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 |