 11/01/2015
Linezolid (Zyvox) (PDF) CP.PMN.27 09/01/2016
Lifitegrast (Xiidra®) (PDF) CP.PMN.73 11/09/2017
Lofexidine (Lucemyra) (PDF) CP.PMN.152 08/01/2018
Lomitapide (Juxtapid) (PDF) CP.PHAR.283 10/01/2016
Lorlatinib (Lorbrena) (PDF) CP.PHAR.406 12/11/2018
Lubiprostone (Amitiza) (PDF) CP.PMN.142 12/01/2014
Luliconazole Cream (Luzu) (PDF) CP.PMN.166 08/28/2018
Lumacaftor-Ivacaftor (Orkambi) (PDF) CP.PHAR.213 05/01/2016
Lumasiran (ALN-GO1) (PDF) CP.PHAR.473 06/01/2020
Lumateperone (Caplyta) (PDF) CP.PMN.232 03/01/2020
Lurasidone (Latuda) (PDF) CP.PMN.50 12/01/2014
Luspatercept-aamt (Reblozyl) (PDF) CP.PHAR.450 03/01/2020
Lusutrombopag (Mulpleta) (PDF) CP.PHAR.407 09/18/2018
Lutetium Lu 177 Dotatate (Lutathera)(PDF) CP.PHAR.384 05/22/2018
Macitentan (Opsumit®) (PDF) CP.PHAR.194 03/01/2016
Mecasermin (Increlex) (PDF) CP.PHAR.150 03/01/2011
Mecamylamine (Vecamyl) (PDF) CP.PMN.136 05/01/2017
Megestrol Acetate (Megace ES) (PDF) CP.PMN.179 12/01/2018
Mepolizumab (Nucala) (PDF) CP.PHAR.200 04/01/2016
Metformin ER (Fortamet, Glumetza) (PDF) CP.PMN.72 11/01/2015
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF) CP.PHAR.134 12/01/2018
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) CP.PHAR.238 06/01/2016
Methylnaltrexone Bromide (Relistor) (PDF) CP.PMN.169 12/01/2018
Metreleptin (Myalept) (PDF) CP.PHAR.425 09/01/2019
Midazolam (Nayzilam) (PDF) CP.PMN.211 09/01/2019
Midostaurin (Rydapt) (PDF) CP.PHAR.344 06/01/2017
Mifepristone (Korlym) (PDF) CP.PHAR.101 05/01/2012
Migalastat (Galafold) (PDF) CP.PHAR.394 09/11/2018
Miglustat (Zavesca) (PDF) CP.PHAR.164 02/01/2016
Milnacipran (Savella) (PDF) CP.PMN.125 08/01/2012
Mipomersen (Kynamro) (PDF) CP.PHAR.284 10/01/2016
Minocycline ER (Solodyn, Ximino, Minolira) and Microspheres (Arestin) (PDF) CP.PMN.80 05/01/2017
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 08/01/2016
Modafinil (Provigil) (PDF) CP.PMN.39 05/01/2008
Mogamulizumab-kpkc (Poteligeo) (PDF) CP.PHAR.139 09/04/2018
Mometasone/Formoterol (Dulera) (PDF) CP.PMN.230 03/01/2020
Mometasone Furoate (Sinuva) (PDF) CP.PHAR.448 03/01/2020
Monomethyl Fumarate (Bafiertam) (PDF) CP.PHAR.460 03/01/2020
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) CP.PHAR.398 10/16/2018
Nadofaragene Firadenovec (Instiladrin) (PDF) CP.PHAR.461 03/01/2020
nafarelin acetate (Synarel®) (PDF) CP.PHAR.174 11/09/2017
Naproxen/Esomeprazole (Vimovo) (PDF) CP.PMN.117 06/01/2018
Natalizumab (Tysabri) (PDF) CP.PHAR.259 07/01/2016
Necitumumab (Portrazza®) (PDF) CP.PHAR.320 03/01/2017
Neomycin/Fluocinolone Cream (Neo-Synalar)_(PDF) CP.PMN.167 08/28/2018
Neratinib (Nerlynx) (PDF) CP.PHAR.365 09/05/2017
Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan)  (PDF) CP.PMN.118 02/13/2018
Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (PDF) CP.PMN.158 09/01/2006
nilotinib (Tasigna) (PDF) CP.PHAR.76 09/01/2011
Nintedanib (Ofev) (PDF) CP.PHAR.285 10/01/2016
Nitisinone (Nityr, Orfadin) (PDF) CP.PHAR.132 08/28/2018
Nivolumab (Opdivo) (PDF) CP.PHAR.121 07/01/2015
No Coverage Criteria/Off-Label Use Policy (PDF) CP.PMN.53 09/12/2017
Nusinersen (Spinraza®)(PDF) CP.PHAR.327 11/28/2017
Obeticholic (Ocaliva) (PDF) CP.PHAR.287 11/01/2016
Obinutuzumab (Gazyva®) (PDF) CP.PHAR.305 02/01/2017
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 04/01/2017
Octreotide (Sandostatin, Sandostatin LAR) (PDF) CP.PHAR.40 03/01/2010
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia) (PDF) CP.PHAR.40 03/01/2010
ofatumumab (Arzerra®) (PDF) CP.PHAR.306 02/01/2017
Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) CP.PHAR.292 12/01/2016
Olaparib (Lynparza) (PDF) CP.PHAR.360 10/03/2017
olaratumab (Lartruvo®) (PDF) CP.PHAR.326 03/01/2017
Omadacycline (Nuzyra) (PDF) CP.PMN.188 11/20/2018
Omacetaxine (Synribo) (PDF) CP.PHAR.108 04/01/2013
Omalizumab (Xolair®) (PDF) CP.PHAR.01 10/1/2008
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 07/01/2016
Onasemnogene Abeparvovec (Zolgensma) (PDF) CP.PHAR.421 06/07/2019
Ondansetron (Zuplenz) (PDF) CP.PMN.45 09/01/2006
Osimertinib (Tagrisso) (PDF) CP.PHAR.294 12/01/2016
Ospemifene (Osphena) (PDF) CP.PMN.168 08/28/2018
Overactive Bladder Agents (PDF) CP.PMN.198 05/01/2016
Ozanimod (PDF) CP.PHAR.462 03/01/2020
Ozenoxacin (Xepi) (PDF) CP.PMN.119 01/30/2018
Paclitaxel, Protein-Bound (Abraxane) (PDF) CP.PHAR.176 07/01/2015
Palbociclib (Ibrance®) (PDF) CP.PHAR.125 10/01/2015
Palivizumab (Synagis) (PDF) CP.PHAR.16 08/01/2009
panitumumab (Vectibix®) (PDF) CP.PHAR.321 03/01/2017
Parathyroid Hormone (Natpara) (PDF) CP.PHAR.282 11/16/2016
Paricalcitol Injection (Zemplar) (PDF) CP.PHAR.270 08/01/2016
Pasireotide (Signifor LAR®) (PDF) CP.PHAR.332 03/01/2017
Patisiran (Onpattro) (PDF) CP.PHAR.395 09/11/2018
Pazopanib (Votrient) (PDF) CP.PHAR.81 10/01/2011
Peanut Allergen Powder-dnfp (Palforzia) (PDF) CP.PMN.220 03/01/2020
Pegademase Bovine (Adagen) (PDF) CP.PHAR.392 08/28/2018
Pegaptanib (Macugen®) (PDF) CP.PHAR.185 03/01/2016
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF) CP.PHAR.353 09/05/2017
Pegfilgrastim (Neulasta) (PDF) CP.PHAR.296 12/01/2016
peginterferon alfa-2b (PegIntron, Sylatron®) (PDF) CP.PHAR.89 10/01/2011
Peginterferon beta-1a (Plegridy) (PDF) CP.PHAR.271 08/01/2016
Pegloticase (Krystexxa®) (PDF) CP.PHAR.115 6/1/2013
Pegvaliase-pqpz (Palynziq) (PDF) CP.PHAR.140 07/31/2018
Pegvisomant (Somavert) (PDF) CP.PHAR.389 12/01/2018
Pemetrexed (Alimta, Pemfexy) (PDF) CP.PHAR.368 10/31/2017
pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 03/01/2017
Perampanel (Fycompa) (PDF) CP.PMN.156 11/16/2016
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 06/01/2016
Pexidartinib (Turalio) (PDF) CP.PHAR.436 12/01/2019
Pitolisant (Wakix) (PDF) CP.PMN.221 03/01/2020
Plerixafor (Mozobil) (PDF) CP.PHAR.323 03/01/2017
Polatuzumab Vedotin-piiq (Polivy) (PDF) CP.PHAR.433 09/01/2019
Pomalidomide (Pomalyst) (PDF) CO.PHAR.116 07/01/2013
Ponatinib (Iclusig) (PDF) CO.PHAR.112 06/01/2013
Pralatrexate (Folotyn®) (PDF) CP.PHAR.313 02/01/2017
Pramlintide (Symlin) (PDF) CP.PMN.129 06/01/2018
Pregabalin (Lyrica, Lyrica CR) (PDF) CP.PMN.33 01/01/2007
Pretomanid (PDF) CP.PMN.222 03/01/2020
Protein C Concentrate, Human (Ceprotin) (PDF) CP.PHAR.330 03/01/2017
Propranolol HCl Oral Solution (Hemangeol) (PDF) CP.PMN.58 05/01/2014
Prucalopride (Motegrity) (PDF) CP.PMN.194 01/29/2019
pyrimethamine (Daraprim®) (PDF) CP.PMN.44 11/01/2015
Quetiapine ER (Seroquel XR) (PDF) CP.PMN.64 12/01/2014
Ramucirumab (Cyramza®) (PDF) CP.PHAR.119 05/01/2015
Ranibizumab (Lucentis®) (PDF) CP.PHAR.186 03/01/2016
Regorafenib (Stivarga) (PDF) CP.PHAR.107 12/01/2012
Remestemcel-L (Prochymal) (PDF) CP.PHAR.474 06/01/2020
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) CP.PHAR.168 03/01/2016
Request for Medically Necessary Drug Not on the PDL (PDF) CP.PMN.16 11/09/2017
Reslizumab (Cinqair) (PDF) CP.PHAR.223 05/01/2016
Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF) CP.PHAR.141 11/16/2016
Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) (PDF) CP.PMN.223 03/01/2020
Rifamycin (Aemcolo) (PDF) CP.PMN.196 01/08/2019
rifaximin (Xifaxan®)(PDF) CP.PMN.47 11/01/2011
Rilonacept (Arcalyst) (PDF) CP.PHAR.266 11/16/2016
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 07/01/2016
Riociguat (Adempas®) (PDF) CP.PHAR.195 03/01/2016
Risdiplam (PDF) CP.PHAR.477 06/01/2020
Risedronate (Actonel, Atelvia) (PDF) CP.PMN.100 03/01/2018
Risperidone Long-Acting Injection (Risperdal Consta) (PDF) CP.PHAR.293 12/01/2016
Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) CP.PHAR.260 07/01/2016
Rolapitant (Varubi) (PDF) CP.PMN.102 02/01/2017
romidepsin (Istodax®) (PDF) CP.PHAR.314 01/01/2017
Romiplostim (Nplate®) (PDF) CP.PHAR.179 03/01/2016
Rucaparib (Rubraca®) (PDF) CP.PHAR.350 09/01/2017
Rufinamide (Banzel) (PDF) CP.PMN.157 12/01/2014
Sacubitril/Valsartan (Entresto) (PDF) CP.PMN.67 11/01/2015
Sacitizumab Govitecan (PDF) CP.PHAR.475 06/01/2020
Safinamide (Xadago) (PDF) CP.PMN.113 07/01/2017
Sapropterin Dihydrochloride (Kuvan) (PDF) CP.PHAR.43 02/01/2010
Sarecycline (Seysara) (PDF) CP.PMN.189 11/13/2018
Sargramostim (Leukine) (PDF) CP.PHAR.295 12/01/2016
Satralizumab (PDF) CP.PHAR.463 03/01/2020
Sebelipase Alfa (Kanuma) (PDF) CP.PHAR.159 02/01/2016
Secnidazole (Solosec) (PDF) CP.PMN.103 10/24/2017
Selexipag (Uptravi®) (PDF) CP.PHAR.196 03/01/2016
Selinexor (Xpovio) (PDF) CP.PHAR.431 09/01/2019
Selpercatinib (LOXO-292) (PDF) CP.PHAR.478 06/01/2020
Selumetinib (Koselugo) (PDF) CP.PHAR.464 03/01/2020
Sildenafil (Revatio®) (PDF) CP.PHAR.197 03/01/2016
Siltuximab (Sylvant®) (PDF) CP.PHAR.329 03/01/2017
Simeprevir (Olysio) (PDF) CP.PHAR.280 09/01/2016
Siponimod (Mayzent) (PDF) CP.PHAR.427 09/01/2019
Sipuleucel-T (Provenge) (PDF) CP.PHAR.120 06/01/2015
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF) CP.PMN.14 09/18/2018
sodium oxybate (Xyrem) (PDF) CP.PMN.42 05/01/2011
Sodium Phenylbutyrate (Buphenyl) (PDF) CP.PHAR.208 05/01/2016
Sofosbuvir (Sovaldi) (PDF) CP.PHAR.281 09/01/2016
Solriamfetol (Sunosi) (PDF) CP.PMN.209 09/01/2019
Somatropin (Growth Hormone) (PDF) CP.PHAR.55 03/01/2011
Sonidegib (Odomzo) (PDF) CP.PHAR.272 05/01/2012
sorafenib (Nexavar) (PDF) CP.PHAR.69 07/01/2011
Step Therapy (PDF) CP.PST.01 12/28/2017
Stiripentol (Diacomit) (PDF) CP.PMN.184 09/25/2018
sunitinib (Sutent) (PDF) CP.PHAR.73 09/01/2011
Suvorexant (Belsomra®) (PDF) CP.PMN.109 02/01/2017
Tadalafil (Adcirca®) (PDF) CP.PHAR.198 03/01/2016
Tadalafil BHP - ED (Cialis) (PDF) CP.PMN.132 06/01/2018
Tafamidis (Vyndaqel, Vyndamax) (PDF) CP.PHAR.432 09/01/2019
Talazoparib (Talzenna) (PDF) CP.PHAR.409 11/27/2018
Taliglucerase Alfa (Elelyso) (PDF) CP.PHAR.157 02/01/2016
Tasimelteon (Hetlioz) (PDF) CP.PMN.104 02/01/2017
Tavaborole (Kerydin) (PDF) CP.PMN.105 03/01/2018
Tazemetostat (Tazverik) (PDF) CP.PHAR.452 03/01/2020
Tedizolid (Sivextro) (PDF) CP.PMN.62 03/01/2015
Teduglutide (Gattex) (PDF) CP.PHAR.114 05/01/2013
Tegaserod (Zelnorm) (PDF) CP.PMN.206 09/01/2019
Telotristat Ethyl (Xermelo) (PDF) CP.PHAR.337 06/01/2017
Temozolomide (Temodar) (PDF) CP.PHAR.77 09/01/2011
temsirolimus (Torisel®) (PDF) CP.PHAR.324 03/01/2017
Tenapanor (Ibsrela) (PDF) CP.PMN.224 03/01/2020
Teprotumumab (Tepezza) (PDF) CP.PHAR.465 01/21/2020
Teriflunomide (Aubagio) (PDF) CP.PHAR.262 08/01/2016
Teriparatide (Forteo®) (PDF) CP.PHAR.188 11/15/2017
Tesamorelin (Egrifta) (PDF) CP.PHAR.109 03/01/2014
Testosterone (Testopel, Jatenzo) (PDF) CP.PHAR.354 08/01/2017
tetrabenazine (Xenazine) (PDF) CP.PHAR.92 12/01/2011
Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF) CP.PHAR.377 04/03/2018
Thalidomide (Thalomid) (PDF) CP.PHAR.78 09/01/2011
Thioguanine (Tabloid) (PDF) CP.PHAR.437 12/01/2019
Thyrotropin Alfa (Thyrogen) (PDF)  CP.PHAR.95 03/01/2012
Timothy grass pollen allergen extract (Grastek®) (PDF) CP.PMN.84 08/31/2017
Tisagenlecleucel (Kymriah) (PDF) CP.PHAR.361 09/26/2017
Tobramycin (Bethkis®, Kitabis Pak®, TOBI®, TOBI Podhaler®) (PDF) CP.PHAR.211 05/01/2016
Tocilizumab (Actemra) (PDF) CP.PHAR.263 07/01/2016
Tofacitinib (Xeljanz, Xeljanz XR) (PDF) CP.PHAR.267 01/30/2018
Tolvaptan (Jynarque) (PDF) CP.PHAR.27 06/05/2018
Topical Immunomodulators (PDF) CP.PMN.107 09/01/2006
Topotecan (Hycamtin)(PDF) CP.PHAR.64 06/01/2011
Trabectedin (Yondelis®) (PDF) CP.PHAR.204 05/01/2016
Trametinib (Mekinist) (PDF) CP.PHAR.240 07/01/2016
Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF) CP.PHAR.228 06/01/2016
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF) CP.PHAR.199 03/01/2016
Triamcinolone ER Injection (Zilretta) (PDF) CP.PHAR.371 03/01/2018
Trientine (Syprine) (PDF) CP.PHAR.438 12/01/2019
triptorelin pamoate (Trelstar®, Triptodur®) (PDF) CP.PHAR.175 11/09/2017
Ubrogepant (Ubrelvy) (PDF) CP.PHAR.475 06/01/2020
Upadacitinib (Rinvoq) (PDF) CP.PHAR.443 12/01/2019
Ustekinumab (Stelara) (PDF) CP.PHAR.264 08/01/2016
Valoctocogene Roxaparvovec (PDF) CP.PHAR.466 03/01/2020
Valproate Sodium for Intravenous Injection (Depacon) (PDF) CP.PHAR.429 09/01/2019
Valrubicin (Valstar) (PDF) CP.PHAR.439 12/01/2019
Vandetanib (Caprelsa®) (PDF) CP.PHAR.80 10/01/2011
Vedolizumab (Entyvio) (PDF) CP.PHAR.265 07/01/2016
Velaglucerase Alfa (VPRIV) (PDF) CP.PHAR.163 02/01/2016
Vemurafenib (Zelboraf®) (PDF) CP.PHAR.91 11/01/2011
Verteporfin (Visudyne®) (PDF) CP.PHAR.187 03/01/2016
Vestronidase alfa-vjbk (Mepsevii) (PDF) CP.PHAR.374 01/19/2018
Vigabatrin (Sabril) (PDF) CP.PHAR.169 02/01/2016
Vilazodone (Viibryd) (PDF) CP.PMN.145 08/01/2012
Viltolarsen (PDF) CP.PHAR.484 06/01/2020
vincristine sulfate liposome injection (Marqibo®) (PDF) CP.PHAR.315 02/01/2017
Vismodegib (Erivedge) (PDF) CP.PHAR.273 08/01/2016
Voretigene neparvovec-rzyl (Luxturna) (PDF) CP.PHAR.372 03/01/2018
Vorinostat (Zolinza) (PDF) CP.PHAR.83 12/01/2012
Vortioxetine (Trintellix®) (PDF) CP.PMN.65 05/31/2017
Voxelotor (Oxbryta) (PDF) CP.PHAR.451 03/01/2020
Zanubrutinib (Brukinsa) (PDF) CP.PHAR.467 03/01/2020
ziv-aflibercept (Zaltrap®) (PDF) CP.PHAR.325 03/01/2017
Zoledronic acid (Reclast, Zometa) (PDF) CP.PHAR.59 03/01/2011
POLICY TITLE POLICY NUMBER EFFECTIVE DATE
Ado-Trastuzumab Emtansine (Kadcyla) (PDF) CP.PHAR.229 06/01/2016
Aflibercept (Eylea®) (PDF) CP.PHAR.184 03/01/2016
Alglucosidase Alfa (Lumizyme) (PDF) CP.PHAR.160 02/01/2016
Anakinra (Kineret) (PDF) CP.PHAR.244 08/01/2016
Ambrisentan (Letairis®) (PDF) CP.PHAR.190 03/01/2016
Benznidazole (PDF) CP.PMN.90 10/17/2017
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF) CP.PHAR.202 03/01/2016
Cabozantinib (Cometriq®, Cabometyx®) (PDF) CP.PHAR.111 06/01/2013
Carglumic acid (Carbaglu®) (PDF) CP.PHAR.206 05/01/2016
Enoxaparin (Lovenox) (PDF) CP.PHAR.224 05/01/2016
Epoprostenol (Flolan®), Veletri®) (PDF) CP.PHAR.192 03/01/2016
Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF) CP.PHAR.297 12/01/2016
Hydroxyprogesterone Caproate (Makena®) (PDF) CP.PHAR.14 11/20/2017
Ibandronate sodium (Boniva®) (PDF) CP.PHAR.189 11/15/2017
Ibrutinib (Imbruvica) (PDF) CP.PHAR.126 10/01/2015
Iloprost (Ventavis®) (PDF) CP.PHAR.193 03/01/2016
Ivacaftor (Kalydeco) (PDF) CP.PHAR.210 05/01/2016
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) CP.PHAR.173 11/09/2017
Lomitapide (Juxtapid) (PDF) CP.PHAR.283 10/01/2016
Mecasermin (Increlex) (PDF) CP.PHAR.150 03/01/2011
Mifepristone (Korlym) (PDF) CP.PHAR.101 05/01/2012
Mipomersen (Kynamro) (PDF) CP.PHAR.284 10/01/2016
Pegaptanib (Macugen®) (PDF) CP.PHAR.185 03/01/2016
Pegloticase (Krystexxa®) (PDF) CP.PHAR.115 06/01/2013
pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 03/01/2017
Plerixafor (Mozobil) (PDF) CP.PHAR.323 03/01/2017
Ranibizumab (Lucentis®) (PDF) CP.PHAR.186 03/01/2016
Riociguat (Adempas®) (PDF) CP.PHAR.195 03/01/2016
Tadalafil (Adcirca®) (PDF) CP.PHAR.198 03/01/2016
Vandetanib (Caprelsa®) (PDF) CP.PHAR.80 10/01/2011
vincristine sulfate liposome injection (Marqibo®) (PDF) CP.PHAR.315 02/01/2017

Payment Policies

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.

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