Clinical & Payment Policies

Clinical Policies

Heritage Health - Nebraska Total Care 

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules.  They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies.  Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

All policies found in the Nebraska Total Care Clinical Policy Manual apply to Nebraska Total Care members. Policies in the Nebraska Total Care Clinical Policy Manual may have either a Nebraska Total Care or a “Centene” heading.  Nebraska Total Care utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Nebraska Total Care 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 Nebraska Total Care. In addition, Nebraska Total Care 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 Nebraska Total Care.   

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


Clinical Policies
Policy Title Policy Number Effective Date
25-Hydroxyvitamin D Testing in Children and Adolescents (PDF) CP.MP.157 12/2017
Acupuncture (PDF) CP.MP.92 11/2016
Air Ambulance (previously Fixed Wing Air Transportation) (PDF) CP.MP.175 04/2019
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia (PDF) CP.MP.108 03/2016
Antithrombin III (Thrombate III, Atryn) (PDF)
CP.MP.179 10/31/2019
Applied Behavioral Analysis (PDF) CP.BH.104 08/2009
Articular Cartilage Defect Repairs (PDF) CP.MP.26 10/2008
Assisted Reproductive Technology (PDF) CP.MP.55 03/2014
Bariatric Surgery (PDF) CP.MP.37 08/2014
Behavioral Health Treatment Documentation Requirements (PDF) CP.BH.500 6/30/2022
Biofeedback (PDF) CP.MP.168 07/2017
Biofeedback for Behavioral Health Disorders (PDF) CP.BH.300 05/2020
Bone-Anchored Hearing Aid (PDF) CP.MP.93 12/2013
Bronchial Thermoplasty (PDF) CP.MP.110 05/2016
Burn Surgery (PDF) CP.MP.186 05/31/2020
Cardiac Biomarker Testing (PDF) CP.MP.156 12/2017
Caudal or Interlaminar Epidural Steroid Injections (PDF) CP.MP.164 08/2018
Clinical Trials (PDF) CP.MP.94 01/2014
Cochlear Implant Replacements (PDF) CP.MP.14 02/2009
Concert Genetics Genetic Testing Gastroenterologic Disorders (non-cancerous) (PDF) CP.MP.215 3/31/2023
Concert Genetics Genetic Testing General Approach to Genetic Testing (PDF) CP.MP.222 3/31/2023
Concert Genetics Genetic Testing Hearing Loss (PDF) CP.MP.223 3/31/2023
Concert Genetics Genetic Testing Hematologic Condition (non-cancerous) (PDF) CP.MP.224 3/31/2023
Concert Genetics Genetic Testing Hereditary Cancer Susceptibility (PDF) CP.MP.225 3/31/2023
Concert Genetics Genetic Testing Immune, Autoimmune, and Rheumatoid Disorders (PDF) CP.MP.226 3/31/2023
Concert Genetics Genetic Testing Kidney Disorders (PDF) CP.MP.227 3/31/2023
Concert Genetics Genetic Testing Lung Disorders (PDF) CP.MP.228 3/31/2023
Concert Genetics Genetic Testing Metabolic, Endocrine, and Mitochondrial Disorders (PDF) CP.MP.229 3/31/2023
Concert Genetics Genetic Testing Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF) CP.MP.230 3/31/2023
Concert Genetics Genetic Testing Non-Invasive Prenatal Screening (NIPS) (PDF) CP.MP.231 3/31/2023
Concert Genetics Genetic Testing Pharmacogenetics (PDF) CP.MP.237 3/31/2023
Concert Genetics Genetic Testing Preimplantation Genetic Testing (PDF) CP.MP.238 3/31/2023
Concert Genetics Genetic Testing Prenatal and Preconception Carrier Screening (PDF) CP.MP.239 3/31/2023
Concert Genetics Genetic Testing Prenatal Diagnosis via Amniocentesis, CVS or PUBS and Pregnancy Loss (PDF) CP.MP.240 3/31/2023
Concert Genetics Genetic Testing Skeletal Dysplasia and Rare Bone Disorders (PDF) CP.MP.241 3/31/2023
Concert Genetics Oncology Algorithmic Testing (PDF) CP.MP.232 3/31/2023
Concert Genetics Oncology Cancer Screening (PDF) CP.MP.233 3/31/2023
Concert Genetics Oncology Circulating Tumor DNA and Circulating Tumor Cells Liquid Biopsy (PDF) CP.MP.234 3/31/2023
Concert Genetics Oncology Cytogenetic Testing (PDF) CP.MP.235 3/31/2023
Concert Genetics Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF) CP.MP.236 3/31/2023
Cosmetic and Reconstructive Procedures (PDF) CP.MP.31 03/2009
Deep Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder (PDF) CP.BH.201 04/30/2021
Diaphragmatic/Phrenic Nerve Stimulation (PDF) CP.MP.203 12/31/2020
Digital EEG Spike Analysis (PDF) CP.MP.105 01/31/2021
Disc Decompression Procedures (PDF) CP.MP.114 07/2016
Discography (PDF) CP.MP.115 07/2016
Donor Lymphocyte Infusion (PDF) CP.MP.101 11/2015
Drugs of Abuse: Definitive Testing (PDF) CP.MP.50 04/30/2021
Drugs of Abuse: Presumptive Testing (PDF) CP.MP.208 04/30/2021 - 11/30/2021
EEG in the Evaluation of Headache (PDF) CP.MP.155 05/31/2021
Electric Tumor Treating Fields (Optune) (PDF) CP.MP.145 05/2017
Endometrial Ablation (PDF) CP.MP.106 01/2016
Evoked Potential Testing (PDF) CP.MP.134 01/16/2023
Experimental Technologies (PDF) CP.MP.36 06/2009
Facet Joint Interventions (PDF) CP.MP.171 09/2018
Facility-Based Sleep Studies for OSA (PDF) CP.MP.248 01/31/2023
Fecal Incontinence Treatments (PDF) CP.MP.137 12/2016
Ferriscan R2-MRI (PDF) CP.MP.53 11/2012
Fertility Preservation (PDF) CP.MP.130 10/2016
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) CP.MP.129 10/2016
Functional MRI (PDF) CP.MP.43 10/2013
Gastric Electrical Stimulation (PDF) CP.MP.40 11/2011
Helicobacter Pylori Serology Testing (PDF) CP.MP.153 12/2017
Heart-Lung Transplant (PDF) CP.MP.132 06/2017
Holter Monitors (PDF) CP.MP.113 08/2016
Home Birth (PDF) CP.MP.136 12/2016
Home Ventilator (PDF) CP.MP.184 05/31/2020
Homocysteine Testing (PDF) CP.MP.121 08/2016
Hospice Services (PDF) CP.MP.54  07/2014
Hyperemesis Gravidarum Treatment (PDF) CP.MP.34 03/2009
Hyperhidrosis Treatments (PDF) CP.MP.62 05/2013
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) CP.MP.180 11/2019
Implantable Intrathecal or Epidural Pain Pump (PDF) CP.MP.173 02/2019
Implantable Loop Recorder (PDF) CP.MP.243 4/30/2022
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 04/2018
Intensity-Modulated Radiotherapy (PDF) CP.MP.69 03/2014
Intestinal and Multivisceral Transplant (PDF) CP.MP.58 02/2014
Intradiscal Steroid Injections for Pain Management (PDF) CP.MP.167 08/2018
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF) CP.MP.61 06/2013
Lantidra (donislecel) Allogenic Pancreatic Islet Cellular Therapy (PDF) CP.MP.250 8/31/2023
Laser Therapy for Skin Conditions (PDF) CP.MP.123 08/2016
Liposuction for Lipedema (PDF) CP.MP.244 05/30/2022
Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF) CP.MP.139 02/2017
Lung Transplantation (PDF) CP.MP.57 02/2014
Lysis of Epidural Lesions (PDF) CP.MP.116 07/2016
Measurement of Serum 1, 25-Dihydroxyvitamin D (PDF) CP.MP.152 10/31/2021
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
CP.MP.144 07/24/2020
Multiple Sleep Latency Testing (PDF) CP.MP.24 10/2008
Neonatal Abstinence Syndrome Guidelines (PDF) CP.MP.86 10/2013
Nerve Blocks for Pain Management (PDF) CP.MP.170 08/2018
Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF) CP.MP.48 07/31/2021
NICU Apnea Bradycardia Guidelines (PDF) CP.MP.82 06/2013
NICU Discharge Guidelines (PDF) CP.MP.81 06/2013
Nonmyeloablative Allogeneic Stem Cell Transplants (PDF) CP.MP.141 04/2017
Obstetrical Home Health Care Programs (PDF) CP.MP.91 01/2014
Omisirge (omidubicel) (PDF) CP.MP.249 06/30/2023
Orthognathic Surgery (PDF) CP.MP.202 10/31/2021
Osteogenic Stimulation (PDF) CP.MP.194 09/30/2021
Outpatient Cardiac Rehabilitation (PDF) CP.MP.176 05/2019
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 12/01/2020
Oxygen Use and Concentrators (PDF) CP.MP.190 09/30/20
Pancreas Transplant (PDF) CP.MP.102 04/2016
Panniculectomy (PDF) CP.MP.109 04/2016
Pediatric Heart Transplant (PDF) CP.MP.138 01/2017
Pediatric Kidney Transplant (PDF) CP.MP.246 09/30/2022
Pediatric Liver Transplant (PDF) CP.MP.120 04/2018
Pediatric Oral Function Therapy (PDF) CP.MP.188 05/31/2020
Percutaneous Left Atrial Appendage (LAA) Closure Device for Stroke Prevention (PDF) CP.MP.147  07/2017
Photodynamic and Intravitreal Therapies and Pharmaceuticals (PDF) CP.VP.40 7/30/2022
Phototherapy for Neonatal Hyperbilirubinemia (PDF) CP.MP.150 12/2017
Physical, Occupational, and Speech Therapy Services (PDF) CP.MP.49 04/2011
Polymerase Chain Reaction (PCR) Respiratory Viral Panel Testing (PDF) CP.MP.181 06/2023
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) CP.MP.133 10/2016
Preventive Health and Clinical Practice Guidelines (PDF) CP.CPC.03 07/2023
Proton and Neutron Beam Therapy (PDF) CP.MP.70 03/2014
Pulmonary Function Testing (PDF) CP.MP.242 06/30/2022
Reduction Mammoplasty and Gynecomastia Surgery (PDF) CP.MP.51 08/2012
Repair of Nasal Valve Compromise (PDF) CP.MP.210 05/31/2021
Sacroiliac Joint Fusion (PDF) CP.MP.126 09/2016
Sacroiliac Joint Interventions for Pain Management (PDF) CP.MP.166 08/2018
Sclerotherapy and Chemical Endovenous Abalation for Varicose Veins (PDF) CP.MP.146 06/2017
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF) CP.MP.174 03/2019
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF) CP.MP.165 08/2018
Short Inpatient Hospital Stay (PDF) CP.MP.182 10/01/2020
Skin Substitutes for Chronic Wounds (PDF) CP.MP.185 04/2020
Sleep Center Polysomnography for Obstructive Sleep Apnea (PDF) CP.MP.248 01/31/2023
Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF) CP.MP.117 07/2016
Stereotactic Body Radiation Therapy (PDF) CP.MP.22 03/2014
Substance Use Disorder Treatment and Services (PDF) CP.BH.100 01/31/2022
Tandem Transplant (PDF) CP.MP.162  07/2018
Testing for Select Genitourinary Conditions (PDF) NE.CP.MP.97 11/1/2022
Therapeutic Utilization of Inhaled Nitric Oxide (PDF) CP.MP.87 08/2013
Therapy Services (PT/OT/ST) (PDF) CP.MP.49 04/2011
Thyroid Hormones and Insulin Testing in Pediatrics (PDF) CP.MP.154 12/2017
TMS for Treatment Resistant Major Depression MDD (PDF) CP.BH.200 8/31/2022
Total Artificial Heart (PDF) CP.MP.127 12/2016
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 05/2016
Transcatheter Closure of Patent Foramen Ovale (PDF) CP.MP.151 12/2017
Transcranial Magnetic Stimulation TMS for Treatment Resistant Major Depression (PDF) CP.BH.200  12/2018
Transplant Service Documentation Requirements (PDF) CP.MP.247 12/31/2022
Trigger Point Injections for Pain Management (PDF) CP.MP.169 08/2018
Ultrasound in Pregnancy (PDF) CP.MP.38 01/2011
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142 04/2017
Urodynamic Testing (PDF) CP.MP.98 04/01/2021
Vagus Nerve Stimulation (PDF) CP.MP.12 10/2013
Ventricular Assist Devices (PDF) CP.MP.46 12/2009
Vitamin D Testing in children (PDF) CP.MP.157 09/30/2022
Wireless Motility Capsule (PDF) CP.MP.143 04/2017



Pharmacy Policies A-E
Rx Policy Title Policy Number Effective Date
Abametapir (Xeglyze) (PDF) CP.PMN.253 11/01/2020
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 05/16/2019
ACEI ARB Duplicate Therapy (PDF) CP.PMN.61 05/17/2019
Acitretin (Soriatane) (PDF) CP.PMN.40 05/06/2020
Ado-Trastuzumab Emtansine (Kadcyla) (PDF) CP.PHAR.229 08/13/2019
Aducanumab (Aduhelm) (PDF) CP.PHAR.468 07/01/2021
aflibercept (Eylea) (PDF) CP.PHAR.184 02/13/2019
agalsidase beta (Fabrazyme) (PDF) CP.PHAR.158 05/16/2019
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 05/14/2019
alglucosidase alfa (Lumizyme) (PDF) CP.PHAR.160 05/16/2019
Allogeneic cultured keratinocytes and dermal fibroblasts (StrataGraft) (PDF) CP.PHAR.562 03/01/2022
Allogenic processed thymus tissue-agdc (Rethymic) (PDF) CP.PHAR.563 03/01/2022
Alpha-1 Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF) CP.PHAR.94 06/26/2019
Amifampridine (Firdapse) (PDF) CP.PHAR.411 09/13/2019
Amisulpride (Barhemsys) (PDF) CP.PMN.236 05/06/2020
Amivantamab-vmjw (Rybrevant) (PDF) CP.PHAR.544 09/01/2021
anifrolumab-fnia (Saphnelo) (PDF) CP.PHAR.551 12/01/2021
Antithrombin III (ATryn, Thrombate III) (PDF) CP.PHAR.564 03/01/2022
Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) CP.PHAR.506 11/01/2020
asenapine (Saphris) (PDF) CP.PMN.15 02/15/2019
asfotase alfa (Strensiq) (PDF) CP.PHAR.328 11/20/2018
atezolizumab (Tecentriq) (PDF) CP.PHAR.235 05/20/2019
Avacincaptad pegol (Izervay) (PDF) CP.PHAR.641 10/01/2023
Avalglucosidase Alfa (NeoGAA) (PDF) CP.PHAR.521 06/01/2021
avelumab (Bacencio) (PDF) CP.PHAR.333 06/26/2019
axicabtagene ciloleucel (Yescarta) (PDF) CP.PHAR.362 08/16/2019
azacitidine (Onureg, Vidaza) (PDF) CP.PHAR.387 11/20/2018
Baclofen (Gablofen, Lioresal, Lyvispah, Ozobax) (PDF) CP.PHAR.149 11/14/2018
Bedaquiline (Sirturo) (PDF) CP.PMN.212 05/06/2020
Belantamab mafodotin (Blenrep) (PDF) CP.PHAR.469 06/01/2021
belatacept (Nulojix) (PDF) CP.PHAR.201 11/14/2018
belimumab (Benlysta) (PDF) CP.PHAR.88 08/10/2019
belinostat (Beleodaq) (PDF) CP.PHAR.311 11/17/2018
bendamustine (Bendeka, Treanda) (PDF) CP.PHAR.307 11/14/2018
Benznidazole (PDF) CP.PMN.90 02/18/2019
Benzyl alcohol (Ulesfia) (PDF) CP.PMN.202 08/17/2019
Beremagene Geperpavec (Vyjuvek) (PDF) CP.PHAR.592 03/01/2023
betaine (Cystadane) (PDF) CP.PHAR.143 11/20/2018
Betibeglogene Autotemcel (Zynteglo) (PDF) CP.PHAR.545 12/01/2022
bevacizumab (Avastin, Mvasi) (PDF) CP.PHAR.93 06/26/2019
Bexarotene (Targretin) (PDF) CP.PHAR.75 05/16/2019
bezlotoxumab (Zinplava) (PDF) CP.PHAR.300 02/15/2019
Bimatoprost (Durysta) (PDF) CP.PHAR.486 11/01/2020
blinatumomab (Blincyto) (PDF) CP.PHAR.312 08/13/2019
Bortezomib (Velcade) (PDF) CP.PHAR.410 02/19/2019
Brand Name Override (PDF) CP.PMN.22 02/19/2019
Bremelanotide (Vyleesi) (PDF) CP.PHAR.434 05/06/2020
brentuximab Vedotin (Adcetris) (PDF) CP.PHAR.303 08/13/2019
Brexanolone (Zulresso) (PDF) CP.PHAR.417 05/13/2019
Brexpiprazole (Rexulti) (PDF) CP.PMN.68 05/06/2020
Brexucabtagene Autoleucel (Tecartus) (PDF) CP.PHAR.472 09/01/2020
Brimonidine (Mirvaso) (PDF) CP.PMN.192 05/13/2019
Brolucizumab (Beovu) (PDF) CP.PHAR.445 04/01/2021
buprenorphine implant (Sublocade) (PDF) CP.PHAR.289 06/01/2023
Burosumab-twza (Crysvita) (PDF) CP.PHAR.11 08/10/2019
cabazitaxel (Jevtana) (PDF) CP.PHAR.316 09/13/2019
Cabotegravir, Cabotegravir-Rilpivirine (Apretude, Cabenuva) (PDF) CP.PHAR.573 06/01/2022
calcifediol (Rayaldee) (PDF) CP.PMN.76 08/16/2019
canakinumab (Ilaris) (PDF) CP.PHAR.246 05/16/2019
Cannabidiol (Epidiolex) (PDF) CP.PMN.164 08/17/2019
Caplacizumab-yhdp (Cablivi) (PDF) CP.PHAR.416 05/13/2019
Carbamazepine ER (Equetro) (PDF) CP.PMN.137 05/17/2019
carfilzomib (Kyprolis) (PDF) CP.PHAR.309 11/14/2018
carglumic acid (Carbaglu) (PDF) CP.PHAR.206 02/14/2019
Cariprazine (Vraylar) (PDF) CP.PMN.91 06/26/2019
Casimersen (Amondys) (PDF) CP.PHAR.470 06/01/2021
Cemiplimab-rwlc (Libtayo) (PDF) CP.PHAR.397 11/26/2018
Cenegermin-bkbj (Oxervate (PDF) CP.PMN.186 08/14/2019
Cenobamate (Xcopri) (PDF) CP.PMN.231 11/01/2020
Cerliponase alfa (Brineura) (PDF) CP.PHAR.338 08/15/2019
cetuximab (Erbitux) (PDF) CP.PHAR.317 11/17/2018
Chloramphenicol (PDF) CP.PHAR.388 02/15/2019
Chronic Use of Opioid Analgesics (PDF) NE.PMN.97 12/06/2018
Ciltacabtagene Autoleucel (Carvykti) (PDF) CP.PHAR.533  05/01/2021
cinacalcet (Sensipar) (PDF) CP.PHAR.61 08/10/2019
Cipaglucosidase alfa-miglustat (Pombiliti) PDF) CP.PHAR.567 11/01/2023
clobazam (Onfi) (PDF) CP.PMN.54 06/26/2019
Colchicine (Lodoco) (PDF) CP.PHAR.640 10/01/2023
collagenase clostridium histolyticum (Xiaflex) (PDF) CP.PHAR.82 08/15/2019
Compounded Medications (PDF) CP.PMN.280 08/01/2022
Conjugated estrogens-bazedoxifene (Duavee) (PDF) CP.PMN.258 03/01/2021
Continuous Glucose Monitors (PDF) NE.PMN.214 01/01/2023
copanlisib (Aliqopa) (PDF) CP.PHAR.357 11/20/2018
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert) (PDF) CP.PHAR.385 09/13/2019
cosyntropin (Cortrosyn) (PDF) CP.PHAR.203 02/13/2019
Crizanlizumab-tmca (Adakveo) (PDF) CP.PHAR.449 06/01/2021
cysteamine (Cystagon, Procysbi) (PDF) CP.PHAR.155 05/16/2019
Cysteamine ophthalmic (Cystaran) (PDF) CP.PMN.130 05/17/2019
Cytomegalovirus Immune Globulin (CytoGam) (PDF) CP.PHAR.277 08/15/2019
daptomycin (Cubicin, Cubicin RF) (PDF) CP.PHAR.351 08/15/2019
daratumumab (Darzalex) (PDF) CP.PHAR.310 08/13/2019
Darbepoetin alfa (Aranesp) (PDF) CP.PHAR.236 05/14/2019
daunorubicin/cytarabine (Vyxeos) (PDF) CP.PHAR.352 11/20/2018
DaxibotulinumtoxinA-lanm (Daxxify) (PDF) CP.PHAR.651 10/01/2023
Decitabine-Cedazuridine (Inqovi) (PDF) CP.PHAR.479 06/01/2021
deferasirox (Jadenu) (PDF) CP.PHAR.145 08/10/2019
deferiprone (Ferriprox) (PDF) CP.PHAR.147 08/17/2019
deferoxamine (Desferal) (PDF) CP.PHAR.146 08/15/2019
degarelix acetate (Firmagon) (PDF) CP.PHAR.170 11/17/2018
Delandistrogene Moxeparvovec (Elevidys) (PDF) CP.PHAR.593 09/01/2023
Denosumab (Prolia, Xgeva) (PDF) CP.PHAR.58 05/16/2019
Desmopressin acetate (DDAVP Injection, Stimate, Noctiva) (PDF) CP.PHAR.214 02/13/2019
Dexrazoxane (Zinecard Totect) (PDF) CP.PHAR.418 05/13/2019
Dextromethorphan/Bupropion (Auvelity) (PDF) CP.PMN.284 01/01/2023
Dextromethorphan-Quinidine (Nuedexta) (PDF) CP.PMN.93 02/18/2019
Diazepam Nasal Spray (Valtoco) (PDF) CP.PMN.216 12/01/2019
Dichlorphenamide (Keveyis) (PDF) CP.PMN.261 03/01/2021
Dostarlimab-gxly (Jemperli) (PDF) CP.PHAR.540 07/01/2021
droxidopa (Northera) (PDF) CP.PMN.17 11/13/2018
Duplicate SSRI/SNRI Therapy (PDF) CP.PMN.60 08/15/2019
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 07/19/2019
Early and Periodic Screening, Diagnostic, and Treatment Benefit for Pediatric Members (PDF) CP.PMN.234 10/01/2022
ecallantide (Kalbitor) (PDF) CP.PHAR.177 09/01/2021
eculizumab (Soliris) (PDF) CP.PHAR.97 05/14/2019
Edaravone (Radicava) (PDF) CP.PHAR.343 05/16/2019
Efgartigimod (Vyvgart, Vyvgart Hytrulo) (PDF) CP.PHAR.555 03/01/2022
Elapegademase-lvlr (Revcovi) (PDF) CP.PHAR.419 05/13/2019
Elivaldogene autotemcel (Skysona) (PDF) CP.PHAR.556 12/01/2022
elosulfase alfa (Vimizim) (PDF) CP.PHAR.162 05/16/2019
elotuzumab (Empliciti) (PDF) CP.PHAR.308 05/14/2019
Elranatamab-bcmm (Elrexfio) (PDF) CP.PHAR.652 10/01/2023
Emapalumab-lzsg (Gamifant) (PDF) CP.PHAR.402 05/30/2019
Enfortumab Vedotin-ejfv (Padcev) (PDF) CP.PHAR.455 09/01/2021
Epcoritamab-bysp (Epkinly) (PDF) CP.PHAR.634 11/01/2023
epoprostenol (Flolan), Veletri) (PDF) CP.PHAR.192 04/02/2019
Eptinezumab (Vyepti) (PDF) CP.PHAR.489 05/06/2020
eribulin Mesylate (Halaven) (PDF) CP.PHAR.318 11/17/2018
erwina asparaginase (Erwinaze) (PDF) CP.PHAR.301 02/15/2019
Esketamine (Spravato) (PDF) CP.PMN.199 09/13/2019
Estradiol Vaginal Ring (Femring) (PDF) CP.PMN.263 01/01/2022
etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 08/13/2019
eteplirsen (Exondys 51) (PDF) CP.PHAR.288 02/15/2019
Etranacogene Dezaparvovec (Hemgenix) (PDF) CP.PHAR.580 03/01/2023
Evinacumab (Evkeeza) (PDF) CP.PHAR.511 06/01/2021



Pharmacy Policies F-N
Rx Policy Title Policy Number Effective Date
Fam-Trastuzumab Deruxtecan-nxki (Enhertu) (PDF) CP.PHAR.456 07/01/2022
faricimab-svoa (Vabysmo) (PDF) CP.PHAR.581 06/01/2022
Fecal Microbiota, Live-jslm (Rebyota) (PDF) CP.PHAR.613 03/01/2023
Fenfluramine (Fintepla) (PDF) CP.PMN.246 01/21/2021
ferric carboxymaltose (Injectafer) (PDF) CP.PHAR.234 02/14/2019
Ferric Derisomaltose (Monoferric) (PDF) CP.PHAR.480 05/31/2020
Ferric Pyrophosphate Citrate (Triferic, Triferic Avnu) (PDF) CP.PHAR.624 06/01/2023
Ferric maltol (Accrufer) (PDF) CP.PMN.213 05/06/2020
ferumoxytol (Feraheme) (PDF) CP.PHAR.165 02/14/2019
Fezolinetant (Veozah) (PDF) CP.PMN.289 09/01/2023
Fibrinogen concentrate (human) (Fibryga, RiaSTAP) (PDF) CP.PHAR.526 06/01/2021
Flibanserin (Addyi) (PDF) CP.PHAR.446 3/1/2020
Fluorouracil Cream (Tolak) (PDF) CP.PMN.165 11/21/2018
Fosdenopterin (Nulibry) (PDF) CP.PHAR.471 06/01/2021
Fulvestrant (Faslodex Injection) (PDF) CP.PHAR.424 08/12/2019
furosemide (Furoscix) (PDF) CP.PHAR.608 03/01/2023
Gabapentin ER (Gralise, Horizant) (PDF) CP.PMN.240 05/06/2020
galsulfase (Naglazyme) (PDF) CP.PHAR.161 05/16/2019
Ganaxolone (Ztalmy) (PDF) CP.PMN.278 08/01/2022
gemtuzumab ozogamicin (Mylotarg) (PDF) CP.PHAR.358 11/14/2018
Givosiran (Givlaari) (PDF) CP.PHAR.457 11/01/2020
Glofitamab-gxbm (Columvi) (PDF) CP.PHAR.636 09/01/2023
glycerol phenylbutyrate (Ravicti) (PDF) CP.PHAR.207 03/13/2019
Glycopyrronium (Qbrexza) (PDF) CP.PMN.177 11/21/2018
goserelin acetate (Zoladex) (PDF) CP.PHAR.171 11/17/2018
hemin (Panhematin) (PDF) CP.PHAR.181 02/13/2019
histrelin acetate (Vantas, Supprelin LA) (PDF) CP.PHAR.172 11/17/2018
Hyaluronate Derivatives (PDF) CP.PHAR.05 09/27/2019
ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 05/17/2019
Idecabtagene Vicleucel (Abecma) (PDF) CP.PHAR.481 06/01/2021
idursulfase (Elaprase) (PDF) CP.PHAR.156 05/17/2019
iloperidone (Fanapt) (PDF) CP.PMN.32 02/15/2019
imiglucerase (Cerezyme) (PDF) CP.PHAR.154 05/16/2019
Immune Globulin Injections (PDF) CP.PHAR.103 08/10/2019
Immunization Coverage (PDF) CP.PHAR.28 08/01/2022
Inclisiran (Leqvio) (PDF) CP.PHAR.568 06/01/2022
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 05/16/2019
Inebilizumab-cdon (Uplizna) (PDF) CP.PHAR.458 11/01/2020
Infliximab (Avsola, Inflectra, Remicade, Renflexis) (PDF) CP.PHAR.254 09/13/2019
Inotersen (Tegsedi) (PDF) CP.PHAR.405 05/30/2019
inotuzumab ozogamicin (Besponsa) (PDF) CP.PHAR.359 11/20/2018
Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF) CP.PHAR.534 06/01/2021
interferon gamma- 1b (Actimmune) (PDF) CP.PHAR.52 02/13/2019
ipilimumab (Yervoy) (PDF) CP.PHAR.319 05/14/2019
irinotecan Liposome (Onivyde) (PDF) CP.PHAR.304 11/14/2018
Isatuximab-irfc (Sarclisa) (PDF) CP.PHAR.482 06/01/2021
isotretinoin (PDF) CP.PMN.143 11/14/2018
Itraconazole (Sporanox ,Onmel, Tolsura) (PDF) CP.PMN.124 05/06/2020
lacosamide (Vimpat) (PDF) CP.PMN.155 08/17/2019
Lactic acid-citric acid-potassium bitartrate (Phexxi) (PDF) CP.PMN.251 11/01/2020
Lactitol (Pizensy) (PDF) CP.PMN.241 05/06/2020
Lanreotide (Somatuline Depot) (PDF) CP.PHAR.391 11/20/2018
laronidase (Aldurazyme) (PDF) CP.PHAR.152 05/16/2019
Lecanemab (Leqembi) (PDF) CP.PHAR.596 03/01/2023
leniolisib (Joenja) (PDF) CP.PHAR.597 03/24/2023
letermovir (Prevymis) (PDF) CP.PHAR.367 02/15/2019
Leucovorin Injection (PDF) CP.PHAR.393 11/20/2018
leuprolide acetate (Eligard, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped) (PDF) CP.PHAR.173 08/16/2019
Levoketoconazole (Recorlev) (PDF) CP.PMN.275 06/01/2022
levoleucovorin (Fusilev) (PDF) CP.PHAR.151 11/14/2018
Lidocaine transdermal (Lidoderm, ZTlido) (PDF) CP.PMN.08 07/01/2023
Lisocabtagene maraleucel (Breyanzi) (PDF) CP.PHAR.483 06/01/2021
Lonafarnib (Zokinvy) (PDF) CP.PHAR.499 03/01/2021
Loncastuximab tesirine-lpyl (Zynlonta) (PDF) CP.PHAR.539 07/01/2021
Lotilaner (Xdemvy) (PDF) CP.PMN.291 10/01/2023
Lumasiran (Oxlumo) (PDF) CP.PHAR.473 03/01/2021
Lumateperone (Caplyta) (PDF) CP.PMN.232 06/01/2022
Lurbinectedin (Zepzelca) (PDF) CP.PHAR.500 09/01/2020
Luspatercept-aamt (Reblozyl) (PDF) CP.PHAR.450 05/06/2020
lutetium Lu 177 dotatate (Lutathera) (PDF) CP.PHAR.384 08/16/2019
Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) (PDF) CP.PHAR.582  06/01/2022
Margetuximab-cmkb (Margenza) (PDF) CP.PHAR.522 03/01/2021
Maribavir (Livtencity) (PDF) CP.PMN.271 03/01/2022
mavacamten (Camzyos) (PDF) CP.PMN.272 06/03/2022
Mecamylamine (Vecamyl) (PDF) CP.PMN.136 05/17/2019
mecasermin (Increlex) (PDF) CP.PHAR.150 08/15/2019
mechlorethamine (Valchlor) (PDF) CP.PHAR.381 08/13/2019
megestrol Acetate Oral Suspension (Megace ES) (PDF) CP.PMN.179 11/21/2018
Melphalan (Hepzato) (PDF) CP.PHAR.653 10/01/2023
Melphalan flufenamide (Pepaxto) (PDF) CP.PHAR.535 06/01/2021
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) CP.PHAR.238 05/16/2019
Metreleptin (Myalept) (PDF) CP.PHAR.425 08/12/2019
Midazolam (Nayzilam) (PDF) CP.PMN.211 08/16/2019
mifepristone (Korlym) (PDF) CP.PHAR.101 02/13/2019
Migalastat (Galafold) (PDF) CP.PHAR.394 02/01/2019
Milnacipran (Savella) (PDF) CP.PMN.125 05/17/2019
minocycline (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) (PDF) CP.PMN.80 11/01/2020
mirvetuximab soravatansine-gynx (Elahere) (PDF) CP.PHAR.617 03/01/2023
Mitapivat (Pyrukynd) (PDF) CP.PHAR.558 06/01/2022
Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF) CP.PHAR.495 09/01/2020
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 05/14/2019
Mixed pollens allergen extract (Oralair) (PDF) CP.PMN.85 08/16/2019
Mogamulizumab-kpkc (Poteligeo) (PDF) CP.PHAR.139 11/20/2018
mosunetuzumab-axgb (Lunsumio) (PDF) CP.PHAR.618 03/01/2023
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) CP.PHAR.398 11/26/2018
Nadofaragene firadenovec-vncg (Adstiladrin) (PDF) CP.PHAR.461 06/01/2023
nafarelin acetate (Synarel) (PDF) CP.PHAR.174 11/17/2018
Natalizumab (Tysabri) (PDF) CP.PHAR.259 05/14/2019
Naxitamab-gqgk (Danyelza) (PDF) CP.PHAR.523 03/01/2021
necitumumab (Portrazza) (PDF) CP.PHAR.320 11/17/2018
Nedosiran (Rivfloza) (PDF) CP.PHAR.619 11/01/2023
Neomycin-fluocinolone cream (Neo-Synalar) (PDF) CP.PMN.167 11/21/2018
Nifurtimox (Lampit) (PDF) CP.PMN.256 11/01/2020
Nirsevimab (Beyfortus) (PDF) CP.PHAR.614 10/01/2023
nitisinone (Orfadin, Nityr) (PDF) CP.PHAR.132 11/20/2018
nivolumab (Opdivo) (PDF) CP.PHAR.121 02/14/2019
Nivolumab and Relatlimab (Opdualag) (PDF) CP.PHAR.588 08/01/2022
No Coverage Criteria (PDF) CP.PMN.255 03/01/2022
Non-preferred blood glucose monitors and test strips (PDF) CP.PMN.215 05/06/2020
nusinersen (Spinraza) (PDF) CP.PHAR.327 08/13/2019



Pharmacy Policies O-Z
Rx Policy Title Policy Number Effective Date
obinutuzumab (Gazyva) (PDF) CP.PHAR.305 11/14/2018
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 05/16/2019
octreotide acetate (Sandostatin, Sandostatin LAR) (PDF) CP.PHAR.40 02/14/2019
ofatumumab (Arzerra) (PDF) CP.PHAR.306 11/17/2018
Off Label Use Policy (PDF) CP.PMN.53 03/01/2022
Olanzapine-samidorphan (Lybalvi) (PDF) CP.PMN.265 07/01/2021
Olipudase alfa (XENPOZYME) (PDF) CP.PHAR.586 01/01/2023
omacetaxine (Synribo) (PDF) CP.PHAR.108 05/14/2019
Omaveloxolone (Skyclarys) (PDF) CP.PHAR.590 06/01/2023
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 09/13/2019
Onasemnogene abeparvovec (Zolgensma) (PDF) CP.PHAR.421 08/12/2019
Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF) CP.PHAR.536 06/01/2021
Osilodrostat (Isturisa) (PDF) CP.PHAR.487 05/06/2020
Ospemifene (Osphena) (PDF) CP.PMN.168 05/15/2019
oxymetazoline (Rhofade) (PDF) CP.PMN.86 5/15/2019
Ozenoxacin (Xepi) (PDF) CP.PMN.119 06/01/2021
Paclitaxel, Protein Bound (Abraxane) (PDF) CP.PHAR.176 07/18/2020
palivizumab (Synagis) (PDF) CP.PHAR.16 11/01/2020
Palovarotene (Sohonos) (PDF) CP.PHAR.548 11/01/2023
panitumumab (Vectibix) (PDF) CP.PHAR.321 11/17/2018
Parathyroid hormone (Natpara) (PDF) CP.PHAR.282 08/15/2019
Paricalcitol (Zemplar) (PDF) CP.PHAR.270 08/10/2019
pasireotide (Signifor LAR) (PDF) CP.PHAR.332 11/14/2018
Patiromer (Veltassa) (PDF) CP.PMN.205 08/12/2019
Patisiran (Onpattro) (PDF) CP.PHAR.395 11/26/2018
pegaspargase (Oncaspar) (PDF) CP.PHAR.353 11/14/2018
Pegcetacoplan (Empaveli,Skyfovre) (PDF) CP.PHAR.524 07/01/2021
peginterferon alfa-2b (Sylatron) (PDF) CP.PHAR.89 08/17/2019
pegloticase (Krystexxa) (PDF) CP.PHAR.115 02/14/2019
Pegunigalsidase Alfa (Elfabrio) (PDF) CP.PHAR.512 09/01/2023
Pegvaliase-pqpz (Palynziq) (PDF) CP.PHAR.140 02/01/2019
pegvisomant (Somavert) (PDF) CP.PHAR.389 11/20/2018
pembrolizumab (Keytruda) (PDF) CP.PHAR.322 08/16/2019
pemetrexed (Alimta) (PDF) CP.PHAR.368 04/02/2019
Pentosan polysulfate sodium (Elmiron) (PDF) CP.PMN.276 06/01/2022
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 05/17/2019
Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (PDF) CP.PHAR.501 09/01/2020
Plasminogen (Ryplazim) (PDF) CP.PHAR.513  10/01/2021
plerixafor (Mozobil) (PDF) CP.PHAR.323 08/13/2019
Polatuzuman vedotin – piiq (Polivy) (PDF) CP.PHAR.433 08/16/2019
Pozelimab-bbfg (Veopoz) (PDF) CP.PHAR.626 11/01/2023
pralatrexate (Folotyn) (PDF) CP.PHAR.313 11/17/2018
Prasterone (Intrarosa) (PDF) CP.PMN.99 02/18/2019
Pretomanid (PDF) CP.PMN.222 09/01/2021
Progesterone (Crinone, Endometrin, Milprosa) (PDF) CP.PMN.243 05/06/2020
protein c concentrate, human (Ceprotin) (PDF) CP.PHAR.330 02/15/2019
Pyrimethamine (Daraprim) (PDF) CP.PMN.44 05/06/2020
QL of Diabetic Test Strips not receiving insulin (PDF) CP.PMN.151 02/14/2019
Quantity Limit Overrides (PDF) CP.PMN.59 02/01/2019
Quetiapine ER (Seroquel XR) (PDF) CP.PMN.64 05/06/2020
Quinine Sulfate (Qualaquin) (PDF) CP.PMN.262 06/01/2021
ramucirumab (Cyramza) (PDF) CP.PHAR.119 09/13/2019
ranibizumab (Byooviz, Lucentis, Susvimo) (PDF) CP.PHAR.186 06/26/2019
Ravulizumab-cwvz (Ultomiris) (PDF) CP.PHAR.415 05/13/2019
Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel) (PDF) CP.PHAR.168 04/02/2019
Request for Medically Necessary Drug not on the PDL (PDF) CP.PMN.16 11/14/2018
reslizumab (Cinqair) (PDF) CP.PHAR.223 02/14/2019
retifanlimab-dlwr (Zynz) (PDF) CP.PHAR.629 06/01/2023
Rifamycin (Aemcolo) (PDF) CP.PMN.196 05/13/2019
rifapentine (Priftin) (PDF) CP.PMN.05 02/15/2019
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 05/16/2019
Risdiplam (Evrysdi) (PDF) CP.PHAR.477 11/01/2020
Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela) (PDF) CP.PHAR.260 6/26/2019
romidepsin (Istodax) (PDF) CP.PHAR.314 03/06/2019
romiplostim (Nplate) (PDF) CP.PHAR.179 03/06/2019
Romosozumab-aqqg (Evenity) (PDF) CP.PHAR.428 08/12/2019
Ropeginterferon alfa-2b-njft (Besremi) (PDF) CP.PHAR.570 03/01/2022
Rozanolixizumab-noli (Rystiggo) (PDF) CP.PHAR.648 10/01/2023
rufinamide (Banzel) (PDF) CP.PMN.157 08/17/2019
Sacituzumab govitecan-hziy (Trodelvy) (PDF) CP.PHAR.475 03/01/2021
sapropterin (Kuvan) (PDF) CP.PHAR.43 05/16/2019
Sarecycline (Seysara) (PDF) CP.PMN.189 05/30/2019
sargramostim (Leukine) (PDF) CP.PHAR.295 08/15/2019
sebelipase alfa (Kanuma) (PDF) CP.PHAR.159 05/17/2019
Setmelanotide (Imcivree) (PDF) CP.PHAR.491 06/01/2021
siltuximab (Sylvant) (PDF) CP.PHAR.329 02/15/2019
Sipuleucel-T (Provenge) (PDF) CP.PHAR.120 05/16/2019
Sodium Oxybate (Xyrem, Lumryz) and Calcium Magnesium Potassium Sodium Oxybate (Xywav) (PDF) CP.PMN.42 05/17/2019
sodium phenylbutyrate (Buphenyl) (PDF) CP.PHAR.208 02/14/2019
Sodium Phenylbutyrate-Taurursodiol (Relyvrio) (PDF) CP.PHAR.584 01/01/2023
Sodium thiosulfate (Pedmark) (PDF) CP.PHAR.610 03/01/2023
Sodium zirconium cyclosilicate (Lokelma) (PDF) CP.PMN.163 08/17/2019
sparsentan (Filspari) (PDF) CP.PHAR.631 06/01/2023
Spesolimab-sbzo (Spevigo) (PDF) CP.PHAR.606 03/01/2023
Stiripentol (Diacomit) (PDF) CP.PMN.184 11/26/2018
Sutimlimab (Enjaymo) (PDF) CP.PHAR.503 03/01/2022
Tadalafil BPH - ED (Cialis) (PDF) CP.PMN.132 05/06/2020
Tafamidis meglumine, Tafamidis (Vyndaquel, Vyndamax) (PDF) CP.PHAR.432 08/16/2019
Tafasitamab-cxix (Monjuvi) (PDF) CP.PHAR.508 11/01/2020
taliglucerase alfa (Elelyso) (PDF) CP.PHAR.157 05/17/2019
Talimogene laherparepvec (Imlygic) (PDF) CP.PHAR.542 07/01/2021
Talquetamab-tgvs (Talvey) (PDF) CP.PHAR.649 10/01/2023
Tebentafusp-tebn (Kimmtrak) (PDF) CP.PHAR.575 06/01/2022
Teclistamab-cqyv (Tecvayli) (PDF) CP.PHAR.611 03/01/2023
teduglutide (Gattex) (PDF) CP.PHAR.114 09/13/2019
Tegaserod (Zelnorm) (PDF) CP.PMN.206 08/12/2019
Telotristat ethyl (Xermelo) (PDF) CP.PHAR.337 05/16/2019
temasmorelin (Egrifta) (PDF) CP.PHAR.109 8/15/2019
temsirolimus (Torisel) (PDF) CP.PHAR.324 11/20/2018
Teplizumab-mzwv (Tzield) (PDF) CP.PHAR.492 03/01/2023
Teprotumumab (Tepezza) (PDF) CP.PHAR.465 05/06/2020
testosterone pellet (Testopel) (PDF) CP.PHAR.354 09/13/2019
Tezepelumab (Tezspire) (PDF) CP.PHAR.576 06/01/2022
thyrotropin alfa (Thyrogen) (PDF) CP.PHAR.95 08/15/2019
tisagenlecleucel (Kymriah) (PDF) CP.PHAR.361 05/01/2022
Tisotumab vedotin - tftv (Tivdak) (PDF) CP.PHAR.561 12/01/2021
tocilizumab (Actemra) (PDF) CP.PHAR.263 06/01/2021
Tofersen (Qalsody) (PDF) CP.PHAR.591 07/01/2023
Tolvaptan (Jynarque, Samsca) (PDF) CP.PHAR.27 08/15/2019
Topiramate ER (Qudexy XR, Trokendi XR (PDF) CP.PMN.281 08/01/2022
trabectedin (Yondelis) (PDF) CP.PHAR.204 02/14/2019
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) CP.PHAR.228 09/13/2019
Tremelimumab-actl (Imjudo) (PDF) CP.PHAR.612 03/01/2023
Triamcinolone ER Injection  (Zilretta) (PDF) CP.PHAR.371 02/15/2019
Triclabendazole (Egaten) (PDF) CP.PMN.207 08/12/2019
Trientine (Syprine) (PDF) CP.PHAR.438 05/06/2020
Triheptanoin (Dojolvi) (PDF) CP.PHAR.509 11/01/2020
triptorelin pamoate (Trelstar, Triptodur) (PDF) CP.PHAR.175 08/16/2019
Trofinetide (Daybue) (PDF) CP.PHAR.600 06/01/2023
Ublituximab-xiiy (Briumvi) (PDF) CP.PHAR.621 06/01/2023
Ulcer Therapy Combinations (Omeclamox Pak, Pylera, Talicia) (PDF) CP.PMN.277 06/01/2022
Umbralisib (Ukoniq) (PDF) CP.PHAR.531 06/01/2021
Valoctocogene Roxaparvovec (Roctavian) (PDF) CP.PHAR.466 09/01/2023
Valproate (Depacon) (PDF) CP.PHAR.429 08/12/2019
Valrubicin (Valstar) (PDF) CP.PHAR.439 05/06/2020
velaglucerase alfa (VPRIV) (PDF) CP.PHAR.163 05/16/2019
Velmanase Alfa (Lamazym, Lamzede) (PDF) CP.PHAR.601 06/01/2023
verteporfin (Visudyne) (PDF) CP.PHAR.187 02/13/2019
vestronidase alfa-vjbk (Mepsevii) (PDF) CP.PHAR.374 05/17/2019
vigabatrin (Sabril) (PDF) CP.PHAR.169 08/10/2019
vilazodone (Viibryd) (PDF) CP.PMN.145 08/17/2019
Viltolarsen (Viltepso) (PDF) CP.PHAR.484 09/01/2020
vincristine sulfate liposome injection (Marqibo) (PDF) CP.PHAR.315 11/17/2018
Voclosporin (Lupkynis) (PDF) CP.PHAR.504 06/01/2021
Voretigene neparvovec-rzyl (Luxturna) (PDF) CP.PHAR.372 02/15/2019
vortioxetine HBr (Trintellix) (PDF) CP.PMN.65 08/16/2019
Vosoritide (Voxzogo) (PDF) CP.PHAR.525 01/01/2022
vutrisiran (Amvuttra) (PDF) CP.PHAR.550 12/01/2022
ziv-aflibercept (Zaltrap) (PDF) CP.PHAR.325 11/20/2018
zoledronic acid (Reclast, Zometa) (PDF) CP.PHAR.59 02/14/2019
Zuranolone (Zurzuvae) (PDF) CP.PHAR.650 10/01/2023


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

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


Payment Policies
Policy Title Policy Number Effective Date
25-Hydroxyvitamin D Testing in Children and Adolescents (PDF) CP.MP.157 12/2017
3-Day Payment Window (PDF) CC.PP.500 07/01/2014
30-Day Readmission (PDF) CC.PP.501 01/01/2015
Add on Code Billed Without Primary Code (PDF) CC.PP.030 01/01/2013
Allergy Testing and Therapy (PDF) CP.MP.100 05/30/2022
Antithrombin III (Thrombate III, Atryn) (PDF)
CP.MP.179 10/31/2019
Assistant Surgeon (PDF) CC.PP.029 01/01/2014
Bilateral Procedures (PDF) CC.PP.037 01/01/2014
Bronchial Thermoplasty (PDF) CP.MP.110 05/2016
Burn Surgery (PDF) CP.MP.186 05/31/2020
Cardiac Biomarker Testing (PDF) CP.MP.156 12/2017
Cerumen Removal (PDF) CC.PP.008 01/01/2014
Clean Claim Reviews (PDF) CC.PI.04 11/01/2012
Clean Claims (PDF) CC.PP.021 01/01/2013
Clinic Facility Charge (PDF) CC.PP.059 01/29/2018
Coding Editing Overview (PDF) CC.PP.011 01/01/2013
Comprehensive Payment Integrity (CPI) (PDF) CC.PP.074 08/01/2023
Cosmetic and Reconstructive Surgery (PDF) CP.MP.31 05/31/2020
Cosmetic Procedures (PDF) CC.PP.024 01/01/2014
Cost to Charge Adjustments on Clean Claim Reviews (PDF) CC.PI.06 09/01/2022
Diagnosis of Vaginitis (PDF) CP.MP.97 06/2016
Digital EEG Spike Analysis (PDF) CP.MP.105 01/31/2021
Distinct Procedural Modifiers (PDF) CC.PP.020 01/01/2013
Drugs of Abuse: Definitive Testing (PDF) CP.MP.50 03/31/2022
Drugs of Abuse: Presumptive Testing (PDF) CP.MP.208 04/30/2021 - 11/30/2021
Duplicate Primary Code Billing (PDF) CC.PP.044 01/01/2014
E&M Medical Decision-Making (PDF) CC.PP.051 06/2017
EEG in the Evaluation of Headache (PDF) CP.MP.155 04/30/2021
Endometrial Ablation (EA) (PDF) CP.MP.106 01/2016
Evoked Potential Testing (PDF) CP.MP.134 04/30/2021
External Ocular Photography (PDF) OC.UM.CP.0043 10/01/2016
Fertility Preservation (PDF) CP.MP.130 10/2016
Fluorescein Angiography (PDF) OC.UM.CP.0028 01/01/2018
Fundus Photography (PDF) OC.UM.CP.0029 01/01/2018
Global Maternity Billing (PDF) CC.PP.016 01/01/2013
Gonioscopy (PDF) OC.UM.CP.0031 10/01/2016
Helicobacter Pylori Serology Testing (PDF) CP.MP.153 12/2017
Holter Monitors (PDF) CP.MP.113 08/2016
Homocysteine Testing (PDF)
CP.MP.121 08/2016
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 01/01/2013
Inpatient Consultation (PDF) CC.PP.038 01/01/2014
Incidental Diagnostic and Laboratory Tests Billed with Evaluation and Management Services (PDF) CC.PP.010 01/01/2013
Inpatient Only Procedures (PDF) CC.PP.018 01/01/2013
IV Hydration (PDF) CC.PP.012 01/01/2013
Laser Therapy for Skin Conditions (PDF) CP.MP.123 08/2016
Leveling of Care: Evaluation and Management Overcoding (PDF) CC.PP.066 11/01/2020
Leveling of ER Services (PDF) CC.PP.053 10/01/2017
Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF) CP.MP.139 02/2017
Maximum Units of Service (PDF) CC.PP.007 01/01/2013
Measurement of Serum 1,25-dihydroxyvitamin D (PDF) CP.MP.152 12/2017
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
CP.MP.144 04/2017 - 07/23/2020
Moderate Conscious Sedation (PDF) CC.PP.015 01/01/2013
Modifier -25 clinical validation (PDF) CC.PP.013 01/01/2013
Modifier -59 clinical validation (PDF) CC.PP.014 01/01/2013
Modifier DOS Validation (PDF) CC.PP.034 01/01/2013
Modifier to Procedure Code Validation (PDF) CC.PP.028 01/01/2013
Multiple CPT Code Replacements (PDF) CC.PP.033 01/01/2014
NCCI Unbundling (PDF) CC.PP.031 01/01/2013
Never Paid Events (PDF) CC.PP.017 01/01/2013
New Patient (PDF) CC.PP.036 01/01/2014
Non-Invasive Home Ventilators (PDF) CP.MP.184 05/31/2020
Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF) CC.PP.061 05/30/18
Not Medically Necessary IP Services (PDF) CC.PP.060 06/01/2018
Orthognathic Surgery (PDF) CP.MP.202 10/31/2021
Outpatient Consultation (PDF) CC.PP.039 01/01/2014
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 12/01/2020
Pediatric Oral Function Therapy (PDF) CP.MP.188 05/31/2020
Physician Visit Codes Billed with Labs (PDF) CC.PP.019 01/01/2013
Physician's Consultation Services (PDF) CC.PP.054 11/01/2017
Place of Service Mismatch (PDF) CC.PP.063 09/01/2018
Post-Operative Visits (PDF) CC.PP.042 01/01/2014
Pre-Operative Visits (PDF) CC.PP.041 01/01/2014
Problem Oriented Visits with Preventive Visits (PDF) CC.PP.057 11/1/2017
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 11/1/2017
Professional Component Modifier -26 (PDF) CC.PP.027 01/01/2013
Pulmonary Function Testing (PDF) CP.MP.242 06/30/2022
Pulse Oximetry (PDF) CC.PP.025 01/01/2014
Robotic Surgery (PDF) CC.PP.050 08/2017
Same Day Visits (PDF) CC.PP.040 11/01/2019
Scanning Computerized Ophthalmic Diagnostic Imaging (PDF) OC.UM.CP.0014 01/01/2018
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF) CP.MP.174 03/2019
Short Inpatient Hospital Stay (PDF) CP.MP.182 10/01/2020
Sleep Studies Place of Services (PDF) CC.PP.035 05/01/2017 
Status "B" Bundled Services (PDF) CC.PP.046 01/01/2014
Status "P" Bundled Services (PDF) CC.PP.049 03/15/2017
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 01/01/2013
Testing for Select Genitourinary Conditions (PDF) NE.CP.MP.97 11/1/2022
Thyroid Hormones and Insulin Testing in Pediatrics (PDF) CP.MP.154 12/2017
Transgender Related Services (PDF) CC.PP.047 01/01/2017
Ultrasound in Pregnancy (PDF) CP.MP.38 01/2011
Unbundled Professional Services (PDF) CC.PP.043 01/01/2014
Unbundled Surgical Procedures (PDF) CC.PP.045 01/01/2014
Unbundling Adjustments on Clean Claim Reviews (PDF) CC.PI.10 09/01/2022
Unlisted Procedure Codes (PDF) CC.PP.009 01/01/2013
Urine Specimen Validity Testing (PDF) CC.PP.056 11/01/2017 
Urodynamic Testing (PDF) CP.MP.98 04/1/2021
Visual Field Test (PDF) OC.UM.CP.0063 01/01/2018
Vitamin D Testing in Children (PDF) CP.MP.157 12/2017
Wheelchair Accessories (PDF) CC.PP.502 07/01/2016
Wheelchair Seating (PDF) CP.MP.99  10/2015
Wireless Motility Capsule (PDF) CP.MP.143  04/2017