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.124 ADHD (PDF)
- LA.CP.BH.300 Biofeedback for Behavioral Health Disorders (PDF)
- LA.CP.BH.500 BH Treatment Documentations Requirements (PDF)
- LA.CP.BH.501c Functional Family Therapy Child Welfare (PDF)
- LA.CP.BH.503c OUD_Treatment_IN_OTPs (PDF)
- LA.CP.BH.504c_MNC_Crisis_Intervention_(PDF)
- LA.CP.BH.505c_Peer_Support_Services_(PDF)
- LA.CP.BH.509c Individual Placement and Support (IPS)(PDF)
- LA.CP.BH.510c Community Brief Crisis Support (PDF)
- LA.CP.BH.513c Adult Crisis Stabilization (PDF)
- LA.CP.BH.520c Homebuilder Services (PDF)
- LA.CP.BH.521c Multi-Systemic Therapy (MST)(PDF)
- LA.CP.CPC.03c Preventive Health and Clinical Practice Guidelines 5.23 (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.31c Cosmetic and Reconstructive Surgery (PDF)
- LA.CP.MP.36 Experimental Technologies (PDF)
- LA.CP.MP.37c Bariatric Surgery (PDF)
- LA.CP.MP.38c Ultrasound in Pregnancy (PDF)
- LA.CP.MP.40 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.50c Outpatient Testing for DOA (PDF)
- LA.CP.MP.51c Reduction Mammoplasty and Gynecomastia Surgery (PDF)
- LA.CP.MP.54c Hospice Service (PDF)
- LA.CP.MP.57 Lung Transplntation (PDF)
- LA.CP.MP.58 Intestinal and Multivisceral Transplant (PDF)
- LA.CP.MP.62 HyperhidrosisTreatments (PDF)
- LA.CP.MP.69 Intensity-Modulated Radiotherapy (PDF)
- LA.CP.MP.70c Proton and Neutron Beam Therapy (PDF)
- LA.CP.MP.87 Inhaled nitric oxide (PDF)
- LA.CP.MP.90c MNC Policy for CPST and PSR (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.98 Urodynamic testing (PDF)
- LA.CP.MP.99 Wheelchair seating (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.107c Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF)
- LA.CP.MP.108 AHCT for Sickle Cell Anemia and beta-Thalassemia (PDF)
- LA.CP.MP.109c 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 Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (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.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.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 and Noncontact Normathermic Would Therapy (PDF)
- LA.CP.MP.141 Nonmyeloablative 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.150 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 Vit D (PDF)
- LA.CP.MP.154 Thyroid Insulin Tests in Ped (PDF)
- LA.CP.MP.155 EEG Headache (PDF)
- LA.CP.MP.156 Cardiac Biomarker Testing (PDF)
- LA.CP.MP.157 Vitamin D Testing Peds (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.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.180 Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)
- LA.CP.MP.184 Home Ventilator (PDF)
- LA.CP.MP.185c Skin and Soft Tissue Substitutes for Chronic Wounds (PDF)
- LA.CP.MP.186 Burn Surgery (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.242 Pulmonary Function Testing (PDF)
- LA.CP.MP.243 Implantable Loop Recorder (PDF)
- LA.CP.MP.246 Pediatric Kidney Transplant (PDF)
- LA.CP.MP.247 Transplant Service Documentation Requirements (PDF)
- LA.CP.MP.248 Facility-Based Sleep Studies for OSA (PDF)
- LA.CP.MP.249 Omisirge (omidubicel) (PDF)
- LA.CP.MP.250 Lantidra (donislecel) Allogeneic Pancreatic Islet Cellular Therapy (PDF)
- LA.CP.MP.500c Enteral Nutrition (PDF)
- LA.CP.MP.506c Cardiovascular Services (PDF)
- LA.CP.MP.507c Cochlear Implants Replacements (PDF)
- LA.CP.MP.508c Personal Care Services (PDF)
- LA.CP.MP.511c Extended Home Health Services (PDF)
- LA.CP.MP.512c DSMT (PDF)
- LA.CP.MP.514c Transportation Policy (PDF)
- LA.CP.MP.515c PCS EPSDT (PDF)
- LA.CP.MP.516c Pediatric Day Health Care (PDHC) (PDF)
- LA.CP.MP.517c ACT Policy (PDF)
- LA.CP.MP.524c ILOS Remote Patient Monitoring (PDF)
- LA.CP.MP.525c Sincus Surgery (PDF)
- LA.CP.MP.526c Transcranial Magnetic Stimulation (TMS)
Concert Genetics
- LA.CP.CG.01 Concert Genetics Aortopathies and Connective Tissue Disorders (PDF)
- LA.CP.CG.02 Concert Genetics Cardiac Disorders (PDF)
- LA.CP.CG.03 Concert Genetics Dermatologic Conditions (PDF)
- LA.CP.CG.04 Concert Genetics Epilepsy Neurodegenerative and Neuromuscular Conditions (PDF)
- LA.CP.CG.05 Concert Genetics Eye Disorders (PDF)
- LA.CP.CG.06 Concert Genetics Gastroenterological Disorders non-cancerous (PDF)
- LA.CP.CG.07 Concert Genetics General Approach to Genetic Testing (PDF)
- LA.CP.CG.08 Concert Genetics Hearing Loss (PDF)
- LA.CP.CG.09 Concert Genetics Hematologic Conditions non-cancerous (PDF)
- LA.CP.CG.10 Concert Genetics Immune Autoimmune and Rheumatoid Disorders (PDF)
- LA.CP.CG.11 Concert Genetics Kidney Disorders (PDF)
- LA.CP.CG.12 Concert Genetics Lung Disorders (PDF)
- LA.CP.CG.13 Concert Genetics Metabolic Endocrine Mitochondrial Disorders (PDF)
- LA.CP.CG.14 Concert Genetics Multisystem Inherited Disorders (PDF)
- LA.CP.CG.15 Concert Genetics Non-invasive Prenatal Screening (PDF)
- LA.CP.CG.16 Concert Genetics Oncology Cancer Screening (PDF)
- LA.CP.CG.17 Concert Genetics Oncology Cytogentic Testing (PDF)
- LA.CP.CG.18 Concert Genetics Preimplantation Genetic Testing (PDF)
- LA.CP.CG.19 Concert Genetics Prenatal and Preconception Carrier Screening (PDF)
- LA.CP.CG.20 Concert Genetics Prenatal Diagnosis Pregnancy Loss (PDF)
- LA.CP.CG.21 Concert Genetics Skeletal Dysplasia Rare Bone Disorders (PDF)
- LA.CP.CG.22 Concert Genetics Hereditary Cancer Susceptibility (PDF)
- LA.CP.CG.23 Concert Genetics Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)
- LA.CP.CG.24 Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF)
- LA.CP.CG.25 Concert Genetics Oncology Algorithmic Testing (PDF)
- LA.CP.CG.26 Concert Genetics Pharmacogenetics (PDF)
- LA.CP.CG.27 ID Respiratory Lab Testing (PDF)
- LA.CP.CG.28 ID Multisystem Lab Testing (PDF)
- LA.CP.CG.29 Dermatologic Lab Testing (PDF)
- LA.CP.CG.30 Gastroenterologic Lab Testing (PDF)
- LA.CP.CG.31 ID Vector Borne and Tropical Disease Lab Testing (PDF)
- LA.CP.CG.32 Primary Care Preventative Lab Testing (PDF)
- LA.CP.CG 33 Genitourinary Lab Testing (PDF)
- LA.CP.CG.34 Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)
Use the Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations) (PDF) to find more information on the drugs that are covered by Medicaid.
- LA.PHAR.05 Hyaluronate Derivatives (PDF)
- LA.PHAR.11 Burosumab-twza (Crysvita) (PDF)
- LA.PHAR.28 Immunization Coverage (PDF)
- LA.PHAR.40 Octreotide Acetate (Sandostatin, Sandostatin LAR Depot) (PDF)
- LA.PHAR.52 Interferon Gamma- 1b (Actimmune) (PDF)
- LA.PHAR.58 Denosumab (Xgeva) (PDF)
- LA.PHAR.82 Collagenase (Xiaflex) (PDF)
- LA.PHAR.93 Bevacizumab (PDF)
- LA.PHAR.94 Alpha-1 Proteinase Inhibitors (PDF)
- LA.PHAR.95 Thyrotropin alfa (PDF)
- LA.PHAR.97 Eculizumab (Soliris) (PDF)
- LA.PHAR.108 Omecetaxine (Synribo) (PDF)
- LA.PHAR.119 Ramucirumab (Cyramza) (PDF)
- LA.PHAR.120 Sipuleucel-T (Provenge) (PDF)
- LA.PHAR.121 Nivolumab (PDF)
- LA.PHAR.139 Mogamulizumab-kpkc (Poteligeo) (PDF)
- LA.PHAR.146 deferoxamine (PDF)
- LA.PHAR.149 Intrathecal Baclofen (Gablofen, Lioresal) (PDF)
- LA.PHAR.151 Levoleucovorin (Fusilev) (PDF)
- LA.PHAR.158 Agalsidase Beta (PDF)
- LA.PHAR.159 Sebelipase Alfa (Kanuma) (PDF)
- LA.PHAR.160 Alglucosidase (Lumizyme) (PDF)
- LA.PHAR.165 Ferumoxytol (Feraheme) (PDF)
- LA.PHAR.170 Degarelix (Firmagon) (PDF)
- LA.PHAR.176 Paclitaxel Protein-Bound (Abraxane) (PDF)
- LA.PHAR.181 Hemin (Panhematin) (PDF)
- LA.PHAR.184 Aflibercept (Eylea) (PDF)
- LA.PHAR.186 Ranibizumab (Lucentis, Susvimo), Lucentis Biosimilars (PDF)
- LA.PHAR.187 Verteporfin (Visudyne) (PDF)
- LA.PHAR.189 Ibandronate sodium (Boniva) (PDF)
- LA.PHAR.192 Epoprostenol (Flolan, Veletri) (PDF)
- LA.PHAR.199 Treprostinil Remodeulin (PDF)
- LA.PHAR.201 Belatacept (Nulojix) (PDF)
- LA.PHAR.203 Cosyntropin (Cortrosyn) (PDF)
- LA.PHAR.204 Trabectedin (Yondelis) (PDF)
- LA.PHAR.212 Dornase Alfa Pulmozyme (PDF)
- LA.PHAR.214 Desmopressin DDAVP Stimate Nocdurna (PDF)
- LA.PHAR.227 Pertuzumab (PDF)
- LA.PHAR.228 Trastuzumab, Trastuzumab-dkst (PDF)
- LA.PHAR.229 Ado-Trastuzumab Emtansine (PDF)
- LA.PHAR.234 Ferric Carboxymaltose (Injectafer) (PDF)
- LA.PHAR.235 Atezolizumab (Tecentriq) (PDF)
- LA.PHAR.258 Mitoxantrone (PDF)
- LA.PHAR.260 Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela) (PDF)
- LA.PHAR.270 Paricalcitol Injection (PDF)
- LA.PHAR.282 Parathyroid Hormone Natpara (PDF)
- LA.PHAR.300 Bezlotoxumab (PDF)
- LA.PHAR.301 Erwinia Asparaginase (Erwinaze) (PDF)
- LA.PHAR.303 Brentuximab (PDF)
- LA.PHAR.304 irinotecan Liposome (PDF)
- LA.PHAR.305 Obinutuzumab (Gazyva) (PDF)
- LA.PHAR.306 Ofatumumab Arzerra (PDF)
- LA.PHAR.307 Bendamustine (Belrapzo, Bendeka, Treanda, Vivimusta) (PDF)
- LA.PHAR.308 Elotuzumab (PDF)
- LA.PHAR.309 Carfilzomib (PDF)
- LA.PHAR.310 Daratumumab Daratumumab-Hyaluronidase-fihj (Darzalex, Darzalex, Faspro) (PDF)
- LA.PHAR.311 belinostat (PDF)
- LA.PHAR.312 Blinatumomab (PDF)
- LA.PHAR.313 Pralatrexate (Folotyn) (PDF)
- LA.PHAR.314 Romidepsin (Istodax) (PDF)
- LA.PHAR.315 Vincristine Liposome (Marqibo) (PDF)
- LA.PHAR.316 Cabazitaxel (Jevtana) (PDF)
- LA.PHAR.317 Cetuximab (PDF)
- LA.PHAR.318 Eribulin Mesylate (Halaven) (PDF)
- LA.PHAR.319 Ipilimumab (Yervoy) (PDF)
- LA.PHAR.320 Necitumumab (Portrazza) (PDF)
- LA.PHAR.321 Panitumumab (PDF)
- LA.PHAR.322 Pembrolizumab (PDF)
- LA.PHAR.323 Plerixafor (Mozobil) (PDF)
- LA.PHAR.324 Temsirolimus (Torisel) (PDF)
- LA.PHAR.325 Ziv-aflibercept (Zaltrap) (PDF)
- LA.PHAR.328 Asfotase Alfa (Strensiq) (PDF)
- LA.PHAR.329 Siltuximab (Sylvant) (PDF)
- LA.PHAR.330 Protein C Concentrate, Human (Ceprotin) (PDF)
- LA.PHAR.332 Pasireotide (Signifor. Signifor LAR) (PDF)
- LA.PHAR.333 Avelumab (Bavencio) (PDF)
- LA.PHAR.338 Cerliponase Alfa (Brineura) (PDF)
- LA.PHAR.339 Durvalumab (PDF)
- LA.PHAR.343 Edaravone (Radicava) (PDF)
- LA.PHAR.351 Daptomycin (PDF)
- LA.PHAR.352 Daunorubicin cytarabine (Vyxeos) (PDF)
- LA.PHAR.353 Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas)(PDF)
- LA.PHAR.357 Copanlisib (Aliqopa) (PDF)
- LA.PHAR.358 Gemtuzumab (Mylotarg) (PDF)
- LA.PHAR.359 Inotuzumab Ozogamicin (Besponsa) (PDF)
- LA.PHAR.361 Tisagenlecleucel (Kymriah) (PDF)
- LA.PHAR.362 Axicabtagene ciloleucel (PDF)
- LA.PHAR.367 Letermovir (PDF)
- LA.PHAR.368 Pemetrexed (Alimta) (PDF)
- LA.PHAR.371 Triamcinolone ER Injectable (PDF)
- LA.PHAR.372 Voretigene neparvovec-rzyl (PDF)
- LA.PHAR.379 Etelcalcetide (Parsabiv) (PDF)
- LA.PHAR.384 Lutetium Lu 177 Dotatate (Lutathera) (PDF)
- LA.PHAR.387 Azacitidine (Vidaza) (PDF)
- LA.PHAR.388 Chloramphenicol Sodium Succinate (PDF)
- LA.PHAR.389 Pegvisomant (Somavert) (PDF)
- LA.PHAR.391 Lanreotide (Somatuline Depot) (PDF)
- LA.PHAR.393 Leucovorin Injection (PDF)
- LA.PHAR.395 Patisiran (Onpattro) (PDF)
- LA.PHAR.397 Cemiplimab-rwlc (Libtayo) (PDF)
- LA.PHAR.398 Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF)
- LA.PHAR.402 Emapalumab-Izsg (Gamifant) (PDF)
- LA.PHAR.405 Inotersen (Tegsedi) (PDF)
- LA.PHAR.410 Bortezomib (Velcade) (PDF)
- LA.PHAR.415 Ravulizumab-cwvz (Ultomiris) (PDF)
- LA.PHAR.418 Dexrazoxane (Zinecard, Totect) (PDF)
- LA.PHAR.419 Elapegademase-lvlr (Revcovi) (PDF)
- LA.PHAR.425 Metreleptin Myalept (PDF)
- LA.PHAR.433 Polatuzumab Vedotin-piiq (Polivy) (PDF)
- LA.PHAR.434 Bremelanotide Vyleesi (PDF)
- LA.PHAR.439 Valrubicin Valstar (PDF)
- LA.PHAR.444 Afamelanotide Scenesse (PDF)
- LA.PHAR.445 Brolucizumab Beovu (PDF)
- LA.PHAR.455 Enfortumab Vedotin-ejfv (Padcev) (PDF)
- LA.PHAR.456 Fam-trastuzumab deruxtecan-nxki (Enhertu) (PDF)
- LA.PHAR.459 Lobenguane I 131 Azedra (PDF)
- LA.PHAR.461 Nadofaragene Firadenovec Vncg Adstiladrin (PDF)
- LA.PHAR.465 Teprotumumab (Tepezza) (PDF)
- LA.PHAR.469 Belantamab Mafodotin Blenrep (PDF)
- LA.PHAR.472 Brexucabtagene autoleucel Tecartus (PDF)
- LA.PHAR.475 Sacituzumab govitecan-hziy (Trodelvy) (PDF)
- LA.PHAR.480 Ferric Derisomaltose Monoferric (PDF)
- LA.PHAR.481 Idecabtagene vicleucel Abecma (PDF)
- LA.PHAR.482 Isatuximab ifc Sarclisa (PDF)
- LA.PHAR.483 Lisocabtagene maraleucel Breyanzi (PDF)
- LA.PHAR.495 Mitomycin Pyelocalyceal Solution (PDF)
- LA.PHAR.500 Lurbinectedin (PDF)
- LA.PHAR.501 Pertuzumab trastuzumab hyaluronidase (PDF)
- LA.PHAR.503 Sutimlimab-jome (Enjaymo) (PDF)
- LA.PHAR.506 Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF)
- LA.PHAR.508 Tafasitamab (PDF)
- LA.PHAR.512 Pegunigalsidase alfa-iwxj (PDF)
- LA.PHAR.513 Plasminogen (PDF)
- LA.PHAR.521 Avalglucosidase (PDF)
- LA.PHAR.522 Margetuximab (PDF)
- LA.PHAR.523 Naxitamab (PDF)
- LA.PHAR.524 Pegcetacoplan (PDF)
- LA.PHAR.526 Fibrinogen concentrate (PDF)
- LA.PHAR.533 Citacabtagene Autoleucel (PDF)
- LA.PHAR.535 Melphalan (PDF)
- LA.PHAR.536 Ophthalmic Riboflavin (PDF)
- LA.PHAR.539 Loncastuximab (PDF)
- LA.PHAR.540 Dostarlimab (PDF)
- LA.PHAR.542 Talimogene (PDF)
- LA.PHAR.544 Amivantamab (PDF)
- LA.PHAR.550 Vutrisiran (PDF)
- LA.PHAR.555 Efgartigimod-alfa-fcab (Vyvgart) (PDF)
- LA.PHAR.561 Tisotumab (PDF)
- LA.PHAR.563 Allogenic (PDF)
- LA.PHAR.564 Antithrombin III (PDF)
- LA.PHAR.567 Cipaglucosidase alfa ATGA Miglustat (Pombiliti-Opfolda) (PDF)
- LA.PHAR.570 Ropeginterferon (PDF)
- LA.PHAR.574 Sirolimus Protein-Bound Particles (PDF)
- LA.PHAR.575 Tebentafusp (PDF)
- LA.PHAR.581 Faricimab (Vabysmo) (PDF)
- LA.PHAR.582 Lutetium Lu 177 (PDF)
- LA.PHAR.584 Sodium Phenylbutyrate-Taurursodiol (PDF)
- LA.PHAR.586 Olipudase (PDF)
- LA.PHAR.588 Nivolumab and Ralatlimab (Opdualag) (PDF)
- LA.PHAR.591 Tofersen (Qalsody) (PDF)
- LA.PHAR.598 Lifileucel (Amtagvi) (PDF)
- LA.PHAR.600 Trofinetide (NNZ-2566) (PDF)
- LA.PHAR.601 Velmanase Alfa-tycv (PDF)
- LA.PHAR.608 Furosemide (PDF)
- LA.PHAR.610 Sodiumthiosulfate (PDF)
- LA.PHAR.611 Teclistamab (PDF)
- LA.PHAR.612 Tremelimumab (PDF)
- LA.PHAR.613 Fecal Microbiota, Live-JSLM (PDF)
- LA.PHAR.616 Zilucoplan (PDF)
- LA.PHAR.617 Mirvetuximab Soravtasine-GYNX (PDF)
- LA.PHAR.618 Mosunetuzumab-AXGB (PDF)
- LA.PHAR.626 Pozelimab-bbfg (Veopoz) (PDF)
- LA.PHAR.633 Eplontersen (Wainua) (PDF)
- LA.PHAR.634 Epcoritamab-bysp (Epkinly) (PDF)
- LA.PHAR.635 ADAMTS13, Recombiant KRHN (Adzynma)(PDF)
- LA.PHAR.636 Glofitamab-gxbm (Columvi) (PDF)
- LA.PHAR.641 Avacincaptad pegol (Izervay) (PDF)
- LA.PHAR.648 Rozanolixizumab-noli (Rystiggo) (PDF)
- LA.PHAR.649 Talquetamab-tgvs (Talvey)(PDF)
- LA.PHAR.651 DaxibotulinumtoxinA-lanm (Daxxify) (PDF)
- LA.PHAR.652 Elranatamab-bcmm (Elrexfio)(PDF)
- LA.PHAR.653 Melphalan (Hepzato)(PDF)
- LA.PHAR.655 Motixafortide (Aphexda)(PDF)
- LA.PHAR.656 Iptacopan (Fabhalta) (PDF)
- LA.PHAR.668 Toripalimab (Loqtorzi) (PDF)
- LA.PHAR.676 Aprocitentan (Tryvio) (PDF)
- LA.PHAR.677 Vadadustat (Vafseo) (PDF)
- LA.PMN.53 Off-Label Use (PDF)
- LA.PMN.177 Glycopyrronium (Qbrexza) (PDF)
- LA.PMN.255 No Coverage Criteria (PDF)
Use the Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations) (PDF) to find more information on the drugs that are covered by Medicaid.
For pharmacy or prescription questions, call Prime Therapeutics State Government Solutions at 1-800-424-1664 (TTY: 711) or visit www.lamcopbmpharmacy.com.
- 25-hydroxyvitamin D Testing in Children and Adolescents (CP.MP.157) (PDF)
- Acupuncture (CP.MP.92) (PDF)
- ADHD (CP.BH.124) (PDF)
- Air Ambulance (CP.MP.175) (PDF)
- Allergy Testing (CP.MP.100) (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia (CP.MP.108) (PDF)
- Applied Behavior Analysis (CP.BH.104) (PDF)
- Applied Behavior Analysis Documentation Requirements (CP.BH.105) (PDF)
- Articular Cartilage Defect Repairs (CP.MP.26) (PDF)
- Behavioral Health Treatment Documentation Requirements (HIM.CP.BH.500) (PDF)
- Biofeedback (CP.MP.168) (PDF)
- Biofeedback for Behavioral Health Disorders (CP.BH.300) (PDF)
- Bone-Anchored Hearing Aid (CP.MP.93) (PDF)
- Bronchial Thermoplasty (CP.MP.110) (PDF)
- Burn Surgery (CP.MP.186) (PDF)
- Cardiac Biomarker (CP.MP.156) (PDF)
- Caudal or Interlaminar Epidural Steroid Injection (CP.MP.164) (PDF)
- CG Aortopathies Connective Tissue (V2.2024) (PDF)
- CG Cardiac Disorders (V2.2024) (PDF)
- CG Dermatologic Conditions (V2.2024) (PDF)
- CG Epilepsy Neurodegenerative and Neuromuscular Disorders (V2.2024) (PDF)
- CG Exome Genome Sequencing (V2.2024) (PDF)
- CG Eye Disorders (V2.2024) (PDF)
- CG Gastroenterologic Disorders Non-Cancerous (V2.2024) (PDF)
- CG General Approach to Genetic and Molecular Testing (V2.2024) (PDF)
- CG Hearing Loss (V2.2024) (PDF)
- CG Hematologic Conditions Non-Cancerous (V2.2024) (PDF)
- CG Hereditary Cancer Susceptibility (V2.2024) (PDF)
- CG Immune, Autoimmune, and Rheumatoid Disorders (V2.2024) (PDF)
- CG Kidney Disorders (V2.2024) (PDF)
- CG Lung Disorders (V2.2024) (PDF)
- CG Metabolic, Endocrine and Mitochondrial Disorders (V2.2024) (PDF)
- CG Multisystem Inherited Disorders, ID and Developmental Delay (V2.2024) (PDF)
- CG Non-invasive Prenatal Screening (V2.2024) (PDF)
- CG Oncology Algorithmic Testing (V2.2024) (PDF)
- CG Oncology Cancer Screening (V2.2024) (PDF)
- CG Oncology Circ Tumor DNA Tumor Cells Liquid Biopsy (V2.2024) (PDF)
- CG Oncology Cytogenetic Testing (V2.2024) (PDF)
- CG Oncology Molecular Analysis of Solid Tumor and Hem Malignancies (V2.2024) (PDF)
- CG Pharmacogenetics (V2.2024) (PDF)
- CG Preimplantation Genetic Testing (V2.2024) (PDF)
- CG Prenatal and Preconception Carrier Screening (V2.2024) (PDF)
- CG Prenatal Dx of Amnio CVS or PUBS and Pregnancy Loss (V2.2024) (PDF)
- CG Skeletal Dysplasia and Rare Bone Disorders (V2.2024) (PDF)
- Clinical Trials (CP.MP.94) (PDF)
- Cochlear Implant Replacements (CP.MP.14) (PDF)
- Cosmetic and Reconstructive (CP.MP.31) (PDF)
- CPG Grid (CPG Grid) (PDF)
- Deep TMS for OCD (CP.BH.201) (PDF)
- Diaphragmatic/Phrenic Nerve Stimulation (CP.MP.203) (PDF)
- Digital Electroencephalography Spike Analysis (CP.MP.105) (PDF)
- Disc Decompression (CP.MP.114) (PDF)
- Discography (CP.MP.115) (PDF)
- Donor Lymphocyte Infusion (CP.MP.101) (PDF)
- Drugs of Abuse: Definitive Drug Testing (CP.MP.50) (PDF)
- Durable Medical Equipment (DME) (CP.MP.107) (PDF)
- Electric Tumor Treating Fields (CP.MP.145) (PDF)
- Electroencephalography in the Evaluation of Headache (CP.MP.155) (PDF)
- Endometrial Ablation (CP.MP.106) (PDF)
- Evoked Potentials (CP.MP.134 ) (PDF)
- Experimental Technologies (CP.MP.36) (PDF)
- Facet Joint Interventions (CP.MP.171) (PDF)
- Facility Based Sleep Studies for Obstructive Sleep Apnea (CP.MP.248) (PDF)
- Fecal Incontinence Treatments (CP.MP.137) (PDF)
- Fertility Preservation (CP.MP.130) (PDF)
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (CP.MP.129) (PDF)
- Functional MRI (CP.MP.43) (PDF)
- Gastric Electrical Stimulation (CP.MP.40) (PDF)
- GI Pathogen Nucleic Acid Detection Panel Testing (CP.MP.209) (PDF)
- H. Pylori Serology Testing (CP.MP.153) (PDF)
- Heart-Lung Transplant (CP.MP.132) (PDF)
- Holter Monitors (CP.MP.113) (PDF)
- Home Birth (CP.MP.136) (PDF)
- Home Ventilators (CP.MP.184) (PDF)
- Homocysteine Testing (CP.MP.121) (PDF)
- Hospice Services (CP.MP.54) (PDF)
- Hyperhidrosis Treatments (CP.MP.62) (PDF)
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (CP.MP.180) (PDF)
- Implantable Intrathecal or Pain Pump (CP.MP.173) (PDF)
- Implantable Loop Recorder (CP.MP.243) (PDF)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (CP.MP.160) (PDF)
- Intensity-Modulated Radiotherapy (CP.MP.69) (PDF)
- Intradiscal Steroid Injections for Pain Management (CP.MP.167) (PDF)
- IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (CP.MP.61) (PDF)
- Lantidra (donislecel) Allogenic Pancreatic Islet Cellular Therapy (CP.MP.250) (PDF)
- Laser Therapy for Skin Conditions (CP.MP.123) (PDF)
- Liposuction for Lipedema (CP.MP.244) (PDF)
- Long Term Care Placement Criteria (CP.MP.71) (PDF)
- Low-frequency Ultrasound and Noncontact Wound Therapy (CP.MP.139) (PDF)
- Lung Transplantation (CP.MP.57) (PDF)
- Lysis of Epidural Lesions (CP.MP.116) (PDF)
- Measurement of Serum 1,25-dihydroxyvitamin D (CP.MP.152) (PDF)
- Mechanical Stretching Devices (CP.MP.144) (PDF)
- Multiple Sleep Latency Testing (CP.MP.24) (PDF)
- Neonatal Abstinence Syndrome Guidelines (CP.MP.86) (PDF)
- Neonatal Sepsis Management (CP.MP.85) (PDF)
- Nerve Blocks and Neurolysis for Pain Management (CP.MP.170) (PDF)
- Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES (CP.MP.48) (PDF)
- NICU Apnea Bradycardia (CP.MP.82) (PDF)
- NICU Discharge Guidelines (CP.MP.81) (PDF)
- Non-Myeloablative Allogeneic Stem Cell Transplants (CP.MP.141) (PDF)
- OB Home Health Programs (CP.MP.91) (PDF)
- Omisirge (omidubicel) (CP.MP.249) (PDF)
- Orthognathic Surgery (CP.MP.202) (PDF)
- Osteogenic Stimulation (CP.MP.194) (PDF)
- Outpatient Cardiac Rehabilitation (CP.MP.176) (PDF)
- Oxygen Use and Concentrators ( Title change to Outpatient Oxygen Use) (CP.MP.190) (PDF)
- Pancreas Transplantation (CP.MP.102) (PDF)
- Panniculectomy (CP.MP.109) (PDF)
- Pediatric Heart Transplant (CP.MP.138 ) (PDF)
- Pediatric Kidney Transplant (CP.MP.246) (PDF)
- Pediatric Liver Transplant (CP.MP.120) (PDF)
- Pediatric Oral Function Therapy (CP.MP.188) (PDF)
- Percutaneous Left Atrial Appendage Closure for Stroke Prevention (CP.MP.147) (PDF)
- Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150) (PDF)
- Physical, Occupational, and Speech Therapy Services (CP.MP.49) (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (CP.MP.133) (PDF)
- Proton and Neutron Beam Therapies (CP.MP.70) (PDF)
- Pulmonary Function Testing (CP.MP.242) (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF)
- Repair of Nasal Valve Compromise (CP.MP.210) (PDF)
- Respiratory PCR Testing (CP.MP.181) (PDF)
- Sacroiliac Joint Fusion (CP.MP.126) (PDF)
- Sacroiliac Joint Interventions for Pain Management (CP.MP.166) (PDF)
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Disorders (CP.MP.146) (PDF)
- Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (CP.MP.174) (PDF)
- Selective Nerve Root Blocks and Transforaminal Epidural Injections (CP.MP.165) (PDF)
- Skin Substitutes for Chronic Wounds (CP.MP.185) (PDF)
- Spinal Cord Stimulation (CP.MP.117) (PDF)
- Stereotactic Body Radiation Therapy (CP.MP.22) (PDF)
- Tandem Transplant (CP.MP.162) (PDF)
- Testing for Select Genitourinary Conditions (CP.MP.97) (PDF)
- Therapeutic Utilization of Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Thyroid Hormones and Insulin Testing in Pediatrics (CP.MP.154) (PDF)
- TMS for Treatment Resistant MDD (CP.BH.200) (PDF)
- Total Artificial Heart (CP.MP.127) (PDF)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (CP.MP.163) (PDF)
- Transcatheter Closure of Patent Foramen Ovale (CP.MP.151) (PDF)
- Transplant Service Documentation Requirements (CP.MP.247) (PDF)
- Trigger Point Injections for Pain Management (CP.MP.169) (PDF)
- Ultrasound in Pregnancy (CP.MP.38) (PDF)
- Urinary Incontinence Devices and Treatments (CP.MP.142) (PDF)
- Urodynamic Testing (CP.MP.98) (PDF)
- Vagus Nerve Stimulation (CP.MP.12) (PDF)
- Ventricular Assist Devices (CP.MP.46) (PDF)
- Wheelchair Seating (CP.MP.99) (PDF)
- Wireless Motility Capsule (CP.MP.143) (PDF)
- Abaloparatide (Tymlos) CP.PHAR.345 (PDF)
- Abemaciclib (Verzenio) CP.PHAR.355 (PDF)
- Abiraterone (Zytiga, Yonsa) CP.PHAR.84 (PDF)
- AbobotulinumtoxinA (Dysport) CP.PHAR.230 (PDF)
- Abrocitinib (Cibinqo) CP.PHAR.578 (PDF)
- Acyclovir Buccal Tablet (Sitavig) CP.PMN.210 (PDF)
- Adagrasib (Krazati) CP.PHAR.605 (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)
- Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) CP.PHAR.562 (PDF)
- Allogenic Processed Thymus Tissue-agdc (Rethymic) CP.PHAR.563 (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)
- Antithrombin III (ATryn, Thrombate III) CP.PHAR.564 (PDF)
- Antithymocyte Globulin (Atgam, Thymoglobulin) CP.PHAR.506 (PDF)
- Apalutamide (Erleada) CP.PCH.45 (PDF)
- Apomorphine (Apokyn, Kynmobi) CP.PHAR.488 (PDF)
- Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) CP.PMN.19 (PDF)
- Aprocitentan (Tryvio) CP.PHAR.676 (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)
- Asciminib (Scemblix) CP.PHAR.565 (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)
- Axatilimab-csfr (Niktimvo) CP.PHAR.691 (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)
- Berdazimer (Zelsuvmi) CP.PMN.293 (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)
- Birch Triterpenes (Filsuvez) CP.PHAR.669 (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.PMN.297 (PDF)
- Brolucizumab-dbll (Beovu) CP.PHAR.445 (PDF)
- Budesonide (Eohilia, Uceris) CP.PMN.294 (PDF)
- Budesonide (Tarpeyo) CP.PHAR.572 (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)
- Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) CP.PHAR.573 (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)
- Capivasertib (Truqap) CP.PHAR.663 (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.PMN.280 (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)
- Daprodustat (Jesduvroq) CP.PHAR.628 (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)
- Denileukin Diftitox-cxdl (Lymphir) CP.PHAR.693 (PDF)
- Denosumab (Prolia, Xgeva) CP.PHAR.58 (PDF)
- Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) CP.PHAR.214 (PDF)
- Deutetrabenazine (Austedo) CP.PCH.42 (PDF)
- Dexrazoxane (Zinecard, Totect) CP.PHAR.418 (PDF)
- Dextromethorphan/Bupropion (Auvelity) CP.PMN.284 (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) HIM.PA.SP69 (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)
- Eflornithine (Iwilfin) CP.PHAR.670 (PDF)
- Elacestrant (Orserdu) CP.PHAR.623 (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)
- Epcoritamab-bysp (Epkinly) CP.PHAR.634 (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) HIM.PA.166 (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)
- Faricimab-svoa (Vabysmo) CP.PHAR.581 (PDF)
- Febuxostat (Uloric) CP.PMN.57 (PDF)
- Fecal Microbiota, Live-jslm (Rebyota) CP.PHAR.613 (PDF)
- Fecal Microbiota Spores, Live-brpk (Vowst) CP.PHAR.632 (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)
- Ferric Pyrophosphate (Triferic, Triferic Avnu) CP.PHAR.624 (PDF)
- Ferumoxytol (Feraheme) CP.PHAR.165 (PDF)
- Fezolinetant (Veozah) CP.PMN.289 (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)
- Fruquintinib (Fruzaqla) CP.PHAR.666 (PDF)
- Fulvestrant (Faslodex Injection) CP.PHAR.424 (PDF)
- Furosemide (Furoscix) CP.PHAR.608 (PDF)
- Futibatinib (Lytgobi) CP.PHAR.604 (PDF)
- Gabapentin ER (Gralise, Horizant) CP.PMN.240 (PDF)
- Galcanezumab-gnlm (Emgality) HIM.PA.SP67 (PDF)
- Galsulfase (Naglazyme) CP.PHAR.161 (PDF)
- Ganaxolone (Ztalmy) CP.PMN.278 (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)
- Glaucoma Agents CP.PMN.286 (PDF)
- Glecaprevir/Pibrentasvir (Mavyret) HIM.PA.SP36 (PDF)
- Glofitamab-gxbm (Columvi) CP.PHAR.636 (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)
- 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)
- Inavolisib (Itovebi) CP.PHAR.702 (PDF)
- IncobotulinumtoxinA (Xeomin) CP.PHAR.231 (PDF)
- Inclisiran (Leqvio) CP.PHAR.568 (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.PCH.46 (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)
- 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)
- Lazertinib (Lazcluze) CP.PHAR.695 (PDF)
- Ledipasvir/Sofosbuvir (Harvoni) HIM.PA.SP3 (PDF)
- Lefamulin (Xenleta) CP.PMN.219 (PDF)
- Lenacapavir (Sunlenca) CP.PHAR.622 (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, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi) CP.PCH.53 (PDF)
- Levodopa Inhalation Powder (Inbrija) CP.PMN.267 (PDF)
- Levoketoconazole (Recorlev) CP.PMN.275 (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)
- 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)
- Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) CP.PHAR.582 (PDF)
- Macitentan (Opsumit) CP.PCH.31 (PDF)
- Maralixibat (Livmarli) CP.PHAR.543 (PDF)
- Margetuximab-cmkb (Margenza) CP.PHAR.522 (PDF)
- Maribavir (Livtencity) CP.PMN.271 (PDF)
- Mavacamten (MYK-461) CP.PMN.272 (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)
- Mirvetuximab soravatansine-gynx (Elahere) CP.PHAR.617 (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)
- Mosunetuzumab-axgb (Lunsumio) CP.PHAR.618 (PDF)
- Moxetumomab pasudotox-tdfk (Lumoxiti) CP.PHAR.398 (PDF)
- Nabumetone Double-Strength (Relafen DS) CP.PMN.287 (PDF)
- Nafarelin Acetate (Synarel) CP.PHAR.174 (PDF)
- Nalmefene (Opvee) CP.PHAR.638 (PDF)
- Naltrexone (Vivitrol) CP.PHAR.96 (PDF)
- Naloxegol (Movantik) HIM.PA.167 (PDF)
- Naproxen Oral Suspension (Naprosyn) HIM.PA.130 (PDF)
- Naproxen/Esomeprazole (Vimovo) CP.PMN.117 (PDF)
- Naxitamab-gqgk (Danyelza) CP.PHAR.523 (PDF)
- Necitumumab (Portrazza) CP.PHAR.320 (PDF)
- Nemolizumab-ilto (Nemluvio) CP.PHAR.703 (PDF)
- Neomycin/Fluocinolone Cream (Neo-Synalar) CP.PMN.167 (PDF)
- Neratinib (Nerlynx) CP.PHAR.365 (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)
- Nirmatrelvir and Ritonavir (Paxlovid) CP.PMN.288 (PDF)
- Nirogacestat (Ogsiveo) CP.PHAR.671 (PDF)
- Nitazoxanide (Alinia) HIM.PA.152 (PDF)
- Nitisinone (Nityr, Orfadin) CP.PHAR.132 (PDF)
- Nivolumab and Relatlimab-rmbw (Opdualag) CP.PHAR.588 (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)
- Olutasidenib (Rezlidhia) CP.PHAR.615 (PDF)
- Omacetaxine (Synribo) CP.PHAR.108 (PDF)
- Omadacycline (Nuzyra) CP.PMN.188 (PDF)
- Omalizumab (Xolair) CP.PCH.49 (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)
- Pacritinib (Vonjo) CP.PHAR.583 (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)
- Palopegteriparatide (Yorvipath) CP.PHAR.696 (PDF)
- Pancrelipase (Creon, Pancreaze, Pertyze, Viokace, Zenpep) CP.PCH.44 (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)
- 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)
- Perfluorohexyloctane (Miebo) CP.PMN.290 (PDF)
- Pertuzumab (Perjeta) CP.PHAR.227 (PDF)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) CP.PHAR.501 (PDF)
- Pexidartinib (Turalio) CP.PHAR.436 (PDF)
- Phendimetrazine CP.PCH.47 (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)
- Pirtobrutinib (Jaypirca) CP.PHAR.620 (PDF)
- Pitolisant (Wakix) CP.PMN.221 (PDF)
- Plasminogen, human-tvmh (Ryplazim) CP.PHAR.513 (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.PCH.51 (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)
- Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel) HIM.PA.168 (PDF)
- Repotrectinib (Augtyro) CP.PHAR.667 (PDF)
- Reslizumab (Cinqair) CP.PHAR.223 (PDF)
- Retifanlimab-dlwr (Zynyz) CP.PHAR.629 (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)
- Ropeginterferon Alfa-2b-njft (BESREMi) CP.PHAR.570 (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)
- Seladelpar (Livdelzi) CP.PHAR.698 (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)
- Semaglutide (Wegovy) CP.PMN.295 (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)
- Sirolimus Protein-Bound Particles (Fyarro) CP.PHAR.574 (PDF)
- Sodium thiosulfate (Pedmark) CP.PHAR.610 (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)
- Sparsentan (Filspari) CP.PHAR.631 (PDF)
- Spesolimab-sbzo (Spevigo) CP.PHAR.606 (PDF)
- Spinosad (Natroba) HIM.PA.134 (PDF)
- Step Therapy HIM.PA.109 (PDF)
- Stiripentol (Diacomit) CP.PMN.184 (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)
- Tebentafusp-tebn (Kimmtrak) CP.PHAR.575 (NEW)
- Teclistamab-cqyv (Tecvayli) CP.PHAR.611 (PDF)
- Tedizolid (Sivextro) CP.PMN.62 (PDF)
- Teduglutide (Gattex) CP.PHAR.114 (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)
- Tezepelumab-ekko (Tezspire) CP.PHAR.576 (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)
- Tiopronin Delayed-Release (Thiola EC) CP.PCH.50 (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)
- Topiramate Extended-Release (Qudexy XR, Trokendi XR) CP.PMN.281 (PDF)
- Topotecan (Hycamtin) CP.PHAR.64 (PDF)
- Toripalimab-tpzi (Loqtorzi) CP.PHAR.668 (PDF)
- Trabectedin (Yondelis) CP.PHAR.204 (PDF)
- Tralokinumab-ldrm (Adbry) CP.PHAR.577 (PDF)
- Trametinib (Mekinist) CP.PHAR.240 (PDF)
- Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase CP.PHAR.228 (PDF)
- Travoprost Implant (iDose TR) CP.PHAR.672 (PDF)
- Tremelimumab-actl (Imjudo) CP.PHAR.612 (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)
- Ublituximab-xiiy (Briumvi) CP.PHAR.621 (PDF)
- Ubrogepant (Ubrelvy) CP.PHAR.476 (PDF)
- Ulcer Therapy Combinations CP.PMN.277 (PDF)
- Umbralisib (Ukoniq) CP.PHAR.531 (PDF)
- Uridine Triacetate (Vistogard) HIM.PA.SP55 (PDF)
- Vadadustat (Vafseo) CP.PHAR.677 (PDF)
- Valbenazine (Ingrezza) CP.PCH.48 (PDF)
- Valganciclovir (Valcyte) CP.PCH.06 (PDF)
- Valoctocogene Roxaparvovec CP.PHAR.466 (PDF)
- Valrubicin (Valstar) CP.PHAR.439 (PDF)
- Vamorolone (Agamree) CP.PHAR.659 (PDF)
- Vandetanib (Caprelsa) CP.PHAR.80 (PDF)
- Varenicline (Tyrvaya) CP.PMN.273 (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)
- Vismodegib (Erivedge) CP.PHAR.273 (PDF)
- Voclosporin (Lupkynis) CP.PHAR.504 (PDF)
- Vorapaxar (Zontivity) HIM.PA.146 (PDF)
- Vorasidenib (Voranigo) CP.PHAR.699 (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)
- Zavegepant (Zavzpret) CP.PHAR.630 (PDF)
- Ziv-aflibercept (Zaltrap) CP.PHAR.325 (PDF)
- Zoledronic Acid (Reclast, Zometa) CP.PHAR.59 (PDF)
Payment Policies
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All policies found in the Louisiana Healthcare Connections Payment Policy Manual apply with respect to Louisiana Healthcare Connections members. Policies in the Louisiana Healthcare Connections Payment Policy Manual may have either a Louisiana Healthcare Connections or a “Centene” heading. In addition, Louisiana Healthcare Connections may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Louisiana Healthcare Connections.
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- LA.PP.007 Maximum Units of Service (PDF)
- LA.PP.009 Unlisted Procedure Codes (PDF)
- LA.PP.010 EM Bundling with Labs and Radiology (PDF)
- LA.PP.011 Coding Editing Overview (PDF)
- LA.PP.012 IV Hydration (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 Professional Services Billed with Labs (PDF)
- LA.PP.020 Distinct Procedural Modifiers (PDF)
- LA.PP.021 Clean Claims (PDF)
- LA.PP.023 Hospital Visit Codes Billed with Labs (PDF)
- LA.PP.024 Cosmetic Procedures (PDF)
- LA.PP.025 Pulse Oximetry with Office Visits (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)
- LA.PP.032 Supplies Billed on Same Day As Surgery (PDF)
- LA.PP.033 Multiple CPT Code Replacement (PDF)
- LA.PP.034 Modifier DOS Validation (PDF)
- LA.PP.035 Sleep Studies Place of Services (PDF)
- LA.PP.036 New Patient (PDF)
- LA.PP.037 Bilateral Procedures (PDF)
- LA.PP.038 Inpatient Consultation (PDF)
- LA.PP.039 Outpatient Consultation (PDF)
- LA.PP.040 Same Day Visits (PDF)
- LA.PP.041 Pre-Operative Visits (PDF)
- LA.PP.042 Post-Operative Visits (PDF)
- LA.PP.043 Unbundled Professional Services (PDF)
- LA.PP.044 Duplicate Primary Code Billing (PDF)
- LA.PP.045 Unbundled Surgical Procedures (PDF)
- LA.PP.046 Status "B" Bundled Services (PDF)
- LA.PP.047 Transgender Related Services (PDF)
- LA.PP.049 Status "P" Bundled Services (PDF)
- LA.PP.051 E&M Medical Decision-Making (PDF)
- LA.PP.056 Urine Specimen Validity Testing (PDF)
- LA.PP.060 Not Medically Necessary Inpatient Professional Services (PDF)
- LA.PP.063 Place of Service Mismatch (PDF)
- LA.PP.067 Renal Hemodialysis (PDF)
- LA.PP.071 E and M Services Billing with Treatment Room Revenue Codes (PDF)
- LA.PP.499c Vitamin D Testing Policy (PDF)
- LA.PP.500c 24 Hour Payment Window (PDF)
- LA.PP.501c CLIA Editing (PDF)
- LA.PP.502c Genetic and Molecular Testing (PDF)
- CC.PI.04 Clean Claim Reviews (PDF)
- CC.PI.06 Cost to Charge Adjustments on Clean Claim Reviews (PDF)
- CC.PI.10 Unbundling Adjustments on Clean Claim Reviews (PDF)
- CC.PP.035 Sleep Studies Place of Service (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.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.065 Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (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)
- CC.PI.04 Clean Claim Reviews (PDF)
- CC.PI.06 Cost to Charge Adjustments on Clean Claim Reviews (PDF)
- CC.PI.10 Unbundling Adjustments on Clean Claim Reviews (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.206 Skilled Nursing Facility Leveling (PDF)
- CC.PP.500 3 Day Payment Window (PDF)
- CC.PP.501 30 Day Readmission (PDF)
- CC.PP.502 Wheelchair Accessories (PDF)
- MC.CP.MP.106 Endometrial Ablation (PDF)
- OC.UM.CP.0026 Extended Ophthalmoscopy (PDF)
- OC.UM.CP.0043 External Ocular Photography (PDF)