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 NH Healthy Families Clinical Policy Manual apply to NH Healthy Families members. Policies in the NH Healthy Families Clinical Policy Manual may have either a NH Healthy Families or a “Centene” heading. NH Healthy Families utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a NH Healthy Families 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 NH Healthy Families. In addition, NH Healthy Families 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 NH Healthy Families.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Clinical Policies
- Applied Behavioral Analysis (PDF)
Effective Date: 1/1/2018 - ADHD Assessment and Treatment (PDF)
Effective Date: 1/1/2019 - Allergy Testing (PDF)
Effective Date: 1/1/2018 - Ambulatory EEG (PDF)
Effective Date: 9/1/2017 - Bariatric Surgery Policy (PDF)
Effective Date: 6/1/2009 - Biofeedback (PDF)
Effective Date: 5/1/2019 - Bronchial Thermoplasty (PDF)
Effective Date: 3/1/2018 - Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: 3/1/2018 - Caudal or Interlaminar Epidural Steroid Injections (PDF)
Effective Date: 8/1/2019 - Dental Anesthesia & Facility Policy (PDF)
Effective Date: 9/1/2018 - Diagnosis of Vaginitis (PDF)
Effective Date: 9/1/2017 - Digital Analysis of EEGs (PDF)
Effective Date: 1/1/2018 - DNA Analysis of Stool (PDF)
Effective Date: 9/1/2017 - EEG in Evaluation of Headache (PDF)
Effective Date: 12/1/2017 - Endometrial Ablation (PDF)
Effective Date: 9/1/2017 - Enteral Nutrition Policy (PDF)
Effective Date: 6/1/2017 - EpiFix Wound Treatment (PDF)
Effective Date: 1/1/2018 - Evoked Potentials (PDF)
Effective Date: 11/1/2017 - Facet Joint Interventions (PDF)
Effective Date: 7/1/2019 - Fecal Calprotectin Assay (PDF) RETIRED 1/25/2019
Effective Date: 11/1/2017 - FeNo Testing (PDF)
Effective Date: 1/1/2018 - H Pylori Testing (PDF)
Effective Date: 12/1/2017 - Holter Monitors (PDF)
Effective Date: 6/1/2018 - Home Health Policy (PDF)
Effective Date: 9/15/2018 - Homocysteine Testing (PDF)
Effective Date: 8/1/2017
- Intradiscal Steroid Injections for Pain Management (PDF)
Effective Date: 8/1/2019 - Laser Skin Treatment (PDF)
Effective Date: 6/1/2009 - Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 1/1/2018 - Measure Serum 1, 25 Vitamin D (PDF)
Effective Date: 12/1/2017 - Mechanical Stretch Devices (PDF)
Effective Date: 1/1/2019 - Medical Policy Adoption Policy (PDF)
Effective Date: 3/15/2018 - Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF)
Effective Date: 5/1/2018
RETIRED: 9/1/2019 - Nerve Blocks fo Pain Management (PDF)
Effective Date: 8/1/2019 - Outpatient Testing for Drugs of Abuse (PDF)
Effective Date: 7/1/2018 - PROM Testing (PDF)
Effective Date: 8/1/2017 - PROM Testing (PDF)
Effective Date: 1/15/2020 - Proton and Neutron Beam Testing (PDF)
Effective Date: 2/1/2018
- Sacroiliac Joint Interventions for Pain Management (PDF)
Effective Date: 8/1/2019 - Selective Dorsal Rhizotomy (PDF)
Effective Date: 3/1/2019 - Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)
Effective Date: 8/1/2019 - Thyroid Testing in Pediatrics (PDF)
Effective Date: 12/1/2017 - Trigger Point Injections for Pain Management (PDF)
Effective Date: 8/1/2019 - Ultrasound in Pregnancy (PDF)
Effective Date: 8/1/2017 - Urodynamic Testing (PDF)
Effective Date: 10/1/2017 - Vitamin D Testing in Children (PDF)
Effective Date: 12/1/2017 - Wheelchair Seating (PDF)
Effective Date: 10/1/2017 - Wireless Motility Capsule (PDF)
Effective Date: 3/1/2018
Medicaid Specialty Pharmacy Policies
- Abaloparatide (Tymlos) (PDF)
Effective Date: 5/1/2017 - Abatacept (Orencia) (PDF)
Effective Date: 8/1/2016 - Abemaciclib (Verzenio) (PDF)
Effective Date: 10/24/2017 - Abiraterone (Zytiga) (PDF)
Effective Date: 10/1/2011 - AbobotulinumtoxinA (Dysport) (PDF)
Effective Date: 7/1/2016 - Acalabrutinib (Calquence) (PDF)
Effective Date: 12/5/2017 - ACEI and ARB Duplicate Therapy (PDF)
Effective Date: 8/1/2014 - Acitretin (Soriatane) (PDF)
Effective Date: 8/1/2010 - Aclidinium/Formoterol (Duaklir Pressair)(PDF)
Effective Date: 9/1/2019 - Acyclovir Buccal Tablet (Sitavig), Opthalmic Ointment (Avaclyr)(PDF)
Effective Date: 11/16/2016 - Adalimumab (Humira) (PDF)
Effective Date: 8/1/2016 - Adefovir (Hepsera) (PDF)
Effective Date: 8/28/2018 - Ado-Trastuzumab Emtansine (Kadcyla) (PDF)
Effective Date: 8/1/2016 - Afatinib (Gilotrif) (PDF)
Effective Date: 1/1/2017 - Aflibercept (Eylea) (PDF)
Effective Date: 3/1/2016 - Agalsidase Beta (Fabrazyme) (PDF)
Effective Date: 2/1/2016 - Age Limit for Tazarotene (PDF)
Effective Date: 11/1/2016 - Age Limit for Topical Tretinoin (PDF)
Effective Date: 1/29/2019 - Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF)
Effective Date: 3/13/2018 - Alectinib (Alecensa) (PDF)
Effective Date: 11/16/2016 - Alemtuzumab (Lemtrada) (PDF)
Effective Date: 6/1/2018 - Alendronate (Binosto, Fosamax plus D) (PDF)
Effective Date: 3/1/2018 - Alglucosidase Alfa (Lumizyme) (PDF)
Effective Date: 2/1/2016 - Alirocumab (Praluent) (PDF)
Effective Date: 11/16/2016 - Alosetron (Lotronex) (PDF)
Effective Date: 11/16/2016 - Alpelisib (Piqray) (PDF)
Effective Date: 7/9/2019 - Alpha-1 Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C Zemaira) (PDF)
Effective Date: 3/1/2012 - Amantadine ER (Gocovri) (PDF)
Effective Date: 10/10/2017 - Ambrisentan (Letairis) (PDF)
Effective Date: 3/1/2016 - Amifampridine (Firdapse) (PDF)
Effective Date: 1/22/2019 - Amikacin (Arikayce) (PDF)
Effective Date: 11/13/2018 - Amlodipine/Atorvastatin (Caduet) (PDF)
Effective Date: 12/1/2018 - Anakinra (Kineret) (PDF)
Effective Date: 8/1/2016 - Apalutamide (Erleada) (PDF)
Effective Date: 3/13/2018 - Aprenilast (Otezla) (PDF)
Effective Date: 8/1/2016 - Aprepitant (Emend) (PDF)
Effective Date: 8/1/2017 - Arformoterol Tartrate (Brovana) (PDF)
Effective Date: 9/1/2018 - Armodafinil (Nuvigil) (PDF)
Effective Date: 5/1/2018 - Asfotase Alfa (Strensiq) (PDF)
Effective Date: 3/1/2017 - Aspirin-dipyridamole (Aggrenox) (PDF)
Effective Date: 2/1/2018 - Atezolizumab (Tecentriq) (PDF)
Effective Date: 2/1/2018 - Atomoxetine (Strattera) (PDF)
Effective Date: 8/1/2017 - Atypical Antipsychotics (PDF)
Effective Date: 12/1/2013 - Avatrombopag (Doptelet) (PDF)
Effective Date: 7/17/2018 - Avelumab (Bavencio) (PDF)
Effective Date: 5/1/2017 - Axicabtagene Ciloleucel (Yescarta) (PDF)
Effective Date: 10/31/2017 - Axitinib (Inlyta) (PDF)
Effective Date: 5/1/2012 - Azacitidine (Vidaza) (PDF)
Effective Date: 8/28/2018 - Aztreonam (Cayston) (PDF)
Effective Date: 5/1/2016 - Baloxavir Marboxil (Xofluza) (PDF)
Effective Date: 10/30/2018 - Baricitinib (Olumiant) (PDF)
Effective Date: 3/1/2016 - Becaplermin (Regranex) (PDF)
Effective Date: 2/1/2018 - Bedaquiline (Sirturo) (PDF)
Effective Date: 9/4/2018 - Belatacept (Nulojix) (PDF)
Effective Date: 3/1/2016 - Belimumab (Benlysta) (PDF)
Effective Date: 10/1/2011 - Belinostat (Beleodaq) (PDF)
Effective Date: 2/1/2017 - Bendamustine (Bendeka, Treanda) (PDF)
Effective Date: 2/1/2017 - Benralizumab (Fasenra) (PDF)
Effective Date: 1/16/2018 - Benznidazole (PDF)
Effective Date: 10/17/2017 - Benzyl Alcohol (Ulesfia) (PDF)
Effective Date: 9/1/2019 - Betaine (Cystadane) (PDF)
Effective Date: 8/28/2018 - Betamethasone Dipropionate Spray (Sernivo) (PDF)
Effective Date: 12/1/2018 - Betrixaban (Bevyxxa) (PDF)
Effective Date: 8/8/2017 - Bevacizumab (Avastin) (PDF)
Effective Date: 12/1/2019 - Bevacizumab-awwb (Mvasi) (PDF)
Effective Date: 10/17/2017 - Bexarotene (Targretin) (PDF)
Effective Date: 9/1/2011 - Bezlotoxumab (Zinplava) (PDF)
Effective Date: 11/16/2016 - Binimetinib (Mektovi) (PDF)
Effective Date: 7/24/2018 - Blinatumomab (Blincyto) (PDF)
Effective Date: 2/1/2017 - Bortezomib (Velcade) (PDF)
Effective Date: 8/1/2016 - Bosentan (Tracleer) (PDF)
Effective Date: 3/1/2016 - Bosutinib (Bosulif) (PDF)
Effective Date: 10/1/2012 - Brand Name Override (PDF)
Effective Date: - Brentuximab Vedotin (Adcetris) (PDF)
Effective Date: 2/1/2017 - Brexanolone (Zulresso) (PDF)
Effective Date: 8/1/2016 - Brigatinib (Alunbrig) (PDF)
Effective Date: 7/17/2017 - Brimonidine Tartrate (Mirvaso), Oxymetazoline (Rhofade) (PDF)
Effective Date: 11/16/2016 - Brodalummab (Siliq) (PDF)
Effective Date: 6/1/2018 - Buprenorphine (PDF)
Effective Date: 9/30/2017 - Buprenorphine Implant, Injectible (Probuphine, Sublocade) (PDF)
Effective Date: 11/30/2016 - Buprenorphine and Naloxone (PDF)
Effective Date: 9/1/2017 - Burosumab-twza (Crysvita) (PDF)
Effective Date: 5/18/2018 - C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda) (PDF)
Effective Date: 3/1/2016 - Cabazitaxel (Jevtana) (PDF)
Effective Date: 12/1/2013 - Cabozantinib (Cometriq, Cabometyx) (PDF)
Effective Date: 11/16/2016 - Calcifediol (Rayaldee) (PDF)
Effective Date: 11/1/2016 - Calcipotriene/Betamethasone Diproprionate Foam (Enstilar) (PDF)
Effective Date: 12/1/2018 - Canakinumab (Ilaris) (PDF)
Effective Date: 8/1/2016 - Cannabidiol (Epidiolex) (PDF)
Effective Date: 7/17/2018 - Capecitabine (Xeloda) (PDF)
Effective Date: 5/1/2011 - Caplacizumab-yhdp (Cablivi) (PDF)
Effective Date: 3/12/2019 - Carbamazepine ER (Equetro) (PDF)
Effective Date: 3/13/2018 - Carfilzomib (Kyprolis) (PDF)
Effective Date: 2/1/2017 - Celecoxib (Celebrex) (PDF)
Effective Date: 1/1/2007 - Cemiplimab-rwlc (Libtayo) (PDF)
Effective Date: 10/16/2018 - Cenegermin-bkbj (Oxervate) (PDF)
Effective Date: 10/9/2018 - Ceritinib (Zykadia) (PDF)
Effective Date: 7/1/2017 - Cerliponase Alfa (Brineura) (PDF)
Effective Date: 7/1/2017 - Certolizumab (Cimzia) (PDF)
Effective Date: 8/1/2016 - Cetuximab (Erbitux) (PDF)
Effective Date: 2/1/2017 - Chloramphenicol Sodium Succinate (PDF)
Effective Date: 12/1/2018 - Cholic Acid (Cholbam) (PDF)
Effective Date: 12/1/2018 - Ciclopirox (Penlac) (PDF)
Effective Date: 9/1/2007 - Cinacalcet (Sensipar) (PDF)
Effective Date: 5/1/2011 - Cladribine (Mavenclad) (PDF)
Effective Date: 5/14/2019 - Clobazam (Onfi) (PDF)
Effective Date: 11/1/2012 - Clomipramine (Anafranil) (PDF)
Effective Date: 3/13/2018 - CNS Stimulants (PDF)
Effective Date: 3/1/2018 - Cobimetinib (Cotellic) (PDF)
Effective Date: 11/16/2016 - Colchicine (Colcrys) (PDF)
Effective Date: 5/1/2011 - Collagenase (Xiaflex) (PDF)
Effective Date: 10/1/2011 - Continuous Glucose Monitors (PDF)
Effective Date: 9/3/2019 - Copanlisib (Aliqopa) (PDF)
Effective Date: 10/17/2017 - Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF)
Effective Date: 5/29/2018 - Corticotropin (H.P. Acthar Gel) (PDF)
Effective Date: 3/1/2016 - Cosyntropin (Cortrosyn) (PDF)
Effective Date: 4/1/2016 - Crisaborole (Eucrisa) (PDF)
Effective Date: 2/21/2017 - Crizotinib (Xalkori) (PDF)
Effective Date: 11/1/2011 - Cyclosporine (Restasis) (PDF)
Effective Date: 5/1/2012 - Cysteamine Opthalmic (Cystaran) (PDF)
Effective Date: 8/1/2017 - Cysteamine Oral (Cystagon, Procysbi) (PDF)
Effective Date: 2/1/2016 - Cytomegalovirus Immune Globulin (Cytogam) (PDF)
Effective Date: 9/1/2018 - Dacomitinib (Vizimpro) (PDF)
Effective Date: 10/16/2018 - Dabigatran (Pradaxa) (PDF)
Effective Date: 5/1/2012 - Dabrafenib (Tafinlar) (PDF)
Effective Date: 11/16/2016 - Dalfampridine (Ampyra) (PDF)
Effective Date: 8/1/2016 - Dalteparin (Fragmin) (PDF)
Effective Date: 5/1/2016 - Daptomycin (Cubicin, Cubicin RF) (PDF)
Effective Date: 11/1/2017 - Daratumumab (Darzalex) (PDF)
Effective Date: 7/1/2017 - Darbepoetin Alfa (Aranesp) (PDF)
Effective Date: 6/1/2016 - Darolutamide (Nubega) (PDF)
Effective Date: 9/3/2019 - Dasatinib (Sprycel) (PDF)
Effective Date: 6/1/2012 - Daunorubicin/Cytarabine (Vyxeos) (PDF)
Effective Date: 12/1/2017 - Defarasirox (Exjade Jadenu) (PDF)
Effective Date: 11/1/2015 - Deferiprone (Ferriprox) (PDF)
Effective Date: 11/1/2015 - Deferoxamine (Desferal) (PDF)
Effective Date: 11/1/2015 - Deflazacort (Emflaza) (PDF)
Effective Date: 3/1/2017 - Degarelix Acetate (Firmagon) (PDF)
Effective Date: 10/1/2016 - Delafloxacin (Baxdela) (PDF)
Effective Date: 8/1/2017 - Denosumab (Prolia, Xgeva) (PDF)
Effective Date: 3/1/2011 - Desmopressin (DDAVP, Stimate) (PDF)
Effective Date: 3/1/2016 - Deutetrabenazine (Austedo) (PDF)
Effective Date: 6/13/2017 - Dexrazoxane (Zinecard, Totect) (PDF)
Effective Date: 3/19/2019 - Dextromethorphan-Quinidine (Nuedexta) (PDF)
Effective Date: 12/5/2017 - Diabetic Test Strip Quantity Limit - Not Receiving Insulin (PDF)
Effective Date: 9/1/2017 - Dimethyl Fumarate (Tecfidera) (PDF)
Effective Date: 8/1/2016 - Dipeptidyl Peptidase-4 Inhibitors (PDF)
Effective Date: 3/1/2018 - Dolasetron (Anzemet) (PDF)
Effective Date: 9/1/2006 - Dornase Alfa (Pulmozyme) (PDF)
Effective Date: 12/1/2013 - Dose Optimization (PDF)
Effective Date: 5/1/2016 - Doxepin (Silenor) (PDF)
Effective Date: 12/1/2018 - Doxycycline (Acticlate, Doryx, Oracea) (PDF)
Effective Date: 5/1/2017 - Dronabinol (Marinol, Syndros) (PDF)
Effective Date: 11/16/2016 - Droxidopa (Northera) (PDF)
Effective Date: 8/1/2016 - Dupilumab (Dupixent) (PDF)
Effective Date: 5/1/2017 - Duplicate SSRI SNRI Therapy (PDF)
Effective Date: 5/1/2014 - Durvalumab (Imfinzi) (PDF)
Effective Date: 7/1/2017 - Dutasteride (Avodart) and Dutasteride/Tamsulosin (Jalyn) (PDF)
Effective Date: 5/1/2016 - Duvelisib (Copiktra) (PDF)
Effective Date: 10/16/2018 - Ecallantide (Kalbitor) (PDF)
Effective Date: 3/1/2016 - Eculizumab (Soliris) (PDF)
Effective Date: 3/1/2012 - Edaravone (Radicava) (PDF)
Effective Date: 7/1/2017 - Efinaconazole (Jublia) (PDF)
Effective Date: 2/1/2017 - Elagolix (Orilissa) (PDF)
Effective Date: 8/28/2018 - Elapegademase-lvlr (Revcovi) (PDF)
Effective Date: 4/23/2019 - Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (PDF)
Effective Date: 12/1/2019 - Eliglustat (Cerdelga) (PDF)
Effective Date: 2/1/2016 - Elosulfase Alfa (Vimizim) (PDF)
Effective Date: 2/1/2016 - Elotuzumab (Empliciti) (PDF)
Effective Date: 2/1/2017 - Eltrombopag (Promacta) (PDF)
Effective Date: 3/1/2016 - Eluxadoline (Viberzi) (PDF)
Effective Date: 12/1/2018 - Emapalumab-lzsg (Gamifant) (PDF)
Effective Date: 12/11/2018 - Emicizumab-kxwh (Hemlibra) (PDF)
Effective Date: 1/16/2018 - Enasidenib (Idhifa) (PDF)
Effective Date: 9/5/2017 - Encorafenib (Braftovi) (PDF)
Effective Date: 7/24/2018 - Enfuvirtide (Fuzeon) (PDF)
Effective Date: 6/1/2010 - Enoxaparin (Lovenox) (PDF)
Effective Date: 5/1/2016 - Enzalutamide (Xtandi) (PDF)
Effective Date: 10/1/2012 - Epinephrine (Epipen, Epipen JR) (PDF)
Effective Date: 8/1/2016 - Epoetin Alfa (Epogen and Procrit) (PDF)
Effective Date: 6/1/2016 - Epoprostenol (Flolan, Veletri) (PDF)
Effective Date: 3/1/2016 - Erdafitinib (Balversa) (PDF)
Effective Date: 5/7/2019 - Erenumab-aaoe (Aimovig) (PDF)
Effective Date: 7/10/2018 - Eribulin Mesylate (Halaven) (PDF)
Effective Date: 3/1/2017 - Erlotinib (Tarceva) (PDF)
Effective Date: 9/1/2017 - Erwina Aspariganase (Erwinaze) (PDF)
Effective Date: 2/1/2017 - Erwina Aspariganase (Erwinaze) (PDF)
Effective Date: 2/1/2017 - Esketamine (Spravato) (PDF)
Effective Date: 3/12/2019 - Etanercept (Enbrel) (PDF)
Effective Date: 8/1/2016 - Etelcalcetide (Parsabiv) (PDF)
Effective Date: 3/20/2018 - Eteplirsen (Exondys) (PDF)
Effective Date: 12/1/2016 - Etidronate (Didronel) (PDF)
Effective Date: 3/1/2018 - Everolimus (Afinitor) (PDF)
Effective Date: 6/1/2011 - Evolocumab (Repatha) (PDF)
Effective Date: 10/1/2015 - Ezetimibe (Zetia) (PDF)
Effective Date: 2/1/2017 - Ezetimibe-Simvastatin (Vytorin) (PDF)
Effective Date: 2/1/2017
- Febuxostat (Uloric) (PDF)
Effective Date: 8/1/2013 - Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF)
Effective Date: 6/1/2015 - Ferric Carboxymaltose (Injectafer) (PDF)
Effective Date: 6/1/2016 - Ferric Gluconate (Ferrlecit) (PDF)
Effective Date: 3/1/2016 - Ferric Maltol (Accrufer) (PDF)
Effective Date: 9/3/2019 - Ferumoxytol (Feraheme) (PDF)
Effective Date: 3/1/2016 - Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-Filgrastim (Granix) (PDF)
Effective Date: 12/1/2016 - Fingolimod (Gilenya) (PDF)
Effective Date: 8/1/2016 - Fluorouracil Cream (Tolak) (PDF)
Effective Date: 12/1/2018 - Fluticasone Proprionate (Xhance) (PDF)
Effective Date: 10/24/2017 - Fluticasone Salmeterol (Advair Diskus, Advair HFA) (PDF)
Effective Date: 8/1/2016 - Fluticasone / Umeclidinium / Vilanterol (Trelegy Elipta) (PDF)
Effective Date: 5/22/2018 - Fondaparinux (Arixtra) (PDF)
Effective Date: 5/1/2016 - Fostamatinib (Tavalisse) (PDF)
Effective Date: 6/5/2018 - Fremanezumab-vfrm (Ajovy) (PDF)
Effective Date: 10/30/2018 - Fulvestrant (Faslodex Injection) (PDF)
Effective Date: 5/14/2019 - Galcanezumab-gnlm (Emgality) (PDF)
Effective Date: 11/13/2018 - Galsulfase (Naglazyme) (PDF)
Effective Date: 2/1/2016 - Gefitinib (Iressa) (PDF)
Effective Date: 1/1/2017 - Gemtuzumab Ozogamicin (Mylotarg) (PDF)
Effective Date: 10/3/2017 - Gilteritinib (Xospata) (PDF)
Effective Date: 1/15/2019 - Glasdegib (Daurismo) (PDF)
Effective Date: 1/8/2019 - Glatiramer (Copaxone, Glatopa) (PDF)
Effective Date: 8/1/2016 - Glecaprevir / Pibrebtasvir (Mavyret) (PDF)
Effective Date: 9/1/2017 - Glucagon-Like Peptide-1 Receptor Agonists (PDF)
Effective Date: 3/1/2018 - Glycopyrronium (Qbrexza) (PDF)
Effective Date: 8/14/2018 - Golimumab (Simponi, Simponi Aria) (PDF)
Effective Date: 7/1/2016 - Goserelin Acetate (Zoladex) (PDF)
Effective Date: 10/1/2016 - Granisetron (Sancuso) (PDF)
Effective Date: 11/1/2016 - Guanfacine ER (Intuniv) (PDF)
Effective Date: 4/1/2010 - Guselkumab (Tremfya) (PDF)
Effective Date: 8/29/2017 - Halobetasol Proprionate Lotion 0.05% (Ultravate) (PDF)
Effective Date: 12/1/2018 - Halobetasol Proprionate / Tazarotene (Duobrii) (PDF)
Effective Date: 5/21/2019 - Hemin (Panhematin) (PDF)
Effective Date: 2/1/2016 - Histrelin Acetate (Vantas, Supprelin LA) (PDF)
Effective Date: 10/1/2016 - House dust mite allergen extract (Odactra) (PDF)
Effective Date: 8/1/2017 - Hyaluronate Derivatives (PDF)
Effective Date: 10/1/2008 - Hydroxyprogesterone Caproate (Makena) (PDF)
Effective Date: 11/20/2017 - Hydroxyurea (Siklos) (PDF)
Effective Date: 2/19/2019 - Ibalizumab-uiyk (Trogarzo) (PDF)
Effective Date: 4/17/2018 - Ibandronate Oral (Boniva) (PDF)
Effective Date: 3/1/2018 - Ibandronate Sodium (Boniva) (PDF)
Effective Date: 11/15/2017 - Ibrutinib (Imbruvica) (PDF)
Effective Date: 10/1/2015 - Ibuprofen and Famotidine (Duexis) (PDF)
Effective Date: 6/1/2018 - Icatibant (Firazyr) (PDF)
Effective Date: 3/1/2016 - Icosapent ethyl (Vascepa) (PDF)
Effective Date: 11/20/2018 - Idelalisib (Zydelig) (PDF)
Effective Date: 12/1/2018 - Idursulfase (Elaprase) (PDF)
Effective Date: 2/1/2016 - Iloprost (Ventavis) (PDF)
Effective Date: 3/1/2016 - Imatinib (Gleevec) (PDF)
Effective Date: 6/1/2011 - Imiglucerase (Cerezyme) (PDF)
Effective Date: 2/1/2016 - Immune Globulins (PDF)
Effective Date: 8/1/2012 - Immunization Coverage (PDF)
Effective Date: 10/1/2008 - IncobotulinumtoxinA (Xeomin) (PDF)
Effective Date: 7/1/2016 - Indacaterol (Arcapta Neohaler) (PDF)
Effective Date: 9/1/2018 - Indacaterol / Glycopyrrolate (Utibron Neohaler) (PDF)
Effective Date: 9/1/2018 - Infliximab (Remicade, Inflectra, Renflexis) (PDF)
Effective Date: 7/1/2016 - Inhaled Combination (PDF)
Effective Date: 11/1/2015 - Inotersen (Tegsedi) (PDF)
Effective Date: 11/20/2018 - Inotuzumab Ozogamicin (Besponsa) (PDF)
Effective Date: 9/26/2017 - Insulin Infusion Pump (Omnipod, Omnipod DASH) (PDF)
Effective Date: 4/23/2019 - Interferon beta-1a (Avonex, Rebif) (PDF)
Effective Date: 8/1/2016 - Interferon beta-1b (Betaseron, Extavia) (PDF)
Effective Date: 8/1/2016 - Interferon Gamma-1b (Actimmune) (PDF)
Effective Date: 6/1/2010 - Intra Baclofen (Gablofen) (PDF)
Effective Date: 12/1/2015 - Ipilimumab (Yervoy) (PDF)
Effective Date: 3/1/2017 - Irinotecan Liposome (Onivyde) (PDF)
Effective Date: 2/1/2017 - Iron Sucrose (Venofer) (PDF)
Effective Date: 3/1/2016 - Isavuconazonium (Cresemba) (PDF)
Effective Date: 11/16/2016 - Isotretinoin (Claravis, Sotret, Amnesteem, Myorisan) (PDF)
Effective Date: 9/5/2017 - Itraconazole (Sporanox, Onmel) (PDF)
Effective Date: 11/1/2006 - Ivabradine (Corlanor) (PDF)
Effective Date: 11/1/2015 - Ivacaftor (Kalydeco) (PDF)
Effective Date: 11/16/2016 - Ivosidenib (Tibsovo) (PDF)
Effective Date: 8/21/2018 - Ixazomib (Ninlaro) (PDF)
Effective Date: 2/1/2017 - Ixekizumab (Taltz) (PDF)
Effective Date: 8/1/2016
- Lacosamide (Vimpat) (PDF)
Effective Date: 12/1/2014 - Lanadelumab-fylo (Takhzyro) (PDF)
Effective Date: 9/25/2018 - Lanreotide (Somatuline Depot) (PDF)
Effective Date: 8/14/2018 - Lapatinib (Tykerb) (PDF)
Effective Date: 10/1/2011 - Laronidase (Aldurazyme) (PDF)
Effective Date: 2/1/2016 - Larotrectinib (Vitrakvi) (PDF)
Effective Date: 1/15/2018 - Latanoprostene Bunod (Vyzulta) (PDF)
Effective Date: 12/12/2017 - Ledipasvir / Sofosbuvir (Harvoni) (PDF)
Effective Date: 9/1/2016 - Lenalidomide (Revlimid) (PDF)
Effective Date: 7/1/2011 - Lenvatinib (Lenvima) (PDF)
Effective Date: 12/1/2018 - Lesinurad (Zurampic), Lesinurad-Allopurinol (Duzallo) (PDF)
Effective Date: 11/16/2016 - Letermovir (Prevymis) (PDF)
Effective Date: 11/28/2017 - Leucovorin Injection (PDF)
Effective Date: 12/1/2018 - Leuprolide Acetate (Eligard, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped) (PDF)
Effective Date: 10/1/2016 - Levelbuterol (Xopenex) (PDF)
Effective Date: 9/1/2006 - Levoleucovorin (Fusilev) (PDF)
Effective Date: 2/1/2016 - L-Glutamine (Endari) (PDF)
Effective Date: 8/22/2017 - Lidocaine Transdermal (Lidoderm) (PDF)
Effective Date: 9/1/2006 - Lifitegrast (Xiidra) (PDF)
Effective Date: 11/1/2016 - Linaclotide (Linzess) (PDF)
Effective Date: 11/1/2015 - Lindane Lotion Shampoo (PDF)
Effective Date: 11/1/2006 - Linezolid (Zyvox) (PDF)
Effective Date: 9/1/2006 - Lisdexamfetamine (Vyvanse) (PDF)
Effective Date: 12/1/2013 - Lofexidine (Lucemyra) (PDF)
Effective Date: 7/31/2018 - Lomitapide (Juxtapid) (PDF)
Effective Date: 10/1/2016 - Long-Acting Injectible Atypical Antipsychotics (PDF)
Effective Date: 3/1/2018 - Lorlatinib (Lorbrena) (PDF)
Effective Date: 12/11/2018 - Lubiprostone (Amitiza) (PDF)
Effective Date: 12/1/2014 - Luliconazole Cream (Luzu) (PDF)
Effective Date: 8/28/2018 - Lumacaftor-Ivacaftor (Orkambi) (PDF)
Effective Date: 5/1/2016 - Lusutrombopag (Mulpleta) (PDF)
Effective Date: 9/18/2018 - Lutetium Lu 177 Dotatate (Lutathera) (PDF)
Effective Date: 5/22/2018 - Macitentan (Opsumit) (PDF)
Effective Date: 3/1/2016 - Mecamylamine (Vecamyl) (PDF)
Effective Date: 5/1/2017 - Mecasermin (Increlex) (PDF)
Effective Date: 3/1/2011 - Mechlorethamine Gel (Valchlor) (PDF)
Effective Date: 11/16/2016 - Medically Necessary Guide for Drug not on PDL (PDF)
Effective Date: 9/1/2015 - Megestrol Acetate 125 mg/mL Oral Suspension (Megace ES) (PDF)
Effective Date: 12/1/2018 - Mepolizumab (Nucala) (PDF)
Effective Date: 4/1/2016 - Metformin ER (Glumetza) (PDF)
Effective Date: 11/1/2015 - Methadone (Dolophine) (PDF)
Effective Date: 11/1/2016 - Methotrexate (Otrexup, Rasuvo, Xatmep) (PDF)
Effective Date: 12/1/2018 - Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) (PDF)
Effective Date: 6/1/2016 - Methylnaltrexone Bromide (Relistor) (PDF)
Effective Date: 12/1/2018 - Metreleptin (Myalept) (PDF)
Effective Date: 11/16/2016 - Midazolam (Nayzilam) (PDF)
Effective Date: 6/25/2019 - Midostaurin (Rydapt) (PDF)
Effective Date: 6/1/2017 - Mifepristone (Korlym) (PDF)
Effective Date: 5/1/2012 - Migalastat (Galafold) (PDF)
Effective Date: 9/11/2018 - Miglustat (Zavesca) (PDF)
Effective Date: 2/1/2016 - Milnacipran (Savella) (PDF)
Effective Date: 8/1/2012 - Minocycline ER and Microspheres (Solodyn) (PDF)
Effective Date: 5/1/2017 - Mipomersen (Kynamro) (PDF)
Effective Date: 10/1/2016 - Mitoxantrone (Novantrone) (PDF)
Effective Date: 8/1/2016 - Mixed Pollens Allergen Extract (Oralair) (PDF)
Effective Date: 8/1/2017 - Modafinil (Provigil) (PDF)
Effective Date: 5/1/2008 - Mogamulizumab-kpkc (Poteligeo) (PDF)
Effective Date: 9/4/2018 - Moxetumoman pasudotox-tdfk (Lumoxiti) (PDF)
Effective Date: 10/16/2018 - Moxidectin (PDF)
Effective Date: 7/31/2018 - Nabilone (Cesamet) (PDF)
Effective Date: 11/16/2016 - Nafarelin Acetate (Synarel) (PDF)
Effective Date: 10/1/2016 - Naldemedine (Symproic) (PDF)
Effective Date: 5/1/2017 - Naloxegol (Movantik) (PDF)
Effective Date: 12/1/2018 - Naloxone (Evzio) (PDF)
Effective Date: 11/16/2016 - Naproxen and Esomeprazole Magnesium (Vimovo) (PDF)
Effective Date: 6/1/2018 - Natalizumab (Tysabri) (PDF)
Effective Date: 7/1/2016 - Necitumumab (Portrazza) (PDF)
Effective Date: 3/1/2017 - Neomycin / Fluocinolone Cream (Neo-Synalar) (PDF)
Effective Date: 8/28/2018 - Neratinib (Nerlynx) (PDF)
Effective Date: 9/5/2017 - Netarsudil (Rhopressa) (PDF)
Effective Date: 2/13/2018 - Netupitant and Palonosetron (Akynzeo) (PDF)
Effective Date: 9/1/2006 - Nilotinib (Tasigna) (PDF)
Effective Date: 9/1/2011 - Nintedanib (Ofev) (PDF)
Effective Date: 10/1/2016 - Niraparib (Zejula) (PDF)
Effective Date: 5/9/2017 - Nitisinone (Nityr, Orfadin) (PDF)
Effective Date: 8/28/2018 - Nivolumab (Opdivo) (PDF)
Effective Date: 7/1/2015 - No Coverage Criteria/Off-Label Use Policy (PDF)
Effective Date: 9/12/2017 - Non-Calcium Phosphate Binders (Auryxia, Fosrenol, Renagel, Renvela, Velphoro) (PDF)
Effective Date: 11/15/2017 - Non-preferred Blood Glucose Monitors and Test Strips (PDF)
Effective Date: 12/1/2019 - Nusinersen (Spinraza) (PDF)
Effective Date: 11/28/2018 - Obeticholic (Ocaliva) (PDF)
Effective Date: 11/1/2016 - Obinutuzumab (Gazyva) (PDF)
Effective Date: 2/1/2017 - Ocrelizumab (Ocrevus) (PDF)
Effective Date: 4/1/2017 - Octreotide (Sandostatin, Sandostatin LAR) (PDF)
Effective Date: 3/1/2010 - Ofatumumab (Arzerra) (PDF)
Effective Date: 2/1/2017 - Olaparib (Lynparza) (PDF)
Effective Date: 10/3/2017 - Olaratumab (Lartruvo) (PDF)
Effective Date: 4/1/2013 - Olodaterol (Striverdi Respimat) (PDF)
Effective Date: 9/1/2018 - Omacetaxine (Synribo) (PDF)
Effective Date: 12/1/2013 - Omadacycline (Nuzyra) (PDF)
Effective Date: 11/20/2018 - Omalizumab (Xolair) (PDF)
Effective Date: 10/1/2008 - Omega-3-Acid Ethyl Esters (Lovaza) (PDF)
Effective Date: 8/1/2012 - Onasemnogene abeparvovec (Zolgensma) (PDF)
Effective Date: 6/7/2019 - Ondansetron (Zuplenz) (PDF)
Effective Date: 9/1/2006 - OnabotulinumtoxinA (PDF)
Effective Date: 7/1/2016 - Opioid Analgesics (PDF)
Effective Date: 6/30/2016 - Oral Antiemetics (5-HT3 Antagonists) (PDF)
Effective Date: 9/1/2006 - Osimertinib (Tagrisso) (PDF)
Effective Date: 12/1/2016 - Ospemifene (Osphena) (PDF)
Effective Date: 8/28/2018 - Overactive Bladder Agents (PDF)
Effective Date: 5/1/2016 - Oxymetazoline (Rhofade) (PDF)
Effective Date: 11/16/2016 - Ozenoxacin (Xepi) (PDF)
Effective Date: 1/30/2018 - Paclitaxel, Protein-Bound (Abraxane) (PDF)
Effective Date: 7/1/2015 - Palbociclib (Ibrance) (PDF)
Effective Date: 10/1/2015 - Palivizumab (Synagis) (PDF)
Effective Date: 8/1/2009 - Panitumumab (Vectibix) (PDF)
Effective Date: 3/1/2017 - Panobinostat (Farydak) (PDF)
Effective Date: 11/16/2016 - Parathyroid hormone (Natpara) (PDF)
Effective Date: 11/16/2016 - Paricalcitol Injection (Zemplar) (PDF)
Effective Date: 8/1/2016 - Pasireotide (Signifor LAR) (PDF)
Effective Date: 3/1/2017 - Patiromer (Veltassa) (PDF)
Effective Date: 9/1/2019 - Patisiran (Onpattro) (PDF)
Effective Date: 9/11/2018 - Pazopanib (Votrient) (PDF)
Effective Date: 10/1/2011 - Pegademase Bovine (Adagen) (PDF)
Effective Date: 8/28/2018 - Pegaptanib (Macugen) (PDF)
Effective Date: 3/1/2016 - Pegaspargase (Oncaspar) (PDF)
Effective Date: 9/5/2017 - Pegfilgrastim (Neulasta) (PDF)
Effective Date: 12/1/2016 - Peginterferon Alfa-2B (Sylatron) (PDF)
Effective Date: 10/1/2011 - Peginterferon Beta-1A (Plegridy) (PDF)
Effective Date: 8/1/2016 - Pegloticase (Krystexxa) (PDF)
Effective Date: 6/1/2013 - Pegvalise-pqpz (Palynziq) (PDF)
Effective Date: 7/31/2018 - Pegvisomant (Somavert) (PDF)
Effective Date: 12/1/2018 - Pembrolizumab (Keytruda) (PDF)
Effective Date: 3/1/2017 - Pemetrexed (Alimta) (PDF)
Effective Date: 10/31/2017 - Perampanel (Fycompa) (PDF)
Effective Date: 11/16/2016 - Perindopril / Amlodipine (Prestalia) (PDF)
Effective Date: 12/1/2018 - Pertuzumab (Perjeta) (PDF)
Effective Date: 6/1/2016 - Pexidartinib (Turalio) (PDF)
Effective Date: 9/3/2019 - Pirfenidone (Esbriet) (PDF)
Effective Date: 10/1/2016 - Plecanatide (Trulance) (PDF)
Effective Date: 2/1/2017 - Plerixafor (Mozobil) (PDF)
Effective Date: 3/1/2017 - Polatuzumab Vedotin-piiq (Polivy) (PDF)
Effective Date: 7/9/2019 - Pomalisomide (Pomalyst) (PDF)
Effective Date: 7/1/2013 - Ponatinib (Iclusig) (PDF)
Effective Date: 6/1/2013 - Pralatrexate (Folotyn) (PDF)
Effective Date: 2/1/2017 - Pramlintide (Symlin) (PDF)
Effective Date: 6/1/2018 - Prasterone (Intrarosa) (PDF)
Effective Date: 12/20/2016 - Pregabalin (Lyrica) (PDF)
Effective Date: 1/1/2007 - Propranolol HCL Solution (Hemangeol) (PDF)
Effective Date: 5/1/2014 - Protein C Concentrate, Human (Ceprotin) (PDF)
Effective Date: 3/1/2017 - Prucalopride (Motegrity) (PDF)
Effective Date: 1/29/2019 - Pyrimethamine (Daraprim) (PDF)
Effective Date: 11/5/2015
- Quantity Limit Override (PDF)
Effective Date: 5/1/2014 - Ramelteon (Rozerem) (PDF)
Effective Date: 12/1/2018 - Ramucirumab (Cyramza) (PDF)
Effective Date: 5/1/2015 - Ranibizumab (Lucentis) (PDF)
Effective Date: 3/1/2016 - Ranolazine (Ranexa) (PDF)
Effective Date: 8/1/2009 - Ravulizumab-cwvz (Ultomiris) (PDF)
Effective Date:2/19/2019 - Regorafenib (Stivarga) (PDF)
Effective Date: 12/1/2012 - Repository Corticotropin Injection (H.P. Acthar Gel) (PDF)
Effective Date: 3/1/2016 - Request for Medically Necessary Drug not on the PDL (PDF)
Effective Date: 9/1/2015 - Reslizumab (Cinqair) (PDF)
Effective Date: 5/1/2016 - Revefenacin (Yupelri) (PDF)
Effective Date: 1/8/2019 - Ribavirin (Copegus, Mederiba, Rebetol, Ribasphere) (PDF)
Effective Date: 11/16/2016 - Ribociclib (Kisqali, Kisqali Femara) (PDF)
Effective Date: 5/1/2017 - Rifamycin (Aemcolo) (PDF)
Effective Date: 1/8/2019 - Rifapentine (Priftin) (PDF)
Effective Date: 2/1/2016 - Rifaximin (Xifaxan) (PDF)
Effective Date: 11/1/2011 - Rilonacept (Arcalyst) (PDF)
Effective Date: 11/16/2016 - RimabotulinumtoxinB (Myobbloc) (PDF)
Effective Date: 7/1/2016 - Riociguat (Adempas) (PDF)
Effective Date: 3/1/2016 - Risankizumab-rzaa (Skyrizi) (PDF)
Effective Date: 6/4/2019 - Risedronate (Actonel, Atelvia) (PDF)
Effective Date: 3/1/2018 - Rituximab (Rituxan), Rituximab and Hyaluronidase (Rituxan Hycela) (PDF)
Effective Date: 7/1/2016 - Rivastigmine (Exelon) (PDF)
Effective Date: 12/1/2013 - Roflumilast (Daliresp) (PDF)
Effective Date: 11/1/2011 - Rolapitant (Varubi) (PDF)
Effective Date: 2/1/2017 - Romidepsin (Istodax) (PDF)
Effective Date: 1/1/2017 - Romiplostim (Nplate) (PDF)
Effective Date: 3/1/2016 - Romosozumab-aqqg (Evenity) (PDF)
Effective Date: 5/21/2019 - Rucaparib (Rubraca) (PDF)
Effective Date: 9/1/2017 - Rufinamide (Banzel) (PDF)
Effective Date: 12/1/2014 - Ruxolitinib (Jakafi) (PDF)
Effective Date: 3/1/2012 - Sacubitril/Valsartan (Entresto) (PDF)
Effective Date: 11/1/2015 - Safinamide (Xadago) (PDF)
Effective Date: 7/1/2017 - Sapropterin Dihydrochloride (Kuvan) (PDF)
Effective Date: 2/1/2010 - Sarecycline (Seysara) (PDF)
Effective Date:11/13/2018 - Sargramostim (Leukine) (PDF)
Effective Date: 12/1/2016 - Sarilumab (Kevzara) (PDF)
Effective Date: 7/18/2017 - Sebelipase Alfa (Kanuma) (PDF)
Effective Date: 2/1/2016 - Secnidazole (Solosec) (PDF)
Effective Date: 10/24/2017 - Secukinumab (Cosentyx) (PDF)
Effective Date: 8/1/2016 - Segesterone acetate / Ethinyl estradiol (Annovera) (PDF)
Effective Date: 10/2/2018 - Selexipag (Uptravi) (PDF)
Effective Date: 3/1/2016 - Selinexor (Xpovio) (PDF)
Effective Date: 7/16/2019 - Short Ragweed Pollen Allergen Extract (Ragwitek) (PDF)
Effective Date: 8/1/2017 - Sildenafil (Revatio) (PDF)
Effective Date: 3/1/2016 - Siltuximab (Sylvant) (PDF)
Effective Date: 3/1/2017 - Siponimod (Mayzent) (PDF)
Effective Date: 5/14/2019 - Sipuleucel-T (Provenge) (PDF)
Effective Date: 6/1/2015 - Sodium Oxybate (Xyrem) (PDF)
Effective Date: 5/1/2011 - Sodium Phenylbutyrate (Buphenyl) (PDF)
Effective Date: 5/1/2016 - Sodium-Glucose Co-Transporter 2 Inhibitors (PDF)
Effective Date: 3/1/2018 - Sodium Zirconium Cyclosilicate (Lokelma) (PDF)
Effective Date: 7/24/2018 - Sofosbuvir (Sovaldi) (PDF)
Effective Date: 9/1/2016 - Sofosbuvir / Velpatasvir (Epclusa) (PDF)
Effective Date: 7/1/2016 - Sofosbuvir / Velpatasvir / Voxilaprevir (Vosevi) (PDF)
Effective Date: 9/1/2017 - Solriamfetol (Sunosi) (PDF)
Effective Date: 5/7/2019 - Somatropin (Growth Hormone) (PDF)
- Effective Date: 3/1/2011
- Sonidegib (Odomzo) (PDF)
Effective Date: 5/1/2012 - Sorafenib (Nexavar) (PDF)
Effective Date: 7/1/2011 - Stiripentol (Diacomit) (PDF)
Effective Date: 9/25/2018 - Sunitinib (Sutent) (PDF)
Effective Date: 9/1/2011 - Suvorexant (Belsomra) (PDF)
Effective Date: 2/1/2017 - Tadalafil (Adcirca) (PDF)
Effective Date: 3/1/2016 - Tadalafil BHP-ED (Cialis) (PDF)
Effective Date: 6/1/2018 - Tafamidis (Vyndaqel, Vyndamax) (PDF)
Effective Date: 6/18/2019 - Tafenoquine (Arakoda) (PDF)
Effective Date: 8/28/2018 - Talazoparib (Talzenna) (PDF)
Effective Date: 11/27/2018 - Taliglucerase Alfa (Elelyso) (PDF)
Effective Date: 2/1/2016 - Tasimelteon (Hetlioz) (PDF)
Effective Date: 2/1/2017 - Tavaborole (Kerydin) (PDF)
Effective Date: 3/1/2018 - Tedizolid (Sivextro) (PDF)
Effective Date: 3/1/2015 - Teduglutide (Gattex) (PDF)
Effective Date: 5/1/2013 - Tegaserod (Zelnorm) (PDF)
Effective Date: 5/14/2019 - Telotristat Ethyl (Xermelo) (PDF)
Effective Date: 6/1/2017 - Temasmorelin (Egrifta) (PDF)
Effective Date: 3/1/2014 - Temozolomide (Temodar) (PDF)
Effective Date: 9/1/2011 - Temsirolimus (Torisel) (PDF)
Effective Date: 3/1/2017 - Teriflunomide (Aubagio) (PDF)
Effective Date: 8/1/2016 - Teriparatide (Forteo) (PDF)
Effective Date: 11/15/2017 - Tesamorelin (Egrifta) (PDF)
Effective Date: 3/1/2014 - Testosterone Pellet (Testopel) (PDF)
Effective Date: 8/1/2017 - Tetrabenazine (Xenazine) (PDF)
Effective Date: 12/1/2017 - Tezacaftor/Ivacafter; Ivacaftor (Symdeko) (PDF)
Effective Date: 4/3/2018 - Thalidomide (Thalomid) (PDF)
Effective Date: 9/1/2011 - Thioguanine (Tabloid) (PDF)
Effective Date: 9/4/2018 - Thyrotropin Alfa (Thyrogen) (PDF)
Effective Date: 3/1/2012 - Timothy Grass Pollen Allergen Extract (Grastek) (PDF)
Effective Date: 8/1/2017 - Tildrakizumab-asmn (Ilumya) (PDF)
Effective Date: 5/1/2018 - Tiotropium / Olodaterol (Stiolto Respimat) (PDF)
Effective Date: 9/1/2018 - Tisagenlecleucel (Kymriah) (PDF)
Effective Date: 9/26/2017 - Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (PDF)
Effective Date: 5/1/2016 - Tocilizumab (Actemra) (PDF)
Effective Date: 7/1/2016 - Tofacitinib (Xeljanz, Xeljanz XR) (PDF)
Effective Date: 1/30/2017 - Tolvaptan (Jynarque) (PDF)
Effective Date: 6/5/2018 - Topical Immunomodulators (PDF)
Effective Date: 9/1/2006 - Topotecan (Hycamtin) (PDF)
Effective Date: 6/1/2011 - Toremifene (Fareston) (PDF)
Effective Date: 4/1/2010 - Trabectedin (Yondelis) (PDF)
Effective Date: 5/1/2016 - Trametinib (Mekinist) (PDF)
Effective Date: 7/1/2016 - Trastuzumab / Biosimilars, Trastuzumab-Hyaluronidase (PDF)
Effective Date: 6/1/2016 - Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF)
Effective Date: 3/1/2016 - Triamcinolone ER Injection (Zilretta) (PDF)
Effective Date: 1/9/2018 - Triclabendazole (Egaten) (PDF)
Effective Date: 4/2/2019 - Trientine (Syprine) (PDF)
Effective Date: 12/1/2018 - Trifluridine, Tipiracil (Lonsurf) (PDF)
Effective Date: 11/16/2016 - Triptorelin Pamoate (Trelstar, Triptodur) (PDF)
Effective Date: 10/1/2016 - Umeclidinium / Vilanterol (Anoro Ellipta) (PDF)
Effective Date: 9/1/2018 - Ustekinumab (Stelara) (PDF)
Effective Date: 8/1/2016
- Valbenazine (Ingrezza) (PDF)
Effective Date: 7/1/2017 - Valrubicin (Valstar) (PDF)
Effective Date: 9/4/2018 - Vandetanib (Caprelsa) (PDF)
Effective Date: 10/1/2011 - Vedolizumab (Entyvio) (PDF)
Effective Date: 7/1/2016 - Velaglucerase Alfa (VPRIV) (PDF)
Effective Date: 2/1/2016 - Vemurafenib (Zelboraf) (PDF)
Effective Date: 11/1/2011 - Venetoclax (Venclexta) (PDF)
Effective Date: 7/17/2018 - Verteporfin (Visudyne) (PDF)
Effective Date: 3/1/2016 - Vestronidase Alfa-vjbk (Mepsevii) (PDF)
Effective Date: 1/9/2018 - Vigabatrin (Sabril) (PDF)
Effective Date: 2/1/2016 - Vilazodone (Viibryd) (PDF)
Effective Date: 12/31/2013 - Vincristine Sulfate Liposome Injection (Marqibo) (PDF)
Effective Date: 2/1/2017 - Vismodegib (Erivedge) (PDF)
Effective Date: 8/1/2017 - Voretigene Neparvovec-rzyl (Luxturna) (PDF)
Effective Date: 1/9/2018 - Vorinostat (Zolinza) (PDF)
Effective Date: 12/1/2012 - Vortioxetine (Trintellix) (PDF)
Effective Date: 2/28/2014 - Ziv-Aflibercept (Zaltrap) (PDF)
Effective Date: 3/1/2017 - Zoledronic Acid (Reclast, Zometa) (PDF)
Effective Date: 3/1/2011 - Zolpidem Tartrate (Edluar, Intermezzo, Zolpimist) (PDF)
Effective Date: 12/1/2018
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 NH Healthy Families Payment Policy Manual apply with respect to NH Healthy Families members. Policies in the NH Healthy Families Payment Policy Manual may have either a NH Healthy Families or a “Centene” heading. In addition, NH Healthy Families 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 NH Healthy Families.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Ambetter Payment Policies
- 30-Day Readmission (PDF)
Effective Date: 1/1/2015 - 3-Day Payment Window (PDF)
Effective Date: 3/1/2018 - Add on Code Billed Without Primary Code (PDF)
Effective Date: 1/1/2013 - Assistant Surgeon (PDF)
Effective Date: 1/1/2014 - Bilateral Procedures (PDF)
Effective Date: 1/1/2014 - Cerumen Removal (PDF)
Effective Date: 1/1/2014 - Clean Claims (PDF)
Effective Date: 1/1/2013 - CLIA Number (PDF)
Effective Date: 1/1/2013 - Coding Overview (PDF)
Effective Date: 1/1/2013 - Cosmetic Procedures (PDF)
Effective Date: 1/1/2014 - Distinct Procedural Modifiers (PDF)
Effective Date: 1/1/2013 - Duplicate Primary Code Billing (PDF)
Effective Date: 1/1/2014 - E&M Medical Decision-Making (PDF)
Effective Date: 1/1/2017 - EM Bundling Kits (PDF)
Effective Date: 1/1/2013 - Global Maternity Billing (PDF)
Effective Date: 1/1/2013 - Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/2013
- Inpatient Consultation (PDF)
Effective Date: 1/1/2014 - Inpatient Only Procedures (PDF)
Effective Date: 1/1/2013 - IV Hydration (PDF)
Effective Date: 1/1/2013 - Leveling of Care Policy (PDF)
Effective Date: 7/1/2019 - Maximum Units (PDF)
Effective Date: 1/1/2013 - Moderate Conscious Sedation (PDF)
Effective Date: 1/1/2013 - Modifier-25 Clinical Validation (PDF)
Effective Date: 1/1/2013 - Modifier-59 Clinical Validation (PDF)
Effective Date: 1/1/2013 - Modifier DOS Validation (PDF)
Effective Date: 1/1/2013 - Modifier to Procedure Code Validation (PDF)
Effective Date: 1/1/2013 - Multiple CPT Code Replacement (PDF)
Effective Date: 1/1/2014 - NCCI Unbundling (PDF)
Effective Date: 1/1/2013 - Never Paid Events (PDF)
Effective Date: 1/1/2013 - New Patient (PDF)
Effective Date: 1/1/2014 - Outpatient Consultation (PDF)
Effective Date: 1/1/2014 - Physician Consultation Services (PDF)
Effective Date: 9/1/2019 - Physician Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/2013 - Post-Operative Visits (PDF)
Effective Date: 1/1/2014 - Pre-Operative Visits (PDF)
Effective Date: 1/1/2014 - Problem Oriented Visits Billed with Preventative Visits (PDF)
Effective Date: 1/15/2020 - Problem Oriented Visits Billed with Surgical Procedures (PDF)
Effective Date: 1/15/2020 - Professional Compenent (PDF)
Effective Date: 1/1/2013 - Pulse Oximetry (PDF)
Effective Date: 1/1/2014
- Robotic Surgery (PDF)
Effective Date: 8/1/2017 - Same Day Visits (PDF)
Effective Date: 3/1/2018 - Sleep Studies Place of Services (PDF)
Effective Date: 5/1/2017 - Status "B" Bundled Services (PDF)
Effective Date: 1/1/2014 - Status "P" Bundled Services (PDF)
Effective Date: 3/15/2017 - Supplies Billed on Same Day as Surgery (PDF)
Effective Date: 1/1/2013 - Transgender Related Services (PDF)
Effective Date: 1/1/2017 - Unbundled Professional Services (PDF)
Effective Date: 1/1/2014 - Unbundled Surgical Procedures (PDF)
Effective Date: 1/1/2014 - Unlisted Procedure Codes (PDF)
Effective Date: 1/1/2013 - Wheelchair Accessories (PDF)
Effective Date: 10/1/2015
Medicaid Payment Policies
- 30-Day Readmission (PDF)
Effective Date: 1/1/2015 - 3-Day Payment Window (PDF)
Effective Date: 3/1/2018 - Add on Code Billed Without Primary Code (PDF)
Effective Date: 1/1/2013 - Anesthesia Payment Policy (PDF)
Effective Date: 8/1/2017 - Applied Behavioral Analysis (PDF)
Effective Date: 5/1/2019 - Assistant Surgeon (PDF)
Effective Date: 1/1/2014 - Bilateral Procedures (PDF)
Effective Date: 1/1/2014 - Cerumen Removal (PDF)
Effective Date: 1/1/2014 - Clean Claims (PDF)
Effective Date: 1/1/2013 - CLIA Number (PDF)
Effective Date: 1/1/2013 - Coding Overview (PDF)
Effective Date: 1/1/2013 - Consultation Services (PDF)
Effective Date: 10/1/2019 - Cosmetic Procedures (PDF)
Effective Date: 1/1/2014 - CPAP Supplies Policy (PDF)
Effective Date: 4/1/2018 - Distinct Procedural Modifiers (PDF)
Effective Date: 1/1/2013 - Duplicate Primary Code Billing (PDF)
Effective Date: 1/1/2014 - E&M Medical Decision-Making (PDF)
Effective Date: 1/1/2017 - EM Bundling Kits (PDF)
Effective Date: 1/1/2013 - Fixed Wing Air Transportation (PDF)
Effective Date: 10/1/19 - Global Maternity Billing (PDF)
Effective Date: 1/1/2013 - Home Health Policy (Payment) (PDF)
Effective Date: 9/15/2018 - Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/2013
- Implantable Intrathecal Pain Pump (PDF)
Effective Date: 10/1/19 - Inpatient Only Procedures (PDF)
Effective Date: 1/1/2013 - IV Hydration (PDF)
Effective Date: 1/1/2013 - Maximum Units (PDF)
Effective Date: 1/1/2013 - Moderate Conscious Sedation (PDF)
Effective Date: 1/1/2013 - Modifier-25 Clinical Validation (PDF)
Effective Date: 1/1/2013 - Modifier-59 Clinical Validation (PDF)
Effective Date: 1/1/2013 - Modifier DOS Validation (PDF)
Effective Date: 1/1/2013 - Modifier to Procedure Code Validation (PDF)
Effective Date: 1/1/2013 - Multiple CPT Code Replacement (PDF)
Effective Date: 1/1/2014 - NCCI Unbundling (PDF)
Effective Date: 1/1/2013 - Never Paid Events (PDF)
Effective Date: 1/1/2013 - New Patient (PDF)
Effective Date: 1/1/2014 - Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 9/1/2018 - Out of Network Payment Policy (PDF)
Effective Date: 1/1/2018 - Outpatient Cardiac Rehabilitation (PDF)
Effective Date: 10/1/19 - Outpatient Injectible Drugs Policy (PDF)
Effective Date: 1/1/2018 - Physician Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/2013 - Place of Service Mismatch (PDF)
Effective Date: 9/1/2018 - Post-Operative Visits (PDF)
Effective Date: 1/1/2014 - Pre-Operative Visits (PDF)
Effective Date: 1/1/2014 - Problem Oriented Visits with Preventative Visits (PDF)
Effective Date: 11/1/2017 - Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: 11/1/2017 - Professional Compenent (PDF)
Effective Date: 1/1/2013 - Pulse Oximetry (PDF)
Effective Date: 1/1/2014
- Robotic Surgery (PDF)
Effective Date: 8/1/2017 - Same Day Visits (PDF)
Effective Date: 3/1/2018 - Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)
Effective Date: 10/1/19 - Sleep Studies Place of Services (PDF)
Effective Date: 5/1/2017 - Status "B" Bundled Services (PDF)
Effective Date: 1/1/2014 - Status "P" Bundled Services (PDF)
Effective Date: 3/15/2017 - Supplies Billed on Same Day as Surgery (PDF)
Effective Date: 1/1/2013 - Telemedicine Services (PDF)
Effective Date: 9/1/2019 - Transgender Related Services (PDF)
Effective Date: 1/1/2017 - Unbundled Professional Services (PDF)
Effective Date: 1/1/2014 - Unbundled Surgical Procedures (PDF)
Effective Date: 1/1/2014 - Unlisted Procedure Codes (PDF)
Effective Date: 1/1/2013 - Waiver Services (PDF)
Effective Date: 1/1/2020 - Wheelchair Accessories (PDF)
Effective Date: 10/1/2015