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Clinical Payment Policies | Ambetter from Coordinated Care
Clinical & Payment Policies
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)
- ADHD Assessment and Treatment (PDF) (CP.MP.124)
- Air Ambulance (PDF) (CP.MP.175)
- Allergy Testing and Therapy (PDF) (CP.MP.100) - effective through 6/30/23
- Allergy Testing and Therapy (PDF) (CP.MP.100) - effective 7/1/23
- Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF) (CP.MP.108) - effective through 6/30/23
- Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF) (CP.MP.108) - effective 7/1/23
- Applied Behavior Analysis (PDF) (CP.BH.104)
- Bariatric Surgery (PDF) (CP.MP.37)
- BH Treatment Documentation Requirements (PDF) (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 for Acute MI (PDF) (CP.MP.156)
- Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF) (CP.MP.164) - policy effective through 5/31/23
- Clinical Trials (PDF) (CP.MP.94)
- Cochlear Implant Replacement (PDF) (CP.MP.14)
- Cosmetic and Reconstructive Surgery (PDF) (CP.MP.31)
- Deep TMS for OCD (PDF) (CP.BH.201)
- Diaphragmatic/Phrenic Nerve Stimulation (PDF) (CP.MP.203)
- Digital Analysis of EEG (PDF) (CP.MP.105)
- Discography (PDF) (CP.MP.115)
- Donor lymphocyte infusion (PDF) (CP.MP.101) - effective through 6/30/23
- Donor lymphocyte infusion (PDF) (CP.MP.101) - effective 7/1/23
- Drugs of Abuse: Definitive Testing (PDF) (CP.MP.50)
- Durable Medical Equipment (DME) (PDF) (CP.MP.107) - effective through 4/30/23
- Durable Medical Equipment (DME) (PDF) (CP.MP.107) - effective 5/1/23
- Electric Tumor Treating Fields (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) - effective through 6/30/23
- Experimental Technologies (PDF) (CP.MP.36) - effective 7/1/23
- Facet Joint Intervention for Pain Management (PDF) (CP.MP.171) - policy effective through 5/31/23
- Fecal incontinence treatments (PDF) (CP.MP.137)
- Fetal surgery in utero for prenatally diagnosed malformations (PDF) (CP.MP.129)
- Gender Affirming Procedures (PDF) (WA.CP.MP.95)
- Gastric Electrical Stimulation (PDF) (CP.MP.40) - effective through 6/30/23
- Gastric Electrical Stimulation (PDF) (CP.MP.40) - effective 7/1/23
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) (CP.MP.209)
- Genetic Testing Aortopathies & Connective Tissue Disorder (PDF) (CP.MP.215)
- Genetic Testing Cardiac Disorders (PDF) (CP.MP.216)
- Genetic Testing Dermatologic Conditions (PDF) (CP.MP.217)
- Genetic Testing Epilepsy Neurodegenerative Neuromuscular Disorder (PDF) (CP.MP.218)
- Genetic Testing Exome and Genome Sequencing (PDF) (CP.MP.219)
- Genetic Testing Eye Disorders (PDF) (CP.MP.220)
- Genetic Testing Gastroenterologic Disorders (Non-Cancerous) (PDF) (CP.MP.221)
- Genetic Testing General Approach to Genetic Testing (PDF) (CP.MP.222)
- Genetic Testing Hearing Loss (PDF) (CP.MP.223)
- Genetic Testing Hematologic Conditions (non-cancerous) (PDF) (CP.MP.224)
- Genetic Testing Hereditary Cancer Susceptibility (PDF) (CP.MP.225)
- Genetic Testing Immune Autoimmune and Rheumatoid Disorders (PDF) (CP.MP.226)
- Genetic Testing Kidney Disorders (PDF) (CP.MP.227)
- Genetic Testing Lung Disorders (PDF) (CP.MP.228)
- Genetic Testing Metabolic Endocrine and Mitochondrial Disorders (PDF) (CP.MP.229)
- Genetic Testing for Multisystem Inherited Disorders, ID & DD (PDF) (CP.MP.230)
- Genetic Testing Non-Invasive Prenatal Screening (NIPS) (PDF) (CP.MP.231)
- Genetic Testing Pharmacogenetics (PDF) (CP.MP.232)
- Genetic Testing Preimplantation Genetic Testing (PDF) (CP.MP.233)
- Genetic Testing Prenatal and Precon Carrier Screening (PDF) (CP.MP.234)
- Genetic Testing Prenatal Diagnosis (Via Amniocentesis CVS or PUBS) & Pregnancy Loss (PDF) (CP.MP.235)
- Genetic Testing Skeletal Dysplasia and Rare Bone Disorders (PDF) (CP.MP.236)
- Oncology Algorithmic Testing (PDF) (CP.MP.237)
- Oncology Cancer Screening (PDF) (CP.MP.238)
- Oncology Circulating Tumor DNA & Circulating Tumor Cells (Lqd Biopsy) (PDF) (CP.MP.239)
- Oncology Cytogenetic Testing (PDF) (CP.MP.240)
- Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF) (CP.MP.241)
- H. Pylori serology testing (PDF) (CP.MP.153)
- Heart-Lung Transplant (PDF) (CP.MP.132) - effective through 6/30/23
- Heart-Lung Transplant (PDF) (CP.MP.132) - effective 7/1/23
- 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 (PDF) (CP.MP.180)
- Implantable Intrathecal or Epidural Pain Pump (PDF) (CP.MP.173)
- Implantable Loop Recorder (CP.MP.243)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) (CP.MP.160)
- Inhaled Nitric Oxide (PDF) (CP.MP.87)
- 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)
- 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) - effective through 6/30/23
- Neonatal Abstinence Syndrome Guidelines (PDF) (CP.MP.86) - effective 7/1/23
- Neonatal Sepsis Management Guidelines (PDF) (CP.MP.85)
- Nerve Blocks for Pain Management (PDF) (CP.MP.170)
- Neuromuscular Electrical Stimulation (NMES) (PDF) (CP.MP.48)
- NICU Apnea Bradycardia Guidelines (PDF) (CP.MP.82)
- NICU Discharge Guidelines (PDF) (CP.MP.81)
- Nonmyeloablative allogeneic SCT (PDF) (CP.MP.141)
- Obstetrical Home Health Care Programs (PDF) (CP.MP.91)
- Optic nerve decompression surgery (PDF) (CP.MP.128)
- 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) - effective through 6/30/23
- Pancreas Transplantation (PDF) (CP.MP.102) - effective 7/1/23
- Panniculectomy (PDF) (CP.MP.109)
- Pediatric Heart Transplant (PDF) (CP.MP.138)
- Pediatric Liver Transplant (PDF) (CP.MP.120) - effective through 6/30/23
- Pediatric Liver Transplant (PDF) (CP.MP.120) - effective 7/1/23
- Pediatric Kidney Transplant (PDF) (CP.MP.246) - effective 2/1/2023
- 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 Therapy (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)
- Sacroiliac Joint Interventions for Pain Management (PDF) (CP.MP.166) - policy effective through 5/31/23
- Sclerotherapy for Varicose Veins (PDF) (CP.MP.146)
- Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF) (CP.MP.165) - policy effective through 5/31/23
- Short Inpatient Hospital Stay (PDF) (CP.MP.182)
- Skilled Nursing Facility Leveling (PDF) (CP.MP.206)
- Skin Substitutes for Chronic Wounds (PDF) (CP.MP.185)
- Sleep Apnea Diagnosis and Treatment (PDF) (WA.CP.MP.248)
- Stereotactic Body Radiation Therapy (PDF) (CP.MP.22)
- Substance Use Treatment and Services (PDF) (CP.BH.100)
- Tandem Transplant (PDF) (CP.MP.162) - effective through 6/30/23
- Tandem Transplant (PDF) (CP.MP.162) - effective 7/1/23
- 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 (PDF) (CP.BH.200)
- Transplant Service Documentation Requirements (PDF) (CP.MP.247) - effective 5/1/23
- 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)
- Casirivimab and Imdevimab (REGEN-COV) (PDF) (CP.PHAR.520)
- 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)
- 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)
- 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)
- 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 gluconate (Ferrlecit®) (PDF) (CP.PHAR.166)
- Ferric Maltol (Accrufer) (PDF) (CP.PMN.213)
- 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) (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)
- Iron sucrose (Venofer®) (PDF) (CP.PHAR.167)
- 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 (Sklice®) (PDF) (HIM.PA.124)
- 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)
- 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)
- Nadofaragene Firadenovec-vncg (Adstiladrin) (PDF) (CP.PHAR.461)
- nafarelin acetate (Synarel®) (PDF) (CP.PHAR.174)
- 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)
- 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)
- 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) (PDF) (CP.PHAR.168)
- Reslizumab (Cinqair) (PDF) (CP.PHAR.223)
- 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)
- 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) (HIM.PA.162)
- 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)
- 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)
- Tucatinib (Tukysa) (PDF) (CP.PHAR.497)
- 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) (HIM.PA.163)
- 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)
- ziv-aflibercept (Zaltrap®) (PDF) (CP.PHAR.325)
- Zometa (PDF) (CP.PHAR.59)
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- Bilateral Procedures (PDF) (CC.PP.037)
- Cerumen Removal (PDF) (CC.PP.008)
- Clean Claims (PDF) (CC.PP.021)
- Coding Overview (PDF) (CC.PP.011)
- Cosmetic Procedures (PDF) (CC.PP.024)
- 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)
- Global Maternity Billing (PDF) (CC.PP.016)
- Hospital Visit Codes Billed with Labs (PDF) (CC.PP.023)
- 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)
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- Modifier DOS Validation (PDF) (CC.PP.034)
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- Multiple CPT Code Replacement (PDF) (CC.PP.033)
- Multiple Diagnostic Cardiovascular Procedure (MDCP) (PDF) (CC.PP.065)
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- Renal Hemodialysis (PDF) (CC.PP.067)
- Robotic Surgery (PDF) (CC.PP.050)
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