Policy Title |
Policy Number |
Effective Date |
---|
25-hydroxyvitamin D Testing in Children and Adolescents (PDF) |
CP.MP.157 |
January 1, 2022 |
Abaloparatide (Tymlos) (PDF) |
CP.PHAR.345
|
March 1, 2022 |
Abatacept (Orencia) (PDF) |
CP.PHAR.241 |
|
AbobotulinumtoxinA (Dysport) (PDF) |
CP.PHAR.230 |
June 1, 2022 - NEW |
Acupuncture (PDF) |
CP.MP.92 |
October 1, 2021 |
ADHD Assessment and Treatment (PDF) |
CP.MP.124 |
May 1, 2022
|
Ado-Trastuzumab (Kadcyla) (PDF) |
CP.PHAR.229 |
June 1, 2022 |
Aducanumab (Aduhelm) (PDF) |
CP.PHAR.468 |
August 1, 2022 |
Aducanumab (Aduhelm) (PDF) |
CP.PHAR.468
|
Retire by August 1, 2022 |
Adult Rehabilitative Day Service (Psychosocial Rehabilitation Services)(PDF) |
CP.BH.AR.1800 |
March 1, 2019 |
Afamelanotide (Scenesse) (PDF) |
CP.PHAR.444 |
March 1, 2022 |
Aflibercept (Eylea) (PDF) |
CP.PHAR.184 |
June 1, 2022 |
Agalsidase beta (Fabrazyme) (PDF) |
CP.PHAR.158 |
June 1, 2022 |
Air Ambulance (PDF) |
CP.MP.175 |
October 1, 2021 |
Alemtuzumab (Lemtrada) (PDF) |
CP.PHAR.243 |
June 1, 2022 |
Alglucosidase (Lumizyme) (PDF) |
CP.PHAR.160 |
August 1, 2022 |
Alglucosidase (Lumizyme) (PDF) |
CP.PHAR.160
|
Retire by August 1, 2022 |
Allogeneic cultured keratinocytes and dermal fibroblasts (StrataGraft)(PDF) |
CP.PHAR.562 |
March 1, 2022 |
Allogenic Hematopoietic Cell Transplants for Sickle Cell (PDF) |
CP.MP.108 |
January 1, 2022 |
Allogenic processed thymus tissue-agdc (Rethymic) (PDF) |
CP.PHAR.563 |
June 1, 2022 - NEW |
Allergy Testing and Therapy (PDF) |
CP.MP.100 |
August 1, 2022 |
Allergy Testing and Therapy (PDF) |
CP.MP.100
|
Retire by August 1, 2022 |
Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF) |
CP.PHAR.94 |
March 1, 2022 |
Amifampridine (Firdapse, Ruzurgi)(PDF) |
CP.PHAR.411 |
April 1, 2022 |
Amikacin (Arikayce) (PDF) |
CP.PHAR.401 |
April 1, 2022 |
Amisulpride (Barhemsys) (PDF) |
CP.PMN.236 |
November 1, 2021 |
Amivantamab-vmjw (Rybrevant) (PDF) |
CP.PHAR.544 |
October 1, 2021 |
Anifrolumab-fnia (Saphnelo) (PDF) |
CP.PHAR.551 |
December 1, 2021 |
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) |
CP.PHAR.217 |
June 1, 2022 |
Antithrombin III (ATryn, Thrombate III) (PDF) |
CP.PHAR.564 |
March 1, 2022 |
Antithrombin III (Thrombate III, Atryn) (PDF) |
CP.MP.179 |
December 1, 2021 |
Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) |
CP.PHAR.506 |
December 1, 2021 |
Apalutamide (Erleada) (PDF) |
CP.PHAR.376 |
August 1, 2021 |
Applied Behavioral Analysis for Autism (PDF) |
CP.BH.104 |
March 1, 2022 |
Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF) |
CP.PMN.19 |
March 1, 2022 |
Articular Cartilage Defect Repairs (PDF) |
CP.MP.26 |
April 1, 2022 |
Assistive Reproductive Technology (PDF) |
CP.MP.55 |
February 1, 2022 |
Atezolizumab (Tecentriq) (PDF) |
CP.PHAR.235 |
April 1, 2022 |
Avacopan (Tavneos) (PDF) |
CP.PHAR.515 |
March 1, 2022 |
Avalglucosidase Alfa-ngpt (Nexviazyme) (PDF) |
CP.PHAR.521 |
June 1, 2022 |
Avapritinib (Ayvakit) (PDF) |
CP.PHAR.454 |
April 1, 2022 |
Avelumab (Bavencio) (PDF) |
CP.PHAR.333 |
April 1, 2022 |
Axicabtagene Ciloleucel (Yescarta®) (PDF) |
CP.PHAR.362 |
June 1, 2021 |
Azacitidine (Vidaza) (PDF) |
CP.PHAR.387 |
March 1, 2022 |
Baclofen (Gablofen, Lioresal, Lyvispah, Ozobax) (PDF) |
CP.PHAR.149 |
April 1, 2022
|
Bamlanivimab-etesevimab (LY-CoV555-LY-CoV016) |
CP.PHAR.532 |
August 1, 2022 |
Bamlanivimab-etesevimab (LY-CoV555-LY-CoV016)
|
CP.PHAR.532
|
Retire by August 1, 2022 |
Bariatric Surgery (PDF) |
CP.MP.37 |
November 1, 2021 |
Behavioral Assistance (Therapeutic Behavioral Services) (PDF) |
CP.BH.AR.1900 |
March 1, 2019 |
Belantamab mafodotin (Blenrep) (PDF) |
CP.PHAR.469 |
June 1, 2022 |
Belatacept (Nulojix) (PDF) |
CP.PHAR.201 |
December 1, 2021 |
Belimumab (Benlysta) (PDF) |
CP.PHAR.88 |
June 1, 2022 |
Belinostat (Beleodaq) (PDF) |
CP.PHAR.311 |
December 1, 2021 |
Bendamustine (Bendeka, Treanda) (PDF) |
CP.PHAR.307 |
February 1, 2020 |
Benralizumab (Fasenra) (PDF) |
CP.PHAR.373 |
March 1, 2022 |
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) |
CP.PHAR.93 |
February 1, 2022 |
Bezlotoxumab (Zinplava) (PDF) |
CP.PHAR.300 |
March 1, 2022 |
Bimatoprost Implant (Durysta)(PDF) |
CP.PHAR.486 |
June 1, 2022 |
Biofeedback (PDF) |
CP.MP.168 |
February 1, 2022 |
Blinatumomab (Blincyto) (PDF) |
CP.PHAR.312 |
November 1, 2021 |
Bone-Anchored Hearing Aid (PDF) |
CP.MP.93 |
October 1, 2021 |
Bortezomib (Velcade) (PDF) |
CP.PHAR.410 |
March 1, 2022 |
Brentuximab Vedotin (Adcetris) (PDF) |
CP.PHAR.303 |
April 1, 2022 |
Brexanolone (Zulresso) (PDF) |
CP.PHAR.417 |
June 1, 2022 |
Brexucabtagene Autoleucel (Tecartus) (PDF) |
CP.PHAR.472 |
March 1, 2022 |
Brolucizumab-dbll (Beovu) (PDF) |
CP.PHAR.445 |
March 1, 2022 |
Bronchial Thermoplasty (PDF) |
CP.MP.110 |
July 1, 2022 - NEW |
Burn Surgery (PDF) |
CP.MP.186 |
February 1, 2022 |
Burprenorphine (Brixadi) (PDF) |
CP.PHAR.498 |
December 1, 20221 |
Buprenorphine implant (Probuphine) (PDF) |
CP.PHAR.289 |
March 1, 2022 |
C1 Esterase Inhibitors (Berinert Cinryze Haegarda Ruconest) (PDF) |
CP.PHAR.202 |
April 1, 2022 |
Cabotegravir, Cabotegravir-Rilpivirine (Apretude Cabenuva) (PDF) |
CP.PHAR.573 |
May 1, 2022 |
Cabazitaxel (Jevtana®) (PDF) |
CP.PHAR.316 |
August 1, 2022 |
Cabazitaxel (Jevtana®) (PDF)
|
CP.PHAR.316
|
Retire by August 1, 2022 |
Cabozantinib (Cabometyx, Cometriq) (PDF) |
CP.PHAR.111 |
March 1, 2022 |
Canakinumab (Ilaris) (PDF) |
CP.PHAR.246 |
June 1, 2022 |
Caplacizumab-yhdp (Cablivi) |
CP.PHAR.416 |
August 1. 2022 |
Caplacizumab-yhdp (Cablivi) |
CP.PHAR.416 |
Retire by August 1, 2022 |
Cardiac Biomarker Testing for Acute MI (PDF) |
CP.MP.156 |
December 1, 2021 |
Carfilzomib (Kyprolis) (PDF) |
CP.PHAR.309 |
December 1, 2021 |
Casimersen (Amondys 45) (PDF) |
CP.PHAR.470 |
June 1, 2021 |
Casirivimab and Imdevimab (REGEN-COV) (PDF) |
CP.PHAR.520 |
August 1, 2022 |
Casirivimab and Imdevimab (REGEN-COV) (PDF)
|
CP.PHAR.520
|
Retire by August 1, 2022 |
Caudal or Interlaminar Epidural Steroid Injections (PDF) |
CP.MP.164 |
November 1, 2021 |
Cemiplimab-rwlc (Libtayo) (PDF) |
CP.PHAR.397 |
December 1, 2021 |
Cerliponase Alfa (Brineura) (PDF) |
CP.PHAR.338 |
November 1, 2021 |
Cetuximab (Erbitux) (PDF) |
CP.PHAR.317 |
December 1, 2021 |
Child and Youth Support Services (PDF) |
CP.BH.AR.1700 |
March 1, 2019 |
Chlorambucil (Leukeran) (PDF) |
CP.PHAR.554 |
March 1, 2022 |
Chloramphenicol (PDF) |
CP.PHAR.388 |
March 1, 2022 |
Ciclopirox (Penlac) (PDF) |
CP.PMN.24 |
April 1, 2022 |
Ciltacabtagene Autoleucel (Carvykti) |
CP.PHAR.533 |
June 1, 2022 |
Clinical Trials (PDF) |
CP.MP.94 |
August 1, 2021 |
CNS Stimulants (PDF) |
CP.PMN.92 |
March 1, 2022 |
Cochlear Implant Replacements (PDF) |
CP.MP.14 |
September 1, 2020 |
Colchicine (Colcrys) (PDF) |
CP.PMN.123 |
March 1, 2022 |
Collagenase (Xiaflex) (PDF) |
CP.PHAR.82 |
November 1, 2021 |
Continuous Glucose Monitors (PDF) |
CP.PMN.214 |
December 1, 2021 |
Continuous Insulin Delivery Systems (V-Go, Omnipod) (PDF) |
CP.PHAR.505 |
December 1, 2020 |
Copanlisib (Aliqopa) (PDF) |
CP.PHAR.357 |
December 1, 2021 |
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) |
CP.PHAR.385 |
June 1, 2022 |
Cosmetic Reconstructive Surgery (PDF) |
CP.MP.31 |
December 1, 2021 |
Cosyntropin (Cortrosyn) (PDF) |
CP.PHAR.203 |
March 1, 2022 |
Crisis Intervention (PDF) |
CP.BH.AR.1500 |
March 1, 2019 |
Crizanlizumab-tmca (Adakveo) (PDF)
|
CP.PHAR.449 |
March 1, 2022 |
Cytomegalovirus Immune Globulin (Cytogam) (PDF) |
CP.PHAR.277 |
November 1, 2021 |
Dalteparin (Fragmin) (PDF) |
CP.PHAR.225 |
March 1, 2022 |
Daptomycin (Cubicin, Cubicin RF) (PDF) |
CP.PHAR.351 |
November 1, 2021 |
Daratumumab (Darzalex) (PDF) |
CP.PHAR.310 |
July 1, 2021 |
Darbepoetin Alfa (Aranesp) (PDF) |
CP.PHAR.236 |
June 1, 2022 |
Daunorubicin and Cytarabine (Vyxeos) (PDF) |
CP.PHAR.352 |
December 1, 2021 |
Deep Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder (PDF) |
CP.BH.201
|
Retire by September 1, 2022 |
Deep Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder (PDF) |
CP.BH.201 |
April 1, 2022 |
Deferoxamine (Desferal) (PDF) |
CP.PHAR.146 |
July 1, 2021 |
Degarelix (Firmagon) (PDF) |
CP.PHAR.170 |
December 1, 2021 |
Delafloxacin (Baxdela) (PDF) |
CP.PMN.115 |
March 1, 2022 |
Denosumab (Prolia, Xgeva) (PDF) |
CP.PHAR.58 |
June 1, 2022 |
Dental Anesthesia (PDF) |
CP.MP.61 |
December 1, 2021 |
Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (PDF) |
CP.PHAR.214 |
March 1, 2022 |
Dexrazoxane (Zinecard, Totect) (PDF) |
CP.PHAR.418 |
June 1, 2022 |
Diaphragmatic/Phrenic Nerve Stimulation (PDF) |
CP.MP.203 |
February 1, 2022 |
Digital Analysis of EEGs (PDF) |
CP.MP.105 |
December 1, 2021 |
Disc Decompression Procedures (PDF) |
CP.MP.114 |
July 1, 2021 |
Discography (PDF) |
CP.MP.115 |
August 1, 2021 |
Dolasetron (Anzemet) (PDF) |
CP.PMN.141 |
December 1, 2021 |
Donor Lymphocyte Infusion (PDF) |
CP.MP.101 |
December 1, 2021 |
Dornase alfa (Pulmozyme) (PDF) |
CP.PHAR.212 |
March 1, 2022 |
Dostarlimab-gxly (Jemperli) (PDF) |
CP.PHAR.540 |
November 1, 2021 |
Dupilumab (Dupixent) (PDF) |
CP.PHAR.336 |
April 1, 2022 |
Durable Medical Equipment (DME) (PDF) |
CP.MP.107 |
February 1, 2022 |
Durvalumab (Imfinzi) (PDF) |
CP.PHAR.339 |
August 1, 2022 |
Durvalumab (Imfinzi) (PDF)
|
CP.PHAR.339
|
Retire by August 1, 2022 |
Duvelisib (Copiktra) (PDF) |
CP.PHAR.400 |
March 1, 2022 |
Ecallantide (Kalbitor) (PDF) |
CP.PHAR.177 |
April 1, 2022 |
Eculizumab (Soliris) (PDF) |
CP.PHAR.97 |
August 1, 2022 |
Eculizumab (Soliris) (PDF)
|
CP.PHAR.97
|
Retire by August 1, 2022 |
Edaravone (Radicava) (PDF) |
CP.PHAR.343 |
June 1, 2022 |
EEG in Evaluation of Headache (PDF) |
CP.MP.155 |
December 1, 2021 |
Efinaconazole (Jublia) (PDF) |
CP.PMN.25 |
April 1, 2022 |
Elapegademase-lvlr (Revcovi) (PDF) |
CP.PHAR.419 |
June 1, 2022 |
Electric Tumor Treatment Fields (PDF) |
CP.MP.145 |
February 1, 2022 |
Elexacaftor-ivacaftor-tezacaftor (Trikafta) (PDF) |
CP.PHAR.440 |
March 1, 2022 |
Elosulfase Alfa (Vimizim) (PDF) |
CP.PHAR.162 |
June 1, 2022 |
Elotuzumab (Empliciti) (PDF) |
CP.PHAR.308 |
December 1, 2021 |
Eltrombopag (Promacta) (PDF) |
CP.PHAR.180 |
March 1, 2022 |
Emapalumab-lzsg (Gamifant) (PDF) |
CP.PHAR.402 |
March 1, 2022 |
Endometrial Ablation (PDF) |
CP.MP.106
|
Retire by September 1, 2022 |
Endometrial Ablation (PDF) |
CP.MP.106 |
June 1, 2022
|
Enfortumab Vedotin-ejfv (Padcev) (PDF) |
CP.PHAR.455 |
March 1, 2022 |
Enfuvirtide (Fuzeon) (PDF) |
CP.PHAR.41 |
November 1, 2021 |
Enoxaparin (Lovenox) (PDF) |
CP.PHAR.224 |
March 1, 2022 |
Epoetin Alfa (Epogen® and Procrit) (PDF) |
CP.PHAR.237 |
June 1, 2022 |
Epoprostenol (Flolan, Veletri) (PDF) |
CP.PHAR.192 |
March 1, 2022 |
Eptinezumab-jjmr (Vyepti) (PDF) |
CP.PHAR.489 |
December 1, 2021 |
Eribulin Mesylate (Halaven) (PDF) |
CP.PHAR.318 |
February 1, 2022 |
Erwinia Asparaginase (Erwinaze) (PDF) |
CP.PHAR.301 |
April 1, 2022 |
Essure Removal (PDF) |
CP.MP.131 |
December 1, 2021 |
Etelcalcetide (Parsabiv) (PDF) |
CP.PHAR.379 |
July 1, 2021 |
Eteplirsen (Exondys 51) (PDF) |
CP.PHAR.288 |
July 1, 2021 |
Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF) |
CP.PHAR.63 |
March 1, 2022 |
Evinacumab-dgnb (Evkeeza) (PDF) |
CP.PHAR.511 |
March 1, 2022 |
Evoked Potential Testing (PDF) |
CP.MP.134 |
October 1, 2021 |
Evolocumab (Repatha) (PDF) |
CP.PHAR.123
|
March 1, 2022 |
Experimental Technologies (PDF) |
CP.MP.36 |
April 1, 2022 |
Facet Joint Interventions (PDF) |
CP.MP.171 |
|
Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (PDF) |
CP.PHAR.220 |
March 1, 2022 |
Factor VIII (Human Recombinant) (PDF) |
CP.PHAR.215 |
June 1, 2022 |
Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF) |
CP.PHAR.216 |
June 1, 2022 |
Factor IX (Human, Recombinant) (PDF) |
CP.PHAR.218 |
June 1, 2022 |
Factor IX Complex, Human (Profilnine) (PDF) |
CP.PHAR.219 |
March 1, 2022 |
Factor XIII, Human (Corifact®) (PDF) |
CP.PHAR.221 |
June 1, 2022 |
Factor XIII A-Subunit, Recombinant (Tretten®) |
CP.PHAR.222 |
June 1, 2022 |
Family Support Partners (PDF) |
CP.BH.AR.1600 |
March 1, 2019 |
Fam-Trastuzumab Deruxtecan-nxki (Enhertu) (PDF) |
CP.PHAR.456 |
March 1, 2022 |
Fecal Incontinence Treatments (PDF) |
CP.MP.137 |
September 1, 2021 |
Ferric Carboxymaltose (Injectafer) (PDF) |
CP.PHAR.234 |
March 1, 2022 |
Ferric Derisomaltose (Monoferric)(PDF) |
CP.PHAR.480 |
June 1, 2022 |
Ferric Gluconate (Ferrlecit) (PDF) |
CP.PHAR.166 |
March 1, 2022 |
Ferriscan R2-MRI (PDF) |
CP.MP.53 |
December 1, 2021 |
Ferumoxytol (Feraheme) (PDF) |
CP.PHAR.165 |
March 1, 2022 |
Fertility Preservation (PDF) |
CP.MP.130 |
November 1, 2021 |
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) |
CP.MP.129 |
December 1, 2021 |
Fibrinogen concentrate (human) (Fibryga, RiaSTAP) (PDF) |
CP.PHAR.526 |
June 1, 2022 |
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) (PDF) |
CP.PHAR.297 |
April 1, 2022
|
Fondaparinux (Arixtra) (PDF) |
CP.PHAR.226 |
March 1, 2022 |
Fosdenopterin (Nulibry) (PDF) |
CP.PHAR.471 |
June 1, 2022 |
Fostemsavir (Rukobia) (PDF) |
CP.PHAR.516 |
April 1, 2022 |
Fulvestrant (Faslodex Injection) (PDF) |
CP.PHAR.424 |
July 1, 2021 |
Functional MRI (PDF) |
CP.MP.43 |
April 1, 2022 |
Galsulfase (Naglazyme) (PDF) |
CP.PHAR.161 |
June 1, 2022 |
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) |
CP.MP.209 |
May 1, 2022 |
Gastric Electrical Stimulation (PDF) |
CP.MP.40 |
April 1, 2022 |
Gemtuzumab (Mylotarg) (PDF) |
CP.PHAR.358 |
|
Gender reassignment surgery (PDF) |
CP.MP.95 |
January 1, 2022 |
Gilteritinib (Xospata) (PDF) |
CP.PHAR.412 |
March 1, 2022 |
Givosiran (Givlaari) (PDF) |
CP.PHAR.457 |
April 1, 2022 |
Golodirsen (Vyondys 53) (PDF) |
CP.PHAR.453 |
July 1, 2021 |
Golimumab (Simponi, Simponi Aria) (PDF) |
CP.PHAR.253 |
February 1, 2022 |
Goserelin Acetate (Zoladex) (PDF) |
CP.PHAR.171 |
December 1, 2021 |
Granisetron (Kytril, Sancuso, Sustol) (PDF) |
CP.PMN.74 |
March 1, 2022 |
Group Psychotherapy (PDF) |
CP.BH.AR.600 |
March 1, 2019 |
Heart-Lung Transplant (PDF) |
CP.MP.132 |
July 1, 2022 - NEW |
Helicobacter Pylori Serology Testing (PDF) |
CP.MP.153 |
December 1, 2021 |
Hemin (Panhematin) (PDF) |
CP.PHAR.181 |
March 1, 2022 |
Histrelin (Vantas, Supprelin LA) (PDF) |
CP.PHAR.172 |
December 1, 2021 |
Holter Monitors (PDF) |
CP.MP.113 |
February 1, 2022 |
Home Birth (PDF) |
CP.MP.136 |
March 1, 2022 |
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) |
CP.MP.150 |
December 1, 2021 |
Homocysteine Testing (PDF) |
CP.MP.121 |
May 1, 2022 |
Hospice Clinical Coverage (PDF) |
CP.MP.54 |
February 1, 2022 |
Human Growth Hormone (Somapacitan, Somatropin) (PDF) |
CP.PHAR.517 |
April 1, 2022 |
Hyaluronate Derivatives (PDF) |
CP.PHAR.05 |
December 1, 2021 |
Hyperemesis Gravidarum Treatment (PDF) |
CP.MP.34 |
April 1, 2022 |
Hyperhidrosis Treatments (PDF) |
CP.MP.62 |
March 1, 2022 |
ibalizumab-uiyk (Trogarzo) (PDF) |
CP.PHAR.378 |
June 1, 2022 |
Ibandronate Injection (Boniva) (PDF) |
CP.PHAR.189 |
March 1, 2022 |
Ibrutinib (Imbruvica) (PDF) |
CP.PHAR.126 |
April 1, 2022 |
Icatibant (Firazyr®) (PDF) |
CP.PHAR.178 |
April 1, 2022 |
Idecabtagene vicleucel (Abecma) (PDF) |
CP.PHAR.481 |
June 1, 2022 |
Idursulfase (Elaprase) (PDF) |
CP.PHAR.156 |
June 1, 2022 |
Iloprost (Ventavis) (PDF) |
CP.PHAR.193 |
March 1, 2022 |
Imiglucerase (Cerezyme) (PDF) |
CP.PHAR.154 |
August 1, 2022 |
Imiglucerase (Cerezyme) (PDF)
|
CP.PHAR.154
|
Retire by August 1, 2022 |
Immune Globulins (PDF) |
CP.PHAR.103 |
March 1, 2022 |
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) |
CP.MP.180 |
January 1, 2022 |
Implantable Intrathecal Pain Pump (PDF) |
CP.MP.173 |
June 1, 2022 |
Implantable Loop Recorder (PDF) |
CP.MP.243 |
Retire by September 1, 2022 |
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) |
CP.MP.160 |
June 1, 2022 |
Inclisiran (Leqvio) (PDF) |
CP.PHAR.568 |
March 1, 2022 |
IncobotulinumtoxinA (Xeomin) (PDF) |
CP.PHAR.231 |
June 1, 2022 |
Individual/Group Pharmacologic Counseling by RN (Medication Training and Support) (PDF) |
CP.BH.AR.1200 |
March 1, 2019 |
Inebilizumab (PDF) |
CP.PHAR.458 |
August 1, 2022 |
Inebilizumab (PDF)
|
CP.PHAR.458
|
Retire by August 1, 2022 |
Infertility and Fertility Preservation (PDF) |
CP.PHAR.131 |
December 1, 2021 |
Infliximab (Remicade, Inflectra, Renflexis) (PDF) |
CP.PHAR.254 |
October 1, 2021 |
Inhaled Nitric Oxide (PDF) |
CP.MP.87 |
June 1, 2022 |
Inotuzumab Ozogamicin (Besponsa) (PDF) |
CP.PHAR.359 |
December 1, 2021 |
Intensity Modulated Radiation Therapy (PDF) |
CP.MP.69 |
February 1, 2022 |
Interferon Gamma- 1b (Actimmune) (PDF) |
CP.PHAR.52 |
March 1, 2022 |
Interpretation of Diagnosis (PDF) |
CP.BH.AR.800 |
March 1, 2019 |
Intestinal & Multivisceral Transplant (PDF) |
CP.MP.58 |
July 1, 2022 - NEW |
Intradiscal Steroid Injections (PDF) |
CP.MP.167 |
October 1, 2021 |
Iobenguane I-131 (Azedra) (PDF) |
CP.PHAR.459 |
March 1, 2022 |
Ipilimumab (Yervoy) (PDF) |
CP.PHAR.319 |
August 1, 2022 |
Ipilimumab (Yervoy) (PDF)
|
CP.PHAR.319
|
Retire by August 1, 2022 |
Irinotecan Liposome (Onivyde) (PDF) |
CP.PHAR.304 |
December 1, 2021 |
Iron Sucrose (Venofer) (PDF) |
CP.PHAR.167 |
March 1, 2022 |
Isatuximab-irfc (Sarclisa)(PDF) |
CP.PHAR.482 |
June 1, 2022 |
Isavuconazonium (Cresemba)
|
CP.PMN.154
|
August 1, 2022 |
Isavuconazonium (Cresemba) |
CP.PMN.154 |
Retire by August 1, 2022 |
Ivacaftor (Kalydeco) (PDF) |
CP.PHAR.210 |
March 1, 2022 |
Lanadelumab-fylo (Takhzyro) (PDF) |
CP.PHAR.396 |
April 1, 2022 |
Lanreotide (Somatuline Depot) (PDF) |
CP.PHAR.391 |
December 1, 2021 |
Laronidase (Aldurazyme) (PDF) |
CP.PHAR.152 |
June 1, 2022 |
Larotrectinib (Vitrakvi) (PDF)
|
CP.PHAR.414 |
March 1, 2022 |
Laser Skin Treatment (PDF) |
CP.MP.123 |
May 1, 2022 |
Lasmiditan (Reyvow) (PDF) |
CP.PMN.218 |
March 1, 2022 |
Ledipasvir-Sofosbuvir (Harvoni) (PDF) |
CP.PHAR.279 |
March 1, 2022 |
Letermovir (Prevymis) (PDF) |
CP.PHAR.367 |
March 1, 2022 |
Leucovorin Injection (PDF) |
CP.PHAR.393 |
December 1, 2021 |
Leuprolide Acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi) (PDF) |
CP.PHAR.173 |
March 1, 2022 |
Levoleucovorin (Fusilev, Khapzory) (PDF) |
CP.PHAR.151 |
December 1, 2021 |
Lifitegrast (Xiidra) (PDF) |
CP.PMN.73 |
April 1, 2022 |
Linezolid (Zyvox) (PDF) |
CP.PMN.27 |
March 1, 2022 |
Liposuction for Lipedema (PDF) |
CP.MP.244 |
October 1, 2022 - NEW |
Lisocabtagene maraleucel (Breyanzi) (PDF) |
CP.PHAR.483 |
June 1, 2022 |
Loncastuximab tesirine-lpyl (Zynlonta) (PDF) |
CP.PHAR.539 |
November 1, 2021 |
Low-Frequency Ultrasound Wound Therapy (PDF) |
CP.MP.139 |
May 1, 2022 |
Lumacaftor-ivacaftor (Orkambi) |
CP.PHAR.213 |
March 1, 2022 |
Lumasiran (Oxlumo) (PDF) |
CP.PHAR.473 |
March 1, 2022 |
Lung Transplantation (PDF) |
CP.MP.57 |
April 1, 2022 |
Lurbinectedin (Zepzelca) (PDF) |
CP.PHAR.500 |
July 1, 2021 |
Lutetium Lu 177 Dotatate (Lutathera) (PDF) |
CP.PHAR.384 |
July 1, 2021 |
Lysis of Epidural Lesions (PDF) |
CP.MP.116 |
July 1, 2022 - NEW |
Margetuximab-cmkb (Margenza) (PDF) |
CP.PHAR.522 |
March 1, 2022 |
Marital/Family BH Counseling with Beneficiary Present (PDF) |
CP.BH.AR.400 |
March 1, 2019 |
Marital/Family BH Counseling without Beneficiary Present (PDF) |
CP.BH.AR.300 |
March 1, 2019 |
Measure Serum 1,25 Vitamin D (PDF) |
CP.MP.152 |
December 1, 2021 |
Mecasermin (Increlex) (PDF) |
CP.PHAR.150 |
July 1, 2021 |
Mechanical Stretch Devices (PDF) |
CP.MP.144 |
February 1, 2022 |
Mepolizumab (Nucala) (PDF) |
CP.PHAR.200 |
April 1, 2022 |
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) |
CP.PHAR.238 |
June 1, 2022 |
Metreleptin (Myalept) (PDF) |
CP.PHAR.425 |
November 1, 2021 |
Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF) |
CP.PHAR.495 |
November 1, 2021 |
Mitoxantrone (Novantrone) (PDF) |
CP.PHAR.258 |
August 1, 2022 |
Mitoxantrone (Novantrone) (PDF)
|
CP.PHAR.258
|
Retire by August 1, 2022 |
Mogamulizumab-kpkc (Poteligeo) (PDF) |
CP.PHAR.139 |
December 1, 2021 |
Mometasone Furoate (Sinuva) (PDF) |
CP.PHAR.448 |
April 1, 2022 |
Moxetumomab Pasudotox-tdfk (Lumoxiti) (PDF) |
CP.PHAR.398 |
December 1, 2021 |
Multi-Family Behavioral Health Counseling (PDF) |
CP.BH.AR.500 |
March 1, 2019 |
Multiple Sleep Latency Testing (PDF) |
CP.MP.24 |
June 1, 2022 |
Nadofaragene Firadenovec (Instiladrin)(PDF) |
CP.PHAR.461 |
March 1, 2022 |
Naltrexone (Vivitrol) (PDF) |
CP.PHAR.96 |
March 1, 2022 |
Natalizumab (Tysabri) (PDF) |
CP.PHAR.259 |
June 1, 2022 |
Naxitamab-gqgk (Danyelza) (PDF) |
CP.PHAR.523 |
March 1, 2022 |
Necitumumab (Portrazza) (PDF) |
CP.PHAR.320 |
December 1, 2021 |
Neonatal Abstinence Syndrome Guidelines (PDF) |
CP.MP.86 |
July 1, 2022 |
Neonatal Sepsis Management Guidelines (PDF) |
CP.MP.85 |
December 1, 2021 |
Neurofeedback for Behavioral Health Disorders (PDF) |
CP.BH.300 |
August 1, 2021 |
Neuromuscular Electrical Stimulation (PDF) |
CP.MP.48 |
June 1, 2022 |
Netupitant and Palonosetron (Akynzeo) (PDF) |
CP.PMN.158 |
December 1, 2021 |
Nerve Blocks for Pain Management (PDF) |
CP.MP.170 |
February 1, 2022 |
NICU Apnea Bradycardia Guidelines (PDF) |
CP.MP.82 |
August 1, 2021 |
NICU Discharge Guidelines (PDF) |
CP.MP.81 |
November 1, 2021 |
Nivolumab (Opdivo) (PDF) |
CP.PHAR.121 |
April 1, 2022 |
No Coverage Criteria (PDF) |
CP.PMN.255 |
March 1, 2022 |
Non-Invasive Home Ventilator (PDF) |
CP.MP.184 |
October 1, 2021 |
Nonmyeloablative allogeneic stem cell transplant (PDF) |
CP.MP.141 |
July 1, 2022 |
Nusinersen (Spinraza®) (PDF) |
CP.PHAR.327 |
March 1, 2022 |
OB Home Health Programs (PDF) |
CP.MP.91 |
February 1, 2022 |
Obinutuzumab (Gazyva) (PDF) |
CP.PHAR.305 |
February 1, 2022 |
Ocrelizumab (Ocrevus) (PDF) |
CP.PHAR.335 |
August 1, 2022 |
Ocrelizumab (Ocrevus) (PDF)
|
CP.PHAR.335
|
Retire by August 1, 2022 |
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF) |
CP.PHAR.40 |
March 1, 2022 |
Ofatumumab (Arzerra, Kesimpta) (PDF) |
CP.PHAR.306 |
June 1, 2022 |
Off-Label Use (PDF) |
CP.PMN.53 |
March 1, 2022 |
Olaparib (Lynparza) (PDF) |
CP.PHAR.360 |
April 1, 2022 |
Olaratumab (Lartruvo) (PDF) |
CP.PHAR.326 |
December 1, 2021 |
Omadacycline (Nuzyra) (PDF) |
CP.PMN.188 |
March 1, 2022 |
Omalizumab (Xolair) (PDF) |
CP.PHAR.01 |
March 1, 2022 |
Omecetaxine (Synribo) (PDF) |
CP.PHAR.108 |
June 1, 2022 |
OnabotulinumtoxinA (Botox) (PDF) |
CP.PHAR.232 |
June 1, 2022 - NEW |
Onasemnogene Abeparvovec (Zolgensma) (PDF) |
CP.PHAR.421 |
June 1, 2022 |
Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) |
CP.PHAR.536 |
June 1, 2022 |
Optic Nerve Decompression Surgery (PDF) |
CP.MP.128 |
October 1, 2021 |
Orthognathic Surgery (PDF) |
CP.MP.202 |
December 1, 2021 |
Osteogenic Stimulation (PDF) |
CP.MP.194 |
November 1, 2021 |
Outpatient Cardiac Rehabilitation (PDF) |
CP.MP.176 |
July 1, 2022 - NEW |
Outpatient Testing for Drugs of Abuse (PDF) |
CP.MP.50 |
May 1, 2022 |
Oxygen Use and Concentrators (PDF) |
CP.MP.190 |
March 1, 2022 |
Ozanimod(PDF) |
CP.PHAR.462 |
June 1, 2021 |
Pancreas Transplantation (PDF) |
CP.MP.102 |
April 1, 2022 |
Panitumumab (Vectibix) (PDF) |
CP.PHAR.321 |
December 1, 2021 |
Panniculectomy (PDF) |
CP.MP.109 |
January 1, 2022 |
Paricalcitol Injection (Zemplar) (PDF) |
CP.PHAR.270 |
October 1, 2021 |
Pasireotide (Signifor, Signifor LAR) (PDF) |
CP.PHAR.332 |
December 1, 2021 |
Patisiran (Onpattro) (PDF) |
CP.PHAR.395 |
February 1, 2022 |
Peanut Allergen Powder-dnfp (Palforzia)(PDF) |
CP.PMN.220 |
March 1, 2021 |
Pediatric Heart Transplant (PDF) |
CP.MP.138 |
July 1, 2022 |
Pediatric Liver Transplant (PDF) |
CP.MP.120 |
July 1, 2022 |
Pediatric Oral Function Therapy (PDF) |
CP.MP.188 |
July 1, 2022 - NEW |
Peer Support (PDF) |
CP.BH.AR.1300 |
March 1, 2019 |
Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas) (PDF) |
CP.PHAR.353 |
February 1, 2022 |
Pegaptanib (Macugen) (PDF) |
CP.PHAR.185 |
March 1, 2022 |
Pegcetacoplan (Empaveli) (PDF) |
CP.PHAR.524 |
March 1, 2022 |
Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) (PDF) |
CP.PHAR.296 |
March 1, 2022 |
Pegvaliase-pqpz (Palynziq) (PDF) |
CP.PHAR.140 |
December 1, 2021 |
Pegvisomant (Somavert) (PDF) |
CP.PHAR.389 |
December 1, 2021 |
Pembrolizumab (Keytruda®) (PDF) |
CP.PHAR.322 |
June 1, 2022 |
Pembrolizumab (Keytruda®) (PDF)
|
CP.PHAR.322
|
Retire by June 1, 2022 |
Pemetrexed (Alimta, Pemfexy) (PDF) |
CP.PHAR.368 |
April 1, 2022 |
Percutaneous LAAD Stroke Prevention (PDF) |
CP.MP.147 |
July 1, 2022 - NEW |
Pertuzumab (Perjeta) (PDF) |
CP.PHAR.227 |
June 1, 2022 |
Pertuzumab-trastuzumab-hyaluronidase-zzxf (Phesgo) (PDF) |
CP.PHAR.501 |
July 1, 2021 |
Pharmacologic Management (PDF) |
CP.BH.AR.1000 |
March 1, 2019 |
Physical, Occupational, and Speech Therapy Services (PDF) |
CP.MP.49 |
August 1, 2021 |
Pitolisant (Wakix) (PDF) |
CP.PMN.221 |
March 1, 2022 |
Plasminogen (Ryplazim) (PDF) |
CP.PHAR.513 |
December 1, 2021 |
Plerixafor (Mozobil) (PDF) |
CP.PHAR.323 |
November 1, 2021 |
Polatuzumab Vedotin-piiq (Polivy) (PDF) |
CP.PHAR.433 |
July 1, 2021 |
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) |
CP.MP.181 |
May 1, 2022 |
Posterior Nerve Stimulation for Voiding Dysfunction (PDF) |
CP.MP.133 |
October 1, 2021 |
Post-Acute Care (PDF) |
CP.MP.213 |
April 1, 2022 |
Potassium Salts (Klor-Con) (PDF) |
HIM.PA.143 |
March 1, 2022 |
Pralatrexate (Folotyn) (PDF) |
CP.PHAR.313 |
December 1, 2021 |
Protein C Concentrate, Human (Ceprotin) PDF) |
CP.PHAR.330 |
March 1, 2022 |
Psychiatric Diagnosis Evaluation (PDF) |
CP.BH.AR.100 |
March 1, 2019 |
Psychoeducation Services (PDF) |
CP.BH.AR.2100 |
March 1, 2019 |
Psychological Evaluation of Psych Testing (PDF) |
CP.BH.AR.900 |
March 1, 2019 |
Psychotherapy (PDF) |
CP.BH.AR.200 |
March 1, 2019 |
Pyrimethamine (Daraprim) (PDF) |
CP.PMN.44 |
April 1, 2022 |
Radial Head Implant (PDF) |
CP.MP.148 |
July 1, 2022 - NEW |
Radiofrequency Ablation of Uterine Fibroids (PDF) |
CP.MP.187 |
April 1, 2022 |
Ramucirumab (Cyramza) (PDF) |
CP.PHAR.119 |
April 1, 2022 |
Ranibizumab (Byooviz, Lucentis, Susvimo) (PDF) |
CP.PHAR.186 |
June 1, 2022 - NEW |
Ravulizumab-cwvz (Ultomiris) (PDF) |
CP.PHAR.415 |
April 1, 2022 |
Reduction Mammoplasty and Gynecomastia Surgery (PDF) |
CP.MP.51 |
November 1, 2021 |
Repair of Nasal Valve Compromise (PDF) |
CP.MP.210 |
July 1, 2022 - NEW |
Reslizumab (Cinqair) (PDF) |
CP.PHAR.223 |
March 1, 2022 |
Rifabutin (Mycobutin), Rifabutin, omeprazole, amoxicillin (Talicia) (PDF) |
CP.PMN.223 |
March 1, 2022 |
Rilonacept (Arcalyst) (PDF) |
CP.PHAR.266 |
June 1, 2022 |
RimabotulinumtoxinB (Myobloc) (PDF) |
CP.PHAR.233 |
June 1, 2022 |
Rimegepant (Nurtec ODT) (PDF) |
CP.PHAR.490 |
April 1, 2022 |
Risdiplam (Evrysdi) (PDF) |
CP.PHAR.477 |
March 1, 2022 |
Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) |
CP.PHAR.260 |
August 1, 2022 |
Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) |
CP.PHAR.260
|
Retire by August 1, 2022 |
Rivaroxaban (Xarelto) (PDF) |
CP.PMN.247 |
March 1, 2022 |
Rolapitant (Varubi) (PDF) |
CP.PMN.102 |
December 1, 2021 |
Romidepsin (Istodax) (PDF) |
CP.PHAR.314 |
February 1, 2022 |
Romiplostim (Nplate®) (PDF) |
CP.PHAR.179 |
March 1, 2022 |
Romosozumab-aqqg (Evenity) (PDF) |
CP.PHAR.428 |
March 1, 2022 |
Ropeginterferon alfa-2b-njft (Besremi)(PDF) |
CP.PHAR.570 |
March 1, 2022 |
Sacituzumab Govitecan-hziy (Trodelvy) (PDF) |
CP.PHAR.475 |
August 1, 2022 |
Sacituzumab Govitecan-hziy (Trodelvy) (PDF)
|
CP.PHAR.475
|
Retire by August 1, 2022 |
Sacroiliac Joint Fusion (PDF) |
CP.MP.126 |
August 1, 2021 |
Sacroiliac Joint Interventions (PDF) |
CP.MP.166 |
October 1, 2021 |
Sargramostim (Leukine) (PDF) |
CP.PHAR.295 |
December 1, 2021 |
Satralizumab-mwge (Enspryng) (PDF) |
CP.PHAR.463 |
March 1, 2022 |
Sclerotherapy (PDF) |
CP.MP.146 |
Retire by September 1, 2022 |
Sclerotherapy (PDF) |
CP.MP.146 |
September 1, 2021 |
Sebelipase Alfa (Kanuma) (PDF) |
CP.PHAR.159 |
June 1, 2022 |
Selective Dorsal Rhizotomy (PDF) |
CP.MP.174 |
January 1, 2022 |
Selective Nerve Root Blocks and Transforaminal Epidural (PDF) |
CP.MP.165 |
October 1, 2021 |
Selinexor (Xpovio) (PDF) |
CP.PHAR.431 |
March 1, 2022 |
Selumetinib (Koselugo) (PDF) |
CP.PHAR.464 |
March 1, 2022 |
Sipuleucel-T (Provenge) (PDF) |
CP.PHAR.120 |
August 1, 2021 |
Siltuximab (Sylvant) (PDF) |
CP.PHAR.329 |
March 1, 2022 |
Skilled Nursing Facility Leveling (PDF) |
CP.MP.206 |
April 1, 2022 |
Skin Substitutes for Chronic Wounds (PDF) |
CP.MP.185 |
June 1, 2022 |
Sofosbuvir (Sovaldi) (PDF) |
CP.PHAR.281 |
March 1, 2022 |
Sotrovimab (VIR-7831) (PDF) |
CP.PHAR.541 |
Pending FDA Approval |
Spinal Cord Stimulation (PDF) |
CP.MP.117 |
April 1, 2022 |
Stereotactic Body Radiation Therapy (PDF) |
CP.MP.22 |
March , 2022 |
Substance Abuse Assessment (PDF) |
CP.BH.AR.1100 |
March 1, 2019 |
SUD (PDF) |
CP.BH.100 |
June 1, 2022 |
Supportive Employment (PDF) |
CP.BH.AR.2000 |
March 1, 2019 |
Supportive Housing (PDF) |
CP.BH.AR.1400 |
March 1, 2019 |
Tafasitamab-cxix (Monjuvi) (PDF) |
CP.PHAR.508 |
December 1, 2021 |
Taliglucerase Alfa (Elelyso) (PDF) |
CP.PHAR.157 |
December 1, 2021 |
Talimogene laherparepvec (Imlygic) (PDF) |
CP.PHAR.542 |
November 1, 2021 |
Tandem Transplant (PDF) |
CP.MP.162 |
April 1, 2022 |
Tasimelteon (Hetlioz) (PDF) |
CP.PMN.104 |
March 1, 2022 |
Tavaborole (Kerydin) (PDF) |
CP.PMN.105 |
April 1, 2022 |
Tebentafusp-(Kimmtrak) (PDF) |
CP.PHAR.575 |
June 1, 2022 |
Tedizolid (Sivextro) (PDF) |
CP.PMN.62 |
March 1, 2022 |
Teduglutide (Gattex) (PDF) |
CP.PHAR.114 |
April 1, 2022 |
Temozolomide (Temodar) (PDF) |
CP.PHAR.77 |
June 1, 2022 |
Temsirolimus (Torisel) (PDF) |
CP.PHAR.324 |
December 1, 2021 |
Teprotumumab (Tepezza) (PDF) |
CP.PHAR.465 |
March 1, 2022 |
Teriparatide (Forteo) (PDF) |
CP.PHAR.188 |
March 1, 2022 |
Testosterone (Testopel, Jatenzo) (PDF) |
CP.PHAR.354 |
June 1, 2022 - NEW |
Tezacaftor-Ivacaftor (Symdeko) (PDF) |
CP.PHAR.377 |
March 1, 2022 |
Tezepelumab (Tezspire) (PDF) |
CP.PHAR.576 |
June 1, 2022 |
Thyrotropin alfa (Thyrogen) (PDF) |
CP.PHAR.95 |
November 1, 2021 |
Tisagenlecleucel (Kymriah) (PDF) |
CP.PHAR.361 |
May 1, 2022 |
Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (PDF) |
CP.PHAR.211 |
March 1, 2022 |
Tocilizumab (Actemra) (PDF) |
CP.PHAR.263 |
December 1, 2021 |
Topical Immunomodulator (PDF) |
CP.PMN.107 |
March 1, 2022 |
Topotecan (Hycamtin) (PDF) |
CP.PHAR.64 |
August 1, 2022 |
Topotecan (Hycamtin) (PDF)
|
CP.PHAR.64
|
Retire by August 1, 2022 |
Total Artificial Heart (PDF) |
CP.MP.127 |
January 1, 2022 |
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) |
CP.MP.163 |
June 1, 2022 |
Trabectedin (Yondelis) (PDF) |
CP.PHAR.204 |
March 1, 2022 |
Tralokinumab-ldrm (Adbry) (PDF) |
CP.PHAR.577 |
June 1, 2022 |
Transcatheter Closure of Patent Foramen Ovale (PDF) |
CP.MP.151 |
January 1, 2022 |
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) |
CP.PHAR.228 |
June 1, 2022 |
Treatment Plan (PDF) |
CP.BH.AR.700 |
March 1, 2019 |
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF) |
CP.PHAR.199 |
March 1, 2022 |
Triamcinolone ER Injection (Zilretta) (PDF) |
CP.PHAR.371 |
April 1, 2022 |
Trigger Point Injections for Pain Management (PDF) |
CP.MP.169 |
October 1, 2021 |
Triptorelin pamoate (Trelstar, Triptodur) (PDF) |
CP.PHAR.175 |
December 1, 2021 |
Urinary Incontinence Devices and Treatments (PDF) |
CP.MP.142 |
January 1, 2022 |
Ustekinumab (Stelara) (PDF) |
CP.PHAR.264 |
February 1, 2022 |
Vagus Nerve Stimulation for Epilepsy (PDF) |
CP.MP.12 |
October 1, 2021 |
Valganciclovir (Valcyte) (PDF) |
CP.PCH.06 |
March 1, 2022 |
Valoctocogene Roxaparvovec(PDF) |
CP.PHAR.466 |
Pending FDA Approval |
Valproate (Depacon) (PDF) |
CP.PHAR.429 |
November 1, 2021 |
Valrubicin (Valstar) (PDF) |
CP.PHAR.439 |
December 1, 2021 |
Vandetanib (Caprelsa) (PDF) |
CP.PHAR.80 |
April 1, 2022 |
Vedolizumab (Entyvio) (PDF) |
CP.PHAR.265 |
February 1, 2022 |
Velaglucerase alfa (VPRIV) (PDF) |
CP.PHAR.163 |
December 1, 2021 |
Vemurafenib (Zelboraf) (PDF) |
CP.PHAR.91 |
March 1, 2022 |
Ventricular Assist Devices (PDF) |
CP.MP.46 |
July 1, 2022 |
Verteporfin (Visudyne) (PDF) |
CP.PHAR.187 |
March 1, 2022 |
Vestronidase Alfa-vjbk (Mepsevii) (PDF) |
CP.PHAR.374 |
June 1, 2022 |
Viltolarsen (Viltepso) (PDF) |
CP.PHAR.484 |
July 1, 2021 |
Vincristine Liposome (Marqibo) (PDF) |
CP.PHAR.315 |
February 1, 2022 |
Vorinostat (Zolinza) (PDF) |
CP.PHAR.83 |
March 1, 2022 |
Vosoritide (Voxzogo) (PDF) |
CP.PHAR.525 |
March 1, 2022 |
Wheelchair seating (PDF) |
CP.MP.99 |
May 1, 2022 |
Zanubrutinib (Brukinsa) (PDF) |
CP.PHAR.467 |
March 1, 2022 |
Ziv-aflibercept (Zaltrap) (PDF) |
CP.PHAR.325 |
December 1, 2021 |
Zika Virus Testing (PDF) |
CP.MP.111 |
July 1, 2020 |
Zoledronic Acid (PDF) |
CP.PHAR.59 |
March 1, 2021 |