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Políticas clínicas y de pago
Clinical Policies
Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information.
All policies found in the Coordinated Care Clinical Policy Manual apply to Coordinated Care members. Policies in the Coordinated Care Clinical Policy Manual may have either a Coordinated Care or a “Centene” heading. Coordinated Care utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Coordinated Care clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Coordinated Care. In addition, Coordinated Care may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or InterQual®criteria is payable by Coordinated Care.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Ambetter Clinical Policies Listing
- Acupuncture (PDF) (CP.MP.92)
- Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF) (CP.BH.124)
- Air Ambulance (PDF) (CP.MP.175)
- Allergy Testing and Therapy (PDF)(CP.MP.100)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-Thalassemia (PDF) (CP.MP.108)
- Applied Behavior Analysis (PDF) (CP.BH.104)
- Applied Behavioral Analysis Documentation Requirements (PDF) (CP.BH.105)
- Bariatric Surgery (PDF) (CP.MP.37)
- Behavioral Health Treatment Documentation Requirements (PDF) (HIM.CP.BH.500)
- Biofeedback (PDF) (CP.MP.168)
- Bone-anchored Hearing Aid (PDF) (CP.MP.93)
- Bronchial Thermoplasty (PDF) (CP.MP.110)
- Burn Surgery (PDF) (CP.MP.186)
- Cardiac Biomarker Testing (PDF) (CP.MP.156)
- Clinical Trials (PDF) (CP.MP.94)
- Cochlear Implant Replacements (PDF) (CP.MP.14)
- Cosmetic and Reconstructive Procedures (PDF) (CP.MP.31)
- Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (PDF) (CP.BH.201)
- Diaphragmatic/Phrenic Nerve Stimulation (PDF) (CP.MP.203)
- Digital EEG Spike Analysis (PDF) (CP.MP.105)
- Disc Decompression Procedures (PDF) (CP.MP.114)
- Discography (PDF) (CP.MP.115)
- Donor Lymphocyte Infusion (PDF) (CP.MP.101)
- Drugs of Abuse: Definitive Testing (PDF) (CP.MP.50)
- Durable Medical Equipment and Orthotics and Prosthetics Guidelines (DME) (PDF) (CP.MP.107)
- Electric Tumor Treating Fields (Optune)(PDF) (CP.MP.145)
- Electroencephalography in the Evaluation of Headache (PDF) (CP.MP.155)
- Endometrial Ablation (PDF) (CP.MP.106)
- Evoked Potential Testing (PDF) (CP.MP.134)
- Experimental Technologies (PDF) (CP.MP.36)
- Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF) (CP.MP.248)
- Fecal Incontinence Treatments (PDF) (CP.MP.137)
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) (CP.MP.129) – effective 12/1/23
- Gender Affirming Procedures (PDF) (WA.CP.MP.95)
- Gastric Electrical Stimulation (PDF) (CP.MP.40)
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) (CP.MP.209)
- Concert Genetic Testing: Aortopathies & Connective Tissue Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Cardiac Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Dermatologic Conditions (V2.2024) (PDF)
- Concert Genetic Testing: Epilepsy Neurodegenerative and Neuromuscular Conditions (V2.2024) (PDF)
- Concert Genetic Testing: Exome and Genome Sequencing for DX of Genetic Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Eye Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (V2.2024) (PDF)
- Concert Genetic Testing: General Approach to Genetic and Molecular Testing (V2.2024) (PDF)
- Concert Genetic Testing: Hearing Loss (V2.2024) (PDF)
- Concert Genetic Testing: Hematologic Conditions (non-cancerous) (V2.2024) (PDF)
- Concert Genetic Testing: Hereditary Cancer Susceptibility (V2.2024) (PDF)
- Concert Genetic Testing: Immune Autoimmune and Rheumatoid Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Kidney Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Lung Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Metabolic Endocrine Mitochondrial Disorders (V2.2024) (PDF)
- Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay (V2.2024) (PDF)
- Concert Genetic Testing: Non-Invasive Prenatal Screening (V2.2024) (PDF)
- Concert Genetic Testing: Pharmacogenetics (V2.2024) (PDF)
- Concert Genetic Testing: Preimplantation Genetic Testing (V2.2024) (PDF)
- Concert Genetic Testing: Prenatal and Preconception Carrier Screening (V2.2024) (PDF)
- Concert Genetics Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (V2.2024) (PDF)
- Concert Genetic Testing: Skeletal Dysplasia Rare Bone Disorders (V2.2024) (PDF)
- Concert Genetics Oncology: Algorithmic Testing (V2.2024) (PDF)
- Concert Genetics Oncology: Cancer Screening (V2.2024) (PDF)
- Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (V2.2024) (PDF)
- Concert Genetics Oncology: Cytogenetic Testing (V2.2024) (PDF)
- Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (V2.2024) (PDF)
- Helicobacter Pylori Serology Testing (PDF) (CP.MP.153)
- Heart-Lung Transplant (PDF) (CP.MP.132)
- Holter Monitors (PDF) (CP.MP.113)
- Home Birth (PDF) (CP.MP.136)
- Home Ventilators (PDF) (CP.MP.184)
- Homocysteine testing (PDF) (CP.MP.121)
- Hospice Services (PDF) (CP.MP.54)
- Hyperhidrosis Treatments (PDF) (CP.MP.62)
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) (CP.MP.180)
- Implantable Intrathecal or Epidural Pain Pump (PDF) (CP.MP.173)
- Implantable Loop Recorder (PDF) (CP.MP.243)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) (CP.MP.160)
- Intensity-Modulated Radiotherapy (PDF) (CP.MP.69)
- Intestinal and Multivisceral Transplant (PDF) (CP.MP.58)
- Intradiscal Steroid Injections for Pain Management (PDF) (CP.MP.167)
- IV Moderate Sedation, IV Deep Sedation and General Anesthesia for Dental Procedures (PDF) (CP.MP.61)
- Lantidra (Donislecel): Allogeneic Pancreatic Islet Cellular Therapy (PDF) (CP.MP.250)
- Laser Therapy for Skin Conditions (PDF) (CP.MP.123)
- Liposuction of Lipedema (PDF) (CP.MP.244)
- Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF) (CP.MP.139)
- Lung Transplantation (PDF) (CP.MP.57)
- Lysis of Epidural Lesions (PDF) (CP.MP.116)
- Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) (CP.MP.144)
- Medical Necessity Review (PDF) (WA.UM.02.01)
- Multiple Sleep Latency Testing (PDF) (CP.MP.24)
- Neonatal Abstinence Syndrome Guidelines (PDF) (CP.MP.86)
- Neonatal Sepsis Management Guidelines (PDF) (CP.MP.85)
- Nerve Blocks and Neurolysis for Pain Management (PDF) (CP.MP.170)
- Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF) (CP.MP.48)
- NICU Apnea Bradycardia Guidelines (PDF) (CP.MP.82)
- NICU Discharge Guidelines (PDF) (CP.MP.81)
- Nonmyeloablative Allogeneic Stem Cell Transplants (PDF) (CP.MP.141)
- Obstetrical Home Care Programs (PDF) (CP.MP.91)
- Omisirge (omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF) (CP.MP.249)
- Orthognathic Surgery (PDF) (CP.MP.202)
- Osteogenic Stimulation (PDF) (CP.MP.194)
- Outpatient Cardiac Rehabilitation (PDF) (CP.MP.176)
- Outpatient Oxygen Use (PDF) (CP.MP.190)
- Pancreas Transplantation (PDF) (CP.MP.102)
- Panniculectomy (PDF) (CP.MP.109)
- Pediatric Heart Transplant (PDF) (CP.MP.138)
- Pediatric Liver Transplant (PDF) (CP.MP.120)
- Pediatric Kidney Transplant (PDF) (CP.MP.246)
- Pediatric Oral Function Therapy (PDF) (CP.MP.188)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) (CP.MP.147)
- Peripheral and Percutaneous Nerve Stimulation (PDF) (WA.CP.MP.117)
- Photherapy for Neonatal Hyperbilirubinemia (PDF) (CP.MP.150)
- Physical, Occupational, and Speech Therapy Services (PDF) (CP.MP.49)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) (CP.MP.181)
- Posterior tibial nerve stimulation for voiding dysfunction (PDF) (CP.MP.133)
- Proton and Neutron Beam Therapies (PDF) (CP.MP.70)
- Pulmonary Function Testing (PDF) (CP.MP.242)
- Reduction Mammoplasty and Gynecomastia Surgery (PDF) (CP.MP.51)
- Repair of Nasal Valve Compromise (PDF) (CP.MP.210)
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF) (CP.MP.146)
- Short Inpatient Hospital Stay (PDF) (CP.MP.182)
- Skin and Soft Tissue Substitutes for Chronic Wounds (PDF) (CP.MP.185)
- Stereotactic Body Radiation Therapy (PDF) (CP.MP.22)
- Tandem Transplant (PDF) (CP.MP.162)
- Therapeutic Utilization of Inhaled Nitric Oxide (PDF) (CP.MP.87)
- Thyroid Hormones and Insulin Testing in Pediatrics (PDF) (CP.MP.154)
- Total Artificial Heart (PDF) (CP.MP.127)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) (CP.MP.163)
- Transcatheter Closure of Patent Foramen Ovale (PDF) (CP.MP.151)
- Transcranial Magnetic Stimulation for Treatment Resistant Major Depression
- (PDF) (CP.BH.200)
- Transplant Service Documentation Requirements (PDF) (CP.MP.247)
- Trigger Point Injections for Pain Management (PDF) (CP.MP.169)
- Ultrasound in Pregnancy (PDF) (WA.CP.MP.38)
- Urinary Incontinence Devices and Treatments (PDF) (CP.MP.142)
- Urodynamic Testing (PDF) (CP.MP.98)
- Vagus Nerve Stimulation (PDF) (CP.MP.12)
- Ventricular Assist Devices (PDF) (CP.MP.46)
- Vitamin D Testing (PDF) (WA.CP.MP.527)
- Wheelchair Seating (PDF) (CP.MP.99)
- Wireless Motility Capsule (PDF) (CP.MP.143)
Ambetter Pharmacy Policies Listing
- Abaloparatide (Tymlos) (PDF) (CP.PHAR.345)
- Abametapir (Xeglyze) (PDF) (CP.PMN.253)
- Abemaciclib (Verzenio) (PDF) (CP.PHAR.355)
- Abrocitinib (Cibinqo) (PDF) (CP.PHAR.578)
- Acalabrutinib (Calquence) (PDF) (CP.PHAR.366)
- Acyclovir Buccal Tablet (Sitavig), Ophthalmic Ointment (Avaclyr) (PDF) (CP.PMN.210)
- Afamelanotide (Scenesse) (PDF) (CP.PHAR.444)
- Abiraterone (PDF) (CP.PHAR.84)
- AbobotulinumtoxinA (Dysport) (PDF) (CP.PHAR.230)
- Adagrasib (Krazati) (PDF) (CP.PHAR.605)
- Adefovir (Hepsera) (PDF) (CP.PHAR.142)
- Ado-Trastuzumab (Kadcyla) (PDF) (CP.PHAR.229)
- Aducanumab (PDF) (CP.PHAR.468)
- Afatinib (Gilotrif) (PDF) (CP.PHAR.298)
- Afinitor (everolimus) (PDF) (CP.PHAR.63)
- Aflibercept (Eylea®) (PDF) (CP.PHAR.184)
- Agalsidase Beta (Fabrazyme) (PDF) (CP.PHAR.158)
- Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) (CP.PMN.138)
- Alectinib (Alecensa) (PDF) (CP.PHAR.369)
- Alemtuzumab (Lemtrada) (PDF) (CP.PHAR.243)
- Alendronate (Binosto, Fosamax plus D) (PDF) (CP.PMN.88)
- Alglucosidase (Lumizyme) (PDF) (CP.PHAR.160)
- Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) (PDF) (CP.PHAR.562)
- Allogenic Processed Thymus Tissue-agdc (Rethymic) (PDF) (CP.PHAR.563)
- Alpelisib (Piqray) (PDF) (CP.PHAR.430)
- Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF) (CP.PHAR.94)
- Amantadine ER (Gocovri, Osmolex ER) (PDF) (CP.PMN.89)
- Ambrisentan (Letairis®) (PDF) (CP.PHAR.190)
- Amifampridine (Firdapse) (PDF) (CP.PHAR.411)
- Amikacin (Arikayce) (PDF) (CP.PHAR.401)
- Amisulpride (Barhemsys) (PDF) (CP.PMN.236)
- Amivantamab-vmjw (Rybrevant) (PDF) (CP.PHAR.544)
- Anifrolumab-fnia (Saphnelo) (PDF) (CP.PHAR.551)
- Anti-Inhibitor Coagulant Complex (Feiba®) (PDF) (CP.PHAR.217)
- Antithrombin III (ATryn, Thrombate III) (PDF) (CP.PHAR.564)
- Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) (CP.PHAR.506)
- Apalutamide (Erleada) (PDF) (CP.PCH.45)
- Apalutamide (Erleada) (PDF) (CP.PHAR.376)
- Apomorphine (Apokyn, Kynmobi) (PDF) (CP.PHAR.488)
- aprepitant (PDF) (CP.PMN.19)
- Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF) (CP.PHAR.290)
- Aripiprazole Orally Disintegrating Tablet (PDF) (CP.PCH.37)
- Armodafinil (Nuvigil) (PDF) (CP.PMN.35)
- Asciminib (Scemblix) (PDF) (CP.PHAR.565)
- Asenapine (Saphris) (PDF) (CP.PMN.15)
- Asfotase Alfa (Strensiq) (PDF) (CP.PHAR.328)
- Aspirin-dipyridamole (Aggrenox) (PDF) (CP.PMN.20)
- Atezolizumab (Tecentriq®) (PDF) (CP.PHAR.235)
- Atogepant (Qulipta) (PDF) (CP.PHAR.566)
- Avacopan (Tavneos) (PDF) (CP.PHAR.515)
- Avalglucosidase Alfa-ngpt (Nexviazyme) (PDF) (CP.PHAR.521)
- Avapritinib (Ayvakit) (PDF) (CP.PHAR.454)
- Avatrombopag (Doptelet) (PDF) (CP.PHAR.130)
- Avelumab (Bavencio®) (PDF) (CP.PHAR.333)
- Axicabtagene Ciloleucel (Yescarta®) (PDF) (CP.PHAR.362)
- Axitinib (Inlyta®) (PDF) (CP.PHAR.100)
- Azacitidine (Vidaza) (PDF) (CP.PHAR.387)
- Azelaic Acid (Finacea) (PDF) (HIM.PA.119)
- Aztreonam (Cayston®) (PDF) (CP.PHAR.209)
- Baloxavir Marboxil (Xofluza) (PDF) (CP.PMN.185)
- Bedaquiline (Sirturo) (PDF) (CP.PMN.212)
- Belantamab Mafodotin (Blenrep) (PDF) (CP.PHAR.469)
- belatacept (Nulojix®) (PDF) (CP.PHAR.201)
- Belimumab (Benlysta) (PDF) (CP.PHAR.88)
- belinostat (Beleodaq®) (PDF) (CP.PHAR.311)
- Belumosudil (Rezurock) (PDF) (CP.PHAR.552)
- Belzutifan (Welireg) (PDF) (CP.PHAR.553)
- Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet) (PDF) (CP.PMN.237)
- bendamustine (Bendeka®, Treanda®) (PDF) (CP.PHAR.307)
- Benralizumab (Fasenra) (PDF) (CP.PHAR.373)
- Benznidazole (PDF) (CP.PMN.90)
- Betaine (Cystadane) (PDF) (CP.PHAR.143)
- Betamethasone Dipropionate Spray (Sernivo) (PDF) (CP.PMN.182)
- Betibeglogene Autotemcel (Zynteglo) (PDF) (CP.PHAR.545)
- Bevacizumab (Avastin) (PDF) (CP.PHAR.93)
- Bexarotene (Targretin Capsules, Gel) (PDF) (CP.PHAR.75)
- Bezlotoxumab (Zinplava) (PDF) (CP.PHAR.300)
- Bimatoprost Implant (Durysta) (PDF) (CP.PHAR.486)
- Binimetinib (PDF) (CP.PHAR.50)
- Biologic DMARDs (PDF) (HIM.PA.SP60)
- Blinatumomab (PDF) (CP.PHAR.312)
- Bortezomib (Velcade) (PDF) (CP.PHAR.410)
- Bosentan (Tracleer®) (PDF) (CP.PHAR.191)
- Bosutinib (Bosulif) (PDF) (CP.PHAR.105)
- Brand Name Override and Non-Formulary Medications (PDF) (HIM.PA.103)
- Brentuximab (PDF) (CP.PHAR.303)
- Brexanolone (Zulresso) (PDF) (CP.PHAR.417)
- Brexpiprazole (Rexulti) (PDF) (CP.PMN.68)
- Brexucabtagene Autoleucel (Tecartus) (PDF) (CP.PHAR.472)
- Brigatinib (Alunbrig) (PDF) (CP.PHAR.342)
- Brimonidine Tartrate (Mirvaso) (PDF) (CP.PMN.192)
- Brinzolamide/Brimonidine (Simbrinza) (PDF) (HIM.PA.15)
- Brivaracetam (Briviact) (PDF) (CP.PCH.26)
- Brodalumab (Siliq) (PDF) (CP.PHAR.375)
- Brolucizumab-dbll (Beovu) (PDF) (CP.PHAR.445)
- Budesonide (Tarpeyo) (PDF) (CP.PHAR.572)
- Budesonide (Uceris) (PDF) (CP.PCH.11)
- Buprenorphine (Subutex) (PDF) (CP.PMN.82)
- buprenorphine implant (Probuphine) (PDF) (CP.PHAR.289)
- Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF) (CP.PMN.81)
- Bupropion/Naltrexone (Contrave) (PDF) (CP.PCH.12)
- Burosumab-twza (Crysvita) (PDF) (CP.PHAR.11)
- Butorphanol Nasal Spray (PDF) (HIM.PA.46)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF) (CP.PHAR.202)
- Cabazitaxel (Jevtana) (PDF) (CP.PHAR.316)
- Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) (PDF) (CP.PHAR.573)
- Cabozantinib (Cometriq®, Cabometyx®) (PDF) (CP.PHAR.111)
- Calcifediol (Rayaldee) (PDF) (CP.PMN.76)
- Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) (PDF) (CP.PMN.181)
- Canakinumab (Ilaris) (PDF) (CP.PHAR.246)
- Cannabidiol (Epidiolex) (PDF) (CP.PMN.164)
- Capecitabine (Xeloda) (PDF) (CP.PHAR.60)
- Caplacizumab-yhdp (Cablivi) (PDF) (CP.PHAR.416)
- Capmatinib (Tabrecta) (PDF) (CP.PHAR.494)
- Carbidopa/Levodopa ER Capsules (Rytary) (PDF) (CP.PMN.238)
- carfilzomib (Kyprolis®) (PDF) (CP.PHAR.309)
- Carglumic Acid (Carbaglu) (PDF) (CP.PHAR.206)
- Cariprazine (Vraylar) (PDF) (CP.PMN.91)
- Casimersen (Amondys 45) (PDF) (CP.PHAR.470)
- Celecoxib (Celebrex) (PDF) (CP.PMN.122)
- Cemiplimab-rwlc (Libtayo) (PDF) (CP.PHAR.397)
- Cenegermin-bkbj (Oxervate) (PDF) (CP.PMN.186)
- Cenobamate (Xcopri) (PDF) (CP.PMN.231)
- Ceritinib (Zykadia) (PDF) (CP.PHAR.349)
- Cerliponase alfa (PDF) (CP.PHAR.338)
- cetuximab (Erbitux®) (PDF) (CP.PHAR.317)
- Chenodiol (Chenodal) (PDF) (CP.PMN.239)
- Chlorambucil (Leukeran) (PDF) (CP.PHAR.554)
- Chloramphenicol Sodium Succinate (PDF) (CP.PHAR.388)
- Cholic Acid (Cholbam) (PDF) (CP.PHAR.390)
- Ciclopirox (Penlac) (PDF) (CP.PMN.24)
- Ciltacabtagene Autoleucel (Carvykti) (PDF) (CP.PHAR.533)
- Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) (CP.PMN.248)
- Ciprofloxacin/Fluocinolone (Otovel) (PDF) (CP.PMN.249)
- Cladribine (Mavenclad) (PDF) (CP.PHAR.422)
- Clascoterone (Winlevi) (PDF) (CP.PMN.257)
- Clobazam (PDF) (CP.PMN.54)
- CNS Stimulants (PDF) (CP.PMN.92)
- Cobimetinib (Cotellic) (PDF) (CP.PHAR.380)
- Colesevelam (Welchol) (PDF) (CP.PMN.250)
- Collagenase (PDF) (CP.PHAR.82)
- Colonoscopy Preparation Products (PDF) (CP.PCH.43)
- Compounded Medications (PDF) (CP.PMN.280)
- Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) (CP.PMN.258)
- Continuous Glucose Monitors (PDF) (CP.PMN.214)
- copanlisib (Aliqopa®) (PDF) (CP.PHAR.357)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert) (PDF) (CP.PHAR.385)
- Cosyntropin (Cortrosyn®) (PDF) (CP.PHAR.203)
- Crisaborole (Eucrisa) (PDF) (CP.PMN.110)
- Crizanlizumab-tmca (Adakveo) (PDF) (CP.PHAR.449)
- Crizotinib (Xalkori) (PDF) (CP.PHAR.90)
- Cyclosporine ophthalmic emulsion (Cequa, Restasis) (PDF) (CP.PMN.48)
- Cyramza® (PDF) (CP.PHAR.119)
- Cysteamine ophthalmic (Cystaran, Cystadrops) (PDF) (CP.PMN.130)
- Cysteamine oral (Cystagon, Procysbi) (PDF) (CP.PHAR.155)
- Cytomegalovirus Immune Globulin (Cytogam) (PDF) (CP.PHAR.277)
- Dabrafenib (Tafinlar) (PDF) (CP.PHAR.239)
- Dacomitinib (Vizimpro) (PDF) (CP.PHAR.399)
- Dalfampridine (Ampyra) (PDF) (CP.PHAR.248)
- Dalteparin (Fragmin) (PDF) (CP.PHAR.225)
- Daptomycin (Cubicin, Cubicin RF) (PDF) (CP.PHAR.351)
- Daratumumab (PDF) (CP.PHAR.310)
- Darbepoetin alfa (Aranesp) (PDF) (CP.PHAR.236)
- Darolutamide (Nubeqa) (PDF) (CP.PHAR.435)
- Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) (PDF) (HIM.PA.SP61)
- Dasatinib (Sprycel) (PDF) (CP.PHAR.72)
- Daprodustat (Jesduvroq) (PDF) (CP.PHAR.628)
- Dapsone (Aczone Gel) (PDF) (CP.PCH.32)
- daunorubicin/cytarabine (Vyxeos®) (PDF) (CP.PHAR.352)
- Decitabine-Cedazuridine (Inqovi) (PDF) (CP.PHAR.479)
- deferasirox (PDF) (CP.PHAR.145)
- Deferoxamine (Desferal) (PDF) (CP.PHAR.146)
- Deflazacort (Emflaza) (PDF) (CP.PHAR.331)
- degarelix acetate (Firmagon®) (PDF) (CP.PHAR.170)
- Delafloxacin (Baxdela) (PDF) (CP.PMN.115)
- Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (PDF) (CP.PHAR.214)
- Deutetrabenazine (Austedo) (PDF) (CP.PCH.42)
- Dexlansoprazole (Dexilant) (PDF) (HIM.PA.05)
- Dexrazoxane (Zinecard Totect) (PDF) (CP.PHAR.418)
- Dextromethorphan/Bupropion (Auvelity) (PDF) (CP.PMN.284)
- Dextromethorphan-Quinidine (Nuedexta) (PDF) (CP.PMN.93)
- Diazepam Nasal Spray (Valtoco) (PDF) (CP.PMN.216)
- Dichlorphenamide (Keveyis) (PDF) (CP.PMN.261)
- Diclofenac (Cambia, Flector, Licart, Pennsaid, Solaraze, Zipsor, Zorvolex) (PDF) (CP.PCH.28)
- Dimethyl Fumarate (Tecfidera) (PDF) (CP.PCH.41)
- Dipeptidyl Peptidase-4 Inhibitors (PDF) (HIM.PA.58)
- Dolasetron (Anzemet) (PDF) (CP.PMN.141)
- Dornase alfa (Pulmozyme) (PDF) (CP.PHAR.212)
- Dostarlimab-gxly (Jemperli) (PDF) (CP.PHAR.540)
- Doxepin Hydrochloride Cream (Prudoxin, Zonalon) (PDF) (HIM.PA.147)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF) (CP.PMN.79)
- Dupilumab (Dupixent) (PDF) (CP.PHAR.336)
- Durvalumab (Imfinzi) (PDF) (CP.PHAR.339)
- Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn) (PDF) (CP.PMN.128)
- Duvelisib (Copiktra) (PDF) (CP.PHAR.400)
- Ecallantide (Kalbitor®) (PDF) (CP.PHAR.177)
- Eculizumab (Soliris®) (CP.PHAR.97)
- Edaravone (Radicava) (PDF) (CP.PHAR.343)
- Efgartigimod Alfa-fcab (Vyvgart) (PDF) (CP.PHAR.555)
- Efinaconazole (Jublia) (PDF) (CP.PMN.25)
- Elacestrant (Orserdu) (PDF) (CP.PHAR.623)
- Elagolix (Orilissa) (PDF) (CP.PHAR.136)
- Elapegademase-lvlr (Revcovi) (PDF) (CP.PHAR.419)
- Elbasvir/Grazoprevir (Zepatier) (PDF) (HIM.PA.SP62)
- Electromyography and Nerve Conduction Studies (PDF) (CP.MP.211) Effective 9/1/21
- Elexacaftor, tezacaftor (Trikafta) (PDF) (CP.PHAR.440)
- Eliglustat (Cerdelga) (PDF) (CP.PHAR.153)
- Elivaldogene Autotemcel (Skysona) (PDF) (CP.PHAR.556)
- Elotuzumab (Empliciti®) (PDF) (CP.PHAR.308)
- Elosulfase alfa (Vimizim) (PDF) (CP.PHAR.162)
- Eltrombopag (Promacta®) (PDF) (CP.PHAR.180)
- Eluxadoline (Viberzi) (PDF) (CP.PMN.170)
- Emapalumab-lzsg (Gamifant) (PDF) (CP.PHAR.402)
- Emicizumab-kxwh (Hemlibra) (PDF) (CP.PHAR.370)
- Emtricitabine/Tenofovir Alafenamide (Descovy) (PDF) (CP.PMN.235)
- Enasidenib (Idhifa) (PDF) (CP.PHAR.363)
- Encorafenib (PDF) (CP.PHAR.127)
- Enfortumab Vedotin-ejfv (Padcev) (PDF) (CP.PHAR.455)
- Enfuvirtide (PDF) (CP.PHAR.41)
- Enoxaparin (Lovenox) (PDF) (CP.PHAR.224)
- Entecavir (Baraclude) (PDF) (HIM.PA.08)
- Entrectinib (Rozlytrek) (PDF) (CP.PHAR.441)
- Enzalutamide (Xtandi) (PDF) (CP.PHAR.106)
- Epoetin alfa (Epogen, Procrit), Epoetin alfa-epbx (Retacrit) (PDF) (CP.PHAR.237)
- Epoprostenol (Flolan®, Veletri®) (PDF) (CP.PHAR.192)
- Eptinezumab-jjmr (Vyepti) (PDF) (HIM.PA.SP64)
- Erdafitinib (Balversa) (PDF) (CP.PHAR.423)
- Eribulin Mesylate (Halaven®) (PDF) (CP.PHAR.318)
- Erlotinib (Tarceva) (PDF) (CP.PHAR.74)
- Erenumab-aaoe (Aimovig) (PDF) (HIM.PA.SP65)
- erwina asparaginase (Erwinaze®) (PDF) (CP.PHAR.301)
- Esketamine (Spravato) (PDF) (CP.PMN.199)
- Estradiol Vaginal Ring (Femring) (PDF) (CP.PMN.263)
- Etelcalcetide (Parsabiv) (PDF) (CP.PHAR.379)
- Eteplirsen (Exondys 51) (PDF) (CP.PHAR.288)
- Etranacogene Dezaparvovec-drlb (Hemgenix) (PDF) (CP.PHAR.580)
- Evinacumab-dgnb (Evkeeza) (PDF) (HIM.PA.166)
- Evolocumab (Repatha) (PDF) (HIM.PA.156)
- Factor IX (Human, Recombinant) (PDF) (CP.PHAR.218)
- Factor IX Complex Human (Bebulin®, Profilnine®) (PDF) (CP.PHAR.219)
- Factor VIIa, Recombinant (NovoSeven® RT) (PDF) (CP.PHAR.220)
- Factor VIII (Human Recombinant) (PDF) (CP.PHAR.215)
- Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF) (CP.PHAR.216)
- Factor XIII A-Subunit, Recombinant (Tretten®) (PDF) (CP.PHAR.222)
- Factor XIII, Human (Corifact®) (PDF) (CP.PHAR.221)
- Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) (CP.PHAR.456)
- Faricimab-svoa (Vabysmo) (PDF) (CP.PHAR.581)
- Febuxostat (Uloric) (PDF) (CP.PMN.57)
- Fecal Microbiota, Live-jslm (Rebyota) (PDF) (CP.PHAR.613)
- Fedratinib (Inrebic) (PDF) (CP.PHAR.442)
- Fenfluramine (Fintepla) (PDF) (CP.PMN.246)
- Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF) (CP.PMN.127)
- Ferric Carboxymaltose (Injectafer) (PDF) (CP.PHAR.234)
- Ferric Derisomaltose (Monoferric) (PDF) (CP.PHAR.480)
- Ferric Maltol (Accrufer) (PDF) (CP.PMN.213)
- Ferric Pyrophosphate (Triferic, Triferic Avnu) (PDF) (CP.PHAR.624)
- Ferumoxytol (Feraheme®) (PDF) (CP.PHAR.165)
- Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP) (PDF) (CP.PHAR.526)
- Filgrastim (PDF) (CP.PHAR.297)
- Finerenone (Kerendia) (PDF) (CP.PMN.266)
- Fingolimod (Gilenya) (PDF) (CP.PCH.38)
- Flibanserin (Addyi) (PDF) (CP.PHAR.446)
- Fluorouracil Cream (Tolak) (PDF) (CP.PMN.165)
- Fluticasone Propionate (Xhance) (PDF) (CP.PMN.95)
- Fondaparinux (Arixtra) (PDF) (CP.PHAR.226)
- Formulary Medications Without Specific Guidelines (PDF) (HIM.PA.33)
- Fosdenopterin (Nulibry) (PDF) (CP.PHAR.471)
- Fostamatinib (Tavalisse) (PDF) (CP.PHAR.24)
- Fremanezumab-vfrm (Ajovy) (PDF) (HIM.PA.SP66)
- Fulvestrant (Faslodex Injection) (PDF) (CP.PHAR.424)
- Furosemide (Furoscix) (PDF) (CP.PHAR.608)
- Futibatinib (Lytgobi) (PDF) (CP.PHAR.604)
- Gabapentin ER (Gralise, Horizant) (PDF) (CP.PMN.240)
- Galcanezumab-gnlm (Emgality) (PDF) (HIM.PA.SP67)
- Galsulfase (Naglazyme) (PDF) (CP.PHAR.161)
- Ganaxolone (Ztalmy) (PDF) (CP.PMN.278)
- Gefitinib (Iressa) (PDF) (CP.PHAR.68)
- gemtuzumab ozogamicin (Mylotarg®) (PDF) (CP.PHAR.358)
- Gilteritinib (Xospata) (PDF) (CP.PHAR.412)
- Givosiran (Givlaari) (PDF) (CP.PHAR.457)
- Glasdegib (Daurismo) (PDF) (CP.PHAR.413)
- Glatiramer (Copaxone, Glatopa) (PDF) (HIM.PA.SP68)
- Glaucoma Agents (PDF) (CP.PMN.286)
- Glecaprevir/Pibrentasvir (Mavyret) (PDF) (HIM.PA.SP36)
- Glucagon-Like Peptide-1 Receptor Agonists (PDF) (HIM.PA.53)
- Glycerol phenylbutyrate (Ravicti®) (PDF) (CP.PHAR.207)
- Golodirsen (Vyondys 53) (PDF) (CP.PHAR.453)
- goserelin acetate (Zoladex®) (PDF) (CP.PHAR.171)
- Granisetron (Sancuso, Sustol) (PDF) (CP.PMN.74)
- Halcinonide (Halog) (PDF) (HIM.PA.20)
- Halobetasol Propionate (Bryhali, Lexette, Ultravate) (PDF) (CP.PMN.180)
- Halobetasol Propionate/Tazarotene (Duobrii) (PDF) (CP.PMN.208)
- Hemin (Panhematin®) (PDF) (CP.PHAR.181)
- histrelin acetate (Vantas®, Supprelin LA®) (PDF) (CP.PHAR.172)
- House Dust Mite Allergen Extract (Odactra) (PDF) (CP.PMN.111)
- Human Growth Hormone (Somapacitan, Somatropin) (PDF) (HIM.PA.161)
- Hyaluronate Derivatives (PDF) (CP.PHAR.05)
- Hydroxyprogesterone Caproate (Makena/compound) (PDF) (CP.PHAR.14)
- Hydroxyurea (Siklos) (PDF) (CP.PMN.193)
- Ibalizumab-uiyk (Trogarzo) (PDF) (CP.PHAR.378)
- Ibandronate Injection (Boniva) (PDF) (CP.PHAR.189)
- Ibrutinib (PDF) (CP.PHAR.126)
- Ibuprofen/Famotidine (Duexis) (PDF) (CP.PMN.120)
- Icatibant (Firazyr®) (PDF) (CP.PHAR.178)
- Icosapent ethyl (Vascepa) (PDF) (CP.PMN.187)
- Idecabtagene Vicleucel (Abecma) (PDF) (CP.PHAR.481)
- Idelalisib (Zydelig) (PDF) (CP.PHAR.133)
- Idursulfase (PDF) (CP.PHAR.156)
- Iloperidone (Fanapt) (PDF) (CP.PMN.32)
- Iloprost (Ventavis®) (PDF) (CP.PHAR.193)
- Imatinib (Gleevec) (CP.PHAR.65) (PDF)
- Imiglucerase (Cerezyme) (PDF) (CP.PHAR.154)
- Immune Globulins (PDF) (CP.PHAR.103)
- Inclisiran (Leqvio) (PDF) (CP.PHAR.568)
- IncobotulinumtoxinA (Xeomin) (PDF) (CP.PHAR.231)
- Inebilizumab-cdon (Uplizna) (PDF) (CP.PHAR.458)
- Inhaled Agents for Asthma and COPD (PDF) (HIM.PA.153)
- Infertility and Fertility Preservation (PDF) (CP.PHAR.131)
- Infigratinib (Truseltiq) (PDF) (CP.PHAR.547)
- Inotersen (Tegsedi) (PDF) (CP.PHAR.405)
- inotuzumab ozogamicin (Besponsa®) (PDF) (CP.PHAR.359)
- Insulin degludec (Tresiba) (PDF) (CP.PMN.285)
- Insulin Degludec (Tresiba) (PDF) (HIM.PA.09)
- Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF) (CP.PHAR.534)
- Interferon beta-1a (Avonex, Rebif) (PDF) (CP.PHAR.255)
- Interferon Beta-1b (Betaseron, Extavia) (PDF) (CP.PCH.46)
- Interferon Gamma- 1b (Actimmune) (PDF) (CP.PHAR.52)
- Intrathecal Baclofen (Gablofen, Lioresal) (PDF) (CP.PHAR.149)
- Iobenguane I-131 (Azedra) (PDF) (CP.PHAR.459)
- Ipilimumab (Yervoy) (PDF) (CP.PHAR.319)
- irinotecan Liposome (Onivyde®) (PDF) (CP.PHAR.304)
- Isatuximab-irfc (Sarclisa) (PDF) (CP.PHAR.482)
- Isavuconazonium (Cresemba®) (PDF) (CP.PMN.154)
- Isotretinoin (PDF) (CP.PMN.143)
- Istradefylline (Nourianz) (PDF) (CP.PMN.217)
- Itraconazole (Sporanox, Onmel) (PDF) (CP.PMN.124)
- Ivabradine (Corlanor) (PDF) (CP.PMN.70)
- Ivacaftor (Kalydeco) (PDF) (CP.PHAR.210)
- Ivermectin (Stromectol, Sklice) (PDF) (CP.PMN.269)
- Ivosidenib (Tibsovo) (PDF) (CP.PHAR.137)
- Ixazomib (PDF) (CP.PHAR.302)
- Ketorolac Nasal Spray (Sprix) (PDF) (CP.PMN.282)
- Korlym (mifepristone) (PDF) (CP.PHAR.101)
- Lanadelumab-fylo (Takhzyro) (PDF) (CP.PHAR.396)
- Lanreotide (Somatuline Depot) (PDF) (CP.PHAR.391)
- lapatinib (Tykerb®) (PDF) (CP.PHAR.79)
- Laronidase (Aldurazyme) (PDF) (CP.PHAR.152)
- Larotrectinib (Vitrakvi) (PDF) (CP.PHAR.414)
- Lasmiditan (Reyvow) (PDF) (CP.PMN.218)
- Lecanemab-irmb (Leqembi) (PDF) (CP.PHAR.596)
- Ledipasvir/Sofosbuvir (Harvoni) (PDF) (HIM.PA.SP3)
- Lefamulin (Xenleta) (PDF) (CP.PMN.219)
- Lenacapavir (Sunlenca) (PDF) (CP.PHAR.622)
- Lenalidomide (Revlimid) (PDF) (CP.PHAR.71)
- Leniolisib (Joenja) (PDF) (CP.PHAR.597)
- Lenvatinib (Lenvima) (PDF) (CP.PHAR.138)
- Letermovir (Prevymis) (PDF) (CP.PHAR.367)
- Levodopa Inhalation Powder (Inbrija) (PDF) (CP.PMN.267)
- Levoketoconazole (Recorlev) (PDF) (CP.PMN.275)
- levoleucovorin (Fusilev) (PDF) (CP.PHAR.151)
- Levomilnacipran (Fetzima) (PDF) (HIM.PA.125)
- Leucovorin Injection (PDF) (CP.PHAR.393)
- Leuprolide Acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi) (PDF) (CP.PHAR.173)
- L-glutamine (Endari) (PDF) (CP.PMN.116)
- lidocaine transdermal (Lidoderm, ZTlido) (PDF) (CP.PMN.08)
- Lifitegrast (Xiidra®) (PDF) (CP.PMN.73)
- Linaclotide (Linzess) (PDF) (CP.PMN.71)
- Linezolid (Zyvox) (PDF) (CP.PMN.27)
- Lisocabtagene Maraleucel (Breyanzi) (PDF) (CP.PHAR.483)
- Lofexidine (Lucemyra) (PDF) (CP.PMN.152)
- Lomustine (Gleostine) (PDF) (CP.PHAR.507)
- Lonafarnib (Zokinvy) (PDF) (CP.PHAR.499)
- Loncastuximab Tesirine-lpyl (Zynlonta) (PDF) (CP.PHAR.539)
- Lorlatinib (Lorbrena) (PDF) (CP.PHAR.406)
- Loteprednol etabonate (Eysuvis) (PDF) (CP.PMN.260)
- Lubiprostone (Amitiza) (PDF) (CP.PMN.142)
- Luliconazole Cream (Luzu) (PDF) (CP.PMN.166)
- Lumacaftor-ivacaftor (PDF) (CP.PHAR.213)
- Lumasiran (Oxlumo) (PDF) (CP.PHAR.473)
- Lumateperone (Caplyta) (PDF) (CP.PMN.232)
- Lurasidone (Latuda) (PDF) (CP.PMN.50)
- Lurbinectedin (Zepzelca) (PDF) (CP.PHAR.500)
- Luspatercept-aamt (Reblozyl) (PDF) (CP.PHAR.450)
- Lusutrombopag (Mulpleta) (PDF) (CP.PHAR.407)
- Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) (PDF) (CP.PHAR.582)
- Lutetium Lu 177 Dotatate (Lutathera) (PDF) (CP.PHAR.384)
- Macitentan (Opsumit) (PDF) (CP.PHAR.194)
- Mannitol (Bronchitol) (PDF) (CP.PHAR.518)
- Maralixibat (LUM001) (PDF) (CP.PHAR.543)
- Margetuximab-cmkb (Margenza) (PDF) (CP.PHAR.522)
- Maribavir (Livtencity) (PDF) (CP.PMN.271)
- Mavacamten (Camzyos) (PDF) (CP.PMN.272)
- Mecamylamine (Vecamyl) (PDF) (CP.PMN.136)
- Mecaserim (PDF) (CP.PHAR.150)
- Mechlorethamine Gel (Valchlor) (PDF) (CP.PHAR.381)
- Megestrol Acetate (Megace ES) (PDF) (CP.PMN.179)
- Melphalan flufenamide (Pepaxto) (PDF) (CP.PHAR.535)
- Memantine ER (Namenda XR), Memantine/Donepezil (Namzaric) (PDF) (CP.PCH.30)
- Mepolizumab (Nucala) (PDF) (CP.PHAR.200)
- Mercaptopurine (Purixan) (PDF) (CP.PHAR.447)
- Metformin ER (Fortamet, Glumetza) (PDF) (CP.PMN.72)
- Methotrexate (Otrexup, Rasuvo, Xatmep) (PDF) (CP.PHAR.134)
- Methoxsalen (Uvadex) (PDF) (HIM.PA.17)
- Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) (CP.PHAR.238)
- Methylnaltrexone Bromide (Relistor) (PDF) (CP.PMN.169)
- Metoclopramide (Gimoti) (PDF) (CP.PMN.252)
- Metreleptin (Myalept) (PDF) (CP.PHAR.425)
- Midazolam (Nayzilam) (PDF) (CP.PMN.211)
- Midostaurin (Rydapt) (PDF) (CP.PHAR.344)
- Migalastat (Galafold) (PDF) (CP.PHAR.394)
- Miglustat (Zavesca) (PDF) (CP.PHAR.164)
- Milnacipran (Savella) (PDF) (CP.PMN.125)
- Minocycline ER (Solodyn, Ximino, Minolira) and Microspheres (Arestin), Foam (Zilxi) (PDF) (CP.PMN.80)
- Mirvetuximab soravatansine-gynx (Elahere) (PDF) (CP.PHAR.617)
- Mitapivat (Pyrukynd) (PDF) (CP.PHAR.558)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF) (CP.PHAR.495)
- Mitoxantrone (Novantrone) (PDF) (CP.PHAR.258)
- Mobocertinib (Exkivity) (PDF) (CP.PHAR.559)
- Modafinil (Provigil) (PDF) (CP.PMN.39)
- Mogamulizumab-kpkc (Poteligeo) (PDF) (CP.PHAR.139)
- Mometasone (Nasonex) (PDF) (HIM.PA.93)
- Mometasone Furoate (Sinuva) (PDF) (CP.PHAR.448)
- Montelukast oral granules (Singulair) (PDF) (HIM.PA.129)
- Mosunetuzumab-axgb (Lunsumio) (PDF) (CP.PHAR.618)
- Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) (CP.PHAR.398)
- Nabumetone Double-Strength (Relafen DS) (PDF) (CP.PMN.287)
- Nadofaragene Firadenovec-vncg (Adstiladrin) (PDF) (CP.PHAR.461)
- nafarelin acetate (Synarel®) (PDF) (CP.PHAR.174)
- Naldemedine (Symproic) (PDF) (CP.PMN.112)
- Naloxegol (Movantik) (PDF) (HIM.PA.167)
- Naltrexone (Vivitrol®) (PDF) (CP.PHAR.96)
- Naproxen/Esomeprazole (Vimovo) (PDF) (CP.PMN.117)
- Naproxen oral suspension (Naprosyn) (PDF) (HIM.PA.130)
- Natalizumab (Tysabri) (PDF) (CP.PHAR.259)
- Naxitamab-gqgk (Danyelza) (PDF) (CP.PHAR.523)
- necitumumab (Portrazza®) (PDF) (CP.PHAR.320)
- Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF) (CP.PMN.167)
- Neratinib (Nerlynx) (PDF) (CP.PHAR.365)
- Netupitant and Palonosetron (Akynzeo) (PDF) (CP.PMN.158)
- Nifurtimox (Lampit) (PDF) (CP.PMN.256)
- Nilotinib (Tasigna) (PDF) (CP.PHAR.76)
- Nintedanib (Ofev) (PDF) (CP.PHAR.285)
- Niraparib (Zejula) (PDF) (CP.PHAR.408)
- Nitazoxanide (Alinia) (PDF) (HIM.PA.152)
- Nitisinone (Nityr, Orfadin) (PDF) (CP.PHAR.132)
- Nivolumab (PDF) (CP.PHAR.121)
- Nivolumab and Relatlimab-rmbw (Opdualag) (PDF) (CP.PHAR.588)
- Non-Calcium Phosphate Binders (PDF) (CP.PMN.04)
- Non-Formulary and Formulary Contraceptives (PDF) (HIM.PA.100)
- Non-Formulary Test Strips (PDF) (HIM.PA.34)
- Nusinersen (PDF) (CP.PHAR.327)
- Obeticholic Aacid (Ocaliva) (PDF) (CP.PHAR.287)
- obinutuzumab (Gazyva®) (PDF) (CP.PHAR.305)
- Ocrelizumab (Ocrevus) (PDF) (CP.PHAR.335)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot) (PDF) (CP.PHAR.40)
- Odevixibat (Bylvay) (PDF) (CP.PHAR.528)
- Ofatumumab (Arzerra, Kesimpta) (PDF) (CP.PHAR.306)
- Off-Label Drug Use (PDF) (HIM.PA.154)
- Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) (CP.PHAR.292)
- Olanzapine/Samidorphan (Lybalvi) (PDF) (CP.PMN.265)
- Olaparib (Lynparza) (PDF) (CP.PHAR.360)
- olaratumab (Lartruvo®) (PDF) (CP.PHAR.326)
- Olipudase Alfa-rpcp (Xenpozyme) (PDF) (CP.PHAR.586)
- Olutasidenib (Rezlidhia) (PDF) (CP.PHAR.615)
- Omaveloxolone (Skyclarys) (PDF) (CP.PHAR.590)
- Omecetaxine (Synribo) (PDF) (CP.PHAR.108)
- Omadacycline (Nuzyra) (PDF) (CP.PMN.188)
- Omalizumab (Xolair) (PDF) (CP.PCH.49)
- OnabotulinumtoxinA (Botox) (PDF) (CP.PHAR.232)
- Onasemnogene abeparvovec (Zolgensma) (PDF) (CP.PHAR.421)
- Ondansetron (Zuplenz) (PDF) (CP.PMN.45)
- Opicapone (Ongentys) (PDF) (CP.PMN.245)
- Opioid Analgesics (PDF) (HIM.PA.139)
- Ophthalmic Corticosteroids (PDF) (HIM.PA.03)
- Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF) (CP.PHAR.536)
- Osilodrostat (Isturisa) (PDF) (CP.PHAR.487)
- Osimertinib (Tagrisso) (PDF) (CP.PHAR.294)
- Ospemifene (Osphena) (PDF) (CP.PMN.168)
- Overactive Bladder Agents (PDF) (CP.PMN.198)
- Oxymetazoline (Rhofade, Upneeq) (PDF) (CP.PMN.86)
- Ozanimod (Zeposia) (PDF) (CP.PHAR.462)
- Ozenoxacin (Xepi) (PDF) (CP.PMN.119)
- Paclitaxel protein-bound (Abraxane) (PDF) (CP.PHAR.176)
- Pacritinib (Vonjo) (PDF) (CP.PHAR.583)
- Palbociclib (Ibrance) (PDF) (CP.PHAR.125)
- Paliperidone Long-Acting Injections (Invega Sustenna, Invega Trinza) (PDF) (CP.PHAR.291)
- Palivizumab (Synagis) (PDF) (CP.PHAR.16)
- Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep) (PDF) (CP.PCH.44)
- panitumumab (Vectibix®) (PDF) (CP.PHAR.321)
- Panobinostat (Farydak) (PDF) (CP.PHAR.382)
- Parathyroid Hormone (Natpara) (PDF) (CP.PHAR.282)
- Paricalcitrol Injection (PDF) (CP.PHAR.270)
- pasireotide (Signifor LAR®) (PDF) (CP.PHAR.332)
- Patiromer (Veltassa) (PDF) (CP.PMN.205)
- Patisiran (Onpattro) (PDF) (CP.PHAR.395)
- Pazopanib (PDF) (CP.PHAR.81)
- Peanut Allergen Powder-dnfp (Palforzia) (PDF) (CP.PMN.220)
- pegaspargase (Oncaspar®) (PDF) (CP.PHAR.353)
- Pegcetacoplan (Empaveli) (PDF) (CP.PHAR.524)
- Pegfilgrastim (PDF) (CP.PHAR.296)
- Peginterferon beta-1a (Plegridy) (PDF) (CP.PHAR.271)
- Pegloticase (Krystexxa®) (PDF) (CP.PHAR.115)
- Pegvaliase-pqpz (Palynziq) (PDF) (CP.PHAR.140)
- Pegvisomant (Somavert) (PDF) (CP.PHAR.389)
- Pembrolizumab (Keytruda®) (PDF) (CP.PHAR.322)
- Pemetrexed (Alimta®) (PDF) (CP.PHAR.368)
- Pemigatinib (Pemazyre) (PDF) (CP.PHAR.496)
- Penicillamine (Cuprimine) (PDF) (CP.PCH.09)
- Perampanel (Fycompa) (PDF) (CP.PMN.156)
- Pertuzumab (Perjeta) (PDF) (CP.PHAR.227)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (PDF) (CP.PHAR.501)
- Pexidartinib (Turalio) (PDF) (CP.PHAR.436)
- Phendimetrazine (PDF) (CP.PCH.47)
- Phentermine (Adipex-P, Lomaira) (PDF) (CP.PCH.13)
- Pilocarpine (Vuity) (PDF) (CP.PMN.270)
- Pimavanserin (Nuplazid) (PDF) (CP.PMN.140)
- Pirfenidone (Esbriet) (PDF) (CP.PHAR.286)
- Pirtobrutinib (Jaypirca) (PDF) (CP.PHAR.620)
- Pitolisant (Wakix) (PDF) (CP.PMN.221)
- Plasminogen, human-tvmh (Ryplazim) (PDF) (CP.PHAR.513)
- Plecanatide (Trulance) (PDF) (HIM.PA.158)
- Plerixafor (PDF) (CP.PHAR.323)
- Polatuzumab Vedotin-piiq (Polivy) (PDF) (CP.PHAR.433)
- Pomalidomide (Pomalyst) (PDF) (CP.PHAR.116)
- Ponatinib (Iclusig) (PDF) (CP.PHAR.112)
- Ponesimod (Ponvory) (PDF) (CP.PHAR.537)
- Potassium (Klor-Con) (PDF) (HIM.PA.143)
- pralatrexate (Folotyn®) (PDF) (CP.PHAR.313)
- Pramlintide (Symlin) (PDF) (CP.PMN.129)
- Prasterone (Intrarosa) (PDF) (CP.PMN.99)
- Pregabalin (Lyrica, Lyrica CR) (PDF) (CP.PMN.33)
- Pretomanid (PDF) (CP.PMN.222)
- Progesterone (Crinone, Endometrin, Milprosa) (PDF) (CP.PMN.243)
- Propranolol HCl Oral Solution (Hemangeol) (PDF) (CP.PMN.58)
- protein c concentrate, human (Ceprotin®) (PDF) (CP.PHAR.330)
- Prucalopride (Motegrity) (PDF) (HIM.PA.159)
- pyrimethamine (Daraprim®) (PDF) (CP.PMN.44)
- Quetiapine ER (Seroquel XR) (PDF) (CP.PMN.64)
- Quinine Sulfate (Qualaquin) (PDF) (CP.PNM.262)
- Tivozanib (Fotivda) (PDF) (CP.PHAR.538)
- Ranibizumab (Lucentis®) (PDF) (CP.PHAR.186)
- rasagiline (Azilect®) (PDF) (HIM.PA.89)
- Ravulizumab-cwvz (Ultomiris) (PDF) (CP.PHAR.415)
- Regorafenib (Stivarga) (PDF) (CP.PHAR.107)
- Relugolix (Orgovyx) (PDF) (CP.PHAR.529)
- Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel) (PDF) (HIM.PA.168)
- Reslizumab (Cinqair) (PDF) (CP.PHAR.223)
- Retifanlimab-dlwr (Zynyz) (PDF) (CP.PHAR.629)
- Revlimid (PDF) (CP.PHAR.71)
- Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF) (CP.PHAR.141)
- Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara) (PDF) (CP.PHAR.334)
- Rifabutin (Mycobutin) (PDF) (CP.PMN.223)
- Rifamycin (Aemcolo) (PDF) (CP.PMN.196)
- Rilonacept (Arcalyst) (PDF) (CP.PHAR.266)
- RimabotulinumtoxinB (Myobloc) (PDF) (CP.PHAR.233)
- Rimegepant (Nurtec ODT) (PDF) (CP.PHAR.490)
- Riociguat (Adempas®) (PDF) (CP.PHAR.195)
- Ripretinib (Qinlock) (PDF) (CP.PHAR.502)
- Risdiplam (Evrysdi) (PDF) (CP.PHAR.477)
- Risedronate (Actonel, Atelvia) (PDF) (CP.PMN.100)
- Risperidone LA Inj (PDF) (CP.PHAR.293)
- rifaximin (PDF) (CP.PMN.47)
- Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela) (PDF) (CP.PHAR.260)
- Rolapitant (Varubi) (PDF) (CP.PMN.102)
- romidepsin (Istodax®) (PDF) (CP.PHAR.314)
- Romiplostim (Nplate®) (PDF) (CP.PHAR.179)
- Romosozumab-aqqg (Evenity) (PDF) (CP.PHAR.428)
- Ropeginterferon Alfa-2b-njft (BESREMi) (PDF) (CP.PHAR.570)
- Rucaparib (Rubraca®) (PDF) (CP.PHAR.350)
- Rufinamide (Banzel) (PDF) (CP.PMN.157)
- Rukobia (fostemsavir) (PDF) (CP.PHAR.516)
- Ruxolitinib (Jakafi) (PDF) (CP.PHAR.98)
- Sacituzumab Govitecan-hziy (Trodelvy) (PDF) (CP.PHAR.475)
- Sacubitril/Valsartan (Entresto) (PDF) (CP.PMN.67)
- Safinamide (Xadago) (PDF) (CP.PMN.113)
- Sapropterin (Kuvan) (PDF) (CP.PHAR.43)
- Sarecycline (Seysara) (PDF) (CP.PMN.189)
- Sargramostim (PDF) (CP.PHAR.295)
- Satralizumab (PDF) (CP.PHAR.463)
- Sebelipase Alfa (Kanuma) (PDF) (CP.PHAR.159)
- Secnidazole (Solosec) (PDF) (CP.PMN.103)
- Selexipag (Uptravi®) (PDF) (CP.PHAR.196)
- Selinexor (Xpovio) (PDF) (CP.PHAR.431)
- Selpercatinib (Retevmo) (PDF) (CP.PHAR.478)
- Selumetinib (PDF) (CP.PHAR.464)
- Sensipar (PDF) (CP.PHAR.61)
- Setmelanotide (Imcivree) (PDF) (CP.PHAR.491)
- Short Ragweed Pollen Allergen Extract (Ragwitek) (PDF) (CP.PMN.83)
- Sildenafil (Revatio®) (PDF) (CP.PHAR.197)
- Sildenafil (Viagra) (PDF) (CP.PCH.07)
- Siltuximab (Sylvant®) (PDF) (CP.PHAR.329)
- Siponimod (Mayzent) (PDF) (CP.PHAR.427)
- Sirolimus Protein-Bound Particles (Fyarro) (PDF) (CP.PHAR.574)
- Sodium-Glucose Co-Transporter 2 Inhibitors (PDF) (HIM.PA.91)
- Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, Sodium Oxybate (Xywav) (PDF) (CP.PMN.42)
- Sodium Phenylbutyrate (Buphenyl) (PDF) (CP.PHAR.208)
- Sodium Phenylbutyrate/Taurursodiol (Relyvrio) (PDF) (CP.PHAR.584)
- Sodium thiosulfate (Pedmark) (PDF) (CP.PHAR.610)
- Sodium Zirconium Cyclosilicate (Lokelma) (PDF) (CP.PMN.163)
- Sofosbuvir (Sovaldi) (PDF) (HIM.PA.SP2)
- Sofosbuvir/Vepatasvir/Voxilaprevir (Vosevi) (PDF) (HIM.PA.SP63)
- Sofosbuvir-Velpatasvir (Epclusa) (PDF) (HIM.PA.SP1)
- Solriamfetol (Sunosi) (PDF) (CP.PMN.209)
- Sonidegib (Odomzo) (PDF) (CP.PHAR.272)
- Sorafenib (Nexavar) (PDF) (CP.PHAR.69)
- Sotorasib (Lumakras) (PDF) (CP.PHAR.549)
- Sparsentan (Filspari) (PDF) (CP.PHAR.631)
- Spesolimab-sbzo (Spevigo) (PDF) (CP.PHAR.606)
- Spinosad (Natroba) (PDF) (HIM.PA.134)
- Step Therapy Criteria (PDF) (HIM.PA.109)
- Stiripentol (Diacomit) (PDF) (CP.PMN.184)
- Sunitinib (Sutent) (PDF) (CP.PHAR.73)
- Sutimlimab-jome (Enjaymo) (PDF) (CP.PHAR.503)
- Suvorexant (Belsomra®) (PDF) (CP.PMN.109)
- Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair) (PDF) (CP.PMN.85)
- Sylatron (peginterferon alfa-2b) (PDF) (CP.PHAR.89)
- Tadalafil (Adcirca®) (PDF) (CP.PHAR.198)
- Tadafil BHP - ED (Cialis) (PDF) (CP.PMN.132)
- Tafamidis (Vyndaqel, Vyndamax) (PDF) (CP.PHAR.432)
- Tafasitamab-cxix (Monjuvi) (PDF) (CP.PHAR.508)
- Talazoparib (Talzenna) (PDF) (CP.PHAR.409)
- Taliglucerase Alfa (Elelyso) (PDF) (CP.PHAR.157)
- Talimogene laherepvec (Imlygic) (PDF) (CP.PHAR.542)
- Tapinarof (Vtama) (PDF) (CP.PMN.283)
- Tasimelteon (Hetlioz) (PDF) (CP.PMN.104)
- Tavaborole (Kerydin®) (PDF) (CP.PMN.105)
- Tazemetostat (PDF) (CP.PHAR.452)
- Tazarotene (Arazlo, Fabior, Tazorac) (PDF) (CP.PMN.244)
- Tebentafusp-tebn (Kimmtrak) (PDF) (CP.PHAR.575)
- Teclistamab-cqyv (Tecvayli) (PDF) (CP.PHAR.611)
- Tedizolid (Sivextro) (PDF) (CP.PMN.62)
- Teduglutide (Gattex) (PDF) (CP.PHAR.114)
- Tegaserod (Zelnorm) (PDF) (HIM.PA.160)
- Telotristat ethyl (Xermelo) (PDF) (CP.PHAR.337)
- Temozolomide (Temodar) (PDF) (CP.PHAR.77)
- temsirolimus (Torisel®) (PDF) (CP.PHAR.324)
- Tetrabenazine (Xenazine) (PDF) (CP.PHAR.92)
- Tenapanor (Ibsrela) (PDF) (CP.PMN.224)
- Tenofovir Alafenamide Fumarate (Vemlidy) (PDF) (CP.PMN.268)
- Teplizumab-mzwv (Tzield) (PDF) (CP.PHAR.492)
- Tepotinib (Tepmetko) (PDF) (CP.PHAR.530)
- Teprotumumab (Tepezza) (PDF) (CP.PHAR.465)
- Teriflunomide (Aubagio) (PDF) (CP.PCH.40)
- Teriparatide (Forteo®) (PDF) (CP.PHAR.188)
- Tesamorelin (PDF) (CP.PHAR.109)
- Testosterone (Testopel, Jatenzo) (PDF) (CP.PHAR.354)
- Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF) (CP.PHAR.377)
- Tezepelumab-ekko (Tezspire) (PDF) (CP.PHAR.576)
- Thalidomide (Thalomid) (PDF) (CP.PHAR.78)
- Thioguanine (Tabloid) (PDF) (CP.PHAR.437)
- Thyrotropin alfa (PDF) (CP.PHAR.95)
- Timothy Grass Pollen Allergen Extract (Grastek) (PDF) (CP.PMN.84)
- Tiopronin Delayed-Release (Thiola EC) (PDF) (CP.PCH.50)
- Tisagenlecleucel (PDF) (CP.PHAR.361)
- Tisotumab vedotin-tftv (Tivdak) (PDF) (CP.PHAR.561)
- Tobramycin (Bethkis®, Kitabis Pak®, TOBI®, TOBI Podhaler®) (PDF) (CP.PHAR.211)
- Tolvaptan (Jynarque) (PDF) (CP.PHAR.27)
- Topical Acne Treatment (PDF) (HIM.PA.71)
- Topical Immunomodulators (PDF) (CP.PMN.107)
- topical testosterone (PDF) (HIM.PA.87)
- Topiramate Extended-Release (Qudexy XR, Trokendi XR) (PDF) (CP.PMN.281)
- Topotecan (Hycamtin) (PDF) (CP.PHAR.64)
- Trabectedin (Yondelis®) (PDF) (CP.PHAR.204)
- Tralokinumab-ldrm (Adbry) (PDF) (CP.PHAR.577)
- Trametinib (Mekinist) (PDF) (CP.PHAR.240)
- Trastuzumab Biosimilars Trastuzumab-Hyaluronidase (PDF) (CP.PHAR.228)
- Tremelimumab-actl (Imjudo) (PDF) (CP.PHAR.612)
- Treprostinil (Orenitram®, Remodulin®, Tyvaso®) (PDF) (CP.PHAR.199)
- Triamcinolone ER Injection (Zilretta) (PDF) (CP.PHAR.371)
- Triclabendazole (Egaten) (PDF) (CP.PMN.207)
- Trientine (Syprine) (PDF) (CP.PHAR.438)
- Trifarotene (Aklief) (PDF) (CP.PMN.225)
- Trifluridine/Tipiracil (Lonsurf) (PDF) (CP.PHAR.383)
- Triheptanoin (Dojolvi) (PDF) (CP.PHAR.509)
- triptorelin pamoate (Trelstar®, Triptodur®) (PDF) (CP.PHAR.175)
- Trofinetide (Daybue) (PDF) (CP.PHAR.600)
- Tucatinib (Tukysa) (PDF) (CP.PHAR.497)
- Ublituximab-xiiy (Briumvi) (PDF) (CP.PHAR.621)
- Ubrogepant (Ubrelvy) (PDF) (CP.PHAR.476)
- Ulcer Therapy Combinations (PDF) (CP.PMN.277)
- Umbralisib (Ukoniq) (PDF) (CP.PHAR.531)
- Uridine acetate (Vistogard) (PDF) (HIM.PA.SP55)
- Valbenazine (Ingrezza) (PDF) (CP.PCH.48)
- valganciclovir (Valcyte) (PDF) (CP.PCH.06)
- Valrubicin (Valstar) (PDF) (CP.PHAR.439)
- Vandetanib (Caprelsa®) (PDF) (CP.PHAR.80)
- Varenicline (Tyrvaya) (PDF) (CP.PMN.273)
- Velaglucerase Alfa (VPRIV) (PDF) (CP.PHAR.163)
- Velmanase Alfa-tycv (Lamzede) (PDF) (CP.PHAR.601)
- Vemurafenib (Zelboraf®) (PDF) (CP.PHAR.91)
- Venetoclax (Venclexta) (PDF) (CP.PHAR.129)
- Verteporfin (Visudyne) (PDF) (CP.PHAR.187)
- Vestronidase alfa-vjbk (Mepsevii) (PDF) (CP.PHAR.374)
- Vigabatrin (PDF) (CP.PHAR.169)
- Vilazodone (Viibryd) (PDF) (CP.PMN.145)
- Viloxazine (Qelbree) (PDF) (CP.PMN.264)
- Viltolarsen (Viltepso) (PDF) (CP.PHAR.484)
- vincristine sulfate liposome injection (Marqibo®) (PDF) (CP.PHAR.315)
- Vismodegib (Erivedge) (PDF) (CP.PHAR.273)
- Voclosporin (Lupkynis) (PDF) (CP.PHAR.504)
- Vorapaxar (Zontivity) (PDF) (HIM.PA.146)
- Voretigene neparvovec-rzyl (Luxturna) (PDF) (CP.PHAR.372)
- Vorinostat (Zolinza) (PDF) (CP.PHAR.83)
- Vortioxetine (Trintellix®) (PDF) (CP.PMN.65)
- Vosoritide (Voxzogo) (PDF) (CP.PHAR.525)
- Voxelotor (Oxbryta) (PDF) (CP.PHAR.451)
- Vutrisiran (Amvuttra) (PDF) (CP.PHAR.550)
- Xgeva (PDF) (CP.PHAR.58)
- Xiaflex™ (PDF) (CP.PHAR.82)
- Zanubrutinib (Brukinsa) (PDF) (CP.PHAR.467)
- Zavegepant (Zavzpret) (PDF) (CP.PHAR.630)
- ziv-aflibercept (Zaltrap®) (PDF) (CP.PHAR.325)
- Zometa (PDF) (CP.PHAR.59)
Payment Policies
Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.
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- 3-Day Payment Window (PDF) (CC.PP.500)
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- Add on Code Billed Without Primary Code (PDF) (CC.PP.030)
- Assistant Surgeon (PDF) (CC.PP.029)
- Bilateral Procedures (PDF) (CC.PP.037)
- Cerumen Removal (PDF) (CC.PP.008)
- Clean Claims (PDF) (CC.PP.021)
- Coding Overview (PDF) (CC.PP.011)
- Concert Laboratory Payment Policy (CG.CC.PP.01) (PDF) - Effective Date: 10/1/2024
- Distinct Procedural Modifiers (PDF) (CC.PP.020)
- DRG Technical Denials (PDF) (CC.PP.801)
- Duplicate Primary Code Billing (PDF) (CC.PP.044)
- E&M Medical Decision-Making (PDF) (CC.PP.051)
- EM Bundling Edits (PDF) (CC.PP.010)
- Genetic and Molecular Testing Services (Version A) (CG.PP.551) (PDF) - Effective Date:10/1/2024
- Global Maternity Billing (PDF) (CC.PP.016)
- Hospital Visit Codes Billed with Labs (PDF) (CC.PP.023)
- Infectious Disease: Dermatologic Lab Testing (CG.CP.MP.03) (PDF) - Effective Date: 10/1/2024
- Infectious Disease: Gastroenterologic Lab Testing (CG.CP.MP.04) (PDF) - Effective Date: 10/1/2024
- Infectious Disease: Genitourinary Lab Testing (CG.CP.MP.07) (PDF) - Effective Date: 10/1/2024
- Infectious Disease: Multisystem Lab Testing (CG.CP.MP.02) (PDF) - Effective Date: 10/1/2024
- Infectious Disease: Primary Care & Preventive Lab Screening (CG.CP.MP.05) (PDF) - Effective Date: 10/1/2024
- Infectious Disease: Respiratory Lab Testing (CG.CP.MP.01) (PDF) - Effective Date: 10/1/2024
- Infectious Disease: Vector-borne and Tropical Diseases Lab Testing (CG.CP.MP.06) (PDF) - Effective Date: 10/1/2024
- Inpatient Consultation (PDF) (CC.PP.038)
- Inpatient Only Procedures (PDF) (CC.PP.018)
- IV Hydration (PDF) (CC.PP.012)
- Leveling of Emergency Room Services (PDF) (CC.PP.053)
- Maximum Units (PDF) (CC.PP.007)
- Moderate Conscious Sedation (PDF) (CC.PP.015)
- Modifier -25 clinical validation (PDF) (CC.PP.013)
- Modifier -59 clinical validation (PDF) (CC.PP.014)
- Modifier DOS Validation (PDF) (CC.PP.034)
- Modifier to Procedure Code Validation (PDF) (CC.PP.028)
- Multiple CPT Code Replacement (PDF) (CC.PP.033)
- Multiple Diagnostic Cardiovascular Procedure (MDCP) (PDF) (CC.PP.065)
- Payment Reduction (MDCR)NCCI Unbundling (PDF) (CC.PP.031)
- Never Paid Events (PDF) (CC.PP.017)
- New Patient (PDF) (CC.PP.036)
- Outpatient Consultation (PDF) (CC.PP.039)
- Pelvic and Transabdominal US (PDF) (CC.PP.061)
- Physician's Consultation Services (PDF) (CC.PP.054)
- Physician’s Office Lab Testing (PDF) (CC.PP.055)
- Physician Visit Codes Billed with Labs (PDF) (CC.PP.019)
- Place of Service Mismatch (PDF) (CC.PP.063)
- Post-Operative Visits (PDF) (CC.PP.042)
- Pre-Operative Visits (PDF) (CC.PP.041)
- Professional Component (PDF) (CC.PP.027)
- Pulse Oximetry (PDF) (CC.PP.025)
- Renal Hemodialysis (PDF) (CC.PP.067)
- Robotic Surgery (PDF) (CC.PP.050)
- Same Day Visits (PDF) (CC.PP.040)
- Sepsis Diagnosis (PDF) (CC.PP.073)
- Severe Malnutrition (PDF) (CC.PP.145)
- Sleep Studies Place of Services (PDF) (CC.PP.035)
- Status "B" Bundled Services (PDF) (CC.PP.046)
- Status P Bundled Services (PDF) (CC.PP.049)
- Supplies Billed on Same Day As Surgery (PDF) (CC.PP.032)
- Transgender Related Services (PDF) (CC.PP.047)
- Unbundled Surgical Procedures (PDF) (CC.PP.045)
- Unbundled Professional Services (PDF) (CC.PP.043)
- Unlisted Procedure Codes (PDF) (CC.PP.009)
- Wheelchair Accessories (PDF) (CC.PP.502)