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Clinical & Payment Policies

To easily search for a policy, use the Ctrl+F (Command+F on Mac) function on your keyboard to search by keyword, policy number, or effective date.

All policies found in the Arkansas Total Care Clinical Policy Manual apply to Arkansas Total Care members. Policies in the Arkansas Total Care Clinical Policy Manual may have an “Arkansas Total Care” or a “Centene” heading. Arkansas Total Care uses InterQual® criteria for services for which an Arkansas Total Care clinical policy does not exist. InterQual is a nationally recognized, evidence-based decision support tool. You may access the InterQual SmartSheets™ for adult and pediatric procedures, durable medical equipment (DME), and imaging procedures by logging in to our Secure Provider Portal or calling Arkansas Total Care at 1-866-282-6280 (TTY: 711).

Arkansas Total Care may use a vendor for the utilization management of certain services. In such cases, the vendor’s guidelines may also be used to support medical necessity and other coverage decisions. Other non-clinical policies, such as payment policies, or contract terms may also be used to determine if a service that is not addressed in the Clinical Policy Manual or InterQual criteria is payable by Arkansas Total Care.

Drug policies and criteria listed under this section are only applicable to products paid under the medical benefit. Please see “Arkansas Total Care Pharmacy Policies” for prior authorization criteria on drugs paid under the pharmacy benefit.

Policy TitlePolicy NumberEffective Date
25-hydroxyvitamin D Testing in Children and Adolescents (PDF)CP.MP.157November 1, 2023
Abatacept (Orencia) (PDF)CP.PHAR.241July 1, 2024
Abatacept (Orencia) (PDF)CP.PHAR.241Retire by July 1, 2024
AbobotulinumtoxinA (Dysport) (PDF)CP.PHAR.230June 1, 2024
Acupuncture (PDF)CP.MP.92September 1, 2023
Ado-Trastuzumab (Kadcyla) (PDF)CP.PHAR.229June 1, 2024
Aducanumab (Aduhelm) (PDF)CP.PHAR.468June 1, 2024
Afamelanotide (Scenesse) (PDF)CP.PHAR.444February 1, 2024
Aflibercept (Eylea) (PDF)CP.PHAR.184June 1, 2024
Agalsidase beta (Fabrazyme) (PDF)CP.PHAR.158July 1, 2024
Air Ambulance (PDF)CP.MP.175July 1, 2024
Alemtuzumab (Lemtrada) (PDF)CP.PHAR.243June 1, 2024
Alglucosidase (Lumizyme) (PDF)CP.PHAR.160July 1, 2024
Alglucosidase (Lumizyme) (PDF)CP.PHAR.160Retire by July 1, 2024
Allogeneic cultured keratinocytes and dermal fibroblasts (StrataGraft)(PDF)CP.PHAR.562February 1, 2024
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF)CP.MP.108December 1, 2023
Allogenic processed thymus tissue-agdc (Rethymic) (PDF)CP.PHAR.563February 1, 2024
Allergy Testing and Therapy (PDF)CP.MP.100November 1, 2023
Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF)CP.PHAR.94February 1, 2024
Amisulpride (Barhemsys) (PDF)CP.PMN.236February 1, 2024
Amivantamab-vmjw (Rybrevant) (PDF)CP.PHAR.544June 1, 2024
Anifrolumab-fnia (Saphnelo) (PDF)CP.PHAR.551January 1, 2024
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF)CP.PHAR.217February 1, 2024
Antithrombin III (ATryn, Thrombate III) (PDF)CP.PHAR.564February 1, 2024
Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF)CP.PHAR.506January 1, 2024
Adzynma (ADAMTS13, recombinant-krhn) (PDF) CP.PHAR.635 May 1, 2024
Applied Behavioral Analysis Documentation Requirements (PDF)CP.BH.105May 1, 2025
Aprepitant (Aponvie, Cinvanti, Emend), (PDF)CP.PMN.19May 1, 2024
Articular Cartilage Defect Repairs (PDF)CP.MP.26April 1, 2024
Asfotase Alfa (Strensiq) (PDF)CP.PHAR.328 December 1, 2022
Assistive Reproductive Technology (PDF)CP.MP.55 March 1, 2024
Atezolizumab (Tecentriq) (PDF)CP.PHAR.235April 1, 2024
Atidarsagene autotemcel (OTL-200) (PDF)CP.PHAR.602Pending FDA Approval
Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF)CP.BH.124August 1, 2023
Avacincaptad pegol (Izervay) (PDF)CP.PHAR.641May 1, 2024
Avalglucosidase Alfa-ngpt (Nexviazyme) (PDF)CP.PHAR.521July 1, 2024
Avalglucosidase Alfa-ngpt (Nexviazyme) (PDF)CP.PHAR.521Retire by July 1, 2024
Avelumab (Bavencio) (PDF)CP.PHAR.333February 1, 2024
Axicabtagene Ciloleucel (Yescarta®) (PDF)CP.PHAR.362February 1, 2024
Azacitidine (Vidaza) (PDF)CP.PHAR.387December 1, 2023
Baclofen (Gablofen, Lioresal, Lyvispah, Ozobax) (PDF)CP.PHAR.149December 1, 2023
Bamlanivimab-etesevimab (LY-CoV555-LY-CoV016) (PDF)CP.PHAR.532July 1, 2023
Bariatric Surgery (PDF)CP.MP.37May 1, 2023
Behavioral Health Treatment Documentation Requirements (PDF)CP.BH.500July 1, 2024
Belantamab mafodotin (Blenrep) (PDF)CP.PHAR.469June 1, 2024
Belatacept (Nulojix) (PDF)CP.PHAR.201December 1, 2023
Belimumab (Benlysta) (PDF)CP.PHAR.88 July 1, 2024
Belimumab (Benlysta) (PDF)CP.PHAR.88 Retire by July 1, 2024
Belinostat (Beleodaq) (PDF)CP.PHAR.311December 1, 2023
Bendamustine (Bendeka, Treanda) (PDF)CP.PHAR.307January 1, 2024
Benralizumab (Fasenra) (PDF)CP.PHAR.373July 1, 2024
Beremagene Geperpavec (Vyjuvek) (PDF) CP.PHAR.592 July 1, 2024
Beremagene Geperpavec (Vyjuvek) (PDF) CP.PHAR.592 Retire by July 1, 2024
Betibeglogene autotemcel (PDF)CP.PHAR.545 August 1, 2023
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF)CP.PHAR.93February 1, 2024
Bezlotoxumab (Zinplava) (PDF)CP.PHAR.300February 1, 2024
Bimatoprost Implant (Durysta)(PDF)CP.PHAR.486June 1, 2024
Biofeedback (PDF)CP.MP.168January 1, 2024
Biofeedback for Behavioral Health Disorders (PDF)CP.BH.300May 1, 2023
Blinatumomab (Blincyto) (PDF)CP.PHAR.312August 1, 2023
Bone-Anchored Hearing Aids (PDF)AR.CP.MP.93August 1, 2023
Bortezomib (Velcade) (PDF)CP.PHAR.410February 1, 2024
Bremelanotide (Vyleesi) (PDF)CP.PHAR.434 February 1, 2023
Brentuximab Vedotin (Adcetris) (PDF)CP.PHAR.303October 2, 2023
Brexanolone (Zulresso) (PDF)CP.PHAR.417June 1, 2024
Brexucabtagene Autoleucel (Tecartus) (PDF)CP.PHAR.472April 1, 2024
Brolucizumab-dbll (Beovu) (PDF)CP.PHAR.445 February 1, 2024
Burn Surgery (PDF)CP.MP.186April 1, 2024
Buprenorphine implant (Probuphine) (PDF)CP.PHAR.289May 1, 2024
C1 Esterase Inhibitors (Berinert Cinryze Haegarda Ruconest) (PDF)CP.PHAR.202May 1, 2024
Cabotegravir, Cabotegravir-Rilpivirine (Apretude Cabenuva) (PDF)CP.PHAR.573February 1, 2024
Cabazitaxel (Jevtana®) (PDF)CP.PHAR.316June 1, 2024
Canakinumab (Ilaris) (PDF)CP.PHAR.246July 1, 2024
Canakinumab (Ilaris) (PDF)CP.PHAR.246Retire by July 1, 2024
Caplacizumab-yhdp (Cablivi)CP.PHAR.416 June 1, 2024
Carbetocin (PDF)CP.PHAR.546Pending FDA Approval
Cardiac Biomarker Testing (PDF)CP.MP.156November 1, 2023
Carfilzomib (Kyprolis) (PDF)CP.PHAR.309January 1, 2024
Casimersen (Amondys 45) (PDF)CP.PHAR.470April 1, 2024
Casirivimab and Imdevimab (REGEN-COV) (PDF)CP.PHAR.520July 1, 2023
Caudal or Interlaminar Epidural Steroid Injections (PDF)CP.MP.164September 1, 2023
Cemiplimab-rwlc (Libtayo) (PDF)CP.PHAR.397January 1, 2024
Cerliponase alfa (Brineura) (PDF)CP.PHAR.338October 2, 2023
Certolizumab (Cimzia) (PDF)CP.PHAR.247July 1, 2024
Certolizumab (Cimzia) (PDF)CP.PHAR.247Retire by July 1, 2024
Cetuximab (Erbitux) (PDF)CP.PHAR.317January 1, 2024
Chloramphenicol (PDF)CP.PHAR.388August 1, 2023
Ciltacabtagene Autoleucel (Carvykti)(PDF)CP.PHAR.533 Retire by August 1, 2024
Ciltacabtagene Autoleucel (Carvykti)(PDF)CP.PHAR.533 August 1, 2024
Cipaglucosidase alfa-atga--miglustat (Pombiliti-Opfolda) (PDF)CP.PHAR.567May 1, 2024
Clinical Trials (PDF)CP.MP.94August 1, 2023
Cochlear Implanted Replacements (PDF)AR.CP.MP.14December 1, 2023
Collagenase (Xiaflex) (PDF)CP.PHAR.82August 1, 2023
Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Cardiac Disorders (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Dermatologic Conditions (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Eye Disorders (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (PDF)V1.2024April 1, 2024
Concert Genetic Testing: General Approach to Genetic and Molecular Testing (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Hearing Loss (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Hematologic Conditions (non-cancerous) (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF)V1.2024June 1, 2024
Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Kidney Disorders (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Lung Disorders (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)V1.2024June 1, 2024
Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Non-Invasive Prenatal Screening (NIPS) (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Pharmacogenetics (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Preimplantation Genetic Testing (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)V1.2024June 1, 2024
Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)V1.2024April 1, 2024
Concert Genetics Oncology: Algorithmic Testing (PDF)V1.2024April 1, 2024
Concert Genetics Oncology: Cancer Screening (PDF)V1.2024April 1, 2024
Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF)V1.2024April 1, 2024
Concert Genetics Oncology: Cytogenetic Testing (PDF)V1.2024April 1, 2024
Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)V1.2024April 1, 2024
Continuous Glucose Monitors (PDF)CP.PMN.214December 1, 2023
Copanlisib (Aliqopa) (PDF)CP.PHAR.357December 1, 2023
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF)CP.PHAR.385August 1, 2023
Corticotropin (H.P. Acthar, Purified Cortrophin Gel) (PDF)CP.PHAR.168May 1, 2023
Cosmetic and Reconstructive Procedures (PDF)CP.MP.31December 1, 2023
Cosyntropin (Cortrosyn) (PDF)CP.PHAR.203February 1, 2024

Crizanlizumab-tmca (Adakveo) (PDF)

CP.PHAR.449February 1, 2024
Cytomegalovirus Immune Globulin (Cytogam) (PDF)CP.PHAR.277August 1, 2023
Dalteparin (Fragmin) (PDF)CP.PHAR.225March 1, 2022
Daprodustat (Jesduvroq) (PDF)CP.PHAR.628July 1, 2024
Daprodustat (Jesduvroq) (PDF)CP.PHAR.628Retire by July 1, 2024
Daptomycin (Cubicin, Cubicin RF) (PDF)CP.PHAR.351February 1, 2024
Daratumumab (Darzalex) (PDF)CP.PHAR.310October 2, 2023
Darbepoetin Alfa (Aranesp) (PDF)CP.PHAR.236July 1, 2024
Darbepoetin Alfa (Aranesp) (PDF)CP.PHAR.236Retire by July 1, 2024
Daunorubicin and Cytarabine (Vyxeos) (PDF)CP.PHAR.352December 1, 2023
DaxibotulinumtoxinA-lanm (Daxxify) (PDF)CP.PHAR.651May 1, 2024
Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (PDF)CP.BH.201August 1, 2023
Deferoxamine (Desferal) (PDF)CP.PHAR.146October 2, 2023
Degarelix (Firmagon) (PDF)CP.PHAR.170December 1, 2023
Delafloxacin (Baxdela) (PDF)CP.PMN.115August 1, 2023
Delandistrogene moxeparvovec-rokl  (Elevidys) (PDF) CP.PHAR.593 June 1, 2024
Denosumab (Prolia, Xgeva) (PDF)CP.PHAR.58July 1, 2024
Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (PDF)CP.PHAR.214February 1, 2024
Dexrazoxane (Zinecard, Totect) (PDF)CP.PHAR.418July 1, 2024
Dexrazoxane (Zinecard, Totect) (PDF)CP.PHAR.418Retire by July 1, 2024
Diaphragmatic/Phrenic Nerve Stimulation (PDF)CP.MP.203October 1, 2023
Disc Decompression Procedures (PDF)CP.MP.114July 1, 2023
Discography (PDF)CP.MP.115July 1, 2024
Donanemab (LY300281) (PDF)CP.PHAR.594January 1, 2024
Donor Lymphocyte Infusion (PDF)CP.MP.101June 1, 2024
Dostarlimab-gxly (Jemperli) (PDF)CP.PHAR.540November 1, 2023
Drugs of Abuse: Definitive Testing (PDF)CP.MP.50August 1, 2023
Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF)CP.MP.107March 1, 2024
Durvalumab (Imfinzi) (PDF)CP.PHAR.339July 1, 2024
Durvalumab (Imfinzi) (PDF)CP.PHAR.339Retire by July 1, 2024
Ecallantide (Kalbitor) (PDF)CP.PHAR.177August 1, 2023
Eculizumab (Soliris) (PDF)CP.PHAR.97August 1, 2023
Edaravone (Radicava) (PDF)CP.PHAR.343June 1, 2024
Efgartigimod alfa-fcab (Vyvgart) (PDF)
CP.PHAR.555
February 1, 2024
Elapegademase-lvlr (Revcovi) (PDF)CP.PHAR.419June 1, 2024
Electric Tumor Treating Fields (Optune) (PDF)CP.MP.145January 1, 2024
Elivaldogene autotemcel  (Skysona) (PDF)CP.PHAR.556December 1, 2023
Elosulfase Alfa (Vimizim) (PDF)CP.PHAR.162June 1, 2024
Elotuzumab (Empliciti) (PDF)CP.PHAR.308December 1, 2023
Elranatamab-bcmm (Elrexfio) (PDF)CP.PHAR.652May 1, 2024
Emapalumab-lzsg (Gamifant) (PDF)CP.PHAR.402April 1, 2024
Endometrial Ablation (PDF)CP.MP.106August 1, 2023
Enfortumab Vedotin-ejfv (Padcev) (PDF)CP.PHAR.455February 1, 2024
Enfuvirtide (Fuzeon) (PDF)CP.PHAR.41August 1, 2023
Enoxaparin (Lovenox) (PDF)CP.PHAR.224February 1, 2024
Epcoritamab-bysp (Epkinly) (PDF)CP.PHAR.634February 1, 2024
Epoetin Alfa (Epogen® and Procrit) (PDF)CP.PHAR.237July 1, 2024
Epoetin Alfa (Epogen® and Procrit) (PDF)CP.PHAR.237Retire by July 1, 2024
Epoprostenol (Flolan, Veletri) (PDF)CP.PHAR.192February 1, 2024
Eptinezumab-jjmr (Vyepti) (PDF)CP.PHAR.489December 1, 2023
Eribulin Mesylate (Halaven) (PDF)CP.PHAR.318January 1, 2024
Erwinia Asparaginase (Erwinaze) (PDF)CP.PHAR.301February 1, 2024
Etelcalcetide (Parsabiv) (PDF)CP.PHAR.379August 1, 2023
Eteplirsen  (Exondys 51) (PDF)CP.PHAR.288April 1, 2024
Etranacogene Dezaparvovec (Hemgenix) (PDF)CP.PHAR.580February 1, 2024
Evinacumab-dgnb (Evkeeza) (PDF)CP.PHAR.511April 1, 2024
Exagamglogene Autotemcel (Exa-Cel) (PDF)CP.PHAR.603July 1, 2024
Exagamglogene Autotemcel (Exa-Cel) (PDF)CP.PHAR.603Retire by July 1, 2024
Experimental Technologies (PDF)CP.MP.36June 1, 2024
Facet Joint Interventions (PDF)CP.MP.171September 1, 2023
Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)CP.MP.248June 1, 2024
Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (PDF)CP.PHAR.220February 1, 2024
Factor VIII (Human Recombinant) (PDF)CP.PHAR.215 June 1, 2024
Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF)CP.PHAR.216June 1, 2024
Factor IX (Human, Recombinant) (PDF)CP.PHAR.218June 1, 2024
Factor IX Complex, Human (Profilnine) (PDF)CP.PHAR.219June 1, 2024
Factor XIII, Human (Corifact®) (PDF)CP.PHAR.221February 1, 2024
Factor XIII A-Subunit, Recombinant (Tretten®)CP.PHAR.222February 1, 2024
Fam-Trastuzumab Deruxtecan-nxki (Enhertu) (PDF)CP.PHAR.456February 1, 2024
Faricimab (Vabysmo) (PDF)CP.PHAR.581June 1, 2024
Fecal Incontinence Treatments (PDF)CP.MP.137December 1, 2023
Ferric Carboxymaltose (Injectafer) (PDF)CP.PHAR.234May 1, 2024
Ferric Derisomaltose (Monoferric)(PDF)CP.PHAR.480June 1, 2024
Ferric Pyrophosphate Citrate (Triferic) (PDF)CP.PHAR.624June 1, 2024
Ferriscan R2-MRI (PDF)CP.MP.53December 1, 2023
Ferumoxytol (Feraheme) (PDF)CP.PHAR.165March 1, 2024
Fertility Preservation (PDF)CP.MP.130March 1, 2024
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)CP.MP.129March 1, 2024
Fibrinogen concentrate (human) (Fibryga, RiaSTAP) (PDF)CP.PHAR.526June 1, 2024
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) (PDF)CP.PHAR.297October 2, 2023
Fondaparinux (Arixtra) (PDF)CP.PHAR.226March 1, 2022
Fosdenopterin (Nulibry) (PDF)CP.PHAR.471 June 1, 2024
Fulvestrant (Faslodex Injection) (PDF)CP.PHAR.424August 1, 2023
Functional MRI (PDF)CP.MP.43April 1, 2024
Galsulfase (Naglazyme) (PDF)CP.PHAR.161June 1, 2024
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)CP.MP.209August 1, 2023
Gastric Electrical Stimulation (PDF)CP.MP.40July 1, 2024
Gemtuzumab (Mylotarg) (PDF)CP.PHAR.358December 1, 2023
Gender-Affirming Procedures (PDF)CP.MP.95October 1, 2023
Givosiran (Givlaari) (PDF)CP.PHAR.457April 1, 2024
Glofitamab-gxbm (Columvi) (PDF) CP.PHAR.636 February 1, 2024
Golodirsen (Vyondys 53) (PDF)CP.PHAR.453April 1, 2024
Golimumab (Simponi, Simponi Aria) (PDF)CP.PHAR.253July 1, 2024
Golimumab (Simponi, Simponi Aria) (PDF)CP.PHAR.253Retire by July 1, 2024
Goserelin Acetate (Zoladex) (PDF)CP.PHAR.171December 1, 2023
Granisetron (Kytril, Sancuso, Sustol) (PDF)CP.PMN.74August 1, 2023
Helicobacter Pylori Serology Testing (PDF)CP.MP.153November 1, 2023
Hemin (Panhematin) (PDF)CP.PHAR.181February 1, 2024
Histrelin (Vantas, Supprelin LA) (PDF)CP.PHAR.172July 1, 2024
Histrelin (Vantas, Supprelin LA) (PDF)CP.PHAR.172Retire by July 1, 2024
Home and Community Based Services (HCBS) (PDF)AR.CP.BH.503November 1, 2023
Home Births (PDF)CP.MP.136March 1, 2024
Home Ventilators (PDF)CP.MP.184August 1, 2023
Hospice Services (PDF)CP.MP.54September 1, 2023
Hyaluronate Derivatives (PDF)CP.PHAR.05April 1, 2024
Hydroxyprogesterone caproate (Makena) (PDF)CP.PHAR.14June 1, 2024
Hyperhidrosis Treatments (PDF)CP.MP.62June 1, 2024
ibalizumab-uiyk (Trogarzo) (PDF)CP.PHAR.378June 1, 2024
Ibandronate Injection (Boniva) (PDF)CP.PHAR.189April 1, 2024
Idecabtagene vicleucel (Abecma) (PDF)CP.PHAR.481 June 1, 2024
Idursulfase (Elaprase) (PDF)CP.PHAR.156June 1, 2024
Iloprost (Ventavis) (PDF)CP.PHAR.193February 1, 2024
Imiglucerase (Cerezyme) (PDF)CP.PHAR.154June 1, 2024
Immune Globulins (PDF)CP.PHAR.103June 1, 2024
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)CP.MP.180January 1, 2024
Implantable Intrathecal or Epidural Pain Pump (PDF)CP.MP.173June 1, 2024
Implantable Loop Recorder (PDF)CP.MP.243June 1, 2024
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)CP.MP.160June 1, 2024
Inclisiran (Leqvio) (PDF)CP.PHAR.568April 1, 2024
IncobotulinumtoxinA (Xeomin) (PDF)CP.PHAR.231July 1, 2024
IncobotulinumtoxinA (Xeomin) (PDF)CP.PHAR.231Retire by July 1, 2024
Inotersen (Tegsedi) (PDF)CP.PHAR.405 February 1, 2023
Inebilizumab (PDF)CP.PHAR.458August 1, 2023
Infertility and Fertility Preservation (PDF)CP.PHAR.131January 1, 2024
Infliximab (Remicade, Inflectra, Renflexis) (PDF)CP.PHAR.254July 1, 2024
Infliximab (Remicade, Inflectra, Renflexis) (PDF)CP.PHAR.254Retire by July 1, 2024
Inotuzumab Ozogamicin (Besponsa) (PDF)CP.PHAR.359December 1, 2023
Intensity-Modulated Radiotherapy (PDF)CP.MP.69October 1, 2023
Interferon Gamma- 1b (Actimmune) (PDF)CP.PHAR.52February 1, 2024
Intestinal and Multivisceral Transplant (PDF)CP.MP.58July 1, 2023 
Intradiscal Steroid Injections for Pain Management (PDF)CP.MP.167October 1, 2023
Iobenguane I-131 (Azedra) (PDF)CP.PHAR.459February 1, 2024
Ipilimumab (Yervoy) (PDF)CP.PHAR.319June 1, 2024
Irinotecan Liposome (Onivyde) (PDF)CP.PHAR.304May 1, 2024
Isatuximab-irfc (Sarclisa)(PDF)CP.PHAR.482June 1, 2024
Isavuconazonium (Cresemba)CP.PMN.154
June 1, 2024
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)CP.MP.61December 1, 2023
Ixekizumab (Taltz) (PDF)CP.PHAR.257June 1, 2023
Lanadelumab-fylo (Takhzyro) (PDF)CP.PHAR.396May 1, 2024
Lanreotide (Somatuline Depot) (PDF)CP.PHAR.391January 1, 2024
Lantidra (Donislecel): Allogenic Pancreatic Islet Cellular Therapy (PDF)CP.MP.250April 1, 2024
Laronidase (Aldurazyme) (PDF)CP.PHAR.152June 1, 2024
Lecanemab-irmb (Leqembi) (PDF)CP.PHAR.596December 1, 2023
Lefamulin (Xenleta) (PDF)CP.PMN.219August 1, 2023
Letermovir (Prevymis) (PDF)CP.PHAR.367February 1, 2024
Leucovorin Injection (PDF)CP.PHAR.393December 1, 2023
Leuprolide Acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi) (PDF)CP.PHAR.173April 1, 2024
Levoleucovorin (Fusilev, Khapzory) (PDF)CP.PHAR.151December 1, 2023
Lifileucel (Amtagvi) (PDF)CP.PHAR.598June 1, 2024
Linezolid (Zyvox) (PDF)CP.PMN.27August 1, 2023
Liposuction for Lipedema (PDF)CP.MP.244July 1, 2024
Lisocabtagene maraleucel (Breyanzi) (PDF)CP.PHAR.483July 1, 2024
Lisocabtagene maraleucel (Breyanzi) (PDF)CP.PHAR.483Retire by July 1, 2024
Loncastuximab tesirine-lpyl (Zynlonta) (PDF)CP.PHAR.539October 2, 2023
Long Term Care Placement (PDF)CP.MP.71April, 1 2024
Lovotibeglogene Autotemcel (Lovo-Cel) (PDF)CP.PHAR.627March 1, 2024
Lumasiran (Oxlumo) (PDF)CP.PHAR.473August 1, 2024
Lumasiran (Oxlumo) (PDF)CP.PHAR.473Retire by August 1, 2024
Lurbinectedin (Zepzelca) (PDF)CP.PHAR.500October 2, 2023
Luspatercept-aamt (Reblozyl) (PDF)CP.PHAR.450February 1, 2024
Lutetium Lu 177 Dotatate (Lutathera) (PDF)CP.PHAR.384August 1, 2023
Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) (PDF)CP.PHAR.582June 1, 2024
Lysis of Epidural Lesions (PDF)CP.MP.116July 1, 2024
Margetuximab-cmkb (Margenza) (PDF)CP.PHAR.522February 1, 2024
Mecasermin (Increlex) (PDF)CP.PHAR.150August 1, 2023
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)CP.MP.144April 1, 2024
Melphalan (Hepzato) (PDF)CP.PHAR.653December 1, 2023
Melphalan flufenamide (Pepaxto) (PDF)CP.PHAR.535June 1, 2024
Mepolizumab (Nucala) (PDF)CP.PHAR.200April 1, 2022
Mesenchymal stem cell-NTF (NurOwn) (PDF)CP.PHAR.637September 1, 2023
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF)CP.PHAR.134 December 1, 2022
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF)CP.PHAR.238 July 1, 2024
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF)CP.PHAR.238 Retire by July 1, 2024
Metreleptin (Myalept) (PDF)CP.PHAR.425August 1, 2023
Mirikizumab-mrkz (Omvoh) (PDF)CP.PHAR.662July 1, 2024
Mirikizumab-mrkz (Omvoh) (PDF)CP.PHAR.662Retire by July 1, 2024
Mirvetuximab soravtansine-gynx (Elahere) (PDF)CP.PHAR.617July 1, 2024
Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF)CP.PHAR.495October 2, 2023
Mitoxantrone (Novantrone) (PDF)CP.PHAR.258July 1, 2024
Mitoxantrone (Novantrone) (PDF)CP.PHAR.258Retire by July 1, 2024
Mogamulizumab-kpkc (Poteligeo) (PDF)CP.PHAR.139December 1, 2023
Mometasone Furoate (Sinuva) (PDF)CP.PHAR.448August 1, 2023
Mosunetuzumab-axgb (Lunsumio) (PDF)CP.PHAR.618February 1, 2024
Motixafortide (Aphexda) (PDF)CP.PHAR.655May 1, 2024
Moxetumomab Pasudotox-tdfk (Lumoxiti) (PDF)CP.PHAR.398December 1, 2023
Multiple Sleep Latency Testing (PDF)CP.MP.24July 1, 2024
Nadofaragene Firadenovec (Instiladrin)(PDF)CP.PHAR.461May 1, 2024
Naltrexone (Vivitrol) (PDF)CP.PHAR.96February 1, 2024
Natalizumab (Tysabri) (PDF)CP.PHAR.259May 1, 2024
Naxitamab-gqgk (Danyelza) (PDF)CP.PHAR.523February 1, 2024
Necitumumab (Portrazza) (PDF)CP.PHAR.320December 1, 2023
Nedosiran (Rivfloza) (PDF)CP.PHAR.619August 1, 2024
Nedosiran (Rivfloza) (PDF)CP.PHAR.619Retire by August 1, 2024
Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)CP.MP.48December 1, 2023
Netupitant and Palonosetron (Akynzeo) (PDF)CP.PMN.158October 2, 2023
Nerve Blocks and Neurolysis for Pain Management (PDF)CP.MP.170June 1, 2024
Nirsevimab (Beyfortus) 08.07.23 (PDF)CP.PHAR.614January 1, 2024
Nivolumab (Opdivo) (PDF)CP.PHAR.121  Retire by August 1, 2024
Nivolumab (Opdivo) (PDF)CP.PHAR.121  August 1, 2024
Nivolumab and Relatlimab (Opdualag) (PDF)CP.PHAR.588August 1, 2023
No Coverage Criteria (PDF)CP.PMN.255November 1, 2023
Nonmyeloablative Allogeneic Stem Cell Transplants (PDF)CP.MP.141July 1, 2024
Nusinersen (Spinraza®) (PDF)CP.PHAR.327February 1, 2024
Obstetrical Home Care Programs (PDF)CP.MP.91July 1, 2024
Obinutuzumab (Gazyva) (PDF)CP.PHAR.305December 1, 2023
Ocrelizumab (Ocrevus) (PDF)CP.PHAR.335June 1, 2024
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF)CP.PHAR.40April 1, 2024
Ofatumumab (Arzerra, Kesimpta) (PDF)CP.PHAR.306June 1, 2024
Off-Label Use (PDF)CP.PMN.53December 1, 2023
Olaparib (Lynparza) (PDF)CP.PHAR.360May 1, 2023
Olipudase alfa-rpcp (Xenpozyme) (PDF)CP.PHAR.586August 1, 2023
Omadacycline (Nuzyra) (PDF)CP.PMN.188August 1, 2023
Omalizumab (Xolair) (PDF)CP.PHAR.01Retire by August 1, 2024
Omalizumab (Xolair) (PDF)CP.PHAR.01August 1, 2024
Omecetaxine (Synribo) (PDF)CP.PHAR.108June 1, 2024
Omisirge (omidubicel): Nicotinamide-modified allogeneic hematopoietic progenitor cell therapy (PDF)CP.MP.249August 1, 2023
OnabotulinumtoxinA (Botox) (PDF)CP.PHAR.232July 1, 2024
Onasemnogene Abeparvovec (Zolgensma) (PDF)CP.PHAR.421July 1, 2024
Ophthalmic Riboflavin (Photrexa, Photrexa Viscous)CP.PHAR.536June 1, 2024
Orthognathic Surgery (PDF)CP.MP.202 December 1, 2023
Osteogenic Stimulation (PDF)CP.MP.194 October 1, 2023
Outpatient Cardiac Rehabilitation (PDF)CP.MP.176July 1, 2023
Outpatient Oxygen Use (PDF)CP.MP.190June 1, 2024
Paclitaxel protein-bound (Abraxane) (PDF)CP.PHAR.176July 1, 2024
Paclitaxel protein-bound (Abraxane) (PDF)CP.PHAR.176Retire by July 1, 2024
Panitumumab (Vectibix) (PDF)CP.PHAR.321January 1, 2024
Panniculectomy (PDF)CP.MP.109December 1, 2023
Paricalcitol Injection (Zemplar) (PDF)CP.PHAR.270February 1, 2024
Pasireotide (Signifor, Signifor LAR) (PDF)CP.PHAR.332December 1, 2023
Patisiran (Onpattro) (PDF)CP.PHAR.395July 1, 2024
Patisiran (Onpattro) (PDF)CP.PHAR.395Retire by July 1, 2024
Peanut Allergen Powder-dnfp (Palforzia)(PDF)CP.PMN.220March 1, 2021
Pediatric Liver Transplant (PDF)CP.MP.120July 1, 2024
Pediatric Oral Function Therapy (PDF)CP.MP.188July 1, 2024
Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas) (PDF)CP.PHAR.353December 1, 2023
Pegcetacoplan (Empaveli) (PDF)CP.PHAR.524February 1, 2024
Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) (PDF)CP.PHAR.296June 1, 2024
Pegloticase (Krystexxa) (PDF)CP.PHAR.115February 1, 2024
Pegunigalsidase alfa-iwxj (Elfabrio) (PDF)CP.PHAR.512February 1, 2024
Pegvaliase-pqpz (Palynziq) (PDF)CP.PHAR.140December 1, 2023
Pegvisomant (Somavert) (PDF)CP.PHAR.389December 1, 2023
Pegzilarginase (AEB1102) (PDF)CP.PHAR.587Pending FDA Approval
Pembrolizumab (Keytruda®) (PDF)CP.PHAR.322May 1, 2024
Pemetrexed (Alimta, Pemfexy) (PDF)CP.PHAR.368February 1, 2024
Percutaneous Left Atrial Appendage Closure for Stroke Prevention (PDF)CP.MP.147July 1, 2024
Personal Care Services Authorization (PDF)ARTC.UM.19July 1, 2024
Pertuzumab (Perjeta) (PDF)CP.PHAR.227June 1, 2024
Pertuzumab-trastuzumab-hyaluronidase-zzxf (Phesgo) (PDF)CP.PHAR.501October 2, 2023
Physical, Occupational, and Speech Therapy Services (PDF)CP.MP.49November 1, 2023
Plasminogen (Ryplazim) (PDF)CP.PHAR.513December 1, 2023
Plerixafor (Mozobil) (PDF)CP.PHAR.323April 1, 2024
Polatuzumab Vedotin-piiq (Polivy) (PDF)CP.PHAR.433October 2, 2023
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)CP.MP.181November 1, 2023
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)CP.MP.133October 1, 2023
Pozelimab (REGN3918) (PDF)CP.PHAR.626May 1, 2024
Prademagene Zamikeracel (EB-101) (PDF)CP.PHAR.609Pending FDA Approval
Pralatrexate (Folotyn) (PDF)CP.PHAR.313December 1, 2023
Protein C Concentrate, Human (Ceprotin) PDF)CP.PHAR.330February 1, 2024
Proton and Neutron Beam Therapies (PDF)CP.MP.70January 1, 2024
Ramucirumab (Cyramza) (PDF)CP.PHAR.119 February 1, 2024
Ranibizumab (Byooviz, Lucentis, Susvimo) (PDF)CP.PHAR.186February 1, 2024
Ravulizumab-cwvz (Ultomiris) (PDF)CP.PHAR.415Retire by August 1, 2024
Ravulizumab-cwvz (Ultomiris) (PDF)CP.PHAR.415August 1, 2024
Reduction Mammoplasty and Gynecomastia Surgery (PDF)CP.MP.51September 1, 2023
Repair of Nasal Valve Compromise (PDF)CP.MP.210July 1, 2024
Reslizumab (Cinqair) (PDF)CP.PHAR.223February 1, 2024
Respiratory Syncytial Virus Vaccine (Abrysvo) C (PDF)CP.PHAR.658January 1, 2024
Retifanlimab-dlwr (Zynyz) (PDF)CP.PHAR.629July 1, 2024
Retifanlimab-dlwr (Zynyz) (PDF)CP.PHAR.629Retire by July 1, 2024
Rilonacept (Arcalyst) (PDF)CP.PHAR.266July 1, 2024
Rilonacept (Arcalyst) (PDF)CP.PHAR.266Retire by July 1, 2024
RimabotulinumtoxinB (Myobloc) (PDF)CP.PHAR.233June 1, 2024
Risankizumab-rzaa (Skyrizi) (PDF)CP.PHAR.426July 1, 2024
Risankizumab-rzaa (Skyrizi) (PDF)CP.PHAR.426Retire by July 1, 2024
Risdiplam (Evrysdi) (PDF)CP.PHAR.477February 1, 2024
Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF)CP.PHAR.260July 1, 2024
Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF)CP.PHAR.260Retire by July 1, 2024
Rolapitant (Varubi) (PDF)CP.PMN.102August 1, 2023
Romidepsin (Istodax) (PDF)CP.PHAR.314December 1, 2023
Romiplostim (Nplate®) (PDF)CP.PHAR.179April 1, 2024
Ropeginterferon alfa-2b-njft (Besremi) (PDF)CP.PHAR.570July 1, 2024
Ropeginterferon alfa-2b-njft (Besremi) (PDF)CP.PHAR.570Retire by July 1, 2024
Rozanolixizumab-noli (Rystiggo) (PDF)CP.PHAR.648December 1, 2023
Sacituzumab Govitecan-hziy (Trodelvy) (PDF)CP.PHAR.475June 1, 2024
Sacroiliac Joint Fusion (PDF)CP.MP.126November 1, 2023
Sacroiliac Joint Interventions for Pain Management (PDF)CP.MP.166October 1, 2023
Sargramostim (Leukine) (PDF)CP.PHAR.295January 1, 2024
Satralizumab-mwge (Enspryng) (PDF)CP.PHAR.463August 1, 2023
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF)CP.MP.146November 1, 2023
Sebelipase Alfa (Kanuma) (PDF)CP.PHAR.159June 1, 2024
Secukinumab (Cosentyx) (PDF)CP.PHAR.261July 1, 2024
Secukinumab (Cosentyx) (PDF)CP.PHAR.261Retire by July 1, 2024
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)CP.MP.174January 1, 2024
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)CP.MP.165October 1, 2023
Setmelanotide (Imcivree) (PDF)CP.PHAR.491 December 1, 2022
Sipuleucel-T (Provenge) (PDF)CP.PHAR.120June 1, 2024
Siltuximab (Sylvant) (PDF) CP.PHAR.329February 1, 2024
Sirolimus Protein-Bound Particles (Fyarro), topical gel (Hyftor)CP.PHAR.574February 1, 2024
Skin and Soft Tissue Substitutes for Chronic Wounds (PDF)CP.MP.185September 1, 2023
Sodium thiosulfate (Pedmark) (PDF)CP.PHAR.610May 1, 2024
Sotatercept (ACE-011) (PDF)CP.PHAR.657Pending FDA Approval
Sotrovimab (VIR-7831) (PDF)CP.PHAR.541July 1, 2023
Spesolimab-sbzo (Spevigo) (PDF)CP.PHAR.606August 1, 2024
Spesolimab-sbzo (Spevigo) (PDF)CP.PHAR.606Retire by August 1, 2024
Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF)CP.MP.117March  1, 2024
Stereotactic Body Radiation Therapy (PDF)CP.MP.22June 1, 2024
Substance Use Disorders Treatment and Services (PDF)CP.BH.100November 1, 2022
Sutimlimab-jome (Enjaymo) (PDF)CP.PHAR.503June 1, 2024
Tafasitamab-cxix (Monjuvi) (PDF)CP.PHAR.508December 1, 2023
Taliglucerase Alfa (Elelyso) (PDF)CP.PHAR.157June 1, 2024
Talimogene laherparepvec (Imlygic) (PDF)CP.PHAR.542August 1, 2023
Talquetamab-tgvs (Talvey) (PDF)CP.PHAR.649May 1, 2024
Tebentafusp-(Kimmtrak) (PDF)CP.PHAR.575 June 1, 2024
Teclistamab-cqyv (Tecvayli) (PDF)CP.PHAR.611February 1, 2024
Tedizolid (Sivextro) (PDF)CP.PMN.62February 1, 2024
Teduglutide (Gattex) (PDF)CP.PHAR.114April 1, 2024
Temozolomide (Temodar) (PDF)CP.PHAR.77July 1, 2024
Temozolomide (Temodar) (PDF)CP.PHAR.77Retire by July 1, 2024
Temsirolimus (Torisel) (PDF)CP.PHAR.324December 1, 2023
Teplizumab-mzwv (Tzield) (PDF)CP.PHAR.492February 1, 2024 (Previously Pending FDA Approval)
Teprotumumab (Tepezza) (PDF)CP.PHAR.465February 1, 2024
Testosterone (Testopel, Jatenzo) (PDF)CP.PHAR.354December 1, 2023
Tezepelumab (Tezspire) (PDF)CP.PHAR.576 February 1, 2024
Therapeutic Utilization of Inhaled Nitric Oxide (PDF)CP.MP.87July 1, 2024
Thyroid Hormones and Insulin Testing in Pediatrics (PDF)CP.MP.154November 1, 2023
Thyrotropin alfa (Thyrogen) (PDF)CP.PHAR.95August 1, 2023
Tildrakizumab-asmn (Ilumya)CP.PHAR.386July 1, 2024
Tildrakizumab-asmn (Ilumya)CP.PHAR.386Retire by July 1, 2024
Tisagenlecleucel (Kymriah) (PDF)CP.PHAR.361April 1, 2024
Tisotumab Vedotin-tftv (Tivdak) (PDF)CP.PHAR.561 December 1, 2023
Tixagevimab-Cilgavimab (Evusheld) (PDF)CP.PHAR.571July 1, 2023
Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (PDF)CP.PHAR.211March 1, 2022
Tocilizumab (Actemra) (PDF)CP.PHAR.263July 1, 2024
Tocilizumab (Actemra) (PDF)CP.PHAR.263Retire by July 1, 2024
Tofersen (Qalsody) (PDF)CP.PHAR.591December 1, 2023
Topotecan (Hycamtin) (PDF)CP.PHAR.64July 1, 2024
Topotecan (Hycamtin) (PDF)CP.PHAR.64Retire by July 1, 2024
Toripalimab (Loqtorzi) (PDF)CP.PHAR.668February 1, 2024
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)CP.MP.163April 1, 2024
Trabectedin (Yondelis) (PDF)CP.PHAR.204February 1, 2024
Tralokinumab-ldrm (Adbry) (PDF)CP.PHAR.577 June 1, 2022
Transcatheter Closure of Patent Foramen Ovale (PDF)CP.MP.151January 1, 2024
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF)CP.BH.200August 1, 2023
Transplant Service Documentation Requirements (PDF)CP.MP.247April 1, 2024
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF)CP.PHAR.228July 1, 2024
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF)CP.PHAR.228Retire by July 1, 2024
Travoprost (iDose TR) (PDF)CP.PHAR.672March 1, 2024
Tremelimumab-actl (Imjudo) (PDF)CP.PHAR.612February 1, 2024
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF)CP.PHAR.199February 1, 2024
Triamcinolone ER Injection (Zilretta) (PDF)CP.PHAR.371February 1, 2024
Trigger Point Injections for Pain Management (PDF)CP.MP.169October 1, 2023
Triptorelin pamoate (Trelstar, Triptodur) (PDF)CP.PHAR.175April 1, 2024
Ublituximab-xiiy (Briumvi) (PDF)CP.PHAR.621June 1, 2024
Urinary Incontinence Devices and Treatments (PDF)CP.MP.142January 1, 2024
Ustekinumab (Stelara) (PDF)CP.PHAR.264July 1, 2024
Ustekinumab (Stelara) (PDF)CP.PHAR.264Retire by July 1, 2024
Vagus Nerve Stimulation (PDF)CP.MP.12October 1, 2023
Valoctocogene Roxaparvovec (PDF)CP.PHAR.466April 1, 2024 (Previously Pending FDA Approval)
Valrubicin (Valstar) (PDF)CP.PHAR.439December 1, 2023
Vedolizumab (Entyvio) (PDF)CP.PHAR.265July 1, 2024
Vedolizumab (Entyvio) (PDF)CP.PHAR.265Retire by July 1, 2024
Velaglucerase alfa (VPRIV) (PDF)CP.PHAR.163June 1, 2024
Velmanase Alfa-tycv (Lamzede) (PDF)CP.PHAR.601June 1, 2024
Ventricular Assist Devices (PDF)CP.MP.46April 1, 2024
Verteporfin (Visudyne) (PDF)CP.PHAR.187February 1, 2024
Vestronidase Alfa-vjbk (Mepsevii) (PDF)CP.PHAR.374July 1, 2024
Vestronidase Alfa-vjbk (Mepsevii) (PDF)CP.PHAR.374Retire by July 1, 2024
Viltolarsen (Viltepso) (PDF)CP.PHAR.484April 1, 2024
Vincristine Liposome (Marqibo) (PDF)CP.PHAR.315January 1, 2024
Voretigene neparvovec-rzyl (Luxturna) (PDF)CP.PHAR.372February 1, 2024
Vosoritide (Voxzogo) (PDF)CP.PHAR.525February 1, 2024
Vutrisiran (Amvuttra) (PDF)CP.PHAR.550 December 1, 2022
Waiver Environmental Modifications Criteria (PDF)ARTC.CC.25September 1, 2022
Wireless Motility Capsule (PDF)CP.MP.143November 1, 2023
Zavegepant (Zavzpret) (PDF)CP.PHAR.630June 1, 2024
Ziv-aflibercept (Zaltrap) (PDF)CP.PHAR.325December 1, 2023
Zoledronic Acid (PDF)CP.PHAR.59February 1, 2024

Policy TitlePolicy NumberEffective Date
3-Day Payment Window (PDF)CC.PP.500July 1, 2014
Add-On Code Billed Without Primary Code (PDF)CC.PP.030October 18, 2016
Aducanumab (Aduhelm) (PDF)CP.PHAR.468December 1, 2021
Assistant Surgeon (PDF)CC.PP.029February 7, 2017
Bevacizumab (PDF)CP.PHAR.93September 1, 2021
Bilateral Procedures (PDF)CC.PP.037February 7, 2017
Bronchial Thermoplasty (PDF)CP.MP.110May 1, 2023
Cerumen Removal (PDF)CC.PP.008August 12, 2016
Clean Claims (PDF)CC.PP.021October 18, 2016
Coding Overview (PDF)CC.PP.011October 18, 2016
Cosmetic Procedures (PDF)CC.PP.024October 18, 2016
Digital EEG Spike Analysis (PDF)CP.MP.105June 1, 2024
Distinct Procedural Modifiers (PDF)CC.PP.020October 18, 2016
Duplicate Primary Code Billing (PDF)CC.PP.044February 7, 2017
EEG in the Evaluation of Headache (PDF)CP.MP.155June 1, 2024
E&M Medical Decision-Making (PDF)CC.PP.051July 25, 2017
EM Bundling Edits (PDF)CC.PP.010August 12, 2016
Evoked Potential Testing (PDF)CP.MP.134June 1, 2024
Global Maternity Billing (PDF)CC.PP.016October 18, 2016
Holter Monitors (PDF)CP.MP.113June 1, 2024
Homocysteine Testing (PDF)CP.MP.121May 1, 2023
Hospital Visit Codes Billed with Labs (PDF)CC.PP.023October 18, 2016
Inpatient Consultation (PDF)CC.PP.038February 7, 2017
Inpatient Only Procedures (PDF)MP.PP.018October 18, 2016
IV Hydration (PDF)CC.PP.012October 18, 2016
Laser Therapy for Skin Conditions (PDF)CP.MP.123June 1, 2024
Leveling of Care: Evaluation and Management Overcoding (PDF)CC.PP.066March 15, 2021
Leveling of Emergency Room (PDF)CC.PP.053 January 1, 2019
Low-frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)CP.MP.139May 1, 2023
Maximum Units (PDF)CC.PP.007August 12, 2016
Measurement of Serum 1,25-dihydroxyvitamin D (PDF)CP.MP.152June 1, 2024
Moderate Conscious Sedation (PDF)CC.PP.015October 18, 2016
Modifier -25 Clinical Validation (PDF)CC.PP.013October 18, 2016
Modifier -59 Clinical Validation (PDF)CC.PP.014October 18, 2016
Modifier DOS Validation (PDF)CC.PP.034October 18, 2016
Modifier to Procedure Code Validation (PDF)CC.PP.028October 18, 2016
Multiple CPT Code Replacement (PDF)CC.PP.033October 18, 2016
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF)CC.PP.065March 15, 2021
Multiple Procedure Reduction: Ophthalmology (PDF)CC.PP.069March 15, 2021
Multiple Procedure Payment Reduction for Therapeutic Services (PDF)CC.PP.068March 15, 2021
NCCI Unbundling (PDF)CC.PP.031October 18, 2016
Never Paid Events (PDF)CC.PP.017October 18, 2016
New Patient (PDF)CC.PP.036February 7, 2017
Non-Obstetrical Pelvic and Transabdominal Ultrasound (PDF)CC.PP.061 March 15, 2021
Outpatient Consultation (PDF)CC.PP.039February 7, 2017
Paclitaxel (PDF)CP.PHAR.176July 1, 2023
Physician’s Consultation Services (PDF)CC.PP.054September 1, 2018
Physician Visit Codes Billed with Labs (PDF)CC.PP.019October 18, 2016
Place of Service Mismatch (PDF)CC.PP.063 December 15, 2018
Post-Operative Visits (PDF)CC.PP.042February 7, 2017
Pre-Operative Visits (PDF)CC.PP.041February 7, 2017
Problem Oriented Visits with Surgical Procedures (PDF)CC.PP.052November 1, 2018
Professional Component (PDF)CC.PP.027October 18, 2016
Pulmonary Function Testing (PDF)CP.MP.242June 1, 2024
Pulse Oximetry (PDF)CC.PP.025October 18, 2016
Renal Hemodialysis (PDF)CC.PP.067March 15, 2021
Robotic Surgery (PDF)CC.PP.050November 1, 2017
Same Day Visits (PDF)CC.PP.040February 7, 2017
Skilled Nursing Facility Leveling (PDF)CC.PP.206June 1, 2024
Status "B" Bundled Services (PDF)CC.PP.046February 7, 2017
Status "P" Bundled Services (PDF)CC.PP.049June 17, 2017
Supplies Billed on Same Day As Surgery (PDF)CC.PP.032October 18, 2016
Supportive Living (PDF)ARTC.PP.1000July 20, 2020
Testing for Select Genitourinary Conditions (PDF)CP.MP.97June 1, 2024
Transgender Related Services (PDF)CC.PP.047February 22, 2017
Ultrasound in Pregnancy (PDF)CP.MP.38June 1, 2024
Unbundled Professional Services (PDF)CC.PP.043April 6, 2017
Unbundled Surgical Procedures (PDF)CC.PP.045April 6, 2017
Unlisted Procedure Codes (PDF)CC.PP.009August 12, 2016
Urine Specimen Validity Testing (PDF)CC.PP.056November 8, 2017
Urodynamic Testing (PDF)CP.MP.98June 1, 2024
Velmanase Alfa-tycv (Lamzede) (PDF)CP.PHAR.601June 1, 2023
Wheelchair Accessories (PDF)CC.PP.502August 12, 2016
Wheelchair Seating (PDF)CP.MP.99May 1, 2023

Policy TitlePolicy NumberEffective Date
Behavioral Health Covered Benefits and Services Addendum F (PDF)CC.BH.UM.28 Addendum FJuly 19, 2022
Waiver Environmental Modifications Criteria (PDF)ARTC.CC.25September 1, 2022