Skip to Main Content

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 Western Sky Community Care Clinical Policy Manual apply to Western Sky Community Care members. Policies in the Western Sky Community Care Clinical Policy Manual may have either a Western Sky Community Care or a “Centene” heading.  Western Sky Community Care utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Western Sky Community Care 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 Western Sky Community Care. In addition, Western Sky Community Care 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 Western Sky Community Care.   

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

 

Policy Number

Policy Title

CP.MP.15725-hydroxyvitamin D Testing in Children and Adolescents (PDF)
CP.MP.92Acupuncture (PDF)
CPG GridAdopted Clinical Practice and Preventive Health Guidelines (PDF)
CP.MP.175Air Ambulance (PDF)
CP.MP.100Allergy Testing and Therapy (PDF)

CP.MP.108

Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF)

CP.MP.158Ambulatory Surgery Center Optimization (PDF)
CP.BH.104Applied Behavior Analysis (PDF)
CP.BH.105Applied Behavioral Analysis Documentation Requirements (PDF)
CP.MP.26Articular Cartilage Defect Repairs (PDF)

CP.MP.55

Assisted Reproductive Technology (PDF)

CP.BH.124Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF)
CP.MP.37Bariatric Surgery (PDF)

CP.MP.168

Biofeedback (PDF)

CP.MP.93Bone-Anchored Hearing Aid (PDF)

CP.MP.110

Bronchial Thermoplasty (PDF)

CP.MP.186

Burn Surgery (PDF)

CP.MP.156Cardiac Biomarker Testing (PDF)
CP.MP.164Caudal or Interlaminar Epidural Steroid Injections (PDF)
CP.MP.94Clinical Trials (PDF)
CP.MP.14Cochlear Implant Replacements (PDF)
V1.2024Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)
V1.2024
Concert Genetic Testing: Cardiac Disorders (PDF)
V1.2024
Concert Genetic Testing: Dermatologic Conditions (PDF)
V1.2024
Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF)
V1.2024
Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)
V1.2024
Concert Genetic Testing: Eye Disorders (PDF)
V1.2024
Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (PDF)
V1.2024
Concert Genetic Testing: General Approach to Genetic Testing and Molecular Testing (PDF)
V1.2024
Concert Genetic Testing: Hearing Loss (PDF)
V1.2024
Concert Genetic Testing: Hematologic Conditions (non-cancerous) (PDF)
V1.2024
Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF)
V1.2024
Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)
V1.2024
Concert Genetic Testing: Kidney Disorders (PDF)
V1.2024
Concert Genetic Testing: Lung Disorders (PDF)
V1.2024
Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)
V1.2024
Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)
V1.2024
Concert Genetic Testing: Non-invasive Prenatal Screening (NIPS) (PDF)
V1.2024
Concert Genetic Testing: Pharmacogenetics (PDF)
V1.2024
Concert Genetic Testing: Preimplantation Genetic Testing (PDF)
V1.2024
Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)
V1.2024
Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF)
V1.2024
Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)
V1.2024
Concert Genetics Oncology: Algorithmic Testing (PDF)
V1.2024
Concert Genetics Oncology: Cancer Screening (PDF)
V1.2024
Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF)
V1.2024
Concert Genetics Oncology: Cytogenetic Testing (PDF)
V1.2024
Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)

CP.MP.31

Cosmetic and Reconstructive Procedures (PDF)

CP.BH.201Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (PDF)
CP.MP.203Diaphragmatic/Phrenic Nerve Stimulation (PDF)
CP.MP.105Digital EEG Spike Analysis (PDF)
CP.MP.114Disc Decompression Procedures (PDF)
CP.MP.115Discography (PDF)

CP.MP.101

Donor Lymphocyte Infusion (PDF)

CP.MP.50 

Drugs of Abuse: Definitive Testing (PDF)

CP.MP.107

Durable Medical Equipment and Orthotics and Prosthetics Guidelines (DME) (PDF)

CP.MP.145

Electric Tumor Treating Fields (Optune) (PDF)

CP.MP.106Endometrial Ablation (PDF)
CP.MP.36Experimental Technologies (PDF)
CP.MP.171Facet Joint Interventions (PDF)
CP.MP.248Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)
CP.MP.137Fecal Incontinence Treatments (PDF)

CP.MP.53

Ferriscan R2-MRI (PDF)

CP.MP.130Fertility Preservation (PDF)
CP.MP.129Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)
CP.MP.43Functional MRI (PDF)
CP.MP.40Gastric Electrical Stimulation (PDF)
CP.MP.95Gender-Affirming Procedures (PDF)
CP.MP.132Heart-Lung Transplant (PDF)
CP.MP.136Home Births (PDF)
CP.MP.184Home Ventilators (PDF)

CP.MP.121

Homocysteine Testing (PDF)

CP.MP.54

Hospice Services (PDF)

CP.MP.62Hyperhidrosis Treatments (PDF)
NM.CP.MP.504Immobilized Lipase Cartriges (Relizorb) (PDF)

CP.MP.180

Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)

CP.MP.173Implantable Intrathecal or Epidural Pain Pump (PDF)
CP.MP.243Implantable Loop Recorder (PDF)
CP.MP.160Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)

CP.MP.69

Intensity- Modulated Radiotherapy (PDF)

CP.MP.58Intestinal and Multivisceral Transplant (PDF)
CP.MP.167Intradiscal Steroid Injections for Pain Management (PDF)

CP.MP.61

IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)

CP.MP.250Lantidra (Donislecel): Allogeneic Pancreatic Islet Cellular Therapy (PDF)
CP.MP.244Liposuction for Lipedema (PDF)
CP.MP.71Long Term Care Placement (PDF)

CP.MP.139

Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)

CP.MP.57Lung Transplantation (PDF)
CP.MP.116Lysis of Epidural Lesions (PDF)

CP.MP.144

Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)

CP.MP.24Multiple Sleep Latency Testing (PDF)
CP.MP.86Neonatal Abstinence Syndrome Guidelines (PDF)
CP.MP.85Neonatal Sepsis Management (PDF)
CP.MP.170Nerve Blocks and Neurolysis for Pain Management (PDF)
CP.MP.48Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)
CP.MP.82NICU Apnea Bradycardia Guidelines (PDF)
CP.MP.81NICU Discharge Guidelines (PDF)
CP.MP.141Nonmyeloablative Allogeneic Stem Cell Transplants (PDF)

CP.MP.91

Obstetrical Home Care Programs (PDF)

CP.MP.249Omisirge (Omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)
CP.MP.128Optic Nerve Decompression Surgery (PDF)

CP.MP.202

Orthognathic Surgery (PDF)

CP.MP.194Osteogenic Stimulation (PDF)
CP.MP.176Outpatient Cardiac Rehabilitation (PDF)
CP.MP.190Outpatient Oxygen Use (PDF)
CP.MP.102Pancreas Transplantation (PDF)

CP.MP.109

Panniculectomy (PDF)

CP.MP.138Pediatric Heart Transplant (PDF)
CP.MP.246Pediatric Kidney Transplant (PDF)
CP.MP.120Pediatric Liver Transplant (PDF)
CP.MP.188Pediatric Oral Function Therapy (PDF)
CP.MP.147Percutaneous Left Atrial Appendage Closure for Stroke Prevention (PDF)

CP.MP.150

Phototherapy for Neonatal Hyperbilirubinemia (PDF)

CP.MP.49Physical, Occupational, and Speech Therapy Services (PDF)
CP.MP.133Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)

CP.MP.70

Proton and Neutron Beam Therapies (PDF)

CP.MP.148Radial Head Implant (PDF)
CP.MP.51Reduction Mammoplasty and Gynecomastia Surgery (PDF)
CP.MP.210Repair of Nasal Valve Compromise (PDF)
CP.MP.126Sacroiliac Joint Fusion (PDF)
CP.MP.166Sacroiliac Joint Interventions for Pain Management (PDF)
CP.MP.146Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF)

CP.MP.174

Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)

CP.MP.165Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)
NM.CP.MP.182Short Inpatient Hospital Stay (PDF)
CP.MP.185Skin and Soft Tissue Substitutes for Chronic Wounds (PDF)
CP.MP.117Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF)
CP.MP.22Stereotactic Body Radiation Therapy (PDF)
CP.MP.162Tandem Transplant (PDF)
CP.MP.87Therapeutic Utilization of Inhaled Nitric Oxide (PDF)
CP.MP.154Thyroid Hormones and Insulin Testing in Pediatrics (PDF)

CP.MP.127

Total Artificial Heart (PDF)

CP.MP.163Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)

CP.MP.151 

Transcatheter Closure of Patent Foramen Ovale (PDF)

CP.BH.200Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF)

CP.MP.247

Transplant Service Documentation Requirements (PDF)

CP.MP.169Trigger Point Injections for Pain Management (PDF)

CP.MP.142

Urinary Incontinence Devices and Treatments (PDF)

CP.MP.12Vagus Nerve Stimulation (PDF)
CP.MP.46Ventricular Assist Devices (PDF)
CP.MP.143Wireless Motility Capsule (PDF)

For Medicare information, please visit our Medicare Prior Authorization website.

POLICY NUMBERPOLICYEFFECTIVE DATE
NM.CP.PPA.09 (PDF) Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere)1/1/2019
CP.PHAR.345 (PDF)Abaloparatide (Tymlos)7/1/17
CP.PMN.253 (PDF)Abametapir (Xeglyze)12/1/20
CP.PHAR.241 (PDF)Abatacept (Orencia)8/1/16
CP.PHAR.355 (PDF)Abemaciclib (Verzenio)10/24/17
CP.PHAR.84 (PDF)Abiraterone (Zytiga, Yonsa)10/1/11
CP.PHAR.230 (PDF)AbobotulinumtoxinA (Dysport)7/1/16
CP.PHAR.578 (PDF)Abrocitinib (Cibinqo)6/1/22
CP.PHAR.366 (PDF)Acalabrutinib (Calquence)3/1/18
CP.PMN.61 (PDF)ACEI and ARB Duplicate Therapy8/1/14
CP.PMN.40 (PDF)Acitretin (Soriatane)8/31/10
CP.PMN.210 (PDF)Acyclovir Buccal Tablet (Sitavig)9/1/19
CP.PHAR.242 (PDF)Adalimumab (Humira), Adalimumab-afzb (Abrilada), Adalimumab-atto (Amjevita), Adalimumab-adbm (Cyltezo), Adalimumab-bwwd (Hadlima), Adalimumab-fkjp (Hulio), Adalimumab-adaz (Hyrimoz)8/1/16
CP.PHAR.142 (PDF)Adefovir (Hepsera)8/28/18
CP.PHAR.229 (PDF)Ado-Trastuzumab Emtansine (Kadcyla)6/1/16
CP.PHAR.468 (PDF)Aducanumab-avwa (Aduhelm)6/1/20
CP.PHAR.444 (PDF)Afamelanotide (Scenesse)3/1/20
CP.PHAR.298 (PDF)Afatinib (Gilotrif)1/1/17
CP.PHAR.184 (PDF)Aflibercept (Eylea)3/1/16
CP.PHAR.158 (PDF)Agalsidase Beta (Fabrazyme)2/1/16
CP.PMN.191 (PDF)Age Limit for Topical Tretinoin1/29/19
CP.PMN.138 (PDF)Age Limit Override (Codeine, Tramadol, Hydrocodone)3/13/18
CP.PHAR.369 (PDF)Alectinib (Alecensa)11/16/16
CP.PHAR.243 (PDF)Alemtuzumab (Lemtrada)8/1/16
CP.PMN.88 (PDF)Alendronate (Binosto, Fosamax Plus D)2/28/18
CP.PHAR.160 (PDF)Alglucosidase Alfa (Lumizyme)2/1/16
CP.PHAR.124 (PDF)Alirocumab (Praluent)10/1/15
CP.PHAR.562 (PDF)Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft)3/1/22
CP.PHAR.563 (PDF)Allogenic Processed Thymus Tissue-agdc (Rethymic)3/1/22
CP.PMN.153 (PDF)Alosetron (Lotronex)11/16/16
CP.PHAR.430 (PDF)Alpelisib (Piqray, Vijoice)9/1/19
CP.PHAR.94 (PDF)Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira)3/1/12
CP.PMN.89 (PDF)Amantadine ER (Gocovri, Osmolex ER)10/10/17
CP.PHAR.190 (PDF)Ambrisentan (Letairis)3/1/16
CP.PHAR.411 (PDF)Amifampridine (Firdapse)1/22/19
CP.PHAR.401 (PDF)Amikacin (Arikayce)11/13/18
CP.PMN.236 (PDF)Amisulpride (Barhemsys)9/1/20
CP.PHAR.544 (PDF)Amivantamab-vmjw (Rybrevant)9/1/21
CP.PMN.176 (PDF)Amlodipine/Atorvastatin (Caduet)12/1/18
CP.PHAR.244 (PDF)Anakinra (Kineret)8/1/16
CP.PHAR.551 (PDF)Anifrolumab-fnia (Saphnelo)12/1/21
CP.PHAR.217 (PDF)Anti-Inhibitor Coagulant Complex, Human (Feiba)5/1/16
CP.PHAR.564 (PDF)Antithrombin III (ATryn, Thrombate III)3/1/22
CP.PHAR.506 (PDF)Antithymocyte Globulin (Atgam, Thymoglobulin)12/1/20
CP.PHAR.376 (PDF)Apalutamide (Erleada)6/1/18
CP.PHAR.488 (PDF)Apomorphine (Apokyn, Kynmobi)9/1/20
CP.PHAR.245 (PDF)Apremilast (Otezla)8/1/16
CP.PMN.19 (PDF)Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection)11/30/16
CP.PHAR.510 (PDF)Arimoclomol (Brand Name)12/1/20
CP.PMN.35 (PDF)Armodafinil (Nuvigil)8/1/09
CP.PHAR.565 (PDF)Asciminib (Scemblix)3/1/22
CP.PMN.15 (PDF)Asenapine (Saphris, Secuado)12/1/14
CP.PHAR.328 (PDF)Asfotase Alfa (Strensiq)3/1/17
CP.PMN.20 (PDF)Aspirin/Dipyridamole (Aggrenox)9/1/06
CP.PHAR.235 (PDF)Atezolizumab (Tecentriq)6/1/16
CP.PHAR.566 (PDF)Atogepant (Qulipta)3/1/22
CP.PHAR.515 (PDF)Avacopan (Tavneos)3/1/21
CP.PHAR.521 (PDF)Avalglucosidase Alfa-ngpt (Nexviazyme)3/1/21
CP.PHAR.454 (PDF)Avapritinib (Ayvakit)3/1/20
CP.PHAR.130 (PDF)Avatrombopag (Doptelet)7/17/18
CP.PHAR.333 (PDF)Avelumab (Bavencio)5/1/17
CP.PHAR.362 (PDF)Axicabtagene Ciloleucel (Yescarta)10/31/17
CP.PHAR.100 (PDF)Axitinib (Inlyta)5/1/12
CP.PHAR.387 (PDF)Azacitidine (Onureg, Vidaza)8/28/18
CP.PHAR.209 (PDF)Aztreonam (Cayston)5/1/16
CP.PHAR.149 (PDF)Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispah, Ozobax)11/9/17
CP.PMN.185 (PDF)Baloxavir Marboxil (Xofluza)10/30/18
CP.PHAR.560 (PDF)Bardoxolone Methyl (RTA 402)12/1/21
CP.PHAR.135 (PDF)Baricitinib (Olumiant)7/24/18
CP.PMN.212 (PDF)Bedaquiline (Sirturo)12/1/19
CP.PHAR.469 (PDF)Belantamab Mafodotin-blmf (Blenrep)6/1/20
CP.PHAR.201 (PDF)Belatacept (Nulojix)11/9/17
CP.PHAR.88 (PDF)Belimumab (Benlysta)10/1/11
CP.PHAR.311 (PDF)Belinostat (Beleodaq)2/1/17
CP.PHAR.552(PDF)Belumosudil (Rezurock)12/1/21
CP.PHAR.553 (PDF)Belzutifan (Welireg)12/1/21
CP.PMN.237 (PDF)Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet)9/1/20
CP.PHAR.307 (PDF)Bendamustine (Belrapzo, Bendeka, Treanda)2/1/17
CP.PHAR.373 (PDF)Benralizumab (Fasenra)1/16/18
CP.PMN.90 (PDF)Benznidazole10/17/17
NM.CP.PPA.16 (PDF)Benzodiazepines and Opioids4/1/2019
CP.PMN.202 (PDF)Benzyl Alcohol (Ulesfia)9/1/19
CP.PHAR.592 (PDF)Beremagene Geperpavec (Vyjuvek)12/1/22
CP.PHAR.485 (PDF)Berotralstat (Orladeyo)6/1/20
CP.PHAR.143 (PDF)Betaine (Cystadane)8/28/18
CP.PMN.182 (PDF)Betamethasone Dipropionate Spray (Sernivo)12/1/18
CP.PHAR.545 (PDF)Betibeglogene Autotemcel (Zynteglo)9/1/21
CP.PHAR.93 (PDF)Bevacizumab (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev)10/31/11
CP.PHAR.75 (PDF)Bexarotene (Targretin Capsules, Gel)9/1/11
CP.PHAR.300 (PDF)Bezlotoxumab (Zinplava)11/16/16
CP.PHAR.486 (PDF)Bimatoprost Implant (Durysta)6/1/20
CP.PHAR.50 (PDF)Binimetinib (Mektovi) 7/24/18
CP.PHAR.312 (PDF)Blinatumomab (Blincyto)2/1/17
CP.PMN.151 (PDF)Blood Glucose Test Strip Quantity Limit - Not Receiving Insulin9/1/07
CP.PHAR.410 (PDF)Bortezomib (Velcade)12/11/18
CP.PHAR.191 (PDF)Bosentan (Tracleer)3/1/16
CP.PHAR.105 (PDF)Bosutinib (Bosulif)10/1/12
CP.PMN.22 (PDF)Brand Name Override9/1/06
CP.PHAR.303 (PDF)Brentuximab Vedotin (Adcetris)2/1/17
CP.PHAR.417 (PDF)Brexanolone (Zulresso)4/16/19
CP.PHAR.472 (PDF)Brexucabtagene Autoleucel (Tecartus)6/1/20
CP.PHAR.342 (PDF)Brigatinib (Alunbrig)7/17/17
CP.PMN.192 (PDF)Brimonidine Tartrate (Mirvaso)11/15/16
CP.PHAR.375 (PDF)Brodalumab (Siliq)6/1/18
CP.PHAR.445  (PDF)Brolucizumab-dbll (Beovu)2/29/20
CP.PHAR.572 (PDF)Budesonide (Tarpeyo)3/1/22
CP.PHAR.589 (PDF)Bulevirtide (Hepcludex)9/1/22
CP.PHAR.11 (PDF)Burosumab-twza (Crysvita)5/8/18
CP.PHAR.202 (PDF)C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest)3/1/16
CP.PHAR.316 (PDF)Cabazitaxel (Jevtana)2/1/17
CP.PHAR.111 (PDF)Cabozantinib (Cabometyx, Cometriq)6/1/13
CP.PMN.76  (PDF)Calcifediol (Rayaldee)11/1/16
CP.PMN.181 (PDF)Calcipotriene/Betamethasone Dipropionate Foam (Enstilar)12/1/18
CP.PHAR.246 (PDF)Canakinumab (Ilaris)8/1/16
CP.PMN.164 (PDF)Cannabidiol (Epidiolex)7/17/18
CP.PHAR.416 (PDF)Caplacizumab-yhdp (Cablivi)3/12/19
CP.PHAR.494 (PDF)Capmatinib (Tabrecta)9/1/20
CP.PMN.137 (PDF)Carbamazepine ER (Equetro)3/13/18
CP.PHAR.546 (PDF)Carbetocin9/1/21
CP.PMN.238 (PDF)Carbidopa/Levodopa ER Capsules (Rytary), Enteral Suspension (Duopa), IR Tablets (Dhivy)9/1/20
CP.PHAR.309 (PDF)Carfilzomib (Kyprolis)2/1/17
CP.PHAR.206 (PDF)Carglumic Acid (Carbaglu)5/1/16
CP.PMN.91 (PDF)Cariprazine (Vraylar)11/16/16
CP.PHAR.470 (PDF)Casimersen (Amondys 45)6/1/20
CP.PHAR.520 (PDF)Casirivimab and Imdevimab (REGEN-COV)12/22/20
CP.PMN.122 (PDF)Celecoxib (Celebrex, Elyxyb)1/1/07
CP.PHAR.397 (PDF)Cemiplimab-rwlc (Libtayo)10/16/18
CP.PMN.186 (PDF)Cenegermin-bkbj (Oxervate)10/9/18
CP.PMN.231 (PDF)Cenobamate (Xcopri)3/1/20
CP.PHAR.349 (PDF)Ceritinib (Zykadia)7/1/17
CP.PHAR.338 (PDF)Cerliponase Alfa (Brineura)7/1/17
CP.PHAR.247(PDF)Certolizumab (Cimzia)8/1/16
CP.PHAR.317 (PDF)Cetuximab (Erbitux)2/1/17
CP.PMN.239 (PDF)Chenodiol (Chenodal)9/1/20
CP.PHAR.554 (PDF)Chlorambucil (Leukeran)12/1/21
CP.PHAR.388 (PDF)Chloramphenicol Sodium Succinate12/1/18
CP.PHAR.390 (PDF)Cholic Acid (Cholbam)12/1/18
CP.PMN.24 (PDF)Ciclopirox (Penlac)9/1/07
CP.PHAR.533 (PDF)Ciltacabtagene Autoleucel (Carvykti)5/7/21
CP.PHAR.61 (PDF)Cinacalcet (Sensipar)5/1/11
CP.PHAR.567 (PDF)Cipaglucosidase Alfa/Miglustat (AT-GAA)3/1/22
CP.PMN.248 (PDF)Ciprofloxacin/Dexamethasone (Ciprodex)12/1/20
CP.PMN.249 (PDF)Ciprofloxacin/Fluocinolone (Otovel)12/1/20
CP.PHAR.422 (PDF)Cladribine (Mavenclad)9/1/19
CP.PMN.257 (PDF)Clascoterone (Winlevi) 2/28/21
CP.PHAR.260 (PDF)Clinical Policy: Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela)7/1/16
CP.PMN.54 (PDF)Clobazam (Onfi, Sympazan)11/1/12
CP.PMN.197 (PDF)Clomipramine (Anafranil)3/13/18
CP.PMN.12 (PDF)Clozapine Orally Disintegrating Tablet8/1/15
CP.PMN.92 (PDF)CNS Stimulants3/1/18
CP.PHAR.380 (PDF)Cobimetinib (Cotellic)11/16/16
CP.PMN.123 (PDF)Colchicine (Colcrys)5/1/11
CP.PMN.250 (PDF)Colesevelam (Welchol)12/1/20
CP.PHAR.82 (PDF)Collagenase Clostridium Histolyticum (Xiaflex)10/1/11
CP.PMN.280 (PDF)Compounded Medications9/1/22
CP.PMN.258 (PDF)Conjugated Estrogens/Bazedoxifene (Duavee)3/1/21
CP.PMN.214 (PDF)Continuous Glucose Monitors12/1/19
CP.PHAR.357 (PDF)Copanlisib (Aliqopa)10/17/17
CP.PHAR.385 (PDF)Corticosteroids for Ophthalmic Injection (Iluvien, Ozurdex, Retisert, Xipere, Yutiq)5/29/18
CP.PHAR.203 (PDF)Cosyntropin (Cortrosyn)4/1/16
CP.PMN.110 (PDF)Crisaborole (Eucrisa)2/21/17
CP.PHAR.449 (PDF)Crizanlizumab-tmca (Adakveo)3/1/20
CP.PHAR.90 (PDF)Crizotinib (Xalkori)11/1/11
CP.PMN.48 (PDF)Cyclosporine (Cequa, Restasis, Verkazia)5/1/12
CP.PMN.130 (PDF)Cysteamine Ophthalmic (Cystaran, Cystadrops)8/1/17
CP.PHAR.155  (PDF)  Cysteamine oral (Cystagon, Procysbi)2/1/16
CP.PHAR.277 (PDF)Cytomegalovirus Immune Globulin (CytoGam)9/1/18
CP.PMN.49 (PDF)Dabigatran (Pradaxa)5/1/12
CP.PHAR.239 (PDF)Dabrafenib (Tafinlar)11/16/16
CP.PHAR.399 (PDF)Dacomitinib (Vizimpro)10/16/18
CP.PHAR.248 (PDF)Dalfampridine (Ampyra)8/1/16
CP.PHAR.225 (PDF)Dalteparin (Fragmin)5/1/16
CP.PHAR.351 (PDF)Daptomycin (Cubicin, Cubicin RF)11/30/17
CP.PHAR.310 (PDF)Daratumumab (Darzalex), Daratumumab/Hyaluronidase-fihj (Darzalex Faspro)7/1/17
CP.PHAR.236 (PDF)Darbepoetin Alfa (Aranesp)6/1/16
CP.PHAR.435 (PDF)Darolutamide (Nubeqa)12/1/19
CP.PHAR.72 (PDF)Dasatinib (Sprycel)6/1/12
CP.PHAR.352 (PDF)Daunorubicin/Cytarabine (Vyxeos)12/1/17
CP.PHAR.479 (PDF)Decitabine/Cedazuridine (Inqovi)6/1/20
CP.PHAR.145 (PDF)Deferasirox (Exjade, Jadenu)11/1/15
CP.PHAR.147 (PDF)Deferiprone (Ferriprox)11/1/15
CP.PHAR.146 (PDF)Deferoxamine (Desferal)11/1/15
CP.PHAR.331 (PDF)Deflazacort (Emflaza)3/1/17
CP.PHAR.170 (PDF)Degarelix Acetate (Firmagon)11/9/17
CP.PMN.115 (PDF)Delafloxacin (Baxdela)11/9/17
CP.PHAR.593 (PDF)Delandistrogene Moxeparvovec (SRP-9001)12/1/22
CP.PHAR.58 (PDF)Denosumab (Prolia, Xgeva)3/1/11
CP.PHAR.214 (PDF)Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva)5/1/16
CP.PHAR.341 (PDF)Deutetrabenazine (Austedo)6/13/17
CP.PHAR.418 (PDF)Dexrazoxane (Totect)3/19/19
CP.PMN.93 (PDF)Dextromethorphan-Quinidine (Nuedexta)3/1/18
CP.PMN.284 (PDF)Dextromethorphan/Bupropion (Auvelity)12/1/22
CP.PMN.216 (PDF)Diazepam Nasal Spray (Valtoco)12/1/19
CP.PMN.261 (PDF)Dichlorphenamide (Keveyis)3/1/21
CP.PMN.274 (PDF)Diclofenac (Pennsaid)3/1/22
CP.PHAR.249 (PDF)Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity), Monomethyl Fumarate (Bafiertam)8/1/16
CP.PMN.03 (PDF)Dipeptidyl Peptidase-4 (DPP-4) Inhibitors9/19/18
CP.PMN.141 (PDF)Dolasetron (Anzemet)9/1/06
CP.PHAR.594 (PDF)Donanemab (LY3002813)12/1/22
CP.PHAR.569 (PDF)Donislecel (Lantidra)3/1/22
CP.PHAR.212 (PDF)Dornase Alfa (Pulmozyme)5/1/16
CP.PHAR.540 (PDF)Dostarlimab-gxly (Jemperli)9/1/21
CP.PMN.175 (PDF)Doxepin (Silenor)12/1/18
CP.PMN.79 (PDF)Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea)5/1/17
CP.PMN.159 (PDF)Dronabinol (Marinol, Syndros)11/16/16
CP.PMN.17 (PDF)Droxidopa (Northera)11/9/17
CP.PHAR.336 (PDF)Dupilumab (Dupixent)5/1/17
CP.PHAR.339 (PDF)Durvalumab (Imfinzi)7/1/17
CP.PMN.128 (PDF)Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn)5/1/16
CP.PHAR.400 (PDF)Duvelisib (Copiktra)10/16/18
CP.PMN.234 (PDF)Early and Periodic Screening, Diagnostic, and Treatment Benefit for Pediatric Members6/1/20
CP.PHAR.177 (PDF)Ecallantide (Kalbitor)3/1/16
CP.PHAR.97 (PDF)Eculizumab (Soliris)3/1/12
CP.PHAR.343 (PDF)Edaravone (Radicava, Radivaca ORS)7/1/17
CP.PMN.227 (PDF)Edoxaban (Savaysa)1/1/20
CP.PHAR.555 (PDF)Efgartigimod Alfa-fcab (Vyvgart)12/1/21
CP.PMN.25 (PDF)Efinaconazole (Jublia)8/1/16
CP.PHAR.595 (PDF)Eladocagene Exuparvovec (Upstaza)12/1/22
CP.PHAR.136 (PDF)Elagolix (Orilissa), Elagolix/Estradiol/Norethinedrone (Oriahnn)8/28/18
CP.PHAR.419 (PDF)Elapegademase-lvlr (Revcovi)4/23/19
CP.PHAR.440 (PDF)Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta)12/1/19
CP.PHAR.153 (PDF)Eliglustat (Cerdelga)2/1/16
CP.PHAR.556 (PDF)Elivaldogene Autotemcel (Skysona)12/1/21
CP.PHAR.162  (PDF)Elosulfase Alfa (Vimizim)2/1/16
CP.PHAR.308 (PDF)Elotuzumab (Empliciti)2/1/17
CP.PHAR.180 (PDF)Eltrombopag (Promacta)3/1/16
CP.PMN.170 (PDF)Eluxadoline (Viberzi)12/1/18
CP.PHAR.402 (PDF)Emapalumab-lzsg (Gamifant)12/11/18
CP.PHAR.370 (PDF)Emicizumab-kxwh (Hemlibra)3/1/18
CP.PHAR.363 (PDF)Enasidenib (Idhifa)9/5/17
CP.PHAR.127 (PDF)Encorafenib (Braftovi)7/24/18
CP.PHAR.455 (PDF)Enfortumab Vedotin-ejfv (Padcev)3/1/20
CP.PHAR.41 (PDF)Enfuvirtide (Fuzeon)6/1/10
CP.PHAR.224 (PDF)Enoxaparin (Lovenox)5/1/16
CP.PHAR.441 (PDF)Entrectinib (Rozlytrek)12/1/19
CP.PHAR.106 (PDF)Enzalutamide (Xtandi)10/1/12
CP.PMN.144 (PDF)Epinephrine (Auvi-Q, EpiPen, EpiPen Jr) Quantity Limit Override8/1/16
CP.PHAR.237 (PDF)Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit)6/1/16
CP.PHAR.192 (PDF)Epoprostenol (Flolan, Veletri)3/1/16
CP.PHAR.489 (PDF)Eptinezumab-jjmr (Vyepti)9/1/20
CP.PHAR.423 (PDF)Erdafitinib (Balversa)9/1/19
CP.PHAR.128 (PDF)Erenumab-aooe (Aimovig)7/10/18
CP.PHAR.318 (PDF)Eribulin Mesylate (Halaven)3/1/17
CP.PHAR.74 (PDF)Erlotinib (Tarceva)9/1/11
CP.PHAR.301 (PDF)Erwinia Asparaginase (Erwinaze, Rylaze)2/1/17
CP.PMN.199 (PDF) (PDF)Esketamine (Spravato)3/12/19
CP.PMN.263 (PDF)Estradiol Vaginal Ring (Femring)1/1/22
CP.PHAR.250 (PDF)Etanercept (Enbrel)8/1/16
CP.PHAR.379 (PDF)Etelcalcetide (Parsabiv)3/20/18
CP.PHAR.288 (PDF)Eteplirsen (Exondys 51)12/1/16
CP.PHAR.580 (PDF)Etranacogene Dezaparvovec (AMT-061)6/1/22
CP.PHAR.63 (PDF)Everolimus (Afinitor, Afinitor Disperz, Zortress)6/1/11
CP.PHAR.511 (PDF)Evinacumab-dgnb (Evkeeza)12/1/20
CP.PHAR.123 (PDF)Evolocumab (Repatha)10/1/15
CP.PHAR.218 (PDF)Factor IX (Human, Recombinant)5/1/16
CP.PHAR.219 (PDF)Factor IX Complex, Human (Profilnine)5/1/16
CP.PHAR.220 (PDF)Factor VIIa, Recombinant (NovoSeven RT, SevenFact)5/1/16
CP.PHAR.215  (PDF)Factor VIII (Human, Recombinant)5/1/16
CP.PHAR.216 (PDF)Factor VIII/von Willebrand Factor Complex (Human – Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi)5/1/16
CP.PHAR.222 (PDF)Factor XIII A-Subunit, Recombinant (Tretten)5/1/16
CP.PHAR.221 (PDF)Factor XIII, Human (Corifact)5/1/16
CP.PHAR.456 (PDF)Fam-Trastuzumab Deruxtecan-nxki (Enhertu)3/1/20
CP.PHAR.581 (PDF)Faricimab-svoa (Vabysmo)6/1/22
CP.PMN.57 (PDF)Febuxostat (Uloric)8/1/13
CP.PHAR.442 (PDF)Fedratinib (Inrebic)12/1/19
CP.PMN.246 (PDF)Fenfluramine (Fintepla)9/1/20
CP.PMN.127 (PDF)Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys)6/1/15
CP.PHAR.234 (PDF)Ferric Carboxymaltose (Injectafer)6/1/16
CP.PHAR.480 (PDF)Ferric Derisomaltose (Monoferric)6/1/20
CP.PHAR.166 (PDF)Ferric Gluconate (Ferrlecit)3/1/16
CP.PMN.213 (PDF)Ferric Maltol (Accrufer)12/1/19
CP.PHAR.165 (PDF)Ferumoxytol (Feraheme)3/1/16
CP.PHAR.526 (PDF)Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP)6/1/21
CP.PHAR.297 (PDF)Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastim-aafi (Nivestym), Filgrastim-ayow (Releuko)12/1/16
CP.PMN.266 (PDF)Finerenone (Kerendia)12/1/21
CP.PHAR.251 (PDF)Fingolimod (Gilenya, Tascenso ODT)8/1/16
CP.PMN.165 (PDF)Fluorouracil Cream (Tolak)12/1/18
CP.PMN.95 (PDF)Fluticasone Propionate (Xhance)10/24/17
CP.PHAR.226 (PDF)Fondaparinux (Arixtra)5/1/16
CP.PHAR.471 (PDF)Fosdenopterin (Nulibry)6/1/20
CP.PHAR.24 (PDF)Fostamatinib (Tavalisse)6/5/18
CP.PHAR.516 (PDF)Fostemsavir (Rukobia)3/1/21
CP.PHAR.403 (PDF)Fremanezumab-vfrm (Ajovy)10/30/18
CP.PHAR.424 (PDF)Fulvestrant (Faslodex Injection)9/1/19
CP.PMN.240 (PDF)Gabapentin ER (Gralise, Horizant)9/1/20
CP.PHAR.404 (PDF)Galcanezumab-gnlm (Emgality)11/13/18
CP.PHAR.161 (PDF)Galsulfase (Naglazyme)2/1/16
CP.PMN.278 (PDF)Ganaxolone (Ztalmy)6/1/22
CP.PHAR.68 (PDF)Gefitinib (Iressa)11/16/16
CP.PHAR.358 (PDF)Gemtuzumab Ozogamicin (Mylotarg)10/3/17
CP.PHAR.412 (PDF)Gilteritinib (Xospata)1/15/19
CP.PHAR.457 (PDF)Givosiran (Givlaari)3/1/20
CP.PHAR.413 (PDF)Glasdegib (Daurismo)1/8/19
CP.PHAR.252 (PDF)Glatiramer Acetate (Copaxone, Glatopa)8/1/16
NM.CP.PPA.01 (PDF)glecaprevir-pibrentasvir (Mavyret) 
CP.PMN.183 (PDF)Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists9/19/18
CP.PHAR.207 (PDF)Glycerol Phenylbutyrate (Ravicti)4/30/16
CP.PMN.177 (PDF)Glycopyrronium (Qbrexza)8/13/18
CP.PHAR.253 (PDF)Golimumab (Simponi, Simponi Aria)7/1/16
CP.PHAR.453 (PDF)Golodirsen (Vyondys 53)3/1/20
CP.PHAR.171 (PDF)Goserelin Acetate (Zoladex)11/9/17
CP.PMN.74 (PDF)Granisetron (Sancuso, Sustol)11/1/16
CP.PHAR.364 (PDF)Guselkumab (Tremfya)8/29/17
CP.PMN.180 (PDF)Halobetasol Propionate (Bryhali, Lexette, Ultravate)12/1/18
CP.PMN.208 (PDF)Halobetasol Propionate/Tazarotene (Duobrii)9/1/19
CP.PHAR.181 (PDF)Hemin (Panhematin)2/1/16
CP.PHAR.172 (PDF)Histrelin Acetate (Vantas, Supprelin LA)11/9/17
NM.CP.PPA.11 (PDF)HIV Medications 
CP.PMN.111  (PDF)House Dust Mite Allergen Extract (Odactra)8/31/17
CP.PHAR.517 (PDF)Human Growth Hormone (Somapacitan, Somatropin)3/1/21
CP.PHAR.05 (PDF)Hyaluronate Derivatives10/1/08
CP.PMN.193 (PDF)Hydroxyurea (Siklos)2/19/19
CP.PHAR.378 (PDF)Ibalizumab-uiyk (Trogarzo)4/17/18
CP.PHAR.189 (PDF)Ibandronate Injection (Boniva)11/15/17
CP.PMN.96 (PDF)Ibandronate Oral (Boniva)3/1/18
CP.PHAR.126 (PDF)Ibrutinib (Imbruvica)10/1/15
CP.PMN.120 (PDF)Ibuprofen/Famotidine (Duexis)6/1/18
CP.PHAR.178 (PDF)Icatibant (Firazyr)3/1/16
CP.PMN.187 (PDF)Icosapent Ethyl (Vascepa)11/20/18
CP.PHAR.481 (PDF)Idecabtagene Vicleucel (Abecma)6/1/20
CP.PHAR.133 (PDF)Idelalisib (Zydelig)12/1/18
CP.PHAR.156 (PDF)Idursulfase (Elaprase)2/1/16
CP.PMN.32 (PDF)Iloperidone (Fanapt)12/1/14
CP.PHAR.193 (PDF)Iloprost (Ventavis)3/1/16
CP.PHAR.65 (PDF)Imatinib (Gleevec)6/1/11
CP.PHAR.154  (PDF)Imiglucerase (Cerezyme)2/1/16
CP.PHAR.103 (PDF)Immune Globulins8/1/12
CP.PHAR.28 (PDF)Immunization Coverage10/1/08
CP.PHAR.568 (PDF)Inclisiran (Leqvio)3/1/22
CP.PHAR.231 (PDF)IncobotulinumtoxinA (Xeomin)7/1/16
CP.PHAR.458 (PDF)Inebilizumab-cdon (Uplizna)3/1/20
CP.PHAR.131 (PDF)Infertility and Fertility Preservation11/16/16
CP.PHAR.547 (PDF)Infigratinib (Truseltiq)9/1/21
CP.PHAR.254 (PDF)Infliximab (Remicade), Infliximab-axxq (Avsola), Infliximab-dyyb (Inflectra), and Infliximab-abda (Renflexis)7/1/16
CP.PMN.259 (PDF)Inhaled Agents for Asthma and COPD3/1/21
CP.PHAR.405 (PDF)Inotersen (Tegsedi)11/20/18
CP.PHAR.359 (PDF)Inotuzumab Ozogamicin (Besponsa)9/26/17
CP.PHAR.534 (PDF)Insulin Delivery Systems (V-Go, Omnipod, InPen)6/1/21
CP.PHAR.255 (PDF)Interferon Beta-1a (Avonex, Rebif)8/1/16
CP.PHAR.256 (PDF)Interferon Beta-1b (Betaseron, Extavia)8/1/16
CP.PHAR.52 (PDF)Interferon Gamma- 1b (Actimmune)6/1/10
CP.PHAR.459 (PDF)Iobenguane I-131 (Azedra)3/1/20
CP.PHAR.319 (PDF)Ipilimumab (Yervoy)4/17/18
CP.PHAR.304 (PDF)Irinotecan Liposome (Onivyde)2/1/17
CP.PHAR.167 (PDF)Iron Sucrose (Venofer)3/1/16
CP.PHAR.482 (PDF)Isatuximab-irfc (Sarclisa)6/1/20
CP.PMN.154 (PDF)Isavuconazonium (Cresemba)11/16/16
CP.PMN.143 (PDF)Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane)12/1/14
CP.PMN.217 (PDF)Istradefylline (Nourianz)3/1/20
CP.PMN.124 (PDF)Itraconazole (Sporanox, Tolsura)11/1/06
CP.PMN.70 (PDF)Ivabradine (Corlanor)11/1/15
CP.PHAR.210 (PDF)Ivacaftor (Kalydeco)5/1/16
CP.PMN.269 (PDF)Ivermectin (Stromectol, Sklice)12/1/21
CP.PHAR.137 (PDF)Ivosidenib (Tibsovo)8/21/18
CP.PHAR.302 (PDF)Ixazomib (Ninlaro)2/1/17
CP.PHAR.257 (PDF)Ixekizumab (Taltz)8/1/16
CP.PMN.282 (PDF)Ketorolac Nasal Spray (Sprix)12/1/22
CP.PMN.116 (PDF)L-glutamine (Endari)11/9/17
CP.PMN.155 (PDF)Lacosamide (Vimpat)12/1/14
CP.PHAR.396 (PDF)Lanadelumab-fylo (Takhzyro)9/25/18
CP.PHAR.391 (PDF)Lanreotide (Somatuline Depot)8/14/18
CP.PHAR.79 (PDF)Lapatinib (Tykerb)11/9/17
CP.PHAR.152 (PDF)Laronidase (Aldurazyme)2/1/16
CP.PHAR.414 (PDF)Larotrectinib (Vitrakvi)1/15/18
CP.PMN.218 (PDF)Lasmiditan (Reyvow)3/1/20
CP.PMN.108 (PDF)Latanoprostene Bunod (Vyzulta)3/1/18
CP.PHAR.596 (PDF)Lecanemab (BAN2401)12/1/22
NM.CP.PPA.04 (PDF)ledipasvir-sofosbuvir (Harvoni) 
CP.PMN.219 (PDF)Lefamulin (Xenleta)3/1/20
CP.PHAR.71 (PDF)Lenalidomide (Revlimid)7/1/11
CP.PHAR.597 (PDF)Leniolisib (CDZ173)12/1/22
CP.PHAR.138 (PDF)Lenvatinib (Lenvima)12/1/18
CP.PHAR.367 (PDF)Letermovir (Prevymis)3/1/18
CP.PHAR.393 (PDF)Leucovorin Injection12/1/18
CP.PHAR.173 (PDF)Leuprolide Acetate (Eligard, Fensolvi, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi)11/9/17
CP.PMN.267 (PDF)Levodopa Inhalation Powder (Inbrija)12/1/21
CP.PMN.275 (PDF)Levoketoconazole (Recorlev)6/1/22
CP.PHAR.151 (PDF)Levoleucovorin (Fusilev, Khapzory)11/9/17
CP.PMN.08 (PDF)Lidocaine Transdermal (Lidoderm, ZTlido)9/1/06
CP.PHAR.598 (PDF)Lifileucel (LN-144)12/1/22
CP.PMN.73 (PDF)Lifitegrast (Xiidra)11/9/17
CP.PMN.71 (PDF)Linaclotide (Linzess)11/1/15
CP.PMN.09  (PDF)Lindane Shampoo11/1/06
CP.PMN.27 (PDF)Linezolid (Zyvox)9/1/16
CP.PHAR.483 (PDF)Lisocabtagene Maraleucel (Breyanzi)6/1/20
CP.PMN.152 (PDF)Lofexidine (Lucemyra)8/1/18
CP.PHAR.283 (PDF)Lomitapide (Juxtapid)10/1/16
CP.PHAR.507 (PDF)Lomustine (Gleostine)12/1/20
CP.PHAR.499 (PDF)Lonafarnib (Zokinvy)9/1/20
CP.PHAR.539 (PDF)Loncastuximab Tesirine-lpyl (Zynlonta)9/1/21
CP.PMN.279 (PDF)Long-term Antibiotic Treatment for Tick-borne Diseases6/2/22
CP.PHAR.406 (PDF)Lorlatinib (Lorbrena)12/11/18
CP.PMN.260 (PDF)Loteprednol etabonate (Eysuvis)3/1/21
CP.PMN.142 (PDF)Lubiprostone (Amitiza)12/1/14
CP.PMN.166 (PDF)Luliconazole Cream (Luzu)8/28/18
CP.PHAR.213 (PDF)Lumacaftor/Ivacaftor (Orkambi)5/1/16
CP.PHAR.473 (PDF)Lumasiran (Oxlumo)6/1/20
CP.PMN.232 (PDF)Lumateperone (Caplyta)3/1/20
CP.PMN.50 (PDF)Lurasidone (Latuda)12/1/14
CP.PHAR.500 (PDF)Lurbinectedin (Zepzelca)9/1/20
CP.PHAR.450 (PDF)Luspatercept-aamt (Reblozyl)3/1/20
CP.PHAR.407 (PDF)Lusutrombopag (Mulpleta)9/18/18
CP.PHAR.384 (PDF)Lutetium Lu 177 Dotatate (Lutathera)5/22/18
CP.PHAR.582 (PDF)Lutetium Lu 177 vipivotide tetraxetan (Pluvicto)6/1/22
CP.PHAR.194 (PDF)Macitentan (Opsumit)3/1/16
CP.PHAR.518 (PDF)Mannitol (Bronchitol)3/1/21
CP.PHAR.543 (PDF)Maralixibat (Livmarli)9/1/21
CP.PHAR.522 (PDF)Margetuximab-cmkb (Margenza)3/1/21
CP.PMN.271 (PDF)Maribavir (Livtencity)3/1/22
CP.PMN.272 (PDF)Mavacamten (Camzyos)3/1/22
CP.PMN.136 (PDF)Mecamylamine (Vecamyl)5/1/17
CP.PHAR.150 (PDF)Mecasermin (Increlex)3/1/11
CP.PHAR.381 (PDF)Mechlorethamine Gel (Valchlor)11/16/16
CP.PMN.179 (PDF)Megestrol Acetate (Megace ES)12/1/18
CP.PHAR.535 (PDF)Melphalan flufenamide (Pepaxto)6/1/21
CP.PHAR.200 (PDF)Mepolizumab (Nucala)4/1/16
CP.PHAR.447 (PDF)Mercaptopurine (Purixan)3/1/20
CP.PMN.72 (PDF)Metformin ER (Fortamet, Glumetza)10/31/15
CP.PMN.161 (PDF)Methadone Hydrochloride12/1/18
CP.PHAR.134 (PDF)Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex)12/1/18
CP.PHAR.238 (PDF)Methoxy Polyethylene Glycol-Epoetin Beta (Mircera)6/1/16
CP.PMN.169 (PDF)Methylnaltrexone Bromide (Relistor)12/1/18
CP.PMN.252 (PDF)Metoclopramide (Gimoti)12/1/20
CP.PHAR.425 (PDF)Metreleptin (Myalept)9/1/19
CP.PMN.211 (PDF)Midazolam (Nayzilam)9/1/19
CP.PHAR.344 (PDF)Midostaurin (Rydapt)6/1/17
CP.PHAR.101 (PDF)Mifepristone (Korlym)5/1/12
CP.PHAR.394 (PDF)Migalastat (Galafold)9/11/18
CP.PHAR.164  (PDF)Miglustat (Zavesca)2/1/16
CP.PMN.125 (PDF)Milnacipran (Savella)8/1/12
CP.PMN.80 (PDF)Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi)4/30/17
CP.PMN.242 (PDF)Minocycline Micronized Foam (Amzeeq)9/1/20
CP.PHAR.558 (PDF)Mitapivat (Pyrukynd)12/1/21
CP.PHAR.495 (PDF)Mitomycin for Pyelocalyceal Solution (Jelmyto)9/1/20
CP.PHAR.258 (PDF)Mitoxantrone8/1/16
CP.PHAR.559 (PDF)Mobocertinib (Exkivity)12/1/21
CP.PMN.39 (PDF)Modafinil (Provigil)5/1/08
CP.PHAR.139 (PDF)Mogamulizumab-kpkc (Poteligeo)9/4/18
CP.PHAR.448 (PDF)Mometasone Furoate (Sinuva)3/1/20
CP.PHAR.398 (PDF)Moxetumomab pasudotox-tdfk (Lumoxiti)10/16/18
CP.PHAR.461 (PDF)Nadofaragene Firadenovec (Instiladrin)3/1/20
CP.PHAR.174 (PDF)Nafarelin Acetate (Synarel)11/9/17
CP.PMN.112 (PDF)Naldemedine (Symproic)5/1/17
CP.PMN.171 (PDF)Naloxegol (Movantik)12/1/18
CP.PHAR.96 (PDF)Naltrexone (Vivitrol)3/1/12
CP.PMN.117 (PDF)Naproxen/Esomeprazole (Vimovo)6/1/18
CP.PHAR.527 (PDF)Narsoplimab (OMS721)6/1/21
CP.PHAR.259 (PDF)Natalizumab (Tysabri)7/1/16
CP.PHAR.523 (PDF)Naxitamab-gqgk (Danyelza)3/1/21
CP.PHAR.320 (PDF)Necitumumab (Portrazza)3/1/17
CP.PMN.167 (PDF)Neomycin/Fluocinolone Cream (Neo-Synalar)8/28/18
CP.PHAR.365 (PDF)Neratinib (Nerlynx)9/5/17
CP.PMN.118 (PDF)Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan)2/13/18
CP.PMN.158 (PDF)Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV)9/1/06
CP.PMN.256 (PDF)Nifurtimox (Lampit)12/1/20
CP.PHAR.76 (PDF)Nilotinib (Tasigna)9/1/11
CP.PHAR.285 (PDF)Nintedanib (Ofev)10/1/16
CP.PHAR.408 (PDF)Niraparib (Zejula)5/9/17
CP.PHAR.132 (PDF)Nitisinone (Nityr, Orfadin)8/28/18
CP.PHAR.121 (PDF)Nivolumab (Opdivo)7/1/15
CP.PHAR.588 (PDF)Nivolumab and Relatlimab-rmbw (Opdualag)9/1/22
CP.PMN.255 (PDF)No Coverage Criteria, Recent Label Changes Pending Clinical Policy Update12/1/20
CP.PMN.04 (PDF)Non-Calcium Phosphate Binders11/15/17
CP.PMN.215 (PDF)Non-Preferred Blood Glucose Monitors/Test Strips12/1/19
CP.PHAR.327 (PDF)Nusinersen (Spinraza)11/28/17
CP.PHAR.287 (PDF)Obeticholic Acid (Ocaliva)11/1/16
CP.PHAR.305 (PDF)Obinutuzumab (Gazyva)2/1/17
CP.PHAR.335 (PDF)Ocrelizumab (Ocrevus)4/1/17
CP.PHAR.40 (PDF)Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa)3/1/10
CP.PHAR.528 (PDF)Odevixibat (Bylvay)6/1/21
CP.PHAR.306 (PDF)Ofatumumab (Arzerra, Kesimpta)2/1/17
CP.PMN.53 (PDF)Off-Label Use9/12/17
CP.PMN.265 (PDF)Olanzapine/Samidorphan (Lybalvi)9/1/21
CP.PHAR.360 (PDF)Olaparib (Lynparza)10/3/17
CP.PHAR.326 (PDF)Olaratumab (Lartruvo)3/1/17
CP.PHAR.586 (PDF)Olipudase Alfa-rpcp (Xenpozyme)6/2/22
CP.PHAR.108 (PDF)Omacetaxine (Synribo)4/1/13
CP.PMN.188 (PDF)Omadacycline (Nuzyra)11/20/18
CP.PHAR.01 (PDF)Omalizumab (Xolair)10/1/08
CP.PHAR.590 (PDF)Omaveloxolone (RTA-408)9/1/22
CP.PHAR.585 (PDF)Omburtamab (Omblastys)12/1/22
CP.PMN.52 (PDF)Omega-3-Acid Ethyl Esters (Lovaza)8/1/12
CP.PHAR.232 (PDF)OnabotulinumtoxinA (Botox)7/1/16
CP.PHAR.421 (PDF)Onasemnogene Abeparvovec (Zolgensma)6/7/19
CP.PMN.45 (PDF)Ondansetron (Zuplenz)9/1/06
CP.PHAR.536 (PDF)Ophthalmic Riboflavin (Photrexa, Photrexa Viscous)6/1/21
CP.PMN.245 (PDF)Opicapone (Ongentys)9/1/20
CP.PMN.97 (PDF)Opioid Analgesics*2/1/11
CP.PHAR.487 (PDF)Osilodrostat (Isturisa)9/1/20
CP.PHAR.294 (PDF)Osimertinib (Tagrisso)12/1/16
CP.PMN.168 (PDF)Ospemifene (Osphena)8/28/18
CP.PMN.198 (PDF)Overactive Bladder Agents5/1/16
CP.PMN.86 (PDF)Oxymetazoline (Rhofade, Upneeq)11/15/16
CP.PHAR.462 (PDF)Ozanimod (Zeposia)3/1/20
CP.PMN.119 (PDF)Ozenoxacin (Xepi)1/30/18
CP.PHAR.176  (PDF)Paclitaxel, Protein-Bound (Abraxane)7/1/15
CP.PHAR.583 (PDF)Pacritinib (Vonjo)6/1/22
CP.PHAR.125 (PDF)Palbociclib (Ibrance)10/1/15
NM.CP.PHAR.10 (PDF)palivizumab (Synagis) 
CP.PHAR.548 (PDF)Palovarotene9/1/21
CP.PMN.226 (PDF)Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep)1/1/20
CP.PHAR.321 (PDF)Panitumumab (Vectibix)3/1/17
CP.PHAR.382 (PDF)Panobinostat (Farydak)11/16/16
CP.PHAR.282 (PDF)Parathyroid Hormone (Natpara)11/16/16
CP.PHAR.270 (PDF)Paricalcitol Injection (Zemplar)8/1/16
CP.PHAR.332 (PDF)Pasireotide (Signifor, Signifor LAR)3/1/17
CP.PMN.205 (PDF)Patiromer (Veltassa)9/1/19
CP.PHAR.395 (PDF)Patisiran (Onpattro)9/11/18
CP.PHAR.81 (PDF)Pazopanib (Votrient)10/1/11
CP.PMN.220 (PDF)Peanut Allergen Powder-dnfp (Palforzia)3/1/20
CP.PHAR.185 (PDF)Pegaptanib (Macugen)3/1/16
CP.PHAR.353 (PDF)Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas)9/5/17
CP.PHAR.524 (PDF)Pegcetacoplan (Empaveli, APL-2)3/1/21
CP.PHAR.296 (PDF)Pegfilgrastim (Neulasta, Neulasta Onpro), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-pbbk (Fylnetra), Pegfilgrastim-apgf (Nyvepria), Eflapegrastim-xnst (Rolvedon), Pegfilgrastim-fpgk (Stimufend), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziexten12/1/16
CP.PHAR.89 (PDF)Peginterferon Alfa-2a,b (Pegasys, PegIntron)10/1/11
CP.PHAR.271 (PDF)Peginterferon Beta-1a (Plegridy)8/1/16
CP.PHAR.115 (PDF)Pegloticase (Krystexxa)6/1/13
CP.PHAR.512 (PDF)Pegunigalsidase Alfa (PRX-102)12/1/20
CP.PHAR.140 (PDF)Pegvaliase-pqpz (Palynziq)7/31/18
CP.PHAR.389 (PDF)Pegvisomant (Somavert)12/1/18
CP.PHAR.587 (PDF)Pegzilarginase (AEB1102)9/1/22
CP.PHAR.322 (PDF)Pembrolizumab (Keytruda)3/1/17
CP.PHAR.368 (PDF)Pemetrexed (Alimta, Pemfexy)10/31/17
CP.PHAR.496 (PDF)Pemigatinib (Pemazyre)9/1/20
CP.PMN.276 (PDF)Pentosan Polysulfate Sodium (Elmiron)6/1/22
CP.PMN.156 (PDF)Perampanel (Fycompa)11/16/16
CP.PMN.174 (PDF)Perindopril/Amlodipine (Prestalia)12/1/18
CP.PHAR.227 (PDF)Pertuzumab (Perjeta)6/1/16
CP.PHAR.501 (PDF)Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo)9/1/20
CP.PHAR.436 (PDF)Pexidartinib (Turalio)12/1/19
CP.PMN.270 (PDF)Pilocarpine (Vuity)12/1/21
CP.PMN.140 (PDF)Pimavanserin (Nuplazid)11/16/16
CP.PHAR.286 (PDF)Pirfenidone (Esbriet)10/1/16
CP.PMN.221 (PDF)Pitolisant (Wakix)3/1/20
CP.PHAR.513 (PDF)Plasminogen, Human-tvmh (Ryplazim)6/3/21
CP.PMN.87 (PDF)Plecanatide (Trulance)2/1/17
CP.PHAR.323 (PDF)Plerixafor (Mozobil)3/1/17
CP.PHAR.433 (PDF)Polatuzumab Vedotin-piiq (Polivy)9/1/19
CP.PHAR.116 (PDF)Pomalidomide (Pomalyst)7/1/13
CP.PHAR.112 (PDF)Ponatinib (Iclusig)6/1/13
CP.PHAR.537 (PDF)Ponesimod (Ponvory)6/1/21
CP.PHAR.313 (PDF)Pralatrexate (Folotyn)2/1/17
CP.PHAR.514 (PDF)Pralsetinib (Gavreto)12/1/20
CP.PMN.129 (PDF)Pramlintide (Symlin)6/1/18
CP.PMN.99 (PDF)Prasterone (Intrarosa)12/20/16
CP.PMN.33 (PDF)Pregabalin (Lyrica, Lyrica CR)1/1/07
CP.PMN.222 (PDF)Pretomanid3/1/20
CP.PMN.243 (PDF)Progesterone (Crinone, Endometrin, Milprosa)9/1/20
CP.PMN.58 (PDF)Propranolol HCl Oral Solution (Hemangeol)5/1/14
CP.PHAR.330 (PDF)Protein C Concentrate, Human (Ceprotin)3/1/17
CP.PMN.194 (PDF)Prucalopride (Motegrity)1/29/19
NM.CP.PPA.15 (PDF)Psychotropic (behavioral health) Medications 
NM.CP.PPA.18 (PDF)Psychotropic Medication Use Parameters for Children 
CP.PMN.44  (PDF)Pyrimethamine (Daraprim)11/1/15
CP.PMN.59 (PDF)Quantity Limit Override and Dose Optimization11/9/17
CP.PMN.262 (PDF)Quinine Sulfate (Qualaquin)6/1/21
CP.PMN.173 (PDF)Ramelteon (Rozerem)12/1/18
CP.PHAR.119 (PDF)Ramucirumab (Cyramza)5/1/15
CP.PHAR.186 (PDF)Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo)4/1/16
CP.PMN.34 (PDF)Ranolazine (Ranexa, Aspruzyo Sprinkle)8/1/09
CP.PHAR.415 (PDF)Ravulizumab-cwvz (Ultomiris)2/19/19
CP.PHAR.107 (PDF)Regorafenib (Stivarga)12/1/12
CP.PHAR.529 (PDF)Relugolix (Orgovyx), Relugolix/Estradiol/Norethinedrone (Myfembree)6/1/21
CP.PHAR.474 (PDF)Remestemcel-L (Ryoncil)6/1/20
CP.PHAR.168 (PDF)Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel)3/1/16
CP.PMN.16 (PDF)Request for Medically Necessary Drug Not on the PDL11/9/17
CP.PHAR.223 (PDF)Reslizumab (Cinqair)5/1/16
CP.PHAR.141 (PDF)Ribavirin (Rebetol, Ribasphere)11/16/16
CP.PHAR.334 (PDF)Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara)5/1/17
CP.PMN.223 (PDF)Rifabutin (Mycobutin)3/1/20
CP.PMN.196 (PDF)Rifamycin (Aemcolo)1/8/19
CP.PMN.05 (PDF)Rifapentine (Priftin)2/1/16
CP.PMN.47 (PDF)Rifaximin (Xifaxan)11/1/11
CP.PHAR.266 (PDF)Rilonacept (Arcalyst)11/16/16
CP.PHAR.233 (PDF)RimabotulinumtoxinB (Myobloc)7/1/16
CP.PHAR.490 (PDF)Rimegepant (Nurtec ODT)9/1/20
CP.PHAR.195 (PDF)Riociguat (Adempas)3/1/16
CP.PHAR.502 (PDF)Ripretinib (Qinlock)9/1/20
CP.PHAR.426 (PDF)Risankizumab-rzaa (Skyrizi)6/3/19
CP.PHAR.477 (PDF)Risdiplam (Evrysdi)8/6/20
CP.PMN.100 (PDF)Risedronate (Actonel, Atelvia)3/1/18
CP.PMN.247 (PDF)Rivaroxaban (Xarelto)9/1/20
CP.PMN.101 (PDF)Rivastigmine (Exelon)3/1/17
CP.PMN.46  (PDF)Roflumilast (Daliresp, Zoryve)11/30/11
CP.PMN.102 (PDF)Rolapitant (Varubi)2/1/17
CP.PHAR.314 (PDF)Romidepsin (Istodax)1/1/17
CP.PHAR.179 (PDF)Romiplostim (Nplate)3/1/16
CP.PHAR.428 (PDF)Romosozumab-aqqg (Evenity)9/1/19
CP.PHAR.570 (PDF)Ropeginterferon Alfa-2b-njft (BESREMi)3/1/22
CP.PHAR.599 (PDF)RP-L20112/1/22
CP.PHAR.350 (PDF)Rucaparib (Rubraca)9/1/17
CP.PMN.157 (PDF)Rufinamide (Banzel)12/1/14
CP.PHAR.98 (PDF)Ruxolitinib (Jakafi, Opzelura)3/1/12
CP.PHAR.475 (PDF)Sacituzumab Govitecan-hziy (Trodelvy)6/1/20
CP.PMN.113 (PDF)Safinamide (Xadago)7/1/17
CP.PHAR.43 (PDF)Sapropterin Dihydrochloride (Kuvan)2/1/10
CP.PMN.189 (PDF)Sarecycline (Seysara)11/13/18
CP.PHAR.295 (PDF)Sargramostim (Leukine)12/1/16
CP.PHAR.346 (PDF)Sarilumab (Kevzara)7/18/17
CP.PHAR.463 (PDF)Satralizumab-mwge (Enspryng) 3/1/20
CP.PHAR.159 (PDF)Sebelipase Alfa (Kanuma)2/1/16
CP.PMN.103 (PDF)Secnidazole (Solosec)10/24/17
CP.PHAR.261 (PDF)Secukinumab (Cosentyx)8/1/16
CP.PHAR.196 (PDF)Selexipag (Uptravi)3/1/16
CP.PHAR.431 (PDF)Selinexor (Xpovio)9/1/19
CP.PHAR.478 (PDF)Selpercatinib (Retevmo)6/1/20
CP.PHAR.464 (PDF)Selumetinib (Koselugo)3/1/20
CP.PHAR.491 (PDF)Setmelanotide (Imcivree)9/1/20
CP.PMN.83  (PDF)Short Ragweed Pollen Allergen Extract (Ragwitek)8/31/17
CP.PHAR.197 (PDF)Sildenafil (Revatio)3/1/16
CP.PHAR.329 (PDF)Siltuximab (Sylvant)3/1/17
CP.PHAR.427 (PDF)Siponimod (Mayzent)9/1/19
CP.PHAR.120 (PDF)Sipuleucel-T (Provenge)6/1/15
CP.PHAR.574 (PDF)Sirolimus Protein-Bound Particles (Fyarro), Topical Gel (Hyftor)3/1/22
CP.PMN.42 (PDF)Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, and Sodium Oxybate (Xywav)5/1/11
CP.PHAR.208 (PDF)Sodium Phenylbutyrate (Buphenyl, Pheburane)5/1/16
CP.PHAR.584 (PDF)Sodium Phenylbutyrate/Taurursodiol (Relyvrio)6/1/22
CP.PMN.163 (PDF)Sodium Zirconium Cyclosilicate (Lokelma)7/24/18
CP.PMN.14 (PDF)Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors9/19/18
NM.CP.PPA.06 (PDF)sofosbuvir (Sovaldi) 
NM.CP.PPA.03 (PDF)sofosbuvir-velpatasvir (Epclusa) 
NM.CP.PPA.05 (PDF)sofosbuvir-velpatasvir-voxilaprevir (Vosevi) 
CP.PMN.209 (PDF)Solriamfetol (Sunosi)9/1/19
CP.PHAR.272 (PDF)Sonidegib (Odomzo)5/1/12
CP.PHAR.69 (PDF)Sorafenib (Nexavar)7/1/11
CP.PHAR.549 (PDF)Sotorasib (Lumakras)9/1/21
CP.PHAR.541 (PDF)Sotrovimab (VIR-7831)9/1/21
CP.PMN.60  (PDF)SSRI/SNRI Duplicate Therapy5/31/14
CP.PMN.184 (PDF)Stiripentol (Diacomit)9/25/18
CP.PHAR.73 (PDF)Sunitinib (Sutent)9/1/11
CP.PHAR.503 (PDF)Sutimlimab-jome (Enjaymo)2/3/22
CP.PMN.109 (PDF)Suvorexant (Belsomra)2/1/17
CP.PMN.85  (PDF)Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair)8/31/17
CP.PHAR.198 (PDF)Tadalafil (Adcirca, Alyq, Tadliq)3/1/16
CP.PMN.132 (PDF)Tadalafil BPH - ED (Cialis)6/1/18
CP.PHAR.432 (PDF)Tafamidis (Vyndaqel, Vyndamax)9/1/19
CP.PHAR.508 (PDF)Tafasitamab-cxix (Monjuvi)12/1/20
CP.PHAR.409 (PDF)Talazoparib (Talzenna)11/27/18
CP.PHAR.157 (PDF)Taliglucerase Alfa (Elelyso)2/1/16
CP.PHAR.542 (PDF)Talimogene laherepvec (Imlygic)9/1/21
CP.PMN.283 (PDF)Tapinarof (Vtama)12/1/22
CP.PMN.104 (PDF)Tasimelteon (Hetlioz, Hetlioz LQ)2/1/17
CP.PMN.105 (PDF)Tavaborole (Kerydin) 3/1/18
CP.PMN.244 (PDF)Tazarotene (Arazlo, Fabior, Tazorac)9/1/20
CP.PHAR.452 (PDF)Tazemetostat (Tazverik)3/1/20
CP.PHAR.575 (PDF)Tebentafusp-tebn (Kimmtrak)6/1/22
CP.PMN.62 (PDF)Tedizolid (Sivextro)3/1/15
CP.PHAR.114 (PDF)Teduglutide (Gattex)5/1/13
CP.PMN.206 (PDF)Tegaserod (Zelnorm)9/1/19
CP.PHAR.337 (PDF)Telotristat Ethyl (Xermelo)6/1/17
CP.PHAR.77 (PDF)Temozolomide (Temodar)9/1/11
CP.PHAR.324 (PDF)Temsirolimus (Torisel)3/1/17
CP.PMN.224 (PDF)Tenapanor (Ibsrela)3/1/20
CP.PMN.268 (PDF)Tenofovir Alafenamide Fumarate (Vemlidy)12/1/21
CP.PHAR.492 (PDF)Teplizumab (PRV-031)9/1/20
CP.PHAR.530 (PDF)Tepotinib (Tepmetko)6/1/21
CP.PHAR.465 (PDF)Teprotumumab (Tepezza)1/21/20
CP.PHAR.262 (PDF)Teriflunomide (Aubagio)8/1/16
CP.PHAR.188 (PDF)Teriparatide (Forteo)11/15/17
CP.PHAR.109 (PDF)Tesamorelin (Egrifta SV)3/1/14
CP.PHAR.354 (PDF)Testosterone (Testopel, Jatenzo, Kyzatrex, Tlando)8/1/17
CP.PHAR.92 (PDF)Tetrabenazine (Xenazine)12/1/11
CP.PHAR.377 (PDF)Tezacaftor/Ivacaftor; Ivacaftor (Symdeko)4/3/18
CP.PHAR.576 (PDF)Tezepelumab-ekko (Tezspire)6/1/22
CP.PHAR.78 (PDF)Thalidomide (Thalomid)9/1/11
CP.PHAR.437 (PDF)Thioguanine (Tabloid)12/1/19
CP.PHAR.95 (PDF)Thyrotropin Alfa (Thyrogen)3/1/12
CP.PHAR.386 (PDF)Tildrakizumab-asmn (Ilumya)5/1/18
CP.PMN.84  (PDF)Timothy Grass Pollen Allergen Extract (Grastek)8/31/17
CP.PHAR.361 (PDF)Tisagenlecleucel (Kymriah)9/26/17
CP.PHAR.561 (PDF)Tisotumab Vedotin-tftv (Tivdak)12/1/21
CP.PHAR.538 (PDF)Tivozanib (Fotivda)6/1/21
CP.PHAR.211 (PDF)Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler)5/1/16
CP.PHAR.263 (PDF)Tocilizumab (Actemra)7/1/16
CP.PHAR.267 (PDF)Tofacitinib (Xeljanz, Xeljanz XR)1/30/18
CP.PHAR.591 (PDF)Tofersen (BIIB067)12/1/22
CP.PHAR.27 (PDF)Tolvaptan (Jynarque, Samsca)6/5/18
CP.PMN.107 (PDF)Topical Immunomodulators9/1/06
CP.PMN.281 (PDF)Topiramate Extended-Release (Qudexy XR, Trokendi XR)9/1/22
CP.PHAR.64 (PDF)Topotecan (Hycamtin)6/1/11
CP.PMN.126 (PDF)Toremifene (Fareston)4/1/10
CP.PHAR.204 (PDF)Trabectedin (Yondelis)5/1/16
CP.PHAR.577 (PDF)Tralokinumab-ldrm (Adbry)6/1/22
CP.PHAR.240 (PDF)Trametinib (Mekinist)7/1/16
CP.PHAR.228 (PDF)Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase6/1/16
CP.PHAR.199  (PDF)Treprostinil (Orenitram, Remodulin, Tyvaso, Tyvaso DPI)3/1/16
CP.PHAR.371 (PDF)Triamcinolone ER Injection (Zilretta)3/1/18
CP.PMN.207 (PDF)Triclabendazole (Egaten)9/1/19
CP.PHAR.438 (PDF)Trientine (Cuvrior, Syprine)12/1/19
CP.PMN.225 (PDF)Trifarotene (Aklief)3/1/20
CP.PHAR.383 (PDF)Trifluridine/Tipiracil (Lonsurf)11/16/16
CP.PHAR.509 (PDF)Triheptanoin (Dojolvi)12/1/20
CP.PHAR.175 (PDF)Triptorelin Pamoate (Trelstar, Triptodur)11/9/17
CP.PHAR.600 (PDF)Trofinetide (NNZ-2566)12/1/22
CP.PHAR.497 (PDF)Tucatinib (Tukysa)9/1/20
CP.PHAR.476 (PDF)Ubrogepant (Ubrelvy)6/1/20
CP.PHAR.557 (PDF)Udenafil12/1/21
CP.PMN.277 (PDF)Ulcer Therapy Combinations6/1/22
CP.PHAR.531 (PDF)Umbralisib (Ukoniq)6/1/21
CP.PHAR.443 (PDF)Upadacitinib (Rinvoq)12/1/19
CP.PHAR.264 (PDF)Ustekinumab (Stelara)8/1/16
CP.PHAR.466 (PDF)Valoctocogene Roxaparvovec3/1/20
CP.PHAR.439 (PDF)Valrubicin (Valstar)12/1/19
CP.PHAR.80 (PDF)Vandetanib (Caprelsa)10/1/11
CP.PMN.273 (PDF)Varenicline (Tyrvaya)3/1/22
CP.PHAR.265 (PDF)Vedolizumab (Entyvio)7/1/16
CP.PHAR.163 (PDF)Velaglucerase Alfa (VPRIV)2/1/16
CP.PHAR.601 (PDF)Velmanase Alfa (Lamazym, Lamzede)12/1/22
CP.PHAR.91 (PDF)Vemurafenib (Zelboraf)11/1/11
CP.PHAR.129 (PDF)Venetoclax (Venclexta)9/1/18
CP.PHAR.187 (PDF)Verteporfin (Visudyne)3/1/16
CP.PHAR.374 (PDF)Vestronidase Alfa-vjbk (Mepsevii)1/19/18
CP.PHAR.169  (PDF)Vigabatrin (Sabril)2/1/16
CP.PMN.145 (PDF)Vilazodone (Viibryd)8/1/12
CP.PHAR.484 (PDF)Viltolarsen (Viltepso)8/12/20
CP.PHAR.315 (PDF)Vincristine Sulfate Liposome Injection (Marqibo)2/1/17
CP.PHAR.273 (PDF)Vismodegib (Erivedge)8/1/16
CP.PHAR.504 (PDF)Voclosporin (Lupkynis)9/1/20
CP.PHAR.372 (PDF)Voretigene Neparvovec-rzyl (Luxturna)3/1/18
CP.PHAR.83 (PDF)Vorinostat (Zolinza)12/1/12
CP.PHAR.525 (PDF)Vosoritide (Voxzogo)3/1/21
CP.PHAR.451 (PDF)Voxelotor (Oxbryta)3/1/20
CP.PHAR.550 (PDF)Vutrisiran (Amvuttra)12/1/21
CP.PHAR.467 (PDF)Zanubrutinib (Brukinsa)3/1/20
CP.PHAR.325 (PDF)Ziv-aflibercept (Zaltrap)3/1/17
CP.PHAR.59 (PDF)Zoledronic Acid (Reclast, Zometa)3/1/11
CP.PMN.172 (PDF)Zolpidem Tartrate (Edluar, Intermezzo, Zolpimist)12/1/18

Payment Policies

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding.  They are used to help identify whether health care services are correctly coded for reimbursement.  Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for  physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the Western Sky Community Care Payment Policy Manual apply with respect to Western Sky Community Care members. Policies in the Western Sky Community Care Payment Policy Manual may have either a Western Sky Community Care or a “Centene” heading.  In addition, Western Sky Community Care 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 Western Sky Community Care.     

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

Policy NumberPolicy Title Effective Date
CC.PP.5003-Day Payment Window (PDF) 
CC.PP.030Add on Code Billed Without Primary Code (PDF) 
CC.PP.029Assistant Surgeon (PDF) 
CC.PP.037Bilateral Procedures (PDF) 
CC.PP.008Cerumen Removal (PDF) 
CC.PP.021Clean Claims (PDF) 
CC.PP.011Coding Overview (PDF) 
CC.PP.024Cosmetic Procedures (PDF) 
CC.PP.020Distinct Procedural Modifiers (PDF) 
CC.PP.044Duplicate Primary Code Billing (PDF) 
CP.MP.155EEG in the Evaluation of Headache (PDF)6/1/24
CC.PP.010EM Bundling Edits (PDF) 
CC.PP.051E&M Medical Decision-Making (PDF) 
CP.MP.134Evoked Potential Testing (PDF)6/1/24
CP.MP.209Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)9/2/24
CG.PP.551Genetic and Molecular Testing Services (PDF) 
CC.PP.016Global Maternity Billing (PDF) 
CP.MP.113Holter Monitors (PDF)6/1/24
CC.PP.023Hospital Visit Codes Billed with Labs (PDF) 
CC.PP.038Inpatient Consultation (PDF) 
CC.PP.018Inpatient Only Procedures (PDF) 
CC.PP.012IV Hydration (PDF) 
CP.MP.123Laser Therapy for Skin Conditions (PDF)6/1/24
CC.PP.053Leveling of ER Services (PDF) 
CC.PP.007Maximum Units (PDF) 
CP.MP.152Measurement of Serum 1,25-dihydroxyvitamin D (PDF)6/1/24
CC.PP.015Moderate Conscious Sedation (PDF) 
CC.PP.013Modifier -25 clinical validation (PDF) 
CC.PP.014Modifier -59 clinical validation (PDF) 
CC.PP.034Modifier DOS Validation (PDF) 
CC.PP.028Modifier to Procedure Code Validation (PDF) 
CC.PP.033Multiple CPT Code Replacement (PDF) 
CC.PP.031NCCI Unbundling (PDF) 
CC.PP.017Never Paid Events (PDF) 
CC.PP.036New Patient (PDF) 
CC.PP.039Outpatient Consultation (PDF) 
CC.PP.019Physician Visit Codes Billed with Labs (PDF) 
CC.PP.063Place of Service Mismatch (PDF) 
CC.PP.041Pre-Operative Visits (PDF) 
CC.PP.042Post-Operative Visits (PDF) 
CC.PP.052Problem Oriented Visits with Surgical Procedures (PDF) 
CC.PP.027Professional Component (PDF) 
CP.MP.242Pulmonary Function Testing (PDF)6/1/24
CC.PP.025Pulse Oximetry (PDF) 
CC.PP.040Same Day Visits (PDF) 
CC.PP.206Skilled Nursing Facility Leveling (PDF)2/21/24
CC.PP.046Status "B" Bundled Services (PDF) 
CC.PP.049Status P Bundled Services (PDF) 
CC.PP.032Supplies Billed on Same Day As Surgery (PDF) 
NM.CP.MP.97Testing for Select Genitourinary Conditions12/5/23
CC.PP.047Transgender Related Services (PDF) 
CP.MP.38Ultrasound in Pregnancy (PDF)6/1/24
CC.PP.043Unbundled Professional Services (PDF) 
CC.PP.045Unbundled Surgical Procedures (PDF) 
CC.PP.009Unlisted Procedure Codes (PDF) 
CC.PP.056Urine Specimen Validity Testing (PDF) 
CP.MP.98Urodynamic Testing (PDF)6/1/24
CC.PP.502Wheelchair Accessories (PDF) 
CP.MP.99Wheelchair Seating (PDF)9/2/24