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     - Back to Top -
     ADHD Stimulant Step Therapy Policy
     Alpha Blockers for BPH ST policy
     Alzheimer's Disease ST policy
     Antidepressants - SNRI Step Therapy Policy
     Cellular Immunotherapy for Prostate Cancer
     Custom Compounded Hormone Replacement Therapy
     Eliquis (apixaban)
     Fasenra (benralizumab)
     Forteo (teriparatide)
     Gabapentin Step Therapy Program
     GLP-1 Agonists
     Minocycline Extended Release
     Ocaliva (obeticholic acid)
     Overactive Bladder (OAB) Step Therapy Program
     Pradaxa (dabigatran) PA policy
     Selzentry (maraviroc) PA policy
     Symlin (pramlintide)
     Tramadol Step Therapy Policy
A     - Back to Top -
     Ablation Procedures for Peripheral Neuromas
     Absorbable Nasal Implant for Treatment of Nasal Valve Collapse
     Accelerated Breast Irradiation and Brachytherapy Boost After Breast-Conserving Surgery for Early-Stage Breast Cancer
     Actemra (tocilizumab)
     Acthar (Repository Corticotropin Injection)
     Actigraphy
     Acupuncture for Pain Management, Nausea and Vomiting, and Opioid Dependence
     Addyi (flibanserin)
     ADHD Non-Stimulant Step Therapy Policy
     Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast
     Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses
     Adoptive Immunotherapy
     Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Treatment of HER-2 Positive Malignancies
     Advanced Practice Nurses (APN); Advanced Registered Nurse Practitioners (ARNP) and Certified Registered Nurse Anesthetists (CRNA)
     Advanced Therapies for Pharmacologic Treatment of Pulmonary Arterial Hypertension
     Air Ambulance
     Aldurazyme (laronidase)
     Aliqopa (copanlisib)
     Allergy Testing and Allergy Immunotherapy
     Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias
     Allogeneic Hematopoietic Stem-Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms
     Allogeneic Pancreas Transplant
     Alpha Reductase Inhibitors BPH Step Therapy Policy
     Alpha-1 Proteinase Inhibitors
     Alunbrig (brigatinib)
     Ambulance Supplies
     Ambulatory Event Monitors and Mobile Outpatient Cardiac Telemetry
     Amniotic Membrane and Amniotic Fluid Injections
     Ampyra (dalfampridine)
     Anesthesia Processing Guidelines
     Antidepressants - SSRI Step Therapy Policy
     Antigen Leukocyte Antibody Test (ALCAT)
     Aqueous Shunts and Stents for Glaucoma
     Arcalyst (rilonacept)
     Arikayce (amikacin)
     Artificial Intervertebral Disc: Cervical Spine
     Artificial Intervertebral Disc: Lumbar Spine
     Artificial Pancreas Device Systems
     Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer (Oncotype)
     Auditory Brainstem Implant
     Austedo (deutetrabenzine)
     Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
     Autologous Chondrocyte Implantation and Other Cell-based Treatments of Focal Articular Cartilage Lesions
     Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure
     Automated Percutaneous and Percutaneous Endoscopic Discectomy
     Automated Point-of-Care Nerve Conduction Tests
     Autonomic Nervous System Testing
     Avastin (bevacizumab)
B     - Back to Top -
     Balloon Dilation of the Eustachian Tube
     Balloon Ostial Dilation for Treatment of Chronic Rhinosinusitis
     Bariatric Surgery
     Bavencio (avelumab)
     BCR-ABL1 Testing for Diagnosis, Monitoring, and Drug Resistance Mutation Detection in Chronic Myelogenous Leukemia
     Benlysta (belimumab)
     Besponsa (inotuzumab ozogamicin)
     Beta-Blockers ST policy
     Bile Acid Sequestrants Step Therapy Policy
     Bio-Engineered Skin and Soft Tissue Substitutes
     Biofeedback as a Treatment of Chronic Pain
     Biofeedback as a Treatment of Fecal Incontinence or Constipation
     Biofeedback as a Treatment of Headache
     Biofeedback as a Treatment of Urinary Incontinence in Adults
     Biofeedback for Miscellaneous Indications
     Bioimpedance Devices for Detection and Management of Lymphedema
     Bisphosphonates (oral) ST policy
     Biventricular Pacemakers for the Treatment of Heart Failure
     Blepharoplasty and Ptosis Repair
     Blincyto (blinatumomab)
     Bone Mineral Density Studies
     Bone Morphogenetic Protein
     Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover
     Botulinum Toxin
     BRAF Gene Variant Testing To Select Melanoma Patients for BRAF Inhibitor Targeted Therapy
     Braftovi (encorafenib)
     Brineura (cerliponase alfa)
     Bronchial Thermoplasty
     Bronchial Valves
     Buprenorphine implant for Treatment of Opioid Dependence
C     - Back to Top -
     C1 Esterase Inhibitors
     Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists
     Calquence (acalabrutinib)
     Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting
     Cardiac Rehabilitation in the Outpatient Setting
     Cardiovascular Risk Panels
     Catheter Ablation as Treatment for Atrial Fibrillation
     Cerezyme (imiglucerase)
     Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions
     Chelation Therapy for Off-Label Uses
     Chemical Peels
     Chenodal (chenodiol)
     Chromoendoscopy as an Adjunct to Colonoscopy
     Chromosomal Microarray Testing for the Evaluation of Pregnancy Loss
     Chronic Intermittent Intravenous Insulin Therapy (CIIIT)
     Cialis (tadalafil) for Benign Prostatic Hyperplasia
     Cimzia (certolizumab)
     Cinqair (reslizumab)
     Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)
     Circulating Tumor DNA for Management of Non-Small-Cell Lung Cancer (Liquid Biopsy)
     Clotting Factors and Coagulant Blood Products
     Cochlear Implants
     Cognitive Rehabilitation
     Combination Beta2-Agonist Corticosteroid Inhalers PA policy
     Compounded Medications
     Computer-assisted Navigation Orthopedic Procedure
     Confocal Laser Endomicroscopy
     Continuous or Intermittent Glucose Monitoring in Interstitial Fluid
     Continuous Passive Motion in the Home Setting
     Contraceptives
     Cooling Devices Used in the Outpatient Setting
     Copiktra (duvelisib)
     Corneal Collagen Cross-Linking
     Corneal Topography Computer-Assisted Corneal Topography/Photokeratoscopy
     Coronary Computed Tomography Angiography With Selective Noninvasive Fractional Flow Reserve
     Cosentyx (secukinumab)
     Cryosurgical Ablation of Miscellaneous Solid Tumors Other than Liver, Prostate, or Dermatologic Tumors
     Cryosurgical Ablation of Primary or Metastatic Liver Tumors
     Crysvita (burosumab-twza)
     Cytochrome P450 Genotyping
D     - Back to Top -
     Daliresp (roflumilast)
     Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)
     Deep Brain Stimulation
     Depakote-Depakene Step Therapy Program
     Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
     Diagnosis and Treatment for Sacroiliac Joint Pain
     Discectomy
     Dopamine Transporter Imaging with Single Photon Emission Computed Tomography DATSPECT
     Doptelet (avatrombopag)
     Drug Infusion Site of Care
     Drug Testing in Pain Management and Substance Use Disorder Treatment
     Dry Needling and Trigger Point Injections for Myofascial Pain
     Dupixent (dupilumab)
     Durable Medical Equipment
     Duzallo (lesinurad and allopurinol)
     Dynamic Posturography
     Dynamic Spinal Visualization
     Dynamic Splinting Devices
     Dynamic Stabilization Systems
E     - Back to Top -
     Egrifta (tesamorelin)
     Elaprase (idursulfase)
     Electric or Power Wheelchairs and Scooters
     Electrical Bone Growth Stimulation of the Appendicular Skeleton
     Electrical Stimulation for Scoliosis
     Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
     Electromagnetic Navigation Bronchoscopy
     Electromyography and Nerve Conduction Studies
     Electronic Brachytherapy for Nonmelanoma Skin Cancer
     Electrostimulation and Electromagnetic Therapy for Treating Wounds
     Emergency Care
     Emflaza (deflazacort)
     Enbrel (etanercept)
     Endari (L-glutamine oral powder)
     Endobronchial Brachytherapy
     Endobronchial Ultrasound for Diagnosing and Staging of Lung Cancer
     Endoscopic Radiofrequency Ablation or Cryoablation for Barrett’s Esophagus
     Endothelial Keratoplasty
     Endovascular Procedures (Angioplasty and/or Stenting) for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
     Endovascular Stent Grafts for Abdominal Aortic Aneurysms
     Endovascular Stent Grafts for Disorders of the Thoracic Aorta
     Endovascular Therapies for Extracranial Vertebral Artery Disease
     Enhanced External Counterpulsation (EECP)
     Entresto (sacubitril-valsartan)
     Entyvio (vedolizumab)
     Epidiolex (cannabidiol)
     Epidural Steroid Injections for Back Pain
     Erleada (apalutamide)
     Erythropoieses-Stimulating Agents
     Esbriet (pirfenidone)
     Esophageal pH Monitoring
     Eucrisa (crisaborole)
     Exondys 51 (eteplirsen)
     Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies
     External (Portable) Infusion Pumps
     Extracorporeal Photopheresis
     Extracorporeal Shock Wave Therapy for Plantar Fasciitis and Other Musculoskeletal Conditions
     Extracranial Carotid Artery/ Stenting
     Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome
F     - Back to Top -
     Fabrazyme (agalsidase beta)
     Facet Arthroplasty
     Facet Joint Denervation
     Facility Routine Supplies and Services
     Fecal Analysis in the Diagnosis of Intestinal Dysboiosis
     Fecal Microbiota Transplantation
     Firazyr (icatibant)
     Forms of Alternative Treatment
     Formulary Non-Covered Drugs
     Functional Neuromuscular Electrical Stimulation
G     - Back to Top -
     Gait Analysis
     Galafold (migalastat)
     Gastric Electrical Stimulation
     Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management
     Gene Expression Profiling for Cutaneous Melanoma
     Gene Expression Testing in the Evaluation of Patients with Stable Ischemic Heart Disease
     Gene Expression-Based Assays for Cancers of Unknown Primary
     Gene Therapy for Inherited Retinal Dystrophy
     General Approach to Evaluating the Utility of Genetic Panels
     General Approach To Genetic Testing
     Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
     Genetic Cancer Susceptibility Panels Using Next Generation Sequencing
     Genetic Testing for Alzheimer Disease
     Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers
     Genetic Testing for Cardiac Ion Channelopathies
     Genetic Testing for Epilepsy
     Genetic Testing for FLT3 and NPM1 Variants in Cytogenetically Normal Acute Myeloid Leukemia
     Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
     Genetic Testing for the Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies
     Gocovri (amantadine extended release)
     Gout Medications Step Therapy policy
H     - Back to Top -
     Heart Transplant
     Heart-Lung Transplant
     Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia
     Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma
     Hematopoietic Cell Transplantation for Germ Cell Tumors (GCT)
     Hematopoietic Stem Cell Transplantation for Acute Lymphoblastic Leukemia
     Hematopoietic Stem Cell Transplantation for Acute Myeloid Leukemia
     Hematopoietic Stem Cell Transplantation for Autoimmune Diseases
     Hematopoietic Stem Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma
     Hematopoietic Stem Cell Transplantation for Epithelial Ovarian Cancer
     Hematopoietic Stem Cell Transplantation for Hodgkin Lymphoma
     Hematopoietic Stem Cell Transplantation for Miscellaneous Solid Tumors in Adults
     Hematopoietic Stem Cell Transplantation for Non-Hodgkin’s Lymphomas
     Hematopoietic Stem Cell Transplantation for Primary Amyloidosis
     Hematopoietic Stem Cell Transplantation for Solid Tumors of Childhood
     Hematopoietic Stem Cell Transplantation for Waldenstrom Macroglobulinemia
     Hematopoietic Stem-Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome
     Hemlibra (emicizumab-kxwh)
     Hepatitis C Virus (HCV) Direct Acting Antivirals (DAAs)
     Herceptin (trastuzumab)
     Hetlioz (tasimelteon)
     High Dose Rate Temporary Prostate Brachytherapy
     Hip Resurfacing
     Hippotherapy
     Home Cardiorespiratory Monitoring
     Homocysteine Testing in the Screening Diagnosis and Management of Cardiovascular Disease
     Human Growth Hormone
     Humira (adalimumab)
     Hyperbaric Oxygen Therapy
I     - Back to Top -
     Identification of Microorganisms Using Nucleic Acid Probes
     Idhifa (enasidenib)
     Ilaris (canakinumab)
     Ilumya (tildrakizumab-asmn)
     Image-Guided Minimally Invasive Decompression for Spinal Stenosis
     IMFINZI (durvalumab)
     Immune Cell Function Assay
     Immune Globulin Therapy (Updated 8-18)
     Immune Prophylaxis for Respiratory Syncytial Virus (RSV)
     Immunizations
     Implantable Bone Conduction and Bone Anchored Hearing Aids
     Implantable Cardioverter Defibrillator (ICD)
     Implantable Infusion Pumps
     Implantable Sinus Spacers and Stents for Postoperative Use Following Endoscopic Sinus Surgery and for Recurrent Sinus Disease
     Implantation of Intrastromal Corneal Ring Segments (INTACS)
     In Vitro Chemoresistance and Chemosensitivity Assays
     Increlex (mecasermin)
     Influenza Therapies
     Ingestible pH and Pressure Capsule
     Ingrezza (valbenazine)
     Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
     Injectable Clostridial Collagenase for Fibroproliferative Disorders
     Intensity Modulated Radiation Therapy (IMRT): Central Nervous System Tumors
     Intensity Modulated Radiotherapy (IMRT): Breast and Lung
     Intensity-Modulated Radiation Therapy (IMRT): Abdomen and Pelvis
     Intensity-Modulated Radiation Therapy (IMRT): Prostate
     Intensity-Modulated Radiotherapy (IMRT): Head, Neck, Thyroid and Brain Cancers
     Interferential Current Stimulation
     Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
     Interventions for Progressive Scoliosis
     Intra-articular Hyaluronan Injections for Osteoarthritis
     Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain
     Intracellular Micronutrient Analysis
     Intradialytic Parenteral Nutrition
     Intraocular Radiotherapy for Age-Related Macular Degeneration
     Intraoperative Fluorescence Imaging Systems
     Intraoperative Neurophysiologic Monitoring (Sensory Evoked Potentials, Motor Evoked Potentials, etc.)
     Intraoperative Radiotherapy (IORT)
     Intravenous Anesthetics for the Treatment of Chronic Pain
     Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease
     Intravitreal Corticosteroid Implants
     Invasive Prenatal (Fetal) Diagnostic Testing
     Iontophoresis and Phonophoresis as a Transdermal Technique for Drug Delivery
     Islet Transplantation
     Isolated Small Bowel Transplant
J     - Back to Top -
     JAK2, MPL and CALR Testing for Myeloproliferative Neoplasms
     Jetrea (ocriplasmin) Symptomatic Vitreomacular Adhesion
     Jivi
     Juxtapid (lomitapide)
     Jynarque (tolvaptan)
K     - Back to Top -
     Kalbitor (ecallantide)
     Kalydeco (ivacaftor)
     Keratoprosthesis (Artficial Cornea)
     Keveyis (dichlorphenamide)
     Kevzara (sarilumab)
     Kidney Transplant
     Kisqali_Kisqali Femara (ribociclib)
     Korlym (mifepristone)
     KRAS, NRAS and BRAF Variant Analysis in Metastatic Colorectal Cancer
     Krystexxa (pegloticase)
     Kuvan (sapropterin)
     Kynamro (mipomersen)
L     - Back to Top -
     Laboratory and Genetic Testing for Use of 5-Fluorouracil (5-FU) in Patients with Cancer
     Laboratory Tests for Heart and Kidney Transplant Rejection
     Laminectomy
     Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids
     Laser Treatment of Onychomycosis
     Lemtrada (alemtuzumab)
     Libtayo (cemiplimab-rwlc)
     Light Therapy for Psoriasis and Eczema
     Lipid Apheresis
     Liver Transplant and Combined Liver-Kidney Transplant
     Long-Acting Opioid Step Therapy Policy
     Low-Level Laser Therapy
     Lumizyme (alglucosidase alfa)
     Lung and Lobar Lung Transplant
     Lung Volume Reduction Surgery for Severe Emphysema
     Lysis of Epidural Adhesions
M     - Back to Top -
     Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease (GERD)
     Magnetic Resonance Imaging‒Targeted Biopsy of the Prostate
     Magnetic Resonance‒Guided Focused Ultrasound
     Magnetoencephalography – Magnetic Source Imaging
     Mandibular/Maxillary (Orthognathic) Surgery
     Manipulation Under Anesthesia
     Manipulations and Chiropractic Care
     Maternity – Global Fee Inclusions and Exclusions
     Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders
     Measurement of Lipoprotein-associated Phospholipase A2 (Lp-PLA2) in the Assessment of Cardiovascular Risk
     Mektovi (binimetinib)
     Meniscal Allografts and Other Meniscus Implants
     Mepsevii (vestronidase-aslfa-vjbk)
     Microprocessor Controlled Prostheses for the Lower Limb
     Microwave Tumor Ablation
     Miscellaneous Genetic and Molecular Diagnostic Testing
     Miscellaneous Investigational Procedures
     Miscellaneous Special Services
     Moderate Penetrance Variants Associated with Breast Cancer in Individuals at High Breast Cancer Risk
     Modifiers
     Molecular Analysis for Targeted Therapy of Non-Small-Cell Lung Cancer
     Molecular Markers in Fine Needle Aspirates of the Thyroid
     Molecular Testing for the Management of Pancreatic Cysts or Barrett Esophagus
     Molecular Testing in the Management of Pulmonary Nodules
     Mozobil (plerixafor)
     Mulpleta (lusutrombopag)
     Multianalyte Assays with Algorithmic Analyses for Predicting Risk of Type 2 Diabetes
     Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis
     Multigene Expression Assay for Predicting Recurrence in Colon Cancer
     Multimarker Serum Testing Related to Ovarian Cancer
     Multiple Sclerosis Therapies
     Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis
     Myalept (metreleptin)
     Mylotarg (gemtuzumab ozogamicin)
     Myoelectric Prosthetic Components for the Upper Limb
N     - Back to Top -
     Negative Pressure Wound Therapy in the Outpatient Setting
     Nerlynx (neratinib)
     Nerve Fiber Density Measurement
     Neural Therapy
     Neurofeedback
     Non-Contact Ultrasound Treatment for Wounds
     Noninvasive Fetal RHD Genotyping Using Cell-Free Fetal DNA
     Noninvasive Prenatal Screening for Fetal Aneuploidies Using Cell-Free Fetal DNA
     Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease
     Non-Invasive Tests for the Detection of Fetal Membrane Rupture
     Non-Invasive Vascular Studies
     Non-Pharmacologic Treatment of Rosacea
     Northera (droxidopa)
     Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
     Nplate (romiplostim)
     Nucala (mepolizumab)
     Nutrient/Nutritional Panel Testing
O     - Back to Top -
     Occipital Nerve Stimulation
     Occlusion of Uterine Arteries using Transcatheter Embolization
     Ocrevus (ocrelizumab)
     Ofev (nintedanib)
     Olumiant (baricitinib)
     Omega-3 Fatty Acid Products
     Oncologic Applications of Photodynamic Therapy, Including Barrett’s Esophagus
     Onpattro (patisiran)
     Opdivo (nivolumab)
     Open and Thoracoscopic Approaches to Treat Atrial Fibrillation (Maze and Related Procedures)
     Ophthalmic Prostaglandin Step Therapy
     Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma
     Opthalmic Dry Eye Disease - Restasis (cyclosporine ophthalmic emulsion)
     Optical Coherence Tomography (OCT) of the Anterior Eye Segment
     Orencia IV SQ (abatacept)
     Orilissa (elagolix)
     Orkambi (lumacaftor-ivacaftor)
     Orthopedic Applications of Platelet-Rich Plasma
     Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used With Autologous Bone Marrow)
     Orthoptic Training for the Treatment of Vision or Learning Disabilities
     Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders
     Otezla (apremilast)
     Outpatient Pulmonary Rehabilitation
     Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
P     - Back to Top -
     Palynziq (pegvaliase-pqpz)
     Panniculectomy and Abdominoplasty
     Paraspinal Surface Electromyography (EMG) to Evaluate and Monitor Back Pain
     Parsabiv (etelcalcetide)
     Patient Controlled End Range of Motion Stretching Devices
     Patient-Specific Instrumentation (eg, Cutting Guides) for Joint Arthroplasty
     Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
     Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty, and Mechanical Vertebral Augmentation
     Percutaneous Electrical Nerve Stimulation PENS and Percutaneous Neuromodulation Therapy (PNT)
     Percutaneous Intradiscal Electrothermal Annuloplasty Radiofrequency Annuloplasty and Biacuplasty
     Percutaneous Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
     Percutaneous Tibial Nerve Stimulation
     Percutaneous Vertebroplasty and Sacroplasty
     Peripheral Subcutaneous Field Stimulation
     Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)
     Perjeta (pertuzumab)
     Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia
     Pharmacogenetic Testing for Pain Management
     Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines
     Photodynamic Therapy for Choroidal Neovascularization
     Placental and Umbilical Cord Blood as a Source of Stem Cells
     Plugs for Anal Fistula Repair
     Pneumatic Compression Pumps for Treatment of Lymphedema
     Polysomnography for Non-Respiratory Sleep Disorders
     Postsurgical Outpatient Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
     Poteligeo (mogamulizmuab-kpkc)
     Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities
     Praluent (alirocumab)
     Preimplantation Genetic Testing
     Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia
     Prolia (denosumab)
     Prolotherapy
     Promacta (eltrombopag)
     Prophylactic Oophorectomy
     Prostatic Urethral Lift
     Proteogenomic Testing in Patients with Cancer
     Proteomic Testing for Systemic Therapy in Non-Small Cell Lung Cancer
     Provigil Nuvigil Step Therapy
Q     - Back to Top -
     Qbrexza (glycopyrronium cloth)
     Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers
     Quantitative Sensory Testing
R     - Back to Top -
     Radicava (edaravone)
     Radioactive Seed Localization of Nonpalpable Breast Lesions
     Radioembolization for Primary and Metastatic Tumors of the Liver
     Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
     Radiofrequency Ablation of Peripheral Nerves to Treat Pain
     Radiofrequency Ablation of Primary or Metastatic Liver Tumors
     Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension
     Radioimmunoscintigraphy (Monoclonal Antibody Imaging) With Indium 111 Capromab Pendetide for Prostate Cancer
     Rebinyn (factor IX (recombinant[glycopegylated]))
     Reconstructive and Cosmetic Services
     Reconstructive Breast Surgery and Management of Breast Implants
     Reduction Mammaplasty
     Remicade (infliximab) Inflectra (infliximab-dyyb) Renflexis (infliximab-abda)
     Repatha (evolocumab)
     Reproductive Techniques
     Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
     Retinal Prosthesis
     Retinal Telescreening for Diabetic Retinopathy
     Rituxan (rituximab)
     Rituxan Hycela (rituximab and hyaluronidase)
     Robotics in Surgery
     Rubraca (rucaparib)
     Rydapt (midostaurin)
S     - Back to Top -
     Sabril, Vigadrone (vigabatrin)
     Sacral Nerve Neuromodulation / Stimulation
     Samsca (tolvaptan)
     Saturation Biopsy for Diagnosis and Staging of Prostate Cancer
     Scintimammography and Gamma Imaging of the Breast and Axilla
     Sensory Integration Therapy and Auditory Integration Therapy
     Serum Biomarker Human Epididymis Protein 4
     Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases
     Short-Acting Fentanyl
     Siliq (brodalumab)
     Simponi (golimumab)
     Small Bowel - Liver and Multivisceral Transplant
     Solaraze (diclofenac sodium 3 percent gel)
     Soliris (eculizumab)
     Solosec (secnidazole)
     Speech Generating Devices
     Sphenopalatine Ganglion Block or Other Intranasal Blockage for Headache
     Spinal Cord and Dorsal Root Ganglion Stimulation
     Spinal Ultrasound
     Spinraza (nusinersen)
     ST2 Assay for Chronic Heart Failure
     Stelara (ustekinumab)
     Step Therapy Policy
     Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
     Sublingual Immunotherapy as a Technique of Allergen Specific Therapy
     Subtalar Arthroereisis
     Surgery for Groin Pain in Athletes
     Surgical Deactivation of Headache Trigger Sites
     Surgical Treatment of Bilateral Gynecomastia
     Surgical Treatment of Femoroacetabular Impingement
     Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
     Surgical Ventricular Restoration
     Symdeko (tezacaftor-ivacaftor)
     Synthetic Cartilage Implants for Joint Pain
     Syprine (trientine)
T     - Back to Top -
     Takhzyro (lanadelumab)
     Taltz (ixekizumab)
     Talzenna (talazoparib)
     Tavalisse (fostamatinib)
     Tegsedi (inotersen)
     Temporomandibular Joint Dysfunction
     Testing Serum Vitamin D Levels
     Testosterone Replacement Therapies
     Therapeutic Radiopharmaceuticals in Oncology
     Thermography and Temperature Gradient Studies
     Thiazolidinedione ST policy
     Three-Dimensional Printed Orthopedic Implants
     Tibsovo (ivosidenib)
     Timed Therapeutic Procedures
     Topical Alpha-Adrenergic Agents for Rosacea
     Topical Antifungals for Onychomycosis Step Therapy Program
     Topical Immunomodulator Step Therapy Program
     Topical Tazarotene
     Total Artificial Hearts and Implantable Ventricular Assist Devices
     Transanal Endoscopic Microsurgery (TEM)
     Transanal Radiofrequency Treatment of Fecal Incontinence
     Transcatheter Aortic-Valve Implantation for Aortic Stenosis
     Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies
     Transcatheter Closure of Septal Defects
     Transcatheter Mitral Valve Repair
     Transcatheter Pulmonary Valve Implantation
     Transcranial Magnetic Stimulation and Cranial Electrical Stimulation (CES) as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
     Transcutaneous Electrical Nerve Stimulation – TENS
     Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease
     Transmyocardial Revascularization
     Transtympanic Micropressure Applications as a Treatment of Meniere’s Disease
     Treatment of Gender Dysphoria
     Treatment of Hyperhidrosis
     Treatment of Tinnitus
     Treatment of Varicose Veins/Venous Insufficiency
     Tremfya (guselkumab)
     Trigger Point and Tender Point Injections
     Triptans Step Therapy Policy
     Triptans Step Therapy Policy (ACA)
     Tumor Treating Fields Therapy
     Tymlos (abaloparatide)
     Tysabri (natalizumab)
U     - Back to Top -
     Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis
     Ultrasound Accelerated Fracture Healing Device
     Ultrasound in Pregnancy
     Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance
     Use of Common Genetic Variants (SNPs) to Predict Risk of Nonfamilial Breast Cancer
V     - Back to Top -
     Vagas Nerve Blocking Therapy for Treatment of Obesity
     Vagus Nerve Stimulation
     Vertebral Axial Decompression
     Vertebral Fracture Assessment with Densitometry
     Vertical Expandable Prosthetic Titanium Rib (VEPTR)
     Verzenio (abemaciclib)
     Vesicular Monoamine Transporter Type 2 (VMAT2) Inhibitors
     Vimizim (elosulfase alfa)
     Viscocanalostomy and Canaloplasty
     Vizimpro (dacomitinib)
     VPRIV (velaglucerase alfa)
     Vyxeos (daunorubicin and cytarabine)
W     - Back to Top -
     Wearable Cardioverter-Defibrillators
     Whole Body Dual X-Ray Absorptiometry (DXA) to Determine Body Composition
     Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders
     Whole Gland Cryoablation of Prostate Cancer
     Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel and Esophagus
X     - Back to Top -
     Xalkori (crizotanib)
     Xarelto (rivaroxaban)
     Xeljanz (tofacitinib)
     Xepi (ozenoxacin)
     Xermelo (telotristat)
     Xgeva (denosumab)
     Xolair (omalizumab)
     Xyrem (sodium oxybate)
Y     - Back to Top -
     Yervoy (ipilimumab)
     Yonsa (abiraterone acetate)
Z     - Back to Top -
     Zejula (niraparib)
     Zetia Step Therapy Program
     Zinplava (bezlotoxumab)
     Zurampic (lesinurad)
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