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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 Peach State Health Plan Clinical Policy Manual apply to Peach State Health Plan members. Policies in the Peach State Health Plan Clinical Policy Manual may have either a Peach State Health Plan or a “Centene” heading. Peach State Health Plan utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Peach State Health Plan 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 Peach State Health Plan. In addition, Peach State Health Plan 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 Peach State Health Plan.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

POLICY TITLEPOLICY NUMBER
Adopted Clinical Practice and Preventive Health Guidelines (PDF)CPG Grid
Air Ambulance (PDF)CP.MP.175
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF)CP.MP.108
Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)CP.MP.249
Assisted Reproductive Technology (PDF)CP.MP.55
Bariatric Surgery (PDF)CP.MP.37
Biofeedback (PDF)CP.MP.168
Bone-Anchored Hearing Aid (PDF)CP.MP.93
Burn Surgery (PDF)CP.MP.186
Cardiac Biomarker Testing (PDF)CP.MP.156
Caudal or Interlaminar Epidural Steroid Injections (PDF)CP.MP.164
Clinical Trials (PDF)CP.MP.94
Cochlear Implant Replacements (PDF)CP.MP.14
Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)V1.2025
Concert Genetic Testing: Cardiac Disorders (PDF)V1.2025
Concert Genetic Testing: Dermatologic Conditions (PDF)V1.2025
Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF)V1.2025
Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)V1.2025
Concert Genetic Testing: Eye Disorders (PDF)V1.2025
Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (PDF)V1.2025
Concert Genetic Testing: General Approach to Genetic and Molecular Testing (PDF)V1.2025
Concert Genetic Testing: Hearing Loss (PDF)V1.2025
Concert Genetic Testing: Hematologic Conditions (non-cancerous) (PDF)V1.2025
Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF)V1.2025
Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)V1.2025
Concert Genetic Testing: Kidney Disorders (PDF)V1.2025
Concert Genetic Testing: Lung Disorders (PDF)V1.2025
Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)V1.2025
Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)V1.2025
Concert Genetic Testing: Pharmacogenetics (Version B) (PDF)V1.2025
Concert Genetic Testing: Preimplantation Genetic Testing (PDF)V1.2025
Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)V1.2025
Concert Genetic Testing: Prenatal Cell-Free DNA Testing (PDF)V1.2025
Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS or PUBS) and Pregnancy Loss (PDF)V1.2025
Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)V1.2025
Concert Genetics Oncology: Algorithmic Testing (PDF)V1.2025
Concert Genetics Oncology: Cancer Screening (PDF)V1.2025
Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF)V1.2025
Concert Genetics Oncology: Cytogenetic Testing (PDF)V1.2025
Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)V1.2025
Cosmetic and Reconstructive Procedures (PDF)CP.MP.31
Diaphragmatic/Phrenic Nerve Stimulation (PDF)CP.MP.203
Disc Decompression Procedures (PDF)CP.MP.114
Discography (PDF)CP.MP.115
Donor Lymphocyte Infusion (PDF)CP.MP.101
Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF)CP.MP.107
Electric Breast Pumps (PDF)GA.CP.MP.500
Electric Tumor Treating Fields (Optune) (PDF)CP.MP.145
Experimental Technologies (PDF)CP.MP.36
Facet Joint Injections (PDF)CP.MP.171
Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)CP.MP.248
Fecal Incontinence Treatments (PDF)CP.MP.137
Fertility Preservation (PDF)CP.MP.130
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)CP.MP.129
Gastric Electrical Stimulation (PDF)CP.MP.40
Gender-Affirming Procedures (PDF)CP.MP.95
Heart-Lung Transplant (PDF)CP.MP.132
Home Births (PDF)CP.MP.136
Home Ventilators (PDF)CP.MP.184
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
Incontinence and Ostomy Supplies (PDF)GA.CP.MP.07
Infant Apnea Monitors (PDF)GA.CP.MP.06
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
Liposuction for Lipedema (PDF)CP.MP.244
Long Term Care Placement (PDF)CP.MP.71
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
Multiple Sleep Latency Testing (PDF)CP.MP.24
Nebulizer with Compressor (PDF)GA.CP.MP.501
Neonatal Abstinence Syndrome Guidelines (PDF)CP.MP.86
Neonatal Sepsis Management (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
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 Kidney Transplant (PDF)CP.MP.246
Pediatric Liver Transplant (PDF)CP.MP.120
Pediatric Oral Function Therapy (PDF)CP.MP.188
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)CP.MP.147
Phototherapy for Neonatal Hyperbilirubinemia (PDF)CP.MP.150
Physical, Occupational, Speech, and Feeding Therapy  (PDF)GA.CP.MP.49 
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)CP.MP.133
Proton and Neutron Beam Therapies (PDF)CP.MP.70
Reduction Mammoplasty and Gynecomastia Surgery (PDF)CP.MP.51
Repair of Nasal Valve Compromise (PDF)CP.MP.210
Sacroiliac Joint Fusion (PDF)CP.MP.126
Sacroiliac Joint Interventions for Pain Management (PDF)CP.MP.166
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF)CP.MP.146
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)CP.MP.174
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)CP.MP.165
Skin and Soft Tissue Substitutes for Chronic Wounds (PDF)CP.MP.185
Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF)CP.MP.117
Stereotactic Body Radiation Therapy (PDF)CP.MP.22
Tandem Transplant (PDF)CP.MP.162
Therapeutic Utilization of Inhaled Nitric Oxide (PDF)CP.MP.87
Total Artificial Heart (PDF)CP.MP.127
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)CP.MP.163
Transplant Service Documentation Requirements (PDF)CP.MP.247
Trigger Point Injections for Pain Management (PDF)CP.MP.169
Urinary Incontinence Devices and Treatments (PDF)CP.MP.142
Vagus Nerve Stimulation (PDF)CP.MP.12
Ventricular Assist Devices (PDF)CP.MP.46

For Ambetter information, please visit our Ambetter website.

For Ambetter information, please visit our Ambetter website.

POLICY TITLEPOLICY NUMBEREFFECTIVE DATE
Adjacent Tissue Transfer Grafts involving Eyelid (PDF)CP.VP.01January 1, 2017
Age Related Macular Degeneration (PDF)CP.VP.02October 1, 2017
Amblyopia (PDF)CP.VP.03January 1, 2017
Anterior Segment Photography with FA (PDF)CP.VP.67October 1, 2017
Aqueous Shunt (PDF)CP.VP.05January 1, 2016
Blepharoplasty, Ptosis and Canthoplasty (PDF)CP.VP.07January 1, 2017
B-Scan (PDF)CP.VP.68January 1, 2018
Cataract Extraction (PDF)CP.VP.08January 1, 2017
Chemodenervation (PDF)CP.VP.10January 1, 2017
Complex Cataract (PDF)CP.VP.12January 1, 2017
Corneal Hysteresis (PDF)CP.VP.17January 1, 2016
Corneal Pachymetry (PDF)CP.VP.16January 1, 2017
Corneal Topography (PDF)CP.VP.18Janury 1, 2017
Dark Adaptation and Color Vision Examinations (92283/92284) (PDF)CP.VP.23January 1, 2017
Destruction of a Localized Lesion of the Retina (PDF)CP.VP.21January 1, 2017
Destruction of Localized Lesion of Choroid (PDF)CP.VP.20January 2,2015
Destruction of Retinopathy (PDF)CP.VP.19January 1, 2018
Dilation Protocol (PDF)CPG.VP.24January 1, 2016
Ectropion and Entropion Repair (PDF)CP.VP.25October 1, 2017
Examination Guidelines for Diabetic Patients (PDF)CPG.VP.22January 1, 2018
Extended Ophthalmoscopy (PDF)CP.VP.26January 1, 2018
External Ocular Photography (PDF)CP.VP.43October 1, 2016
Fluorescein Angiography (PDF)CP.VP.28January 1, 2018
Fundus Photography (PDF)CP.VP.29January 1, 2018
Glaucoma (PDF)CPG.VP.30January 1, 2017
Gonioscopy (PDF)CP.VP.31October 1, 2016
Indocyanine Green (ICG) Angiography (PDF)CP.VP.32January 1, 2017
Infracture of the Inferior Turbinate (PDF)CP.VP.33January 2, 2016
Iris Coloboma (PDF)CP.VP.34January 1, 2018
Keratoplasty (PDF)CP.VP.36January 1, 2016
Laser Iridotomy and Iridectomy for Glaucoma (PDF)CP.VP.37January 1, 2018
Laser Trabeculoplasty for POAG (PDF)CP.VP.38January 1, 2018
Ocular Prosthesis (PDF)CP.VP.44January 1, 2017
Ophthalmic Biometry (PDF)CP.VP.45January 1, 2017
Photodynamic and Intravitreal Therapies and Pharmaceuticals (PDF)CP.VP.40September 1, 2017
Probing and Closure of the Lacrimal Duct System (PDF)CP.VP.11December 1, 2021
Prophylaxis of Retinal Detachment (PDF)CP.VP.53January 1, 2016
Recurrent Erosion Syndrome and PTK (PDF)CP.VP.49January 1, 2016
Refractive Surgery (PDF)CP.VP.52January 1, 2016
Refraction (PDF)CP.VP.35December 1, 2019
Repair of Retinal Detachment (PDF)CP.VP.54January 1, 2016
Secondary IOL (PDF)CP.VP.48January 1, 2016
Sensorimotor Examination (PDF)CP.VP.55January 1, 2017
Specular Microscopy (PDF)CP.VP.66January 1, 2018
Strabismus Surgeries (PDF)CP.VP.57January 1, 2016
Surgical Excision of Eyelid Lesions (PDF)CP.VP.75December 1, 2021
Teleretinal Screening for Diabetic Retinopathy (PDF)CP.VP.88January 1, 2017
Trabeculetomy Ab Externo (PDF)CP.VP.61January 1, 2016
Visual Field Testing (PDF)CP.VP.63January 1, 2018
Visual Therapy (PDF)CP.VP.46January 1, 2018
Vitrectomy (PDF)CP.VP.64January 1, 2017
YAG Laser Capsulotomy (PDF)CP.VP.65January 1, 2017

POLICY TITLEPOLICY NUMBEREFFECTIVE DATE
340B Shared Savings Model (PDF)GA.PHAR.20April 1, 2017
Abaloparatide (Tymlos) (PDF)CP.PHAR.345July 1, 2017
abatacept (Orencia) (PDF)CP.PHAR.241August 1, 2016
Abiraterone (Zytiga) (PDF)CP.PHAR.84October 1, 2011
Abiraterone (Zytiga, Yonsa) (PDF)CP.PHAR.84October 1, 2011
AbobotulinumtoxinA (Dysport) (PDF)CP.PHAR.230July 1, 2016
Adalimumab (Humira) (PDF)CP.PHAR.242August 1, 2016
Addendum (PDF)CC.PHAR.10April 1, 2007
Adefovir (Hepsera) (PDF)CP.PHAR.142August 28, 2018
Aducanumab (PDF)CP.PHAR.468June 1, 2020
Afatinib (Gilotrif) (PDF)CP.PHAR.298January 1, 2017
Aflibercept (Eylea®) (PDF)CP.PHAR.184March 1, 2016
Agalsidase Beta (Fabrazyme) (PDF)CP.PHAR.158February 1, 2016
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF)CP.PMN.138March 13, 2018
Age Limit for Tazarotene (Tazorac, Arazlo) (PDF)CP.PMN.244November 9, 2017
Alectinib (Alecensa) (PDF)CP.PHAR.369November 16, 2016
Alemtuzumab (Lemtrada) (PDF)CP.PHAR.243August 1, 2016
Alendronate (Binosto, Fosamax plus D) (PDF)CP.PMN.88March 1, 2018
Alglucosidase Alfa (Lumizyme) (PDF)CP.PHAR.160February 1, 2016
Alirocumab (Praluent) (PDF)CP.PHAR.124October 1, 2015
Alpelisib (Piqray) (PDF)CP.PHAR.430September 1, 2019
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF)CP.PHAR.94March 1, 2012
Ambrisentan (Letairis®) (PDF)CP.PHAR.190March 1, 2016
Amifampridine (Firdapse, Ruzurgi) (PDF)CP.PHAR.411January 22, 2019
Amikacin (Arikayce) (PDF)CP.PHAR.401November 13, 2018
Anakinra (Kineret) (PDF)CP.PHAR.244August 1, 2016
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF)CP.PHAR.217May 1, 2016
Apalutamide (Erleada) (PDF)CP.PHAR.376June 1, 2018

Appropriate Use and Safety Edits (PDF)

Appropriate Use and Safety Edits: Attachment A (PDF)

GA.PMN.01May 1, 2012
Apremilast (Otezla) (PDF)CP.PHAR.245August 1, 2016
Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF)CP.PMN.19November 30, 2016
Arformoterol Tartrate (Brovana) (PDF)CP.PMN.259September 1, 2019
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF)CP.PHAR.290December 1, 2016
Armodafinil (Nuvigil) (PDF)CP.PMN.35August 1, 2009
Asenapine (Saphris, Secuado) (PDF)CP.PMN.15December 1, 2014
asfotase alfa (Strensiq®) (PDF)CP.PHAR.328March 1, 2017
Aspirin-dipyridamole (Aggrenox) (PDF)CP.PMN.20September 1, 2006
Atezolizumab (Tecentriq®) (PDF)CP.PHAR.235June 1, 2016
Avapritinib (Ayvakit) (PDF)CP.PHAR.454March 1, 2020
Avatrombopag (Doptelet) (PDF)CP.PHAR.130July 17, 2018
Avelumab (Bavencio®) (PDF)CP.PHAR.333May 1, 2017
Axicabtagene Ciloleucel (Yescarta) (PDF)CP.PHAR.362October 31, 2017
Axitinib (Inlyta®) (PDF)CP.PHAR.100May 1, 2012
Azacitidine (Vidaza) (PDF)CP.PHAR.387August 28, 2017
Aztreonam (Cayston®) (PDF)CP.PHAR.209May 1, 2016
Baclofen (Gablofen, Lioresal, Ozobax) (PDF)CP.PHAR.149November 9, 2017
Baloxavir Marboxil (Xofluza) (PDF)CP.PMN.185October 30, 2018
Bedaquiline (Sirturo) (PDF)CP.PMN.212December 1, 2019
belatacept (Nulojix®) (PDF)CP.PHAR.201November 9, 2017
Belimumab (Benlysta) (PDF)CP.PHAR.88October 1, 2011
belinostat (Beleodaq®) (PDF)CP.PHAR.311February 1, 2017
Bendamustine (Bendeka®, Treanda®) (PDF)CP.PHAR.307February 1, 2017
Benralizumab (Fasenra) (PDF)CP.PHAR.373January 16, 2018
Benzodiazepine Use in Pediatric Seizure Disorders (PDF)GA.PMN.08March 1, 2016
Benznidazole (PDF)CP.PMN.90October 17, 2017
Berotralstat (PDF)CP.PHAR.485June 1, 2020
Betaine (Cystadane) (PDF)CP.PHAR.143August 28, 2018
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF)CP.PHAR.93November 1, 2011
Bexarotene (Targretin) (PDF)CP.PHAR.75September 1, 2011
Bezlotoxumab (Zinplava) (PDF)CP.PHAR.300November 16, 2016
Bimatoprost Implant (Durysta) (PDF)CP.PHAR.486June 1, 2020
Binimetinib (Mektovi) (PDF)CP.PHAR.50July 24, 2018
Biologic Drug Dose Escalation (PDF)GA.PMN.21September 1, 2017
Blinatumomab (Blincyto) (PDF)CP.PHAR.312February 1, 2017
Blocking Adjudication of Controlled Substance Prescriptions for Selected Prescribers (PDF)GA.PHAR.19November 1, 2001
Bortezomib (Velcade) (PDF)CP.PHAR.410December 11, 2018
Bosentan (Tracleer®) (PDF)CP.PHAR.191March 1, 2016
Bosutinib (Bosulif) (PDF)CP.PHAR.105October 1, 2012
Brentuximab Vedotin (Adcetris) (PDF)CP.PHAR.303February 1, 2017
Brexanolone (Zulresso) (PDF)CP.PHAR.417April 16, 2019
Brexpiprazole (Rexulti) (PDF)CP.PMN.68November 5, 2015
Brexucabtagene Autoleucel (Tecartus) (PDF)
CP.PHAR.472June 1, 2020
Brigatinib (Alunbrig) (PDF)CP.PHAR.342July 17, 2017
Brimonidine Tartrate (Mirvaso) (PDF)CP.PMN.192November 16, 2016
Brolucizumab-dbll (Beovu) (PDF)CP.PHAR.445March 1, 2020
Buprenorphine Injection (Sublocade, Brixadi) (PDF)CP.PHAR.289November 16, 2016
Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF)CP.PMN.81September 1, 2017
Buprenorphine (Subutex) (PDF)CP.PMN.82September 1, 2017
Burosumab-twza (Crysvita)(PDF)CP.PHAR.11May 8, 2018
C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF)CP.PHAR.202March 1, 2016
cabazitaxel (Jevtana® (PDF)CP.PHAR.316February 1, 2017
Cabozantinib (Cometriq®, Cabometyx®) (PDF)CP.PHAR.111June 1, 2013
Cannabidiol (Epidiolex) (PDF)CP.PMN.164July 17, 2018
Canakinumab (Ilaris) (PDF)CP.PHAR.246August 1, 2016
capecitabine (Xeloda) (PDF)CP.PHAR.60May 1, 2011
Caplacizumab-yhdp (Cablivi) (PDF)CP.PHAR.416March 12, 2019
carfilzomib (Kyprolis®) (PDF)CP.PHAR.309February 1, 2017
Carglumic acid (Carbaglu®) (PDF)CP.PHAR.206May 1, 2016
Casimersen (PDF)CP.PHAR.470June 1, 2020
Casimersen (Amondys 45) (PDF)GA.PMN.31January 1, 2023
Cedazuridine/Decitabine (ASTX-727) (PDF)CP.PHAR.479June 1, 2020
Celecoxib (Celebrex, Elyxyb) (PDF)CP.PMN.122January 1, 2007
Cenegermin-bkbj (Oxervate) (PDF)CP.PMN.186October 9, 2018
Cenobamate (Xcopri) (PDF)CP.PMN.231March 1, 2020
Cemiplimab-rwlc (Libtayo) (PDF)CP.PHAR.397October 16, 2018
Ceritinib (Zykadia) (PDF)CP.PHAR.349July 1, 2017
Cerliponase alfa (Brineura) (PDF)CP.PHAR.338July 1, 2017
Certolizumab (Cimzia) (PDF)CP.PHAR.247August 1, 2016
Cetuximab (Erbitux®) (PDF)CP.PHAR.317February 1, 2017
Chloramphenicol Sodium Succinate (PDF)CP.PHAR.388December 1, 2018
Cholic Acid (Cholbam) (PDF)CP.PHAR.390December 1, 2018
Cinacalcet (Sensipar) (PDF)CP.PHAR.61May 1, 2011
Cladribine (Mavenclad) (PDF)CP.PHAR.422September 1, 2019
Clinical Pharmacy Services Inter-rater Reliability (PDF)GA.PHAR.04April 1, 2021
Clobazam (Onfi) (PDF)CP.PMN.54November 1, 2012
CNS Stimulants (PDF)CP.PMN.92March 1, 2018
Cobimetinib (Cotellic) (PDF)CP.PHAR.380November 16, 2016
Collagenase (Xiaflex) (PDF)CP.PHAR.82October 1, 2011
Continuous Glucose Monitors (PDF)CP.PMN.214December 1, 2019
copanlisib (Aliqopa®) (PDF)CP.PHAR.357October 17, 2017
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF)CP.PHAR.385May 29, 2018
Cosyntropin (Cortrosyn®) (PDF)CP.PHAR.203April 1, 2016
Crisaborole (Eucrisa) (PDF)CP.PMN.110February 21, 2017
Crizanlizumab-tmca (Adakveo) (PDF)CP.PHAR.449March 1, 2020
Crizotinib (Xalkori) (PDF)CP.PHAR.90November 1, 2011
Cyclosporine (Cequa, Restasis) (PDF)CP.PMN.48May 1, 2012
Cysteamine ophthalmic (Cystaran) (PDF)CP.PMN.130August 1, 2017
Cysteamine oral (Cystagon, Procysbi) (PDF)CP.PHAR.155February 1, 2016
Cytomegalovirus Immune Globulin (Cytogam)(PDF)CP.PHAR.277September 1, 2018
Dabrafenib (Tafinlar) (PDF)CP.PHAR.239November 16, 2016
Dacomitinib (Vizimpro) (PDF)CP.PHAR.399October 16, 2018
Dalfampridine (Ampyra) (PDF)CP.PHAR.248August 1, 2016
Dalteparin (Fragmin) (PDF)CP.PHAR.225May 1, 2016
Daptomycin (Cubicin, Cubicin RF) (PDF)CP.PHAR.351November 30, 2017
Daratumumab (Darzalex) (PDF)CP.PHAR.310July 1, 2017
Darbepoetin Alfa (Aranesp) (PDF)CP.PHAR.236June 1, 2016
Darolutamide (Nubeqa) (PDF)
CP.PHAR.435December 1, 2019
Dasatinib (Sprycel) (PDF)CP.PHAR.72June 1, 2012
daunorubicin/cytarabine (Vyxeos®) (PDF)CP.PHAR.352December 1, 2017
Deferasirox (Exjade Jadenu) (PDF)CP.PHAR.145November 1, 2015
Deferiprone (Ferriprox) (PDF)CP.PHAR.147November 1, 2015
Deferoxamine (Desferal) (PDF)CP.PHAR.146November 1, 2015
Deflazacort (Emflaza) (PDF)CP.PHAR.331March 1, 2017
Degarelix acetate (Firmagon®) (PDF)CP.PHAR.170November 9, 2017
Denosumab (Prolia, Xgeva) (PDF)CP.PHAR.58March 1, 2011
Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF)CP.PHAR.214May 1, 2016
Deutetrabenazine (Austedo) (PDF)CP.PHAR.341June 13, 2017
Dexrazoxane (Zinecard, Totect) (PDF)CP.PHAR.418March 19, 2019
Dextromethorphan-Quinidine (Nuedexta) (PDF)CP.PMN.93March 1, 2018
Diazepam Nasal Spray (Valtoco) (PDF)CP.PMN.216December 1, 2019
Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity) (PDF)CP.PHAR.249August 1, 2016
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF)CP.PMN.03September 19, 2018
Dolasetron (Anzemet) (PDF)CP.PMN.141September 1, 2006
Dornase alfa (Pulmozyme) (PDF)CP.PHAR.212May 1, 2016
Dose Escalation of Biologics (PDF)GA.PMN.21September 1, 2017
Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF)CP.PMN.79May 1, 2017
droxidopa (Northera®) (PDF)CP.PMN.17November 9, 2017
Dupilumab (Dupixent) (PDF)GA.PMN.32July 1, 2024
Durvalumab (Imfinzi) (PDF)CP.PHAR.339July 1, 2017
Duvelisib (Copiktra) (PDF)CP.PHAR.400October 16, 2018
Early and Periodic Screening, Diagnostic, and Treatment Benefit for Pediatric Members (PDF)CP.PMN.234June 1, 2020
Ecallantide (Kalbitor®) (PDF)CP.PHAR.177March 1, 2016
Eculizumab (Soliris®) (PDF)CP.PHAR.97March 1, 2012
Edaravone (Radicava) (PDF)CP.PHAR.343July 1, 2017
Efinaconazole (Jublia) (PDF)CP.PMN.25August 1, 2016
Elagolix (Orilissa) (PDF)CP.PHAR.136August 28, 2018
Elapegademase-lvlr (Revcovi) (PDF)CP.PHAR.419April 23, 2019
Elbasvir/Grazoprevir (Zepatier) (PDF)GA.PMN.16December 1, 2016
Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (PDF)GA.PMN.04December 1, 2019
Eliglustat (Cerdelga) (PDF)CP.PHAR.153February 1, 2016
Elosulfase Alfa (Vimizim) (PDF)CP.PHAR.162February 1, 2016
Elotuzumab (Empliciti®) (PDF)CP.PHAR.308February 1, 2017
Eltrombopag (Promacta®) (PDF)CP.PHAR.180March 1, 2016
Emapalumab-lzsg (Gamifant) (PDF)CP.PHAR.402December 11, 2018
Emicizumab-kxwh (Hemlibra) (PDF)CP.PHAR.370March 1, 2018
Emtricitabine/Tenofovir Alafenamide (Descovy)(PDF)CP.PMN.235June 1, 2020
Enasidenib (Idhifa) (PDF)CP.PHAR.363September 5, 2017
Encorafenib (Braftovi) (PDF)CP.PHAR.127July 24, 2018
Enfortumab Vedotin-ejfv (Padcev) (PDF)CP.PHAR.455March 1, 2020
Enfuvirtide (Fuzeon) (PDF)CP.PHAR.41June 1, 2010
Enoxaparin (Lovenox) (PDF)CP.PHAR.224May 1, 2016
Entrectinib (Rozlytrek) (PDF)CP.PHAR.441December 1, 2019
Enzalutamide (Xtandi) (PDF)CP.PHAR.106October 1, 2012
EoE (PDF)GA.PMN.11September 1, 2016
Epinephrine Injection Device - Quantity Limit Override (PDF)GA.PMN.03March 1, 2015
Epoetin Alfa (Epogen® and Procrit) (PDF)CP.PHAR.237June 1, 2016
Epoprostenol (Flolan®), Veletri®) (PDF)CP.PHAR.192March 1, 2016
Erdafitinib (Balversa)(PDF)CP.PHAR.423September 1, 2019
Erenumab-aaoe (Aimovig) (PDF)CP.PHAR.128July 10, 2018
Eribulin Mesylate (Halaven®) (PDF)CP.PHAR.318March 1, 2017
Erlotinib (Tarceva) (PDF)CP.PHAR.74September 1, 2011
Erwinia Asparaginase (Erwinaze) (PDF)CP.PHAR.301February 1, 2017
Esketamine (Spravato) (PDF)CP.PMN.199March 12, 2019
Etanercept (Enbrel) (PDF)CP.PHAR.250August 1, 2016
Etelcalcetide (Parsabiv) (PDF)CP.PHAR.379March 20, 2018
Eteplersen (Exondys 51) (PDF)GA.PMN.29January 1, 2023
Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF)CP.PHAR.63June 1, 2011
Evolocumab (Repatha) (PDF)CP.PHAR.123October 1, 2015
Exagamglogene Autotemcel (Casgevy) (PDF)GA.PMN.33December 8, 2023
Factor IX (Human, Recombinant) (PDF)CP.PHAR.218May 1, 2016
Factor IX Complex, Human (Profilnine) (PDF)CP.PHAR.219May 1, 2016
Factor VIII (Human Recombinant) (PDF)CP.PHAR.215May 1, 2016
Factor VIII/von Willebrand Factor Complex (Human - Alphanate, Humate-P, Wilate) (PDF)CP.PHAR.216May 1, 2016
Factor VIIa, Recombinant (NovoSeven® RT) (PDF)CP.PHAR.220May 1, 2016
Factor XIII A-Subunit, Recombinant (Tretten®) (PDF)CP.PHAR.222May 1, 2016
Factor XIII, Human (Corifact®) (PDF)CP.PHAR.221May 1, 2016
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF)CP.PHAR.456March 1, 2020
Febuxostat (Uloric) (PDF)CP.PMN.57August 1, 2013
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF)CP.PMN.127June 1, 2015
Ferric Carboxymaltose (Injectafer) (PDF)CP.PHAR.234June 1, 2016
Ferumoxytol (Feraheme®) (PDF)CP.PHAR.165March 1, 2016
Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF)CP.PHAR.297December 1, 2016
Fingolimod (Gilenya) (PDF)CP.PHAR.251August 1, 2016
Fondaparinux (Arixtra) (PDF)CP.PHAR.226May 1, 2016
Fosdenopterin (PDF)CP.PHAR.471June 1, 2020
Fostamatinib (Tavalisse) (PDF)CP.PHAR.24June 5, 2018
Fluorouracil Cream (Tolak(PDF)CP.PMN.165December 1, 2018
Fluticasone Propionate (Xhance) (PDF)CP.PMN.95October 24, 2017
Fluticasone/Vilanterol (Breo Ellipta) (PDF)CP.PMN.259March 1, 2020
Fremanezumab-vfrm (Ajovy) (PDF)CP.PHAR.403October 30, 2018
Fulvestrant (Faslodex Injection)(PDF)CP.PHAR.424September 1, 2019
Galcanezumab-gnlm (Emgality) (PDF)CP.PHAR.404November 13, 2018
Galsulfase (Naglazyme) (PDF)CP.PHAR.161February 1, 2016
Gefitinib (Iressa) (PDF)CP.PHAR.68November 16, 2016
gemtuzumab ozogamicin (Mylotarg®) (PDF)C.PHAR.358October 3, 2017
Gilteritinib (Xospata) (PDF)CP.PHAR.412January 15, 2019
Givosiran (Givlaari) (PDF)CP.PHAR.457March 1, 2020
Glasdegib (Daurismo) (PDF)CP.PHAR.413January 8, 2019
Glatiramer (Copaxone, Glatopa) (PDF)CP.PHAR.252Augustt 1, 2016
Glecaprevir/pibrentasvir (Mavyret) (PDF)GA.PMN.24September 1, 2017
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF)CP.PMN.183September 19, 2018
Glycerol phenylbutyrate (Ravicti®) (PDF)CP.PHAR.207May 1, 2016
Golimumab (Simponi, Simponi Aria) (PDF)CP.PHAR.253July 1, 2016
Golodirsen (Vyondys 53) (PDF)GA.PMN.30March 1, 2020
goserelin acetate (Zoladex®) (PDF)CP.PHAR.171November 9, 2017
Granisetron (Kytril, Sancuso, Sustol) (PDF)CP.PMN.74November 1, 2016
Hemin (Panhematin®) (PDF)CP.PHAR.181Februay 1, 2016
histrelin acetate (Vantas®, Supprelin LA®) (PDF)CP.PHAR.172November 9, 2017
Human Growth Hormone (Somapacitan, Somatropin, Lonapegsomatropin) (PDF)GA.PMN.28January 1, 2022
Hyaluronate Derivatives (PDF)CP.PHAR.05October 1, 2008
Hydroxyurea (Siklos) (PDF)CP.PMN.193February 19, 2019
Ibalizumab-uiyk (Trogarzo) (PDF)CP.PHAR.378April 17, 2018
Ibandronate sodium (Boniva®) (PDF)CP.PHAR.189November 15, 2017
Ibrutinib (Imbruvica) (PDF)CP.PHAR.126October 1, 2015
Ibuprofen/Famotidine (Duexis) (PDF)CP.PMN.120June 1, 2018
Icatibant (Firazyr) (PDF)CP.PHAR.178March 1, 2016
Icosapent ethyl (Vascepa) (PDF)CP.PMN.187November 20, 2018
Idecabtagene Vicleucel (BB2121) (PDF)CP.PHAR.481June 1, 2020
Idelalisib (Zydelig) (PDF)CP.PHAR.133December 1, 2018
Idursulfase (Elaprase) (PDF)CP.PHAR.156February 1, 2016
Iloperidone (Fanapt) (PDF)CP.PMN.32December 1, 2014
Iloprost (Ventavis®) (PDF)CP.PHAR.193March 1, 2016
Imatinib (Gleevec) (PDF)CP.PHAR.65June 1, 2011
Imiglucerase (Cerezyme) (PDF)CP.PHAR.154February 1, 2016
Immune Globulins (PDF)CP.PHAR.103August 1, 2012
IncobotulinumtoxinA (Xeomin) (PDF)CP.PHAR.231July 1, 2016
Inebilizumab (PDF)CP.PHAR.458March 1, 2020
Infertility and Fertility Preservation (PDF)CP.PHAR.131November 16, 2016
Infliximab (Remicade, Inflectra, Renflexis) (PDF)CP.PHAR.254July 1, 2016
Inotersen (Tegsedi) (PDF)CP.PHAR.405November 20, 2018
inotuzumab ozogamicin (Besponsa®) (PDF)CP.PHAR.359September 26, 2017
Insulin Delivery Systems (V-Go, OmniPod, InPen) (PDF)CP.PHAR.534 June 1, 2021
Interferon beta-1a (Avonex, Rebif) (PDF)CP.PHAR.255August 1, 2016
Interferon beta-1b (Betaseron, Extavia) (PDF)CP.PHAR.256August 1, 2016
Interferon Gamma- 1b (Actimmune) (PDF)CP.PHAR.52June 1, 2010
Itraconazole (Sporanox, Onmel, Tolsura) (PDF)CP.PMN.124November 1, 2006
Intrathecal Baclofen (Gablofen, Lioresal) (PDF)CP.PHAR.149November 9, 2017
Iobenguane I-131 (Azedra) (PDF)CP.PHAR.459March 1, 2020
Ipilimumab (Yervoy) (PDF)CP.PHAR.319April 17, 2018
irinotecan Liposome (Onivyde®) (PDF)CP.PHAR.304February 1, 2017
Isatuximab-irfc (Sarclisa)(PDF)CP.PHAR.482June 1, 2020
Isavuconazonium (Cresemba) (PDF)CP.PMN.154November 16, 2016
Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (PDF)CP.PMN.143December 1, 2014
Istradefylline (Nourianz) (PDF)CP.PMN.217March 1, 2020
Ivabradine (Corlanor) (PDF)CP.PMN.70November 1, 2015
Ivacaftor (Kalydeco) (PDF)CP.PHAR.210May 1, 2016
Ivosidenib (Tibsovo) (PDF)
CP.PHAR.137August 21, 2018
Ixazomib (Ninlaro) (PDF)CP.PHAR.302February 1, 2017
Ixekizumab (Taltz) (PDF)CP.PHAR.257August 1, 2016
Lacosamide (Vimpat) (PDF)CP.PMN.155December 1, 2014
Lanadelumab-fylo (Takhzyro) (PDF)CP.PHAR.396September 25, 2018
Lanreotide (Somatuline Depot) (PDF)CP.PHAR.391August 28, 2018
lapatinib (Tykerb®) (PDF)CP.PHAR.79November 9, 2017
Laronidase (Aldurazyme) (PDF)CP.PHAR.152February 1, 2016
Larotrectinib (Vitrakvi) (PDF)CP.PHAR.414January 15, 2018
Lasmiditan (Reyvow) (PDF)CP.PMN.218March 1, 2020
Ledipasvir/Sofosbuvir (Harvoni) (PDF)GA.PMN.13December 1, 2016
Ledipasvir/Sofosbuvir (Harvoni) (PDF)CP.PHAR.279September 1, 2016
Lefamulin (Xenleta) (PDF)CP.PMN.219March 1, 2020
Lenalidomide (Revlimid) (PDF)CP.PHAR.71July 1, 2011
Lenvatinib (Lenvima) (PDF)CP.PHAR.138December 1, 2018
Letermovir (Prevymis) (PDF)CP.PHAR.367March 1, 2018
Leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF)CP.PHAR.173November 9, 2017
Levoleucovorin (Fusilev®) (PDF)CP.PHAR.151November 9, 2017
Levofloxacin (Levaquin) in Pediatric Community Acquired Pneumonia (PDF)GA.PMN.05March 1, 2016
Lidocaine Transdermal (Lidoderm, ZTlido) (PDF)CP.PMN.08September 1, 2006
Linaclotide (Linzess) (PDF)CP.PMN.71November 1, 2015
Linezolid (Zyvox) (PDF)CP.PMN.27September 1, 2016
Lifitegrast (Xiidra®) (PDF)CP.PMN.73November 9, 2017
Lofexidine (Lucemyra) (PDF)CP.PMN.152August 1, 2018
Lomitapide (Juxtapid) (PDF)CP.PHAR.283October 1, 2016
Lorlatinib (Lorbrena) (PDF)CP.PHAR.406December 11, 2018
Lovotibeglogene Autotemcel (Lyfgenia) (PDF)CP.PHAR.627December 8, 2023
Lubiprostone (Amitiza) (PDF)CP.PMN.142December 1, 2014
Luliconazole Cream (Luzu) (PDF)CP.PMN.166August 28, 2018
Lumacaftor-Ivacaftor (Orkambi) (PDF)CP.PHAR.213May 1, 2016
Lumasiran (ALN-GO1) (PDF)CP.PHAR.473June 1, 2020
Lumateperone (Caplyta) (PDF)CP.PMN.232March 1, 2020
Luspatercept-aamt (Reblozyl) (PDF)CP.PHAR.450March 1, 2020
Lusutrombopag (Mulpleta) (PDF)CP.PHAR.407September 18, 2018
Lutetium Lu 177 Dotatate (Lutathera)(PDF)CP.PHAR.384May 22, 2018
Macitentan (Opsumit®) (PDF)CP.PHAR.194March 1, 2016
Maximum Allowable Cost Requirement (PDF)GA.PHAR.21July 1, 2017
Mecasermin (Increlex) (PDF)CP.PHAR.150March 1, 2011
Mecamylamine (Vecamyl) (PDF)CP.PMN.136May 1, 2017

Medicaid Prior Authorization Review Process (PDF)

Addendum (PDF)

CC.PHARM.03AApril 1, 2017
Medication Safety Policy (PDF)GA.PMN.22July 1, 2017
Megestrol Acetate (Megace ES) (PDF)CP.PMN.179December 1, 2018
Mepolizumab (Nucala) (PDF)CP.PHAR.200April 1, 2016
Metformin ER (Fortamet, Glumetza) (PDF)CP.PMN.72November 1, 2015
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF)CP.PHAR.134December 1, 2018
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF)CP.PHAR.238June 1, 2016
Methylnaltrexone Bromide (Relistor) (PDF)CP.PMN.169December 1, 2018
Metreleptin (Myalept) (PDF)CP.PHAR.425September 1, 2019
Midazolam (Nayzilam) (PDF)CP.PMN.211September 1, 2019
Midostaurin (Rydapt) (PDF)CP.PHAR.344June 1, 2017
Mifepristone (Korlym) (PDF)CP.PHAR.101May 1, 2012
Migalastat (Galafold) (PDF)CP.PHAR.394September 11, 2018
Miglustat (Zavesca) (PDF)CP.PHAR.164February 1, 2016
Milnacipran (Savella) (PDF)CP.PMN.125August 1, 2012
Minocycline ER (Solodyn, Ximino, Minolira) and Microspheres (Arestin) (PDF)CP.PMN.80May 1, 2017
Mitoxantrone (Novantrone) (PDF)CP.PHAR.258August 1, 2016
Modafinil (Provigil) (PDF)CP.PMN.39May 1, 2008
Mogamulizumab-kpkc (Poteligeo) (PDF)CP.PHAR.139September 4, 2018
Mometasone/Formoterol (Dulera) (PDF)CP.PMN.259March 1, 2020
Mometasone Furoate (Sinuva) (PDF)CP.PHAR.448March 1, 2020
Monomethyl Fumarate (Bafiertam) (PDF)CP.PHAR.249March 1, 2020
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF)CP.PHAR.39810/16/2018
Nadofaragene Firadenovec (Instiladrin) (PDF)CP.PHAR.461March 1, 2020
nafarelin acetate (Synarel®) (PDF)CP.PHAR.17411/09/2017
Naproxen/Esomeprazole (Vimovo) (PDF)CP.PMN.11706/01/2018
Natalizumab (Tysabri) (PDF)CP.PHAR.25907/01/2016
Necitumumab (Portrazza®) (PDF)CP.PHAR.320March 1, 2017
Neomycin/Fluocinolone Cream (Neo-Synalar)_(PDF)CP.PMN.167August 28, 2018
Neratinib (Nerlynx) (PDF)CP.PHAR.365September 5, 2017
Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan)  (PDF)CP.PMN.86February 13, 2018
Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (PDF)CP.PMN.158September 1, 2006
nilotinib (Tasigna) (PDF)CP.PHAR.76September 1, 2011
Nintedanib (Ofev) (PDF)CP.PHAR.285October 1, 2016
Nitisinone (Nityr, Orfadin) (PDF)CP.PHAR.132August 28, 2018
Nivolumab (Opdivo) (PDF)CP.PHAR.121July 1, 2015
No Coverage Criteria/Off-Label Use Policy (PDF)CP.PMN.53September 12, 2017
Nusinersen (Spinraza®)(PDF)CP.PHAR.327November 28, 2017
Obeticholic (Ocaliva) (PDF)CP.PHAR.287November 1, 2016
Obinutuzumab (Gazyva®) (PDF)CP.PHAR.305Februay 1, 2017
Ocrelizumab (Ocrevus) (PDF)CP.PHAR.335April 1, 2017
Octreotide (Sandostatin, Sandostatin LAR) (PDF)CP.PHAR.40March 1, 2010
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia) (PDF)CP.PHAR.40March 1, 2010
ofatumumab (Arzerra®) (PDF)CP.PHAR.306February 1, 2017
Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF)CP.PHAR.292December 1, 2016
Olaparib (Lynparza) (PDF)CP.PHAR.360October 3, 2017
Omadacycline (Nuzyra) (PDF)CP.PMN.188November 20, 2018
Omacetaxine (Synribo) (PDF)CP.PHAR.108April 1, 2013
Omalizumab (Xolair®) (PDF)CP.PHAR.01October 1, 2008
OnabotulinumtoxinA (Botox) (PDF)CP.PHAR.232July 1, 2016
Onasemnogene Abeparvovec (Zolgensma) (PDF)CP.PHAR.421June 7, 2019
Opioid Analgesics (PDF)GA.PMN.26October 1, 2019
Osimertinib (Tagrisso) (PDF)CP.PHAR.294December 1, 2016
Ospemifene (Osphena) (PDF)CP.PMN.168August 28, 2018
Overactive Bladder Agents (PDF)CP.PMN.198May 1, 2016
Ozanimod (PDF)CP.PHAR.462March 1, 2020
Ozenoxacin (Xepi) (PDF)CP.PMN.119January 30, 2018
Paclitaxel, Protein-Bound (Abraxane) (PDF)CP.PHAR.176July 1, 2015
Palbociclib (Ibrance®) (PDF)CP.PHAR.125October 1, 2015
Palivizumab (Synagis) (PDF)CP.PHAR.16August 1, 2009
panitumumab (Vectibix®) (PDF)CP.PHAR.321March 1, 2017
Parathyroid Hormone (Natpara) (PDF)CP.PHAR.282November 16, 2016
Paricalcitol Injection (Zemplar) (PDF)CP.PHAR.270August 1, 2016
Pasireotide (Signifor LAR®) (PDF)CP.PHAR.332March 1, 2017
Patisiran (Onpattro) (PDF)CP.PHAR.395September 11, 2018
Pazopanib (Votrient) (PDF)CP.PHAR.81October 1, 2011
Peanut Allergen Powder-dnfp (Palforzia) (PDF)CP.PMN.220March 1, 2020
Pediatric Benzodiazepine Use in Chemotherapy Induced Nausea and Vomiting (CINV) (PDF)GA.PMN.07August 1, 2016
Pediatric BZD Seizures (PDF)GA.PMN.08March 1, 2016
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF)CP.PHAR.353September 5, 2017
Pegfilgrastim (Neulasta) (PDF)CP.PHAR.296December 1, 2016
peginterferon alfa-2b (PegIntron, Sylatron®) (PDF)CP.PHAR.89October 1, 2011
Peginterferon beta-1a (Plegridy) (PDF)CP.PHAR.271August 1, 2016
Pegloticase (Krystexxa®) (PDF)CP.PHAR.115June 1, 2013
Pegvaliase-pqpz (Palynziq) (PDF)CP.PHAR.140July 31, 2018
Pegvisomant (Somavert) (PDF)CP.PHAR.389December 1, 2018
Pemetrexed (Alimta, Pemfexy) (PDF)CP.PHAR.368October 31, 2017
pembrolizumab (Keytruda®) (PDF)CP.PHAR.322March 1, 2017
Perampanel (Fycompa) (PDF)CP.PMN.156November 16, 2016
Pertuzumab (Perjeta) (PDF)CP.PHAR.227June 1, 2016
Pexidartinib (Turalio) (PDF)CP.PHAR.436December 1, 2019

Pharmacy Lock-In Program (PDF)

Lock-In Letter (PDF)

Lock-In Release Letter (PDF)

GA.PHAR.06July 1, 2006
Pharmacy Program (PDF)GA.PHAR.01October 1, 2006
Pharmacy & Therapeutics Committee (PDF)CC.PHAR.13February 1, 2010
Pitolisant (Wakix) (PDF)CP.PMN.221March 1, 2020
Plerixafor (Mozobil) (PDF)CP.PHAR.323March 1, 2017
Polatuzumab Vedotin-piiq (Polivy) (PDF)CP.PHAR.433September 1, 2019
Pomalidomide (Pomalyst) (PDF)CP.PHAR.116July 1, 2013
Ponatinib (Iclusig) (PDF)CP.PHAR.112June 1, 2013
Pralatrexate (Folotyn®) (PDF)CP.PHAR.313February 1, 2017
Pramlintide (Symlin) (PDF)CP.PMN.129June 1, 2018
Preferred Drug List (PDF)CC.PHAR.10April 1, 2007
Pregabalin (Lyrica, Lyrica CR) (PDF)CP.PMN.33January 1, 2007
Pretomanid (PDF)CP.PMN.222March 1, 2020
Protein C Concentrate, Human (Ceprotin) (PDF)CP.PHAR.330March 1, 2017
Propranolol HCl Oral Solution (Hemangeol) (PDF)CP.PMN.58May 1, 2014
Prucalopride (Motegrity) (PDF)CP.PMN.194January 29, 2019
Psychotropic Medication Continuity of Care (COC) (PDF)GA.PMN.10December 1, 2016
pyrimethamine (Daraprim®) (PDF)CP.PMN.44November 1, 2015
Quetiapine ER (Seroquel XR) (PDF)CP.PMN.64December 1, 2014
Ramucirumab (Cyramza®) (PDF)CP.PHAR.119May 1, 2015
Ranibizumab (Lucentis®) (PDF)CP.PHAR.186March 1, 2016
Regorafenib (Stivarga) (PDF)CP.PHAR.107December 1, 2012
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF)CP.PHAR.168March 1, 2016
Request for Medically Necessary Drug Not on the PDL (PDF)CP.PMN.16November 9, 2017
Reslizumab (Cinqair) (PDF)CP.PHAR.223May 1, 2016
Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF)CP.PHAR.141November 16, 2016
Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) (PDF)CP.PMN.223March 1, 2020
Rifamycin (Aemcolo) (PDF)CP.PMN.196January 8, 2019
rifaximin (Xifaxan®)(PDF)CP.PMN.47November 1, 2011
Rilonacept (Arcalyst) (PDF)CP.PHAR.266November 16, 2016
RimabotulinumtoxinB (Myobloc) (PDF)CP.PHAR.233July 1, 2016
Riociguat (Adempas®) (PDF)CP.PHAR.195March 1, 2016
Risdiplam (PDF)CP.PHAR.477June 1, 2020
Risedronate (Actonel, Atelvia) (PDF)CP.PMN.100March 1, 2018
Risperidone Long-Acting Injection (Risperdal Consta) (PDF)CP.PHAR.293December 1, 2016
Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF)CP.PHAR.260July 1, 2016
Rolapitant (Varubi) (PDF)CP.PMN.102February 1, 2017
romidepsin (Istodax®) (PDF)CP.PHAR.314January 1, 2017
Romiplostim (Nplate®) (PDF)CP.PHAR.179March 1, 2016
Rucaparib (Rubraca®) (PDF)CP.PHAR.350September 1, 2017
Rufinamide (Banzel) (PDF)CP.PMN.157December 1, 2014
Sacubitril/Valsartan (Entresto) (PDF)CP.PMN.67November 1, 2015
Sacitizumab Govitecan (PDF)CP.PHAR.475June 1, 2020
Safinamide (Xadago) (PDF)CP.PMN.113July 1, 2017
Sapropterin Dihydrochloride (Kuvan) (PDF)CP.PHAR.43February 1, 2010
Sarecycline (Seysara) (PDF)CP.PMN.189November 13, 2018
Sargramostim (Leukine) (PDF)CP.PHAR.295December 1, 2016
Satralizumab (PDF)CP.PHAR.463March 1, 2020
Sebelipase Alfa (Kanuma) (PDF)CP.PHAR.159February 1, 2016
Secnidazole (Solosec) (PDF)CP.PMN.103October 24, 2017
Secukinumab
(Cosentyx) (PDF)		CP.PHAR.261 
Selexipag (Uptravi®) (PDF)CP.PHAR.196March 1, 2016
Selinexor (Xpovio) (PDF)CP.PHAR.431September 1, 2019
Selpercatinib (LOXO-292) (PDF)CP.PHAR.478June 1, 2020
Selumetinib (Koselugo) (PDF)CP.PHAR.464March 1, 2020
Sildenafil (Revatio®) (PDF)CP.PHAR.197March 1, 2016
Siltuximab (Sylvant®) (PDF)CP.PHAR.329March 1, 2017
Siponimod (Mayzent) (PDF)CP.PHAR.427September 1, 2019
Sipuleucel-T (Provenge) (PDF)CP.PHAR.120June 1, 2015
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF)CP.PMN.14September 18, 2018
sodium oxybate (Xyrem) (PDF)CP.PMN.42May 1, 2011
Sodium Phenylbutyrate (Buphenyl) (PDF)CP.PHAR.208May 1, 2016
Sofosbuvir/Ledipasvir (Harvoni) (PDF)GA.PMN.13December 1, 2016
Sofosbuvir (Sovaldi) (PDF)CP.PHAR.281September 1, 2016
Sofosbuvir (Sovaldi) (PDF)GA.PMN.17December 1, 2016
Sofosbuvir/Velpatasvir (Epclusa) (PDF)GA.PMN.06December 1, 2016
Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (PDF)GA.PMN.25September 1, 2017
Solriamfetol (Sunosi) (PDF)CP.PMN.209September 1, 2019
Sonidegib (Odomzo) (PDF)CP.PHAR.272May 1, 2012
sorafenib (Nexavar) (PDF)CP.PHAR.69July 1, 2011
Specialty Drug Classification (PDF)GA.PHAR.15March 12, 2000
Specialty Pharmacy Program (PDF)GA.PHAR.18March 12, 2014
Step Therapy (PDF)CP.PST.01December 28, 2017
Stiripentol (Diacomit) (PDF)CP.PMN.184September 25, 2018
sunitinib (Sutent) (PDF)CP.PHAR.73September 1, 2011
Suvorexant (Belsomra®) (PDF)CP.PMN.109February 1, 2017
Tadalafil (Adcirca®) (PDF)CP.PHAR.198March 1, 2016
Tadalafil BHP - ED (Cialis) (PDF)CP.PMN.132June 1, 2018
Tafamidis (Vyndaqel, Vyndamax) (PDF)CP.PHAR.432September 1, 2019
Talazoparib (Talzenna) (PDF)CP.PHAR.409November 27, 2018
Taliglucerase Alfa (Elelyso) (PDF)CP.PHAR.157February 1, 2016
Tasimelteon (Hetlioz) (PDF)CP.PMN.104Februray 1, 2017
Tavaborole (Kerydin) (PDF)CP.PMN.105March 1, 2018
Tazemetostat (Tazverik) (PDF)CP.PHAR.452March 1, 2020
Tedizolid (Sivextro) (PDF)CP.PMN.62March 1, 2015
Teduglutide (Gattex) (PDF)CP.PHAR.114May 1, 2013
Telotristat Ethyl (Xermelo) (PDF)CP.PHAR.337June 1, 2017
Temozolomide (Temodar) (PDF)CP.PHAR.77September 1, 2011
temsirolimus (Torisel®) (PDF)CP.PHAR.324March 1, 2017
Tenapanor (Ibsrela) (PDF)CP.PMN.224March 1, 2020
Teprotumumab (Tepezza) (PDF)CP.PHAR.465January 21, 2020
Teriflunomide (Aubagio) (PDF)CP.PHAR.262August 1, 2016
Teriparatide (Forteo®) (PDF)CP.PHAR.188November 15, 2017
Tesamorelin (Egrifta) (PDF)CP.PHAR.109March 1, 2014
Testosterone (Testopel, Jatenzo) (PDF)CP.PHAR.354August 1, 2017
tetrabenazine (Xenazine) (PDF)CP.PHAR.92December 1, 2011
Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF)CP.PHAR.377April 3, 2018
Thalidomide (Thalomid) (PDF)CP.PHAR.78September 1, 2011
Thioguanine (Tabloid) (PDF)CP.PHAR.437December 1, 2019
Thyrotropin Alfa (Thyrogen) (PDF) CP.PHAR.95March 1, 2012
Timothy grass pollen allergen extract (Grastek®) (PDF)CP.PMN.84August 31, 2017
Tisagenlecleucel (Kymriah) (PDF)CP.PHAR.361September 26, 2017
Tobramycin (Bethkis®, Kitabis Pak®, TOBI®, TOBI Podhaler®) (PDF)CP.PHAR.211May 1, 2016
Tocilizumab (Actemra) (PDF)CP.PHAR.263July 1, 2016
Tofacitinib (Xeljanz, Xeljanz XR) (PDF)CP.PHAR.267January 30, 2018
Tolvaptan (Jynarque) (PDF)CP.PHAR.27June 5, 2018
Topical Immunomodulators (PDF)CP.PMN.107September 1, 2006
Topical Steroid Use For Eosinophilic Esophagitis (PDF)GA.PMN.11September 1, 2016
Topical Tretinoin in Adult Acne Vulgaris (PDF)GA.PMN.09March 1, 2016
Topotecan (Hycamtin)(PDF)CP.PHAR.64June 1, 2011
Trabectedin (Yondelis®) (PDF)CP.PHAR.204May 1, 2016
Trametinib (Mekinist) (PDF)CP.PHAR.240July 1, 2016
Transition of Care (PDF)GA.PHAR.02October 1, 2020
Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF)CP.PHAR.228June 1, 2016
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF)CP.PHAR.199March 1, 2016
Triamcinolone ER Injection (Zilretta) (PDF)CP.PHAR.371March 1, 2018
Trientine (Syprine) (PDF)CP.PHAR.438December 1, 2019
triptorelin pamoate (Trelstar®, Triptodur®) (PDF)CP.PHAR.175November 9, 2017
Ubrogepant (Ubrelvy) (PDF)CP.PHAR.475June 1, 2020
Upadacitinib (Rinvoq) (PDF)CP.PHAR.443December 1, 2019
Ustekinumab (Stelara) (PDF)CP.PHAR.264August 1, 2016
Valoctocogene Roxaparvovec (PDF)CP.PHAR.466March 1, 2020
Valrubicin (Valstar) (PDF)CP.PHAR.439December 1, 2019
Vandetanib (Caprelsa®) (PDF)CP.PHAR.80October 1, 2011
Vedolizumab (Entyvio) (PDF)CP.PHAR.265July 1, 2016
Velaglucerase Alfa (VPRIV) (PDF)CP.PHAR.163February 1, 2016
Vemurafenib (Zelboraf®) (PDF)CP.PHAR.91November 1, 2011
Verteporfin (Visudyne®) (PDF)CP.PHAR.187March 1, 2016
Vestronidase alfa-vjbk (Mepsevii) (PDF)CP.PHAR.374January 19, 2018
Vigabatrin (Sabril) (PDF)CP.PHAR.169February 1, 2016
Vilazodone (Viibryd) (PDF)CP.PMN.145August 1, 2012
Viltolarsen (PDF)CP.PHAR.484June 1, 2020
Vismodegib (Erivedge) (PDF)CP.PHAR.273August 1, 2016
Voretigene neparvovec-rzyl (Luxturna) (PDF)CP.PHAR.372March 1, 2018
Vorinostat (Zolinza) (PDF)CP.PHAR.83December 1, 2012
Vortioxetine (Trintellix®) (PDF)CP.PMN.65May 31, 2017
Voxelotor (Oxbryta) (PDF)CP.PHAR.451March 1, 2020
Zanubrutinib (Brukinsa) (PDF)CP.PHAR.467March 1, 2020
ziv-aflibercept (Zaltrap®) (PDF)CP.PHAR.325March 1, 2017
Zoledronic acid (Reclast, Zometa) (PDF)CP.PHAR.59March 1, 2011

POLICY TITLEPOLICY NUMBEREFFECTIVE DATE
72 Hour Supply of Medication (PDF)GA.PHAR.07June 1, 2006
Ado-Trastuzumab Emtansine (Kadcyla) (PDF)CP.PHAR.229June 1, 2016
Aflibercept (Eylea®) (PDF)CP.PHAR.184March 1, 2016
Alglucosidase Alfa (Lumizyme) (PDF)CP.PHAR.160February 1, 2016
Anakinra (Kineret) (PDF)CP.PHAR.244August 1, 2016
Ambrisentan (Letairis®) (PDF)CP.PHAR.190March 1, 2016

Appropriate Use and Safety Edits (PDF)

Appropriate Use and Safety Edits: Attachment A (PDF)

GA.PMN.01May 1, 2012
Benznidazole (PDF)CP.PMN.90October 17, 2017
Blocking Adjudication of Controlled Substance Prescriptions for Selected Prescribers (PDF)GA.PHAR.19November 1, 2001
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF)CP.PHAR.202March 1, 2016
Cabozantinib (Cometriq®, Cabometyx®) (PDF)CP.PHAR.111June 1, 2013
Carglumic acid (Carbaglu®) (PDF)CP.PHAR.206May 1, 2016
Dose Escalation of Biologics (PDF)GA.PMN.21September 1, 2017
Drug Recall Notification Process (PDF)GA.PHAR.08July 1, 2008
Drug Utilization Review (PDF)GA.PHAR.13April 1, 2007
Enoxaparin (Lovenox) (PDF)CP.PHAR.224May 1, 2016
Epoprostenol (Flolan®), Veletri®) (PDF)CP.PHAR.192March 1, 2016
Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF)CP.PHAR.297December 1, 2016
Hydroxyprogesterone Caproate (Makena®) (PDF)CP.PHAR.14November 20, 2017
Ibandronate sodium (Boniva®) (PDF)CP.PHAR.189November 15, 2017
Ibrutinib (Imbruvica) (PDF)CP.PHAR.126October 1, 2015
Iloprost (Ventavis®) (PDF)CP.PHAR.193March 1, 2016
Ivacaftor (Kalydeco) (PDF)CP.PHAR.210May 1, 2016
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF)CP.PHAR.173November 9, 2017
Lomitapide (Juxtapid) (PDF)CP.PHAR.283October 1, 2016
Lost, Stolen, Spilled or Broken Medications (PDF)GA.PHAR.10April 1, 2007
Maximum Allowable Cost (MAC) Requirement (PDF)GA.PHAR.21July 1, 2017
Mecasermin (Increlex) (PDF)CP.PHAR.150March 1, 2011
Medication Safety Policy (PDF)GA.PMN.22July 1, 2017
Mifepristone (Korlym) (PDF)CP.PHAR.101May 1, 2012
Mipomersen (Kynamro) (PDF)CP.PHAR.284October 1, 2016
Pegaptanib (Macugen®) (PDF)CP.PHAR.185March 1, 2016
Pegloticase (Krystexxa®) (PDF)CP.PHAR.115June 1, 2013
pembrolizumab (Keytruda®) (PDF)CP.PHAR.322March 1, 2017
Pharmacy and Therapeutics Committee (PDF)GA.PHAR.17August 9, 2011
Pharmaceutical Management (PDF)GA.PHAR.03February 1, 2003
Pharmacy Prior Authorization and Medical Necessity Criteria (PDF)GA.PHAR.16July 9, 2010
Plerixafor (Mozobil) (PDF)CP.PHAR.323March 1, 2017
Ranibizumab (Lucentis®) (PDF)CP.PHAR.186March 1, 2016
Riociguat (Adempas®) (PDF)CP.PHAR.195March 1, 2016
Step Therapy (PDF)MCPS.ST.00January 1, 2021
Tadalafil (Adcirca®) (PDF)CP.PHAR.198March 1, 2016
Vandetanib (Caprelsa®) (PDF)CP.PHAR.80October 1, 2011
vincristine sulfate liposome injection (Marqibo®) (PDF)CP.PHAR.315February 1, 2017

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.

All policies found in the Peach State Health Plan Payment Policy Manual apply with respect to Peach State Health Plan members. Policies in the Peach State Health Plan Payment Policy Manual may have either a Peach State Health Plan or a “Centene” heading.  In addition, Peach State Health Plan may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Peach State Health Plan.     

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

For Ambetter information, please visit our Ambetter website.

POLICY TITLEPOLICY NUMBEREFFECTIVE DATE
25-hydroxyvitamin D Testing in Children and Adolescents (PDF)CP.MP.157December 20, 2023
Allergy Testing and Therapy (PDF)CP.MP.100August 31, 2016
Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF)CP.BH.124July 12, 2023
Bilateral Procedures (PDF)CC.PP.037January 1, 2014
Bronchial Thermoplasty (PDF)CP.MP.110May 31, 2016
Cardiac Biomarker Testing (PDF)CP.MP.156October 1, 2025
Cerumen Removal Policy (PDF)CC.PP.008January 1, 2014
Clean Claims Policy (PDF)CC.PP.021January 1, 2013
Clean Claim Reviews (PDF)CC.PI.04November 1, 2012
Clinical Validation of Modifier 25 (PDF)CC.PP.013January 1, 2013
Clinical Validation of Modifier 59 (PDF)CC.PP.014January 1, 2013
Code Editing Overview (PDF)CC.PP.011January 1, 2013
Concert Laboratory Payment Policy (PDF)CG.CC.PP.01September 1, 2024
Cosmetic Procedures (PDF)CC.PP.024January 1, 2014
Cost to Charge Adjustments on Clean Claim Reviews (PDF)CC.PI.06Sepember 1, 2022
Digital EEG Spike Analysis (PDF)CP.MP.105December 20, 2023
Distinct Procedure Modifiers Policy (PDF)CC.PP.020January 1, 2013
Drugs of Abuse: Definitive Testing (PDF)CP.MP.50September 25, 2023
Duplicate Primary Code Billing (PDF)CC.PP.044January 1, 2014
E&M Bundling with Labs and Radiology (PDF)CC.PP.010January 1, 2013
E&M Services Billed with Treatment Room Revenue Codes (PDF)CC.PP.071September 28, 2021
EEG in the Evaluation of Headache (PDF)CP.MP.155December 20, 2023
EM Medical Decision Making (PDF)CC.PP.051June 1, 2017
Endometrial Ablation (PDF)CP.MP.106October 1, 2025
Evoked Potential Testing (PDF)CP.MP.134November 30, 2016
Genetic and Molecular Testing Services (PDF)CG.PP.551 August 1, 2024
Helicobacter Pylori Serology Testing (PDF)CP.MP.153October 1, 2025
Holter Monitors (PDF)CP.MP.113August 30, 2016
Homocysteine Testing (PDF)CP.MP.121August 30, 2016
Hospital Visit Codes Billed with Labs (PDF)CC.PP.023January 1, 2016
Infectious Disease: Dermatologic Lab Testing (PDF)CG.CP.MP.03September 1, 2024
Infectious Disease: Gastroenterologic Lab Testing (PDF)CG.CP.MP.04September 1, 2024
Infectious Disease: Genitourinary Lab Testing (PDF)CG.CP.MP.07September 1, 2024
Infectious Disease: Multisystem Lab Testing (PDF)CG.CP.MP.02September 1, 2024
Infectious Disease: Primary Care & Preventive Lab Screening (PDF)CG.CP.MP.05September 1, 2024
Infectious Disease: Respiratory Lab Testing (PDF)CG.CP.MP.01September 1, 2024
Infectious Disease: Vector-borne and Tropical Diseases Lab Testing (PDF)CG.CP.MP.06September 1, 2024
Inpatient Consultation (PDF)CC.PP.038January 1, 2014
Inpatient Only Procedures Policy (PDF)CC.PP.018January 1, 2018
Insulin Testing in Pediatrics (PDF)GA.CP.MP.154 
IV Hydration Policy (PDF)CC.PP.012January 1, 2013
Laser Therapy for Skin Conditions (PDF)CP.MP.123August 30, 2016
Leveling of Care: Evaluation and Management Overcoding (PDF)CC.PP.066February 6, 2020
Leveling Professional Fees for Emergency Room Services (PDF)GA.PP.053December 16, 2020
Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)CP.MP.139February 28, 2017
Max Units Payment Policy (PDFCC.PP.007January 1, 2013
Measurement of Serum 1,25-dihydroxyvitamin D (PDF)CP.MP.152December 20, 2023
Moderate Conscious Sedation (PDF)CC.PP.015January 1, 2013
Modifier DOS Validation (PDF)CC.PP.034January 1, 2015
Modifier to Procedure Code Validation (PDF)CC.PP.028January 1, 2013
Multiple CPT Code Replace (PDF)CC.PP.033January 1, 2013
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF)CC.PP.065February 6, 2020
Multiple Procedure Reduction: Ophthalmology (PDF)CC.PP.069August 18, 2020
Multiple Procedure Payment Reduction: Therapeutic Services (PDF)CC.PP.068July 1, 2021
NCCI Unbundling (PDF)CC.PP.031January 1, 2013
Never Paid Events (PDF)CC.PP.017January 1, 2013
New Patient (PDF)CC.PP.036January 1, 2014
Non-obstectrical Pelvic and Transvaginal Ultrasounds (PDF)CC.PP.061June 1, 2018
Not Medically Necessary Inpatient Service (PDF)CC.PP.060June 1, 2018
Outpatient Consultation (PDF)CC.PP.039January 1, 2014
Physician's Office Lab Testing (PDF)CC.PP.055December 1, 2019
Place of Service Mismatch (PDF)CC.PP.063September 1, 2018
Postoperative Visits (PDF)CC.PP.042January 1, 2014
Preoperative Visits (PDF)CC.PP.041January 1, 2014
Problem Oriented Visits with Surgical Procedures (PDF)CC.PP.052November 1, 2017
Professional Component Modifier (PDF)CC.PP.027January 1, 2013
Pulmonary Function Testing (PDF)CP.MP.242March 1, 2023
Pulse Oximetry w Office Visits (PDF)CC.PP.025January 1, 2013
Renal Hemodialysis (PDF)CC.PP.067March 1, 2021
Reporting the Global Maternity Package (PDF)GA.PP.016January 1, 2013
Robotic Surgeries (PDF)CC.PP.050August 1, 2017
Same Day Visits (PDF)CC.PP.040January 1, 2014
Sepsis Diagnosis (PDF)CC.PP.073October 1, 2025
Severe Malnutrition (PDF)CC.PP.145October 1, 2025
Skilled Nursing Facility Leveling (PDF)CC.PP.206June 23, 2025
Sleep Studies POS (PDF)CC.PP.035June 15, 2017
Status B Bundled Services (PDF)CC.PP.046January 1, 2014
Status P Bundled Services (PDF)CC.PP.049January 1, 2014
Supplies Same Day as Surgery (PDF)CC.PP.032January 1, 2013
Thyroid Hormones and Insulin Testing in Pediatrics (PDF)CP.MP.154October 1, 2025
Transgender Related Services (PDF)CC.PP.047January 1, 2017
Ultrasound in Pregnancy (PDF)CP.MP.38October 1, 2025
Unbundled Professional Services (PDF)CC.PP.043March 15, 2017
Unbundled Surgical Procedures (PDF)CC.PP.045March 15, 2017
Unbundling Adjustments on Clean Claim Reviews (PDF)CC.PI.10September 1, 2022
Unlisted Procedure Codes Policy (PDF)CC.PP.009January 1, 2017
Urodynamic Testing (PDF)CP.MP.98October 30, 2015
Wheelchair Seating (PDF)CP.MP.99October 31, 2015
Wheelchairs and Accessories (PDF)CC.PP.502October 1, 2015
Wireless Motility Capsule (PDF)CP.MP.143December 20, 2023

POLICY TITLEPOLICY NUMBEREFFECTIVE DATE
3 Day Payment Window (PDF)CC.PP.500July 1, 2014
30 Day Readmission (PDF)CC.PP.501January 1, 2015
340B Drug Payment Reduction (PDF)CC.PP.070July 1, 2021
Add On Policy (PDF)CC.PP.030January 1, 2013
Assistant Surgeon (PDF)CC.PP.029January 1, 2014
Bilateral Procedures (PDF)CC.PP.037January 1, 2014
Cerumen Removal Policy (PDF)CC.PP.008January 1, 2014
Clean Claims Policy (PDF)CC.PP.021January 1, 2013
Clean Claim Reviews (PDF)CC.PI.04November 1, 2012
Clinical Validation of Modifier 25 (PDF)CC.PP.013January 1, 2013
Clinical Validation of Modifier 59 (PDF)CC.PP.014January 1, 2013
Code Editing Overview (PDF)CC.PP.011January 1, 2013
Cosmetic Procedures (PDF)CC.PP.024January 1, 2014
Cost to Charge Adjustments on Clean Claim Reviews (PDF)CC.PI.06Sepember 1, 2022
Distinct Procedure Modifiers Policy (PDF)CC.PP.020January 1, 2013
Duplicate Primary Code Billing (PDF)CC.PP.044January 1, 2014
E&M Bundling with Labs and Radiology (PDF)CC.PP.010January 1, 2013
E&M Services Billed with Treatment Room Revenue Codes (PDF)CC.PP.071September 28, 2021
EM Medical Decision Making (PDF)CC.PP.051June 1, 2017
Hospital Visit Codes Billed with Labs (PDF)CC.PP.023January 1, 2016
Inpatient Consultation (PDF)CC.PP.038January 1, 2014
Inpatient Only Procedures Policy (PDF)CC.PP.018January 1, 2018
IV Hydration Policy (PDF)CC.PP.012January 1, 2013
Leveling of Care: Evaluation and Management Overcoding (PDF)CC.PP.066February 6, 2020
Leveling of Emergency Room Services (PDF)GA.PP.506December 16, 2020
Maximum Units (PDF)CC.PP.007January 1, 2013
Moderate Conscious Sedation (PDF)CC.PP.015January 1, 2013
Modifier DOS Validation (PDF)CC.PP.034January 1, 2015
Modifier to Procedure Code Validation (PDF)CC.PP.028January 1, 2013
Multiple CPT Code Replace (PDF)CC.PP.033January 1, 2013
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF)CC.PP.065February 6, 2020
Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)CC.PP.068December 16, 2020
Multiple Procedure Reduction: Ophthalmology (PDF)CC.PP.069August 18, 2020
NCCI Unbundling (PDF)CC.PP.031January 1, 2013
Never Paid Events (PDF)CC.PP.017January 1, 2013
New Patient (PDF)CC.PP.036January 1, 2014
Non-obstectrical Pelvic and Transvaginal Ultrasounds (PDF)CC.PP.061June 1, 2018
Not Medically Necessary Inpatient Service (PDF)CC.PP.060June 1, 2018
Outpatient Consultation (PDF)CC.PP.039January 1, 2014
Physician's Office Lab Testing (PDF)CC.PP.055December 16, 2020
Place of Service Mismatch (PDF)CC.PP.063September 1, 2018
Postoperative Visits (PDF)CC.PP.042January 1, 2014
Preoperative Visits (PDF)CC.PP.041January 1, 2014
Problem Oriented Visits with Preventative Services (PDF)CC.PP.057October 1, 2017
Problem Oriented Visits with Surgical Procedures (PDF)CC.PP.052November 1, 2017
Professional Component Modifier (PDF)CC.PP.027January 1, 2013
Pulse Oximetry w Office Visits (PDF)CC.PP.025January 1, 2013
Renal Hemodialysis (PDF)CC.PP.067March 1, 2021
Same Day Visits (PDF)CC.PP.040January 1, 2014
Sleep Studies POS (PDF)CC.PP.035June 15, 2017
Status B Bundled Services (PDF)CC.PP.046January 1, 2014
Status P Bundled Services (PDF)CC.PP.049January 1, 2014
Supplies Same Day as Surgery (PDF)CC.PP.032January 1, 2013
Transgender Related Services (PDF)CC.PP.047January 1, 2017
Unbundled Professional Services (PDF)CC.PP.043March 15, 2017
Unbundled Surgical Procedures (PDF)CC.PP.045March 15, 2017
Unbundling Adjustments on Clean Claim Reviews (PDF)CC.PI.10September 1, 2022
Unlisted Procedure Codes Policy (PDF)CC.PP.009January 1, 2013
Urine Specimen Validity Testing (PDF)CC.PP.056October 1, 2017
Wheelchairs and Accessories (PDF)CC.PP.502October 1, 2015