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 Louisiana Healthcare Connections Clinical Policy Manual apply to Louisiana Healthcare Connections members. Policies in the Louisiana Healthcare Connections Clinical Policy Manual may have either a Louisiana Healthcare Connections or a “Centene” heading. Louisiana Healthcare Connections utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Louisiana Healthcare Connections 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 Louisiana Healthcare Connections. In addition, Louisiana Healthcare Connections 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 Louisiana Healthcare Connections.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
- Medicaid: 1-866-595-8133
- Marketplace (Ambetter): 1-833-635-0450
- Medicare: HMO 1-855-766-1572; HMO D-SNP 1-833-541-0767 (TTY: 711)
- LA.CP.BH.104 Applied Behavioral Analysis (PDF)
- LA.CP.BH.300 Neurofeedback for Behavioral Health Disorders (PDF)
- LA.CP.CPC.02 Clinical Policy Web Posting (PDF)
- LA.CP.CPC.03 Preventive Health and Clinical Practice Guidelines (PDF)
- LA.CP.CPC.04 State specific clinical policy process (PDF)
- LA.CP.CPC.05 Medical Necessity Criteria (PDF)
- LA.CP.MP.12 Vagus Nerve Stimulation (PDF)
- LA.CP.MP.22 Stereotactic Body Radiation Therapy (PDF)
- LA.CP.MP.24 Multiple Sleep Latency Testing (PDF)
- LA.CP.MP.26 Articular Cartilage Defect Repairs (PDF)
- LA.CP.MP.31 Cosmetic and Reconstructive Surgery (PDF)
- LA.CP.MP.34 Hyperemesis Gravidarum Treatment (PDF)
- LA.CP.MP.36 Experimental Technologies (PDF)
- LA.CP.MP.37 Bariatric Surgery (PDF)
- LA.CP.MP.38 Ultrasound in Pregnancy (PDF)
- LA.CP.MP.40 Gastric electrical stimulation (PDF)
- LA.CP.MP.43 Functional MRI (PDF)
- LA.CP.MP.46 Ventricular Assist Devices (PDF)
- LA.CP.MP.48 Neuromuscular Electrical Stimulation (PDF)
- LA.CP.MP.49 Therapy Services (PT,OT,ST) (PDF)
- LA.CP.MP.51 Reduction mammoplasty and gynecomastia surgery (PDF)
- LA.CP.MP.53 Ferriscan R2 MRI (PDF)
- LA.CP.MP.57 Lung Transplntation (PDF)
- LA.CP.MP.58 Intestinal and multivisceral transplant (PDF)
- LA.CP.MP.61 Dental Anesthesia (PDF)
- LA.CP.MP.62 HyperhidrosisTreatments (PDF)
- LA.CP.MP.69 Intensity-Modulated Radiotherapy (PDF)
- LA.CP.MP.70 Proton and Neutron Beam Therapy (PDF)
- LA.CP.MP.84 Cell-free Fetal DNA Testing (PDF)
- LA.CP.MP.85 Neonatal sepsis management (PDF)
- LA.CP.MP.86 Neonatal abstinence syndrome guidelines (PDF)
- LA.CP.MP.87 Inhaled nitric oxide (PDF)
- LA.CP.MP.89 Genetic Testing (PDF)
- LA.CP.MP.91 Obstetrical Home Care Programs (PDF)
- LA.CP.MP.93 Bone-Anchored Hearing Aid (PDF)
- LA.CP.MP.94 Clinical Trials (PDF)
- LA.CP.MP.95 Gender Affirming Surgery (PDF)
- LA.CP.MP.96 Ambulatory EEG (PDF)
- LA.CP.MP.97 Testing Select GU Conditions (PDF)
- LA.CP.MP.98 Urodynamic testing (PDF)
- LA.CP.MP.99 Wheelchair seating (PDF)
- LA.CP.MP.90 MNC Policy for CPST and PSR (PDF)
- LA.CP.MP.100 Allergy Testing and Therapy (PDF)
- LA.CP.MP.101 Donor Lymphocyte Infusion (PDF)
- LA.CP.MP.102 Pancreas Transplantation (PDF)
- LA.CP.MP.105 Digital electroencephalography spike analysis (PDF)
- LA.CP.MP.106 Endometrial ablation (PDF)
- LA.CP.MP.107 Durable Medical Equipment (DME) (PDF)
- LA.CP.MP.108 Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF)
- LA.CP.MP.109 Panniculectomy (PDF)
- LA.CP.MP.110 Bronchial Thermoplasty (PDF)
- LA.CP.MP.113 Holter Monitors (PDF)
- LA.CP.MP.114 Disc Decompression Procedure (PDF)
- LA.CP.MP.115 Discography (PDF)
- LA.CP.MP.116 Lysis Of Epidural Lesions (PDF)
- LA.CP.MP.117 Spinal Cord Stimulation (PDF)
- LA.CP.MP.119 Balloon Sinus Ostial Dilation (PDF)
- LA.CP.MP.120 Pediatric Liver Transplant (PDF)
- LA.CP.MP.121 Homocysteine testing (PDF)
- LA.CP.MP.123 Laser therapy for skin conditions (PDF)
- LA.CP.MP.124 ADHD Assessment and Treatment (PDF)
- LA.CP.MP.126 Sacroiliac joint fusion (PDF)
- LA.CP.MP.127 Total Artificial Heart (PDF)
- LA.CP.MP.128 Optic nerve decompression surgery (PDF)
- LA.CP.MP.129 Fetal surgery in utero for prenatally diagnosed malformations (PDF)
- LA.CP.MP.131 Essure Removal (PDF)
- LA.CP.MP.132 Heart-Lung Transplant (PDF)
- LA.CP.MP.133 Posterior Nerve Stimulation for Voiding Dysfunction (PDF)
- LA.CP.MP.134 Evoked Potential Testing (PDF)
- LA.CP.MP.137 Fecal Incontinence Treatments (PDF)
- LA.CP.MP.138 Pediatric Heart Transplant (PDF)
- LA.CP.MP.139 Low-frequency ultrasound therapy for wound management (PDF)
- LA.CP.MP.141 Non-myeloablative allogeneic stem cell transplants (PDF)
- LA.CP.MP.142 Urinary Incontinence Devices and Treatments (PDF)
- LA.CP.MP.143 Wireless Motility Capsule (PDF)
- LA.CP.MP.144 Mechanical Stretching Devices (PDF)
- LA.CP.MP.145 Electric Tumor Treating Fields (PDF)
- LA.CP.MP.146 Sclerotherapy for Vericose Veins (PDF)
- LA.CP.MP.147 Percutaneous LAAD Stroke Prevention (PDF)
- LA.CP.MP.148 Radial Head Implant (PDF)
- LA.CP.MP.149 Testing for Rupture of Fetal Membranes (PDF)
- LA.CP.MP.150 Home phototherapy for neonatal hyperbilirubinemia (PDF)
- LA.CP.MP.151 Transcatheter closure of patent foramen ovale (PDF)
- LA.CP.MP.152 Measurement of serum 1,25-dihydroxyvitamin D (PDF)
- LA.CP.MP.153 H. Pylori serology testing (PDF)
- LA.CP.MP.154 Thyroid hormones and insulin testing in pediatrics (PDF)
- LA.CP.MP.155 Electroencephalography in the evaluation of headache (PDF)
- LA.CP.MP.156 Cardiac Biomarker Testing (PDF)
- LA.CP.MP.157 25-hydroxyvitamin D testing in children and adolescents (PDF)
- LA.CP.MP.158 Ambulatory Surgery Center Optimization (PDF)
- LA.CP.MP.160 Implantable Wireless PAP Monitoring (PDF)
- LA.CP.MP.162 Tandem Transplant (PDF)
- LA.CP.MP.163 TPN IDPN (PDF)
- LA.CP.MP.164 Caudal or Interlaminar ESI (PDF)
- LA.CP.MP.165 Selective Nerve Root Blocks and Transforaminal Epidural (PDF)
- LA.CP.MP.166 Sacroiliac Joint Interventions (PDF)
- LA.CP.MP.167 Intradiscal Steroid Injections (PDF)
- LA.CP.MP.169 Trigger Point Injections for Pain Management (PDF)
- LA.CP.MP.170 Nerve Blocks for Pain Management (PDF)
- LA.CP.MP.171 Facet Joint Interventions (PDF)
- LA.CP.MP.173 Implantable Intrathecal Pain Pump (PDF)
- LA.CP.MP.174 Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)
- LA.CP.MP.175 Fixed Wing Air Transportation (PDF)
- LA.CP.MP.176 Outpatient Cardiac Rehabilitation (PDF)
- LA.CP.MP.177 Video EEG Monitoring (PDF)
- LA.CP.MP.179 Antithrombin III (Thrombate III, Atryn) (PDF)
- LA.CP.MP.180 Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)
- LA.CP.MP.181 Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)
- LA.CP.MP.184 Non-Invasive Home Ventilators (PDF)
- LA.CP.MP.185 Skin Substitutes for Chronic Wounds (PDF)
- LA.CP.MP.186 Burn Surgery (PDF)
- LA.CP.MP.187 Radiofrequency Ablation of Uterine Fibroids (PDF)
- LA.CP.MP.189 Thymus Transplant (PDF)
- LA.CP.MP.190 Oxygen Use and Concentrators (PDF)
- LA.CP.MP.194 Osteogenic Stimulation (PDF)
- LA.CP.MP.202 Orthognathic Surgery (PDF)
- LA.CP.MP.203 Diaphragmatic Phernic Nerve Stimulation (PDF)
- LA.CP.MP.210 Repair of Nasal Valve Compromise (PDF)
- LA.CP.MP.211 EMG and NCS (PDF)
- LA.CP.MP.490 Outpatient Applied Behavior Analysis Medical Necessity (PDF)
- LA.CP.MP.500 Enteral and Oral Nutrition(CP) (PDF)
- LA.CP.MP.502 Ambulatory Insulin Pump (PDF)
- LA.CP.MP.503 OUD_Treatment_IN_OTPs (PDF)
- LA.CP.MP.504_MNC_Crisis_Intervention_(PDF)
- LA.CP.MP.505_Peer_Support_Services_(PDF)
- LA.CP.MP.506 Cardiovascular Services (PDF)
- LA.CP.MP.507 Cochlear Implants (PDF)
- LA.CP.MP.508 Personal Care Services (PDF)
- LA.CP.MP.509 Individual Placement and Support (PDF)
- LA.CP.MP.510 Community Brief Crisis Support (PDF)
- LA.CP.MP.511 PDN Policy (PDF)
- LA.CP.MP.512 DSMT (PDF)
- LA.UM.90 Mental Health Rehabilitation Medical Necessity (PDF)
- LA.UM.97_Homebuilders_Services (PDF)
- CP.PHAR.05 Hyaluronate Derivatives (PDF)
- CP.PHAR.11 Burosumab-twza (Crysvita) (PDF)
- LA.PHAR.40 Octreotide Acetate (Sandostatin, Sandostatin LAR Depot) (PDF)
- CP.PHAR.52 Interferon Gamma- 1b (Actimmune) (PDF)
- LA.PHAR.58-Denosumab-(Prolia-Xgeva) (PDF)
- CP.PHAR.82 Collagenase (PDF)
- LA.PHAR.93 Bevacizumab (PDF)
- CP.PHAR.94 Alpha-1 Proteinase Inhibitors (PDF)
- CP.PHAR.95 Thyrotropin alfa (PDF)
- CP.PHAR.97 Eculizumab (Soliris) (PDF)
- CP.PHAR.108 Omecetaxine (Synribo) (PDF)
- LA.PHAR.119 Ramucirumab (Cyramza) (PDF)
- CP.PHAR.120 Sipuleucel-T (Provenge) (PDF)
- LA.PHAR.121 Nivolumab (PDF)
- CP.PHAR.139 Mogamulizumab-kpkc (Poteligeo) (PDF)
- CP.PHAR.146 deferoxamine (PDF)
- CP.PHAR.149 Intrathecal Baclofen (Gablofen, Lioresal) (PDF)
- CP.PHAR.151 Levoleucovorin (Fusilev) (PDF)
- CP.PHAR.158 Agalsidase Beta (PDF)
- CP.PHAR.159 Sebelipase Alfa (PDF)
- CP.PHAR.160 Alglucosidase Alfa (PDF)
- CP.PHAR.165 Ferumoxytol (Feraheme) (PDF)
- LA.PHAR.167 Iron sucrose (Venofer) (Acthar Gel) (PDF)
- CP.PHAR.170 Degarelix Acetate (Firmagon) (PDF)
- CP.PHAR.176 Paclitaxel Protein-Bound (PDF)
- CP.PHAR.181 Hemin (Panhematin) (PDF)
- CP.PHAR.184 Aflibercept (Eylea) (PDF)
- CP.PHAR.185 Pegaptanib (Macugen) (PDF)
- CP.PHAR.186 Ranibizumab (Lucentis) (PDF)
- CP.PHAR.187 Verteporfin (Visudyne) (PDF)
- CP.PHAR.189 Ibandronate sodium (Boniva) (PDF)
- CP.PHAR.192 Epoprostenol (Flolan, Veletri) (PDF)
- CP.PHAR.197 Sildenafil (Revatio) (PDF)
- CP.PHAR.199 Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF)
- CP.PHAR.201 Belatacept (Nulojix) (PDF)
- CP.PHAR.203 Cosyntropin (Cortrosyn) (PDF)
- CP.PHAR.204 Trabectedin (Yondelis) (PDF)
- CP.PHAR.227 Pertuzumab (PDF)
- CP.PHAR.228 Trastuzumab, Trastuzumab-dkst (PDF)
- CP.PHAR.229 Ado-Trastuzumab Emtansine (PDF)
- CP.PHAR.234 Ferric Carboxymaltose (Injectafer) (PDF)
- LA.PHAR.235 Atezolizumab (Tecentriq) (PDF)
- CP.PHAR.258 Mitoxantrone (PDF)
- CP.PHAR.260 Rituximab, Rituxan and Hyaluronidase (PDF)
- CP.PHAR.270 Paricalcitol Injection (PDF)
- CP.PHAR.300 Bezlotoxumab (PDF)
- CP.PHAR.301 Erwinia Asparaginase (Erwinaze) (PDF)
- CP.PHAR.303 Brentuximab (PDF)
- CP.PHAR.304 irinotecan Liposome (PDF)
- CP.PHAR.305 obinutuzumab (PDF)
- CP.PHAR.307 bendamustine (PDF)
- CP.PHAR.308 elotuzumab (PDF)
- CP.PHAR.309 carfilzomib (PDF)
- CP.PHAR.310 Daratumumab (PDF)
- CP.PHAR.311 belinostat (PDF)
- CP.PHAR.312.Blinatumomab (PDF)
- CP.PHAR.313 pralatrexate (PDF)
- CP.PHAR.314 romidepsin (PDF)
- CP.PHAR.315 vincristine sulfate liposome injection (PDF)
- CP.PHAR.316 cabazitaxel (PDF)
- CP.PHAR.317cetuximab (PDF)
- CP.PHAR.318- eribulin Mesylate (PDF)
- CP.PHAR.319 Ipilimumab (PDF)
- CP.PHAR.320 necitumumab (PDF)
- CP.PHAR.321 panitumumab (PDF)
- LA.PHAR.322 pembrolizumab (PDF)
- CP.PHAR.323.Plerixafor (PDF)
- CP.PHAR.324 temsirolimus (PDF)
- CP.PHAR.325 ziv-aflibercept (PDF)
- CP.PHAR.326 olaratumab (PDF)
- CP.PHAR.328 asfotase alfa (PDF)
- CP.PHAR.329 Siltuximab (Sylvant) (PDF)
- CP.PHAR.330 Protein C Concentrate, Human (Ceprotin) (PDF)
- CP.PHAR.332 pasireotide (PDF)
- CP.PHAR.333 Avelumab (Bavencio) (PDF)
- CP.PHAR.338 Cerliponase Alfa (PDF)
- CP.PHAR.339 Durvalumab (PDF)
- CP.PHAR.343 Edaravone (PDF)
- CP.PHAR.351 daptomycin (PDF)
- CP.PHAR.352 daunorubicin cytarabine (PDF)
- CP.PHAR.353 pegaspargase (PDF)
- CP.PHAR.357 copanlisib (PDF)
- CP.PHAR.358 gemtuzumab ozogamicin (PDF)
- CP.PHAR.359 inotuzumab ozogamicin (PDF)
- CP.PHAR.361 Tisagenlecleucel (PDF)
- CP.PHAR.362 Axicabtagene ciloleucel (PDF)
- CP.PHAR.367 Letermovir (PDF)
- CP.PHAR.368 Pemetrexed (Alimta) (PDF)
- CP.PHAR.371 Triamcinolone ER Injection (PDF)
- CP.PHAR.372 Voretigene neparvovec-rzyl (PDF)
- CP.PHAR.379 Etelcalcetide (Parsabiv) (PDF)
- CP.PHAR.384 Lutetium Lu 177 Dotatate (Lutathera) (PDF)
- CP.PHAR.387 Azacitidine (Vidaza) (PDF)
- CP.PHAR.388 Chloramphenicol Sodium Succinate (PDF)
- CP.PHAR.389 Pegvisomant (Somavert) (PDF)
- LA.PHAR.391 Lanreotide (Somatuline Depot) (PDF)
- CP.PHAR.392 Pegademase Bovine (Adagen) (PDF)
- CP.PHAR.393 Leucovorin Injection (PDF)
- CP.PHAR.395 Patisiran (Onpattro) (PDF)
- CP.PHAR.397 Cemiplimab-rwlc (Libtayo) (PDF)
- CP.PHAR.398 Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF)
- CP.PHAR.402 Emapalumab-Izsg (Gamifant) (PDF)
- CP.PHAR.405 Inotersen (Tegsedi) (PDF)
- CP.PHAR.410 Bortezomib (Velcade) (PDF)
- LA.PHAR.415 Ravulizumab-cwvz (Ultomiris) (PDF)
- CP.PHAR.418 Dexrazoxane (Zinecard, Totect) (PDF)
- CP.PHAR.419 Elapegademase-lvlr (Revcovi) (PDF)
- LA.PMN.53 Off-Label Use (PDF)
- CP.PMN.102 Rolapitant (PDF)
- LA.PMN.255 No Coverage Criteria (PDF)
- CP.MP.38 Ultrasound in Pregnancy (PDF)
- CP.MP.50 Drugs of Abuse: Definitive Testing (previously Outpatient Testing for Drugs of Abuse) (PDF)
- CP.MP.96 Ambulatory EEG (PDF)
- CP.MP.97 Testing for Select Genitourinary Conditions (previously Diagnosis of Vaginitis) (PDF)
- CP.MP.98 Urodynamic Testing (PDF)
- CP.MP.99 Wheelchair Seating (PDF)
- CP.MP.100 Allergy Testing (PDF)
- CP.MP.105 Digital EEG Analysis (PDF)
- CP.MP.106 Endometrial Ablation (PDF)
- CP.MP.110 Bronchial Thermoplasty (PDF)
- CP.MP.113 Holter Monitors (PDF)
- CP.MP.121 Homocysteine Testing (PDF)
- CP.MP.123 Laser Skin Treatment (PDF)
- CP.MP.124 ADHD Assessment and Treatment (PDF)
- CP.MP.134 Evoked Potentials (PDF)
- CP.MP.139 Low-Frequency Ultrasound Wound Therapy (PDF)
- CP.MP.143 Wireless Motility Capsule (PDF)
- CP.MP.149 PROM Testing (PDF)
- CP.MP.152 Measure Serum 1,25 Vitamin D (PDF)
- CP.MP.153 H Pylori Testing (PDF)
- CP.MP.154 Thyroid Testing in Pediatrics (PDF)
- CP.MP.155 EEG in Evaluation of Headache (PDF)
- CP.MP.156 Cardiac Biomarker Testing for Acute MI (PDF)
- CP.MP.157 Vitamin D Testing in Children (PDF)
- CP.MP.181 Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)
- CP.MP.209 Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)
- Abaloparatide (Tymlos) CP.PHAR.345 (PDF)
- Abametapir (Xeglyze) CP.PMN.253 (PDF)
- Abemaciclib (Verzenio) CP.PHAR.355 (PDF)
- Abiraterone (Zytiga, Yonsa) CP.PHAR.84 (PDF)
- AbobotulinumtoxinA (Dysport) CP.PHAR.230 (PDF)
- Acyclovir Buccal Tablet (Sitavig) CP.PMN.210 (PDF)
- Adefovir (Hepsera) CP.PHAR.142 (PDF)
- Ado-Trastuzumab Emtansine (Kadcyla) CP.PHAR.229 (PDF)
- Aducanumab-avwa (Aduhelm) CP.PHAR.468 (PDF)
- Afamelanotide (Scenesse) CP.PHAR.444 (PDF)
- Afatinib (Gilotrif) CP.PHAR.298 (PDF)
- Aflibercept (Eylea) CP.PHAR.184 (PDF)
- Agalsidase Beta (Fabrazyme) CP.PHAR.158 (PDF)
- Age Limit Override (Codeine, Tramadol, Hydrocodone) CP.PMN.138 (PDF)
- Alectinib (Alecensa) CP.PHAR.369 (PDF)
- Alemtuzumab (Lemtrada) CP.PHAR.243 (PDF)
- Alendronate (Binosto, Fosamax Plus D) CP.PMN.88 (PDF)
- Alglucosidase Alfa (Lumizyme) CP.PHAR.160 (PDF)
- Alpelisib (Piqray) CP.PHAR.430 (PDF)
- Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) CP.PHAR.94 (PDF)
- Amantadine ER (Gocovri, Osmolex ER) CP.PMN.89 (PDF)
- Ambrisentan (Letairis) CP.PHAR.190 (PDF)
- Amifampridine (Firdapse, Ruzurgi) CP.PHAR.411 (PDF)
- Amikacin (Arikayce) CP.PHAR.401 (PDF)
- Amisulpride (Barhemsys) CP.PMN.236 (PDF)
- Amivantamab-vmjw (Rybrevant) CP.PHAR.544 (PDF)
- Anifrolumab-fnia (Saphnelo) CP.PHAR.551 (PDF)
- Anti-Inhibitor Coagulant Complex, Human (Feiba) CP.PHAR.217 (PDF)
- Antithymocyte Globulin (Atgam, Thymoglobulin) CP.PHAR.506 (PDF)
- Apalutamide (Erleada) CP.PHAR.376 (PDF)
- Apomorphine (Apokyn, Kynmobi) CP.PHAR.488 (PDF)
- Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) CP.PMN.19 (PDF)
- Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada, Aristada Initio) CP.PHAR.290 (PDF)
- Aripiprazole Orally Disintegrating Tablet CP.PCH.37 (PDF)
- Armodafinil (Nuvigil) CP.PMN.35 (PDF)
- Asenapine (Saphris, Secuado) CP.PMN.15 (PDF)
- Asfotase Alfa (Strensiq) CP.PHAR.328 (PDF)
- Aspirin/Dipyridamole (Aggrenox) CP.PMN.20 (PDF)
- Atezolizumab (Tecentriq) CP.PHAR.235 (PDF)
- Avalglucosidase Alfa-ngpt (Nexviazyme) CP.PHAR.521 (PDF)
- Avapritinib (Ayvakit) CP.PHAR.454 (PDF)
- Avatrombopag (Doptelet) CP.PHAR.130 (PDF)
- Avelumab (Bavencio) CP.PHAR.333 (PDF)
- Axicabtagene Ciloleucel (Yescarta) CP.PHAR.362 (PDF)
- Axitinib (Inlyta) CP.PHAR.100 (PDF)
- Azacitidine (Onureg, Vidaza) CP.PHAR.387 (PDF)
- Azelaic Acid (Finacea Topical Gel) HIM.PA.119 (PDF)
- Aztreonam (Cayston) CP.PHAR.209 (PDF)
- Baclofen (Gablofen, Lioresal, Ozobax) CP.PHAR.149 (PDF)
- Baloxavir Marboxil (Xofluza) CP.PMN.185 (PDF)
- Bamlanivimab + Etesevimab (LY-CoV555 + LY-CoV016) CP.PHAR.532 (PDF)
- Bedaquiline (Sirturo) CP.PMN.212 (PDF)
- Belantamab Mafodotin (Blenrep) CP.PHAR.469 (PDF)
- Belatacept (Nulojix) CP.PHAR.201 (PDF)
- Belimumab (Benlysta) CP.PHAR.88 (PDF)
- Belinostat (Beleodaq) CP.PHAR.311 (PDF)
- Belumosudil (Rezurock) CP.PHAR.552 (PDF)
- Belzutifan (Welireg) CP.PHAR.553 (PDF)
- Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet) CP.PMN.237 (PDF)
- Bendamustine (Belrapzo, Bendeka, Treanda) CP.PHAR.307 (PDF)
- Benralizumab (Fasenra) CP.PHAR.373 (PDF)
- Benznidazole CP.PMN.90 (PDF)
- Berotralstat (Orladeyo) CP.PHAR.485 (PDF)
- Betaine (Cystadane) CP.PHAR.143 (PDF)
- Betamethasone Dipropionate Spray (Sernivo) CP.PMN.182 (PDF)
- Bevacizumab (Avastin, Mvasi, Zirabev) CP.PHAR.93 (PDF)
- Bexarotene (Targretin Capsules, Gel) CP.PHAR.75 (PDF)
- Bezlotoxumab (Zinplava) CP.PHAR.300 (PDF)
- Bimatoprost Implant (Durysta) CP.PHAR.486 (PDF)
- Binimetinib (Mektovi) CP.PHAR.50 (PDF)
- Biologic DMARDs HIM.PA.SP60 (PDF)
- Blinatumomab (Blincyto) CP.PHAR.312 (PDF)
- Bortezomib (Velcade) CP.PHAR.410 (PDF)
- Bosentan (Tracleer) CP.PHAR.191 (PDF)
- Bosutinib (Bosulif) CP.PHAR.105 (PDF)
- Brand Name Override and Non-Formulary Medications HIM.PA.103 (PDF)
- Brentuximab Vedotin (Adcetris) CP.PHAR.303 (PDF)
- Brexanolone (Zulresso) CP.PHAR.417 (PDF)
- Brexpiprazole (Rexulti) CP.PMN.68 (PDF)
- Brexucabtagene Autoleucel (Tecartus) CP.PHAR.472 (PDF)
- Brigatinib (Alunbrig) CP.PHAR.342 (PDF)
- Brimonidine Tartrate (Mirvaso) CP.PMN.192 (PDF)
- Brinzolamide/Brimonidine (Simbrinza) HIM.PA.15 (PDF)
- Brivaracetam (Briviact) CP.PCH.26 (PDF)
- Brolucizumab-dbll (Beovu) CP.PHAR.445 (PDF)
- Budesonide (Uceris) CP.PCH.11 (PDF)
- Buprenorphine (Subutex) CP.PMN.82 (PDF)
- Buprenorphine Implant/Injection (Probuphine , Sublocade) CP.PHAR.289 (PDF)
- Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) CP.PMN.81 (PDF)
- Bupropion/Naltrexone (Contrave) CP.PCH.12 (PDF)
- Burosumab-twza (Crysvita) CP.PHAR.11 (PDF)
- Butorphanol Nasal Spray HIM.PA.46 (PDF)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) CP.PHAR.202 (PDF)
- Cabazitaxel (Jevtana) CP.PHAR.316 (PDF)
- Cabozantinib (Cabometyx, Cometriq) CP.PHAR.111 (PDF)
- Calcifediol (Rayaldee) CP.PMN.76 (PDF)
- Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) CP.PMN.181 (PDF)
- Canakinumab (Ilaris) CP.PHAR.246 (PDF)
- Cannabidiol (Epidiolex) CP.PMN.164 (PDF)
- Capecitabine (Xeloda) CP.PHAR.60 (PDF)
- Caplacizumab-yhdp (Cablivi) CP.PHAR.416 (PDF)
- Capmatinib (Tabrecta) CP.PHAR.494 (PDF)
- Carbidopa/Levodopa ER Capsules (Rytary), Enteral Suspension (Duopa) CP.PMN.238 (PDF)
- Carfilzomib (Kyprolis) CP.PHAR.309 (PDF)
- Carglumic Acid (Carbaglu) CP.PHAR.206 (PDF)
- Casimersen (Amondys 45) CP.PHAR.470 (PDF)
- Casirivimab and Imdevimab (REGEN-COV) CP.PHAR.520 (PDF)
- Celecoxib (Celebrex, Elyxyb) CP.PMN.122 (PDF)
- Cemiplimab-rwlc (Libtayo) CP.PHAR.397 (PDF)
- Cenegermin-bkbj (Oxervate) CP.PMN.186 (PDF)
- Cenobamate (Xcopri) CP.PMN.231 (PDF)
- Ceritinib (Zykadia) CP.PHAR.349 (PDF)
- Cerliponase alfa (Brineura) CP.PHAR.338 (PDF)
- Cetuximab (Erbitux) CP.PHAR.317 (PDF)
- Chenodiol (Chenodal) CP.PMN.239 (PDF)
- Chlorambucil (Leukeran) CP.PHAR.554 (PDF)
- Chloramphenicol Sodium Succinate CP.PHAR.388 (PDF)
- Cholic Acid (Cholbam) CP.PHAR.390 (PDF)
- Ciclopirox (Penlac) CP.PMN.24 (PDF)
- Cinacalcet (Sensipar) CP.PHAR.61 (PDF)
- Ciprofloxacin/Dexamethasone (Ciprodex) CP.PMN.248 (PDF)
- Ciprofloxacin/Fluocinolone (Otovel) CP.PMN.249 (PDF)
- Cladribine (Mavenclad) CP.PHAR.422 (PDF)
- Clascoterone (Winlevi) CP.PMN.257 (PDF)
- Clobazam (Onfi, Sympazan) CP.PMN.54 (PDF)
- CNS Stimulants CP.PMN.92 (PDF)
- Cobimetinib (Cotellic) CP.PHAR.380 (PDF)
- Colchicine (Colcrys) CP.PMN.123 (PDF)
- Colesevelam (Welchol) CP.PMN.250 (PDF)
- Collagenase Clostridium Histolyticum (Xiaflex) CP.PHAR.82 (PDF)
- Colonoscopy Preparation Products CP.PCH.43 (PDF)
- Compounded Medications CP.PCH.27 (PDF)
- Conjugated Estrogens/Bazedoxifene (Duavee) CP.PMN.258 (PDF)
- Continuous Glucose Monitors CP.PMN.214 (PDF)
- Copanlisib (Aliqopa) CP.PHAR.357 (PDF)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) CP.PHAR.385 (PDF)
- Cosyntropin (Cortrosyn) CP.PHAR.203 (PDF)
- Crisaborole (Eucrisa) CP.PMN.110 (PDF)
- Crizanlizumab-tmca (Adakveo) CP.PHAR.449 (PDF)
- Crizotinib (Xalkori) CP.PHAR.90 (PDF)
- Cyclosporine (Cequa, Restasis, Verkazia) CP.PMN.48 (PDF)
- Cysteamine ophthalmic (Cystaran, Cystadrops) CP.PMN.130 (PDF)
- Cysteamine oral (Cystagon, Procysbi) CP.PHAR.155 (PDF)
- Cytomegalovirus Immune Globulin (Cytogam) CP.PHAR.277 (PDF)
- Dabrafenib (Tafinlar) CP.PHAR.239 (PDF)
- Daclatasvir (Daklinza) HIM.PA.SP27 (PDF)
- Dacomitinib (Vizimpro) CP.PHAR.399 (PDF)
- Dalfampridine (Ampyra) CP.PHAR.248 (PDF)
- Dalteparin (Fragmin) CP.PHAR.225 (PDF)
- Dapsone (Aczone Gel) CP.PCH.32 (PDF)
- Daptomycin (Cubicin, Cubicin RF) CP.PHAR.351 (PDF)
- Daratumumab (Darzalex), Daratumumab/Hyaluronidase-fihj (Darzalex Faspro) CP.PHAR.310 (PDF)
- Darbepoetin Alfa (Aranesp) CP.PHAR.236 (PDF)
- Darolutamide (Nubeqa) CP.PHAR.435 (PDF)
- Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) HIM.PA.SP61 (PDF)
- Dasatinib (Sprycel) CP.PHAR.72 (PDF)
- Daunorubicin/Cytarabine (Vyxeos) CP.PHAR.352 (PDF)
- Decitabine/Cedazuridine (Inqovi) CP.PHAR.479 (PDF)
- Deferasirox (Exjade, Jadenu) CP.PHAR.145 (PDF)
- Deferoxamine (Desferal) CP.PHAR.146 (PDF)
- Deflazacort (Emflaza) CP.PHAR.331 (PDF)
- Degarelix Acetate (Firmagon) CP.PHAR.170 (PDF)
- Delafloxacin (Baxdela) CP.PMN.115 (PDF)
- Denosumab (Prolia, Xgeva) CP.PHAR.58 (PDF)
- Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) CP.PHAR.214 (PDF)
- Deutetrabenazine (Austedo) CP.PCH.42 (PDF)
- Dexlansoprazole (Dexilant) HIM.PA.05 (PDF)
- Dexrazoxane (Zinecard, Totect) CP.PHAR.418 (PDF)
- Dextromethorphan-Quinidine (Nuedexta) CP.PMN.93 (PDF)
- Diazepam Nasal Spray (Valtoco) CP.PMN.216 (PDF)
- Dichlorphenamide (Keveyis) CP.PMN.261 (PDF)
- Diclofenac (Cambia, Flector, Licart, Pennsaid, Solaraze, Zipsor, Zorvolex) CP.PCH.28 (PDF)
- Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity), Monomethyl Fumarate (Bafiertam) CP.PCH.41 (PDF)
- Dipeptidyl Peptidase-4 (DPP-4) Inhibitors HIM.PA.58 (PDF)
- Dolasetron (Anzemet) CP.PMN.141 (PDF)
- Dornase Alfa (Pulmozyme) CP.PHAR.212 (PDF)
- Dostarlimab-gxly (Jemperli) CP.PHAR.540 (PDF)
- Doxepin (Silenor, Prudoxin, Zonalon) HIM.PA.147 (PDF)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) CP.PMN.79 (PDF)
- Dupilumab (Dupixent) CP.PHAR.336 (PDF)
- Durvalumab (Imfinzi) CP.PHAR.339 (PDF)
- Duvelisib (Copiktra) CP.PHAR.400 (PDF)
- Ecallantide (Kalbitor) CP.PHAR.177 (PDF)
- Eculizumab (Soliris) CP.PHAR.97 (PDF)
- Edaravone (Radicava) CP.PHAR.343 (PDF)
- Efinaconazole (Jublia) CP.PMN.25 (PDF)
- Elagolix (Orilissa), Elagolix/Estradiol/Norethinedrone (Oriahnn) CP.PHAR.136 (PDF)
- Elapegademase-lvlr (Revcovi) CP.PHAR.419 (PDF)
- Elbasvir/Grazoprevir (Zepatier) HIM.PA.SP62 (PDF)
- Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) CP.PHAR.440 (PDF)
- Eliglustat (Cerdelga) CP.PHAR.153 (PDF)
- Elosulfase Alfa (Vimizim) CP.PHAR.162 (PDF)
- Elotuzumab (Empliciti) CP.PHAR.308 (PDF)
- Eltrombopag (Promacta) CP.PHAR.180 (PDF)
- Eluxadoline (Viberzi) CP.PMN.170 (PDF)
- Emapalumab-lzsg (Gamifant) CP.PHAR.402 (PDF)
- Emicizumab-kxwh (Hemlibra) CP.PHAR.370 (PDF)
- Emtricitabine/Tenofovir Alafenamide (Descovy) CP.PMN.235 (PDF)
- Enasidenib (Idhifa) CP.PHAR.363 (PDF)
- Encorafenib (Braftovi) CP.PHAR.127 (PDF)
- Enfortumab Vedotin-ejfv (Padcev) CP.PHAR.455 (PDF)
- Enfuvirtide (Fuzeon) CP.PHAR.41 (PDF)
- Enoxaparin (Lovenox) CP.PHAR.224 (PDF)
- Entecavir (Baraclude) HIM.PA.08 (PDF)
- Entrectinib (Rozlytrek) CP.PHAR.441 (PDF)
- Enzalutamide (Xtandi) CP.PHAR.106 (PDF)
- Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) CP.PHAR.237 (PDF)
- Epoprostenol (Flolan, Veletri) CP.PHAR.192 (PDF)
- Eptinezumab-jjmr (Vyepti) HIM.PA.SP64 (PDF)
- Erdafitinib (Balversa) CP.PHAR.423 (PDF)
- Erenumab-aaoe (Aimovig) HIM.PA.SP65 (PDF)
- Eribulin Mesylate (Halaven) CP.PHAR.318 (PDF)
- Erlotinib (Tarceva) CP.PHAR.74 (PDF)
- Erwinia Asparaginase (Erwinaze, Rylaze) CP.PHAR.301 (PDF)
- Esketamine (Spravato) CP.PMN.199 (PDF)
- Estradiol Vaginal Ring (Femring) CP.PMN.263 (PDF)
- Etelcalcetide (Parsabiv) CP.PHAR.379 (PDF)
- Eteplirsen (Exondys 51) CP.PHAR.288 (PDF)
- Everolimus (Afinitor, Afinitor Disperz, Zortress) CP.PHAR.63 (PDF)
- Evinacumab-dgnb (Evkeeza) CP.PHAR.511 (PDF)
- Evolocumab (Repatha) HIM.PA.156 (PDF)
- Factor IX (Human, Recombinant) CP.PHAR.218 (PDF)
- Factor IX Complex, Human (Profilnine) CP.PHAR.219 (PDF)
- Factor VIIa, Recombinant (NovoSeven RT, SevenFact) CP.PHAR.220 (PDF)
- Factor VIII (Human, Recombinant) CP.PHAR.215 (PDF)
- Factor VIII/von Willebrand Factor Complex (Human – Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi) CP.PHAR.216 (PDF)
- Factor XIII A-Subunit, Recombinant (Tretten) CP.PHAR.222 (PDF)
- Factor XIII, Human (Corifact) CP.PHAR.221 (PDF)
- Fam-Trastuzumab Deruxtecan-nxki (Enhertu) CP.PHAR.456 (PDF)
- Febuxostat (Uloric) CP.PMN.57 (PDF)
- Fedratinib (Inrebic) CP.PHAR.442 (PDF)
- Fenfluramine (Fintepla) CP.PMN.246 (PDF)
- Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) CP.PMN.127 (PDF)
- Ferric Carboxymaltose (Injectafer) CP.PHAR.234 (PDF)
- Ferric Derisomaltose (Monoferric) CP.PHAR.480 (PDF)
- Ferric Gluconate (Ferrlecit) CP.PHAR.166 (PDF)
- Ferric Maltol (Accrufer) CP.PMN.213 (PDF)
- Ferumoxytol (Feraheme) CP.PHAR.165 (PDF)
- Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP) CP.PHAR.526 (PDF)
- Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastim-aafi (Nivestym) CP.PHAR.297 (PDF)
- Finerenone (Kerendia) CP.PMN.266 (PDF)
- Fingolimod (Gilenya) CP.PCH.38 (PDF)
- Flibanserin (Addyi) CP.PHAR.446 (PDF)
- Fluorouracil Cream (Tolak) CP.PMN.165 (PDF)
- Fluticasone Propionate (Xhance) CP.PMN.95 (PDF)
- Fondaparinux (Arixtra) CP.PHAR.226 (PDF)
- Formulary Medications Without Specific Guidelines HIM.PA.33 (PDF)
- Fosdenopterin (Nulibry) CP.PHAR.471 (PDF)
- Fostamatinib (Tavalisse) CP.PHAR.24 (PDF)
- Fremanezumab-vfrm (Ajovy) HIM.PA.SP66 (PDF)
- Fulvestrant (Faslodex Injection) CP.PHAR.424 (PDF)
- Gabapentin ER (Gralise, Horizant) CP.PMN.240 (PDF)
- Galcanezumab-gnlm (Emgality) HIM.PA.SP67 (PDF)
- Galsulfase (Naglazyme) CP.PHAR.161 (PDF)
- Gefitinib (Iressa) CP.PHAR.68 (PDF)
- Gemtuzumab Ozogamicin (Mylotarg) CP.PHAR.358 (PDF)
- Gilteritinib (Xospata) CP.PHAR.412 (PDF)
- Givosiran (Givlaari) CP.PHAR.457 (PDF)
- Glasdegib (Daurismo) CP.PHAR.413 (PDF)
- Glatiramer Acetate (Copaxone, Glatopa) HIM.PA.SP68 (PDF)
- Glecaprevir/Pibrentasvir (Mavyret) HIM.PA.SP36 (PDF)
- Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists HIM.PA.53 (PDF)
- Glycerol Phenylbutyrate (Ravicti) CP.PHAR.207 (PDF)
- Golodirsen (Vyondys 53) CP.PHAR.453 (PDF)
- Goserelin Acetate (Zoladex) CP.PHAR.171 (PDF)
- Halcinonide (Halog) HIM.PA.20 (PDF)
- Halobetasol Propionate (Bryhali, Lexette, Ultravate) CP.PMN.180 (PDF)
- Halobetasol Propionate/Tazarotene (Duobrii) CP.PMN.208 (PDF)
- Hemin (Panhematin) CP.PHAR.181 (PDF)
- Histrelin Acetate (Vantas, Supprelin LA) CP.PHAR.172 (PDF)
- House dust mite allergen extract (Odactra) CP.PMN.111 (PDF)
- Human Growth Hormone (Somapacitan, Somatropin) HIM.PA.161 (PDF)
- Hyaluronate Derivatives CP.PHAR.05 (PDF)
- Hydroxyprogesterone Caproate (Makena/compound) CP.PHAR.14 (PDF)
- Hydroxyurea (Siklos) CP.PMN.193 (PDF)
- Ibalizumab-uiyk (Trogarzo) CP.PHAR.378 (PDF)
- Ibandronate Injection (Boniva) CP.PHAR.189 (PDF)
- Ibrutinib (Imbruvica) CP.PHAR.126 (PDF)
- Ibuprofen/Famotidine (Duexis) CP.PMN.120 (PDF)
- Icatibant (Firazyr) CP.PHAR.178 (PDF)
- Icosapent Ethyl (Vascepa) CP.PMN.187 (PDF)
- Idecabtagene Vicleucel (Abecma) CP.PHAR.481 (PDF)
- Idelalisib (Zydelig) CP.PHAR.133 (PDF)
- Idursulfase (Elaprase) CP.PHAR.156 (PDF)
- Iloperidone (Fanapt) CP.PMN.32 (PDF)
- Iloprost (Ventavis) CP.PHAR.193 (PDF)
- Imatinib (Gleevec) CP.PHAR.65 (PDF)
- Imiglucerase (Cerezyme) CP.PHAR.154 (PDF)
- Immune Globulins CP.PHAR.103 (PDF)
- IncobotulinumtoxinA (Xeomin) CP.PHAR.231 (PDF)
- Inebilizumab-cdon (Uplizna) CP.PHAR.458 (PDF)
- Infertility and Fertility Preservation CP.PHAR.131 (PDF)
- Infigratinib (Truseltiq) CP.PHAR.547 (PDF)
- Inhaled Agents for Asthma and COPD HIM.PA.153 (PDF)
- Inotersen (Tegsedi) CP.PHAR.405 (PDF)
- Inotuzumab Ozogamicin (Besponsa) CP.PHAR.359 (PDF)
- Insulin Delivery Systems (V-Go, Omnipod, InPen) CP.PHAR.534 (PDF)
- Insulin Glargine (Semglee, Toujeo) HIM.PA.09 (PDF)
- Interferon Beta-1a (Avonex, Rebif) CP.PHAR.255 (PDF)
- Interferon Beta-1b (Betaseron, Extavia) CP.PHAR.256 (PDF)
- Interferon Gamma- 1b (Actimmune) CP.PHAR.52 (PDF)
- Iobenguane I-131 (Azedra) CP.PHAR.459 (PDF)
- Ipilimumab (Yervoy) CP.PHAR.319 (PDF)
- Irinotecan Liposome (Onivyde) CP.PHAR.304 (PDF)
- Iron Sucrose (Venofer) CP.PHAR.167 (PDF)
- Isatuximab-irfc (Sarclisa) CP.PHAR.482 (PDF)
- Isavuconazonium (Cresemba) CP.PMN.154 (PDF)
- Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) CP.PMN.143 (PDF)
- Istradefylline (Nourianz) CP.PMN.217 (PDF)
- Itraconazole (Sporanox, Tolsura) CP.PMN.124 (PDF)
- Ivabradine (Corlanor) CP.PMN.70 (PDF)
- Ivacaftor (Kalydeco) CP.PHAR.210 (PDF)
- Ivermectin (Stromectol, Sklice) CP.PMN.269 (PDF)
- Ivosidenib (Tibsovo) CP.PHAR.137 (PDF)
- Ixazomib (Ninlaro) CP.PHAR.302 (PDF)
- lacosamide (Vimpat) CP.PMN.155 (PDF)
- Lactitol (Pizensy) CP.PMN.241 (PDF)
- Lanadelumab-fylo (Takhzyro) CP.PHAR.396 (PDF)
- Lanreotide (Somatuline Depot) CP.PHAR.391 (PDF)
- Lapatinib (Tykerb) CP.PHAR.79 (PDF)
- Laronidase (Aldurazyme) CP.PHAR.152 (PDF)
- Larotrectinib (Vitrakvi) CP.PHAR.414 (PDF)
- Lasmiditan (Reyvow) CP.PMN.218 (PDF)
- Latanoprostene Bunod (Vyzulta) CP.PMN.108 (PDF)
- Ledipasvir/Sofosbuvir (Harvoni) HIM.PA.SP3 (PDF)
- Lefamulin (Xenleta) CP.PMN.219 (PDF)
- Lenalidomide (Revlimid) CP.PHAR.71 (PDF)
- Lenvatinib (Lenvima) CP.PHAR.138 (PDF)
- Lesinurad (Zurampic), Lesinurad/Allopurinol (Duzallo) CP.PMN.150 (PDF)
- Letermovir (Prevymis) CP.PHAR.367 (PDF)
- Leucovorin Injection CP.PHAR.393 (PDF)
- Leuprolide Acetate (Eligard, Fensolvi, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi) CP.PHAR.173 (PDF)
- Levodopa Inhalation Powder (Inbrija) CP.PMN.267 (PDF)
- Levoleucovorin (Fusilev, Khapzory) CP.PHAR.151 (PDF)
- Levomilnacipran (Fetzima) HIM.PA.125 (PDF)
- L-glutamine (Endari) CP.PMN.116 (PDF)
- Lidocaine transdermal (Lidoderm, ZTlido) CP.PMN.08 (PDF)
- Lifitegrast (Xiidra) CP.PMN.73 (PDF)
- Linaclotide (Linzess) CP.PMN.71 (PDF)
- Linezolid (Zyvox) CP.PMN.27 (PDF)
- Lisocabtagene Maraleucel (Breyanzi) CP.PHAR.483 (PDF)
- Lofexidine (Lucemyra) CP.PMN.152 (PDF)
- Lomustine (Gleostine) CP.PHAR.507 (PDF)
- Lonafarnib (Zokinvy) CP.PHAR.499 (PDF)
- Loncastuximab Tesirine-lpyl (Zynlonta) CP.PHAR.539 (PDF)
- Lorcaserin (Belviq, Belviq XR) CP.PCH.03 (PDF)
- Lorlatinib (Lorbrena) CP.PHAR.406 (PDF)
- Loteprednol etabonate (Eysuvis) CP.PMN.260 (PDF)
- Lubiprostone (Amitiza) CP.PMN.142 (PDF)
- Luliconazole Cream (Luzu) CP.PMN.166 (PDF)
- Lumacaftor/Ivacaftor (Orkambi) CP.PHAR.213 (PDF)
- Lumasiran (Oxlumo) CP.PHAR.473 (PDF)
- Lumateperone (Caplyta) CP.PMN.232 (PDF)
- Lurasidone (Latuda) CP.PMN.50 (PDF)
- Lurbinectedin (Zepzelca) CP.PHAR.500 (PDF)
- Luspatercept-aamt (Reblozyl) CP.PHAR.450 (PDF)
- Lusutrombopag (Mulpleta) CP.PHAR.407 (PDF)
- Lutetium Lu 177 dotatate (Lutathera) CP.PHAR.384 (PDF)
- Macitentan (Opsumit) CP.PCH.31 (PDF)
- Maralixibat (Livmarli) CP.PHAR.543 (PDF)
- Margetuximab-cmkb (Margenza) CP.PHAR.522 (PDF)
- Mecamylamine (Vecamyl) CP.PMN.136 (PDF)
- Mecasermin (Increlex) CP.PHAR.150 (PDF)
- Mechlorethamine Gel (Valchlor) CP.PHAR.381 (PDF)
- Megestrol Acetate (Megace ES) CP.PMN.179 (PDF)
- Melphalan flufenamide (Pepaxto) CP.PHAR.535 (PDF)
- Memantine ER (Namenda XR), Memantine/Donepezil (Namzaric) CP.PCH.30 (PDF)
- Mepolizumab (Nucala) CP.PHAR.200 (PDF)
- Mercaptopurine (Purixan) CP.PHAR.447 (PDF)
- Metformin ER (Fortamet, Glumetza) CP.PMN.72 (PDF)
- Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) CP.PHAR.134 (PDF)
- Methoxsalen (Uvadex) HIM.PA.17 (PDF)
- Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) CP.PHAR.238 (PDF)
- Methylnaltrexone Bromide (Relistor) CP.PMN.169 (PDF)
- Metoclopramide (Gimoti) CP.PMN.252 (PDF)
- Metreleptin (Myalept) CP.PHAR.425 (PDF)
- Midazolam (Nayzilam) CP.PMN.211 (PDF)
- Midostaurin (Rydapt) CP.PHAR.344 (PDF)
- Mifepristone (Korlym) CP.PHAR.101 (PDF)
- Migalastat (Galafold) CP.PHAR.394 (PDF)
- Miglustat (Zavesca) CP.PHAR.164 (PDF)
- Milnacipran (Savella) CP.PMN.125 (PDF)
- Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) CP.PMN.80 (PDF)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) CP.PHAR.495 (PDF)
- Mitoxantrone (Novantrone) CP.PHAR.258 (PDF)
- Mobocertinib (Exkivity) CP.PHAR.559 (PDF)
- Modafinil (Provigil) CP.PMN.39 (PDF)
- Mogamulizumab-kpkc (Poteligeo) CP.PHAR.139 (PDF)
- Mometasone (Nasonex) HIM.PA.93 (PDF)
- Mometasone Furoate (Sinuva) CP.PHAR.448 (PDF)
- Montelukast Oral Granules (Singulair) HIM.PA.129 (PDF)
- Moxetumomab pasudotox-tdfk (Lumoxiti) CP.PHAR.398 (PDF)
- Nafarelin Acetate (Synarel) CP.PHAR.174 (PDF)
- Naltrexone (Vivitrol) CP.PHAR.96 (PDF)
- Naproxen Oral Suspension (Naprosyn) HIM.PA.130 (PDF)
- Naproxen/Esomeprazole (Vimovo) CP.PMN.117 (PDF)
- Natalizumab (Tysabri) HIM.PA.SP17 (PDF)
- Naxitamab-gqgk (Danyelza) CP.PHAR.523 (PDF)
- Nebivolol (Bystolic) HIM.PA.131 (PDF)
- Necitumumab (Portrazza) CP.PHAR.320 (PDF)
- Neomycin/Fluocinolone Cream (Neo-Synalar) CP.PMN.167 (PDF)
- Neratinib (Nerlynx) CP.PHAR.365 (PDF)
- Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan) CP.PMN.118 (PDF)
- Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) CP.PMN.158 (PDF)
- Nifurtimox (Lampit) CP.PMN.256 (PDF)
- Nilotinib (Tasigna) CP.PHAR.76 (PDF)
- Nintedanib (Ofev) CP.PHAR.285 (PDF)
- Niraparib (Zejula) CP.PHAR.408 (PDF)
- Nitazoxanide (Alinia) HIM.PA.152 (PDF)
- Nitisinone (Nityr, Orfadin) CP.PHAR.132 (PDF)
- Nivolumab (Opdivo) CP.PHAR.121 (PDF)
- No Coverage Criteria CP.PMN.255 (PDF)
- Non-Formulary and Formulary Contraceptives HIM.PA.100 (PDF)
- Non-Formulary Test Strips HIM.PA.34 (PDF)
- Nusinersen (Spinraza) CP.PHAR.327 (PDF)
- Obeticholic Acid (Ocaliva) CP.PHAR.287 (PDF)
- Obinutuzumab (Gazyva) CP.PHAR.305 (PDF)
- Ocrelizumab (Ocrevus) CP.PHAR.335 (PDF)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) CP.PHAR.40 (PDF)
- Odevixibat (Bylvay) CP.PHAR.528 (PDF)
- Ofatumumab (Arzerra, Kesimpta) CP.PHAR.306 (PDF)
- Off-Label Drug Use HIM.PA.154 (PDF)
- Olanzapine Long-Acting Injection (Zyprexa Relprevv) CP.PHAR.292 (PDF)
- Olanzapine/Samidorphan (Lybalvi) CP.PMN.265 (PDF)
- Olaparib (Lynparza) CP.PHAR.360 (PDF)
- Olaratumab (Lartruvo) CP.PHAR.326 (PDF)
- Omacetaxine (Synribo) CP.PHAR.108 (PDF)
- Omadacycline (Nuzyra) CP.PMN.188 (PDF)
- Omalizumab (Xolair) CP.PHAR.01 (PDF)
- Omega-3-Acid Ethyl Esters (Lovaza) CP.PMN.52 (PDF)
- OnabotulinumtoxinA (Botox) CP.PHAR.232 (PDF)
- Onasemnogene Abeparvovec (Zolgensma) CP.PHAR.421 (PDF)
- Ondansetron (Zuplenz) CP.PMN.45 (PDF)
- Ophthalmic Corticosteroids HIM.PA.03 (PDF)
- Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) CP.PHAR.536 (PDF)
- Opicapone (Ongentys) CP.PMN.245 (PDF)
- Opioid Analgesics HIM.PA.139 (PDF)
- Osilodrostat (Isturisa) CP.PHAR.487 (PDF)
- Osimertinib (Tagrisso) CP.PHAR.294 (PDF)
- Ospemifene (Osphena) CP.PMN.168 (PDF)
- Overactive Bladder Agents CP.PMN.198 (PDF)
- Oxymetazoline (Rhofade, Upneeq) CP.PMN.86 (PDF)
- Ozanimod (Zeposia) CP.PHAR.462 (PDF)
- Ozenoxacin (Xepi) CP.PMN.119 (PDF)
- Paclitaxel, Protein-Bound (Abraxane) CP.PHAR.176 (PDF)
- Palbociclib (Ibrance) CP.PHAR.125 (PDF)
- Paliperidone Long-Acting Injections (Invega Hafyera, Invega Sustenna, Invega Trinza) CP.PHAR.291 (PDF)
- Palivizumab (Synagis) CP.PHAR.16 (PDF)
- Pancrelipase (Creon, Pancreaze, Pertyze, Viokace, Zenpep) HIM.PA.155 (PDF)
- Panitumumab (Vectibix) CP.PHAR.321 (PDF)
- Panobinostat (Farydak) CP.PHAR.382 (PDF)
- Parathyroid Hormone (Natpara) CP.PHAR.282 (PDF)
- Paricalcitol Injection (Zemplar) CP.PHAR.270 (PDF)
- Pasireotide (Signifor, Signifor LAR) CP.PHAR.332 (PDF)
- Patiromer (Veltassa) CP.PMN.205 (PDF)
- Patisiran (Onpattro) CP.PHAR.395 (PDF)
- Pazopanib (Votrient) CP.PHAR.81 (PDF)
- Peanut Allergen Powder-dnfp (Palforzia) CP.PMN.220 (PDF)
- Pegaptanib (Macugen) CP.PHAR.185 (PDF)
- Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas) CP.PHAR.353 (PDF)
- Pegcetacoplan (Empaveli) CP.PHAR.524 (PDF)
- Pegfilgrastim (Neulasta, Neulasta Onpro), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo), Pegfilgrastim-apgf (Nyvepria) CP.PHAR.296 (PDF)
- Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) CP.PHAR.89 (PDF)
- Peginterferon Beta-1a (Plegridy) CP.PHAR.271 (PDF)
- Pegloticase (Krystexxa) CP.PHAR.115 (PDF)
- Pegvaliase-pqpz (Palynziq) CP.PHAR.140 (PDF)
- Pegvisomant (Somavert) CP.PHAR.389 (PDF)
- Pembrolizumab (Keytruda) CP.PHAR.322 (PDF)
- Pemetrexed (Alimta, Pemfexy) CP.PHAR.368 (PDF)
- Pemigatinib (Pemazyre) CP.PHAR.496 (PDF)
- Penicillamine (Cuprimine) CP.PCH.09 (PDF)
- Perampanel (Fycompa) CP.PMN.156 (PDF)
- Pertuzumab (Perjeta) CP.PHAR.227 (PDF)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) CP.PHAR.501 (PDF)
- Pexidartinib (Turalio) CP.PHAR.436 (PDF)
- Phendimetrazine IR (Bontril PDM) HIM.PA.114 (PDF)
- Phentermine (Adipex-P, Lomaira) CP.PCH.13 (PDF)
- Pilocarpine CP.PMN.270 (PDF)
- Pimavanserin (Nuplazid) CP.PMN.140 (PDF)
- Pirfenidone (Esbriet) CP.PHAR.286 (PDF)
- Pitolisant (Wakix) CP.PMN.221 (PDF)
- Plasminogen, human-tvmh (Ryplazim) CP.PHAR.513 (PDF)
- Plecanatide (Trulance) HIM.PA.158 (PDF)
- Plerixafor (Mozobil) CP.PHAR.323 (PDF)
- Polatuzumab Vedotin-piiq (Polivy) CP.PHAR.433 (PDF)
- Pomalidomide (Pomalyst) CP.PHAR.116 (PDF)
- Ponatinib (Iclusig) CP.PHAR.112 (PDF)
- Ponesimod (Ponvory) CP.PHAR.537 (PDF)
- Potassium Chloride for Oral Solution (Klor-Con Powder) HIM.PA.143 (PDF)
- Pralatrexate (Folotyn) CP.PHAR.313 (PDF)
- Pramlintide (Symlin) CP.PMN.129 (PDF)
- Prasterone (Intrarosa) CP.PMN.99 (PDF)
- Pregabalin (Lyrica, Lyrica CR) CP.PMN.33 (PDF)
- Pretomanid CP.PMN.222 (PDF)
- Progesterone (Crinone, Endometrin, Milprosa) CP.PMN.243 (PDF)
- Propranolol HCl Oral Solution (Hemangeol) CP.PMN.58 (PDF)
- Protein C Concentrate, Human (Ceprotin) CP.PHAR.330 (PDF)
- Prucalopride (Motegrity) HIM.PA.159 (PDF)
- Pyrimethamine (Daraprim) CP.PMN.44 (PDF)
- Quetiapine Extended-Release (Seroquel XR) CP.PMN.64 (PDF)
- Quinine Sulfate (Qualaquin) CP.PMN.262 (PDF)
- Ramucirumab (Cyramza) CP.PHAR.119 (PDF)
- Ranibizumab (Lucentis) CP.PHAR.186 (PDF)
- Rasagiline (Azilect) HIM.PA.89 (PDF)
- Ravulizumab-cwvz (Ultomiris) CP.PHAR.415 (PDF)
- Regorafenib (Stivarga) CP.PHAR.107 (PDF)
- Relugolix (Orgovyx), Relugolix/Estradiol/Norethinedrone (Myfembree) CP.PHAR.529 (PDF)
- Remestemcel-L (Ryoncil) CP.PHAR.474 (PDF)
- Repository Corticotropin Injection (H.P. Acthar Gel) CP.PHAR.168 (PDF)
- Reslizumab (Cinqair) CP.PHAR.223 (PDF)
- Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) CP.PHAR.141 (PDF)
- Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara) CP.PHAR.334 (PDF)
- Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) CP.PMN.223 (PDF)
- Rifamycin (Aemcolo) CP.PMN.196 (PDF)
- Rifaximin (Xifaxan) CP.PMN.47 (PDF)
- Rilonacept (Arcalyst) CP.PHAR.266 (PDF)
- RimabotulinumtoxinB (Myobloc) CP.PHAR.233 (PDF)
- Rimegepant (Nurtec ODT) CP.PHAR.490 (PDF)
- Riociguat (Adempas) CP.PHAR.195 (PDF)
- Ripretinib (Qinlock) CP.PHAR.502 (PDF)
- Risdiplam (Evrysdi) CP.PHAR.477 (PDF)
- Risedronate (Actonel, Atelvia) CP.PMN.100 (PDF)
- Risperidone Long-Acting Injection (Perseris, Risperdal Consta) CP.PHAR.293 (PDF)
- Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) CP.PHAR.260 (PDF)
- Rolapitant (Varubi) CP.PMN.102 (PDF)
- Romidepsin (Istodax) CP.PHAR.314 (PDF)
- Romiplostim (Nplate) CP.PHAR.179 (PDF)
- Romosozumab-aqqg (Evenity) CP.PHAR.428 (PDF)
- Rucaparib (Rubraca) CP.PHAR.350 (PDF)
- Rufinamide (Banzel) CP.PMN.157 (PDF)
- Rukobia (fostemsavir) CP.PHAR.516 (PDF)
- Ruxolitinib (Jakafi, Opzelura) CP.PHAR.98 (PDF)
- Sacituzumab Govitecan-hziy (Trodelvy) CP.PHAR.475 (PDF)
- Sacubitril/Valsartan (Entresto) CP.PMN.67 (PDF)
- Safinamide (Xadago) CP.PMN.113 (PDF)
- Sapropterin Dihydrochloride (Kuvan) CP.PHAR.43 (PDF)
- Sarecycline (Seysara) CP.PMN.189 (PDF)
- Sargramostim (Leukine) CP.PHAR.295 (PDF)
- Satralizumab-mwge (Enspryng) CP.PHAR.463 (PDF)
- Sebelipase Alfa (Kanuma) CP.PHAR.159 (PDF)
- Secnidazole (Solosec) CP.PMN.103 (PDF)
- Selexipag (Uptravi) CP.PHAR.196 (PDF)
- Selinexor (Xpovio) CP.PHAR.431 (PDF)
- Selpercatinib (Retevmo) CP.PHAR.478 (PDF)
- Selumetinib (Koselugo) CP.PHAR.464 (PDF)
- Setmelanotide (Imcivree) CP.PHAR.491 (PDF)
- Short ragweed pollen allergen extract (Ragwitek) CP.PMN.83 (PDF)
- Sildenafil (Revatio) CP.PHAR.197 (PDF)
- Sildenafil for ED (Viagra) CP.PCH.07 (PDF)
- Siltuximab (Sylvant) CP.PHAR.329 (PDF)
- Siponimod (Mayzent) CP.PHAR.427 (PDF)
- Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, and Sodium Oxybate (Xywav) CP.PMN.42 (PDF)
- Sodium Phenylbutyrate (Buphenyl) CP.PHAR.208 (PDF)
- Sodium zirconium cyclosilicate (Lokelma) CP.PMN.163 (PDF)
- Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors HIM.PA.91 (PDF)
- Sofosbuvir (Sovaldi) HIM.PA.SP2 (PDF)
- Sofosbuvir/Velpatasvir (Epclusa) HIM.PA.SP1 (PDF)
- Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) HIM.PA.SP63 (PDF)
- Solriamfetol (Sunosi) CP.PMN.209 (PDF)
- Sonidegib (Odomzo) CP.PHAR.272 (PDF)
- Sorafenib (Nexavar) CP.PHAR.69 (PDF)
- Sotorasib (Lumakras) CP.PHAR.549 (PDF)
- Spinosad (Natroba) HIM.PA.134 (PDF)
- Step Therapy HIM.PA.109 (PDF)
- Stiripentol (Diacomit) CP.PMN.184 (PDF)
- Sucroferric Oxyhydroxide (Velphoro) HIM.PA.SP30 (PDF)
- Sunitinib (Sutent) CP.PHAR.73 (PDF)
- Sutimlimab CP.PHAR.503 (PDF)
- Suvorexant (Belsomra) CP.PMN.109 (PDF)
- Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair) CP.PMN.85 (PDF)
- Tadalafil (Adcirca, Alyq) CP.PHAR.198 (PDF)
- Tadalafil BHP - ED (Cialis) CP.PMN.132 (PDF)
- Tafamidis (Vyndaqel, Vyndamax) CP.PHAR.432 (PDF)
- Tafasitamab-cxix (Monjuvi) CP.PHAR.508 (PDF)
- Talazoparib (Talzenna) CP.PHAR.409 (PDF)
- Taliglucerase Alfa (Elelyso) HIM.PA.162 (PDF)
- Talimogene laherepvec (Imlygic) CP.PHAR.542 (PDF)
- Tasimelteon (Hetlioz, Hetlioz LQ) CP.PMN.104 (PDF)
- Tavaborole (Kerydin) CP.PMN.105 (PDF)
- Tazarotene (Arazlo, Fabior, Tazorac) CP.PMN.244 (PDF)
- Tazemetostat (Tazverik) CP.PHAR.452 (PDF)
- Tedizolid (Sivextro) CP.PMN.62 (PDF)
- Teduglutide (Gattex) CP.PHAR.114 (PDF)
- Tegaserod (Zelnorm) HIM.PA.160 (PDF)
- Telotristat Ethyl (Xermelo) CP.PHAR.337 (PDF)
- Temozolomide (Temodar) CP.PHAR.77 (PDF)
- Temsirolimus (Torisel) CP.PHAR.324 (PDF)
- Tenapanor (Ibsrela) CP.PMN.224 (PDF)
- Tenofovir Alafenamide Fumarate (Vemlidy) CP.PMN.268 (PDF)
- Tepotinib (Tepmetko) CP.PHAR.530 (PDF)
- Teprotumumab (Tepezza) CP.PHAR.465 (PDF)
- Teriflunomide (Aubagio) CP.PCH.40 (PDF)
- Teriparatide (Forteo) CP.PHAR.188 (PDF)
- Tesamorelin (Egrifta SV) CP.PHAR.109 (PDF)
- Testosterone (Androderm) HIM.PA.87 (PDF)
- Testosterone (Testopel, Jatenzo) CP.PHAR.354 (PDF)
- Tetrabenazine (Xenazine) CP.PHAR.92 (PDF)
- Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) CP.PHAR.377 (PDF)
- Thalidomide (Thalomid) CP.PHAR.78 (PDF)
- Thioguanine (Tabloid) CP.PHAR.437 (PDF)
- Thyrotropin alfa (Thyrogen) CP.PHAR.95 (PDF)
- Timothy grass pollen allergen extract (Grastek) CP.PMN.84 (PDF)
- Tisagenlecleucel (Kymriah) CP.PHAR.361 (PDF)
- Tisotumab vedotin-tftv (Tivdak) CP.PHAR.561 (PDF)
- Tivozanib (Fotivda) CP.PHAR.538 (PDF)
- Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) CP.PHAR.211 (PDF)
- Tolvaptan (Jynarque, Samsca) CP.PHAR.27 (PDF)
- Topical Acne Treatment HIM.PA.71 (PDF)
- Topical Immunomodulators CP.PMN.107 (PDF)
- Topotecan (Hycamtin) CP.PHAR.64 (PDF)
- Trabectedin (Yondelis) CP.PHAR.204 (PDF)
- Trametinib (Mekinist) CP.PHAR.240 (PDF)
- Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase CP.PHAR.228 (PDF)
- Treprostinil (Orenitram, Remodulin, Tyvaso) CP.PHAR.199 (PDF)
- Triamcinolone ER Injection (Zilretta) CP.PHAR.371 (PDF)
- Triclabendazole (Egaten) CP.PMN.207 (PDF)
- Trientine (Syprine) CP.PHAR.438 (PDF)
- Trifarotene (Aklief) CP.PMN.225 (PDF)
- Trifluridine/Tipiracil (Lonsurf) CP.PHAR.383 (PDF)
- Triheptanoin (Dojolvi) CP.PHAR.509 (PDF)
- Triptorelin Pamoate (Trelstar, Triptodur) CP.PHAR.175 (PDF)
- Tucatinib (Tukysa) CP.PHAR.497 (PDF)
- Ubrogepant (Ubrelvy) CP.PHAR.476 (PDF)
- Umbralisib (Ukoniq) CP.PHAR.531 (PDF)
- Uridine Triacetate (Vistogard) HIM.PA.SP55 (PDF)
- Valganciclovir (Valcyte) CP.PCH.06 (PDF)
- Valoctocogene Roxaparvovec CP.PHAR.466 (PDF)
- Valproate Sodium for Intravenous Injection (Depacon) CP.PHAR.429 (PDF)
- Valrubicin (Valstar) CP.PHAR.439 (PDF)
- Vandetanib (Caprelsa) CP.PHAR.80 (PDF)
- Velaglucerase Alfa (VPRIV) HIM.PA.163 (PDF)
- Vemurafenib (Zelboraf) CP.PHAR.91 (PDF)
- Venetoclax (Venclexta) CP.PHAR.129 (PDF)
- Verteporfin (Visudyne) CP.PHAR.187 (PDF)
- Vestronidase alfa-vjbk (Mepsevii) CP.PHAR.374 (PDF)
- Vigabatrin (Sabril) CP.PHAR.169 (PDF)
- Vilazodone (Viibryd) CP.PMN.145 (PDF)
- Viltolarsen (Viltepso) CP.PHAR.484 (PDF)
- Vincristine Sulfate Liposome Injection (Marqibo) CP.PHAR.315 (PDF)
- Vismodegib (Erivedge) CP.PHAR.273 (PDF)
- Voclosporin (Lupkynis) CP.PHAR.504 (PDF)
- Vorapaxar (Zontivity) HIM.PA.146 (PDF)
- Voretigene Neparvovec-rzyl (Luxturna) CP.PHAR.372 (PDF)
- Vorinostat (Zolinza) CP.PHAR.83 (PDF)
- Vortioxetine (Trintellix) CP.PMN.65 (PDF)
- Voxelotor (Oxbryta) CP.PHAR.451 (PDF)
- Zanubrutinib (Brukinsa) CP.PHAR.467 (PDF)
- Ziv-aflibercept (Zaltrap) CP.PHAR.325 (PDF)
- Zoledronic Acid (Reclast, Zometa) CP.PHAR.59 (PDF)
- Ambulatory EEG (CP.MP.96) (PDF)
- Bronchial Thermoplasty (CP.MP.110) (PDF)
- Cardiac Biomarker Testing for Acute MI (CP.MP.156) (PDF)
- Digital Analysis of EEGs (CP.MP.105) (PDF)
- DNA Analysis of Stool (CP.MP.125) (PDF)
- EEG in Evaluation of Headache (CP.MP.155) (PDF)
- Endometrial Ablation (EA) (CP.MP.106) (PDF)
- EpiFix Wound Treatment (CP.MP.140) (PDF)
- Evoked Potentials (CP.MP.134) (PDF)
- Fecal Calprotectin Assay (CP.MP.135) (PDF)
- FeNo Testing (CP.MP.103) (PDF)
- H Pylori Testing (CP.MP.153) (PDF)
- Holter Monitors (CP.MP.113) (PDF)
- Homocysteine Testing (CP.MP.121) (PDF)
- Laser Skin Treatment (CP.MP.123) (PDF)
- Measure Serum 1,25 Vitamin D (CP.MP.152) (PDF)
- Mechanical Stretch Devices (CP.MP.144) (PDF)
- Monitored Anesthesia Care for Gastrointestinal Endoscopy (CP.MP.161) (PDF)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (CP.MP.181) (PDF)
- Proton and Neutron Beam Therapy (CP.MP.70) (PDF)
- Testing for Select Genitourinary Conditions (CP.MP.97) (PDF)
- Ultrasound in Pregnancy (CP.MP.38) (PDF)
- Urodynamic Testing (CP.MP.98) (PDF)
- Wheelchair Seating (CP.MP.99) (PDF)
- Wireless Motility Capsule (CP.MP.143) (PDF)
- Alergy Testing (CP.MP.100) (PDF)
- Flu/Strep Testing (CP.MP.112) (PDF)
- ADHD Assessment and Treatment (CP.MP.124) (PDF)
- Outpatient Testing for Drugs of Abuse (CP.MP.50) (PDF)
- Digital Breast Tomosynthesis (CP.MP.90) (PDF)
- HBR Initiative PISCES Internal Code Editing
- HBR Initiative CXT Optimization Study
- HBR Initiative Cotiviti 8 Correct Coding Edits - Batch 2 (CNC-WCG Integration Value Capture)
- HBR Initiative Cotiviti 8 Correct Coding Edits - Batch 3 (CNC-WCG Integration Value Capture)
- HBR Initiative CXT Flexible Provider Matching
- HBR Initiative Cotiviti 8 Correct Coding Edits - Batch 1 (CNC-WCG Integration Value Capture)
- HBR Initiative Emergency Room and Urgent Care Pend Process with IP Billing/24hrs
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- LA.PP.007 Maximum Units (PDF)
- LA.PP.009 Unlisted Procedure Codes (PDF)
- LA.PP.010 EM Bundling Edits (PDF)
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- LA.PP.012 IV Hydration (PDF)
- LA.PP.013 Modifier -25 clinical validation (PDF)
- LA.PP.014 Modifier -59 clinical validation (PDF)
- LA.PP.015 Moderate Conscious Sedation (PDF)
- LA.PP.016 Global Maternity Billing (PDF)
- LA.PP.017 Never Paid Events (PDF)
- LA.PP.018 Inpatient Only Procedures (PDF)
- LA.PP.019 Physician Visit Codes Billed with Labs (PDF)
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- LA.PP.023 Hospital Visit Codes Billed with Labs (PDF)
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- LA.PP.025 Pulse Oximetry (PDF)
- LA.PP.027 Professional Component (PDF)
- LA.PP.028 Modifier to Procedure Code Validation (PDF)
- LA.PP.029 Assistant Surgeon (PDF)
- LA.PP.030 Add on Code Billed Without Primary Code (PDF)
- LA.PP.031 NCCI Unbundling (PDF)
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- LA.PP.033 Multiple CPT Code Replacement (PDF)
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- LA.PP.035 Sleep Studies Place of Services (PDF)
- LA.PP.036 New Patient (PDF)
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- LA.PP.065 Multiple Procedure Payment Reduction.MPPR. for diagnostic Cardiovascular Procedure (PDF)
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- LA.PP.071 E and M Services Billing with Treatment Room Revenue Codes (PDF)
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- CC.PP.035 Sleep Studies Place of Service (PDF)
- CC.PP.050 Robotic Surgery (PDF)
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- CC.PP.053 Non-Emergent ER Services (fka Leveling of ER Services) (PDF)
- CC.PP.054 Physician's Consultation Services (PDF)
- CC.PP.056 Urine Specimen Validity Testing (PDF)
- CC.PP.057 Problem-Oriented Visits with Preventative Visits (PDF)
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- CC.PP.065 Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF)
- CC.PP.067 Renal Hemodialysis (PDF)
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- CC.PP.070 340B Drug Payment Reduction (PDF)
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- CC.PP.502 Wheelchair Accessories (PDF)
- OC.UM.CP.0026 Extended Ophthalmoscopy (PDF)
- OC.UM.CP.0043 External Ocular Photography (PDF)
- CC.PP.035 Sleep Studies Place of Service (PDF)
- CC.PP.049 Status P Bundled Services (PDF)
- CC.PP.050 Robotic Surgery (PDF)
- CC.PP.052 Problem-Oriented Visits with Surgical Procedures (PDF)
- CC.PP.053 Non-Emergent ER Services (fka Leveling of ER Services) (PDF)
- CC.PP.054 Physician's Consultation Services (PDF)
- CC.PP.055 Physician's Office Lab Testing (PDF)
- CC.PP.056 Urine Specimen Validity Testing (PDF)
- CC.PP.057 Problem-Oriented Visits with Preventative Visits (PDF)
- CC.PP.061 Non-Obstetrical and OB Pelvic and Transvaginal Ultrasounds (PDF)
- CC.PP.063 Place of Service Mismatch (PDF)
- CC.PP.065 Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF)
- CC.PP.066 Leveling of Care: Evaluation and Management Overcoding (PDF)
- CC.PP.067 Renal Hemodialysis (PDF)
- CC.PP.068 Multiple Procedure Payment Reduction for Therapeutic Services (PDF)
- CC.PP.069 Multiple Procedure Reduction: Ophthalmology (PDF)
- CC.PP.070 340B Drug Payment Reduction (PDF)
- CC.PP.500 3 Day Payment Window (PDF)
- CC.PP.501 30 Day Readmission (PDF)
- CC.PP.502 Wheelchair Accessories (PDF)
- OC.UM.CP.0026 Extended Ophthalmoscopy (PDF)
- OC.UM.CP.0043 External Ocular Photography (PDF)