Políticas clínicas y de pago

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 NumberPolicy Title
CP.MP.101Donor Lymphocyte Infusion (PDF)
CP.MP.102Pancreas Transplantation (PDF)
CP.MP.106Endomatrial Ablation (PDF)
CP.MP.107Durable Medical Equipment and Orthotics and Prosthetics Guidelines (DME) (PDF)
CP.MP.108Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia (PDF)
CP.MP.109Panniculectomy (PDF)
CP.MP.117Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF)
CP.MP.12Vagus Nerve Stimulation (PDF)
CP.MP.120Pediatric Liver Transplant (PDF)
CP.MP.127Total Artificial Heart (PDF)
CP.MP.128Optic Nerve Decompression Surgery (PDF)
CP.MP.129Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)
CP.MP.130Fertility Preservation (PDF)
CP.MP.132Heart-Lung Transplant (PDF)
CP.MP.133Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)
CP.MP.136Home Births (PDF)
CP.MP.137Fecal Incontinence Treatments (PDF)
CP.MP.138Pediatric Heart Transplant (PDF)
CP.MP.14Cochlear Implant Replacements (PDF)
CP.MP.141Non-Myeloablative Allogeneic Stem Cell Transplants (PDF)
CP.MP.142Urinary Incontinence Devices and Treatments (PDF)
CP.MP.144Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
CP.MP.145Electric Tumor Treating Fields (Optune) (PDF)
CP.MP.150Phototherapy for Neonatal Hyperbilirubinemia (PDF)
CP.MP.160Implantable Wireless Pulmonary Artery Pressure Monitoring  (PDF)
CP.MP.162Tandem Transplant (PDF)
CP.MP.164Caudal or Interlaminar Epidural Steroid Injections (PDF)
CP.MP.165Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)
CP.MP.166Sacroiliac Joint Interventions for Pain Management (PDF)
CP.MP.167Intradiscal Steroid Injections for Pain Management (PDF)
CP.MP.168Biofeedback (PDF)
CP.MP.169Trigger Point Injections for Pain Management (PDF)
CP.MP.170Nerve Blocks and Neurolysis for Pain Management (PDF)
CP.MP.171Facet Joint Interventions (PDF)
CP.MP.173Implantable Intrathecal or Epidural Pain Pump (PDF)
CP.MP.174Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)
CP.MP.180Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)
CP.MP.182Short Inpatient Hospital Stay (PDF)
CP.MP.185Skin Substitutes for Chronic Wounds (PDF)
CP.MP.186Burn Surgery (PDF)
CP.MP.190Outpatient Oxygen Use  (PDF)
CP.MP.194Osteogenic Stimulation (PDF)
CP.MP.202Orthognathic Surgery (PDF)
CP.MP.203Diaphragmatic/Phrenic Nerve Stimulation (PDF)
CP.MP.206Skilled Nursing Facility Leveling (PDF)
CP.MP.22Stereotactic Body Radiation Therapy (PDF)
CP.MP.246Pediatric Kidney Transplant (PDF)
CP.MP.26Articular Cartilage Defect Repairs (PDF)
CP.MP.31Cosmetic and Reconstructive Procedures (PDF)
CP.MP.36Experimental Technologies (PDF)
CP.MP.37Bariatric Surgery (PDF)
CP.MP.40Gastric Electrical Stimulation (PDF)
CP.MP.43Functional MRI (PDF)
CP.MP.46Ventricular Assist Devices (PDF)
CP.MP.48Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)
CP.MP.51Reduction Mammoplasty and Gynecomastia Surgery (PDF)
CP.MP.53Ferriscan R2-MRI (PDF)
CP.MP.54Hospice Services (PDF)
CP.MP.55Assisted Reproductive Technology (PDF)
CP.MP.57Lung Transplantation (PDF)
CP.MP.61IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)
CP.MP.62Hyperhidrosis Treatments (PDF)
CP.MP.69Intensity-Modulated Radiotherapy (PDF)
CP.MP.70Proton and Neutron Beam Therapies (PDF)
CP.MP.81NICU Discharge Guidelines (PDF)
CP.MP.85Neonatal Sepsis Management (PDF)
CP.MP.86Neonatal Abstinence Syndrome Guidelines (PDF)
CP.MP.91Obstetrical Home Care Programs (PDF)
CP.MP.92Acupuncture (PDF)
CP.MP.95Gender Affirming Procedures (PDF)
V2.2023Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)
V2.2023Concert Genetic Testing: Cardiac Disorders (PDF)
V2.2023Concert Genetic Testing: Dermatologic Conditions (PDF)
V2.2023Concert Genetic Testing: Epilepsy Neurodegenerative and Neuromuscular Conditions (PDF)
V2.2023Concert Genetic Testing: Exome and Genome Sequencing for Dx of Genetic Disorders (PDF)
V2.2023Concert Genetic Testing: Eye Disorders (PDF)
V2.2023Concert Genetic Testing: Gastroenterologic Disorders non cancerous (PDF)
V2.2023Concert Genetic Testing: General Approach to Genetic Testing (PDF)
V2.2023Concert Genetic Testing: Hearing Loss (PDF)
V2.2023Concert Genetic Testing: Hematologic Conditions non cancerous (PDF)
V2.2023Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF)
V2.2023Concert Genetic Testing: Immune Autoimmune and Rheumatoid Disorders (PDF)
V2.2023Concert Genetic Testing: Kidney Disorders (PDF)
V2.2023Concert Genetic Testing: Lung Disorders (PDF)
V2.2023Concert Genetic Testing: Metabolic Endocrine Mitochondrial Disorders (PDF)
V2.2023Concert Genetic Testing: Multisys Inherited Disorders IDD (PDF)
V2.2023Concert Genetic Testing: Non invasive Prenatal Screening (PDF)
V2.2023Concert Genetic Oncology: Algorithmic Testing (PDF)
V2.2023Concert Genetic Oncology: Cancer Screening (PDF)
V2.2023Concert Genetic Oncology: Circulating Tumor DNA Tumor Cells Liquid Biopsy (PDF)
V2.2023Concert Genetic Oncology: Cytogenetic Testing (PDF)
V2.2023Concert Genetic Oncology: Mol Analysis Solid Tmrs Hem Malig (PDF)
V2.2023Concert Genetic Testing: Pharmacogenetics (PDF)
V2.2023Concert Genetic Testing: Preimplantation Genetic Testing (PDF)
V2.2023Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)
V2.2023Concert Genetic Testing: Prenatal Diagnosis Pregnancy Loss (PDF)
V2.2023Concert Genetic Testing: Skeletal Dysplasia Rare Bone Disorders (PDF)

For members 18 years of age or older authorizations for oncology-related chemotherapeutic drugs and supportive agents are administered by New Century Health. For members 17 years of age or younger the oncology clinical policies listed below apply.

Policy NumberMedication Name
CP.PCH.06 (PDF)VALCYTE, Valganciclovir HCl
CP.PCH.07 (PDF)VIAGRA, Sildenafil Citrate
CP.PCH.09 (PDF)CUPRIMINE, Penicillamine
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.26 (PDF)BRIVIACT, Brivaracetam
CP.PCH.27 (PDF)Compounded Medications
CP.PCH.28 (PDF)Diclofenac (Cambia, Flector, Licart, Pennsaid, Solaraze, Zipsor, Zorvolex)
CP.PCH.30 (PDF)Memantine ER (Namenda XR), Memantine/Donepezil (Namzaric)
CP.PCH.32 (PDF)Dapsone (Aczone Gel)
CP.PCH.37 (PDF)
Aripiprazole Orally Disintegrating Tablet
CP.PCH.38 (PDF)Fingolimod (Gilenya)
CP.PCH.40 (PDF)Teriflunomide (Aubagio)
CP.PCH.41 (PDF)
Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity), Monomethyl Fumarate (Bafiertam)
CP.PCH.42 (PDF)Deutetrabenazine (Austedo)
CP.PCH.43 (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
CP.PCH.44 (PDF)Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep)
CP.PCH.45 (PDF)Apalutamide (Erleada)
CP.PCH.46 (PDF)Interferon Beta-1b (Betaseron, Extavia)
CP.PCH.47 (PDF)Phendimetrazine 
CP.PCH.48 (PDF)Valbenazine (Ingrezza)
CP.PCH.49 (PDF)Omalizumab (Xolair®)
CP.PHAR.01 (PDF)XOLAIR, Omalizumab
CP.PHAR.05 (PDF)Hyaluronate Derivatives
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.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.68 (PDF)Gefitinib (Iressa)
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.96 (PDF)Naltrexone (Vivitrol)
CP.PHAR.97 (PDF)SOLIRIS, Eculizumab
CP.PHAR.98 (PDF)JAKAFI, Ruxolitinib Phosphate
CP.PHAR.100 (PDF)INLYTA, Axitinib
CP.PHAR.101 (PDF)Mifepristone (Korlym)
CP.PHAR.103 (PDF)Immune Globulins
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.112 (PDF)Ponatinib (Iclusig)
CP.PHAR.114 (PDF)GATTEX, Teduglutide (rDNA)
CP.PHAR.115 (PDF)Pegloticase (Krystexxa)
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.124 (PDF)Alirocumab (Praluent)
CP.PHAR.125 (PDF)Palbociclib (Ibrance)
CP.PHAR.126 (PDF)IMBRUVICA, Ibrutinib
CP.PHAR.127 (PDF)BRAFTOVI, Encorafenib
CP.PHAR.128 (PDF)AIMOVIG, Erenumab-aooe
CP.PHAR.129 (PDF)Venetoclax (Venclexta)
CP.PHAR.130 (PDF)DOPTELET, Avatrombopag Maleate
CP.PHAR.131 (PDF)Infertility and Fertility Preservation
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.136 (PDF)Elagolix (Orilissa), Elagolix/Estradiol/Norethinedrone (Oriahnn)
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.147 (PDF)Deferiprone (Ferriprox)
CP.PHAR.149 (PDF)LIORESAL INTRATHECAL, Baclofen
GABLOFEN, Baclofen
OZOBAX, Baclofen
CP.PHAR.150 (PDF)INCRELEX, Mecasermin
CP.PHAR.151 (PDF)Levoleucovorin (Fusilev, Khapzory)
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.165 (PDF)Ferumoxytol (Feraheme)
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.177 (PDF)Ecallantide (Kalbitor)
CP.PHAR.178 (PDF)FIRAZYR, Icatibant Acetate
CP.PHAR.179 (PDF)NPLATE, Romiplostim
CP.PHAR.180 (PDF)PROMACTA, Eltrombopag Olamine
CP.PHAR.181 (PDF)Hemin (Panhematin)
CP.PHAR.184 (PDF)EYLEA, Aflibercept
CP.PHAR.186 (PDF)LUCENTIS, Ranibizumab
CP.PHAR.187 (PDF)Verteporfin
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.196 (PDF)Selexipag (Uptravi)
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.203 (PDF)Cosyntropin (Cortrosyn)
CP.PHAR.204 (PDF)YONDELIS, Trabectedin
CP.PHAR.206 (PDF)CARBAGLU, Carglumic Acid
CP.PHAR.207 (PDF)Glycerol Phenylbutyrate (Ravicti)
CP.PHAR.208 (PDF)Sodium Phenylbutyrate (Buphenyl)
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)Factor VIII (Human, Recombinant)
CP.PHAR.216 (PDF)Factor VIII/von Willebrand Factor Complex (Human – Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi)
CP.PHAR.217 (PDF)FEIBA, Antiinhibitor Coagulant Complex
CP.PHAR.218 (PDF)Factor IX (Human, Recombinant)
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.223 (PDF)Reslizumab (Cinqair)
CP.PHAR.224 (PDF)Enoxaparin (Lovenox)
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.234 (PDF)Ferric Carboxymaltose (Injectafer)
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.259 (PDF)TYSABRI MS, Natalizumab
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.271 (PDF)Peginterferon Beta-1a (Plegridy)
CP.PHAR.272 (PDF)ODOMZO, Sonidegib Phosphate
CP.PHAR.273 (PDF)ERIVEDGE, Vismodegib
CP.PHAR.277 (PDF)CYTOGAM, Cytomegalovirus Immune Globulin (Human)
CP.PHAR.282 (PDF)Parathyroid Hormone (Natpara)
CP.PHAR.283 (PDF)Lomitapide (Juxtapid)
CP.PHAR.285 (PDF)OFEV, Nintedanib Esylate
CP.PHAR.286 (PDF)Pirfenidone (Esbriet)
CP.PHAR.287 (PDF)Obeticholic Acid (Ocaliva)
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.291 (PDF)Paliperidone Long-Acting Injections (Invega Hafyera, Invega Sustenna, Invega Trinza)
CP.PHAR.292 (PDF)ZYPREXA RELPREVV, Olanzapine Pamoate
CP.PHAR.293 (PDF)RISPERDAL CONSTA, Risperidone Microspheres
PERSERIS, Risperidone
CP.PHAR.294 (PDF)Osimertinib (Tagrisso)
CP.PHAR.295 (PDF)LEUKINE, Sargramostim
CP.PHAR.296 (PDF)
  • Pegfilgrastim (Neulasta®, Neulasta® Onpro®) and its biosimilars
  • Egfilgrastim-jmdb (Fulphila™)
  • Pegfilgrastim-pbbk (Fylnetra®)
  • Pegfilgrastim-apgf (Nyvepria™)
  • Eflapegrastim-xnst (Rolvedon™)
  • Pegfilgrastim-fpgk (Stimufend®)
  • Pegfilgrastim-cbqv (Udenyca™)
  • Pegfilgrastim-bmez (Ziextenzo™)
CP.PHAR.297 (PDF)GRANIX, Tbo-Filgrastim
ZARXIO, Filgrastim-sndz
NEUPOGEN, Filgrastim
NIVESTYM, Filgrastim-aafi
CP.PHAR.298 (PDF)GILOTRIF, Afatinib Dimaleate
CP.PHAR.300 (PDF)Bezlotoxumab (Zinplava)
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)Ofatumumab (Arzerra®, Kesimpta®)
CP.PHAR.307 (PDF)Bendamustine (Belrapzo, Bendeka, Treanda, Vivimusta)
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.328 (PDF)Asfotase Alfa (Strensiq)
CP.PHAR.329 (PDF)Siltuximab (Sylvant)
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.334 (PDF)Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara)
CP.PHAR.335 (PDF)OCREVUS, Ocrelizumab
CP.PHAR.336 (PDF)DUPIXENT, Dupilumab
DUPIXENT, Dupilumab (Asthma)
CP.PHAR.337 (PDF)Telotristat Ethyl (Xermelo)
CP.PHAR.338 (PDF)BRINEURA, Cerliponase Alfa
CP.PHAR.339 (PDF)IMFINZI, Durvalumab
CP.PHAR.341 (PDF)AUSTEDO, Deutetrabenazine
CP.PHAR.342 (PDF)Brigatinib (Alunbrig)
CP.PHAR.343 (PDF)RADICAVA, Edaravone
CP.PHAR.344 (PDF)Midostaurin (Rydapt)
CP.PHAR.345 (PDF)TYMLOS, Abaloparatide
CP.PHAR.349 (PDF)ZYKADIA, Ceritinib
CP.PHAR.350 (PDF)Rucaparib (Rubraca)
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.355 (PDF)Abemaciclib (Verzenio)
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.363 (PDF)Enasidenib (Idhifa)
CP.PHAR.365 (PDF)Neratinib (Nerlynx)
CP.PHAR.367 (PDF)PREVYMIS, Letermovir
CP.PHAR.368 (PDF)ALIMTA, Pemetrexed Disodium
CP.PHAR.369 (PDF)Alectinib (Alecensa)
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.377 (PDF)Tezacaftor/Ivacaftor; Ivacaftor (Symdeko)
CP.PHAR.378 (PDF)TROGARZO, Ibalizumab-uiyk
CP.PHAR.379 (PDF)PARSABIV, Etelcalcetide HCl
CP.PHAR.380 (PDF)Cobimetinib (Cotellic)
CP.PHAR.381 (PDF)Mechlorethamine Gel (Valchlor)
CP.PHAR.382 (PDF)Panobinostat (Farydak)
CP.PHAR.383 (PDF)Trifluridine/Tipiracil (Lonsurf)
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.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.408 (PDF)Niraparib (Zejula)
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.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.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.434 (PDF)Bremelanotide (Vyleesi)
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.444 (PDF)Afamelanotide (Scenesse)
CP.PHAR.445 (PDF)Brolucizumab-dbll (Beovu)
CP.PHAR.446 (PDF)Flibanserin (Addyi)
CP.PHAR.447 (PDF)Mercaptopurine (Purixan)
CP.PHAR.448 (PDF)Mometasone Furoate (Sinuva)
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.PHAR.454 (PDF)Avapritinib (Ayvakit)
CP.PHAR.455 (PDF)Enfortumab Vedotin-ejfv (Padcev)
CP.PHAR.456 (PDF)Fam-Trastuzumab Deruxtecan-nxki (Enhertu)
CP.PHAR.457 (PDF)Givosiran (Givlaari)
CP.PHAR.458 (PDF)Inebilizumab-cdon (Uplizna)
CP.PHAR.459 (PDF)Iobenguane I-131 (Azedra)
CP.PHAR.461 (PDF)Nadofaragene Firadenovec (Instiladrin)
CP.PHAR.462 (PDF)Ozanimod (Zeposia)
CP.PHAR.463 (PDF)Satralizumab-mwge (Enspryng) 
CP.PHAR.464 (PDF)Selumetinib (Koselugo)
CP.PHAR.465 (PDF)Teprotumumab (Tepezza)
CP.PHAR.466 (PDF)Valoctocogene Roxaparvovec
CP.PHAR.467 (PDF)
Zanubrutinib (Brukinsa)
CP.PHAR.468 (PDF)Aducanumab-avwa (Aduhelm)
CP.PHAR.469 (PDF)Belantamab Mafodotin (Blenrep)
CP.PHAR.470 (PDF)Casimersen (Amondys 45)
CP.PHAR.471 (PDF)Fosdenopterin (Nulibry)
CP.PHAR.472 (PDF)
Brexucabtagene Autoleucel (Tecartus)
CP.PHAR.473 (PDF)Lumasiran (Oxlumo)
CP.PHAR.475 (PDF)Sacituzumab Govitecan-hziy (Trodelvy)
CP.PHAR.476 (PDF)Ubrogepant (Ubrelvy)
CP.PHAR.477 (PDF)Risdiplam (Evrysdi)
CP.PHAR.478 (PDF)Selpercatinib (Retevmo)
CP.PHAR.479 (PDF)Decitabine/Cedazuridine (Inqovi)
CP.PHAR.480 (PDF)Ferric Derisomaltose (Monoferric)
CP.PHAR.481 (PDF)Idecabtagene Vicleucel (BB2121)
CP.PHAR.482 (PDF)Isatuximab-irfc (Sarclisa)
CP.PHAR.483 (PDF)Lisocabtagene Maraleucel (Breyanzi)
CP.PHAR.484 (PDF)
Viltolarsen (Viltepso)
CP.PHAR.485 (PDF)Berotralstat (Orladeyo)
CP.PHAR.486 (PDF)Bimatoprost Implant (Durysta)
CP.PHAR.487 (PDF)Osilodrostat (Isturisa)
CP.PHAR.488 (PDF)APOKYN, Apomorphine Hydrochloride
CP.PHAR.490 (PDF)Rimegepant (Nurtec ODT)
CP.PHAR.491 (PDF)Setmelanotide (Imcivree)
CP.PHAR.492 (PDF)Teplizumab (PRV-031)
CP.PHAR.494 (PDF)Capmatinib (Tabrecta)
CP.PHAR.495 (PDF)Mitomycin for Pyelocalyceal Solution (Jelmyto)
CP.PHAR.496 (PDF)Pemigatinib (Pemazyre) 
CP.PHAR.497 (PDF)Tucatinib (Tukysa)
CP.PHAR.499 (PDF)Lonafarnib (Zokinvy)
CP.PHAR.500 (PDF)Lurbinectedin (Zepzelca)
CP.PHAR.501 (PDF)Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo)
CP.PHAR.502 (PDF)Ripretinib (Qinlock)
CP.PHAR.503 (PDF)Sutimlimab-jome (Enjaymo)
CP.PHAR.504 (PDF)Voclosporin (Lupkynis)
CP.PHAR.506 (PDF)Antithymocyte Globulin (Atgam, Thymoglobulin)
CP.PHAR.507 (PDF)Lomustine (Gleostine)
CP.PHAR.508 (PDF)Tafasitamab-cxix (Monjuvi)
CP.PHAR.509 (PDF)Triheptanoin (Dojolvi)
CP.PHAR.511 (PDF)Evinacumab
CP.PHAR.513 (PDF)
Plasminogen (Ryplazim)
CP.PHAR.514 (PDF)
Pralsetinib (Gavreto)
CP.PHAR.515 (PDF)Avacopan (Tavneos)
CP.PHAR.516 (PDF)Fostemsavir (Rukobia)
CP.PHAR.518 (PDF)Mannitol (Bronchitol)
CP.PHAR.521 (PDF)Avalglucosidase Alfa-ngpt (Nexviazyme)
CP.PHAR.522 (PDF)Margetuximab-cmkb (Margenza)
CP.PHAR.523 (PDF)Naxitamab-gqgk (Danyelza)
CP.PHAR.524 (PDF)Pegcetacoplan (Empaveli)
CP.PHAR.525 (PDF)Vosoritide (Voxzogo)
CP.PHAR.526 (PDF)Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP)
CP.PHAR.528 (PDF)Odevixibat (A4250)
CP.PHAR.529 (PDF)
  • Relugolix (Orgovyx™)
  • Relugolix/estradiol/norethinedrone (Myfembree®)
CP.PHAR.530 (PDF)Tepotinib (Tepmetko)
CP.PHAR.531 (PDF)Umbralisib (Ukoniq)
CP.PHAR.533 (PDF)Ciltacabtagene Autoleucel
CP.PHAR.534 (PDF)Insulin Delivery Systems (V-Go, Omnipod, InPen)
CP.PHAR.535 (PDF)Melphalan flufenamide (Pepaxto)
CP.PHAR.536 (PDF)Ophthalmic Riboflavin (Photrexa, Photrexa Viscous)
CP.PHAR.537 (PDF)Ponesimod (Ponvory)
CP.PHAR.538 (PDF)Tivozanib (Fotivda)
CP.PHAR.539 (PDF)Loncastuximab Tesirine-lpyl (Zynlonta)
CP.PHAR.540 (PDF)Dostarlimab-gxly (Jemperli)
CP.PHAR.541 (PDF)Sotrovimab (VIR-7831)
CP.PHAR.542 (PDF)Talimogene laherepvec (Imlygic)
CP.PHAR.543 (PDF)Maralixibat (LUM001)
CP.PHAR.544 (PDF)Amivantamab-vmjw (Rybrevant)
CP.PHAR.545 (PDF)Betibeglogene Autotemcel
CP.PHAR.546 (PDF)Carbetocin
CP.PHAR.547 (PDF)Infigratinib (Truseltiq)
CP.PHAR.548 (PDF)Palovarotene (Brand Name)
CP.PHAR.549 (PDF)Sotorasib (Lumakras)
CP.PHAR.550 (PDF)Vutrisiran (ALN-TTRsc02)
CP.PHAR.551 (PDF)Anifrolumab-fnia (Saphnelo)
CP.PHAR.552 (PDF)Belumosudil (Rezurock)
CP.PHAR.553 (PDF)Belzutifan (Welireg)
CP.PHAR.554 (PDF)LEUKERAN, Chlorambucil
CP.PHAR.555 (PDF)Efgartigimod Alfa-fcab (Vyvgart)
CP.PHAR.556 (PDF)Elivaldogene Autotemcel
CP.PHAR.558 (PDF)Mitapivat (Pyrukynd)
CP.PHAR.559 (PDF)Mobocertinib (Exkivity)
CP.PHAR.561 (PDF)Tisotumab vedotin-tftv (Tivdak)
CP.PHAR.562 (PDF)Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft)
CP.PHAR.563 (PDF)Allogenic Processed Thymus Tissue-agdc (Rethymic)
CP.PHAR.564 (PDF)Antithrombin III (ATryn, Thrombate III)
CP.PHAR.565 (PDF)Asciminib (Scemblix)
CP.PHAR.566 (PDF)Atogepant (Qulipta)
CP.PHAR.568 (PDF)Inclisiran (Leqvio)
CP.PHAR.570 (PDF)Ropeginterferon Alfa-2b-njft (BESREMi)
CP.PHAR.572 (PDF)Budesonide (Tarpeyo)
CP.PHAR.573 (PDF)Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva)
CP.PHAR.574 (PDF)Sirolimus Protein-Bound Particles (Fyarro), Topical Gel (Hyftor)
CP.PHAR.575 (PDF)Tebentafusp-tebn (Kimmtrak)
CP.PHAR.576 (PDF)Tezepelumab-ekko (Tezspire)
CP.PHAR.577 (PDF)Tralokinumab-ldrm (Adbry)
CP.PHAR.578 (PDF)Abrocitinib (Cibinqo)
CP.PHAR.580 (PDF)Etranacogene Dezaparvovec (AMT-061)
CP.PHAR.581 (PDF)Faricimab-svoa (Vabysmo)
CP.PHAR.582 (PDF)Lutetium Lu 177 vipivotide tetraxetan (Pluvicto)
CP.PHAR.583 (PDF)Pacritinib (Vonjo)
CP.PHAR.584 (PDF)Sodium Phenylbutyrate/Taurursodiol (AMX0035)
CP.PHAR.586 (PDF)Olipudase alfa (GZ402665)
CP.PHAR.588 (PDF)Nivolumab and Relatlimab-rmbw (Opdualag)
CP.PHAR.590 (PDF)Omaveloxolone (RTA-408)
CP.PHAR.624 (PDF)Ferric Pyrophosphate (Triferic, Triferic Avnu)
CP.PMN.04 (PDF)VELPHORO, Sucroferric Oxyhydroxide
CP.PMN.08 (PDF)Lidocaine Transdermal (Lidoderm, ZTlido)
CP.PMN.15 (PDF)Asenapine (Saphris, Secuado)
CP.PMN.17 (PDF)Droxidopa (Northera)
CP.PMN.19 (PDF)Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection)
CP.PMN.20 (PDF)Aspirin/Dipyridamole (Aggrenox)
CP.PMN.24 (PDF)Ciclopirox (Penlac)
CP.PMN.25 (PDF)JUBLIA, Efinaconazole
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.45 (PDF)
Ondansetron (Zuplenz)
CP.PMN.46 (PDF)Roflumilast (Daliresp)
CP.PMN.47 (PDF)XIFAXAN, Rifaximin
CP.PMN.48 (PDF)RESTASIS, Cyclosporine (Ophth)
CP.PMN.52 (PDF)Omega-3-Acid Ethyl Esters (Lovaza)
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.72 (PDF)Metformin ER (Fortamet, Glumetza)
CP.PMN.73 (PDF)Lifitegrast (Xiidra)
CP.PMN.74 (PDF)Granisetron (Sancuso, Sustol)
CP.PMN.76 (PDF)Calcifediol (Rayaldee)
CP.PMN.79 (PDF)Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea)
CP.PMN.80 (PDF)Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi)
CP.PMN.81 (PDF)SUBOXONE, Buprenorphine HCl-Naloxone HCl Dihydrate
BUNAVAIL, Buprenorphine HCl-Naloxone HCl Dihydrate
CP.PMN.82 (PDF)SUBUTEX, Buprenorphine HCl
CP.PMN.83 (PDF)Short Ragweed Pollen Allergen Extract (Ragwitek)
CP.PMN.84 (PDF)GRASTEK, Timothy Grass Pollen Allergen Extract
CP.PMN.85 (PDF)Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair)
CP.PMN.86 (PDF)Oxymetazoline (Rhofade, Upneeq)
CP.PMN.87 (PDF)Plecanatide (Trulance)
CP.PMN.88 (PDF)BINOSTO, Alendronate Sodium
FOSAMAX PLUS D, Alendronate Sodium-Cholecalciferol
CP.PMN.89 (PDF)Amantadine ER (Gocovri, Osmolex ER)
CP.PMN.90 (PDF)BENZNIDAZOLE, Benznidazole
CP.PMN.91 (PDF)Cariprazine (Vraylar)
CP.PMN.92 (PDF)CNS Stimulants
CP.PMN.93 (PDF)NUEDEXTA, Dextromethorphan HBr-Quinidine Sulfate
CP.PMN.95 (PDF)Fluticasone Propionate (Xhance)
CP.PMN.99 (PDF)Prasterone (Intrarosa)
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.105 (PDF)KERYDIN, Tavaborole
CP.PMN.107 (PDF)PROTOPIC, Tacrolimus (Topical)
ELIDEL, Pimecrolimus
CP.PMN.109 (PDF)BELSOMRA, Suvorexant
CP.PMN.110 (PDF)EUCRISA, Crisaborole
CP.PMN.111 (PDF)House Dust Mite Allergen Extract (Odactra)
CP.PMN.112 (PDF)Naldemedine (Symproic)
CP.PMN.113 (PDF)Safinamide (Xadago)
CP.PMN.115 (PDF)BAXDELA, Delafloxacin Meglumine
CP.PMN.116 (PDF)L-glutamine (Endari)
CP.PMN.117 (PDF)Naproxen/Esomeprazole (Vimovo)
CP.PMN.119 (PDF)Ozenoxacin (Xepi)
CP.PMN.120 (PDF)Ibuprofen/Famotidine (Duexis)
CP.PMN.122 (PDF)CELEBREX, Celecoxib
CP.PMN.123 (PDF)Colchicine (Colcrys)
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.128 (PDF)Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn)
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.139 (PDF)Naloxone (Evzio)
CP.PMN.140 (PDF)Pimavanserin (Nuplazid)
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.152 (PDF)LUCEMYRA, Lofexidine HCl
CP.PMN.153 (PDF)Alosetron (Lotronex)
CP.PMN.154 (PDF)Isavuconazonium (Cresemba)
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.159 (PDF)Dronabinol (Marinol, Syndros)
CP.PMN.163 (PDF)Sodium Zirconium Cyclosilicate (Lokelma)
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.170 (PDF)Eluxadoline (Viberzi)
CP.PMN.172 (PDF)Zolpidem Tartrate (Edluar, Intermezzo, Zolpimist)
CP.PMN.173 (PDF)Ramelteon (Rozerem)
CP.PMN.174 (PDF)Perindopril/Amlodipine (Prestalia)
CP.PMN.175 (PDF)Doxepin (Silenor)
CP.PMN.176 (PDF)Amlodipine/Atorvastatin (Caduet)
CP.PMN.177 (PDF)Glycopyrronium (Qbrexza)
CP.PMN.179 (PDF)MEGACE ES, Megestrol Acetate (Appetite)
CP.PMN.180 (PDF)Halobetasol Propionate (Bryhali, Lexette, Ultravate)
CP.PMN.181 (PDF)Calcipotriene/Betamethasone Dipropionate Foam (Enstilar)
CP.PMN.182 (PDF)Betamethasone Dipropionate Spray (Sernivo)
CP.PMN.184 (PDF)DIACOMIT, Stiripentol
CP.PMN.185 (PDF)Baloxavir Marboxil (Xofluza)
CP.PMN.186 (PDF)OXERVATE, Cenegermin-bkbj
CP.PMN.187 (PDF)VASCEPA, Icosapent Ethyl
CP.PMN.188 (PDF)NUZYRA, Omadacycline Tosylate
CP.PMN.189 (PDF)Sarecycline (Seysara)
CP.PMN.192 (PDF)MIRVASO, Brimonidine Tartrate (Topical)
CP.PMN.193 (PDF)Hydroxyurea (Siklos)
CP.PMN.196 (PDF)Rifamycin (Aemcolo)
CP.PMN.198 (PDF)MYRBETRIQ, Mirabegron
VESICARE, Solifenacin Succinate
TOVIAZ, Fesoterodine Fumarate
ENABLEX, Darifenacin Hydrobromide
CP.PMN.199 (PDF)SPRAVATO, Esketamine HCl
CP.PMN.205 (PDF)Patiromer (Veltassa)
CP.PMN.207 (PDF)EGATEN, Triclabendazole
CP.PMN.208 (PDF)Halobetasol Propionate/Tazarotene (Duobrii)
CP.PMN.209 (PDF)SUNOSI, Solriamfetol HCl
CP.PMN.210 (PDF)Acyclovir Buccal Tablet (Sitavig), Ophthalmic Ointment (Avaclyr)
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.217 (PDF)Istradefylline (Nourianz)
CP.PMN.218 (PDF)Lasmiditan (Reyvow)
CP.PMN.219 (PDF)Lefamulin (Xenleta)
CP.PMN.220 (PDF)Peanut Allergen Powder-dnfp (Palforzia)
CP.PMN.221 (PDF)Pitolisant (Wakix)
CP.PMN.222 (PDF)Pretomanid
CP.PMN.223 (PDF)MYCOBUTIN, Rifabutin
CP.PMN.224 (PDF)Tenapanor (Ibsrela)
CP.PMN.225 (PDF)Trifarotene (Aklief)
CP.PMN.231 (PDF)Cenobamate (Xcopri)
CP.PMN.232 (PDF)Lumateperone (Caplyta)
CP.PMN.235 (PDF)Emtricitabine/Tenofovir Alafenamide (Descovy)
CP.PMN.236 (PDF)Amisulpride (Barhemsys)
CP.PMN.237 (PDF)Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet)
CP.PMN.238 (PDF)Carbidopa/Levodopa ER Capsules (Rytary), Enteral Suspension (Duopa), IR Tablets (Dhivy)
CP.PMN.239 (PDF)Chenodiol (Chenodal)
CP.PMN.240 (PDF)Gabapentin ER (Gralise, Horizant)
CP.PMN.242 (PDF)Minocycline Micronized Foam (Amzeeq)
CP.PMN.243 (PDF)Progesterone (Crinone, Endometrin, Milprosa)
CP.PMN.244 (PDF)Tazarotene (Arazlo, Fabior, Tazorac)
CP.PMN.245 (PDF)Opicapone (Ongentys)
CP.PMN.246 (PDF)Fenfluramine (Fintepla)
CP.PMN.248 (PDF)Ciprofloxacin/Dexamethasone (Ciprodex)
CP.PMN.249 (PDF)Ciprofloxacin/Fluocinolone (Otovel)
CP.PMN.250 (PDF)Colesevelam (WelChol)
CP.PMN.251 (PDF)Lactic Acid/Citric Acid/Potassium Bitartrate (Phexxi)
CP.PMN.252 (PDF)Metoclopramide (Gimoti)
CP.PMN.253 (PDF)Abametapir (Xeglyze)
CP.PMN.255 (PDF)No Coverage Criteria
CP.PMN.256 (PDF)Nifurtimox (Lampit)
CP.PMN.257 (PDF)Clascoterone (Winlevi) 
CP.PMN.258 (PDF)DUAVEE, Conjugated Estrogens-Bazedoxifene
CP.PMN.260 (PDF)Loteprednol etabonate (Eysuvis)
CP.PMN.261 (PDF)KEVEYIS, Dichlorphenamide
CP.PMN.262 (PDF)Quinine Sulfate (Qualaquin)
CP.PMN.263 (PDF)Estradiol Vaginal Ring (Femring)
CP.PMN.264 (PDF)Viloxazine (Qelbree)
CP.PMN.265 (PDF)Olanzapine/Samidorphan (Lybalvi)
CP.PMN.266 (PDF)Finerenone (Kerendia)
CP.PMN.267 (PDF)Levodopa Inhalation Powder (Inbrija)
CP.PMN.268 (PDF)Tenofovir Alafenamide Fumarate (Vemlidy)
CP.PMN.269 (PDF)SKLICE, Ivermectin (Pediculicide)
CP.PMN.270 (PDF)Pilocarpine (Vuity)
CP.PMN.271 (PDF)Maribavir (Livtencity)
CP.PMN.272 (PDF)Camzyos (mavacamten)
CP.PMN.273 (PDF)Varenicline (Tyrvaya)
CP.PMN.275 (PDF)Levoketoconazole (Recorlev)
CP.PMN.277 (PDF)Ulcer Therapy Combinations
CP.PMN.278 (PDF)Ganaxolone (Ztalmy)
CP.PMN.280 (PDF)Compounded Medications
CP.PMN.281 (PDF)Topiramate Extended-Release (Qudexy XR, Trokendi XR)
HIM.PA.03 (PDF)Ophthalmic Corticosteroids
HIM.PA.05 (PDF)DEXILANT, Dexlansoprazole
HIM.PA.08 (PDF)BARACLUDE, Entecavir
HIM.PA.09 (PDF)TRESIBA, Insulin Degludec
HIM.PA.15 (PDF)SIMBRINZA, Brinzolamide-Brimonidine Tartrate
HIM.PA.17 (PDF)UVADEX, Methoxsalen (Photopheresis)
HIM.PA.20 (PDF)HALOG, Halcinonide
HIM.PA.33 (PDF)Formulary Medications Without Specific Guidelines,
HIM.PA.34 (PDF)Non-Formulary Test Strips,
HIM.PA.46 (PDF)BUTORPHANOL TARTRATE, Butorphanol Tartrate
HIM.PA.53 (PDF)
  • Dulaglutide (Trulicity®)
  • Xenatide ER (Bydureon®, Bydureon BCise®)
  • Exenatide IR (Byetta®),
  • Liraglutide (Victoza®)
  • Liraglutide/insulin degludec (Xultophy®)
  • Lixisenatide (Adlyxin®)
  • Lixisenatide/insulin glargine (Soliqua®)
  • Semaglutide (Ozempic®, Rybelsus®)
  • Tirzepatide (Mounjaro™)
HIM.PA.58 (PDF)ONGLYZA, Saxagliptin HCl
GLYXAMBI, Empagliflozin-Linagliptin
NESINA, Alogliptin Benzoate
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.87 (PDF)ANDRODERM, Testosterone
HIM.PA.89 (PDF)AZILECT, Rasagiline Mesylate
HIM.PA.91 (PDF)Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors - The following agents contain a sodium-glucose co-transporter 2 (SGLT2) inhibitor and require prior authorization: bexagliflozin (Brenzavvy™), canagliflozin (Invokana®), canagliflozin/metformin (Invokamet®, Invokamet® XR), dapagliflozin (Farxiga®), dapagliflozin/metformin (Xigduo® XR), dapagliflozin/saxagliptin (Qtern®), empagliflozin/linagliptin (Glyxambi®), empagliflozin/linagliptin/metformin (Trijardy™ XR), empagliflozin/metformin (Synjardy®, Synjardy® XR), ertugliflozin (Steglatro®), ertugliflozin/metformin (Segluromet®), and ertugliflozin/sitagliptin (Steglujan™).
HIM.PA.93 (PDF)NASONEX, Mometasone Furoate (Nasal)
HIM.PA.100 (PDF)Non-Formulary and Formulary Contraceptives
HIM.PA.103 (PDF)Brand Name Override and Non-Formulary Medication Policy,
HIM.PA.109 (PDF)Step Therapy
HIM.PA.119 (PDF)FINACEA, Azelaic Acid
HIM.PA.125 (PDF)FETZIMA, Levomilnacipran HCl
HIM.PA.129 (PDF)SINGULAIR, Montelukast Sodium
HIM.PA.130 (PDF)NAPROSYN, Naproxen
HIM.PA.134 (PDF)NATROBA, Spinosad
HIM.PA.139 (PDF)Opioid Analgesics,
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.152 (PDF)Nitazoxanide (Alinia)
HIM.PA.153 (PDF)
Inhaled Agents for Asthma and COPD
HIM.PA.154 (PDF)Off-Label Drug Use
HIM.PA.156 (PDF)Evolocumab (Repatha)
HIM.PA.158 (PDF)Plecanatide (Trulance)
HIM.PA.159 (PDF)Prucalopride (Motegrity)
HIM.PA.160 (PDF)Tegaserod (Zelnorm)
HIM.PA.161 (PDF)
  • hGH analogs: somapacitan-beco (Sogroya®)
  • Recombinant hGH (rhGH) formulations: somatropin (Genotropin®, Humatrope®, Norditropin®, Nutropin AQ® NuSpin®, Omnitrope®, Saizen®, Serostim®, Zomacton®, Zorbtive®)
HIM.PA.166 (PDF)Evinacumab-dgnb (Evkeeza)
HIM.PA.SP1 (PDF)EPCLUSA, Sofosbuvir-Velpatasvir
HIM.PA.SP2 (PDF)SOVALDI, Sofosbuvir
HIM.PA.SP3 (PDF)HARVONI, Ledipasvir-Sofosbuvir
HIM.PA.SP36 (PDF)MAVYRET, Glecaprevir-Pibrentasvir
HIM.PA.SP55 (PDF)VISTOGARD, Uridine Triacetate (Emergency Treatment)
HIM.PA.SP60 (PDF)Biologic DMARDs. The following are biologic and non-biologic disease-modifying anti-rheumatic drugs (DMARDs) requiring prior authorization: tocilizumab (Actemra®), infliximab-axxq (Avsola™), certolizumab pegol (Cimzia®), secukinumab (Cosentyx®), etanercept (Enbrel®), vedolizumab (Entyvio®), adalimumab (Humira®), tildrakizumab-asmn (Ilumya™), infliximab-dyyb (Inflectra®), sarilumab (Kevzara®), anakinra (Kineret®), baricitinib (Olumiant®), abatacept (Orencia®), apremilast (Otezla®), infliximab (Remicade®), infliximab-abda (Renflexis™), upadacitinib (Rinvoq™), brodalumab (Siliq™), golimumab (Simponi®, Simponi Aria®), risankizumab-rzaa (Skyrizi™), ustekinumab (Stelara®), ixekizumab (Taltz®), guselkumab (Tremfya®), natalizumab (Tysabri®), tofacitinib (Xeljanz®, Xeljanz® XR), ozanimod (Zeposia®).
HIM.PA.SP61 (PDF)Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak)
HIM.PA.SP62 (PDF)ZEPATIER, Elbasvir-Grazoprevir
HIM.PA.SP63 (PDF)Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi)
HIM.PA.SP64 (PDF)Eptinezumab-jjmr (Vyepti)
HIM.PA.SP65 (PDF)Erenumab-aaoe (Aimovig)
HIM.PA.SP66 (PDF)AJOVY, Fremanezumab-vfrm
HIM.PA.SP67 (PDF)Galcanezumab-gnlm (Emgality)
HIM.PA.SP68 (PDF)Glatiramer Acetate (Copaxone, Glatopa)

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
CC.PP.007Maximum Units (PDF)
CC.PP.008Cerumen Removal (PDF)
CC.PP.009Unlisted Procedure Codes (PDF)
CC.PP.010EM Bundling Edits (PDF)
CC.PP.011Coding Overview (PDF)
CC.PP.012IV Hydration (PDF)
CC.PP.013Modifier -25 clinical validation (PDF)
CC.PP.014Modifier -59 clinical validation (PDF)
CC.PP.015Moderate Conscious Sedation (PDF)
CC.PP.016Global Maternity Billing (PDF)
CC.PP.017Never Paid Events (PDF)
CC.PP.018Inpatient Only Procedures (PDF)
CC.PP.019Physician Visit Codes Billed with Labs (PDF)
CC.PP.020Distinct Procedural Modifiers (PDF)
CC.PP.021Clean Claims (PDF)
CC.PP.023Hospital Visit Codes Billed with Labs (PDF)
CC.PP.024Cosmetic Procedures (PDF)
CC.PP.025Pulse Oximetry (PDF)
CC.PP.027Professional Component (PDF)
CC.PP.028Modifier to Procedure Code Validation (PDF)
CC.PP.029Assistant Surgeon (PDF)
CC.PP.030Add on Code Billed Without Primary Code (PDF)
CC.PP.031NCCI Unbundling (PDF)
CC.PP.032Supplies Billed on Same Day As Surgery (PDF)
CC.PP.033Multiple CPT Code Replacement (PDF)
CC.PP.034Modifier DOS Validation (PDF)
CC.PP.036New Patient (PDF)
CC.PP.037Bilateral Procedures (PDF)
CC.PP.038Inpatient Consultation (PDF)
CC.PP.039Outpatient Consultation (PDF)
CC.PP.040Same Day Visits (PDF)
CC.PP.041Pre-Operative Visits (PDF)
CC.PP.042Post-Operative Visits (PDF)
CC.PP.043Unbundled Professional Services (PDF)
CC.PP.044Duplicate Primary Code Billing (PDF)
CC.PP.045Unbundled Surgical Procedures (PDF)
CC.PP.046Status "B" Bundled Services (PDF)
CC.PP.047Transgender Related Services (PDF)
CC.PP.049Status P Bundled Services (PDF)
CC.PP.050Robotic Surgery (PDF)
CC.PP.051E&M Medical Decision-Making (PDF)
CC.PP.052Problem Oriented Visits with Surgical Procedures (PDF)
CC.PP.053Leveling of ER Services (PDF)
CC.PP.054Physician's Consultation Services (PDF)
CC.PP.055Physician's Office Lab Testing (PDF)
CC.PP.056Urine Specimen Validity Testing (PDF)
CC.PP.057Problem Oriented Visits with Preventative Visits (PDF)
CC.PP.060Not Medically Necessary IP Serv (PDF)
CC.PP.061Non-obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds (PDF) Effective 1/1/2021
CC.PP.064
Emergency Department (ED) Outpatient Facility Coding Policy Enhancement (PDF) Effective 8/1/2021
CC.PP.065Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF) Effective 9/1/2020
CC.PP.066Leveling of Care: Evaluation & Management Overcoding (PDF) Updating 9/1/2022
CC.PP.067Renal Hemodialysis (PDF) Effective 1/1/2021
CC.PP.068Multiple Procedure Payment Reduction for Therapeutic Services (PDF) Effective 1/1/2021
CC.PP.069Multiple Procedure Reduction: Ophthalmology (PDF) Effective 1/1/2021
CC.PP.070340B Drug Payment Reduction (PDF) Effective 3/1/2022
CC.PP.071Evaluation and Management Services Billed with Treatment Rooms (PDF) Effective 3/1/2022
CC.PP.5003-Day Payment Window (PDF)
CC.PP.502Wheelchair Accessories (PDF)
CP.MP.100Allergy Testing and Therapy (PDF) Effective 5/30/2023
CP.MP.105Digital Electroencephalography Spike Analysis (PDF)
CP.MP.106Endometrial Ablation (PDF)
CP.MP.113Holter Monitors (PDF)
CP.MP.121Homocysteine Testing (PDF)
CP.MP.123Laser Therapy for Skin Conditions (PDF)
CP.MP.134Evoked Potential Testing (PDF)
CP.MP.139Low-frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)
CP.MP.143Wireless Motility Capsule (PDF)
CP.MP.152Measurement of Serum 1,25-dihydroxyvitamin D (PDF)
CP.MP.153Helicobacter Pylori Serology Testing (PDF)
CP.MP.154Thyroid Hormones and Insulin Testing in Pediatrics (PDF)
CP.MP.155Electroencephalography in the Evaluation of Headache (PDF)
CP.MP.156Cardiac Biomarker Testing (PDF)
CP.MP.15725-hydroxyvitamin D Testing in Children and Adolescents (PDF)
CP.MP.181Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)
CP.MP.209Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)
CP.MP.242Pulmonary Function Testing (PDF)
CP.MP.38Ultrasound in Pregnancy (PDF)
CP.MP.50Drugs of Abuse: Definitive Testing (PDF)
CP.MP.97Testing for Select Genitourinary Conditions (PDF) Effective 5/30/2023
CP.MP.98Urodynamic Testing (PDF)
CP.MP.99Wheelchair Seating (PDF)