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 Delaware First Health Clinical Policy Manual apply to Delaware First Health members. Policies in the Delaware First Health Clinical Policy Manual may have either a Delaware First Health or a “Centene” heading. Delaware First Health utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Delaware First Health 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 Delaware First Health. In addition, Delaware First Health 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 Delaware First Health.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Medicaid Clinical Policies
- Air Ambulance (CP.MP.175) (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia (CP.MP.108) (PDF)
- Applied Behavioral Analysis (CP.BH.104) (PDF)
- Articular Cartilage Defect Repairs (CP.MP.26) (PDF)
- Bariatric Surgery (CP.MP.37) (PDF)
- BH Treatment Documentation Requirements (CP.BH.500) (PDF)
- Biofeedback (CP.MP.168) (PDF)
- Bone-Anchored Hearing Aid (CP.MP.93) (PDF)
- Burn Surgery (CP.MP.186) (PDF)
- Caudal or Interlaminar Epidural Steroid Injections (CP.MP.164) (PDF)
- Clinical Practice Guideline Grid (CPG Grid) (PDF)
- Clinical Trials (CP.MP.94) (PDF)
- Cochlear Implant Replacements (CP.MP.14) (PDF)
- Cosmetic and Reconstructive Surgery (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)
- Disc Decompression Procedures (CP.MP.114) (PDF)
- Discography (CP.MP.115) (PDF)
- Donor Lymphocyte Infusion (CP.MP.101) (PDF)
- Electric Tumor Treating Fields (Optune) (CP.MP.145) (PDF)
- Experimental Technologies (CP.MP.36) (PDF)
- Facet Joint Interventions (CP.MP.171) (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.40) (PDF)
- Genetic Testing Aortopathies and Connective Tissue Disorders (CP.MP.215) (PDF)
- Genetic Testing Cardiac Disorders (CP.MP.216) (PDF)
- Genetic Testing Dermatologic Conditions (CP.MP.217) (PDF)
- Genetic Testing Epilepsy Neurodegenerative and Neuromuscular Disorders (CP.MP.218) (PDF)
- Genetic Testing Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (CP.MP.219) (PDF)
- Genetic Testing Eye Disorders (CP.MP.220) (PDF)
- Genetic Testing for Non-Invasive Prenatal Screening (NIPS) (CP.MP.231) (PDF)
- Genetic Testing Gastroenterologic Disorders (non-cancerous) (CP.MP.221) (PDF)
- Genetic Testing General Approach to Genetic Testing (CP.MP.222) (PDF)
- Genetic Testing Hearing Loss (CP.MP.223) (PDF)
- Genetic Testing Hematologic Condition (non-cancerous) (CP.MP.224) (PDF)
- Genetic Testing Immune, Autoimmune, and Rheumatoid Disorders (CP.MP.226) (PDF)
- Genetic Testing Kidney Disorders (CP.MP.227) (PDF)
- Genetic Testing Lung Disorders (CP.MP.228) (PDF)
- Genetic Testing Metabolic, Endocrine, and Mitochondrial Disorders (CP.MP.229) (PDF)
- Genetic Testing Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (CP.MP.230) (PDF)
- Genetic Testing Pharmacogenetics (CP.MP.232) (PDF)
- Genetic Testing Preimplantation Genetic Testing (CP.MP.233) (PDF)
- Genetic Testing Prenatal and Preconception Carrier Screening (CP.MP.234) (PDF)
- Genetic Testing Prenatal Diagnosis (Via Amniocentises, CVS, or PUBS) and Pregnancy Loss (CP.MP.235) (PDF)
- Genetic Testing Skeletal Dysplasia and Rare Bone Disorders (CP.MP.236) (PDF)
- Heart-Lung Transplant (CP.MP.132) (PDF)
- Home Births (CP.MP.136) (PDF)
- Home Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150) (PDF)
- Home Ventilators (CP.MP.184) (PDF)
- Hyperemesis Gravidarum Treatment (CP.MP.34) (PDF)
- Hyperhidrosis Treatments (CP.MP.62) (PDF)
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (CP.MP.180) (PDF)
- Implantable Intrathecal Pain Pump (CP.MP.173) (PDF)
- Implantable Loop Recorder (CP.MP.243) (PDF)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (CP.MP.160) (PDF)
- Inhaled Nitric Oxide (CP.MP.87) (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)
- Liposuction for Lipedema (CP.MP.244) (PDF)
- Long Term Care Placement (CP.MP.71) (PDF)
- Lung Transplantation (CP.MP.57) (PDF)
- Lysis of Epidural Lesions (CP.MP.116) (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 and Neurolysis for Pain Management (CP.MP.170) (PDF)
- Neurofeedback for Behavioral Health Disorders (CP.BH.300) (PDF)
- Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (CP.MP.48) (PDF)
- NICU Apnea Bradycardia Guidelines (CP.MP.82) (PDF)
- NICU Discharge Guidelines (CP.MP.81) (PDF)
- Non-Myeloablative Allogeneic Stem Cell Transplants (CP.MP.141) (PDF)
- Obstetrical Home Health Care Programs (CP.MP.91) (PDF)
- Optic Nerve Decompression Surgery (CP.MP.128) (PDF)
- Orthognathic Surgery (CP.MP.202) (PDF)
- Outpatient Cardiac Rehabilitation (CP.MP.176) (PDF)
- Pancreas Transplant (CP.MP.102) (PDF)
- Panniculectomy (CP.MP.109) (PDF)
- Pediatric Heart Transplant (CP.MP.138) (PDF)
- Pediatric Kidney Transplant (CP.MP.246) (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)
- Physical, Occupational, and Speech Therapy Services (CP.MP.49) (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (CP.MP.133) (PDF)
- Proton and Neutron Beam Therapies (CP.MP.70) (PDF)
- Radial Head Implant (CP.MP.148) (PDF)
- Radiofrequency Ablation of Uterine Fibroids (CP.MP.187) (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 Injections (CP.MP.165) (PDF)
- Short Inpatient Hospital Stay (CP.MP.182) (PDF)
- Skin 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)
- Tandem Transplant (CP.MP.162) (PDF)
- Total Artificial Heart (CP.MP.127) (PDF)
- Transcatheter Closure of Patent Foramen Ovale (CP.MP.151) (PDF)
- Trigger Point Injections for Pain Management (CP.MP.169) (PDF)
- Urinary Incontinence Devices and Treatments (CP.MP.142) (PDF)
- Vagus Nerve Stimulation (CP.MP.12) (PDF)
- Ventricular Assist Devices (CP.MP.46) (PDF)
Medicaid Pharmacy Policies
Abiraterone (Zytiga, Yonsa) (PDF)
AbobotulinumtoxinA (Dysport) (PDF)
Acalabrutinib (Calquence) (PDF)
ACEI and ARB Duplicate Therapy (PDF)
Acyclovir Buccal Tablet (Sitavig) (PDF)
Ado-Trastuzumab Emtansine (Kadcyla) (PDF)
Aducanumab-avwa (Aduhelm) (PDF)
Afamelanotide (Scenesse) (PDF)
Agalsidase Beta (Fabrazyme) (PDF)
Age Limit for Topical Tretinoin (PDF)
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF)
Alendronate (Binosto, Fosamax Plus D) (PDF)
Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) (PDF)
Allogenic Processed Thymus Tissue-agdc (Rethymic) (PDF)
Alpelisib (Piqray, Vijoice) (PDF)
Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF)
Amantadine ER (Gocovri, Osmolex ER) (PDF)
Amifampridine (Firdapse) (PDF)
Amivantamab-vmjw (Rybrevant) (PDF)
Amlodipine/Atorvastatin (Caduet) (PDF)
Anifrolumab-fnia (Saphnelo) (PDF)
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF)
Anti-Obesity Medications (PDF)
Antithrombin III (ATryn, Thrombate III) (PDF)
Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF)
Apomorphine (Apokyn, Kynmobi) (PDF)
Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF)
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada, Aristada Initio) (PDF)
Asenapine (Saphris, Secuado) (PDF)
Asfotase Alfa (Strensiq) (PDF)
Aspirin/Dipyridamole (Aggrenox) (PDF)
Atezolizumab (Tecentriq) (PDF)
Avalglucosidase Alfa-ngpt (Nexviazyme) (PDF)
Axicabtagene Ciloleucel (Yescarta) (PDF)
Azacitidine (Onureg, Vidaza) (PDF)
Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispah, Ozobax) (PDF)
Baloxavir Marboxil (Xofluza) (PDF)
Bamlanivimab + Etesevimab (LY-CoV555 + LY-CoV016) (PDF)
Bardoxolone Methyl (RTA 402) (PDF)
Bebtelovimab (LY-CoV1404) (PDF)
Belantamab Mafodotin-blmf (Blenrep) (PDF)
Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet) (PDF)
Bendamustine (Belrapzo, Bendeka, Treanda) (PDF)
Benzyl alcohol (Ulesfia) (PDF)
Betamethasone Dipropionate Spray (Sernivo) (PDF)
Betibeglogene Autotemcel (Zynteglo) (PDF)
Bevacizumab (Alymsys, Avastin, Mvasi, Zirabev) (PDF)
Bexarotene (Targretin Capsules, Gel) (PDF)
Bimatoprost Implant (Durysta) (PDF)
Blood Glucose Test Strip Quantity Limit - Not Receiving Insulin (PDF)
Brentuximab Vedotin (Adcetris) (PDF)
Brexucabtagene Autoleucel (Tecartus) (PDF)
Brimonidine Tartrate (Mirvaso) (PDF)
Brolucizumab-dbll (Beovu) (PDF)
Budesonide/Formoterol (Symbicort) (PDF)
Buprenorphine Implant/Injection (Probuphine , Sublocade) (PDF)
Buprenorphine Injection (Brixadi) (PDF)
Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF)
Burosumab-twza (Crysvita) (PDF)
C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF)
Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) (PDF)
Cabozantinib (Cabometyx, Cometriq) (PDF)
Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) (PDF)
Caplacizumab-yhdp (Cablivi) (PDF)
Carbamazepine ER (Equetro) (PDF)
Carbidopa/Levodopa ER Capsules (Rytary), Enteral Suspension (Duopa), IR Tablets (Dhivy) (PDF)
Carglumic Acid (Carbaglu) (PDF)
Casirivimab and Imdevimab (REGEN-COV) (PDF)
Celecoxib (Celebrex, Elyxyb) (PDF)
Cemiplimab-rwlc (Libtayo) (PDF)
Cenegermin-bkbj (Oxervate) (PDF)
Cerliponase alfa (Brineura) (PDF)
Chloramphenicol Sodium Succinate (PDF)
Ciltacabtagene Autoleucel (Carvykti) (PDF)
Cipaglucosidase Alfa/Miglustat (AT-GAA) (PDF)
Ciprofloxacin/Dexamethasone (Ciprodex) (PDF)
Ciprofloxacin/Fluocinolone (Otovel) (PDF)
Clobazam (Onfi, Sympazan) (PDF)
Clomipramine (Anafranil) (PDF)
Clozapine Orally Disintegrating Tablet (PDF)
Collagenase Clostridium Histolyticum (Xiaflex) (PDF)
Conjugated Estrogens/Bazedoxifene (Duavee) (PDF)
Continuous Glucose Monitors (PDF)
Corticosteroids for Ophthalmic Injection (Iluvien, Ozurdex, Retisert, Xipere, Yutiq) (PDF)
Crizanlizumab-tmca (Adakveo) (PDF)
Cyclosporine (Cequa, Restasis, Verkazia) (PDF)
Cysteamine Ophthalmic (Cystaran, Cystadrops) (PDF)
Cysteamine oral (Cystagon, Procysbi) (PDF)
Cytomegalovirus Immune Globulin (Cytogam) (PDF)
Daptomycin (Cubicin, Cubicin RF) (PDF)
Daratumumab (Darzalex), Daratumumab/Hyaluronidase-fihj (Darzalex Faspro) (PDF)
Darbepoetin Alfa (Aranesp) (PDF)
Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) (PDF)
Daunorubicin/Cytarabine (Vyxeos) (PDF)
Decitabine/Cedazuridine (Inqovi) (PDF)
Deferasirox (Exjade, Jadenu) (PDF)
Degarelix Acetate (Firmagon) (PDF)
Denosumab (Prolia, Xgeva) (PDF)
Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (PDF)
Deutetrabenazine (Austedo) (PDF)
Dextromethorphan-Quinidine (Nuedexta) (PDF)
Diazepam Nasal Spray (Valtoco) (PDF)
Dichlorphenamide (Keveyis) (PDF)
Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity), Monomethyl Fumarate (Bafiertam) (PDF)
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF)
Dornase Alfa (Pulmozyme) (PDF)
Dostarlimab-gxly (Jemperli) (PDF)
Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF)
Dronabinol (Marinol, Syndros) (PDF)
Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn) (PDF)
Early and Periodic Screening, Diagnostic, and Treatment Benefit for Pediatric Members (PDF)
Edaravone (Radicava, Radicava ORS) (PDF)
Efgartigimod Alfa-fcab (Vyvgart) (PDF)
Elagolix (Orilissa), Elagolix/Estradiol/Norethinedrone (Oriahnn) (PDF)
Elapegademase-lvlr (Revcovi) (PDF)
Elbasvir/Grazoprevir (Zepatier) (PDF)
Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (PDF)
Elivaldogene Autotemcel (Skysona) (PDF)
Elosulfase Alfa (Vimizim) (PDF)
Emapalumab-lzsg (Gamifant) (PDF)
Emicizumab-kxwh (Hemlibra) (PDF)
Enfortumab Vedotin-ejfv (Padcev) (PDF)
Epinephrine (EpiPen and EpiPen Jr) Quanity Limit Override (PDF)
Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) (PDF)
Epoprostenol (Flolan, Veletri) (PDF)
Eptinezumab-jjmr (Vyepti) (PDF)
Eribulin Mesylate (Halaven) (PDF)
Erwinia Asparaginase (Erwinaze, Rylaze) (PDF)
Estradiol Vaginal Ring (Femring) (PDF)
Etelcalcetide (Parsabiv) (PDF)
Etranacogene Dezaparvovec (AMT-061) (PDF)
Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF)
Evinacumab-dgnb (Evkeeza) (PDF)
Factor IX (Human, Recombinant) (PDF)
Factor IX Complex, Human (Profilnine) (PDF)
Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (PDF)
Factor VIII (Human, Recombinant) (PDF)
Factor XIII A-Subunit, Recombinant (Tretten) (PDF)
Factor XIII, Human (Corifact) (PDF)
Fam-Trastuzumab Deruxtecan-nxki (Enhertu) (PDF)
Faricimab-svoa (Vabysmo) (PDF)
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF)
Ferric Carboxymaltose (Injectafer) (PDF)
Ferric Derisomaltose (Monoferric) (PDF)
Ferric Gluconate (Ferrlecit) (PDF)
Ferric Maltol (Accrufer) (PDF)
Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP) (PDF)
Fingolimod (Gilenya, Tascenso ODT) (PDF)
Fluticasone Propionate (Xhance) (PDF)
Fostamatinib (Tavalisse) (PDF)
Fulvestrant (Faslodex Injection)
Gabapentin ER (Gralise, Horizant) (PDF)
Galcanezumab-gnlm (Emgality) (PDF)
Gemtuzumab Ozogamicin (Mylotarg) (PDF)
Glatiramer (Copaxone, Glatopa) (PDF)
Glecaprevir/Pibrentasvir (Mavyret) (PDF)
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF)
Glycerol Phenylbutyrate (Ravicti) (PDF)
Glycopyrronium (Qbrexza) (PDF)
Golimumab (Simponi, Simponi Aria) (PDF)
Goserelin Acetate (Zoladex) (PDF)
Halobetasol Propionate (Bryhali, Lexette, Ultravate) (PDF)
Halobetasol Propionate/Tazarotene (Duobrii) (PDF)
Histrelin Acetate (Vantas, Supprelin LA) (PDF)
House dust mite allergen extract (Odactra) (PDF)
Human Growth Hormone (Somapacitan, Somatropin) (PDF)
Hydroxyprogesterone Caproate (Makena/compound) (PDF)
Ibandronate Injection (Boniva) (PDF)
Ibandronate Oral (Boniva) (PDF)
Ibuprofen/Famotidine (Duexis) (PDF)
Icosapent Ethyl (Vascepa) (PDF)
Idecabtagene Vicleucel (Abecma) (PDF)
IncobotulinumtoxinA (Xeomin) (PDF)
Inebilizumab-cdon (Uplizna) (PDF)
Infertility and Fertility Preservation (PDF)
Infigratinib (Truseltiq) (PDF)
Inhaled Agents for Asthma and COPD (PDF)
Inotuzumab Ozogamicin (Besponsa) (PDF)
Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF)
Interferon Beta-1a (Avonex, Rebif) (PDF)
Interferon Beta-1b (Betaseron, Extavia) (PDF)
Interferon Gamma- 1b (Actimmune) (PDF)
Iobenguane I-131 (Azedra) (PDF)
Irinotecan Liposome (Onivyde) (PDF)
Isatuximab-irfc (Sarclisa) (PDF)
Isavuconazonium (Cresemba) (PDF)
Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (PDF)
Istradefylline (Nourianz) (PDF)
Itraconazole (Sporanox, Tolsura) (PDF)
Ivermectin (Stromectol, Sklice) (PDF)
Ketorolac Nasal Spray (Sprix) (PDF)
Lactic Acid/Citric Acid/Potassium Bitartrate (Phexxi) (PDF)
Lanadelumab-fylo (Takhzyro) (PDF)
Lanreotide (Somatuline Depot) (PDF)
Larotrectinib (Vitrakvi) (PDF)
Latanoprostene Bunod (Vyzulta) (PDF)
Ledipasvir/Sofosbuvir (Harvoni) (PDF)
Levodopa Inhalation Powder (Inbrija) (PDF)
Levoketoconazole (Recorlev) (PDF)
Levoleucovorin (Fusilev, Khapzory) (PDF)
Lidocaine transdermal (Lidoderm, ZTlido) (PDF)
Lisdexamfetamine (Vyvanse) (PDF)
Lisocabtagene Maraleucel (Breyanzi) (PDF)
Loncastuximab Tesirine-lpyl (Zynlonta) (PDF)
Loteprednol etabonate (Eysuvis) (PDF)
Luliconazole Cream (Luzu) (PDF)
Lumacaftor/Ivacaftor (Orkambi) (PDF)
Lurbinectedin (Zepzelca) (PDF)
Luspatercept-aamt (Reblozyl) (PDF)
Lusutrombopag (Mulpleta) (PDF)
Lutetium Lu 177 dotatate (Lutathera)
Lutetium Lu 177 vipivotide tetraxetan (Pluvicto)
Margetuximab-cmkb (Margenza) (PDF)
Mechlorethamine Gel (Valchlor) (PDF)
Megestrol Acetate (Megace ES) (PDF)
Melphalan flufenamide (Pepaxto) (PDF)
Mercaptopurine (Purixan) (PDF)
Metformin ER (Fortamet, Glumetza) (PDF)
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF)
Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) (PDF)
Methylnaltrexone Bromide (Relistor) (PDF)
Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) (PDF)
Minocycline Micronized Foam (Amzeeq) (PDF)
Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF)
Mogamulizumab-kpkc (Poteligeo) (PDF)
Mometasone Furoate (Sinuva) (PDF)
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF)
Nadofaragene Firadenovec (Instiladrin) (PDF)
Nafarelin Acetate (Synarel) (PDF)
Naproxen/Esomeprazole (Vimovo) (PDF)
Naxitamab-gqgk (Danyelza) (PDF)
Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF)
Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan) (PDF)
Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (PDF)
Nitisinone (Nityr, Orfadin) (PDF)
Nivolumab and Relatlimab (Opdualag) (PDF)
No Coverage Criteria, Recent Label Changes Pending Clinical Policy Update (PDF)
Non-Calcium Phosphate Binders (PDF)
Non-Preferred Blood Glucose Monitors/Test Strips (PDF)
Obeticholic Acid (Ocaliva) (PDF)
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF)
Ofatumumab (Arzerra, Kesimpta) (PDF)
Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF)
Olanzapine Orally Disintegrating Tablet (Zyprexa Zydis) (PDF)
Olanzapine/Samidorphan (Lybalvi) (PDF)
Olipudase Alfa-rpcp (Xenpozyme) (PDF)
Omega-3-Acid Ethyl Esters (Lovaza) (PDF)
OnabotulinumtoxinA (Botox) (PDF)
Onasemnogene Abeparvovec (Zolgensma) (PDF)
Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF)
Overactive Bladder Agents (PDF)
Oxymetazoline (Rhofade, Upneeq) (PDF)
Paclitaxel, Protein-Bound (Abraxane) (PDF)
Paliperidone Long-Acting Injections (Invega Hafyera, Invega Sustenna, Invega Trinza) (PDF)
Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep) (PDF)
Parathyroid Hormone (Natpara) (PDF)
Paricalcitol Injection (Zemplar) (PDF)
Pasireotide (Signifor, Signifor LAR) (PDF)
Peanut Allergen Powder-dnfp (Palforzia) (PDF)
Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas) (PDF)
Pegcetacoplan (Empaveli, APL-2) (PDF)
Peginterferon Alfa-2a,b (Pegasys, PegIntron) (PDF)
Peginterferon Beta-1a (Plegridy) (PDF)
Pegunigalsidase Alfa (PRX-102) (PDF)
Pegvaliase-pqpz (Palynziq) (PDF)
Pegzilarginase (AEB1102) (PDF)
Pembrolizumab (Keytruda) (PDF)
Pemetrexed (Alimta, Pemfexy) (PDF)
Pentosan Polysulfate Sodium (Elmiron) (PDF)
Perindopril/Amlodipine (Prestalia) (PDF)
Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (PDF)
Plasminogen, human-tvmh (Ryplazim) (PDF)
Polatuzumab Vedotin-piiq (Polivy) (PDF)
Pregabalin (Lyrica, Lyrica CR) (PDF)
Progesterone (Crinone, Endometrin, Milprosa) (PDF)
Propranolol HCl Oral Solution (Hemangeol) (PDF)
Protein C Concentrate, Human (Ceprotin) (PDF)
Prucalopride (Motegrity) (PDF)
Pyrimethamine (Daraprim) (PDF)
Quantity Limit Override and Dose Optimization (PDF)
Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo) (PDF)
Ranolazine (Ranexa, Aspruzyo Sprinkle) (PDF)
Ravulizumab-cwvz (Ultomiris) (PDF)
Relugolix (Orgovyx), Relugolix/Estradiol/Norethinedrone (Myfembree) (PDF)
Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel) (PDF)
Request for Medically Necessary Drug Not on the PDL (PDF)
Ribavirin (Rebetol, Ribasphere) (PDF)
Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara) (PDF)
RimabotulinumtoxinB (Myobloc) (PDF)
Risankizumab-rzaa (Skyrizi) (PDF)
Risedronate (Actonel, Atelvia) (PDF)
Risperidone Long-Acting Injection (Perseris, Risperdal Consta) (PDF)
Roflumilast (Daliresp, Zoryve) (PDF)
Romosozumab-aqqg (Evenity) (PDF)
Ropeginterferon Alfa-2b-njft (BESREMi) (PDF)
Ruxolitinib (Jakafi, Opzelura) (PDF)
Sacituzumab Govitecan-hziy (Trodelvy) (PDF)
Sacubitril/Valsartan (Entresto) (PDF)
Sapropterin Dihydrochloride (Kuvan) (PDF)
Satralizumab-mwge (Enspryng) (PDF)
Sebelipase Alfa (Kanuma) (PDF)
Setmelanotide (Imcivree) (PDF)
Short ragweed pollen allergen extract (Ragwitek) (PDF)
Sirolimus Protein-Bound Particles (Fyarro), Topical Gel (Hyftor) (PDF)
Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, and Sodium Oxybate (Xywav) (PDF)
Sodium Phenylbutyrate (Buphenyl, Pheburane) (PDF)
Sodium Phenylbutyrate/Taurursodiol (Relyvrio) (PDF)
Sodium zirconium cyclosilicate (Lokelma) (PDF)
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF)
Sofosbuvir/Velpatasvir (Epclusa), Epclusa Pellets (PDF)
Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (PDF)
SSRI SNRI Duplicate Thearapy (PDF)
State-Specific Pharmacy Guideline Process (PDF)
Sutimlimab-jome (Enjaymo) (PDF)
Tadalafil (Adcirca, Alyq, Tadliq) (PDF)
Tadalafil BHP - ED (Cialis) (PDF)
Tafamidis (Vyndaqel, Vyndamax) (PDF)
Tafasitamab-cxix (Monjuvi) (PDF)
Taliglucerase alfa (Elelyso) (PDF)
Talimogene laherepvec (Imlygic) (PDF)
Tasimelteon (Hetlioz, Hetlioz LQ) (PDF)
Tazarotene (Arazlo, Fabior, Tazorac) (PDF)
Tebentafusp-tebn (Kimmtrak) (PDF)
Telotristat Ethyl (Xermelo) (PDF)
Tenofovir Alafenamide Fumarate (Vemlidy) (PDF)
Tesamorelin (Egrifta SV) (PDF)
Testosterone (Testopel, Jatenzo, Kyzatrex, Tlando) (PDF)
Tetrabenazine (Xenazine) (PDF)
Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF)
Tezepelumab-ekko (Tezspire) (PDF)
Thyrotropin alfa (Thyrogen) (PDF)
Tildrakizumab-asmn (Ilumya) (PDF)
Timothy grass pollen allergen extract (Grastek) (PDF)
Tisagenlecleucel (Kymriah) (PDF)
Tisotumab Vedotin-tftv (Tivdak) (PDF)
Tixagevimab and Cilgavimab (Evusheld) (PDF)
Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (PDF)
Tofacitinib (Xeljanz, Xeljanz XR) (PDF)
Tolvaptan (Jynarque, Samsca) (PDF)
Topical Immunomodulators (PDF)
Topiramate ER (Qudexy XR, Trokendi XR (PDF)
Tralokinumab-ldrm (Adbry) (PDF)
Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF)
Triamcinolone ER Injection (Zilretta) (PDF)
Triclabendazole (Egaten) (PDF)
Trientine (Cuvrior, Syprine) (PDF)
Trifluridine/Tipiracil (Lonsurf) (PDF)
Triptorelin Pamoate (Trelstar, Triptodur) (PDF)
Ulcer Therapy Combinations (PDF)
Valoctocogene Roxaparvovec (PDF)
Velaglucerase alfa (VPRIV) (PDF)
Vestronidase Alfa-vjbk (Mepsevii) (PDF)
Vincristine Sulfate Liposome Injection (Marqibo) (PDF)
Voretigene Neparvovec-rzyl (Luxturna) (PDF)
Vortioxetine (Trintellix) (PDF)
Vosoritide (Voxzogo) (PDF)
Voxelotor (Oxbryta) (PDF)
Ziv-aflibercept (Zaltrap) (PDF)
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.
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Medicaid Payment Policies
- 25-hydroxyvitamin D Testing in Children and Adolescents (CP.MP.157) (PDF)
- Allergy Testing and Therapy (CP.MP.100) (PDF)
- Attention Deficit Hyperactivity Disorder Assessment and Treatment (CP.MP.124) (PDF)
- Bronchial Thermoplasty (CP.MP.110) (PDF)
- Cardiac Biomarker Testing (CP.MP.156) (PDF)
- Digital Electroencephalography Spike Analysis (CP.MP.105) (PDF)
- Drugs of Abuse: Definitive Testing (CP.MP.50) (PDF)
- Electroencephalography in the Evaluation of Headache (CP.MP.155) (PDF)
- Endometrial Ablation (CP.MP.106) (PDF)
- Evoked Potential Testing (CP.MP.134) (PDF)
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (CP.MP.209) (PDF)
- Helicobacter Pylori Serology Testing (CP.MP.153) (PDF)
- Holter Monitors (CP.MP.113) (PDF)
- Homocysteine Testing (CP.MP.121) (PDF)
- Laser Therapy for Skin Conditions (CP.MP.123) (PDF)
- Low-frequency Ultrasound and Noncontact Normothermic Wound Therapy (CP.MP.139) (PDF)
- Measurement of Serum 1,25-dihydroxyvitamin D (CP.MP.152) (PDF)
- Polymerase Chain Reaction Respiratory Viral Panel Testing (CP.MP.181) (PDF)
- Pulmonary Function Testing (CP.MP.242) (PDF)