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Clinical, Payment & Pharmacy Policies

Clinical policies are one set of guidelines used to assist in administering Iowa Total Care benefits, either by prior authorization or payment rules. These 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 listed here apply to Iowa Total Care members. These policies may have either an Iowa Total Care or a Centene heading. Iowa Total Care utilizes InterQual® criteria for those medical technologies, procedures, or services for which an Iowa Total Care clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. You may access the InterQual® SmartSheet(s)™ for adult and pediatric procedures and durable medical equipment by logging into the secure provider portal or by calling Iowa Total Care. In addition, Iowa Total Care may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or InterQual® criteria is payable by Iowa Total Care.     

If you have any questions regarding these policies, please contact Provider Services.

Policy Title
(Listed Alphabetically)
Policy NumberEffective Date
25-hydroxyvitamin D Testing in Children and Adolescents (PDF)CP.MP.157
Acupuncture (PDF)CP.MP.929/12/2023
Air Ambulance (PDF)CP.MP.1758/25/2023
Allergy Testing and Therapy (PDF)CP.MP.10012/13/2023
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF)CP.MP.1081/12/2024
Ambulatory Surgery Center Optimization (PDF)CP.MP.1588/25/2023
Applied Behavior Analysis (PDF)CP.BH.1043/29/2024
Applied Behavioral Analysis Documentation Requirements (PDF)CP.BH.1053/12/2024
Articular Cartilage Defect Repairs (PDF)CP.MP.265/10/2024
Assisted Reproductive Technology (PDF)CP.MP.553/29/2024
Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF)CP.BH.1245/25/2023
Bariatric Surgery (PDF)CP.MP.376/5/2024
Behavioral Health Treatment Documentation Requirements (PDF)CP.BH.5003/10/2023
Biofeedback (PDF)CP.MP.1682/23/2024
Biofeedback for Behavioral Health Disorders (PDF)CP.BH.3003/10/2023
Bone-Anchored Hearing Aid (PDF)CP.MP.938/25/2023
Bronchial Thermoplasty (PDF)CP.MP.1105/25/2023
Burn Surgery (PDF)CP.MP.1862/23/2024
Cardiac Biomarker Testing (PDF)CP.MP.15612/13/2023
Caudal or Interlaminar Epidural Steroid Injections (PDF)CP.MP.1649/12/2023
Clinical Practice & Preventive Health Guidelines (PDF)CPG GRID9/18/2023
Clinical Trials (PDF)CP.MP.948/25/2023
Cochlear Implant Replacements (PDF)CP.MP.149/18/2023
Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)V2.20247/11/2024
Concert Genetic Testing: Cardiac Disorders (PDF)V2.20247/11/2024
Concert Genetic Testing: Dermatologic Conditions (PDF)V2.20247/11/2024
Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF)V2.20247/11/2024
Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)V2.20247/11/2024
Concert Genetic Testing: Eye Disorders (PDF)V2.20247/11/2024
Concert Genetic Testing: Gastroenterologic Disorders (Non-Cancerous) (PDF)V2.20247/11/2024
Concert Genetic Testing: General Approach to Genetic Testing (PDF)V2.20247/11/2024
Concert Genetic Testing: Hearing Loss (PDF)V2.20247/11/2024
Concert Genetic Testing: Hematologic Conditions (Non-Cancerous) (PDF)V2.20247/11/2024
Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF)V2.20247/11/2024
Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)V2.20247/11/2024
Concert Genetic Testing: Kidney Disorders (PDF)V2.20247/11/2024
Concert Genetic Testing: Lung Disorders (PDF)V2.20247/11/2024
Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)V2.20247/11/2024
Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)V2.20247/11/2024
Concert Genetic Testing: Non-Invasive Prenatal Screening (NIPS) (PDF)V2.20247/11/2024
Concert Genetic Testing: Pharmacogenetics (PDF)V2.20247/11/2024
Concert Genetic Testing: Preimplantation Genetic Testing (PDF)V2.20247/11/2024
Concert Genetic Testing: Prenatal and Preconception Carrier ScreeningV2.20247/11/2024
Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS or PUBS) and Pregnancy Loss (PDF)V2.20247/11/2024
Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)V2.20247/11/2024
Concert Genetics Oncology: Algorithmic Testing (PDF)V2.20247/11/2024
Concert Genetics Oncology: Cancer Screening (PDF)V2.20247/11/2024
Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF)V2.20247/11/2024
Concert Genetics Oncology: Cytogenetic Testing (PDF)V2.20247/11/2024
Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)V2.20247/11/2024
Cosmetic and Reconstructive Procedures (PDF)CP.MP.311/12/2024
Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (PDF)CP.BH.2016/5/2024
Diaphragmatic/Phrenic Nerve Stimulation (PDF)CP.MP.20311/4/2023
Digital EEG Spike Analysis (PDF)CP.MP.1053/29/2024
Disc Decompression Procedures (PDF)CP.MP.1147/24/2023
Discography (PDF)CP.MP.1158/25/2023
Donor Lymphocyte Infusion (PDF)CP.MP.1017/5/2024
Drugs of Abuse: Definitive Testing (PDF)CP.MP.508/25/2023
Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF)CP.MP.1071/12/2024
EEG in the Evaluation of Headache (PDF)CP.MP.15512/13/2023
Electric Tumor Treating Fields (Optune) (PDF)CP.MP.1452/23/2024
Endometrial Ablation (PDF)CP.MP.1065/25/2023
Evoked Potential Testing (PDF)CP.MP.13412/13/2023
Experimental Technologies (PDF)CP.MP.366/5/2024
Facet Joint Interventions (PDF)CP.MP.1719/12/2023
Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)CP.MP.2483/29/2024
Fecal Incontinence Treatments (PDF)CP.MP.1379/12/2023
Ferriscan R2-MRI (PDF)CP.MP.531/12/2024
Fertility Preservation (PDF)CP.MP.1303/29/2024
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)CP.MP.1293/29/2024
Functional MRI (PDF)CP.MP.435/30/2024
Gastric Electrical Stimulation (PDF)CP.MP.405/10/2024
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)CP.MP.2095/25/2023
Gender-Affirming Procedures (PDF)CP.MP.9511/4/2023
Heart-Lung Transplant (PDF)CP.MP.1325/10/2024
Helicobacter Pylori Serology Testing (PDF)CP.MP.15312/13/2023
Holter Monitors (PDF)CP.MP.11312/13/2023
Home Births (PDF)CP.MP.1363/29/2024
Home Ventilators (PDF)CP.MP.1848/25/2023
Homocysteine Testing (PDF)CP.MP.1215/25/2023
Hospice Services (PDF)CP.MP.549/12/2023
Hyperhidrosis Treatments (PDF)CP.MP.626/5/2024
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)CP.MP.1802/23/2024
Implantable Intrathecal or Epidural Pain Pump (PDF)
Implantable Loop RecorderCP.MP.2433/29/2024
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)CP.MP.1607/5/2024
Intensity-Modulated Radiotherapy (PDF)CP.MP.697/5/2024
Intestinal and Multivisceral Transplant (PDF)CP.MP.587/24/2023
Intradiscal Steroid Injections for Pain Management (PDF)CP.MP.16711/4/2023
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)CP.MP.611/12/2024
Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy (PDF)CP.MP.2505/10/2024
Laser Therapy for Skin Conditions (PDF)CP.MP.1235/25/2023
Liposuction for Lipedema (PDF)CP.MP.2447/24/2023
Long Term Care Placement (PDF)CP.MP.715/10/2024
Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)CP.MP.1395/25/2023
Lung Transplantation (PDF)CP.MP.577/5/2024
Lysis of Epidural Lesions (PDF)CP.MP.1167/24/2023
Measurement of Serum 1,25-dihydroxyvitamin D (PDF)CP.MP.15212/13/2023
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)CP.MP.1442/23/2024
Multiple Sleep Latency Testing (PDF)CP.MP.246/23/2023
Neonatal Abstinence Syndrome Guidelines (PDF)CP.MP.863/29/2024
Neonatal Sepsis Management (PDF)CP.MP.853/29/2024
Nerve Blocks and Neurolysis for Pain Management (PDF)CP.MP.1707/5/2024
Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)CP.MP.489/18/2023
NICU Apnea Bradycardia Guidelines (PDF)CP.MP.823/29/2024
NICU Discharge Guidelines (PDF)CP.MP.813/29/2024
Nonmyeloablative Allogeneic Stem Cell Transplants (PDF)CP.MP.1415/10/2024
Obstetrical Home Care Programs (PDF)CP.MP.915/10/2024
Omisirge (Omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)CP.MP.2498/25/2023
Orthognathic Surgery (PDF)CP.MP.2021/12/2024
Osteogenic Stimulation (PDF)CP.MP.19411/4/2023
Outpatient Cardiac Rehabilitation (PDF)CP.MP.1767/5/2024
Outpatient Oxygen Use (PDF)CP.MP.1903/29/2024
Pancreas Transplantation (PDF)CP.MP.1025/10/2024
Panniculectomy (PDF)CP.MP.1091/12/2024
Pediatric Heart Transplant (PDF)CP.MP.1381/12/2024
Pediatric Kidney Transplant (PDF)CP.MP.2467/5/2024
Pediatric Liver Transplant (PDF)CP.MP.1205/5/2023
Pediatric Oral Function Therapy (PDF)CP.MP.1887/24/2023
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)CP.MP.1477/24/2023
Phototherapy for Neonatal Hyperbilirubinemia (PDF)CP.MP.1501/12/2024
Physical, Occupational, and Speech Therapy Services (PDF)CP.MP.498/25/2023
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)CP.MP.1812/23/2024
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)CP.MP.13311/4/2023
Proton and Neutron Beam Therapies (PDF)CP.MP.702/23/2024
Pulmonary Function Testing (PDF)CP.MP.2425/25/2023
Reduction Mammoplasty and Gynecomastia Surgery (PDF)CP.MP.519/12/2023
Repair of Nasal Valve Compromise (PDF)CP.MP.2107/24/2023
Sacroiliac Joint Fusion (PDF)CP.MP.1268/25/2023
Sacroiliac Joint Interventions for Pain Management (PDF)CP.MP.16611/4/2023
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF)CP.MP.1467/5/2024
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)CP.MP.1742/23/2024
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)CP.MP.16511/4/2023
Short Inpatient Hospital Stay (PDF)CP.MP.1827/5/2024
Skin and Soft Tissue Substitutes for Chronic Wounds (PDF)CP.MP.1856/5/2024
Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF)CP.MP.1173/29/2024
Stereotactic Body Radiation Therapy (PDF)CP.MP.223/29/2024
Substance Use Disorders Treatment and Services (PDF)CP.BH.1003/10/2023
Tandem Transplant (PDF)CP.MP.1625/10/2024
Testing for Select Genitourinary Conditions (PDF)CP.MP.9712/13/2023
Therapeutic Utilization of Inhaled Nitric Oxide (PDF)CP.MP.876/23/2023
Thyroid Hormones and Insulin Testing in Pediatrics (PDF) CP.MP.15412/13/2023
Total Artificial Heart (PDF)CP.MP.1279/12/2023
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)CP.MP.1635/10/2024
Transcatheter Closure of Patent Foramen Ovale (PDF)CP.MP.1512/23/2024
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF)IA.CP.BH.2002/15/2024
Transplant Service Documentation Requirements (PDF)CP.MP.2472/23/2024
Trigger Point Injections for Pain Management (PDF)CP.MP.16911/4/2023
Ultrasound in Pregnancy (PDF)CP.MP.381/12/2024
Urinary Incontinence Devices and Treatments (PDF)CP.MP.1422/23/2024
Urodynamic Testing (PDF)CP.MP.985/25/2023
Vagus Nerve Stimulation (PDF)CP.MP.1211/4/2023
Ventricular Assist Devices (PDF)CP.MP.465/10/2024
Wheelchair Seating (PDF)CP.MP.993/29/2024
Wireless Motility Capsule (PDF)CP.MP.14312/13/2023

Payment policies are guidelines used to administer payment rules that are generally based on accepted principles of correct coding. These policies are used to determine whether health care services are correctly coded for reimbursement. Many payment policies are implemented through pre-payment claims editing. Each payment rule is sourced to a generally accepted coding principle including, but not limited to, claims processing guidelines published by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04 Claims Processing Manual, the CMS National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits, Medically Unlikely Edits (MUE), and policy manual, Current Procedural Terminology (CPT) guidance published by the American Medical Association (AMA), health plan clinical policies based on medical necessity, and at times state-specific claims reimbursement guidance.

All policies published on the Iowa Total Care website apply to Iowa Total Care members. Policies may have either an Iowa Total Care or a Centene heading. In addition, Iowa Total Care 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 a payment policy is payable by Iowa Total Care.     

The Payment Policies may be accessed through the links below.  

If you have any questions regarding these policies, please contact Provider Services.


3-Day Payment Window (PDF)CC.PP.5007/1/2019
30-Day Readmission (PDF)CC.PP.50112/1/2021
Add-On Code Billed Without Primary Code (PDF)CC.PP.0307/1/2019
Assistant Surgeon (PDF)CC.PP.0297/1/2019
Bilateral Procedures (PDF)CC.PP.0377/1/2019
Cerumen Removal (PDF)CC.PP.0087/1/2019
Clean Claims (PDF)CC.PP.0217/1/2019
Clean Claim Reviews (PDF)CC.PI.041/21/2023
Clean Claim Reviews: Cost to Charge Adjustments (PDF)CC.PI.061/21/2023
Clean Claim Reviews: Unbundling Adjustments (PDF)CC.PI.101/21/2023
Coding Overview (PDF)CC.PP.0117/1/2019
Cosmetic Procedures (PDF)CC.PP.0247/1/2019
Distinct Procedural Modifiers: XE, XS, XP, & XU (PDF)CC.PP.0207/1/2019
Duplicate Primary Code Billing (PDF)CC.PP.0447/1/2019
E&M Medical Decision-Making (PDF)CC.PP.0517/1/2019
E&M Services Billed with Treatment Room Revenue Codes (PDF)CC.PP.0713/30/2022
E&M Bundling Edits (PDF)CC.PP.0107/1/2019
Global Maternity Package Reporting (PDF)CC.PP.0167/1/2019
Hospital Visit Codes Billed with Labs (PDF)CC.PP.0237/1/2019
Inpatient Consultation (PDF)CC.PP.0387/1/2019
Inpatient Only Procedures (PDF)CC.PP.0187/1/2019
IV Hydration (PDF)CC.PP.0127/1/2019
Maximum Units (PDF)CC.PP.0077/1/2019
Moderate Conscious Sedation (PDF)CC.PP.0157/1/2019
Modifier -25 Clinical Validation (PDF)CC.PP.0137/1/2019
Modifier -59 Clinical Validation (PDF)CC.PP.0147/1/2019
Modifier Date of Service Validation (PDF)CC.PP.0347/1/2019
Modifier to Procedure Code Validation (PDF)CC.PP.0287/1/2019
Multiple CPT Code Replacement (PDF)CC.PP.0337/1/2019
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF)CC.PP.06510/1/2020
Multiple Procedure Payment Reduction (MPPR): Therapeutic Services (PDF)CC.PP.0685/2/2022
Multiple Procedure Payment Reduction: Ophthalmology (PDF)CC.PP.0695/2/2022
National Correct Coding Initiative (CMS) Unbundling Edits (PDF)CC.PP.0317/1/2019
Never Paid Events (PDF)CC.PP.0177/1/2019
New Patient (PDF)CC.PP.0367/1/2019
Non-Obstetrical and Obstetrical Transabdominal & Transvaginal Ultrasounds (PDF)CC.PP.0615/2/2022
Optum Comprehensive Payment Integrity (CPI) (PDF)
Outpatient Consultations (PDF)CC.PP.0397/1/2019
Physician's Consultation Services (PDF)CC.PP.0547/1/2019
Physician's Office Lab Testing (PDF)CC.PP.05512/22/2021
Place of Service Mismatch (PDF)CC.PP.0637/1/2019
Post-Operative Visits (PDF)CC.PP.0427/1/2019
Pre-Operative Visits (PDF)CC.PP.0417/1/2019
Problem Oriented Visits Billed with Preventative Visits (PDF)CC.PP.0577/1/2019
Problem Oriented Visits Billed with Surgical Procedures (PDF)CC.PP.0527/1/2019
Professional Component: Modifier -26 (PDF)CC.PP.0277/1/2019
Professional Services (Visit Codes) Billed With Labs (PDF)CC.PP.0197/1/2019
Pulse Oximetry (PDF)CC.PP.0257/1/2019
Renal Hemodialysis (PDF)CC.PP.0675/2/2022
Robotic Surgery (PDF)CC.PP.0507/1/2019
Sepsis Diagnosis (PDF)CC.PP.0733/29/2024
Severe Malnutrition (PDF)CC.PP.1453/29/2024
Sleep Studies Place of Services (PDF)CC.PP.0357/1/2019
Status "B" Bundled Services (PDF)CC.PP.0467/1/2019
Status "P" Bundled Services (PDF)CC.PP.0497/1/2019
Supplies Billed on Same Day As Surgery (PDF)CC.PP.0327/1/2019
Unbundled Professional Services (PDF)CC.PP.0437/1/2019
Unbundled Surgical Procedures (PDF)CC.PP.0457/1/2019
Unlisted Procedure Codes (PDF)CC.PP.0097/1/2019
Urine Specimen Validity Testing (PDF)CC.PP.0567/1/2019
Visits on Same Day as Surgery (PDF)CC.PP.0407/1/2019
Wheelchair Accessories (PDF)CC.PP.5027/1/2019

Policy Title
(Listed Alphabetically)
Policy NumberEffective DateAbobotulinumtoxinA (Dysport) (PDF)
AbobotulinumtoxinA (Dysport) (PDF)CP.PHAR.2306/12/2023
Amivantamab-vmjw (Rybrevant) (PDF)CP.PHAR.5446/5/2024
Aflibercept (Eylea, Eylea HD) (PDF)CP.PHAR.1846/5/2024
Aprepitant (Aponvie, Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF)CP.PMN.195/10/2024
Azacitidine (Vidaza, Onureg) (PDF)CP.PHAR.38711/4/2023
Belantamab Mafodotin-blmf (Blenrep) (PDF)CP.PHAR.4693/3/2023
Belimumab (Benlysta) (PDF)CP.PHAR.8811/21/2022
Bendamustine (Belrapzo, Bendeka, Treanda, Vivimusta) (PDF)CP.PHAR.3073/10/2023
Beremagene Geperpavec (Vyjuvek) (PDF)CP.PHAR.5923/15/2024
Bevacizumab (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev)CP.PHAR.9311/4/2023
Bortezomib (Velcade) (PDF)CP.PHAR.4109/10/2022
Brentuximab Vedotin (Adcetris) (PDF)CP.PHAR.3033/10/2023
Brexanolone (Zulresso) (PDF)CP.PHAR.41710/7/2022
Brolucizumab-dbll (Beovu) (PDF)CP.PHAR.4459/10/2022
Buprenorphine Implant/Injection (Probuphine, Sublocade) (PDF)CP.PHAR.2899/10/2022
Cabazitaxel (Jevtana) (PDF)CP.PHAR.3163/15/2024
Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) (PDF)CP.PHAR.5739/10/2022
Casimersen (Amondys 45) (PDF)CP.PHAR.4706/12/2023
Cemiplimab-rwlc (Libtayo) (PDF)CP.PHAR.3973/3/2023
Ciltacabtagene Autoleucel (Carvykti) (PDF)CP.PHAR.53312/22/2022
Corticotropin (H.P. Acthar, Purified Cortrophin Gel) (PDF)CP.PHAR.1683/15/2024
Corticosteroids for Ophthalmic Injection (Iluvien, Ozurdex, Retisert, Xipere, Yutiq) (PDF)CP.PHAR.3859/10/2022
Daptomycin (Cubicin, Cubicin RF, Dapzura RT) (PDF)CP.PHAR.3516/12/2023
Darbepoetin alfa (Aranesp) (PDF)CP.PHAR.23611/4/2023
Daprodustat (Jesduvroq) (PDF)CP.PHAR.6283/15/2024
Delandistrogene moxeparvovec-rokl (Elevidys) (PDF)CP.PHAR.5939/12/2023
Denosumab (Prolia, Xgeva) (PDF)CP.PHAR.587/19/2024
Dichlorphenamide (Keveyis) (PDF)CP.PMN.26111/17/2023
Dostarlimab-gxly (Jemperli) (PDF)CP.PHAR.54011/17/2023
Durvalumab (Imfinzi) (PDF)CP.PHAR.3393/1/2023
Edaravone (Radicava, Radicava ORS) (PDF)CP.PHAR.3439/10/2022
Efgartigimod alfa, efgartigimod-hyaluronidase (Vyvgart, Vyvgart Hytrulo) (PDF)CP.PHAR.5559/28/2023
Enfortumab Vedotin-ejfv (Padcev) (PDF)CP.PHAR.455 7/14/2023
Epcoritamab-bysp (Epkinly) (PDF)CP.PHAR.6343/15/2024
Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) (PDF)CP.PHAR.23711/4/2023
Eptinezumab-jjmr (Vyepti) (PDF)CP.PHAR.4899/10/2022
Evinacumab-dgnb (Evkeeza) (PDF)CP.PHAR.5116/12/2023
Factor IX (Human, Recombinant) (PDF)CP.PHAR.2187/12/2023
Factor VIII (Human, Recombinant) (PDF)CP.PHAR.21511/17/2023
Factor VIII-von Willebrand (Alphanate, Humate-P, Vonvendi, Wilate) (PDF)CP.PHAR.21611/17/2023
Fam-Trastuzumab Deruxtecan-nxki (Enhertu) (PDF)CP.PHAR.4569/10/2022
Faricimab-svoa (Vabysmo) (PDF)CP.PHAR.58112/22/2022
Ferric Carboxymaltose (Injectafer) (PDF)CP.PHAR.234 5/10/2024
Ferric Derisomaltose (Monoferric) (PDF)CP.PHAR.4801/12/2024
Ferric Pyrophosphate Citrate (Triferic, Triferic Avnu) (PDF)CP.PHAR.62411/4/2023
Ferumoxytol (Feraheme) (PDF)CP.PHAR.1651/12/2024
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastim-aafi (Nivestym), Filgrastim-ayow (Releuko) (PDF)CP.PHAR.297

Fondaparinux (Arixtra) (PDF)CP.PHAR.2266/12/2023
Glofitamab-gxbm (Columvi) (PDF)CP.PHAR.6365/30/2024
Human Growth Hormone (Somapacitan, Somatrogon, Somatropin) (PDF)CP.PHAR.517 9/28/2023
Immune Globulins (PDF)CP.PHAR.10311/17/2023
Inclisiran (Leqvio) (PDF)CP.PHAR.56811/9/2023
Infliximab (Remicade), Infliximab-axxq (Avsola), Infliximab-dyyb (Inflectra), and Infliximab-abda (Renflexis) (PDF)CP.PHAR.2546/1/2022
Ipilimumab (Yervoy) (PDF)CP.PHAR.3199/10/2022
Isavuconazonium (Cresemba) (PDF)CP.PMN.1543/15/2024
Lanreotide (Somatuline Depot and Unbranded) (PDF)CP.PHAR.3912/23/2024
Leuprolide Acetate (Eligard, Fensolvi, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi) (PDF)CP.PHAR.1734/8/2024
Melphalan Flufenamide (Pepaxto) (PDF)CP.PHAR.5355/10/2024
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex, Jylamvo) (PDF)CP.PHAR.1345/10/2024
Natalizumab (Tysabri) (PDF)CP.PHAR.2595/10/2024
Nirsevimab (Beyfortus) (PDF)CP.PHAR.6141/12/2024
Nivolumab (Opdivo) (PDF)CP.PHAR.1216/5/2024
No Coverage Criteria, Recent Label Changes Pending (PDF)CP.PMN.255 9/28/2023
Ocrelizumab (Ocrevus)CP.PHAR.3351/25/2024
Off-Label Use (PDF)CP.PMN.533/10/2023
Omalizumab (Xolair) (PDF)CP.PHAR.016/12/2023
Paclitaxel, Protein-Bound (Abraxane)CP.PHAR.1767/12/2023
Pegcetacoplan (Empaveli, Syfovre) (PDF)CP.PHAR.5243/15/2024
Pegfilgrastim (Neulasta, Neulasta Onpro), Pegfilgrastimjmdb (Fulphila), Pegfilgrastim-pbbk (Fylnetra), Pegfilgrastim-apgf (Nyvepria), Eflapegrastim-xnst (Rolvedon), Pegfilgrastim-fpgk (Stimufend), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo) (PDF)CP.PHAR.2964/8/2024
Pegunigalsidase alfa-iwxj (Elfabrio) (PDF)CP.PHAR.5123/15/2024
Pembrolizumab (Keytruda) (PDF)CP.PHAR.3225/10/2024
Pemetrexed (Alimta, Pemfexy) (PDF)CP.PHAR.3687/12/2023
Pertuzumab (Perjeta) (PDF)CP.PHAR.22712/22/2022
Plasminogen, human-tvmh (Ryplazim) (PDF)CP.PHAR.5139/10/2022
Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo) (PDF)CP.PHAR.1867/12/2023
Ravulizumab-cwvz (Ultomiris) (PDF)CP.PHAR.4156/5/2024
Retifanlimab-dlwr (Zynyz) (PDF)CP.PHAR.6293/15/2024
Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) (PDF)CP.PHAR.2609/10/2022
Sirolimus Protein-Bound Particles (Fyarro), Topical Gel (Hyftor) (PDF)CP.PHAR.5749/10/2022
Sutimlimab-jome (Enjaymo) (PDF)CP.PHAR.50312/22/2022
Tebentafusp-tebn (Kimmtrak) (PDF)CP.PHAR.57512/22/2022
Teprotumumab (Tepezza (PDF)CP.PHAR.4657/12/2023
Tezepelumab-ekko (Tezspire) (PDF)CP.PHAR.5769/10/2022
Tildrakizumab-asmn (Ilumya) (PDF)CP.PHAR.38611/17/2023
Tisagenlecleucel (Kymriah) (PDF)CP.PHAR.3619/10/2022
Trastuzumab Biosimilars Trastuzumab-Hyaluronidase (PDF)CP.PHAR.22811/4/2023
Tremelimumab-actl (Imjudo) (PDF)CP.PHAR.6127/12/2023
Triptorelin Pamoate (Trelstar, Triptodur) (PDF)CP.PHAR.1754/8/2024
Valoctocogene Roxaparvovec-rvox (Roctavian) (PDF)CP.PHAR.4669/12/2023
Vedolizumab (Entyvio) (PDF)CP.PHAR.2655/10/2024
Velmanase Alfa-tycv (Lamzede) (PDF)CP.PHAR.6013/15/2024
Voretigene Neparvovec-rzyl (Luxturna) (PDF)CP.PHAR.3726/12/2023

New Technology

Health technology is always changing and we want to grow with it. If we think a new medical advancement can benefit our members, we evaluate it for coverage.

These advancements include:

  • New technology
  • New medical procedures
  • New drugs
  • New devices
  • New application of existing technology

Sometimes, our medical director and/or medical management staff will identify technological advances that could benefit our members. The Clinical Policy Committee (CPC) reviews requests for coverage and decides whether we should change any of our benefits to include the new technology. If the CPC doesn’t review a request for coverage of new technology, our Medical Director will review the request and make a one-time determination. The CPC may then review the new technology request at a future meeting.