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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. 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.

Not all policies found in the Sunflower Health Plan Clinical Policy Manual apply to all Sunflower Health Plan members. Sunflower policies are applied according to member eligibility and medical necessity criteria as defined in policy CP.MP.68. Policies in the Sunflower Health Plan Clinical Policy Manual may have either a Sunflower or a “Centene” heading. Sunflower utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Sunflower 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 Sunflower. In addition, Sunflower 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 Sunflower Health Plan.

If you have any questions regarding these policies, please contact Customer Service and ask to be directed to the Medical Management department.

Policy Number Policy Title
CP.MP.92 Acupuncture (PDF)
CP.MP.124 ADHD Assessment and Treatment (PDF) Effective 8/14/2020
CP.MP.100 Allergy Testing and Therapy (PDF)
CP.MP.108 Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF)
CP.MP.96 Ambulatory EEG (PDF)
CP.MP.158 Ambulatory Surgery Center Optimization (PDF)
CP.MP.179 Antithrombin III (PDF)
KS.CP.01 Applied Behavioral Analysis (PDF)
CP.MP.26 Articular Cartilage Defect Repairs (PDF)
CP.MP.55 Assisted Reproductive Technology (PDF)
CP.MP.119 Balloon sinus ostial dilation (PDF)
CP.MP.37 Bariatric Surgery (PDF)
CP.MP.168 Biofeedback (PDF)
CP.MP.93 Bone-anchored hearing aid (PDF)
CP.MP.110 Bronchial Thermoplasty (PDF)
CP.MP.156 Cardiac biomarker testing (PDF)
CP.MP.83 Carrier Screening in Pregnancy (PDF)
CP.MP.164 Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF)
CP.MP.84 Cell-free Fetal DNA Testing (PDF)
CP.MP.94 Clinical Trials (PDF)
CP.MP.14 Cochlear Implant Replacements (PDF)
CP.MP.31 Cosmetic and Reconstructive Surgery (PDF)
CP.MP.61 Dental Anesthesia (PDF)
CP.MP.90 Digital breast tomosynthesis (Policy retired)
CP.MP.105 Digital electroencephalography spike analysis (PDF)
CP.MP.114 Disc Decompression Procedures (PDF)
CP.MP.115 Discography (PDF)
CP.MP.125 DNA analysis of stool to screen for colorectal cancer (PDF)
CP.MP.101 Donor lymphocyte infusion (PDF)
CP.MP.107 Durable Medical Equipment (DME) (PDF)
CP.MP.145 Electric Tumor Treating Fields (PDF)
CP.MP.155 Electroencephalography in the evaluation of headache (PDF)
CP.MP.106 Endometrial ablation (PDF)
CP.MP.140 EpiFix Wound Treatment (PDF) Effective until July 23, 2020
CP.MP.131 Essure Removal (PDF)
CP.MP.134 Evoked Potential Testing (PDF)
CP.MP.36 Experimental Technologies (PDF)
CP.MP.171 Facet Joint Interventions (PDF)
CP.MP.135 Fecal calprotectin assay (retired)
CP.MP.137 Fecal incontinence treatments (PDF)
CP.MP.53 Ferriscan R2-MRI (PDF)
CP.MP.130 Fertility preservation (PDF)
CP.MP.129 Fetal surgery in utero for prenatally diagnosed malformations (PDF)
CP.MP.103 Fractional exhaled nitric oxide (PDF)
CP.MP.43 Functional MRI (PDF)
CP.MP.40 Gastric electrical stimulation (PDF)
CP.MP.95 Gender reassignment surgery (PDF)
CP.MP.89 Genetic Testing (PDF)
CP.MP.153 H. Pylori serology testing (PDF)
CP.MP.132 Heart-Lung Transplant (PDF)
CP.MP.113 Holter Monitors (PDF)
CP.MP.136 Home Birth (PDF)
CP.MP.150 Home phototherapy for neonatal hyperbilirubinemia (PDF)
CP.MP.121 Homocysteine testing (PDF) Retired for Allwell (Medicare). Effective 8/14/2020.
CP.MP.54 Hospice Services (PDF)
CP.MP.27 Hyperbaric Oxygen Therapy (PDF)
CP.MP.34 Hyperemesis gravidarum treatment (PDF)
CP.MP.62 Hyperhidrosis treatments (PDF)
CP.MP.180 Implantable Hypoglossal Nerve Stimulation (PDF)
CP.MP.173 Implantable Intrathecal Pain Pump (PDF)
CP.MP.160 Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)
CP.MP.159 Infusion SOC Optimization (PDF)
CP.MP.87 Inhaled nitric oxide (PDF)
CP.MP.118 Injections for Pain Management (Policy retired)
CP.MP.69 Intensity-Modulated Radiotherapy (PDF)
CP.MP.58 Intestinal and multivisceral transplant (PDF)
CP.MP.167 Intradiscal Steroid Injections for Pain Management (PDF)
CP.MP.123 Laser therapy for skin conditions (PDF)
CP.MP.71 Long Term Care Placement Criteria (PDF)
CP.MP.139 Low-frequency ultrasound therapy for wound management (PDF)
CP.MP.57 Lung Transplantation (PDF)
CP.MP.116 Lysis of Epidural Lesions (PDF)
CP.MP.152 Measurement of serum 1,25-dihydroxyvitamin D (PDF)
CP.MP.144 Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) Effective 7/23/2020
CP.MP.68 Medical Necessity Criteria (Retired)
CP.MP.161 Monitored Anesthesia Care for Gastrointestinal Endoscopy (Retired effective 9/1/2019)
CP.MP.24 Multiple Sleep Latency Testing (PDF)
CP.MP.86 Neonatal abstinence syndrome guidelines (PDF)
CP.MP.85 Neonatal sepsis management (PDF)
CP.MP.170 Nerve Blocks for Pain Management (PDF)
CP.MP.82 NICU Apnea Bradycardia Guidelines (PDF)
CP.MP.81 NICU discharge guidelines (PDF)
CP.MP.141 Non-myeloablative allogeneic stem cell transplants (PDF)
CP.MP.91 Obstetrical Home Health Care Programs (PDF)
CP.MP.128 Optic nerve decompression surgery (PDF)
CP.MP.50 Outpatient testing for drugs of abuse (PDF)
CP.MP.102 Pancreas transplant (PDF)
CP.MP.109 Panniculectomy (PDF)
CP.MP.138 Pediatric heart transplant (PDF)
CP.MP.120 Pediatric Liver Transplant (PDF)
CP.MP.147 Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)
CP.MP.133 Posterior tibial nerve stimulation for voiding dysfunction (PDF)
CP.MP.70 Proton and neutron beam therapy (PDF)
CP.MP.148 Radial Head Implant (PDF)
CP.MP.51 Reduction mammoplasty and gynecomastia surgery (PDF)
CP.MP.126 Sacroiliac joint fusion (PDF)
CP.MP.166 Sacroiliac Joint Interventions for Pain Management (PDF)
CP.MP.146 Sclerotherapy for Vericose Veins (PDF)
CP.MP.165 Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF)
CP.MP.88 Sickle cell disease observation (PDF)
CP.MP.185 Skin Substitutes for Chronic Wounds (PDF) Effective 7/23/2020
CP.MP.117 Spinal Cord Stimulation (PDF)
CP.MP.22 Stereotactic Body Radiation Therapy (PDF)
CP.MP.162 Tandem Transplant (PDF)
CP.MP.149 Testing for rupture of fetal membranes (PDF)
CP.MP.97 Testing for select genitourinary conditions (PDF)
CP.MP.49 Therapy Services (PT/OT/ST) (PDF)
CP.MP.154 Thyroid hormones and insulin testing in pediatrics (PDF)
CP.MP.127 Total artificial heart (PDF)
CP.MP.163 Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
CP.MP.151 Transcatheter closure of patent foramen ovale (PDF)
CP.MP.172 Transcranial Magnetic Stimulation (PDF)
CP.MP.169 Trigger Point Injections for Pain Management (PDF)
KS.CP.MP.38 Ultrasound in Pregnancy (PDF)
CP.MP.142 Urinary Incontinence Devices and Treatments (PDF)
CP.MP.98 Urodynamic testing (PDF)
CP.MP.12 Vagus Nerve Stimulation (PDF)
CP.MP.46 Ventricular Assist Devices (PDF)
CP.MP.56 Ventriculectomy and cardiomyoplasty (PDF)
CP.MP.177 Video Electroencephalographic (VEEG) Monitoring (PDF)
CP.MP.157 Vitamin D Testing in Children (PDF)
CP.MP.99 Wheelchair seating (PDF)
CP.MP.143 Wireless Motility Capsule (PDF)
CP.MP.111 Zika Virus Testing (PDF)

Please refer to the KDHE website for detailed information regarding clinical prior authorization criteria.

Please refer to the Allwell website for detailed information regarding Allwell pharmacy policies. 

Policy Number Medication Name
CP.PCH.02 (PDF) AUBAGIO, Teriflunomide
CP.PCH.03 (PDF) BELVIQ, Lorcaserin HCl
CP.PCH.04 (PDF) KEVEYIS, Dichlorphenamide
CP.PCH.06 (PDF) VALCYTE, Valganciclovir HCl
CP.PCH.07 (PDF) VIAGRA, Sildenafil Citrate
CP.PCH.09 (PDF) CUPRIMINE, Penicillamine
CP.PCH.10 (PDF) QUALAQUIN, Quinine Sulfate
CP.PCH.11 (PDF) UCERIS, Budesonide (Intrarectal)
CP.PCH.12 (PDF) CONTRAVE, Naltrexone HCl-Bupropion HCl
CP.PCH.13 (PDF) ADIPEX-P, Phentermine HCl
CP.PCH.14 (PDF) APOKYN, Apomorphine Hydrochloride
CP.PCH.15 (PDF) DAKLINZA, Daclatasvir Dihydrochloride
CP.PCH.16 (PDF) ZEPATIER, Elbasvir-Grazoprevir
CP.PCH.17 (PDF) AJOVY, Fremanezumab-vfrm
CP.PCH.18 (PDF) MAVYRET, Glecaprevir-Pibrentasvir
CP.PCH.19 (PDF) HARVONI, Ledipasvir-Sofosbuvir
CP.PCH.20 (PDF) SOVALDI, Sofosbuvir
CP.PCH.21 (PDF) EPCLUSA, Sofosbuvir-Velpatasvir
CP.PCH.22 (PDF) VOSEVI, Sofosbuvir-Velpatasvir-Voxilaprevir
CP.PHAR.01 (PDF) XOLAIR, Omalizumab
CP.PHAR.05 (PDF) SYNVISC ONE, Hylan
SYNVISC, Hylan
MONOVISC, Hyaluronan
ORTHOVISC, Hyaluronan
HYMOVIS, Hyaluronan
GEL-ONE, Cross-Linked Hyaluronate
SUPARTZ FX, Sodium Hyaluronate (Viscosupplement)
HYALGAN, Sodium Hyaluronate (Viscosupplement)
GENVISC 850, Sodium Hyaluronate (Viscosupplement)
GELSYN-3, Sodium Hyaluronate (Viscosupplement)
EUFLEXXA, Sodium Hyaluronate (Viscosupplement)
TRILURON,
SYNOJYNT,
VISCO-3, Sodium Hyaluronate (Viscosupplement)
TRIVISC, Sodium Hyaluronate (Viscosupplement)
DUROLANE, Sodium Hyaluronate (Viscosupplement)
CP.PHAR.11 (PDF) CRYSVITA, Burosumab-twza
CP.PHAR.14 (PDF) MAKENA, Hydroxyprogesterone Caproate
HYDROXYPROGESTERONE CAPROATE, Hydroxyprogesterone Caproate
CP.PHAR.16 (PDF) SYNAGIS, Palivizumab
CP.PHAR.24 (PDF) TAVALISSE, Fostamatinib Disodium
CP.PHAR.27 (PDF) JYNARQUE, Tolvaptan
SAMSCA, Tolvaptan
CP.PHAR.40 (PDF) SANDOSTATIN, Octreotide Acetate
SANDOSTATIN LAR DEPOT, Octreotide Acetate
CP.PHAR.41 (PDF) FUZEON, Enfuvirtide
CP.PHAR.43 (PDF) KUVAN, Sapropterin Dihydrochloride
CP.PHAR.50 (PDF) MEKTOVI, Binimetinib
CP.PHAR.52 (PDF) ACTIMMUNE, Interferon Gamma-1B
CP.PHAR.55 (PDF) GENOTROPIN, Somatropin
NUTROPIN AQ NUSPIN, Somatropin
ZORBTIVE, Somatropin
ZOMACTON, Somatropin
SEROSTIM, Somatropin
SAIZEN, Somatropin
OMNITROPE, Somatropin
NORDITROPIN FLEXPRO, Somatropin
HUMATROPE COMBO PACK, Somatropin
HUMATROPE, Somatropin
GENOTROPIN MINIQUICK, Somatropin
CP.PHAR.58 (PDF) PROLIA, Denosumab
XGEVA, Denosumab
CP.PHAR.59 (PDF) RECLAST, Zoledronic Acid
ZOMETA, Zoledronic Acid
CP.PHAR.60 (PDF) XELODA, Capecitabine
CP.PHAR.61 (PDF) SENSIPAR, Cinacalcet HCl
CP.PHAR.63 (PDF) AFINITOR, Everolimus
ZORTRESS, Everolimus (Immunosuppressant)
AFINITOR DISPERZ, Everolimus
CP.PHAR.64 (PDF) HYCAMTIN, Topotecan HCl
CP.PHAR.65 (PDF) GLEEVEC, Imatinib Mesylate
CP.PHAR.69 (PDF) NEXAVAR, Sorafenib Tosylate
CP.PHAR.71 (PDF) REVLIMID, Lenalidomide
CP.PHAR.72 (PDF) SPRYCEL, Dasatinib
CP.PHAR.73 (PDF) SUTENT, Sunitinib Malate
CP.PHAR.74 (PDF) TARCEVA, Erlotinib HCl
CP.PHAR.75 (PDF) TARGRETIN, Bexarotene
CP.PHAR.76 (PDF) TASIGNA, Nilotinib HCl
CP.PHAR.77 (PDF) TEMODAR, Temozolomide
CP.PHAR.78 (PDF) THALOMID, Thalidomide
CP.PHAR.79 (PDF) TYKERB, Lapatinib Ditosylate
CP.PHAR.80 (PDF) CAPRELSA, Vandetanib
CP.PHAR.81 (PDF) VOTRIENT, Pazopanib HCl
CP.PHAR.82 (PDF) XIAFLEX, Collagenase Clostridium Histolyticum
CP.PHAR.83 (PDF) ZOLINZA, Vorinostat
CP.PHAR.84 (PDF) ZYTIGA, Abiraterone Acetate
YONSA, Abiraterone Acetate
CP.PHAR.88 (PDF) BENLYSTA, Belimumab
CP.PHAR.89 (PDF) PEGASYS, Peginterferon alfa-2a
SYLATRON, Peginterferon alfa-2b (Antineoplastic)
PEGINTRON, Peginterferon alfa-2b
CP.PHAR.90 (PDF) XALKORI, Crizotinib
CP.PHAR.91 (PDF) ZELBORAF, Vemurafenib
CP.PHAR.92 (PDF) XENAZINE, Tetrabenazine
CP.PHAR.93 (PDF) AVASTIN, Bevacizumab
ZIRABEV
MVASI
CP.PHAR.94 (PDF) ARALAST NP, Alpha1-Proteinase Inhibitor (Human)
GLASSIA, Alpha1-Proteinase Inhibitor (Human)
ZEMAIRA, Alpha1-Proteinase Inhibitor (Human)
PROLASTIN-C, Alpha1-Proteinase Inhibitor (Human)
CP.PHAR.95 (PDF) THYROGEN, Thyrotropin Alfa
CP.PHAR.97 (PDF) SOLIRIS, Eculizumab
CP.PHAR.98 (PDF) JAKAFI, Ruxolitinib Phosphate
CP.PHAR.100 (PDF) INLYTA, Axitinib
CP.PHAR.103 (PDF) PRIVIGEN, Immune Globulin (Human) IV
OCTAGAM, Immune Globulin (Human) IV
GAMASTAN S/D, Immune Globulin (Human) IM
PANZYGA, Immune Globulin (Human)-ifas
GAMMAPLEX, Immune Globulin (Human) IV
CARIMUNE NANOFILTERED, Immune Globulin (Human) IV
BIVIGAM, Immune Globulin (Human) IV
XEMBIFY
FLEBOGAMMA DIF, Immune Globulin (Human) IV
ASCENIV
Immune Globulins
CUTAQUIG, Immune Globulin (Human)-hipp
HIZENTRA, Immune Globulin (Human) Subcutaneous
GAMUNEX-C, Immune Globulin (Human) IV or Subcutaneous
GAMMAKED, Immune Globulin (Human) IV or Subcutaneous
GAMMAGARD S/D IGA LESS THAN 1MCG/ML, Immune Globulin (Human) IV
GAMMAGARD LIQUID, Immune Globulin (Human) IV or Subcutaneous
CUVITRU, Immune Globulin (Human) Subcutaneous
HYQVIA, Immune Globulin (Human)-Hyaluronidase (Human Recombinant)
CP.PHAR.105 (PDF) BOSULIF, Bosutinib
CP.PHAR.106 (PDF) XTANDI, Enzalutamide
CP.PHAR.107 (PDF) STIVARGA, Regorafenib
CP.PHAR.108 (PDF) SYNRIBO, Omacetaxine Mepesuccinate
CP.PHAR.109 (PDF) EGRIFTA, Tesamorelin Acetate
CP.PHAR.111 (PDF) COMETRIQ, Cabozantinib S-Malate
CABOMETYX, Cabozantinib S-Malate
CP.PHAR.114 (PDF) GATTEX, Teduglutide (rDNA)
CP.PHAR.116 (PDF) POMALYST, Pomalidomide
CP.PHAR.119 (PDF) CYRAMZA, Ramucirumab
CP.PHAR.120 (PDF) PROVENGE, Sipuleucel-T
CP.PHAR.121 (PDF) OPDIVO, Nivolumab
CP.PHAR.123 (PDF) REPATHA, Evolocumab
CP.PHAR.126 (PDF) IMBRUVICA, Ibrutinib
CP.PHAR.127 (PDF) BRAFTOVI, Encorafenib
CP.PHAR.128 (PDF) AIMOVIG, Erenumab-aooe
CP.PHAR.130 (PDF) DOPTELET, Avatrombopag Maleate
CP.PHAR.131 (PDF) BRAVELLE, Urofollitropin Purified
HUMAN CHORIONIC GONADOTROPIN, Chorionic Gonadotropin (Bulk)
GONAL-F, Follitropin Alfa
GANIRELIX ACETATE, Ganirelix Acetate
CETROTIDE, Cetrorelix Acetate
PREGNYL W/DILUENT BENZYLALCOHOL/NACL, Chorionic Gonadotropin
NOVAREL, Chorionic Gonadotropin
OVIDREL, Choriogonadotropin Alfa
FOLLISTIM AQ, Follitropin Beta
GONAL-F RFF, Follitropin Alfa
MENOPUR, Menotropins
CP.PHAR.132 (PDF) NITYR, Nitisinone
ORFADIN, Nitisinon
CP.PHAR.133 (PDF) ZYDELIG, Idelalisib
CP.PHAR.134 (PDF) OTREXUP, Methotrexate (Antirheumatic)
XATMEP, Methotrexate
RASUVO, Methotrexate (Antirheumatic)
CP.PHAR.137 (PDF) TIBSOVO, Ivosidenib
CP.PHAR.138 (PDF) LENVIMA, Lenvatinib Mesylate
CP.PHAR.139 (PDF) POTELIGEO, Mogamulizumab-kpkc
CP.PHAR.140 (PDF) PALYNZIQ, Pegvaliase-pqpz
CP.PHAR.141 (PDF) COPEGUS, Ribavirin (Hepatitis C)
RIBASPHERE RIBAPAK, Ribavirin (Hepatitis C)
RIBASPHERE, Ribavirin (Hepatitis C)
MODERIBA, Ribavirin (Hepatitis C)
REBETOL, Ribavirin (Hepatitis C)
CP.PHAR.142 (PDF) HEPSERA, Adefovir Dipivoxil
CP.PHAR.143 (PDF) CYSTADANE, Betaine
CP.PHAR.145 (PDF) JADENU, Deferasirox
EXJADE, Deferasirox
CP.PHAR.146 (PDF) DESFERAL, Deferoxamine Mesylate
CP.PHAR.149 (PDF) LIORESAL INTRATHECAL, Baclofen
GABLOFEN, Baclofen
OZOBAX, Baclofen
CP.PHAR.150 (PDF) INCRELEX, Mecasermin
CP.PHAR.152 (PDF) ALDURAZYME, Laronidase
CP.PHAR.153 (PDF) CERDELGA, Eliglustat Tartrate
CP.PHAR.154 (PDF) CEREZYME, Imiglucerase
CP.PHAR.155 (PDF) CYSTAGON, Cysteamine Bitartrate
CP.PHAR.156 (PDF) ELAPRASE, Idursulfase
CP.PHAR.157 (PDF) ELELYSO, Taliglucerase Alfa
CP.PHAR.158 (PDF) FABRAZYME, Agalsidase beta
CP.PHAR.159 (PDF) KANUMA, Sebelipase Alfa
CP.PHAR.160 (PDF) LUMIZYME, Alglucosidase Alfa
CP.PHAR.161 (PDF) NAGLAZYME, Galsulfase
CP.PHAR.162 (PDF) VIMIZIM, Elosulfase Alfa
CP.PHAR.163 (PDF) VPRIV, Velaglucerase Alfa
CP.PHAR.164 (PDF) ZAVESCA, Miglustat
CP.PHAR.168 (PDF) H.P. ACTHAR, Corticotropin
CP.PHAR.169 (PDF) SABRIL, Vigabatrin
CP.PHAR.170 (PDF) FIRMAGON, Degarelix Acetate
CP.PHAR.171 (PDF) ZOLADEX, Goserelin Acetate
CP.PHAR.172 (PDF) SUPPRELIN LA, Histrelin Acetate (CPP)
VANTAS, Histrelin Acetate
CP.PHAR.173 (PDF) ELIGARD, Leuprolide Acetate (3 Month)
LUPRON DEPOT-PED, Leuprolide Acetate (CPP)
LUPRON DEPOT, Leuprolide Acetate
LUPANETA PACK, Leuprolide Acetate & Norethindrone Acetate
CP.PHAR.174 (PDF) SYNAREL, Nafarelin Acetate
CP.PHAR.175 (PDF) TRIPTODUR, Triptorelin Pamoate (CPP)
TRELSTAR, Triptorelin Pamoate
CP.PHAR.176 (PDF) ABRAXANE, Paclitaxel Protein-Bound Particles
CP.PHAR.178 (PDF) FIRAZYR, Icatibant Acetate
CP.PHAR.179 (PDF) NPLATE, Romiplostim
CP.PHAR.180 (PDF) PROMACTA, Eltrombopag Olamine
CP.PHAR.184 (PDF) EYLEA, Aflibercept
CP.PHAR.186 (PDF) LUCENTIS, Ranibizumab
CP.PHAR.188 (PDF) FORTEO, Teriparatide (Recombinant)
CP.PHAR.189 (PDF) BONIVA INJ, Ibandronate Sodium
CP.PHAR.190 (PDF) LETAIRIS, Ambrisentan
CP.PHAR.191 (PDF) TRACLEER, Bosentan
CP.PHAR.192 (PDF) FLOLAN, Epoprostenol Sodium
VELETRI, Epoprostenol Sodium
CP.PHAR.193 (PDF) VENTAVIS, Iloprost
CP.PHAR.194 (PDF) OPSUMIT, Macitentan
CP.PHAR.195 (PDF) ADEMPAS, Riociguat
CP.PHAR.197 (PDF) REVATIO, Sildenafil Citrate (Pulmonary Hypertension)
CP.PHAR.198 (PDF) ADCIRCA, Tadalafil (Pulmonary Hypertension)
CP.PHAR.199 (PDF) REMODULIN, Treprostinil Sodium
TYVASO, Treprostinil
ORENITRAM, Treprostinil Diolamine
CP.PHAR.200 (PDF) NUCALA, Mepolizumab
CP.PHAR.201 (PDF) NULOJIX, Belatacept
CP.PHAR.202 (PDF) RUCONEST, C1 Esterase Inhibitor (Recombinant)
BERINERT, C1 Esterase Inhibitor (Human)
HAEGARDA, C1 Esterase Inhibitor (Human)
CINRYZE, C1 Esterase Inhibitor (Human)
CP.PHAR.204 (PDF) YONDELIS, Trabectedin
CP.PHAR.206 (PDF) CARBAGLU, Carglumic Acid
CP.PHAR.209 (PDF) CAYSTON, Aztreonam Lysine
CP.PHAR.210 (PDF) KALYDECO, Ivacaftor
CP.PHAR.211 (PDF) TOBI, Tobramycin
KITABIS PAK, Tobramycin
BETHKIS, Tobramycin
TOBI PODHALER, Tobramycin
CP.PHAR.212 (PDF) PULMOZYME, Dornase Alfa
CP.PHAR.213 (PDF) ORKAMBI, Lumacaftor-Ivacaftor
CP.PHAR.214 (PDF) DDAVP, Desmopressin Acetate
NOCDURNA, Desmopressin Acetate
STIMATE, Desmopressin Acetate
NOCTIVA, Desmopressin Acetate
CP.PHAR.215 (PDF) REFACTO
XYNTHA SOLOFUSE, Antihemophilic Factor (Recombinant)
XYNTHA, Antihemophilic Factor (Recombinant)
RECOMBINATE, Antihemophilic Factor (Recombinant)
OBIZUR, Antihemophilic Factor (Recombinant)
NUWIQ, Antihemophilic Factor (Recombinant)
NOVOEIGHT, Antihemophilic Factor (Recombinant)
KOVALTRY, Antihemophilic Factor (Recombinant)
KOGENATE FS BIO-SET, Antihemophilic Factor (Recombinant)
KOGENATE FS, Antihemophilic Factor (Recombinant)
HELIXATE FS, Antihemophilic Factor (Recombinant)
ELOCTATE, Antihemophilic Factor (Recombinant)
AFSTYLA, Antihemophilic Factor (Recombinant)
ADYNOVATE, Antihemophilic Factor (Recombinant)
ADVATE, Antihemophilic Factor (Recombinant)
JIVI, Antihemophilic Factor (Human)
KOATE-DVI, Antihemophilic Factor (Human)
HEMOFIL M, Antihemophilic Factor (Human)
ESPEROCT
CP.PHAR.216 (PDF) WILATE, Antihemophilic Factor/von Willebrand Factor Complex (Human)
HUMATE-P, Antihemophilic Factor/von Willebrand Factor Complex (Human)
ALPHANATE/VON WILLEBRANDFACTOR COMPLEX/HUMAN, Antihemophilic Factor/von Willebrand Factor Complex (Human)
CP.PHAR.217 (PDF) FEIBA, Antiinhibitor Coagulant Complex
CP.PHAR.218 (PDF) ALPHANINE SD, Coagulation Factor IX
RIXUBIS, Coagulation Factor IX
REBINYN, Coagulation Factor IX
MONONINE, Coagulation Factor IX
IXINITY, Coagulation Factor IX
IDELVION, Coagulation Factor IX
BENEFIX, Coagulation Factor IX
ALPROLIX, Coagulation Factor IX
CP.PHAR.219 (PDF) BEBULIN, Factor IX Complex
PROFILNINE, Factor IX Complex
CP.PHAR.220 (PDF) NOVOSEVEN RT, Coagulation Factor VIIa (Recombinant)
CP.PHAR.221 (PDF) CORIFACT, Factor XIII Concentrate (Human)
CP.PHAR.222 (PDF) TRETTEN, Coagulation Factor XIII A-Subunit (Recombinant)
CP.PHAR.225 (PDF) FRAGMIN, Dalteparin Sodium
CP.PHAR.226 (PDF) ARIXTRA, Fondaparinux Sodium
CP.PHAR.227 (PDF) PERJETA, Pertuzumab
CP.PHAR.228 (PDF) TRAZIMERA
ONTRUZANT
HERZUMA
HERCEPTIN HYLECTA, Trastuzumab-Hyaluronidase-oysk
HERCEPTIN, Trastuzumab
OGIVRI, Trastuzumab-dkst
KANJINTI
CP.PHAR.229 (PDF) KADCYLA, Ado-Trastuzumab Emtansine
CP.PHAR.230 (PDF) DYSPORT, AbobotulinumtoxinA
CP.PHAR.231 (PDF) XEOMIN, IncobotulinumtoxinA
CP.PHAR.232 (PDF) BOTOX, OnabotulinumtoxinA
CP.PHAR.233 (PDF) MYOBLOC, RimabotulinumtoxinB
CP.PHAR.235 (PDF) TECENTRIQ, Atezolizumab
CP.PHAR.236 (PDF) ARANESP ALBUMIN FREE, Darbepoetin Alfa
CP.PHAR.237 (PDF) EPOGEN, Epoetin Alfa
PROCRIT, Epoetin Alfa
RETACRIT, Epoetin Alfa-epbx
CP.PHAR.238 (PDF) MIRCERA, Methoxy Polyethylene Glycol-Epoetin Beta
CP.PHAR.239 (PDF) TAFINLAR, Dabrafenib Mesylate
CP.PHAR.240 (PDF) MEKINIST, Trametinib Dimethyl Sulfoxide
CP.PHAR.243 (PDF) LEMTRADA, Alemtuzumab (MS)
CP.PHAR.246 (PDF) ILARIS, Canakinumab
CP.PHAR.248 (PDF) AMPYRA, Dalfampridine
CP.PHAR.249 (PDF) TECFIDERA, Dimethyl Fumarate
VUMERITY, Diroximel Fumarate
CP.PHAR.251 (PDF) GILENYA, Fingolimod HCl
CP.PHAR.252 (PDF) COPAXONE, Glatiramer Acetate
GLATOPA, Glatiramer Acetate
CP.PHAR.255 (PDF) AVONEX, Interferon Beta-1a
REBIF, Interferon Beta-1a
CP.PHAR.256 (PDF) EXTAVIA, Interferon Beta-1b
BETASERON, Interferon Beta-1b
CP.PHAR.258 (PDF) NOVANTRONE, Mitoxantrone HCl
CP.PHAR.260 (PDF) TRUXIMA, Rituximab-abbs
RITUXAN HYCELA, Rituximab-Hyaluronidase Human
RITUXAN, Rituximab
RUXIENCE
CP.PHAR.266 (PDF) ARCALYST, Rilonacept
CP.PHAR.270 (PDF) ZEMPLAR, Paricalcitol
CP.PHAR.272 (PDF) ODOMZO, Sonidegib Phosphate
CP.PHAR.273 (PDF) ERIVEDGE, Vismodegib
CP.PHAR.277 (PDF) CYTOGAM, Cytomegalovirus Immune Globulin (Human)
CP.PHAR.285 (PDF) OFEV, Nintedanib Esylate
CP.PHAR.288 (PDF) EXONDYS 51, Eteplirsen
CP.PHAR.289 (PDF) PROBUPHINE IMPLANT KIT, Buprenorphine HCl
SUBLOCADE, Buprenorphine
PROBUPHINE IMPLANT KIT, Buprenorphine HCl
SUBLOCADE, Buprenorphine
CP.PHAR.290 (PDF) ARISTADA, Aripiprazole Lauroxil
ABILIFY MAINTENA, Aripiprazole
ARISTADA INITIO, Aripiprazole Lauroxil
CP.PHAR.292 (PDF) ZYPREXA RELPREVV, Olanzapine Pamoate
CP.PHAR.293 (PDF) RISPERDAL CONSTA, Risperidone Microspheres
PERSERIS, Risperidone
CP.PHAR.295 (PDF) LEUKINE, Sargramostim
CP.PHAR.296 (PDF) NEULASTA, Pegfilgrastim
UDENYCA, Pegfilgrastim-cbqv
FULPHILA, Pegfilgrastim-jmdb
CP.PHAR.297 (PDF) GRANIX, Tbo-Filgrastim
ZARXIO, Filgrastim-sndz
NEUPOGEN, Filgrastim
NIVESTYM, Filgrastim-aafi
CP.PHAR.298 (PDF) GILOTRIF, Afatinib Dimaleate
CP.PHAR.301 (PDF) ERWINAZE, Asparaginase Erwinia Chrysanthemi
CP.PHAR.302 (PDF) NINLARO, Ixazomib Citrate
CP.PHAR.303 (PDF) ADCETRIS, Brentuximab Vedotin
CP.PHAR.304 (PDF) ONIVYDE, Irinotecan HCl Liposome
CP.PHAR.305 (PDF) GAZYVA, Obinutuzumab
CP.PHAR.306 (PDF) ARZERRA, Ofatumumab
CP.PHAR.307 (PDF) BENDEKA, Bendamustine HCl
TREANDA, Bendamustine HCl
CP.PHAR.308 (PDF) EMPLICITI, Elotuzumab
CP.PHAR.309 (PDF) KYPROLIS, Carfilzomib
CP.PHAR.310 (PDF) DARZALEX, Daratumumab
CP.PHAR.311 (PDF) BELEODAQ, Belinostat
CP.PHAR.312 (PDF) BLINCYTO, Blinatumomab
CP.PHAR.313 (PDF) FOLOTYN, Pralatrexate
CP.PHAR.314 (PDF) ISTODAX (OVERFILL), Romidepsin
CP.PHAR.315 (PDF) MARQIBO, Vincristine Sulfate Liposome
CP.PHAR.316 (PDF) JEVTANA, Cabazitaxel
CP.PHAR.317 (PDF) ERBITUX, Cetuximab
CP.PHAR.318 (PDF) HALAVEN, Eribulin Mesylate
CP.PHAR.319 (PDF) YERVOY, Ipilimumab
CP.PHAR.320 (PDF) PORTRAZZA, Necitumumab
CP.PHAR.321 (PDF) VECTIBIX, Panitumumab
CP.PHAR.322 (PDF) KEYTRUDA, Pembrolizumab
CP.PHAR.323 (PDF) MOZOBIL, Plerixafor
CP.PHAR.324 (PDF) TORISEL, Temsirolimus
CP.PHAR.325 (PDF) ZALTRAP, Ziv-Aflibercept
CP.PHAR.326 (PDF) LARTRUVO, Olaratumab
CP.PHAR.327 (PDF) SPINRAZA, Nusinersen
CP.PHAR.330 (PDF) CEPROTIN, Protein C Concentrate (Human)
CP.PHAR.331 (PDF) EMFLAZA, Deflazacort
CP.PHAR.332 (PDF) SIGNIFOR, Pasireotide Diaspartate
SIGNIFOR LAR, Pasireotide Pamoate
CP.PHAR.333 (PDF) BAVENCIO, Avelumab
CP.PHAR.335 (PDF) OCREVUS, Ocrelizumab
CP.PHAR.336 (PDF) DUPIXENT, Dupilumab
DUPIXENT, Dupilumab (Asthma)
CP.PHAR.338 (PDF) BRINEURA, Cerliponase Alfa
CP.PHAR.339 (PDF) IMFINZI, Durvalumab
CP.PHAR.341 (PDF) AUSTEDO, Deutetrabenazine
CP.PHAR.343 (PDF) RADICAVA, Edaravone
CP.PHAR.345 (PDF) TYMLOS, Abaloparatide
CP.PHAR.349 (PDF) ZYKADIA, Ceritinib
CP.PHAR.351 (PDF) CUBICIN RF, Daptomycin
CUBICIN, Daptomycin
CP.PHAR.352 (PDF) VYXEOS, Daunorubicin-Cytarabine Liposome
CP.PHAR.353 (PDF) ONCASPAR, Pegaspargase
ASPARLAS, Calaspargase Pegol-mknl
CP.PHAR.354 (PDF) JATENZO
TESTOPEL, Testosterone
CP.PHAR.357 (PDF) ALIQOPA, Copanlisib HCl
CP.PHAR.358 (PDF) MYLOTARG, Gemtuzumab Ozogamicin
CP.PHAR.359 (PDF) BESPONSA, Inotuzumab Ozogamicin
CP.PHAR.360 (PDF) LYNPARZA, Olaparib
CP.PHAR.361 (PDF) KYMRIAH, Tisagenlecleucel
CP.PHAR.362 (PDF) YESCARTA, Axicabtagene Ciloleucel
CP.PHAR.367 (PDF) PREVYMIS, Letermovir
CP.PHAR.368 (PDF) ALIMTA, Pemetrexed Disodium
CP.PHAR.370 (PDF) HEMLIBRA, Emicizumab-kxwh
CP.PHAR.371 (PDF) ZILRETTA, Triamcinolone Acetonide
CP.PHAR.372 (PDF) LUXTURNA, Voretigene Neparvovec-rzyl
CP.PHAR.373 (PDF) FASENRA, Benralizumab
CP.PHAR.374 (PDF) MEPSEVII, Vestronidase alfa-vjbk
CP.PHAR.378 (PDF) TROGARZO, Ibalizumab-uiyk
CP.PHAR.379 (PDF) PARSABIV, Etelcalcetide HCl
CP.PHAR.384 (PDF) LUTATHERA, Lutetium Lu 177 Dotatate
CP.PHAR.385 (PDF) YUTIQ, Fluocinolone Acetonide (Ophth)
OZURDEX, Dexamethasone (Ophth)
RETISERT, Fluocinolone Acetonide (Ophth)
ILUVIEN, Fluocinolone Acetonide (Ophth)
CP.PHAR.387 (PDF) VIDAZA, Azacitidine
CP.PHAR.388 (PDF) CHLORAMPHENICOL SODIUM SUCCINATE, Chloramphenicol Sodium Succinate
CP.PHAR.389 (PDF) SOMAVERT, Pegvisomant
CP.PHAR.390 (PDF) CHOLBAM, Cholic Acid
CP.PHAR.391 (PDF) SOMATULINE DEPOT, Lanreotide Acetate
CP.PHAR.392 (PDF) ADAGEN, Pegademase Bovine
CP.PHAR.393 (PDF) LEUCOVORIN CALCIUM, Leucovorin Calcium
CP.PHAR.394 (PDF) GALAFOLD, Migalastat HCl
CP.PHAR.395 (PDF) ONPATTRO, Patisiran Sodium
CP.PHAR.396 (PDF) TAKHZYRO, Lanadelumab-flyo
CP.PHAR.397 (PDF) LIBTAYO, Cemiplimab-rwlc
CP.PHAR.398 (PDF) LUMOXITI, Moxetumomab Pasudotox-tdfk
CP.PHAR.399 (PDF) VIZIMPRO, Dacomitinib
CP.PHAR.400 (PDF) COPIKTRA, Duvelisib
CP.PHAR.401 (PDF) ARIKAYCE, Amikacin Sulfate Liposome
CP.PHAR.402 (PDF) GAMIFANT, Emapalumab-lzsg
CP.PHAR.405 (PDF) TEGSEDI, Inotersen Sodium
CP.PHAR.406 (PDF) LORBRENA, Lorlatinib
CP.PHAR.407 (PDF) MULPLETA, Lusutrombopag
CP.PHAR.409 (PDF) TALZENNA, Talazoparib Tosylate
CP.PHAR.410 (PDF) VELCADE, Bortezomib
CP.PHAR.411 (PDF) FIRDAPSE, Amifampridine Phosphate
RUZURGI, Amifampridine
CP.PHAR.412 (PDF) XOSPATA, Gilteritinib Fumarate
CP.PHAR.413 (PDF) DAURISMO, Glasdegib Maleate
CP.PHAR.414 (PDF) VITRAKVI, Larotrectinib Sulfate
CP.PHAR.415 (PDF) ULTOMIRIS, Ravulizumab-cwvz
CP.PHAR.416 (PDF) CABLIVI, Caplacizumab-yhdp
CP.PHAR.417 (PDF) ZULRESSO, Brexanolone
CP.PHAR.418 (PDF) ZINECARD, Dexrazoxane HCl
TOTECT, Dexrazoxane HCl
CP.PHAR.419 (PDF) REVCOVI, Elapegademase-lvlr
CP.PHAR.420 (PDF) OMNIPOD, Insulin Infusion Disposable Pump
CP.PHAR.421 (PDF) ZOLGENSMA, Onasemnogene Abeparvovec-xioi
CP.PHAR.422 (PDF) MAVENCLAD, Cladribine (Multiple Sclerosis)
CP.PHAR.423 (PDF) BALVERSA, Erdafitinib
CP.PHAR.424 (PDF) FASLODEX, Fulvestrant
CP.PHAR.425 (PDF) MYALEPT, Metreleptin
CP.PHAR.427 (PDF) MAYZENT, Siponimod Fumarate
CP.PHAR.428 (PDF) EVENITY, Romosozumab-aqqg
CP.PHAR.429 (PDF) DEPACON, Valproate Sodium
CP.PHAR.430 (PDF) PIQRAY, Alpelisib
CP.PHAR.431 (PDF) XPOVIO, Selinexor
CP.PHAR.432 (PDF) VYNDAQEL, Tafamidis Meglumine (Cardiac)
VYNDAMAX,
CP.PHAR.433 (PDF) POLIVY, Polatuzumab Vedotin-piiq
CP.PHAR.435 (PDF) NUBEQA, Darolutamide
CP.PHAR.436 (PDF) TURALIO, Pexidartinib HCl
CP.PHAR.437 (PDF) TABLOID, Thioguanine
CP.PHAR.438 (PDF) SYPRINE, Trientine HCl
CP.PHAR.439 (PDF) VALSTAR, Valrubicin
CP.PHAR.440 (PDF) TRIKAFTA, Elexacaftor-Tezacaftor-Ivacaftor
CP.PHAR.441 (PDF) ROZLYTREK, Entrectinib
CP.PHAR.442 (PDF) INREBIC, Fedratinib HCl
CP.PHAR.445 (PDF) Brolucizumab-dbll (Beovu)
CP.PHAR.449 (PDF) ADAKVEO, Crizanlizumab-tmca
CP.PHAR.450 (PDF) REBLOZYL, Luspatercept-aamt
CP.PHAR.451 (PDF) OXBRYTA, Voxelotor
CP.PHAR.452 (PDF) EPZ-6438
TAZEMETOSTAT
EPZ438
CP.PHAR.453 (PDF) VYONDYS 53, Golodirsen
CP.PMN.07 (PDF) XOPENEX, Levalbuterol HCl
CP.PMN.08 (PDF) LIDODERM, Lidocaine
ZTLIDO, Lidocaine
CP.PMN.15 (PDF) SAPHRIS, Asenapine Maleate
CP.PMN.19 (PDF) EMEND, Aprepitant
EMEND IV, Fosaprepitant Dimeglumine
CINVANTI, Aprepitant
CP.PMN.20 (PDF) AGGRENOX, Aspirin-Dipyridamole
CP.PMN.27 (PDF) ZYVOX, Linezolid
CP.PMN.32 (PDF) FANAPT, Iloperidone
CP.PMN.33 (PDF) LYRICA, Pregabalin
CP.PMN.35 (PDF) NUVIGIL, Armodafinil
CP.PMN.39 (PDF) PROVIGIL, Modafinil
CP.PMN.42 (PDF) XYREM, Sodium Oxybate
CP.PMN.44 (PDF) DARAPRIM, Pyrimethamine
CP.PMN.47 (PDF) XIFAXAN, Rifaximin
CP.PMN.48 (PDF) RESTASIS, Cyclosporine (Ophth)
CP.PMN.50 (PDF) LATUDA, Lurasidone HCl
CP.PMN.53 (PDF) Off-Label Use, No Coverage Criteria,
CP.PMN.54 (PDF) SYMPAZAN, Clobazam
ONFI, Clobazam
CP.PMN.57 (PDF) ULORIC, Febuxostat
CP.PMN.58 (PDF) HEMANGEOL, Propranolol HCl
CP.PMN.62 (PDF) SIVEXTRO, Tedizolid Phosphate
CP.PMN.64 (PDF) SEROQUEL XR, Quetiapine Fumarate
CP.PMN.65 (PDF) TRINTELLIX, Vortioxetine HBr
CP.PMN.67 (PDF) ENTRESTO, Sacubitril-Valsartan
CP.PMN.68 (PDF) REXULTI, Brexpiprazole
CP.PMN.70 (PDF) CORLANOR, Ivabradine HCl
CP.PMN.71 (PDF) LINZESS, Linaclotide
CP.PMN.82 (PDF) SUBUTEX, Buprenorphine HCl
CP.PMN.84 (PDF) GRASTEK, Timothy Grass Pollen Allergen Extract
CP.PMN.88 (PDF) BINOSTO, Alendronate Sodium
FOSAMAX PLUS D, Alendronate Sodium-Cholecalciferol
CP.PMN.90 (PDF) BENZNIDAZOLE, Benznidazole
CP.PMN.93 (PDF) NUEDEXTA, Dextromethorphan HBr-Quinidine Sulfate
CP.PMN.95 (PDF) Fluticasone Propionate (Xhance)
CP.PMN.100 (PDF) ATELVIA, Risedronate Sodium
ACTONEL, Risedronate Sodium
CP.PMN.101 (PDF) EXELON, Rivastigmine
CP.PMN.102 (PDF) VARUBI, Rolapitant HCl
CP.PMN.103 (PDF) SOLOSEC, Secnidazole
CP.PMN.104 (PDF) HETLIOZ, Tasimelteon
CP.PMN.107 (PDF) PROTOPIC, Tacrolimus (Topical)
ELIDEL, Pimecrolimus
CP.PMN.109 (PDF) BELSOMRA, Suvorexant
CP.PMN.110 (PDF) EUCRISA, Crisaborole
CP.PMN.115 (PDF) BAXDELA, Delafloxacin Meglumine
CP.PMN.122 (PDF) CELEBREX, Celecoxib
CP.PMN.124 (PDF) SPORANOX, Itraconazole
ONMEL, Itraconazole
TOLSURA, Itraconazole
CP.PMN.125 (PDF) SAVELLA, Milnacipran HCl
CP.PMN.127 (PDF) ABSTRAL, Fentanyl Citrate
SUBSYS, Fentanyl
LAZANDA, Fentanyl Citrate
FENTORA, Fentanyl Citrate
ACTIQ, Fentanyl Citrate
CP.PMN.129 (PDF) SYMLIN, Pramlintide Acetate
CP.PMN.130 (PDF) CYSTARAN, Cysteamine HCl
CP.PMN.132 (PDF) CIALIS, Tadalafil
CP.PMN.136 (PDF) VECAMYL, Mecamylamine HCl
CP.PMN.138 (PDF) Age Limit Override (Codeine, Tramadol, Hydrocodone),
HYDROCODONE, Hydrocodone Bitartrate
HYDROCODONE
TRAMADOL, Tramadol HCl
CODEINE
CP.PMN.141 (PDF) ANZEMET, Dolasetron Mesylate
CP.PMN.142 (PDF) AMITIZA, Lubiprostone
CP.PMN.143 (PDF) ABSORICA, Isotretinoin
AMNESTEEM, Isotretinoin
MYORISAN, Isotretinoin
ZENATANE, Isotretinoin
CLARAVIS, Isotretinoin
CP.PMN.145 (PDF) VIIBRYD, Vilazodone HCl
CP.PMN.150 (PDF) DUZALLO, Lesinurad-Allopurinol
ZURAMPIC, Lesinurad
CP.PMN.152 (PDF) LUCEMYRA, Lofexidine HCl
CP.PMN.155 (PDF) VIMPAT, Lacosamide
CP.PMN.156 (PDF) FYCOMPA, Perampanel
CP.PMN.157 (PDF) BANZEL, Rufinamide
CP.PMN.158 (PDF) AKYNZEO IV, Fosnetupitant Choride-Palonosetron HCl
AKYNZEO, Netupitant-Palonosetron
CP.PMN.164 (PDF) EPIDIOLEX, Cannabidiol
CP.PMN.165 (PDF) TOLAK, Fluorouracil (Topical)
CP.PMN.166 (PDF) LUZU, Luliconazole
CP.PMN.167 (PDF) NEO-SYNALAR KIT, Neomycin-Fluocinolone & Emollient
CP.PMN.168 (PDF) OSPHENA, Ospemifene
CP.PMN.169 (PDF) RELISTOR, Methylnaltrexone Bromide
CP.PMN.179 (PDF) MEGACE ES, Megestrol Acetate (Appetite)
CP.PMN.184 (PDF) DIACOMIT, Stiripentol
CP.PMN.186 (PDF) OXERVATE, Cenegermin-bkbj
CP.PMN.188 (PDF) NUZYRA, Omadacycline Tosylate
CP.PMN.190 (PDF) ANNOVERA, Segesterone Acetate-Ethinyl Estradiol
CP.PMN.192 (PDF) MIRVASO, Brimonidine Tartrate (Topical)
CP.PMN.195 (PDF) YUPELRI, Revefenacin
CP.PMN.198 (PDF) MYRBETRIQ, Mirabegron
VESICARE, Solifenacin Succinate
TOVIAZ, Fesoterodine Fumarate
ENABLEX, Darifenacin Hydrobromide
CP.PMN.199 (PDF) SPRAVATO, Esketamine HCl
CP.PMN.201 (PDF) BROVANA, Arformoterol Tartrate
CP.PMN.207 (PDF) EGATEN, Triclabendazole
CP.PMN.209 (PDF) SUNOSI, Solriamfetol HCl
CP.PMN.211 (PDF) NAYZILAM, Midazolam (Anticonvulsant)
CP.PMN.212 (PDF) SIRTURO, Bedaquiline Fumarate
CP.PMN.213 (PDF) ACCRUFER,
CP.PMN.214 (PDF) Continuous Glucose Monitors,
CP.PMN.216 (PDF) VALTOCO, Diazepam (Anticonvulsant)
CP.PMN.221 (PDF) Pitolisant (Wakix)
HIM.PA.03 (PDF) DUREZOL, Difluprednate
MAXIDEX, Dexamethasone (Ophth)
PRED MILD, Prednisolone Acetate (Ophth)
LOTEMAX, Loteprednol Etabonate
ALREX, Loteprednol Etabonate
FML FORTE, Fluorometholone (Ophth)
FML, Fluorometholone (Ophth)
HIM.PA.04 (PDF) CLENPIQ, Sodium Picosulfate-Magnesium Oxide-Anhydrous Citric Acid
OSMOPREP, Sodium Phosphate Monobasic-Sodium Phosphate Dibasic
MOVIPREP, PEG 3350-KCl-NaCl-Na Sulfate-Na Ascorbate-Ascorbic Acid
PREPOPIK, Sodium Picosulfate-Magnesium Oxide-Anhydrous Citric Acid
HIM.PA.05 (PDF) DEXILANT, Dexlansoprazole
HIM.PA.06 (PDF) DUAKLIR PRESSAIR, Aclidinium Bromide-Formoterol Fumarate
HIM.PA.07 (PDF) BRIVIACT, Brivaracetam
HIM.PA.08 (PDF) BARACLUDE, Entecavir
HIM.PA.09 (PDF) TRESIBA, Insulin Degludec
HIM.PA.11 (PDF) RESCULA, Unoprostone Isopropyl
HIM.PA.12 (PDF) MYCOBUTIN, Rifabutin
HIM.PA.14 (PDF) OTOVEL, Ciprofloxacin-Fluocinolone Acetonide
HIM.PA.15 (PDF) SIMBRINZA, Brinzolamide-Brimonidine Tartrate
HIM.PA.16 (PDF) ATGAM, Lymphocyte Immune Globulin,Anti-Thymocyte Globulin (Equine)
THYMOGLOBULIN, Anti-Thymocyte Globulin (Rabbit), Lymphocyte Immune Globulin
HIM.PA.17 (PDF) UVADEX, Methoxsalen (Photopheresis)
HIM.PA.19 (PDF) GLEOSTINE, Lomustine
HIM.PA.20 (PDF) HALOG, Halcinonide
HIM.PA.21 (PDF) EVOCLIN, Clindamycin Phosphate (Topical)
HIM.PA.25 (PDF) JUBLIA, Efinaconazole
HIM.PA.29 (PDF) VASCEPA, Icosapent Ethyl
HIM.PA.31 (PDF) BENZACLIN, Clindamycin Phosphate-Benzoyl Peroxide
HIM.PA.33 (PDF) Formulary Medications Without Specific Guidelines,
HIM.PA.34 (PDF) Non-Formulary Test Strips,
HIM.PA.35 (PDF) SUBOXONE, Buprenorphine HCl-Naloxone HCl Dihydrate
BUNAVAIL, Buprenorphine HCl-Naloxone HCl Dihydrate
HIM.PA.42 (PDF) APRISO, Mesalamine
HIM.PA.46 (PDF) BUTORPHANOL TARTRATE, Butorphanol Tartrate
HIM.PA.48 (PDF) PULMICORT, Budesonide (Inhalation)
HIM.PA.53 (PDF) TRULICITY, Dulaglutide
BYDUREON BCISE, Exenatide
BYDUREON, Exenatide
XULTOPHY 100/3.6, Insulin Degludec-Liraglutide
VICTOZA, Liraglutide
BYETTA, Exenatide
HIM.PA.58 (PDF) ONGLYZA, Saxagliptin HCl
GLYXAMBI, Empagliflozin-Linagliptin
NESINA, Alogliptin Benzoate
HIM.PA.65 (PDF) ALVESCO, Ciclesonide
HIM.PA.71 (PDF) DUAC, Clindamycin Phosphate-Benzoyl Peroxide (Refrigerate)
RETIN-A MICRO, Tretinoin Microsphere
BENZAMYCIN, Benzoyl Peroxide-Erythromycin
DIFFERIN (cream, gel), Adapalene
HIM.PA.78 (PDF) TRUVADA, Emtricitabine-Tenofovir Disoproxil Fumarate
HIM.PA.87 (PDF) ANDRODERM, Testosterone
HIM.PA.89 (PDF) AZILECT, Rasagiline Mesylate
HIM.PA.91 (PDF) INVOKANA, Canagliflozin
GLYXAMBI, Empagliflozin-Linagliptin
SYNJARDY, Empagliflozin-Metformin HCl
JARDIANCE, Empagliflozin
XIGDUO XR, Dapagliflozin-Metformin HCl
FARXIGA, Dapagliflozin Propanediol
INVOKAMET, Canagliflozin-Metformin HCl
HIM.PA.93 (PDF) NASONEX, Mometasone Furoate (Nasal)
HIM.PA.100 (PDF) Non-Formulary and Formulary Contraceptives,
HIM.PA.102 (PDF) UTIBRON NEOHALER, Indacaterol Maleate-Glycopyrrolate
HIM.PA.103 (PDF) Brand Name Override and Non-Formulary Medication Policy,
HIM.PA.106 (PDF) ANORO ELLIPTA, Umeclidinium-Vilanterol
HIM.PA.108 (PDF) CRESEMBA, Isavuconazonium Sulfate
HIM.PA.109 (PDF) ODEFSEY, Emtricitabine-Rilpivirine-Tenofovir Alafenamide Fumarate
ATRIPLA, Efavirenz-Emtricitabine-Tenofovir Disoproxil Fumarate
TRIBENZOR, Olmesartan Medoxomil-Amlodipine-Hydrochlorothiazide
MIGRANAL, Dihydroergotamine Mesylate
AZOR, Amlodipine Besylate-Olmesartan Medoxomil
DELSTRIGO, Doravirine-Lamivudine-Tenofovir Disoproxil Fumarate
SYMTUZA, Darunavir-Cobicistat-Emtricitabine-Tenofovir Alafenamide
NEVANAC, Nepafenac
ILEVRO, Nepafenac
PONSTEL, Mefenamic Acid
PROFENO, Fenoprofen Calcium
SUPRAX, Cefixime
TACLONEX, Calcipotriene-Betamethasone Dipropionate
OLUX, Clobetasol Propionate
SUMADAN WASH, Sulfacetamide Sodium w/ Sulfur
ZIANA, Clindamycin Phosphate-Tretinoin
VELTIN, Clindamycin Phosphate-Tretinoin
EPIDUO, Adapalene-Benzoyl Peroxide
AZELEX, Azelaic Acid (Acne)
DIFFERIN (lotion), Adapalene
ADAPALENE, Adapalene
LUMIGAN, Bimatoprost
REQUIP XL, Ropinirole Hydrochloride
APTIOM, Eslicarbazepine Acetate
ZOMIG, Zolmitriptan
FROVA, Frovatriptan Succinate
RELPAX, Eletriptan Hydrobromide
AXERT, Almotriptan Malate
VYVANSE, Lisdexamfetamine Dimesylate
ROZEREM, Ramelteon
LUNESTA, Eszopiclone
VENLAFAXINE HCL ER, Venlafaxine HCl
LIVALO, Pitavastatin Calcium
ALTOPREV, Lovastatin
EDARBI, Azilsartan Medoxomil
EQUETRO, Carbamazepine (Antipsychotic)
Step Therapy Criteria
COMPLERA, Emtricitabine-Rilpivirine-Tenofovir Disoproxil Fumarate
HIM.PA.114 (PDF) BONTRIL PDM, Phendimetrazine Tartrate
HIM.PA.117 (PDF) KERYDIN, Tavaborole
HIM.PA.119 (PDF) FINACEA, Azelaic Acid
HIM.PA.120 (PDF) CIPRODEX, Ciprofloxacin-Dexamethasone
HIM.PA.121 (PDF) WELCHOL, Colesevelam HCl
HIM.PA.123 (PDF) FLECTOR, Diclofenac Epolamine
SOLARAZE, Diclofenac Sodium (Actinic Keratoses)
HIM.PA.124 (PDF) SKLICE, Ivermectin (Pediculicide)
HIM.PA.125 (PDF) FETZIMA, Levomilnacipran HCl
HIM.PA.129 (PDF) SINGULAIR, Montelukast Sodium
HIM.PA.130 (PDF) NAPROSYN, Naproxen
HIM.PA.131 (PDF) BYSTOLIC, Nebivolol HCl
HIM.PA.134 (PDF) NATROBA, Spinosad
HIM.PA.139 (PDF) Opioid Analgesics,
HIM.PA.140 (PDF) DUAVEE, Conjugated Estrogens-Bazedoxifene
HIM.PA.143 (PDF) KLOR-CON, Potassium Chloride
HIM.PA.146 (PDF) ZONTIVITY, Vorapaxar Sulfate
HIM.PA.147 (PDF) ZONALON, Doxepin HCl (Antipruritic)
PRUDOXIN, Doxepin HCl (Antipruritic)
SILENOR, Doxepin HCl (Sleep)
HIM.PA.SP14 (PDF) AVONEX, Interferon Beta-1a
REBIF, Interferon Beta-1a
HIM.PA.SP17 (PDF) TYSABRI MS, Natalizumab
HIM.PA.SP18 (PDF) PLEGRIDY, Peginterferon Beta-1a
HIM.PA.SP30 (PDF) VELPHORO, Sucroferric Oxyhydroxide
HIM.PA.SP39 (PDF) ZOMACTON, Somatropin
SEROSTIM, Somatropin
SAIZEN, Somatropin
OMNITROPE, Somatropin
ZORBTIVE, Somatropin
NORDITROPIN FLEXPRO, Somatropin
HUMATROPE, Somatropin
GENOTROPIN MINIQUICK, Somatropin
GENOTROPIN, Somatropin
NUTROPIN AQ NUSPIN, Somatropin
HUMATROPE COMBO PACK, Somatropin
HIM.PA.SP55 (PDF) VISTOGARD, Uridine Triacetate (Emergency Treatment)
HIM.PA.SP59 (PDF) LEUKERAN, Chlorambucil
HIM.PA.SP60 (PDF) XELJANZ XR, Tofacitinib Citrate
XELJANZ, Tofacitinib Citrate
TREMFYA, Guselkumab
TALTZ, Ixekizumab
SIMPONI ARIA, Golimumab
SILIQ, Brodalumab
OLUMIANT, Baricitinib
KEVZARA, Sarilumab
ILUMYA, Tildrakizumab-asmn
ENTYVIO, Vedolizumab
CIMZIA, Certolizumab Pegol
RENFLEXIS, Infliximab-abda
INFLECTRA, Infliximab-dyyb
REMICADE, Infliximab
STELARA, Ustekinumab
KINERET, Anakinra
ORENCIA, Abatacept
OTEZLA, Apremilast
SIMPONI, Golimumab
COSENTYX, Secukinumab
ACTEMRA, Tocilizumab
HUMIRA, Adalimumab
ENBREL, Etanercept
TYSABRI CD, Natalizumab
HIM.PHAR.21 (PDF) Off-Label Drug Use

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 Sunflower Health Plan Payment Policy Manual apply with respect to Sunflower Health Plan members. Policies in the Sunflower Health Plan Payment Policy Manual may have either a Sunflower Health Plan or a “Centene” heading.  In addition, Sunflower Health Plan 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 Sunflower Health Plan.     

If you have any questions regarding these policies, please contact Customer Service and ask to be directed to the Medical Management department.

Policy # Title Description
KS.PP.501 15-Day Readmission (PDF) Aims to incentivize providers to increase quality of care by denying payment to providers for preventable readmissions within 15 days of initial discharge.
CC.PP.500 3-Day Payment Window (PDF) Aims to ensure that payment for the technical component of all outpatient diagnostic services and related non-diagnostic services are bundled with the claim for an inpatient stay when services are furnished within 3 calendar days. 
CC.PP.030 Add-on Code Billed Without Primary Code (PDF) The purpose of this policy is explain the parameters for add-on codes submitted on physician claims.
CC.PP.029 Assistant Surgeon (PDF) The purpose of this policy is to define payment criteria for procedures which are appropriate to be billed with the assistant surgeon modifier to be used in making payment decisions and administering benefits.
CC.PP.037 Bilateral Procedures (PDF) The purpose of this policy is to define the appropriate billing criteria for bilateral services.
CC.PP.008 Cerumen Removal (PDF) The purpose of this policy is to define separate payment criteria for removal of impacted cerumen to be used by Health Plan in making payment decisions and administering benefits.
CC.PP.021 Clean Claims (PDF) The purpose of this policy is to define the minimum claim submission requirements for claims submitted to the health plan for processing from all providers, including facilities (e.g., hospitals, ambulatory surgery centers) and professional providers (e...
CC.PP.013 Clinical Validation of Modifier 25 (PDF) The policy applies to the use of modifier 25; which should only be used to indicate that a “significant, separately identifiable evaluation and management service (was provided) by the same physician on the same day of the procedure or other service.”
CC.PP.014 Clinical Validation of Modifier 59 (PDF) The policy applies to the use of modifier 59; which should only be used to indicate that two or more procedures are performed at different anatomic sites or different patient encounters. 
CC.PP.011 Coding Overview (PDF) The purpose of this policy is to serve as a reference guide for general coding and claims editing information.
CC.PP.024 Cosmetic Procedures (PDF) Cosmetic procedures or procedures connected with the cosmetic surgery are not reimbursable. The Centers for Medicare and Medicaid Services (CMS) define cosmetic procedures as “any surgical procedure, directed at improving appearance, except when required ...
CC.PP.020 Distinct Procedural Modifiers: XE, XS, XP, & XU (PDF) The policy applies to use of 4 new modifiers to be used in place of modifier 59.
CC.PP.044 Duplicate Primary Code Billing (PDF) The purpose of this policy is to define payment criteria when a primary procedure code is billed in multiple quantities instead of the more appropriate "add-on" code.
CC.PP.051 E&M Medical Decision-Making (PDF) The policy discusses the appropriate assignment of moderate to high complexity E&M services with an emphasis on medical decision making as a key component of the assignment process.
CC.PP.010 E&M Bundling (PDF) The purpose of this policy is to define payment criteria for those physician services included in the payment for E/M services to be used by Health Plan in making payment decisions and administering benefits.
CC.PP.016 Global Maternity Package (PDF) The purpose of this policy is to serve as a reference guide for coding global obstetrical package for reimbursement.
CC.PP.023 Hospital Visit Codes Billed with Labs (PDF) The purpose of this policy is to serve as a reference guide for coding hospital visits with laboratory tests.
CC.PP.038 Inpatient Consultation (PDF) The purpose of this policy is to outline how the health plan evaluates CPT consultation codes 99251-99255 and HCPCS codes G0406-G0408 for reimbursement, particularly identifying those that should have been billed at the appropriate level of subsequent hos...
CC.PP.018 Inpatient Only Procedures (PDF) The purpose of this policy is to serve as a reference guide on procedures that will reimbursed as inpatient only services.
CC.PP.012 Intravenous Hydration (PDF) According to the American Medical Association (AMA), CPT code 96360 is used to report intravenous (IV) infusions for hydration purposes. The code is used to report the first 31 minutes to 1 hour of hydration therapy. CPT code 96361 is used to report eac...
CC.PP.007 Maximum Units (PDF) The purpose of this policy is to define payment criteria for the maximum units of service billed on a claim to be used by Health Plan in making payment decisions and administering benefits. 
CC.PP.015 Moderate Conscious Sedation (PDF) The purpose of this policy is to serve as a reference guide for coding drug induced depression of consciousness for reimbursement.
CC.PP.034 Modifier DOS Validation (PDF) Providers append modifiers to procedures and services to indicate that a procedure or service has been altered by some circumstance, but the definition of the procedure or the procedure code itself is unchanged.
CC.PP.028 Modifier to Procedure Code Validation (PDF) Providers append modifiers to procedures codes to indicate that a procedure or service has been altered by some circumstance, but the definition of the procedure or the procedure code itself is unchanged. This policy is relevant to modifiers identified a...
CC.PP.033 Multiple CPT Code Replacement (PDF) When a single, more comprehensive procedure code exists to describe a service, the single more comprehensive code should be used versus multiple CPT codes.
CC.PP.031 NCCI Unbundling (PDF) The health plan administers unbundling edits based on the Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI).  The NCCI edit reimbursement methodologies dictate that when two relatable procedure codes are billed for...
CC.PP.017 Never Paid Events (PDF) The purpose of this policy is to serve as a reference guide for Never Events for non-payment.
CC.PP.036 New Patient (PDF) The purpose of this policy is to define payment criteria and appropriate use of the new patient evaluation and management (E&M) procedure codes.
CC.PP.060 Not Medically Necessary Inpatient Professional Services (PDF) The purpose of this policy is to define payment criteria for medical professional services when the inpatient facility admission is denied as not medically necessary.
CC.PP.039 Outpatient Consultations (PDF) The purpose of this policy is to outline how the health plan evaluates CPT consultation codes 99241-99245 and HCPS codes G0425-G0427 for reimbursement, particularly identifying those that should have been billed at the appropriate level of office visit, e...
CC.PP.041 Pre-operative Visits (PDF) The purpose of this policy is to define payment criteria for E&M services when billed with surgical procedures having a 000, 010 or 090, MMM, and ZZZ global period to be used in making payment decisions and administering benefits.
CC.PP.042 Post-operative Visits (PDF) The purpose of this policy is to define payment criteria for E&M services when billed with surgical procedures having a 000, 010 or 090, MMM, and ZZZ global period to be used in making payment decisions and administering benefits.
CC.PP.027 Professional Component (PDF)  Certain procedure codes represent both the technical and professional component of a procedure or service.
CC.PP.019 Professional Services (Visit Codes) Billed With Labs (PDF) Providers may receive reimbursement for visit codes (evaluation and management services) in addition to a laboratory test, but only when the provider performs a distinct and separately identifiable service in addition to the test.
CC.PP.025 Pulse Oximetry (PDF) The purpose of this policy is to define payment criteria for pulse oximetry testing when billed separately from an office visit.
CC.PP.035 Sleep Studies Place of Service (PDF) The purpose of this policy is to define the appropriate place of service for sleep studies.
CC.PP.049 Status B Bundled Services (PDF) The purpose of this policy is to define payment criteria for covered services designated by CMS as always bundled to another procedure or service to be used in making payment decisions and administering benefits.
CC.PP.046 Status P Bundled Services (PDF) The purpose of this policy is to define payment criteria for covered services designated by CMS as always bundled to another physician's procedure or service to be used in making payment decisions and administering benefits.
CC.PP.032 Supplies Billed on Same Day As Surgery (PDF) The purpose of this policy is to define payment criteria for supplies billed on the same date as a surgical procedure to be used by the health plan in making payment decisions.
KS.CP.MP.38 Ultrasound in Pregnancy - KS (PDF) This policy outlines the medical necessity criteria for ultrasound use in pregnancy. 
CC.PP.043 Unbundled Professional Services (PDF) The purpose of this policy is to define payment criteria for national specialty society surgical code pair edit relationships to be used in making payment decisions and administering benefits
CC.PP.045 Unbundled Surgical Procedures (PDF) The purpose of this policy is to define payment criteria for national specialty society surgical code pair edit relationships to be used in making payment decisions and administering benefits
CC.PP.009 Unlisted Procedure Codes (PDF) Outlines the parameters and documentation requirements necessary when an unlisted or unspecified procedure code is utilized. 
CC.PP.040 Visits On Same Day As Surgery (PDF) For purposes of this policy, “same day visits” address evaluation and management services that occur on the same day as the surgical procedure.
CC.PP.502 Wheelchairs and Accessories (PDF) The purpose of this policy is to define coverage criteria for options and accessories for manual and powered wheelchairs to be used by the Health Plan in making coverage decisions and administering benefits. 
Policy # Title
CC.PP.007 Maximum Units (PDF)
CC.PP.008 Cerumen Removal (PDF)
CC.PP.009 Unlisted Procedure Codes (PDF)
CC.PP.010 EM Bundling Edits (PDF)
CC.PP.011 Coding Overview (PDF)
CC.PP.012 IV Hydration (PDF)
CC.PP.013 Modifier -25 clinical validation (PDF)
CC.PP.014 Modifier -59 clinical validation (PDF)
CC.PP.015 Moderate Conscious Sedation (PDF)
CC.PP.016 Global Maternity Billing (PDF)
CC.PP.017 Never Paid Events (PDF)
CC.PP.018 Inpatient Only Procedures (PDF)
CC.PP.019 Physician Visit Codes Billed with Labs (PDF)
CC.PP.020 Distinct Procedural Modifiers (PDF)
CC.PP.021 Clean Claims (PDF)
CC.PP.023 Hospital Visit Codes Billed with Labs (PDF)
CC.PP.024 Cosmetic Procedures (PDF)
CC.PP.025 Pulse Oximetry (PDF)
CC.PP.027 Professional Component (PDF)
CC.PP.028 Modifier to Procedure Code Validation (PDF)
CC.PP.029 Assistant Surgeon (PDF)
CC.PP.030 Add on Code Billed Without Primary Code (PDF)
CC.PP.031 NCCI Unbundling (PDF)
CC.PP.032 Supplies Billed on Same Day As Surgery (PDF)
CC.PP.033 Multiple CPT Code Replacement (PDF)
CC.PP.034 Modifier DOS Validation (PDF)
CC.PP.035
Sleep Studies Place of Services (PDF)
CC.PP.036 New Patient (PDF)
CC.PP.037 Bilateral Procedures (PDF)
CC.PP.038 Inpatient Consultation (PDF)
CC.PP.039 Outpatient Consultation (PDF)
CC.PP.040 Same Day Visits (PDF)
CC.PP.041 Pre-Operative Visits (PDF)
CC.PP.042 Post-Operative Visits (PDF)
CC.PP.043 Unbundled Professional Services (PDF)
CC.PP.044 Duplicate Primary Code Billing (PDF)
CC.PP.045 Unbundled Surgical Procedures (PDF)
CC.PP.046 Status "B" Bundled Services (PDF)
CC.PP.047 Transgender Related Services (PDF)
CC.PP.049 Status P Bundled Services (PDF)
CC.PP.051 E&M Medical Decision-Making (PDF)
CC.PP.052 Problem Oriented Visits with Surgical Procedures (PDF)
CC.PP.053 Leveling of ER Services (PDF)
CC.PP.055 Physician's Office Lab Testing (PDF)
CC.PP.056 Urine Specimen Validity Testing (PDF)
CC.PP.057 Problem Oriented Visits with Preventative Visits (PDF)
CC.PP.060 Not Medically Necessary IP Serv (PDF)
CC.PP.061 Pelvic and Transabdominal US (PDF)
CC.PP.065 Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF) Effective 9/1/2020
CC.PP.500 3-Day Payment Window (PDF)
CC.PP.501 30-Day Readmission (PDF)
CC.PP.502 Wheelchair Accessories (PDF)
Policy # Title
CC.PP.007 Maximum Units (PDF)
CC.PP.008 Cerumen Removal (PDF)
CC.PP.009 Unlisted Procedure Codes (PDF)
CC.PP.010 EM Bundling Edits (PDF)
CC.PP.011 Coding Overview (PDF)
CC.PP.012 IV Hydration (PDF)
CC.PP.013 Modifier -25 clinical validation (PDF)
CC.PP.014 Modifier -59 clinical validation (PDF)
CC.PP.015 Moderate Conscious Sedation (PDF)
CC.PP.016 Global Maternity Billing (PDF)
CC.PP.017 Never Paid Events (PDF)
CC.PP.018 Inpatient Only Procedures (PDF)
CC.PP.019 Physician Visit Codes Billed with Labs (PDF)
CC.PP.020 Distinct Procedural Modifiers (PDF)
CC.PP.021 Clean Claims (PDF)
CC.PP.023 Hospital Visit Codes Billed with Labs (PDF)
CC.PP.024 Cosmetic Procedures (PDF)
CC.PP.025 Pulse Oximetry (PDF)
CC.PP.027 Professional Component (PDF)
CC.PP.028 Modifier to Procedure Code Validation (PDF)
CC.PP.029 Assistant Surgeon (PDF)
CC.PP.030 Add on Code Billed Without Primary Code (PDF)
CC.PP.031 NCCI Unbundling (PDF)
CC.PP.032 Supplies Billed on Same Day As Surgery (PDF)
CC.PP.033 Multiple CPT Code Replacement (PDF)
CC.PP.034 Modifier DOS Validation (PDF)
CC.PP.036 New Patient (PDF)
CC.PP.037 Bilateral Procedures (PDF)
CC.PP.038 Inpatient Consultation (PDF)
CC.PP.039 Outpatient Consultation (PDF)
CC.PP.040 Same Day Visits (PDF)
CC.PP.041 Pre-Operative Visits (PDF)
CC.PP.042 Post-Operative Visits (PDF)
CC.PP.043 Unbundled Professional Services (PDF)
CC.PP.044 Duplicate Primary Code Billing (PDF)
CC.PP.045 Unbundled Surgical Procedures (PDF)
CC.PP.046 Status "B" Bundled Services (PDF)
CC.PP.047 Transgender Related Services (PDF)
CC.PP.049 Status P Bundled Services (PDF)
CC.PP.050 Robotic Surgery (PDF)
CC.PP.051 E&M Medical Decision-Making (PDF)
CC.PP.052 Problem Oriented Visits with Surgical Procedures (PDF)
CC.PP.053 Leveling of ER Services (PDF)
CC.PP.054 Physician's Consultation Services (PDF)
CC.PP.055 Physician's Office Lab Testing (PDF)
CC.PP.056 Urine Specimen Validity Testing (PDF)
CC.PP.057 Problem Oriented Visits with Preventative Visits (PDF)
CC.PP.060 Not Medically Necessary IP Serv (PDF)
CC.PP.061 Pelvic and Transabdominal US (PDF)
CC.PP.065 Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF) Effective 9/1/2020
CC.PP.500 3-Day Payment Window (PDF)
CC.PP.502 Wheelchair Accessories (PDF)
OC.UM.CP.0029 Fundus Photography (PDF)