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
- Air Ambulance (CP.MP.175) (PDF)
- Applied Behavior Analysis (CP.BH.104) (PDF)
- Attention Deficit Hyperactivity Disorder Assessment and Treatment (CP.BH.124) (PDF)
- Allergy Testing and Therapy (CP.MP.100) (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia (CP.MP.108) (PDF)
- Ambulatory Surgery Center Optimization (CP.MP.158) (PDF)
- Articular Cartilage Defect Repairs (CP.MP.26) (PDF)
- Assisted Reproductive Technology (CP.MP.55) (PDF)
- Bariatric Surgery (CP.MP.37) (PDF)
- Behavioral Health Treatment Documentation Requirements (CP.BH.500) (PDF)
- Biofeedback (CP.MP.168) (PDF)
- Biofeedback for Behavioral Health Disorders (CP.BH.300) (PDF)
- Bone-Anchored Hearing Aid (CP.MP.93) (PDF)
- Bronchial Thermoplasty (CP.MP.110) (PDF)
- Burn Surgery (CP.MP.186) (PDF)
- Cardiac Biomarker Testing (CP.MP.156) (PDF)
- Caudal or Interlaminar Epidural Steroid Injections (CP.MP.164) (PDF)
- Clinical Trials (CP.MP.94) (PDF)
- Cochlear Implant Replacements (CP.MP.14) (PDF)
- Cosmetic and Reconstructive Procedures (CP.MP.31) (PDF)
- Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (CP.BH.201) (PDF)
- Diaphragmatic/Phrenic Nerve Stimulation (CP.MP.203) (PDF)
- Digital Analysis of EEGs (CP.MP.105) (PDF)
- Disc Decompression Procedures (CP.MP.114) (PDF)
- Discography (CP.MP.115) (PDF)
- Donor Lymphocyte Infusion (CP.MP.101) (PDF)
- Drugs of Abuse: Definitive Testing (CP.MP.50) (PDF)
- Durable Medical Equipment (DME) (CP.MP.107) (PDF)
- EEG in Evaluation of Headache (CP.MP.155) (PDF)
- Electric Tumor Treating Fields (Optune) (CP.MP.145) (PDF)
- Endometrial Ablation (CP.MP.106) (PDF)
- Evoked Potential Testing (CP.MP.134) (PDF)
- Experimental Technologies (CP.MP.36) (PDF)
- Facet Joint Interventions (CP.MP.171) (PDF)
- Facility-based Sleep Studies for Obstructive Sleep Apnea (CP.MP.248) (PDF)
- Fecal Incontinence Treatments (CP.MP.137) (PDF)
- Ferriscan R2-MRI (CP.MP.53) (PDF)
- Fertility Preservation (CP.MP.130) (PDF)
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (CP.MP.129) (PDF)
- Functional MRI (CP.MP.43) (PDF)
- Gastric Electrical Stimulation (CP.MP.42) (PDF)
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (CP.MP.209) (PDF)
- Gender-Affirming Procedures (CP.MP.95) (PDF)
- H Pylori Testing (CP.MP.153) (PDF)
- Heart-Lung Transplant (CP.MP.132) (PDF)
- Holter Monitors (CP.MP.113) (PDF)
- Home Births (CP.MP.136) (PDF)
- Homocysteine Testing (CP.MP.121) (PDF)
- Hospice Services (CP.MP.54) (PDF)
- Hyperhidrosis Treatments (CP.MP.62) (PDF)
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (CP.MP.180) (PDF)
- Implantable Intrathecal or Epidural Pain Pump (CP.MP.173) (PDF)
- Implantable Loop Recorder (CP.MP.243) (PDF)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (CP.MP.160) (PDF)
- Intensity-Modulated Radiotherapy (CP.MP.69) (PDF)
- Intestinal and Multivisceral Transplant (CP.MP.58) (PDF)
- Intradiscal Steroid Injections for Pain Management (CP.MP.167) (PDF)
- IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (CP.MP.61) (PDF)
- Laser Therapy for Skin Conditions (CP.MP.123) (PDF)
- Long Term Care Placement Criteria (CP.MP.71) (PDF)
- Low-frequency Ultrasound and Noncontact Normothermic Wound Therapy (CP.MP.139) (PDF)
- Lung Transplantation (CP.MP.57) (PDF)
- Lysis of Epidural Lesions (CP.MP.116) (PDF)
- Measurement of Serum 1, 25 Vitamin D (CP.MP.152) (PDF)
- Mechanical Stretching Devices for Joint Stiffness and Contracture (CP.MP.144) (PDF)
- Multiple Sleep Latency Testing (CP.MP.24) (PDF)
- Neonatal Abstinence Syndrome Guidelines (CP.MP.86) (PDF)
- Neonatal Sepsis Management (CP.MP.85) (PDF)
- Nerve Blocks fo Pain Management (CP.MP.170) (PDF)
- Neuromuscular Electrical Stimulation (NMES) (CP.MP.48) (PDF)
- NICU Apnea Bradycardia Guidelines (CP.MP.82) (PDF)
- NICU Discharge Guidelines (CP.MP.81) (PDF)
- Non-Invasive Home Ventilators (CP.MP.184) (PDF)
- Nonmyeloablative Allogeneic Stem Cell Transplants (CP.MP.141) (PDF)
- Obstetrical Home Care Programs (CP.MP.91) (PDF)
- Orthognathic Surgery (CP.MP.202) (PDF)
- Outpatient Cardiac Rehabilitation (CP.MP.176) (PDF)
- Outpatient Oxygen Use (CP.MP.190) (PDF)
- Pancreas Transplant (CP.MP.102) (PDF)
- Panniculectomy (CP.MP.109) (PDF)
- Pediatric Heart Transplant (CP.MP.138) (PDF)
- Pediatric Liver Transplant (CP.MP.120) (PDF)
- Pediatric Oral Function Therapy (CP.MP.188) (PDF)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (CP.MP.147) (PDF)
- Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.1450) (PDF)
- Physical, Occupational, and Speech Therapy Services (CP.MP.49) (PDF)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (CP.MP.181) (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (CP.MP.133) (PDF)
- Proton and Neutron Beam Therapies (CP.MP.70) (PDF)
- Pulmonary Function Testing (CP.MP.242) (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF)
- Repair of Nasal Valve Compromise (CP.MP.210) (PDF)
- Sacroiliac Joint Fusion (CP.MP.126) (PDF)
- Sacroiliac Joint Interventions for Pain Management (CP.MP.166) (PDF)
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins (CP.MP.146) (PDF)
- Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (CP.MP.174) (PDF)
- Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (CP.MP.165) (PDF)
- Short Inpatient Hospital Stay (CP.MP.182) (PDF)
- Skilled Nursing Facility Leveling (CP.MP.206) (PDF)
- Skin and Soft Tissue Substitutes for Chronic Wounds (CP.MP.185) (PDF)
- Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (CP.MP.117) (PDF)
- Stereotactic Body Radiation Therapy (CP.MP.22) (PDF)
- Substance Use Disorders Treatment and Services (CP.BH.100) (PDF)
- Tandem Transplant (CP.MP.162) (PDF)
- Testing for Select Genitourinary Conditions (CP.MP.97) (PDF)
- Therapeutic Utilization of Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Thyroid Hormones and Insulin Testing in Pediatrics (CP.MP.154) (PDF)
- Total Artificial Heart (CP.MP.127) (PDF)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (CP.MP.163) (PDF)
- Transcatheter Closure of Patent Foramen Ovale (CP.MP.151) (PDF)
- Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (CP.BH.200) (PDF)
- Transplant Service Documentation Requirements (CP.MP.247) (PDF)
- Trigger Point Injections for Pain Management (CP.MP.169) (PDF)
- Ultrasound in Pregnancy (CP.MP.38) (PDF)
- Urinary Incontinence Devices and Treatments (CP.MP.142) (PDF)
- Urodynamic Testing (CP.MP.98) (PDF) (PDF)
- Vagus Nerve Stimulation (CP.MP.12) (PDF)
- Ventricular Assist Devices (CP.MP.46) (PDF)
- Vitamin D Testing in Children (CP.MP.157) (PDF)
- Wheelchair Seating (CP.MP.99) (PDF)
- Wireless Motility Capsule (CP.MP.143) (PDF)
Medicaid Specialty Pharmacy Policies
- Abaloparatide (Tymlos) (PDF)
Effective Date: 5/1/2017 - Abametapir (Xeglyze) (PDF)
Effective Date: 12/1/2020 - Abatacept (Orencia) (PDF)
Effective Date: 12/1/2021 - AbobotulinumtoxinA (Dysport) (PDF)
Effective Date: 7/1/2016 - ACEI and ARB Duplicate Therapy (PDF)
Effective Date: 8/1/2014 - Acitretin (Soriatane) (PDF)
Effective Date: 8/1/2010 - Acyclovir Buccal Tablet (Sitavig), Opthalmic Ointment (Avaclyr)(PDF)
Effective Date: 11/16/2016 - Aducanumab-avwa (Aduhelm) (PDF)
Effective Date: 6/7/2021 - Adalimumab (Humira) Humira Biosimilars (PDF)
Effective Date: 8/1/2016 - Adefovir (Hepsera) (PDF)
Effective Date: 8/28/2018 - Afamelanotide (Scenesse) (PDF)
Effective Date: 3/1/2020 - Aflibercept (Eylea) (PDF)
Effective Date: 3/1/2016 - Agalsidase Beta (Fabrazyme) (PDF)
Effective Date: 2/1/2016 - Age Limit for Topical Tretinoin (PDF)
Effective Date: 1/29/2019 - Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF)
Effective Date: 3/13/2018 - 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 - Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) (PDF)
Effective Date: 3/1/2022 - Allogenic Processed Thymus Tissue-agdc (Rethymic) (PDF)
Effective Date: 3/1/2022 - 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 - Amisulpride (Barhemsys) (PDF)
Effective Date: 9/1/2020 - Amlodipine/Atorvastatin (Caduet) (PDF)
Effective Date: 12/1/2018 - Anakinra (Kineret) (PDF)
Effective Date: 8/1/2016 - Anifrolumab-fnia (Saphnelo) (PDF)
Effective Date: 12/1/2021 - Anti-Obesity Medications (PDF)
Effective Date: 7/1/2021 - Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF)
Effective Date: 12/1/2020 - Apomorphine (Apokyn) (PDF)
Effective Date: 9/1/2020 - Apremilast (Otezla) (PDF)
Effective Date: 8/1/2016 - Aprepitant (Emend) (PDF)
Effective Date: 8/1/2017 - Armodafinil (Nuvigil) (PDF)
Effective Date: 5/1/2018 - Asenapine (Saphris, Secuado) (PDF)
Effective Date: 12/1/2014 - Asfotase Alfa (Strensiq) (PDF)
Effective Date: 3/1/2017 - Aspirin-dipyridamole (Aggrenox) (PDF)
Effective Date: 2/1/2018 - Atezolizumab (Tecentriq) (PDF)
Effective Date: 6/1/2016 - Atogepant (Qulipta) (PDF)
Effective Date: 3/1/2022 - Atypical Antipsychotics (PDF)
Effective Date: 2/1/2012 - Avapritinib (Ayvakit) (PDF)
Effective Date: 3/1/2020 - Avatrombopag (Doptelet) (PDF)
Effective Date: 7/17/2018 - Axicabtagene Ciloleucel (Yescarta) (PDF)
Effective Date: 10/31/2017 - Aztreonam (Cayston) (PDF)
Effective Date: 5/1/2016 - Baclofen (Gablofen, Lioresal, Ozobax) (PDF)
Effective Date: 12/1/2021 - Baloxavir Marboxil (Xofluza) (PDF)
Effective Date: 10/30/2018 - Baricitinib (Olumiant) (PDF)
Effective Date: 3/1/2016 - Bedaquiline (Sirturo) (PDF)
Effective Date: 9/4/2018 - Belatacept (Nulojix) (PDF)
Effective Date: 3/1/2016 - Belimumab (Benlysta) (PDF)
Effective Date: 10/1/2011 - Belumosudil (Rezurock) (PDF)
Effective Date: 12/1/2021 - Belzutifan (Welireg) (PDF)
Effective Date: 12/1/2021 - Bempedoic Acid (Nexletol), Bempedoic Acid-Ezetimibe (Nexlizet) (PDF)
Effective Date: 9/1/2020 - 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 - Bevacizumab (Avastin) (PDF)
Effective Date: 12/1/2019 - Bevacizumab-awwb (Mvasi) (PDF)
Effective Date: 10/17/2017 - Bezlotoxumab (Zinplava) (PDF)
Effective Date: 11/16/2016 - Bimatoprost Implant (Durysta) (PDF)
Effective Date: 6/1/2020 - Bosentan (Tracleer) (PDF)
Effective Date: 3/1/2016 - Brand Name Override (PDF)
Effective Date: 9/1/2006 - Brexanolone (Zulresso) (PDF)
Effective Date: 8/1/2016 - Brimonidine (Mirvaso) (PDF)
Effective Date: 11/16/2016 - Brodalummab (Siliq) (PDF)
Effective Date: 6/1/2018 - Brolucizumab-dbll (Beovu) (PDF)
Effective Date: 3/1/2020 - Buprenorphine (PDF)
Effective Date: 9/30/2017 - Buprenorphine Implant, Injectible (Probuphine, Sublocade) (PDF)
Effective Date: 12/1/2016 - Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF)
Effective Date: 9/1/2017 - Buprenorphine (Subutex) (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 - 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 - Caplacizumab-yhdp (Cablivi) (PDF)
Effective Date: 3/12/2019 - Carbamazepine ER (Equetro) (PDF)
Effective Date: 3/13/2018 - Carbidopa-Levodopa ER Capsules (Rytary) (PDF)
Effective Date: 9/1/2020 - Casimersen (Amondys 45) (PDF)
Effective Date: 2/25/2021 - Celecoxib (Celebrex, Elyxyb) (PDF)
Effective Date: 1/1/2007 - Cenegermin-bkbj (Oxervate) (PDF)
Effective Date: 10/9/2018 - Cenobamate (Xcopri) (PDF)
Effective Date: 3/1/2020 - Cerliponase Alfa (Brineura) (PDF)
Effective Date: 7/1/2017 - Certolizumab (Cimzia) (PDF)
Effective Date: 12/1/2021 - Chenodiol (Chenodal) (PDF)
Effective Date: 9/1/2020 - 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 - Ciprofloxacin/Dexamethasone (Ciprodex) (PDF)
Effective Date: 12/1/2020 - Ciprofloxacin/Fluocinolone (Otovel) (PDF)
Effective Date: 12/1/2020 - 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 - Colchicine (Colcrys) (PDF)
Effective Date: 5/1/2011 - Colesevelam (WelChol) (PDF)
Effective Date: 12/1/2020 - Collagenase (Xiaflex) (PDF)
Effective Date: 10/1/2011 - Compounded Medications (PDF)
Effective Date: 9/1/2022 - Continuous Glucose Monitors (PDF)
Effective Date: 9/3/2019 - 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 - Crizanlizumab-tmca (Adakveo) (PDF)
Effective Date: 3/1/2020 - Cyclosporine Ophthalmic Emulsion (Cequa, Restasis) (PDF)
Effective Date: 5/1/2012 - Cysteamine Opthalmic (Cystaran, Cystadrops) (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 - Dabigatran (Pradaxa) (PDF)
Effective Date: 5/1/2012 - 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 - Darbepoetin Alfa (Aranesp) (PDF)
Effective Date: 6/1/2016 - Decitabine-Cedazuridine (Inqovi)
Effective Date: 7/7/2020 - 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 - Delafloxacin (Baxdela) (PDF)
Effective Date: 8/1/2017 - Denosumab (Prolia, Xgeva) (PDF)
Effective Date: 3/1/2011 - Desmopressing Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (PDF)
Effective Date: 3/1/2016 - Deutetrabenazine (Austedo) (PDF)
Effective Date: 6/13/2017 - Dextromethorphan-Quinidine (Nuedexta) (PDF)
Effective Date: 12/5/2017 - Diabetic Test Strip Quantity Limit - Not Receiving Insulin (PDF)
Effective Date: 9/1/2017 - Dichlorphenamide (Keveyis) (PDF)
Effective Date: 3/1/2021 - Diclofenac (Pennsaid) (PDF)
Effective Date: 3/1/2022 - Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity), Monomethyl Fumarate (Bafiertam) (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 - 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 - Dutasteride (Avodart) and Dutasteride/Tamsulosin (Jalyn) (PDF)
Effective Date: 5/1/2016 - 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 - 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 - Emtricitabine-Tenofovir Alafenamide (Descovy) (PDF)
Effective Date: 6/1/2020 - Enfortumab Vedotin-ejfv (Padcev) (PDF)
Effective Date: 3/1/2020 - Enfuvirtide (Fuzeon) (PDF)
Effective Date: 6/1/2010 - Enoxaparin (Lovenox) (PDF)
Effective Date: 5/1/2016 - Epinephrine (Epipen, Epipen JR) (PDF)
Effective Date: 8/1/2016 - Epoetin Alfa (Epogen and Procrit) Epoetin Alfa-epbx (Retacrit) (PDF)
Effective Date: 12/1/2020 - Epoprostenol (Flolan, Veletri) (PDF)
Effective Date: 3/1/2016 - EPSDT Benefit for Pediatric Members (PDF)
Effective Date: 6/1/2020 - Eptinezumab (Vyepti) (PDF)
Effective Date: 9/1/2020 - Erenumab-aaoe (Aimovig) (PDF)
Effective Date: 7/10/2018 - Erwina Aspariganase (Erwinaze) (PDF)
Effective Date: 2/1/2017 - Esketamine (Spravato) (PDF)
Effective Date: 3/12/2019 - Esomeprazole-Naproxen (Vimovo) (PDF)
Effective Date: 6/1/2018 - Etanercept (Enbrel) (PDF)
Effective Date: 8/1/2016 - Etelcalcetide (Parsabiv) (PDF)
Effective Date: 3/20/2018 - Eteplirsen (Exondys) (PDF)
Effective Date: 12/1/2016 - Everolimus (Afinitor) (PDF)
Effective Date: 6/1/2011 - Evinacumab-dgnb (Evkeeza) (PDF)
Effective Date: 2/11/2021 - Evolocumab (Repatha) (PDF)
Effective Date: 10/1/2015
- Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF)
Effective Date: 3/1/2020 - Famotidine-Ibuprofen (Duexis) (PDF)
Effective Date: 6/1/2018 - 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 Derisomaltose (Monoferric) (PDF)
Effective Date: 6/1/2020 - Ferric Gluconate (Ferrlecit) (PDF)
Effective Date: 3/1/2016 - Ferric Maltol (Accrufer) (PDF)
Effective Date: 9/3/2019 - Ferric Pyrophosphate Citrate (Triferic) (PDF)
Effective Date: 6/1/2023 - Ferumoxytol (Feraheme) (PDF)
Effective Date: 3/1/2016 - Fibrinogen Concentrate (human) (Fibryga, RiaSTAP) (PDF)
Effective Date: 6/1/2021 - Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-Filgrastim (Granix) (PDF)
Effective Date: 12/1/2016 - Finerenone (Kerendia) (PDF)
Effective Date: 12/1/2021 - Fingolimod (Gilenya) (PDF)
Effective Date: 8/1/2016 - Flibanserin (Addyi) (PDF)
Effective Date: 3/1/2020 - Fluorouracil Cream (Tolak) (PDF)
Effective Date: 12/1/2018 - Fluticasone Proprionate (Xhance) (PDF)
Effective Date: 10/24/2017 - Fondaparinux (Arixtra) (PDF)
Effective Date: 5/1/2016 - Fosdenopterin (Nulibry) (PDF)
Effective Date: 3/26/2021 - Fostamatinib (Tavalisse) (PDF)
Effective Date: 6/5/2018 - Fremanezumab-vfrm (Ajovy) (PDF)
Effective Date: 10/30/2018 - Gabapentin ER (Gralise, Horizant) (PDF)
Effective Date: 9/1/2020 - Galcanezumab-gnlm (Emgality) (PDF)
Effective Date: 11/13/2018 - Galsulfase (Naglazyme) (PDF)
Effective Date: 2/1/2016 - Givosiran (Givlaari) (PDF)
Effective Date: 3/1/2020 - Glatiramer (Copaxone, Glatopa) (PDF)
Effective Date: 8/1/2016 - Glucagon-Like Peptide-1 Receptor Agonists (PDF)
Effective Date: 4/1/2021 - Glycopyrronium (Qbrexza) (PDF)
Effective Date: 8/14/2018 - Golimumab (Simponi, Simponi Aria) (PDF)
Effective Date: 12/1/2021 - Golodirsen (Vyondys 53) (PDF)
Effective Date: 3/1/2020 - Granisetron (Sancuso) (PDF)
Effective Date: 11/1/2016 - Guselkumab (Tremfya) (PDF)
Effective Date: 12/1/2021 - 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 - Hepatitis C Agents (PDF)
Effective Date: 11/1/2023 - Histrelin Acetate (Vantas, Supprelin LA) (PDF)
Effective Date: 10/1/2016 - House dust mite allergen extract (Odactra) (PDF)
Effective Date: 8/1/2017 - Human Growth Hormone (Somapacitan, Somatropin) (PDF)
Effective Date: 7/1/2020 - 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 - 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 - Idecabtagene vicleucel (Abecma) ^
Effective Date: 3/26/2021 - Idursulfase (Elaprase) (PDF)
Effective Date: 2/1/2016 - Iloprost (Ventavis) (PDF)
Effective Date: 3/1/2016 - 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 - Inebilizumab (PDF)
Effective Date: 8/28/2018 - Infliximab (Avsola, Inflectra, Remicade, Renflexis) (PDF)
Effective Date: 7/1/2016 - Inhaled Asthma and COPD Agents (PDF)
Effective Date: 3/1/2021 - Inotersen (Tegsedi) (PDF)
Effective Date: 11/20/2018 - Insulin degludec (Tresiba) (PDF)
Effective Date: 6/1/2023 - Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF)
Effective Date: 6/1/2021 - 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 - Iobenguane I-131 (Azedra) (PDF)
Effective Date: 8/28/2018 - Iron Sucrose (Venofer) (PDF)
Effective Date: 3/1/2016 - Isatuximab-irfc (Sarclisa) (PDF)
Effective Date: 6/1/2020 - Isavuconazonium (Cresemba) (PDF)
Effective Date: 11/16/2016 - Isotretinoin (Claravis, Sotret, Amnesteem, Myorisan) (PDF)
Effective Date: 9/5/2017 - Istradefylline (Nourianz) (PDF)
Effective Date: 3/1/2020 - Itraconazole (Sporanox, Tolsura) (PDF)
Effective Date: 11/1/2006 - Ivabradine (Corlanor) (PDF)
Effective Date: 11/1/2015 - Ivacaftor (Kalydeco) (PDF)
Effective Date: 11/16/2016 - Ixekizumab (Taltz) (PDF)
Effective Date: 8/1/2016 - Ketorolac Nasal Spray (PDF)
Effective Date: 12/1/2022
- Lacosamide (Vimpat) (PDF)
Effective Date: 12/1/2014 - Lactic Acid/Citric Acid/Potassium Bitartrate (Phexxi) (PDF)
Effective Date: 12/1/2020 - Lanadelumab-fylo (Takhzyro) (PDF)
Effective Date: 9/25/2018 - Lanreotide (Somatuline Depot) (PDF)
Effective Date: 8/14/2018 - Laronidase (Aldurazyme) (PDF)
Effective Date: 2/1/2016 - Lasmiditan (Reyvow) (PDF)
Effective Date: 3/1/2020 - Latanoprostene Bunod (Vyzulta) (PDF)
Effective Date: 12/12/2017 - Lefamulin (Xenleta) (PDF)
- Effective Date: 3/1/2020
- Lenacapavir (Sunlenca) (PDF)
Effective Date: 6/1/203 - 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 - Levodopa Inhalation Powder (Inbrija) (PDF)
Effective Date: 12/1/2021 - Levoketoconazole (Recorlev) (PDF)
Effective Date: 6/1/2022 - 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: 3/1/2022 - Lisocabtagene Maraleucel (Breyanzi) (PDF)
Effective Date: 2/5/2021 - Lofexidine (Lucemyra) (PDF)
Effective Date: 7/31/2018 - Lomitapide (Juxtapid) (PDF)
Effective Date: 10/1/2016 - Loteprednol Etabonate (Eysuvis) (PDF)
Effective Date: 3/1/2021 - 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 - Luspatercept-aamt (Reblozyl) (PDF)
Effective Date: 3/1/2020 - 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 - Maralixibat (LUM001) (PDF)
Effective Date: 12/1/2021 - Maribavir (Livtencity) (PDF)
Effective Date: 3/1/2022 - Mecamylamine (Vecamyl) (PDF)
Effective Date: 5/1/2017 - Mecasermin (Increlex) (PDF)
Effective Date: 3/1/2011 - 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 - Melphalan Flufenamide (Pepaxto) (PDF)
Effective Date: 6/1/2021 - Mepolizumab (Nucala) (PDF)
Effective Date: 4/1/2016 - Mercaptopurine (Purixan) (PDF)
Effective Date: 3/1/2020 - Metformin ER (Glumetza) (PDF)
Effective Date: 11/1/2015 - Methadone (Dolophine) (PDF)
Effective Date: 11/1/2016 - Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) (PDF)
Effective Date: 6/1/2016 - Methylnaltrexone Bromide (Relistor) (PDF)
Effective Date: 12/1/2018 - Metoclopramide (Gimoti) (PDF)
Effective Date: 12/1/2020 - Metreleptin (Myalept) (PDF)
Effective Date: 11/16/2016 - Midazolam (Nayzilam) (PDF)
Effective Date: 6/25/2019 - 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 (Solodyn, Ximino, Minolira) and Microspheres (Arestin) (PDF)
Effective Date: 5/1/2017 - Minocycline Micronized Foam (Amzeeq) (PDF)
Effective Date: 9/1/2020 - 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 - Mometasone Furoate (Sinuva) (PDF)
Effective Date: 3/1/2020 - Nabumatone Double-Strength (Relafen DS) (PDF)
Effective Date: 6/1/2023 - 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 - Naltrexone (Vivitrol) (PDF)
Effective Date: 3/1/2012 - Naproxen and Esomeprazole Magnesium (Vimovo) (PDF)
Effective Date: 6/1/2018 - Natalizumab (Tysabri) (PDF)
Effective Date: 8/1/2016 - Neomycin / Fluocinolone Cream (Neo-Synalar) (PDF)
Effective Date: 8/28/2018 - Netarsudil (Rhopressa), Netarsudil-Latanoprost (Rocklatan) ( (PDF)
Effective Date: 2/13/2018 - Netupitant and Palonosetron (Akynzeo) (PDF)
Effective Date: 9/1/2006 - Nifurtimox (Lampit) (PDF)
Effective Date: 12/1/2020 - Nintedanib (Ofev) (PDF)
Effective Date: 10/1/2016 - Nitisinone (Nityr, Orfadin) (PDF)
Effective Date: 8/28/2018 - No Coverage Criteria (PDF)
Effective Date: 12/1/2020 - 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 - Ocrelizumab (Ocrevus) (PDF)
Effective Date: 4/1/2017 - Octreotide (Sandostatin, Sandostatin LAR) (PDF)
Effective Date: 3/1/2010 - Off-Label Use (PDF)
Effective Date: 9/12/2017 - 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 - Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF)
Effective Date: 6/1/2021 - OnabotulinumtoxinA (Botox) (PDF)
Effective Date: 7/1/2016 - Opicapone (Ongentys) (PDF)
Effective Date: 9/1/2020 - Opioid Analgesics (PDF)
Effective Date: 6/30/2016 - Osilodrostat (Isturisa) (PDF)
Effective Date: 9/1/2020 - Ospemifene (Osphena) (PDF)
Effective Date: 8/28/2018 - Overactive Bladder Agents (PDF)
Effective Date: 5/1/2016 - Oxymetazoline (Rhofade, Upneeq) (PDF)
Effective Date: 11/16/2016 - Ozanimod (PDF)
Effective Date: 3/1/2020 - Ozenoxacin (Xepi) (PDF)
Effective Date: 1/30/2018 - Palivizumab (Synagis) (PDF)
Effective Date: 8/1/2009 - Pancrelipase (Pertyze, Viokace, Pancreaze) (PDF)
Effective Date: 9/1/2020 - 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 - Pegaptanib (Macugen) (PDF)
Effective Date: 3/1/2016 - 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 - Pentosan Polysulfate Sodium (Elmiron) (PDF)
Effective Date: 6/1/2022 - Perampanel (Fycompa) (PDF)
Effective Date: 11/16/2016 - Perindopril / Amlodipine (Prestalia) (PDF)
Effective Date: 12/1/2018 - Pexidartinib (Turalio) PDF
Effective Date: 12/1/19 - Pirfenidone (Esbriet) (PDF)
Effective Date: 10/1/2016 - Pitolisant (Wakix) (PDF)
Effective Date: 3/1/2020 - Plecanatide (Trulance) (PDF)
Effective Date: 2/1/2017 - Ponesimod (Ponvory) (PDF)
Effective Date: 6/1/2021 - 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, Lyrica CR) (PDF)
Effective Date: 1/1/2007 - Pretomanid (PDF)
Effective Date: 3/1/2020 - Progesterone (Crinone, Endometrin, Milprosa) (PDF)
Effective Date: 9/1/2020 - 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 and Dose Optimization (PDF)
Effective Date: 5/1/2014 - Quinine Sulfate (Qualaquin) (PDF)
Effective Date: 6/1/2021 - 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 - Repository Corticotropin Injection (H.P. Acthar Gel) (PDF)
Effective Date: 3/1/2016 - Request for Non-Preferred Medically Necessary Drug not on the PDL (PDF)
Effective Date: 9/1/2019 - Reslizumab (Cinqair) (PDF)
Effective Date: 5/1/2016 - Ribavirin (Copegus, Mederiba, Rebetol, Ribasphere) (PDF)
Effective Date: 11/16/2016 - Ribociclib (Kisqali, Kisqali Femara) (PDF)
Effective Date: 5/1/2017 - Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) (PDF)
Effective Date: 3/1/2020 - 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 - Rimegepant (Nurtec ODT) (PDF)
Effective Date: 9/1/2020 - Riociguat (Adempas) (PDF)
Effective Date: 3/1/2016 - Risankizumab-rzaa (Skyrizi) (PDF)
Effective Date: 6/4/2019 - Risdiplam (Evrysdi) (PDF)
Effective Date: 8/7/2020 - Risedronate (Actonel, Atelvia) (PDF)
Effective Date: 3/1/2018 - Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela) (PDF)
Effective Date: 7/1/2016 - Rivaroxaban (Xarelto) (PDF)
Effective Date: 9/1/2020 - Rivastigmine (Exelon) (PDF)
Effective Date: 12/1/2013 - Roflumilast (Daliresp) (PDF)
Effective Date: 11/1/2011 - Rolapitant (Varubi) (PDF)
Effective Date: 2/1/2017 - Romiplostim (Nplate) (PDF)
Effective Date: 3/1/2016 - Romosozumab-aqqg (Evenity) (PDF)
Effective Date: 5/21/2019 - Ropeginterferon Alfa-2b-njft (BESREMi) (PDF)
Effective Date: 3/1/2022 - Rufinamide (Banzel) (PDF)
Effective Date: 12/1/2014 - Ruxolitinib (Jakafi, Opzelura) (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 - Satralizumab (PDF)
Effective Date: 8/28/2018 - Sebelipase Alfa (Kanuma) (PDF)
Effective Date: 2/1/2016 - Secnidazole (Solosec) (PDF)
Effective Date: 10/24/2017 - Secukinumab (Cosentyx) (PDF)
Effective Date: 12/1/2020 - Selexipag (Uptravi) (PDF)
Effective Date: 3/1/2016 - Selumetinib (PDF)
Effective Date: 3/1/2020 - Setmelanotide (Imcivree) (PDF)
Effective Date: 2/25/2021 - 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 - Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium (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 - Solriamfetol (Sunosi) (PDF)
Effective Date: 5/7/2019 - Somatropin (Growth Hormone) (PDF)
Effective Date: 3/1/2011 - Split-Fill Program (PDF)
Effective Date: 6/1/2022 - Step Therapy (PDF)
Effective Date: 1/1/2023 - Stiripentol (Diacomit) (PDF)
Effective Date: 9/25/2018 - 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 - Taliglucerase Alfa (Elelyso) (PDF)
Effective Date: 2/1/2016 - Tapinarof (Vtma) (PDF)
Effective Date: 12/1/2022 - Tasimelteon (Hetlioz, Hetlioz LQ) (PDF)
Effective Date: 4/1/2022 - Tavaborole (Kerydin) (PDF)
Effective Date: 3/1/2018 - Tazarotene (Arazlo, Fabior, Tazorac) (PDF)
Effective Date: 9/1/2020 - Tedizolid (Sivextro) (PDF)
Effective Date: 3/1/2015 - Teduglutide (Gattex) (PDF)
Effective Date: 5/1/2013 - Tegaserod (Zelnorm) (PDF)
Effective Date: 5/14/2019 - Temasmorelin (Egrifta) (PDF)
Effective Date: 3/1/2014 - Tenapanor (Ibsrela) (PDF)
Effective Date: 3/1/2020 - Tenofovir Alafenamide Fumarate (Vemlidy) (PDF)
Effective Date: 12/1/2021 - Teplizumab (PDF)
Effective Date: 9/1/2020 - Teprotumumab (Tepezza) (PDF)
Effective Date: 3/1/2020 - 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 - Tezepelumab (Tezspire) (PDF)
Effective Date: 6/1/2022 - Thalidomide (Thalomid) (PDF)
Effective Date: 9/1/2011 - 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: 12/1/2021 - Tisagenlecleucel (Kymriah) (PDF)
Effective Date: 9/26/2017 - Tivozanib (Fotivda) (PDF)
Effective Date: 6/1/2021 - 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 - Topiramate ER (Qudexy XR, Trokendi XR) (PDF)
Effective Date: 9/1/2022 - Tralokinumab-ldrm (Adbry) (PDF)
Effective Date: 6/1/2022 - 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 - Trifarotene (Aklief) (PDF)
Effective Date: 3/1/2020 - Triheptanoin (Dojolvi) (PDF)
Effective Date: 12/1/2020
- Ublituximab-xiiy (Briumvi) (PDF)
Effective Date: 6/1/2023 - Ubrogepant (Ubrelvy) (PDF)
Effective Date: 6/1/2020 - Ulcer Therapy Combinations (Omeclamox Pak, Pylera, Talicia) (PDF)
Effective Date: 6/1/2022 - Umbralisib (Ukoniq)
Effective Date: 5/1/2021 - Upadacitinib (Rinvoq) (PDF)
Effective Date: 12/1/2021 - Ustekinumab (Stelara) (PDF)
Effective Date: 12/1/2020
- Valbenazine (Ingrezza) (PDF)
Effective Date: 7/1/2017 - Varenicline (Tyrvaya) (PDF)
Effective Date: 3/1/2022 - Vedolizumab (Entyvio) (PDF)
Effective Date: 7/1/2016 - Velaglucerase Alfa (VPRIV) (PDF)
Effective Date: 2/1/2016 - 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 - Viloxazine (Qelbree) (PDF)
- Effective Date: 6/1/2021
- Voclosporin (Lupkynis) (PDF)
Effective Date: 1/22/2021 - Voretigene Neparvovec-rzyl (Luxturna) (PDF)
Effective Date: 1/9/2018 - Vortioxetine (Trintellix) (PDF)
Effective Date: 5/1/2015 - Voxelotor (Oxbryta) (PDF)
Effective Date: 3/1/2020 - Zanubrutinib (Brukinsa) (PDF)
Effective Date: 3/1/2020 - Zoledronic Acid (Reclast, Zometa) (PDF)
Effective Date: 3/1/2011 - Zolpidem Tartrate (Edluar, Intermezzo, Zolpimist) (PDF)
Effective Date: 12/1/2018
NH Healthy Families is pleased to announce its collaboration with New Century Health (NCH), an oncology quality management company, to implement a new oncology pre-approval program, NH Healthy Families Oncology Pathway Solutions. The program will simplify the administrative process for providers to support the effective delivery of quality patient care.
Beginning May 1, 2020, all oncology-related chemotherapeutic drugs and supportive agents will require clinical review by NCH before being administered in a physician’s office, outpatient hospital or ambulatory setting. This prior authorization requirement applies to both pharmacy dispensed and office administered medication requests for all NH Healthy Families Medicaid members ages 18 and over.
NH Healthy Families Oncology Pathway Solutions program benefits include:
- The use of clinical criteria, based on nationally-recognized guidelines, to promote evidence-based cancer care.
- Increased collaboration with physician offices to foster a team approach.
- Peer-to-peer discussions with medical oncologists who can understand and better discuss treatment plans.
- A provider web portal to:
- Obtain real-time approvals when selecting evidence-based NCH treatment care pathways.
- Determine which clinical documentation is necessary for medical necessity review.
- View all submitted requests for authorization in one location.
- Check member eligibility.
- The requesting physician must complete an authorization request using one of the following methods:
- Logging into the NCH Provider Web Portal
- Calling 1-888-999-7713, Option 1, Monday–Friday (8 a.m. - 8 p.m. ET)
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 - Clean Claim Reviews (PDF)
Effective Date: 11/1/2022 - CLIA Number (PDF)
Effective Date: 1/1/2013 - Coding Overview (PDF)
Effective Date: 1/1/2013 - Cosmetic Procedures (PDF)
Effective Date: 1/1/2014 - Cost to Charge Adjustments on Clean Claim Reviews (PDF)
Effective Date: 9/1/2022 - 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 - Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF)
Effective Date: 10/1/2020
- Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)
Effective Date: 6/1/2022 - 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 - Office Visits Billed with Treatment Rooms (PDF)
Effective Date: 5/1/2022 - Optum Comprehensive Payment Integrity (CPI) (PDF)
Effective Date: 4/1/2023 - Outpatient Consultation (PDF)
Effective Date: 1/1/2014 - Outpatient Testing for Drugs of Abuse (PDF)
Effective Date: 5/1/2019 - 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 - Sepsis Diagnosis (PDF)
Effective Date: 3/1/2022 - 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: 9/18/2020 - 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 - Unbundling Adjustments on Clean Claim Reviews (PDF)
Effective Date: 9/1/2022 - 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: 12/1/2021 - 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 - Early and Periodic Screening, Diagnostics, and Treatment (EPSDT) (PDF)
Effective Date: 8/1/2015 - 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 - Home Health Policy (Payment) (PDF)
Effective Date: 9/15/2018 - Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/2013
- 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 - Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF)
Effective Date: 10/1/2020 - Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)
Effective Date: 6/1/2022 - 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 - Observation/Outpatient Stays (PDF)
Effective Date: 4/1/2018
- Office Visits Billed with Treatment Rooms (PDF)
Effective Date: 5/1/2022
- Optum Comprehensive Payment Integrity (CPI) (PDF)
Effective Date: 4/1/2023 - Out of Network Payment Policy (PDF)
Effective Date: 1/1/2018 - 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 - Sepsis Diagnosis (PDF)
Effective Date: 3/1/2022 - 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 - Substance Use Assessments (PDF)
Effective Date: 12/01/2020 - Supplies Billed on Same Day as Surgery (PDF)
Effective Date: 1/1/2013 - Telemedicine Services (PDF)
Effective Date: 9/18/2020 - 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