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 |