Policy Title |
Policy Number |
Effective Date |
---|
Abatacept (Orencia) (PDF) |
CP.PHAR.241 |
August 1, 2021 - NEW |
AbobotulinumtoxinA (Dysport) (PDF) |
CP.PHAR.230 |
June 1, 2020 |
Ado-trastuzumab (Kadcyla) (PDF) |
CP.PHAR.229 |
June 1, 2021 |
Adopted Clinical Practice and Preventive Health Guidelines (PDF) |
N/A |
June 1, 2020 |
Adult Rehabilitative Day Service (Psychosocial Rehabilitation Services)(PDF) |
CP.BH.AR.1800 |
March 1, 2019 |
Afamelanotide (Scenesse) (PDF) |
CP.PHAR.444 |
June 1, 2020 |
Aflibercept (Eylea) (PDF) |
CP.PHAR.184 |
June 1, 2020 |
Agalsidase beta (Fabrazyme) (PDF) |
CP.PHAR.158 |
August 1, 2021 - NEW |
Alemtuzumab (Lemtrada) (PDF) |
CP.PHAR.243 |
June 1, 2020 |
Alglucosidase (Lumizyme) (PDF) |
CP.PHAR.160 |
June 1, 2021 |
Allogenic Hematopoietic Cell Transplants for Sickle Cell (PDF) |
CP.MP.108 |
January 1, 2021 |
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF) |
CP.PHAR.94 |
June 1, 2020 |
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) |
CP.PHAR.217 |
December 1, 2020 |
Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) |
CP.PHAR.506 |
December 1, 2020 |
Apalutamide (Erleada) (PDF) |
CP.PHAR.376 |
August 1, 2021 - NEW |
Applied Behavioral Analysis for Autism (PDF) |
CP.BH.104 |
June 1, 2019 |
Articular Cartilage Defect Repairs (PDF) |
CP.MP.26 |
April 1, 2021 |
Assistive Reproductive Technology (PDF) |
CP.MP.55 |
May 1, 2021 |
Atezolizumab (Tecentriq) (PDF) |
CP.PHAR.235 |
June 1, 2020 |
Avelumab (Bavencio) (PDF) |
CP.PHAR.333 |
June 1, 2020 |
axicabtagene ciloleucel (Yescarta®) (PDF) |
CP.PHAR.362 |
June 1, 2020 |
Azacitidine (Vidaza) (PDF) |
CP.PHAR.387 |
December 1, 2020 |
Balloon Sinus Ostial Dilation (PDF) |
CP.MP.119 |
November 1, 2020 |
Behavioral Assistance (Therapeutic Behavioral Services) (PDF) |
CP.BH.AR.1900 |
March 1, 2019 |
Belantamab mafodotin (Blenrep) (PDF) |
CP.PHAR.469 |
December 1, 2020 |
Belatacept (Nulojix) (PDF) |
CP.PHAR.201 |
December 1, 2020 |
Belimumab (Benlysta) (PDF) |
CP.PHAR.88 |
June 1, 2021 |
Belinostat (Beleodaq) (PDF) |
CP.PHAR.311 |
December 1, 2020 |
Bendamustine (Bendeka, Treanda) (PDF) |
CP.PHAR.307 |
December 1, 2020 |
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) |
CP.PHAR.93 |
March 1, 2021 |
Bimatoprost Implant (Durysta)(PDF) |
CP.PHAR.486 |
June 1, 2020 |
Binimetinib (Mektovi) (PDF) |
CP.PHAR.50 |
August 1, 2021 - NEW |
Biofeedback (PDF) |
CP.MP.168 |
July 1, 2020 |
Biologic DMARDs (PDF) |
HIM.PA.SP60 |
August 1, 2021 - NEW |
Bone-Anchored Hearing Aid (PDF) |
CP.MP.93 |
October 1, 2020 |
Bosutinib (Bosulif) (PDF) |
CP.PHAR.105 |
August 1, 2021 - NEW |
Brentuximab Vedotin (Adcetris) (PDF) |
CP.PHAR.303 |
September 1, 2020 |
Brexanolone (Zulresso) (PDF) |
CP.PHAR.417 |
June 1, 2020 |
Brexucabtagene Autoleucel (Tecartus) (PDF) |
CP.PHAR.472 |
September 1, 2020 |
Brolucizumab-dbll (Beovu) (PDF) |
CP.PHAR.445 |
March 1, 2021 |
C1 Esterase Inhibitors (PDF) |
CP.PHAR.202 |
June 1, 2020 |
cabazitaxel (Jevtana®) (PDF) |
CP.PHAR.316 |
August 1, 2021 - NEW |
Caplacizumab-yhdp (Cablivi) (PDF) |
CP.PHAR.416 |
June 1, 2021 |
Canakinumab (Ilaris) (PDF) |
CP.PHAR.246 |
August 1, 2021 - NEW |
Carfilzomib (Kyprolis) (PDF) |
CP.PHAR.309 |
December 1, 2020 |
Carrier Screening in Pregnancy (PDF) |
CP.MP.83 |
July 1, 2020 |
Casimersen (Amondys 45) (PDF) |
CP.PHAR.470 |
June 1, 2021 |
Caudal or Interlaminar Epidural Steroid Injections (PDF) |
CP.MP.164 |
December 10, 2018 |
Cell-Free Fetal DNA Testing (PDF) |
CP.MP.84 |
March 16, 2017 |
Cemiplimab-rwlc (Libtayo) (PDF) |
CP.PHAR.397 |
June 1, 2021 |
Certolizumab (Cimzia) (PDF) |
CP.PHAR.247 |
August 1, 2021 - NEW |
Cetuximab (Erbitux) (PDF) |
CP.PHAR.317 |
December 1, 2020 |
Child and Youth Support Services (PDF) |
CP.BH.AR.1700 |
March 1, 2019 |
Clinical Policy: Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) |
CP.PHAR.260 |
August 1, 2021 - NEW |
Clinical Trials (PDF) |
CP.MP.94 |
December 1, 2017 |
Cochlear Implant Replacements (PDF) |
CP.MP.14 |
May 1, 2019 |
Continuous Insulin Delivery Systems (V-Go, Omnipod) (PDF) |
CP.PHAR.505 |
December 1, 2020 |
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) |
CP.PHAR.385 |
September 1, 2020 |
Cosmetic Reconstructive Surgery (PDF) |
CP.MP.31 |
March 1, 2021 |
Cosyntropin (Cortrosyn) (PDF) |
CP.PHAR.203 |
March 1, 2021 |
Crisis Intervention (PDF) |
CP.BH.AR.1500 |
March 1, 2019 |
Crizanlizumab-tmca (Adakveo) (PDF)
|
CP.PHAR.449 |
June 1, 2020 |
Dabrafenib (Tafinlar) (PDF) |
CP.PHAR.239 |
August 1, 2021 - NEW |
Daratumumab (Darzalex) (PDF) |
CP.PHAR.310 |
March 1, 2021 |
Darbepoetin alfa (Aranesp) (PDF) |
CP.PHAR.236 |
August 1, 2021 - NEW |
Daunorubicin-cytarabine (Vyxeos) (PDF) |
CP.PHAR.352 |
December 1, 2020 |
Deferoxamine (Desferal) (PDF) |
CP.PHAR.146 |
September 1, 2020 |
Denosumab (Prolia, Xgeva) (PDF) |
CP.PHAR.58 |
June 1, 2020 |
Dental Anesthesia (PDF) |
CP.MP.61 |
May 1, 2021 |
Dexrazoxane (Zinecard, Totect) (PDF) |
CP.PHAR.418 |
December 1, 2020 |
Diaphragmatic/Phrenic Nerve Stimulation (PDF) |
CP.MP.203 |
May 1, 2021 |
Disc Decompression Procedures (PDF) |
CP.MP.114 |
July 1, 2020 |
Discography (PDF) |
CP.MP.115 |
October 19, 2018 |
Donor lymphocyte infusion (PDF) |
CP.MP.101 |
December 1, 2020 |
Doxycycline (Doryx, Oracea, Acticlate) (PDF) |
CP.PMN.79 |
August 1, 2021 - NEW |
Drugs of Abuse: Presumptive Testing (PDF) |
CP.MP.208 |
July 1, 2021 |
Dupilumab (Dupixent) (PDF) |
CP.PHAR.336 |
June 1, 2020 |
Durable Medical Equipment (DME) (PDF) |
CP.MP.107 |
May 1, 2021 |
Durvalumab (Imfinzi) (PDF) |
CP.PHAR.339 |
August 1, 2021 - NEW |
Eculizumab (Soliris) (PDF) |
CP.PHAR.97 |
June 1, 2020 |
Edaravone (Radicava) (PDF) |
CP.PHAR.343 |
June 1, 2021 |
Elapegademase-lvlr (Revcovi) (PDF) |
CP.PHAR.419 |
August 1, 2021 - NEW |
Electric Tumor Treatment Fields (PDF) |
CP.MP.145 |
May 1, 2021 |
Elosulfase alfa (Vimizim) (PDF) |
CP.PHAR.162 |
June 1, 2021 |
Elotuzumab (Empliciti) (PDF) |
CP.PHAR.308 |
December 1, 2020 |
Enfortumab Vedotin-ejfv (Padcev) (PDF) |
CP.PHAR.455 |
June 1, 2020 |
Eptinezumab-jjmr (Vyepti) (PDF) |
CP.PHAR.489 |
March 1, 2021 |
Epoetin Alfa (Epogen® and Procrit) (PDF) |
CP.PHAR.237 |
August 1, 2021 - NEW |
Eribulin mesylate (Halaven) (PDF) |
CP.PHAR.318 |
March 1, 2021 |
Erwinia Asparaginase (Erwinaze) (PDF) |
CP.PHAR.301 |
June 1, 2020 |
Esketamine (Spravato) (PDF) |
CP.PMN.199 |
August 1, 2021 - NEW |
Esomeprazole-Naproxen (Vimovo) (PDF) |
CP.PMN.117 |
August 1, 2021 - NEW |
Essure Removal (PDF) |
CP.MP.131 |
December 1, 2020 |
Etelcalcetide (Parsabiv) (PDF) |
CP.PHAR.379 |
December 1, 2020 |
Eteplirsen (Exondys 51) (PDF) |
CP.PHAR.288 |
June 1, 2020 |
Evinacumab-dgnb (Evkeeza) (PDF) |
CP.PHAR.511 |
August 1, 2021 - NEW |
Experimental Technologies (PDF) |
CP.MP.36 |
March 15, 2017 |
Facet Joint Interventions (PDF) |
CP.MP.171 |
December 10, 2018 |
Factor VIII (Human Recombinant) (PDF) |
CP.PHAR.215 |
October 1, 2020 |
Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF) |
CP.PHAR.216 |
June 1, 2020 |
Factor IX (Human, Recombinant) (PDF) |
CP.PHAR.218 |
December 1, 2020 |
Factor XIII, Human (Corifact®) (PDF) |
CP.PHAR.221 |
December 1, 2020 |
Factor XIII A-Subunit, Recombinant (Tretten®) |
CP.PHAR.222 |
December 1, 2020 |
Family Support Partners (PDF) |
CP.BH.AR.1600 |
March 1, 2019 |
Famotidine-Ibuprofen (Duexis) (PDF) |
CP.PMN.120 |
August 1, 2021 - NEW |
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) |
CP.PHAR.456 |
June 1, 2020 |
Fecal incontinence treatments (PDF) |
CP.MP.137 |
March 5, 2019 |
Ferric Derisomaltose (Monoferric)(PDF) |
CP.PHAR.480 |
August 1, 2021 - NEW |
Ferriscan R2-MRI (PDF) |
CP.MP.53 |
December 1, 2020 |
Fertility Preservation (PDF) |
CP.MP.130 |
November 1, 2020 |
Fetal surgery in utero for prenatally diagnosed malformations (PDF) |
CP.MP.129 |
May 1, 2019 |
Fibrinogen concentrate (human) (Fibryga, RiaSTAP) (PDF) |
CP.PHAR.526 |
June 1, 2021 |
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) (PDF) |
CP.PHAR.297 |
March 1, 2021 |
Fixed Wing Air Transportation (PDF) |
CP.MP.175 |
February 1, 2021 |
Fulvestrant (Faslodex Injection) (PDF) |
CP.PHAR.424 |
September 1, 2020 |
Functional MRI (PDF) |
CP.MP.43 |
March 15, 2017 |
Galsulfase (Naglazyme) (PDF) |
CP.PHAR.161 |
June 1, 2021 |
Gastric Electrical Stimulation (PDF) |
CP.MP.40 |
March 15, 2017 |
Gemtuzumab (Mylotarg) (PDF) |
CP.PHAR.358 |
December 1, 2020 |
Gender reassignment surgery (PDF) |
CP.MP.95 |
February 1, 2021 |
Genetic Testing (PDF) |
CP.MP.89 |
May 1, 2021 |
Givosiran (Givlaari) (PDF) |
CP.PHAR.457 |
June 1, 2020 |
Golimumab (Simponi, Simponi Aria) (PDF) |
CP.PHAR.253 |
August 1, 2021 - NEW |
Golodirsen (Vyondys 53) (PDF) |
CP.PHAR.453 |
June 1, 2020 |
Group Psychotherapy (PDF) |
CP.BH.AR.600 |
March 1, 2019 |
Heart-Lung Transplant (PDF) |
CP.MP.132 |
October 19, 2018 |
Home Birth (PDF) |
CP.MP.136 |
February 1, 2021 |
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) |
CP.MP.150 |
March 1, 2021 |
Hospice Clinical Coverage (PDF) |
CP.MP.54 |
March 15, 2017 |
Hyaluronate derivatives (PDF) |
CP.PHAR.05 |
December 1, 2020 |
Hyperemesis Gravidarum Treatment (PDF) |
CP.MP.34 |
July 1, 2021 |
Hyperhidrosis Treatments (PDF) |
CP.MP.62 |
March 1, 2021 |
ibalizumab-uiyk (Trogarzo) (PDF) |
CP.PHAR.378 |
June 1, 2020 |
Ibandronate sodium (PDF) |
CP.PHAR.189 |
June 1, 2020 |
Idursulfase (Elaprase) (PDF) |
CP.PHAR.156 |
June 1, 2021 |
Imiglucerase (Cerezyme) (PDF) |
CP.PHAR.154 |
June 1, 2021 |
Immune Globulins (PDF) |
CP.PHAR.103 |
June 1, 2020 |
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) |
CP.MP.180 |
January 1, 2021 |
Implantable Intrathecal Pain Pump (PDF) |
CP.MP.173 |
March 1, 2021 |
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) |
CP.MP.160 |
January 1, 2020 |
IncobotulinumtoxinA (Xeomin) (PDF) |
CP.PHAR.231 |
June 1, 2020 |
Individual/Group Pharmacologic Counseling by RN (Medication Training and Support) (PDF) |
CP.BH.AR.1200 |
March 1, 2019 |
Inebilizumab (PDF) |
CP.PHAR.458 |
June 1, 2020 |
Infliximab (Remicade, Inflectra, Renflexis) (PDF) |
CP.PHAR.254 |
August 1, 2021 - NEW |
Infusion SOC optimization (PDF) |
CP.MP.159 |
October 31, 2019 |
Inhaled Nitric Oxide (PDF) |
CP.MP.87 |
January 1, 2021 |
Inotuzumab Ozogamicin (Besponsa) (PDF) |
CP.PHAR.359 |
October 1, 2020 |
Intensity Modulated Radiation Therapy (PDF) |
CP.MP.69 |
February 1, 2021 |
Interferon Gamma- 1b (Actimmune) (PDF) |
CP.PHAR.52 |
June 1, 2020 |
Interpretation of Diagnosis (PDF) |
CP.BH.AR.800 |
March 1, 2019 |
Intestinal & Multivisceral Transplant (PDF) |
CP.MP.58 |
July 1, 2020 |
Intradiscal Steroid Injections (PDF) |
CP.MP.167 |
October 1, 2020 |
Iobenguane I-131 (Azedra) (PDF) |
CP.PHAR.459 |
June 1, 2020 |
Ipilimumab (Yervoy) (PDF) |
CP.PHAR.319 |
August 1, 2021 - NEW |
Irinotecan Liposome (Onivyde) (PDF) |
CP.PHAR.304 |
March 1, 2020 |
Isatuximab-irfc (Sarclisa)(PDF) |
CP.PHAR.482 |
June 1, 2020 |
Isavuconazonium (Cresemba) (PDF) |
CP.PMN.154 |
June 1, 2021 |
Lanreotide (Somatuline Depot) (PDF) |
CP.PHAR.391 |
December 1, 2020 |
Laronidase (Aldurazyme) (PDF) |
CP.PHAR.152 |
August 1, 2021 - NEW |
Lefamulin (Xenleta)(PDF) |
CP.PMN.219 |
March 1, 2021 |
Lenalidomide (Revlimid) (PDF) |
CP.PHAR.71 |
August 1, 2021 - NEW |
Letermovir (Prevymis) (PDF) |
CP.PHAR.367 |
June 1, 2020 |
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) |
CP.PHAR.173 |
March 1, 2021 |
Levoleucovorin (Fusilev, Khapzory) (PDF) |
CP.PHAR.151 |
December 1, 2020 |
Lisocabtagene maraleucel (Breyanzi) (PDF) |
CP.PHAR.483 |
June 1, 2021 |
Lung Transplantation (PDF) |
CP.MP.57 |
July 1, 2020 |
Lurbinectedin (Zepzelca) (PDF) |
CP.PHAR.500 |
December 1, 2020 |
Lutetium Lu 177 Dotatate (Lutathera) (PDF) |
CP.PHAR.384 |
September 1, 2020 |
Lysis of Epidural Lesions (PDF) |
CP.MP.116 |
November 1, 2020 |
Marital Family BH Counseling with Beneficiary Present (PDF) |
CP.BH.AR.400 |
March 1, 2019 |
Marital Family BH Counseling without Beneficiary Present (PDF) |
CP.BH.AR.300 |
March 1, 2019 |
Mecasermin (Increlex) (PDF) |
CP.PHAR.150 |
December 1, 2020 |
Mechanical Stretch Devices (PDF) |
CP.MP.144 |
October 1, 2020 |
Medical Necessity Criteria (PDF) |
CP.MP.68 |
March 16, 2017 |
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF) |
CP.PHAR.134 |
June 1, 2020 |
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) |
CP.PHAR.238 |
June 1, 2020 |
Mitoxantrone (Novantrone) (PDF) |
CP.PHAR.258 |
August 1, 2021 - NEW |
Mometasone Furoate (Sinuva) (PDF) |
CP.PHAR.448 |
June 1, 2020 |
Multi-Family Behavioral Health Counseling (PDF) |
CP.BH.AR.500 |
March 1, 2019 |
Multiple Sleep Latency Testing (PDF) |
CP.MP.24 |
October 19, 2018 |
Nadofaragene Firadenovec (Instiladrin)(PDF) |
CP.PHAR.461 |
June 1, 2020 |
Naltrexone (Vivitrol) (PD) |
CP.PHAR.96 |
October 1, 2020 |
Natalizumab (Tysabri) (PDF) |
HIM.PA.SP17 |
June 1, 2021 |
Natalizumab (Tysabri) (PDF) |
CP.PHAR.259 |
December 1, 2020 |
Neonatal Abstinence Syndrome Guidelines (PDF) |
CP.MP.86 |
March 16, 2017 |
Neonatal Sepsis Management Guidelines (PDF) |
CP.MP.85 |
March 16, 2017 |
Netupitant and Palonosetron (Akynzeo) (PDF) |
CP.PMN.158 |
September 1, 2020 |
Nerve Blocks for Pain Management (PDF) |
CP.MP.170 |
February 1, 2021 |
NICU Apnea Bradycardia Guidelines (PDF) |
CP.MP.82 |
July 1, 2020 |
NICU Discharge Guidelines (PDF) |
CP.MP.81 |
June 30, 2020 |
Nivolumab (Opdivo) (PDF) |
CP.PHAR.121 |
June 1, 2020 |
No Coverage Criteria (PDF) |
CP.PMN.255 |
December 1, 2020 |
Non-Invasive Home Ventilator (PDF) |
CP.MP.184 |
December 1, 2020 |
Nonmyeloablative allogeneic stem cell transplant (PDF) |
CP.MP.141 |
April 1, 2021 |
nusinersen (Spinraza®) (PDF) |
CP.PHAR.327 |
June 1, 2020 |
OB Home Health Programs (PDF) |
CP.MP.91 |
May 1, 2021 |
Ocrelizumab (Ocrevus) (PDF) |
CP.PHAR.335 |
June 1, 2020 |
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF) |
CP.PHAR.40 |
September 1, 2020 |
Ofatumumab (Arzerra, Kesimpta) (PDF) |
CP.PHAR.306 |
August 1, 2021 - NEW |
Omalizumab (PDF) |
CP.PHAR.01 |
June 1, 2021 |
Omecetaxine (Synribo) (PDF) |
CP.PHAR.108 |
August 1, 2021 - NEW |
OnabotulinumtoxinA (Botox) (PDF) |
CP.PHAR.232 |
August 1, 2021 - NEW |
Onasemnogene abeparvovec (Zolgensma) (PDF) |
CP.PHAR.421 |
December 1, 2020 |
Optic Nerve Decompression Surgery (PDF) |
CP.MP.128 |
October 11, 2020 |
Outpatient Cardiac Rehabilitation (PDF) |
CP.MP.176 |
July 1, 2020 |
Outpatient Testing for Drugs of Abuse (PDF) |
CP.MP.50 |
July 1, 2021 |
Oxygen Use and Concentrators (PDF) |
CP.MP.190 |
January 1, 2021 |
Ozanimod(PDF) |
CP.PHAR.462 |
June 1, 2020 |
Pain Management Procedures (PDF) |
CP.MP.63 |
March 16, 2017 |
Palivizumab (Synagis) (PDF) |
CP.PHAR.16 |
August 1, 2021 - NEW |
Pancreas Transplantation (PDF) |
CP.MP.102 |
April 1, 2021 |
Panitumumab (Vectibix) (PDF) |
CP.PHAR.321 |
December 1, 2020 |
Panniculectomy (PDF) |
CP.MP.109 |
August 1, 2021 - NEW |
Paricalcitol Injection (Zemplar) (PDF) |
CP.PHAR.270 |
September 1, 2020 |
Pasireotide (Signifor, Signifor LAR) (PDF) |
CP.PHAR.332 |
December 1, 2020 |
Patisiran (Onpattro) (PDF) |
CP.PHAR.395 |
December 1, 2020 |
Peanut Allergen Powder-dnfp (Palforzia)(PDF) |
CP.PMN.220 |
June 1, 2020 |
Pediatric Heart Transplant (PDF) |
CP.MP.138 |
May 1, 2021 |
Pediatric Liver Transplant (PDF) |
CP.MP.120 |
March 1, 2021 |
Peer Support (PDF) |
CP.BH.AR.1300 |
March 1, 2019 |
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF) |
CP.PHAR.353 |
June 1, 2020 |
Pegaptanib (Macugen) (PDF) |
CP.PHAR.185 |
December 1, 2020 |
Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) (PDF) |
CP.PHAR.296 |
July 1, 2021 |
Pegvaliase-pqpz (Palynziq) (PDF) |
CP.PHAR.140 |
March 1, 2021 |
pembrolizumab (Keytruda®) (PDF) |
CP.PHAR.322 |
June 1, 2020 |
Pemetrexed (Alimta, Pemfexy) (PDF) |
CP.PHAR.368 |
June 1, 2020 |
Percutaneous LAAD Stroke Prevention (PDF) |
CP.MP.147 |
July 1, 2020 |
Pertuzumab (Perjeta) (PDF) |
CP.PHAR.227 |
August 1, 2021 - NEW |
Pertuzumab-trastuzumab-hyaluronidase-zzxf (Phesgo) (PDF) |
CP.PHAR.501 |
December 1, 2020 |
Pharmacologic Management (PDF) |
CP.BH.AR.1000 |
March 1, 2019 |
Phendimetrazine (PDF) |
HIM.PA.114 |
August 1, 2021 - NEW |
Pitolisant (Wakix) (PDF) |
CP.PMN.221 |
August 1, 2021 - NEW |
Polatuzumab Vedotin-piiq (Polivy) (PDF) |
CP.PHAR.433 |
September 1, 2020 |
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) |
CP.MP.181 |
March 15, 2021 |
Pomalidomide (Pomalyst) (PDF) |
CP.PHAR.116 |
August 1, 2021 - NEW |
Ponatinib (Iclusig) (PDF) |
CP.PHAR.112 |
August 1, 2021 - NEW |
Posterior Nerve Stimulation for Voiding Dysfunction (PDF) |
CP.MP.133 |
October 1, 2020 |
Pralatrexate (Folotyn) (PDF) |
CP.PHAR.313 |
December 1, 2020 |
Psychiatric Diagnosis Evaluation (PDF) |
CP.BH.AR.100 |
March 1, 2019 |
Psychoeducation Services (PDF) |
CP.BH.AR.2100 |
March 1, 2019 |
Psychological Evaluation of Psych Testing (PDF) |
CP.BH.AR.900 |
March 1, 2019 |
Psychotherapy (PDF) |
CP.BH.AR.200 |
March 1, 2019 |
Radial Head Implant (PDF) |
CP.MP.148 |
July 1, 2020 |
Radiofrequency Ablation of Uterine Fibroids (PDF) |
CP.MP.187 |
August 1, 2020 |
Ramucirumab (Cyramza) (PDF) |
CP.PHAR.119 |
December 1, 2020 |
Ranibizumab (Lucentis) (PDF) |
CP.PHAR.186 |
December 1, 2020 |
Reduction Mammoplasty and Gynecomastia Surgery (PDF) |
CP.MP.51 |
December 10, 2018 |
Rifamycin (Aemcolo) (PDF) |
CP.PMN.196 |
June 1, 2021 |
Rilonacept (Arcalyst) (PDF) |
CP.PHAR.266 |
August 1, 2021 - NEW |
RimabotulinumtoxinB (Myobloc) (PDF) |
CP.PHAR.233 |
June 1, 2020 |
Risdiplam (Evrysdi) (PDF) |
CP.PHAR.477 |
September 1, 2020 |
Romidepsin (Istodax) (PDF) |
CP.PHAR.314 |
December 1, 2020 |
Romiplostim (Nplate®) (PDF) |
CP.PHAR.179 |
December 1, 2020 |
Sacituzumab Govitecan-hziy (Trodelvy) (PDF) |
CP.PHAR.475 |
March 1, 2021 |
Sacroiliac Joint Fusion (PDF) |
CP.MP.126 |
April 18, 2017 |
Sacroiliac Joint Interventions for Pain Management (PDF) |
CP.MP.166 |
October 1, 2020 |
Sapropterin (Kuvan) (PDF) |
CP.PHAR.43 |
August 1, 2021 - NEW |
Sargramostim (Leukine) (PDF) |
CP.PHAR.295 |
September 1, 2020 |
Satralizumab(PDF) |
CP.PHAR.463 |
March 1, 2021 |
Sclerotherapy (PDF) |
CP.MP.146 |
October 1, 2020 |
Sebelipase alfa (Kanuma) (PDF) |
CP.PHAR.159 |
June 1, 2021 |
Selective Dorsal Rhizotomy (PDF) |
CP.MP.174 |
May 1, 2021 |
Selective Nerve Root Blocks and Transforaminal Epidural (PDF) |
CP.MP.165 |
October 1, 2020 |
Sipuleucel-T (Provenge) (PDF) |
CP.PHAR.120 |
August 1, 2021 - NEW |
Siltuximab (Sylvant) (PDF) |
CP.PHAR.329 |
March 1, 2021 |
Skilled Nursing Facility Leveling (PDF) |
CP.MP.206 |
March 1, 2021 |
Skin Substitutes for Chronic Wounds (PDF) |
CP.MP.185 |
June 1, 2020 |
Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, Sodium Oxybate (Xywav) (PDF) |
CP.PMN.42 |
August 1, 2021 - NEW |
Sonidegib (Odomzo) (PDF) |
CP.PHAR.272 |
August 1, 2021 - NEW |
Sorafenib (Nexavar) (PDF) |
CP.PHAR.69 |
August 1, 2021 - NEW |
Spinal Cord Stimulation (PDF) |
CP.MP.117 |
April 18, 2017 |
Stereotactic Body Radiation Therapy (PDF) |
CP.MP.22 |
March , 2021 |
Substance Abuse Assessment (PDF) |
CP.BH.AR.1100 |
March 1, 2019 |
Sunitinib (Sutent) (PDF) |
CP.PHAR.73 |
August 1, 2021 - NEW |
Supportive Employment (PDF) |
CP.BH.AR.2000 |
March 1, 2019 |
Supportive Housing (PDF) |
CP.BH.AR.1400 |
March 1, 2019 |
Tafasitamab-cxix (Monjuvi) (PDF) |
CP.PHAR.508 |
December 1, 2020 |
Taliglucerase alfa (Elelyso) (PDF) |
CP.PHAR.157 |
June 1, 2021 |
Tandem Transplant (PDF) |
CP.MP.162 |
May 1, 2019 |
Temozolomide (Temodar) |
CP.PHAR.77 |
August 1, 2021 - NEW |
Teprotumumab (Tepezza)(PDF) |
CP.PHAR.465 |
December 1, 2020 |
Testosterone (Testopel, Jatenzo) (PDF) |
CP.PHAR.354 |
December 1, 2020 |
Therapy Services (PT/OT/ST) (PDF) |
CP.MP.49 |
April 1, 2021 |
Thymus Transplantation (PDF) |
CP.MP.189 |
October 1, 2020 |
Tisagenlecleucel (Kymriah) (PDF) |
CP.PHAR.361 |
June 1, 2020 |
Tocilizumab (Actemra) (PDF) |
CP.PHAR.263 |
August 1, 2021 - NEW |
Topotecan (Hycamtin) (PDF) |
CP.PHAR.64 |
June 1, 2021 |
Toremifene (Fareston) (PDF) |
CP.PMN.126 |
August 1, 2021 - NEW |
Total Artificial Heart (PDF) |
CP.MP.127 |
January 1, 2021 |
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) |
CP.MP.163 |
January 1, 2020 |
Trametinib (Mekinist) (PDF) |
CP.PHAR.240 |
August 1, 2021 - NEW |
Transcatheter closure of patent foramen ovale (PDF) |
CP.MP.151 |
January 1, 2021 |
Transcranial Magnetic Stimulation(PDF) |
CP.MP.172 |
May 1, 2019 |
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) |
CP.PHAR.228 |
March 1, 2021 |
Treatment Plan (PDF) |
CP.BH.AR.700 |
March 1, 2019 |
Treprostinil (Orenitram®, Remodulin®, Tyvaso®) (PDF) |
CP.PHAR.199 |
June 1, 2020 |
Trigger Point Injections for Pain Management (PDF) |
CP.MP.169 |
February 1, 2021 |
Urinary Incontinence Devices and Treatments (PDF) |
CP.MP.142 |
May 1, 2021 |
Ustekinumab (Stelara) (PDF) |
CP.PHAR.264 |
August 1, 2021 - NEW |
Vagus Nerve Stimulation for Epilepsy (PDF) |
CP.MP.12 |
February 1, 2021 |
Valoctocogene Roxaparvovec(PDF) |
CP.PHAR.466 |
June 1, 2020 |
Valrubicin (Valstar) (PDF) |
CP.PHAR.439 |
December 1, 2020 |
Vedolizumab (Entyvio) (PDF) |
CP.PHAR.265 |
August 1, 2021 - NEW |
Velaglucerase alfa (VPRIV) (PDF) |
CP.PHAR.163 |
June 1, 2021 |
Ventricular Assist Devices (PDF) |
CP.MP.46 |
July 1, 2021 |
Verteporfin (Visudyne) (PDF) |
CP.PHAR.187 |
December 1, 2020 |
Vestronidase alfa-vjbk (Mepsevii) (PDF) |
CP.PHAR.374 |
June 1, 2021 |
Video Electroencephalographic (VEEG) Monitoring (PDF) |
CP.MP.177 |
June 1, 2020 |
Viltolarsen (Viltepso) (PDF) |
CP.PHAR.484 |
September 1, 2020 |
Vismodegib (Erivedge) (PDF) |
CP.PHAR.273 |
August 1, 2021 - NEW |
Wheelchair seating (PDF) |
CP.MP.99 |
October 1, 2018 |
Ziv-aflibercept (Zaltrap) (PDF) |
CP.PHAR.325 |
December 1, 2020 |
Zika Virus Testing (PDF) |
CP.MP.111 |
July 1, 2020 |
Zoledronic acid (PDF) |
CP.PHAR.59 |
June 1, 2020 |