| Policy Title |
Policy Number |
Effective Date |
|---|
| 25-hydroxyvitamin D Testing in Children and Adolescents (PDF) |
CP.MP.157 |
November 1, 2023 |
| Abatacept (Orencia) (PDF) |
CP.PHAR.241 |
January 1, 2024 |
| Abatacept (Orencia) (PDF) |
CP.PHAR.241 |
Retire by January 1, 2024 |
| AbobotulinumtoxinA (Dysport) (PDF) |
CP.PHAR.230 |
June 1, 2023 |
| Acupuncture (PDF) |
CP.MP.92 |
September 1, 2023 |
| Ado-Trastuzumab (Kadcyla) (PDF) |
CP.PHAR.229 |
June 1, 2023 |
| Aducanumab (Aduhelm) (PDF) |
CP.PHAR.468 |
August 1, 2022 |
| Aflibercept (Eylea) (PDF) |
CP.PHAR.184 |
December 1, 2023 |
| Agalsidase beta (Fabrazyme) (PDF) |
CP.PHAR.158 |
June 1, 2022 |
| Air Ambulance (PDF) |
CP.MP.175 |
August 1, 2023 |
| Alemtuzumab (Lemtrada) (PDF) |
CP.PHAR.243 |
December 1, 2023 |
| Alglucosidase (Lumizyme) (PDF) |
CP.PHAR.160 |
August 1, 2022 |
| Allogeneic cultured keratinocytes and dermal fibroblasts (StrataGraft)(PDF) |
CP.PHAR.562 |
March 1, 2023 |
| Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF) |
CP.MP.108 |
December 1, 2023 |
| Allogenic processed thymus tissue-agdc (Rethymic) (PDF) |
CP.PHAR.563 |
March 1, 2023 |
| Allergy Testing and Therapy (PDF) |
CP.MP.100 |
November 1, 2023 |
| Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF) |
CP.PHAR.94 |
March 1, 2023 |
| Amisulpride (Barhemsys) (PDF) |
CP.PMN.236 |
August 1, 2023 |
| Amivantamab-vmjw (Rybrevant) (PDF) |
CP.PHAR.544 |
August 1, 2023 |
| Anifrolumab-fnia (Saphnelo) (PDF) |
CP.PHAR.551 |
January 1, 2024 |
| Anifrolumab-fnia (Saphnelo) (PDF) |
CP.PHAR.551 |
Retire by January 1, 2024 |
| Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) |
CP.PHAR.217 |
November 1, 2023 |
| Antithrombin III (ATryn, Thrombate III) (PDF) |
CP.PHAR.564 |
March 1, 2023 |
| Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) |
CP.PHAR.506 |
January 1, 2024 |
| Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) |
CP.PHAR.506 |
Retire by January 1, 2024 |
| Apadamtase alfa (TAK-755) (PDF) |
CP.PHAR.635 |
September 1, 2023 |
| Applied Behavioral Analysis (PDF) |
CP.BH.104 |
May 1, 2023 |
| Aprepitant (Aponvie, Cinvanti, Emend), (PDF) |
CP.PMN.19
|
Retire by February 1, 2024 |
| Aprepitant (Aponvie, Cinvanti, Emend), (PDF) |
CP.PMN.19 |
February 1, 2024 |
| Articular Cartilage Defect Repairs (PDF) |
CP.MP.26 |
July 1, 2023 |
| Asfotase Alfa (Strensiq) (PDF) |
CP.PHAR.328 |
December 1, 2022 |
| Assistive Reproductive Technology (PDF) |
CP.MP.55 |
June 1, 2023 |
| Atezolizumab (Tecentriq) (PDF) |
CP.PHAR.235 |
March 1, 2023 |
| Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF) |
CP.BH.124 |
August 1, 2023 |
| Avacincaptad pegol (Izervay) (PDF) |
CP.PHAR.641 |
December 1, 2023 |
| Avalglucosidase Alfa-ngpt (Nexviazyme) (PDF) |
CP.PHAR.521 |
June 1, 2022 |
| Avelumab (Bavencio) (PDF) |
CP.PHAR.333 |
May 1, 2023 |
| Axicabtagene Ciloleucel (Yescarta®) (PDF) |
CP.PHAR.362 |
March 1, 2023 |
| Azacitidine (Vidaza) (PDF) |
CP.PHAR.387 |
December 1, 2023 |
| Baclofen (Gablofen, Lioresal, Lyvispah, Ozobax) (PDF) |
CP.PHAR.149 |
December 1, 2023 |
| Bamlanivimab-etesevimab (LY-CoV555-LY-CoV016) (PDF) |
CP.PHAR.532 |
July 1, 2023 |
| Bariatric Surgery (PDF) |
CP.MP.37 |
May 1, 2023 |
| Belantamab mafodotin (Blenrep) (PDF) |
CP.PHAR.469 |
June 1, 2023 |
| Belatacept (Nulojix) (PDF) |
CP.PHAR.201 |
December 1, 2023 |
| Belimumab (Benlysta) (PDF) |
CP.PHAR.88 |
October 1, 2022 |
| Belinostat (Beleodaq) (PDF) |
CP.PHAR.311 |
December 1, 2023 |
| Bendamustine (Bendeka, Treanda) (PDF) |
CP.PHAR.307 |
January 1, 2024 |
| Bendamustine (Bendeka, Treanda) (PDF) |
CP.PHAR.307 |
Retire by January 1, 2024 |
| Benralizumab (Fasenra) (PDF) |
CP.PHAR.373 |
May 1, 2023 |
| Beremagene Geperpavec (Vyjuvek) (PDF) |
CP.PHAR.592 |
September 1, 2023 |
| Betibeglogene autotemcel (PDF) |
CP.PHAR.545 |
August 1, 2023 |
| Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) |
CP.PHAR.93 |
January 1, 2024 |
| Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) |
CP.PHAR.93 |
Retire by January 1, 2024 |
| Bimatoprost Implant (Durysta)(PDF) |
CP.PHAR.486 |
June 1, 2023 |
| Behavioral Health Treatment Documentation Requirements (PDF) |
CP.BH.500 |
November 1, 2022 |
| Biofeedback (PDF) |
CP.MP.168 |
January 1, 2023 |
| Biofeedback for Behavioral Health Disorders (PDF) |
CP.BH.300 |
May 1, 2023 |
| Blinatumomab (Blincyto) (PDF) |
CP.PHAR.312 |
August 1, 2023 |
| Bone-Anchored Hearing Aids (PDF) |
AR.CP.MP.93 |
August 1, 2023 |
| Bortezomib (Velcade) (PDF) |
CP.PHAR.410 |
March 1, 2023 |
| Bremelanotide (Vyleesi) (PDF) |
CP.PHAR.434 |
February 1, 2023 |
| Brentuximab Vedotin (Adcetris) (PDF) |
CP.PHAR.303 |
October 2, 2023 |
| Brexanolone (Zulresso) (PDF) |
CP.PHAR.417 |
September 1, 2022 |
| Brexucabtagene Autoleucel (Tecartus) (PDF) |
CP.PHAR.472 |
March 1, 2023 |
| Brolucizumab-dbll (Beovu) (PDF) |
CP.PHAR.445 |
March 1, 2023 |
| Burn Surgery (PDF) |
CP.MP.186 |
January 1, 2023 |
| Buprenorphine implant (Probuphine) (PDF) |
CP.PHAR.289 |
August 1, 2023 |
| C1 Esterase Inhibitors (Berinert Cinryze Haegarda Ruconest) (PDF) |
CP.PHAR.202 |
October 2, 2023 |
| Cabotegravir, Cabotegravir-Rilpivirine (Apretude Cabenuva) (PDF) |
CP.PHAR.573 |
March 1, 2023 |
| Cabazitaxel (Jevtana®) (PDF) |
CP.PHAR.316 |
June 1, 2023 |
| Canakinumab (Ilaris) (PDF) |
CP.PHAR.246 |
December 1, 2023 |
| Caplacizumab-yhdp (Cablivi) |
CP.PHAR.416 |
June 1, 2023 |
| Carbetocin (PDF) |
CP.PHAR.546 |
Pending FDA Approval |
| Cardiac Biomarker Testing (PDF) |
CP.MP.156 |
November 1, 2023 |
| Carfilzomib (Kyprolis) (PDF) |
CP.PHAR.309 |
January 1, 2024 |
| Carfilzomib (Kyprolis) (PDF) |
CP.PHAR.309 |
Retire by January 1, 2024 |
| Casimersen (Amondys 45) (PDF) |
CP.PHAR.470 |
March 1, 2023 |
| Casirivimab and Imdevimab (REGEN-COV) (PDF) |
CP.PHAR.520 |
July 1, 2023 |
| Caudal or Interlaminar Epidural Steroid Injections (PDF) |
CP.MP.164 |
September 1, 2023 |
| Cemiplimab-rwlc (Libtayo) (PDF) |
CP.PHAR.397 |
January 1, 2024 |
| Cemiplimab-rwlc (Libtayo) (PDF) |
CP.PHAR.397 |
Retire by January 1, 2024 |
| Cerliponase alfa (Brineura) (PDF) |
CP.PHAR.338 |
October 2, 2023 |
| Cetuximab (Erbitux) (PDF) |
CP.PHAR.317 |
January 1, 2024 |
| Cetuximab (Erbitux) (PDF) |
CP.PHAR.317 |
Retire by January 1, 2024 |
| Chloramphenicol (PDF) |
CP.PHAR.388 |
August 1, 2023 |
| Ciltacabtagene Autoleucel (Carvykti) |
CP.PHAR.533 |
September 1, 2023 |
| Clinical Trials (PDF) |
CP.MP.94 |
August 1, 2023 |
| Cochlear Implanted Replacements (PDF) |
AR.CP.MP.14 |
December 1, 2023 |
| Collagenase (Xiaflex) (PDF) |
CP.PHAR.82 |
August 1, 2023 |
| Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: Cardiac Disorders (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: Dermatologic Conditions (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: Eye Disorders (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: General Approach to Genetic Testing (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: Hearing Loss (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: Hematologic Conditions (non-cancerous) (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF) |
V2.2023 |
November 1, 2023 |
| Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: Kidney Disorders (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: Lung Disorders (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: Non-invasive Prenatal Screening (NIPS) (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: Pharmacogenetics (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: Preimplantation Genetic Testing (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF) |
V2.2023 |
August 1, 2023 |
| Concert Genetics Oncology: Algorithmic Testing (PDF) |
V2.2023 |
November 1, 2023 |
| Concert Genetics Oncology: Cancer Screening (PDF) |
V2.2023 |
November 1, 2023 |
| Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF) |
V2.2023 |
November 1, 2023 |
| Concert Genetics Oncology: Cytogenetic Testing (PDF) |
V2.2023 |
November 1, 2023 |
| Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF) |
V2.2023 |
November 1, 2023 |
| Continuous Glucose Monitors (PDF) |
CP.PMN.214 |
December 1, 2023 |
| Copanlisib (Aliqopa) (PDF) |
CP.PHAR.357 |
December 1, 2023 |
| Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) |
CP.PHAR.385 |
August 1, 2023 |
| Corticotropin (H.P. Acthar, Purified Cortrophin Gel) (PDF) |
CP.PHAR.168 |
May 1, 2023 |
| Cosmetic and Reconstructive Procedures (PDF) |
CP.MP.31 |
December 1, 2023 |
| Cosyntropin (Cortrosyn) (PDF) |
CP.PHAR.203 |
May 1, 2023 |
Crizanlizumab-tmca (Adakveo) (PDF)
|
CP.PHAR.449 |
March 1, 2023 |
| Cytomegalovirus Immune Globulin (Cytogam) (PDF) |
CP.PHAR.277 |
August 1, 2023 |
| Dalteparin (Fragmin) (PDF) |
CP.PHAR.225 |
March 1, 2022 |
| Daprodustat (Jesduvroq) (PDF) |
CP.PHAR.628 |
August 1, 2023 |
| Daptomycin (Cubicin, Cubicin RF) (PDF) |
CP.PHAR.351 |
August 1, 2023 |
| Daratumumab (Darzalex) (PDF) |
CP.PHAR.310 |
October 2, 2023 |
| Darbepoetin Alfa (Aranesp) (PDF) |
CP.PHAR.236 |
October 9, 2023 |
| Daunorubicin and Cytarabine (Vyxeos) (PDF) |
CP.PHAR.352 |
December 1, 2023 |
| DaxibotulinumtoxinA-lanm (Daxxify) (PDF) |
CP.PHAR.651 |
December 1, 2023 |
| Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (PDF) |
CP.BH.201 |
August 1, 2023 |
| Deferoxamine (Desferal) (PDF) |
CP.PHAR.146 |
October 2, 2023 |
| Degarelix (Firmagon) (PDF) |
CP.PHAR.170 |
December 1, 2023 |
| Delafloxacin (Baxdela) (PDF) |
CP.PMN.115 |
August 1, 2023 |
| Delandistrogene moxeparvovec-rokl (Elevidys) (PDF) |
CP.PHAR.593 |
December 1, 2023 |
| Denosumab (Prolia, Xgeva) (PDF) |
CP.PHAR.58 |
October 9, 2023 |
| Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (PDF) |
CP.PHAR.214 |
November 1, 2023 |
| Dexrazoxane (Zinecard, Totect) (PDF) |
CP.PHAR.418 |
July 1, 2023 |
| Diaphragmatic/Phrenic Nerve Stimulation (PDF) |
CP.MP.203 |
October 1, 2023 |
| Digital EEG Spike Analysis (PDF) |
CP.MP.105 |
November 1, 2023 |
| Disc Decompression Procedures (PDF) |
CP.MP.114 |
July 1, 2023 |
| Discography (PDF) |
CP.MP.115 |
August 1, 2023 |
| Donanemab (LY300281) (PDF) |
CP.PHAR.594 |
January 1, 2024 |
| Donanemab (LY300281) (PDF) |
CP.PHAR.594 |
Retire by January 1, 2024 |
| Donor Lymphocyte Infusion (PDF) |
CP.MP.101 |
December 1, 2023 |
| Dostarlimab-gxly (Jemperli) (PDF) |
CP.PHAR.540 |
November 1, 2023 |
| Drugs of Abuse: Definitive Testing (PDF) |
CP.MP.50 |
August 1, 2023 |
| Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF) |
CP.MP.107 |
May 1, 2023 |
| Durvalumab (Imfinzi) (PDF) |
CP.PHAR.339 |
June 1, 2023 |
| Ecallantide (Kalbitor) (PDF) |
CP.PHAR.177 |
August 1, 2023 |
| Eculizumab (Soliris) (PDF) |
CP.PHAR.97 |
August 1, 2023 |
| Edaravone (Radicava) (PDF) |
CP.PHAR.343 |
June 1, 2023 |
| EEG in the Evaluation of Headache (PDF) |
CP.MP.155 |
November 1, 2023 |
Efgartigimod alfa-fcab (Vyvgart) (PDF)
|
CP.PHAR.555
|
September 1, 2023 |
| Elapegademase-lvlr (Revcovi) (PDF) |
CP.PHAR.419 |
June 1, 2023 |
| Electric Tumor Treatment Fields (Optune) (PDF) |
CP.MP.145 |
April 1, 2023 |
| Elivaldogene autotemcel (Skysona) (PDF) |
CP.PHAR.556 |
December 1, 2023 |
| Elosulfase Alfa (Vimizim) (PDF) |
CP.PHAR.162 |
June 1, 2022 |
| Elotuzumab (Empliciti) (PDF) |
CP.PHAR.308 |
December 1, 2023 |
| Elranatamab-bcmm (Elrexfio) (PDF) |
CP.PHAR.652 |
December 1, 2023 |
| Emapalumab-lzsg (Gamifant) (PDF) |
CP.PHAR.402 |
May 1, 2023 |
| Endometrial Ablation (PDF) |
CP.MP.106 |
August 1, 2023
|
| Enfortumab Vedotin-ejfv (Padcev) (PDF) |
CP.PHAR.455 |
August 1, 2023 |
| Enfuvirtide (Fuzeon) (PDF) |
CP.PHAR.41 |
August 1, 2023 |
| Enoxaparin (Lovenox) (PDF) |
CP.PHAR.224 |
May 1, 2023 |
| Epcoritamab-bysp (Epkinly) (PDF) |
CP.PHAR.634 |
August 1, 2023 |
| Epoetin Alfa (Epogen® and Procrit) (PDF) |
CP.PHAR.237 |
October 9, 2023 |
| Epoprostenol (Flolan, Veletri) (PDF) |
CP.PHAR.192 |
March 1, 2023 |
| Eptinezumab-jjmr (Vyepti) (PDF) |
CP.PHAR.489 |
December 1, 2023 |
| Eribulin Mesylate (Halaven) (PDF) |
CP.PHAR.318 |
January 1, 2024 |
| Eribulin Mesylate (Halaven) (PDF) |
CP.PHAR.318 |
Retire by January 1, 2024 |
| Erwinia Asparaginase (Erwinaze) (PDF) |
CP.PHAR.301 |
May 1, 2023 |
| Etelcalcetide (Parsabiv) (PDF) |
CP.PHAR.379 |
August 1, 2023 |
| Eteplirsen (Exondys 51) (PDF) |
CP.PHAR.288 |
March 1, 2023 |
| Etranacogene Dezaparvovec (Hemgenix) (PDF) |
CP.PHAR.580 |
August 1, 2023 |
| Evinacumab-dgnb (Evkeeza) (PDF) |
CP.PHAR.511 |
May 1, 2023 |
| Evoked Potential Testing (PDF) |
CP.MP.134 |
November 1, 2023 |
| Experimental Technologies (PDF) |
CP.MP.36 |
July 1, 2023 |
| Facet Joint Interventions (PDF) |
CP.MP.171 |
September 1, 2023 |
| Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF) |
CP.MP.248 |
October 1, 2023 |
| Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (PDF) |
CP.PHAR.220 |
March 1, 2023 |
| Factor VIII (Human Recombinant) (PDF) |
CP.PHAR.215 |
November 1, 2023 |
| Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF) |
CP.PHAR.216 |
November 1, 2023 |
| Factor IX (Human, Recombinant) (PDF) |
CP.PHAR.218 |
November 1, 2023 |
| Factor IX Complex, Human (Profilnine) (PDF) |
CP.PHAR.219 |
March 1, 2023 |
| Factor XIII, Human (Corifact®) (PDF) |
CP.PHAR.221 |
March 1, 2023 |
| Factor XIII A-Subunit, Recombinant (Tretten®) |
CP.PHAR.222 |
March 1, 2023 |
| Fam-Trastuzumab Deruxtecan-nxki (Enhertu) (PDF) |
CP.PHAR.456 |
March 1, 2023 |
| Faricimab (Vabysmo) (PDF) |
CP.PHAR.581 |
June 1, 2023 |
| Fecal Incontinence Treatments (PDF) |
CP.MP.137 |
December 1, 2023 |
| Ferric Carboxymaltose (Injectafer) (PDF) |
CP.PHAR.234 |
December 1, 2023 |
| Ferric Carboxymaltose (Injectafer) (PDF) |
CP.PHAR.234 |
Retire by December 1, 2023 |
| Ferric Derisomaltose (Monoferric)(PDF) |
CP.PHAR.480 |
December 1, 2023 |
| Ferric Derisomaltose (Monoferric)(PDF) |
CP.PHAR.480 |
Retire by December 1, 2023 |
| Ferric Gluconate (Ferrlecit) (PDF) |
CP.PHAR.166 |
July 1, 2023 |
| Ferric Pyrophosphate Citrate (Triferic) (PDF) |
CP.PHAR.624 |
December 1, 2023 |
| Ferric Pyrophosphate Citrate (Triferic) (PDF) |
CP.PHAR.624 |
Retire by December 1, 2023 |
| Ferriscan R2-MRI (PDF) |
CP.MP.53 |
December 1, 2023 |
| Ferumoxytol (Feraheme) (PDF) |
CP.PHAR.165 |
December 1, 2023 |
| Ferumoxytol (Feraheme) (PDF) |
CP.PHAR.165 |
Retire by December 1, 2023 |
| Fertility Preservation (PDF) |
CP.MP.130 |
October 1, 2023 |
| Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) |
CP.MP.129 |
December 1, 2023 |
| Fibrinogen concentrate (human) (Fibryga, RiaSTAP) (PDF) |
CP.PHAR.526 |
June 1, 2023 |
| Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) (PDF) |
CP.PHAR.297 |
October 2, 2023 |
| Fondaparinux (Arixtra) (PDF) |
CP.PHAR.226 |
March 1, 2022 |
| Fosdenopterin (Nulibry) (PDF) |
CP.PHAR.471 |
June 1, 2023 |
| Fulvestrant (Faslodex Injection) (PDF) |
CP.PHAR.424 |
August 1, 2023 |
| Functional MRI (PDF) |
CP.MP.43 |
April 1, 2023 |
| Galsulfase (Naglazyme) (PDF) |
CP.PHAR.161 |
June 1, 2022 |
| Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) |
CP.MP.209 |
August 1, 2023 |
| Gastric Electrical Stimulation (PDF) |
CP.MP.40 |
July 1, 2023 |
| Gemtuzumab (Mylotarg) (PDF) |
CP.PHAR.358 |
December 1, 2023 |
| Gender-Affirming Procedures (PDF) |
CP.MP.95 |
October 1, 2023 |
| Givosiran (Givlaari) (PDF) |
CP.PHAR.457 |
March 1, 2023 |
| Glofitamab-gxbm (Columvi) (PDF) |
CP.PHAR.636 |
September 1, 2023 |
| Golodirsen (Vyondys 53) (PDF) |
CP.PHAR.453 |
March 1, 2023 |
| Golimumab (Simponi, Simponi Aria) (PDF) |
CP.PHAR.253 |
January 1, 2024 |
| Golimumab (Simponi, Simponi Aria) (PDF) |
CP.PHAR.253 |
Retire by January 1, 2024 |
| Goserelin Acetate (Zoladex) (PDF) |
CP.PHAR.171 |
December 1, 2023 |
| Granisetron (Kytril, Sancuso, Sustol) (PDF) |
CP.PMN.74 |
August 1, 2023 |
| Helicobacter Pylori Serology Testing (PDF) |
CP.MP.153 |
November 1, 2023 |
| Hemin (Panhematin) (PDF) |
CP.PHAR.181 |
May 1, 2023 |
| Histrelin (Vantas, Supprelin LA) (PDF) |
CP.PHAR.172 |
June 1, 2023 |
| Holter Monitors (PDF) |
CP.MP.113 |
November 1, 2023 |
| Home and Community Based Services (HCBS) (PDF) |
AR.CP.BH.503 |
November 1, 2023 |
| Home Births (PDF) |
CP.MP.136 |
March 1, 2023 |
| Home Ventilators (PDF) |
CP.MP.184 |
August 1, 2023 |
| Hospice Services (PDF) |
CP.MP.54 |
September 1, 2023 |
| Hyaluronate Derivatives (PDF) |
CP.PHAR.05 |
December 1, 2023 |
| Hydroxyprogesterone caproate (Makena) (PDF) |
CP.PHAR.14 |
June 1, 2023 |
| Hyperhidrosis Treatments (PDF) |
CP.MP.62 |
June 1, 2023 |
| ibalizumab-uiyk (Trogarzo) (PDF) |
CP.PHAR.378 |
June 1, 2022 |
| Ibandronate Injection (Boniva) (PDF) |
CP.PHAR.189 |
March 1, 2023 |
| Idecabtagene vicleucel (Abecma) (PDF) |
CP.PHAR.481 |
August 1, 2022 |
| Idursulfase (Elaprase) (PDF) |
CP.PHAR.156 |
June 1, 2022 |
| Iloprost (Ventavis) (PDF) |
CP.PHAR.193 |
March 1, 2023 |
| Imiglucerase (Cerezyme) (PDF) |
CP.PHAR.154 |
November 1, 2022 |
| Immune Globulins (PDF) |
CP.PHAR.103 |
November 1, 2023 |
| Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) |
CP.MP.180 |
April 1, 2023 |
| Implantable Intrathecal or Epidural Pain Pump (PDF) |
CP.MP.173 |
March 1, 2023 |
| Implantable Loop Recorder (PDF) |
CP.MP.243 |
June 1, 2023 |
| Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) |
CP.MP.160 |
June 1, 2023 |
| Inclisiran (Leqvio) (PDF) |
CP.PHAR.568 |
December 1, 2023 |
| IncobotulinumtoxinA (Xeomin) (PDF) |
CP.PHAR.231 |
July 1, 2023 |
| Inotersen (Tegsedi) (PDF) |
CP.PHAR.405 |
February 1, 2023 |
| Inebilizumab (PDF) |
CP.PHAR.458 |
August 1, 2023 |
| Infertility and Fertility Preservation (PDF) |
CP.PHAR.131 |
January 1, 2024 |
| Infertility and Fertility Preservation (PDF) |
CP.PHAR.131 |
Retire by January 1, 2024 |
| Infliximab (Remicade, Inflectra, Renflexis) (PDF) |
CP.PHAR.254 |
June 1, 2023 |
| Inotuzumab Ozogamicin (Besponsa) (PDF) |
CP.PHAR.359 |
December 1, 2023 |
| Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF) |
CP.PHAR.534 |
August 1, 2023 |
| Intensity-Modulated Radiotherapy (PDF) |
CP.MP.69 |
October 1, 2023 |
| Interferon Gamma- 1b (Actimmune) (PDF) |
CP.PHAR.52 |
March 1, 2023 |
| Intestinal and Multivisceral Transplant (PDF) |
CP.MP.58 |
July 1, 2023 |
| Intradiscal Steroid Injections for Pain Management (PDF) |
CP.MP.167 |
October 1, 2023 |
| Iobenguane I-131 (Azedra) (PDF) |
CP.PHAR.459 |
March 1, 2023 |
| Ipilimumab (Yervoy) (PDF) |
CP.PHAR.319 |
July 1, 2023 |
| Irinotecan Liposome (Onivyde) (PDF) |
CP.PHAR.304 |
December 1, 2023 |
| Iron Sucrose (Venofer) (PDF) |
CP.PHAR.167 |
July 1, 2023 |
| Isatuximab-irfc (Sarclisa)(PDF) |
CP.PHAR.482 |
June 1, 2023 |
Isavuconazonium (Cresemba)
|
CP.PMN.154
|
December 1, 2023 |
| IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF) |
CP.MP.61 |
December 1, 2023 |
| Ixekizumab (Taltz) (PDF) |
CP.PHAR.257 |
June 1, 2023 |
| Lanadelumab-fylo (Takhzyro) (PDF) |
CP.PHAR.396 |
August 1, 2023 |
| Lanreotide (Somatuline Depot) (PDF) |
CP.PHAR.391 |
December 1, 2023 |
| Lantidra (donislecel) Allogenic Pancreatic Islet Cellular Therapy (PDF) |
CP.MP.250 |
October 1, 2023 |
| Laronidase (Aldurazyme) (PDF) |
CP.PHAR.152 |
November 1, 2022 |
| Lecanemab-irmb (Leqembi) (PDF) |
CP.PHAR.596 |
December 1, 2023 |
| Lefamulin (Xenleta) (PDF) |
CP.PMN.219 |
August 1, 2023 |
| Letermovir (Prevymis) (PDF) |
CP.PHAR.367 |
September 1, 2023 |
| Leucovorin Injection (PDF) |
CP.PHAR.393 |
December 1, 2023 |
| Leuprolide Acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi) (PDF) |
CP.PHAR.173 |
January 1, 2024 |
| Leuprolide Acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi) (PDF) |
CP.PHAR.173 |
Retire by January 1, 2024 |
| Levoleucovorin (Fusilev, Khapzory) (PDF) |
CP.PHAR.151 |
December 1, 2023 |
| Linezolid (Zyvox) (PDF) |
CP.PMN.27 |
August 1, 2023 |
| Liposuction for Lipedema (PDF) |
CP.MP.244 |
July 1, 2023 |
| Lisocabtagene maraleucel (Breyanzi) (PDF) |
CP.PHAR.483 |
June 1, 2022 |
| Loncastuximab tesirine-lpyl (Zynlonta) (PDF) |
CP.PHAR.539 |
October 2, 2023 |
| Lovotibeglogene Autotemcel (Lovo-Cel) (PDF) |
CP.PHAR.627 |
Pending FDA Approval |
| Lumasiran (Oxlumo) (PDF) |
CP.PHAR.473 |
May 1, 2023 |
| Lurbinectedin (Zepzelca) (PDF) |
CP.PHAR.500 |
October 2, 2023 |
| Luspatercept-aamt (Reblozyl) (PDF) |
CP.PHAR.450 |
December 1, 2023 |
| Lutetium Lu 177 Dotatate (Lutathera) (PDF) |
CP.PHAR.384 |
August 1, 2023 |
| Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) (PDF) |
CP.PHAR.582 |
July 1, 2023 |
| Lysis of Epidural Lesions (PDF) |
CP.MP.116 |
July 1, 2023 |
| Margetuximab-cmkb (Margenza) (PDF) |
CP.PHAR.522 |
March 1, 2023 |
| Measurement of Serum 1,25-dihydroxyvitamin D (PDF) |
CP.MP.152 |
November 1, 2023 |
| Mecasermin (Increlex) (PDF) |
CP.PHAR.150 |
August 1, 2023 |
| Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) |
CP.MP.144 |
January 1, 2023 |
| Melphalan (Hepzato) (PDF) |
CP.PHAR.653 |
December 1, 2023 |
| Melphalan flufenamide (Pepaxto) (PDF) |
CP.PHAR.535 |
June 1, 2023 |
| Mepolizumab (Nucala) (PDF) |
CP.PHAR.200 |
April 1, 2022 |
| Mesenchymal stem cell-NTF (NurOwn) (PDF) |
CP.PHAR.637 |
September 1, 2023 |
| Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF) |
CP.PHAR.134 |
December 1, 2022 |
| Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) |
CP.PHAR.238 |
June 1, 2023 |
| Metreleptin (Myalept) (PDF) |
CP.PHAR.425 |
August 1, 2023 |
| Mirvetuximab soravtansine-gynx (Elahere) (PDF) |
CP.PHAR.617 |
August 1, 2023 |
| Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF) |
CP.PHAR.495 |
October 2, 2023 |
| Mitoxantrone (Novantrone) (PDF) |
CP.PHAR.258 |
December 1, 2023 |
| Mogamulizumab-kpkc (Poteligeo) (PDF) |
CP.PHAR.139 |
December 1, 2023 |
| Mometasone Furoate (Sinuva) (PDF) |
CP.PHAR.448 |
August 1, 2023 |
| Mosunetuzumab-axgb (Lunsumio) (PDF) |
CP.PHAR.618 |
August 1, 2023 |
| Motixafortide (Aphexda) (PDF) |
CP.PHAR.655 |
December 1, 2023 |
| Moxetumomab Pasudotox-tdfk (Lumoxiti) (PDF) |
CP.PHAR.398 |
December 1, 2023 |
| Multiple Sleep Latency Testing (PDF) |
CP.MP.24 |
June 1, 2023 |
| Nadofaragene Firadenovec (Instiladrin)(PDF) |
CP.PHAR.461 |
August 1, 2023 |
| Naltrexone (Vivitrol) (PDF) |
CP.PHAR.96 |
March 1, 2023 |
| Natalizumab (Tysabri) (PDF) |
CP.PHAR.259 |
January 1, 2024 |
| Natalizumab (Tysabri) (PDF) |
CP.PHAR.259 |
Retire by January 1, 2024 |
| Naxitamab-gqgk (Danyelza) (PDF) |
CP.PHAR.523 |
March 1, 2023 |
| Necitumumab (Portrazza) (PDF) |
CP.PHAR.320 |
December 1, 2023 |
| Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF) |
CP.MP.48 |
December 1, 2023 |
| Netupitant and Palonosetron (Akynzeo) (PDF) |
CP.PMN.158 |
October 2, 2023 |
| Nerve Blocks and Neurolysis for Pain Management (PDF) |
CP.MP.170 |
October 1, 2023 |
| Nirsevimab (Beyfortus) 08.07.23 (PDF) |
CP.PHAR.614 |
December 1, 2023 |
| Nivolumab (Opdivo) (PDF) |
CP.PHAR.121 |
May 1, 2023 |
| Nivolumab and Relatlimab (Opdualag) (PDF) |
CP.PHAR.588 |
August 1, 2023 |
| No Coverage Criteria (PDF) |
CP.PMN.255 |
November 1, 2023 |
| Nonmyeloablative Allogeneic Stem Cell Transplants (PDF) |
CP.MP.141 |
April 1, 2023 |
| Nusinersen (Spinraza®) (PDF) |
CP.PHAR.327 |
March 1, 2023 |
| Obstetrical Home Care Programs (PDF) |
CP.MP.91 |
June 1, 2023 |
| Obinutuzumab (Gazyva) (PDF) |
CP.PHAR.305 |
December 1, 2023 |
| Ocrelizumab (Ocrevus) (PDF) |
CP.PHAR.335 |
December 1, 2023 |
| Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF) |
CP.PHAR.40 |
February 1, 2023 |
| Ofatumumab (Arzerra, Kesimpta) (PDF) |
CP.PHAR.306 |
December 1, 2023 |
| Off-Label Use (PDF) |
CP.PMN.53 |
December 1, 2023 |
| Olaparib (Lynparza) (PDF) |
CP.PHAR.360 |
May 1, 2023 |
| Olaratumab (Lartruvo) (PDF) |
CP.PHAR.326 |
December 1, 2023 |
| Olipudase alfa-rpcp (Xenpozyme) (PDF) |
CP.PHAR.586 |
August 1, 2023 |
| Omadacycline (Nuzyra) (PDF) |
CP.PMN.188 |
August 1, 2023 |
| Omalizumab (Xolair) (PDF) |
CP.PHAR.01 |
May 1, 2023 |
| Omecetaxine (Synribo) (PDF) |
CP.PHAR.108 |
June 1, 2023 |
| Omisirge (omidubicel): Nicotinamide-modified allogeneic hematopoietic progenitor cell therapy (PDF) |
CP.MP.249 |
August 1, 2023 |
| OnabotulinumtoxinA (Botox) (PDF) |
CP.PHAR.232 |
December 1, 2023 |
| Onasemnogene Abeparvovec (Zolgensma) (PDF) |
CP.PHAR.421 |
June 1, 2022 |
| Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) |
CP.PHAR.536 |
June 1, 2023 |
| Orthognathic Surgery (PDF) |
CP.MP.202 |
December 1, 2023 |
| Osteogenic Stimulation (PDF) |
CP.MP.194 |
October 1, 2023 |
| Outpatient Cardiac Rehabilitation (PDF) |
CP.MP.176 |
July 1, 2023 |
| Outpatient Oxygen Use (PDF) |
CP.MP.190 |
June 1, 2023 |
| Paclitaxel protein-bound (Abraxane) (PDF) |
CP.PHAR.176 |
August 1, 2023 |
| Panitumumab (Vectibix) (PDF) |
CP.PHAR.321 |
January 1, 2024 |
| Panitumumab (Vectibix) (PDF) |
CP.PHAR.321 |
Retire by January 1, 2024 |
| Panniculectomy (PDF) |
CP.MP.109 |
December 1, 2023 |
| Paricalcitol Injection (Zemplar) (PDF) |
CP.PHAR.270 |
August 1, 2023 |
| Pasireotide (Signifor, Signifor LAR) (PDF) |
CP.PHAR.332 |
December 1, 2023 |
| Patisiran (Onpattro) (PDF) |
CP.PHAR.395 |
December 1, 2023 |
| Peanut Allergen Powder-dnfp (Palforzia)(PDF) |
CP.PMN.220 |
March 1, 2021 |
| Pediatric Oral Function Therapy (PDF) |
CP.MP.188 |
July 1, 2023 |
| Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas) (PDF) |
CP.PHAR.353 |
December 1, 2023 |
| Pegaptanib (Macugen) (PDF) |
CP.PHAR.185 |
May 1, 2023 |
| Pegcetacoplan (Empaveli) (PDF) |
CP.PHAR.524 |
August 1, 2023 |
| Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) (PDF) |
CP.PHAR.296 |
December 1, 2023 |
| Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) (PDF) |
CP.PHAR.296 |
Retire by December 1, 2023 |
| Pegloticase (Krystexxa) (PDF) |
CP.PHAR.115 |
March 1, 2023 |
| Pegunigalsidase alfa-iwxj (Elfabrio) (PDF) |
CP.PHAR.512 |
August 1, 2023 |
| Pegvaliase-pqpz (Palynziq) (PDF) |
CP.PHAR.140 |
December 1, 2023 |
| Pegvisomant (Somavert) (PDF) |
CP.PHAR.389 |
December 1, 2023 |
| Pegzilarginase (AEB1102) (PDF) |
CP.PHAR.587 |
Pending FDA Approval |
| Pembrolizumab (Keytruda®) (PDF) |
CP.PHAR.322 |
August 1, 2023 |
| Pemetrexed (Alimta, Pemfexy) (PDF) |
CP.PHAR.368 |
August 1, 2023 |
| Percutaneous Left Atrial Appendage Closure for Stroke Prevention (PDF) |
CP.MP.147 |
July 1, 2023 |
| Pertuzumab (Perjeta) (PDF) |
CP.PHAR.227 |
June 1, 2023 |
| Pertuzumab-trastuzumab-hyaluronidase-zzxf (Phesgo) (PDF) |
CP.PHAR.501 |
October 2, 2023 |
| Physical, Occupational, and Speech Therapy Services (PDF) |
CP.MP.49 |
November 1, 2023 |
| Plasminogen (Ryplazim) (PDF) |
CP.PHAR.513 |
December 1, 2023 |
| Plerixafor (Mozobil) (PDF) |
CP.PHAR.323 |
August 1, 2023 |
| Polatuzumab Vedotin-piiq (Polivy) (PDF) |
CP.PHAR.433 |
October 2, 2023 |
| Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) |
CP.MP.181 |
November 1, 2023 |
| Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) |
CP.MP.133 |
October 1, 2023 |
| Pozelimab (REGN3918) (PDF) |
CP.PHAR.626 |
December 1, 2023 |
| Prademagene Zamikeracel (EB-101) (PDF) |
CP.PHAR.609 |
March 1, 2023 |
| Pralatrexate (Folotyn) (PDF) |
CP.PHAR.313 |
December 1, 2023 |
| Protein C Concentrate, Human (Ceprotin) PDF) |
CP.PHAR.330 |
March 1, 2023 |
| Proton and Neutron Beam Therapy (PDF) |
CP.MP.70 |
January 1, 2023 |
| Ramucirumab (Cyramza) (PDF) |
CP.PHAR.119 |
May 1, 2023 |
| Ranibizumab (Byooviz, Lucentis, Susvimo) (PDF) |
CP.PHAR.186 |
August 1, 2023 |
| Ravulizumab-cwvz (Ultomiris) (PDF) |
CP.PHAR.415 |
August 1, 2023 |
| Reduction Mammoplasty and Gynecomastia Surgery (PDF) |
CP.MP.51 |
September 1, 2023 |
| Repair of Nasal Valve Compromise (PDF) |
CP.MP.210 |
July 1, 2023 |
| Reslizumab (Cinqair) (PDF) |
CP.PHAR.223 |
May 1, 2023 |
| Retifanlimab-dlwr (Zynyz) (PDF) |
CP.PHAR.629 |
August 1, 2023 |
| Rilonacept (Arcalyst) (PDF) |
CP.PHAR.266 |
June 1, 2023 |
| RimabotulinumtoxinB (Myobloc) (PDF) |
CP.PHAR.233 |
June 1, 2023 |
| Risankizumab-rzaa (Skyrizi) (PDF) |
CP.PHAR.426 |
January 1, 2024 |
| Risankizumab-rzaa (Skyrizi) (PDF) |
CP.PHAR.426 |
Retire by January 1, 2024 |
| Risdiplam (Evrysdi) (PDF) |
CP.PHAR.477 |
March 1, 2023 |
| Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) |
CP.PHAR.260 |
August 1, 2023 |
| Rolapitant (Varubi) (PDF) |
CP.PMN.102 |
August 1, 2023 |
| Romidepsin (Istodax) (PDF) |
CP.PHAR.314 |
December 1, 2023 |
| Romiplostim (Nplate®) (PDF) |
CP.PHAR.179 |
May 1, 2023 |
| Ropeginterferon alfa-2b-njft (Besremi) (PDF) |
CP.PHAR.570 |
May 1, 2023 |
| Rozanolixizumab-noli (Rystiggo) (PDF) |
CP.PHAR.648 |
December 1, 2023 |
| Sacituzumab Govitecan-hziy (Trodelvy) (PDF) |
CP.PHAR.475 |
June 1, 2023 |
| Sacroiliac Joint Fusion (PDF) |
CP.MP.126 |
November 1, 2023 |
| Sacroiliac Joint Interventions for Pain Management (PDF) |
CP.MP.166 |
October 1, 2023 |
| Sargramostim (Leukine) (PDF) |
CP.PHAR.295 |
August 1, 2023 |
| Satralizumab-mwge (Enspryng) (PDF) |
CP.PHAR.463 |
August 1, 2023 |
| Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF) |
CP.MP.146 |
November 1, 2023 |
| Sebelipase Alfa (Kanuma) (PDF) |
CP.PHAR.159 |
June 1, 2022 |
| Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF) |
CP.MP.174 |
January 1, 2023 |
| Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF) |
CP.MP.165 |
October 1, 2023 |
| Setmelanotide (Imcivree) (PDF) |
CP.PHAR.491 |
December 1, 2022 |
| Sipuleucel-T (Provenge) (PDF) |
CP.PHAR.120 |
June 1, 2023 |
| Siltuximab (Sylvant) (PDF) |
CP.PHAR.329 |
March 1, 2023 |
| Sirolimus Protein-Bound Particles (Fyarro), topical gel (Hyftor) |
CP.PHAR.574 |
March 1, 2023 |
| Skilled Nursing Facility Leveling (PDF) |
CP.MP.206 |
October 1, 2022 |
| Skin and Soft Tissue Substitutes for Chronic Wounds (PDF) |
CP.MP.185 |
September 1, 2023 |
| Sodium thiosulfate (Pedmark) (PDF) |
CP.PHAR.610 |
August 1, 2023 |
| Sotatercept (ACE-011) (PDF) |
CP.PHAR.657 |
Pending FDA Approval |
| Sotrovimab (VIR-7831) (PDF) |
CP.PHAR.541 |
July 1, 2023 |
| Spesolimab-sbzo (Spevigo) (PDF) |
CP.PHAR.606 |
August 1, 2023 |
| Spinal Cord Stimulation (PDF) |
CP.MP.117 |
July 1, 2023 |
| Stereotactic Body Radiation Therapy (PDF) |
CP.MP.22 |
March 1, 2023 |
| Substance Use Disorders Treatment and Services (PDF) |
CP.BH.100 |
November 1, 2022 |
| Sutimlimab-jome (Enjaymo) (PDF) |
CP.PHAR.503 |
June 1, 2023 |
| Tafasitamab-cxix (Monjuvi) (PDF) |
CP.PHAR.508 |
December 1, 2023 |
| Taliglucerase Alfa (Elelyso) (PDF) |
CP.PHAR.157 |
December 1, 2021 |
| Talimogene laherparepvec (Imlygic) (PDF) |
CP.PHAR.542 |
August 1, 2023 |
| Talquetamab-tgvs (Talvey) (PDF) |
CP.PHAR.649 |
December 1, 2023 |
| Tebentafusp-(Kimmtrak) (PDF) |
CP.PHAR.575 |
June 1, 2023 |
| Teclistamab-cqyv (Tecvayli) (PDF) |
CP.PHAR.611 |
August 1, 2023 |
| Tedizolid (Sivextro) (PDF) |
CP.PMN.62 |
August 1, 2023 |
| Teduglutide (Gattex) (PDF) |
CP.PHAR.114 |
March 1, 2023 |
| Temozolomide (Temodar) (PDF) |
CP.PHAR.77 |
Retire by February 1, 2024 |
| Temozolomide (Temodar) (PDF) |
CP.PHAR.77 |
February 1, 2024 |
| Temsirolimus (Torisel) (PDF) |
CP.PHAR.324 |
December 1, 2023 |
| Teplizumab-mzwv (Tzield) (PDF) |
CP.PHAR.492 |
Pending FDA Approval |
| Teprotumumab (Tepezza) (PDF) |
CP.PHAR.465 |
August 1, 2023 |
| Testing for Select Genitourinary Conditions (PDF) |
CP.MP.97 |
November 1, 2023 |
| Testosterone (Testopel, Jatenzo) (PDF) |
CP.PHAR.354 |
December 1, 2023 |
| Tezepelumab (Tezspire) (PDF) |
CP.PHAR.576 |
May 1, 2023 |
| Therapeutic Utilization of Inhaled Nitric Oxide (PDF) |
CP.MP.87 |
June 1, 2023 |
| Thyroid Hormones and Insulin Testing in Pediatrics (PDF) |
CP.MP.154 |
November 1, 2023 |
| Thyrotropin alfa (Thyrogen) (PDF) |
CP.PHAR.95 |
August 1, 2023 |
| Tisagenlecleucel (Kymriah) (PDF) |
CP.PHAR.361 |
March 1, 2023 |
| Tisotumab Vedotin-tftv (Tivdak) (PDF) |
CP.PHAR.561 |
December 1, 2023 |
| Tixagevimab-Cilgavimab (Evusheld) (PDF) |
CP.PHAR.571 |
July 1, 2023 |
| Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (PDF) |
CP.PHAR.211 |
March 1, 2022 |
| Tocilizumab (Actemra) (PDF) |
CP.PHAR.263 |
June 1, 2023 |
| Tofersen (Qalsody) (PDF) |
CP.PHAR.591 |
December 1, 2023 |
| Topotecan (Hycamtin) (PDF) |
CP.PHAR.64 |
July 1, 2023 |
| Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) |
CP.MP.163 |
June 1, 2023 |
| Trabectedin (Yondelis) (PDF) |
CP.PHAR.204 |
March 1, 2023 |
| Tralokinumab-ldrm (Adbry) (PDF) |
CP.PHAR.577 |
June 1, 2022 |
| Transcatheter Closure of Patent Foramen Ovale (PDF) |
CP.MP.151 |
April 1, 2023 |
| Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF) |
CP.BH.200 |
August 1, 2023 |
| Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) |
CP.PHAR.228 |
October 9, 2023 |
| Tremelimumab-actl (Imjudo) (PDF) |
CP.PHAR.612 |
August 1, 2023 |
| Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF) |
CP.PHAR.199 |
August 1, 2022 |
| Triamcinolone ER Injection (Zilretta) (PDF) |
CP.PHAR.371 |
March 1, 2023 |
| Trigger Point Injections for Pain Management (PDF) |
CP.MP.169 |
October 1, 2023 |
| Triptorelin pamoate (Trelstar, Triptodur) (PDF) |
CP.PHAR.175 |
December 1, 2023 |
| Ublituximab-xiiy (Briumvi) (PDF) |
CP.PHAR.621 |
December 1, 2023 |
| Urinary Incontinence Devices and Treatments (PDF) |
CP.MP.142 |
August 1, 2023 |
| Ustekinumab (Stelara) (PDF) |
CP.PHAR.264 |
January 1, 2024 |
| Ustekinumab (Stelara) (PDF) |
CP.PHAR.264 |
Retire by January 1, 2024 |
| Vagus Nerve Stimulation (PDF) |
CP.MP.12 |
October 1, 2023 |
| Valoctocogene Roxaparvovec (PDF) |
CP.PHAR.466 |
Pending FDA Approval |
| Valrubicin (Valstar) (PDF) |
CP.PHAR.439 |
December 1, 2023 |
| Vedolizumab (Entyvio) (PDF) |
CP.PHAR.265 |
January 1, 2024 |
| Vedolizumab (Entyvio) (PDF) |
CP.PHAR.265 |
Retire by January 1, 2024 |
| Velaglucerase alfa (VPRIV) (PDF) |
CP.PHAR.163 |
December 1, 2021 |
| Velmanase Alfa-tycv (Lamzede) (PDF) |
CP.PHAR.601 |
June 1, 2023 |
| Ventricular Assist Devices (PDF) |
CP.MP.46 |
October 1, 2023 |
| Verteporfin (Visudyne) (PDF) |
CP.PHAR.187 |
March 1, 2023 |
| Vestronidase Alfa-vjbk (Mepsevii) (PDF) |
CP.PHAR.374 |
June 1, 2023 |
| Viltolarsen (Viltepso) (PDF) |
CP.PHAR.484 |
March 1, 2023 |
| Vincristine Liposome (Marqibo) (PDF) |
CP.PHAR.315 |
January 1, 2024 |
| Vincristine Liposome (Marqibo) (PDF) |
CP.PHAR.315 |
Retire by January 1, 2024 |
| Voretigene neparvovec-rzyl (Luxturna) (PDF) |
CP.PHAR.372 |
March 1, 2023 |
| Vosoritide (Voxzogo) (PDF) |
CP.PHAR.525 |
March 1, 2023 |
| Vutrisiran (Amvuttra) (PDF) |
CP.PHAR.550 |
December 1, 2022 |
| Waiver Environmental Modifications Criteria (PDF) |
ARTC.CC.25 |
September 1, 2022 |
| Wireless Motility Capsule (PDF) |
CP.MP.143 |
November 1, 2023 |
| Zavegepant (Zavzpret) (PDF) |
CP.PHAR.630 |
August 1, 2023 |
| Ziv-aflibercept (Zaltrap) (PDF) |
CP.PHAR.325 |
December 1, 2023 |
| Zoledronic Acid (PDF) |
CP.PHAR.59 |
March 1, 2023 |
