Next Gen Clinical Policies - ODM Provisional Approval
Medicaid Clinical - ODM
BH Clinical - ODM Prov Apprl
Policy Title | Policy # | Reviewed Date |
---|---|---|
Applied Behavior Analysis (PDF) | CP.BH.104 | 13-Jan-23 |
Applied Behavior Analysis Addendum (PDF) | CP.BH.104_Addendum | 13-Jan-23 |
Biofeedback for Behavioral Health Disorders (PDF) | CP.BH.300 | 13-Jan-23 |
Deep Transcranial Magnetic Stimulation (PDF) | CP.BH.201 | 13-Jan-23 |
Institutions for Mental Disease (IMD) Policy (PDF) | CC.BH.UM.12 | Look Up - Not in AEM |
Institutions for Mental Disease (IMD) Policy Addendum (PDF) | CC.BH.UM.12_ Addendum | Look Up - Not in AEM |
Substance Use and Treatment Services (PDF) | CP.BH.100 | 13-Jan-23 |
Transcranial Magnetic Stimulation (PDF) | CP.BH.200 | 13-Jan-23 |
Pharmacy Clinical Policies
Policy Title | Policy # | Review Date |
---|---|---|
AbobotulinumtoxinA (Dysport) (PDF) | CP.PHAR.230 | May 2022 |
Aducanumab-avwa (Aduhelm) (PDF) | CP.PHAR.468 | May 2022 |
Aflibercept (Eylea) (PDF) | CP.PHAR.184 | Feb 2023 |
Agalsidase Beta (Fabrazyme) (PDF) | CP.PHAR.158 | May 2022 |
Alemtuzumab (Lemtrada) (PDF) | CP.PHAR.243 | May 2022 |
Alglucosidase Alfa (Lumizyme) (PDF) | CP.PHAR.160 | May 2022 |
Anifrolumab-fnia (Saphnelo) (PDF) | CP.PHAR.551 | Nov 2022 |
Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) | CP.PHAR.506 | Nov 2022 |
Axicabtagene ciloleucel (Yescarta) (PDF) | CP.PHAR.362 | Feb 2023 |
Belumumab (Benlysta) (PDF) | CP.PHAR.88 | May 2022 |
Bezlotoxumab (Zinplava) (PDF) | CP.PHAR.300 | Feb 2023 |
Bimatoprost Implant (Durysta) (PDF) | CP.PHAR.486 | May 2022 |
Brexanolone (Zulresso) (PDF) | CP.PHAR.417 | May 2022 |
Brexucabtagene autoleucel (Tecartus) (PDF) | CP.PHAR.472 | Feb 2023 |
Brolucizumab (Beovu) (PDF) | CP.PHAR.445 | Feb 2023 |
Caplacizumab-yhdp (Cablivi) (PDF) | CP.PHAR.416 | Aug 2022 |
Casimersen (Amondys 45) (PDF) | CP.PHAR.470 | Feb 2023 |
Crizanlizumab-tmca (Adakveo) (PDF) | CP.PHAR.449 | Feb 2023 |
Deferoxamine (Desferal) (PDF) | CP.PHAR.146 | Aug 2022 |
Denosumab (Prolia, Xgeva) (PDF) | CP.PHAR.58 | Feb 2023 |
Dupilumab (Dupixent) (PDF) | CP.PHAR.336 | Feb 2023 |
Eculizumab (Soliris) (PDF) | CP.PHAR.97 | Feb 2023 |
Edaravone (Radicava, Radivaca ORS) (PDF) | CP.PHAR.343 | May 2022 |
Elapegademase-lvlr (Revcovi) (PDF) | CP.PHAR.419 | May 2022 |
Eptinezumab-jjmr (Vyepti) (PDF) | CP.PHAR.489 | Nov 2022 |
Etelcalcetide (Parsabiv) (PDF) | CP.PHAR.379 | Aug 2022 |
Eteplirsen (Exondys 51) (PDF) | CP.PHAR.288 | Feb 2023 |
Evinacumab-dgnb (Evkeeza) (PDF) | CP.PHAR.511 | Feb 2023 |
Golodirsen (Vyondys 53) (PDF) | CP.PHAR.453 | Feb 2023 |
Histrelin Acetate (Vantas, Supprelin LA) (PDF) | CP.PHAR.172 | Nov 2022 |
Hyaluronate Derivatives (PDF) | CP.PHAR.05 | Nov 2022 |
Ibandronate injection (Boniva) (PDF) | CP.PHAR.189 | Feb 2023 |
Idecabtagene Vicleucel (Abecma) (PDF) | CP.PHAR.481 | May 2022 |
Immune Globulins (PDF) | CP.PHAR.103 | Aug 2022 |
IncobotulinumtoxinA (Xeomin) (PDF) | CP.PHAR.231 | May 2022 |
Infliximab, Infliximab-axxq. Inflismab-dyyb, Infiximab-abda (PDF) | CP.PHAR.254 | May 2022 |
Leuprolide Acetate, Leuprolide Mesylate (PDF) | CP.PHAR.173 | Nov 2022 |
Lisocabtagene Maraleucel (Breyanzi) (PDF) | CP.PHAR.483 | Nov 2022 |
Loncastuximab Tesirine-lpyl (Zynlonta) (PDF) | CP.PHAR.539 | Aug 2022 |
Mitoxantrone (PDF) | CP.PHAR.258 | May 2022 |
Natalizumab (Tysabri) (PDF) | CP.PHAR.259 | May 2022 |
Nusinersen (Spinraza) (PDF) | CP.PHAR.327 | Feb 2023 |
Ocrelizumab (Ocrevus) (PDF) | CP.PHAR.335 | May 2022 |
OnabotulinumtoxinA (Botox) (PDF) | CP.PHAR.232 | May 2022 |
Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF) | CP.PHAR.536 | May 2022 |
Palivizumab (Synagis) (PDF) | CP.PHAR.16 | May 2022 |
Pasireotide (Signifor, Signifor LAR) (PDF) | CP.PHAR.332 | Nov 2022 |
Patisiran (Onpattro) (PDF) | CP.PHAR.395 | Nov 2022 |
Pegaptanib (Macguen) (PDF) | CP.PHAR.185 | Feb 2022 |
Pegloticase (Krystexxa) (PDF) | CP.PHAR.115 | Feb 2023 |
Ranibizumab (Byooviz, Lucentis, Susvimo) (PDF) | CP.PHAR.186 | Feb 2023 |
Ravulizumab-cwvz (Ultomiris) (PDF) | CP.PHAR.415 | Feb 2023 |
Resilizumab (Cinqair) (PDF) | CP.PHAR.223 | Feb 2023 |
RimabotulinumtoxinB (Myobloc) (PDF) | CP.PHAR.233 | May 2022 |
Siltuximab (Sylvant) (PDF) | CP.PHAR.329 | Feb 2023 |
Teprotumumab (Tepezza) (PDF) | CP.PHAR.465 | Feb 2023 |
Tisagenlecleucel (Kymriah) (PDF) | CP.PHAR.361 | Feb 2023 |
Triptorelin Pamoate (Trelstar, Triptodur) (PDF) | CP.PHAR. 175 | Nov 2022 |
Vedolizumab (Entyvio) (PDF) | CP.PHAR.265 | May 2022 |
Verteporfin (Visudyne) (PDF) | CP.PHAR.187 | Feb 2023 |
Viltolarsen (Vilteplso) (PDF) | CP.PHAR.484 | Feb 2023 |
Voretigene neparvovec-rzyl (Luxturna) (PDF) | CP.PHAR.372 |
Feb 2023 |