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     Nurtec (rimegepant)
2     - Back to Top -
     2021 Utilization Management Addendum to the Radiology/Cardiology Guidelines Effective 3/22/2021
     2021 Utilization Management Addendum to the Radiology/Cardiology Guidelines Effective August 1, 2021
     2021 Utilization Management Addendum to the Radiology/Cardiology Guidelines Effective August 1, 2021
A     - Back to Top -
     Abdomen Imaging
     Abilify Mycite
     Ablation of Peripheral Nerves to Treat Pain
     Ablation Procedures for Peripheral Neuromas
     Actemra (tocilizumab)
     Acthar (Repository Corticotropin Injection)
     Actigraphy
     Acupuncture for Pain Management, Nausea and Vomiting, and Opioid Dependence
     Adakveo (crizanlizumab-tcma)
     ADHD Stimulant ST Policy
     Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast
     Adoptive Immunotherapy
     Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Treatment of HER-2 Positive Malignancies
     Aducanumab for Alzheimer Disease
     Advanced Therapies for Pharmacologic Treatment of Pulmonary Arterial Hypertension
     Air Ambulance
     Alcohol Injections for Treatment of Peripheral Morton Neuromas
     Aldurazyme (laronidase)
     Aliqopa (copanlisib)
     Allergen Testing
     Allergy Testing and Allergy Immunotherapy
     Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms
     Allogenic Pancreas Transplant
     Allograft Injection for Degenerative Disc Disease
     Alpha-1 Proteinase Inhibitors
     Alunbrig (brigatinib)
     Alzheimer's Disease Step Therapy Policy
     Ambulance Supplies
     Amifampridine
     Amniotic Membrane and Amniotic Fluid Injections
     ANA/ENA Testing
     Aqueous Shunts and Stents for Glaucoma
     Arcalyst (rilonacept)
     Arikayce (amikacin)
     Artificial Pancreas Device Systems
     Asparlas (calaspargase pegol-mknl)
     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 Point-of-Care Nerve Conduction Tests
     Autonomic Nervous System Testing
     Avastin (bevacizumab) - Policy Changes Effective 06-01-21
     Ayvakit (avapritinib)
B     - Back to Top -
     Balloon Dilation of the Eustachian Tube
     Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis
     Balversa (erdafitinib)
     Bavencio (avelumab)
     BCR - ABL 1 Testing
     Benlysta (belimumab)
     Besponsa (inotuzumab ozogamicin)
     Biochemical Markers of Alzheimer Disease and Dementia
     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
     Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases
     Blenrep (belantamab mafodotin-blmf)
     Blincyto (blinatumomab)
     Bone Mineral Density Studies
     Bone Morphogenetic Protein
     Bone Turnover Markers Testing
     Botulinum Toxin
     BRCA
     Breast Imaging
     Brexanolone for Postpartum Depression
     Brexanolone for Postpartum Depression
     Brineura (cerliponase alfa)
     Bronchial Valves
     Brukinsa (zanubrutinib)
     Buprenorphine Implant for Treatment of Opioid Dependence
C     - Back to Top -
     C1 Esterase Inhibitors
     Cablivi (caplacizumab-yhdp)
     Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists
     Calquence (acalabrutinib)
     Cardiac Biomarkers for Myocardial Infarction
     Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting
     Cardiac Imaging
     Cardiac Rehabilitation in the Outpatient Setting
     Cardiovascular Disease Risk Assessment
     Catheter Ablation as Treatment for Atrial Fibrillation
     Celiac Disease Testing
     Cellular Immunotherapy for Prostate Cancer
     Cerezyme (imiglucerase)
     Cervical Cancer Screening
     Chelation Therapy for Off-Label Uses
     Chemical Peels
     Chenodal (chenodiol)
     Chest Imaging
     Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma
     Chimeric Antigen Receptor Therapy for Multiple Myeloma
     Chromoendoscopy as an Adjunct to Colonoscopy
     Chromosomal Microarray
     Chronic Intermittent Intravenous Insulin Therapy (CIIIT)
     Cialis (tadalafil) for Benign Prostatic Hyperplasia
     Cimzia (certolizumab)
     Cinqair (reslizumab)
     Closure Devices for Patent Foramen Ovale and Atrial Septal Defects
     Clotting Factors and Coagulant Blood Products
     Cognitive Rehabilitation
     Compounded Medications
     Computer-assisted Navigation Orthopedic Procedure
     Confocal Laser Endomicroscopy
     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
     Cosela (trilaciclib)
     Cosela (Trilaciclib)
     Cosentyx (secukinumab)
     Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone
     Cryosurgical Ablation of Primary or Metastatic Liver Tumors
     Crysvita (burosumab-twza)
     Custom Compounded Hormone Replacement Therapy
     Cystaran (cysteamine)
D     - Back to Top -
     Daliresp (roflumilast)
     Danyelza (naxitamab-gqgk)
     Daraprim (pyrimethamine)
     Darzalex (daratumumab)
     Darzalex Faspro (daratumumab and hyaluronidase-fihj)
     Daurismo (glasdegib)
     Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)
     Diacomit (stiripentol)
     Diagnosis and Treatment for Sacroiliac Joint Pain
     Diagnosis of Idiopathic Environmental Intolerance
     Diagnosis of Vaginitis including Multi-target PCR Testing
     Diagnostic Testing of Common Sexually Transmitted Infections
     Diagnostic Testing of Influenza
     Diagnostic Testing of Iron Homeostasis & Metabolism
     Digital Health Therapies for Attention Deficit/Hyperactivity Disorder
     Digital Health Therapies for Substance Abuse
     Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Step Therapy
     DNA Ploidy Cell Cycle Analysis
     Dojolvi (triheptanoin)
     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)
     Dynamic Posturography
     Dynamic Spinal Visualization
     Dynamic Splinting Devices
E     - Back to Top -
     Egrifta (tesamorelin)
     Elaprase (idursulfase)
     Electric or Power Wheelchairs and Scooters
     Electrical Stimulation for Scoliosis
     Electromagnetic Navigation Bronchoscopy
     Electronic Brachytherapy for Nonmelanoma Skin Cancer
     Elmiron (pentosan polysulfate sodium)
     Elzonris (tagraxofusp-erzs)
     Emergency Care
     Emflaza (deflazacort)
     Enbrel (etanercept)
     Endari (L-glutamine oral powder)
     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
     Enhertu (fam-trastuzumab deruxtecan-nxki)
     Enspryng (satralizumab-mwge)
     Entyvio (vedolizumab)
     Epidiolex (cannabidiol)
     Epidural Steroid Injections for Neck or Back Pain
     Epithelial Cell Cytology in Breast Cancer Risk Assessment
     Erectile Dysfunction
     Erleada (apalutamide)
     Esbriet (pirfenidone)
     Esophageal Pathology Testing
     Eucrisa (crisaborole)
     Evaluation of Dry Eyes
     Evenity (romosozumab-aqqg)
     Evkeeza (evinacumab-dgnb)
     Evkeeza (evinacumab-dgnb)
     Extracorporeal Photopheresis
     Extracorporeal Shock Wave Therapy for Plantar Fasciitis and Other Musculoskeletal Conditions
     Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome
     Eysuvis (loteprednol etabonate)
F     - Back to Top -
     Fabrazyme (agalsidase beta)
     Facet Arthroplasty
     Fasenra (benralizumab)
     Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing
     Fecal Calprotectin Testing
     Fecal Microbiota Transplantation
     Fibromyalgia Testing
     Fintepla (fenfluramine)
     Firazyr (icatibant)
     Flow Cytometry
     Focal Treatments for Prostate Cancer
     Folate Testing
     Forms of Alternative Treatment
     Formulary Non-Covered Drugs
     Forteo (teriparatide)
     Fotivda (tivozanib)
     Functional Neuromuscular Electrical Stimulation
G     - Back to Top -
     Gabapentin Step Therapy Program
     Gait Analysis
     Galafold (migalastat)
     Gamifant (emapalumab-lzsg)
     Gamma-glutamyl Transferase
     Gas Permeable Scleral Contact Lens
     Gavreto (pralsetinib)
     Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management
     Gene Expression Testing for Breast Cancer Prognosis
     Gene Therapy for Inherited Retinal Dystrophy
     Gene Variants Associated with Breast Cancer in Individuals at High Breast Cancer Risk
     General Genetic Testing, Germline Disorders
     General Genetic Testing, Somatic Disorders
     General Inflammation Testing
     Genetic Cancer Susceptibility Panels using Next Generation Sequencing
     Genetic Testing and Genetic Expression Profiling in Patients with Cutaneous Melanoma (BRAF)
     Genetic Testing and Genetic Expression Profiling in Patients with Uveal Melanoma
     Genetic Testing for Acute Myeloid Leukemia
     Genetic Testing for Adolescent Idiopathic Scoliosis
     Genetic Testing for Alpha- and Beta- Thalassemia
     Genetic Testing for CHARGE Syndrome
     Genetic Testing for Connective Tissue Disorders
     Genetic Testing for Cystic Fibrosis
     Genetic Testing for Diagnosis of Inherited Peripheral Neuropathies
     Genetic Testing for Duchenne, Becker, Facioscapulohumeral, and Limb-Girdle Muscular Dystrophies
     Genetic Testing for Epilepsy
     Genetic Testing for Familial Alzheimer's Disease
     Genetic Testing for Familial Cutaneous Malignant Melanoma
     Genetic Testing for Familial Hypercholesterolemia
     Genetic Testing for Fanconi Anemia
     Genetic Testing for FMR1 Mutations
     Genetic Testing for Germline Mutations of the RET Proto-Oncogene
     Genetic Testing for Hereditary Hearing Loss
     Genetic Testing for Hereditary Hemochromatosis
     Genetic Testing for Hereditary Pancreatitis
     Genetic Testing for Inherited Cardiomyophathies and Channelopathies
     Genetic Testing for Lactase Insufficiency
     Genetic Testing for Li-Fraumeni Syndrome
     Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment and/or CVD Risk Assessment
     Genetic Testing for Mental Health Disorders
     Genetic Testing for Neurodegenerative Disorders
     Genetic Testing for Neurofibromatosis and Related Disorders
     Genetic Testing for Ophthalmologic Conditions
     Genetic Testing for Polyposis Syndromes
     Genetic Testing for PTEN Hamartoma Tumor Syndrome
     Genetic Testing for Rett Syndrome
     Genetic Testing of CADASIL Syndrome
     Genetic Testing of Mitochondrial Disorders
     Givlaari (givosiran)
     GLP-1 Agonists
     Gocovri (amantadine extended release)
     Gout Medications ST policy
H     - Back to Top -
     Head Imaging
     Heart Transplant
     Heart-Lung Transplant
     Helicobacter Pylori Testing
     Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
     Hematopoietic Cell Transplantation for Acute Myeloid Leukemia
     Hematopoietic Cell Transplantation for Autoimmune Diseases
     Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia
     Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma
     Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer
     Hematopoietic Cell Transplantation for Germ Cell Tumors (GCT)
     Hematopoietic Cell Transplantation for Hodgkin Lymphoma
     Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults
     Hematopoietic Cell Transplantation for Solid Tumors of Childhood
     Hematopoietic Stem Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma
     Hematopoietic Stem Cell Transplantation for Non-Hodgkin’s Lymphomas
     Hematopoietic Stem Cell Transplantation for Primary Amyloidosis
     Hematopoietic Stem-Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome
     Hemlibra (emicizumab-kxwh)
     Hemoglobin A1c
     Hepatitis C
     Hepatitis C Positive Organs for Transplantation to Non-Viremic Patients
     Hepatitis C Virus (HCV) Direct Acting Antivirals (DAAs)
     Herceptin (trastuzumab) and Biosimilars - Policy Changes Effective 6-1-21
     Herceptin Hylecta
     Hetlioz (tasimelteon)
     Hip Resurfacing
     Hippotherapy
     HIV Genotyping and Phenotyping
     Home Cardiorespiratory Monitoring
     Hormonal Testing in Adult Females
     Hormonal Testing in Adult Males
     Human Growth Hormone
     Humira (adalimumab)
     Hypoactive Sexual Desire Disorder (HSDD) Therapies
I     - Back to Top -
     Ibrance (palbociclib)
     Identification of Microorganisms using Nucleic Acid Probes
     Idhifa (enasidenib)
     Ilaris (canakinumab)
     Ilumya (tildrakizumab-asmn)
     Image-Guided Minimally Invasive Decompression for Spinal Stenosis
     Imcivree (setmelanotide)
     IMFINZI (durvalumab)
     Immune Cell Function Assay
     Immune Globulin Therapy
     Immune Prophylaxis for Respiratory Syncytial Virus (RSV)
     Immunizations
     Immunohistochemistry
     Immunopharmacologic Monitoring of Therapeutic Serum Antibodies
     Implantable Cardioverter Defibrillator (ICD)
     In Vitro Chemoresistance and Chemosensitivities Assays
     Increlex (mecasermin)
     Influenza Therapies
     Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
     Injectable Clostridial Collagenase for Fibroproliferative Disorders
     Inqovi (decitabine and cedazuridine)
     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
     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.)
     Intravitreal and Punctum Corticosteroid Implants
     Islet Transplantation
     Isolated Small Bowel Transplant
     Istodax (romidepsin non-lyophilized)
     Istodax (romidepsin)
     Isturisa (osilodrostat)
J     - Back to Top -
     Jelmyto (mitomycin)
     Juxtapid (lomitapide)
     Jynarque (tolvaptan)
K     - Back to Top -
     Kalbitor (ecallantide)
     Kalydeco (ivacaftor)
     Keratoprosthesis (Artficial Cornea)
     Kesimpta (ofatumumab)
     Keveyis (dichlorphenamide)
     Kevzara (sarilumab)
     Kidney Transplant
     Kineret (anakinra)
     Kisqali_Kisqali Femara
     Korlym (mifepristone)
     Koselugo (selumetinib)
     KRAS, NRAS and BRAF Mutation Analysis in Colorectal Cancer
     Krystexxa (pegloticase)
     Kuvan (sapropterin)
L     - Back to Top -
     Laboratory Procedures Reimbursement Policy
     Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease
     Leadless Cardiac Pacemakers
     Lemtrada (alemtuzumab)
     Libtayo (cemiplimab-rwlc)
     Lipid Apheresis
     Liquid Biopsy
     Liver Transplant and Combined Liver-Kidney Transplant
     Lobrena (lorlatinib)
     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
     Lupkynis (voclosporin)
     Lyme Disease
     Lynch Syndrome
M     - Back to Top -
     Magnetic Resonance Imaging‒Targeted Biopsy of the Prostate
     Magnetic Resonance‒Guided Focused Ultrasound
     Mandibular/Maxillary (Orthognathic) Surgery
     Manipulation Under Anesthesia
     Manipulations and Chiropractic Care
     Margenza (margetuximab)
     Margenza (margetuximab-cmkb)
     Mavenclad (cladribine)
     MCG Guidelines - FAQ
     Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders
     Measurement of Thromboxane Metabolites for ASA Resistance
     Medical Cannabis for the Treatment of Pain and Spasticity
     Mektovi (binimetinib)
     Meniscal Allografts and Other Meniscus Implants
     Mepsevii (vestronidase-aslfa-vjbk)
     Metabolite Markers of Thiopurines Testing
     Microprocessor Controlled Prostheses for the Lower Limb
     Minimal Residual Disease
     Minocycline Extended Release
     Miscellaneous Investigational Procedures
     Miscellaneous Special Services
     Molecular Analysis for Gliomas
     Molecular Markers in Fine Needle Aspirates of the Thyroid
     Molecular Panel Testing of Cancers for Diagnosis, Prognosis, and Identification of Targeted Therapy
     Molecular Profiling for Cancers of Unknown Primary Origin
     Molecular Testing of Pulmonary Specimens
     Monjuvi (tafasitamab-cxix)
     Mozobil (plerixafor)
     Mulpleta (lusutrombopag)
     Multigene Expression Assay for Predicting Colon Cancer Recurrence
     Musculoskeletal (MSK) Imaging
     Mutation Analysis in Myeloproliferative Neoplasms
     Myalept (metreleptin)
     Mylotarg (gemtuzumab ozogamicin)
     Myoelectric Prosthetic Components for the Upper Limb
N     - Back to Top -
     Natpara (parathyroid hormone)
     Neck Imaging
     Negative Pressure Wound Therapy in the Outpatient Setting
     Nerlynx (neratinib)
     Nerve Blocks for the Treatment Headaches or Neuralgia
     Nerve Fiber Density Testing
     Neural Therapy
     Neurofeedback
     Nexletol (bempedoic acid) and Nexlizet (bempedoic acid-ezetimibe)
     Non-Contact Ultrasound Treatment for Wounds
     Non-Invasive Tests for the Detection of Fetal Membrane Rupture
     Non-Pharmacologic Treatment of Rosacea
     Northera (droxidopa)
     Nourianz (istradefylline)
     Noxafil (posaconazole)
     Nplate (romiplostim)
     Nucala (mepolizumab)
     Nulibry (fosdenopterin)
     Nutrient/Nutritional Panel Testing
O     - Back to Top -
     Observation Room Services
     Ocaliva (obeticholic acid)
     Ocrevus (ocrelizumab)
     Ofev (nintedanib)
     Olumiant (baricitinib)
     Oncologic Applications of Photodynamic Therapy, Including Barrett’s Esophagus
     Oncology Imaging
     Onpattro (patisiran)
     Onureg (azacitidine)
     Onychomycosis Testing
     Opdivo (nivolumab)
     Open and Thoracoscopic Approaches to Treat Atrial Fibrillation (Maze and Related Procedures)
     Oral Screening Lesion Identification Systems and Genetic Screening
     Orencia IV SQ (abatacept)
     Orgovyx (relugolix)
     Oriahnn
     Orilissa (elagolix)
     Orkambi (lumacaftor-ivacaftor)
     Orladeyo (berotralstat)
     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
     Oxbryta (voxelotor)
     Oxervate (cenegermin-bkbj)
P     - Back to Top -
     Padcev (enfortumab vedotin-ejfv)
     Palforzia (peanut allergen powder)
     Palynziq (pegvaliase-pqpz)
     Pancreatic Cancer Risk Testing Using Molecular Classifier in Pancreatic Cyst Fluid
     Pancreatic Enzyme Testing for Acute Pancreatitis
     Panniculectomy and Abdominoplasty
     Paraspinal Surface Electromyography (EMG) to Evaluate and Monitor Back Pain
     Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing
     Parsabiv (etelcalcetide)
     Pathogen Panel Testing
     Patient Controlled End Range of Motion Stretching Devices
     Patient-Specific Instrumentation (eg, Cutting Guides) for Joint Arthroplasty
     Payment Policies
     Pediatric Abdomen Imaging
     Pediatric Cardiac Imaging
     Pediatric Chest Imaging
     Pediatric Head Imaging
     Pediatric Musculoskeletal (MSK) Imaging
     Pediatric Neck Imaging
     Pediatric Oncology Imaging
     Pediatric Pelvis Imaging
     Pediatric Peripheral Nerve Disorders (PND) Imaging
     Pediatric Peripheral Vascular Disease (PVD) Imaging
     Pediatric Preventive Screening
     Pediatric Spine Imaging
     Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
     Pelvis Imaging
     Pemazyre (pemigatinib)
     Pepaxto (melphalan flufenamide)
     Pepaxto (melphalan flufenamide)
     Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty, and Mechanical Vertebral Augmentation
     Percutaneous Electrical Nerve Stimulation PENS and Percutaneous Neuromodulation Therapy (PNT)
     Percutaneous Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
     Percutaneous Vertebroplasty and Sacroplasty
     Peripheral Nerve Disorder (PND) Imaging
     Peripheral Subcutaneous Field Stimulation
     Peripheral Vascular Disease (PVD) Imaging
     Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)
     Perjeta (pertuzumab)
     Pharmacogenic Testing
     Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf)
     Phexxi (lactic acid, citric acid, and potassium bitartrate gel)
     Piqray (alpelisib)
     Plasma HIV-1 and HIV-2 RNA Quantification for HIV Infection
     Plugs for Anal Fistula Repair
     Pneumatic Compression Pumps for Treatment of Lymphedema
     Polivy (polatuzumab vedotin–piiq)
     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)
     Pre-Implantation Genetic Testing
     Prenatal Screening
     Prenatal Screening for Fetal Aneuploidy
     Pre-Operative Testing
     Prescription Medication and Illicit Drug Testing in the Outpatient Setting
     Preventive Screening in Adults
     Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia
     Prolia (denosumab)
     Prolotherapy
     Promacta (eltrombopag)
     Prophylactic Oophorectomy
     Prostate Biopsies
     Prostate Specific Antigen (PSA) Testing
     Prostatic Urethral Lift
     Proteogenomic Testing of Individuals with Cancer
     Provigil Nuvigil Step Therapy
Q     - Back to Top -
     Qinlock (ripretinib)
     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 the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension
     Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions
     Reblozyl (luspatercept-aamt)
     Reconstructive and Cosmetic Services
     Reconstructive Breast Surgery and Management of Breast Implants
     Red Blood Cell Molecular Testing
     Reduction Mammaplasty
     Remicade (infliximab) and Biosimilars
     Repatha (evolocumab)
     Reproductive Techniques
     Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
     Retevmo (selpercatinib)
     Retinal Prosthesis
     Revcovi (elapegademase-lvlr)
     Reyvow (lasmiditan)
     Rinvoq (upadacitinib)
     Rituxan (rituximab)
     Rituxan Hycela (rituximab and hyaluronidase)
     Robotics in Surgery
     Rubraca (rucaparib)
     Rydapt (midostaurin)
S     - Back to Top -
     Sabril, Vigadrone (vigabatrin)
     Salivary Hormone Testing
     Samsca (tolvaptan)
     Sarclisa (isatuximab-irfc)
     Scenesse (afamelanotide)
     Scintimammography and Gamma Imaging of the Breast and Axilla
     Sensory Integration Therapy and Auditory Integration Therapy
     Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases
     Serum Testing for Evidence of Mild Traumatic Brain Injury
     Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
     Serum Tumor Markers for Malignancies
     Short Acting Opioid Management
     Short-Acting Fentanyl
     Siliq (brodalumab)
     Simponi (golimumab)
     Skyrizi (risankizumab-rzaa)
     Small Bowel - Liver and Multivisceral Transplant
     Soliris (eculizumab)
     Solosec (secnidazole)
     Spine Imaging
     Spravato (esketamine)
     ST2 Assay For Chronic Heart Failure
     Stelara (ustekinumab)
     Step Therapy Policy
     Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
     Steroid-Eluting Sinus Stents
     Strensiq (asfotase alfa)
     Stromectol (ivermectin)
     Subtalar Arthroereisis
     Sunosi (solriamfetol)
     Surgery for Groin Pain in Athletes
     Surgical Treatment of Femoroacetabular Impingement
     Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
     Surgical Ventricular Restoration
     Symdeko (tezacaftor-ivacaftor)
     Symlin (pramlintide)
     Synthetic Cartilage Implants for Joint Pain
     Syprine (trientine)
T     - Back to Top -
     Tabrecta (capmatinib)
     Takhzyro (lanadelumab)
     Taltz (ixekizumab)
     Talzenna (talazoparib)
     Tavalisse (fostamatinib)
     Tazverik (tazemetostat)
     Tegsedi (inotersen)
     Temporomandibular Joint Dysfunction Non Surgical Care
     Tepezza (teprotumumab-trbw)
     Tepmetko (tepotinib)
     Testing for Alpha-1 Antitrypsin Deficiency
     Testing for Autism Spectrum Disorder and Development Delay
     Testing for Diagnosis of Active or Latent Tuberculosis
     Testing for Mosquito- or Tick-Related Infections
     Testing for Targeted Therapy of Non-Small-Cell Lung Cancer
     Testing of Homocysteine Metabolism-Related Conditions
     Testosterone Replacement Therapies
     Therapeutic Drug Monitoring for 5-Fluorouracil
     Therapeutic Radiopharmaceuticals in Oncology
     Thermography and Temperature Gradient Studies
     Thiola EC (tiopronin)
     Thyroid Disease Testing
     Tibsovo (ivosidenib)
     Topical Alpha-Adrenergic Agents for Rosacea
     Topical Antifungals for Onychomycosis Step Therapy
     Topical Products for Rosacea
     Topical Tazarotene
     Total Artificial Hearts and Implantable Ventricular Assist Devices
     Transanal Endoscopic Microsurgery (TEM)
     Transcatheter Aortic-Valve Implantation for Aortic Stenosis
     Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies
     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
     Transmyocardial Revascularization
     Transplant Rejection Testing
     Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hypertrophy
     Treatment for Duchenne Muscular Dystrophy
     Treatment for Spinal Muscular Atrophy
     Treatment of Gender Dysphoria
     Treatment of Hyperhidrosis
     Treatment of Nasal Valve Collapse
     Treatment of Tinnitus
     Tremfya (guselkumab)
     Trigger Point and Tender Point Injections
     Trikafta (elexacaftor-tezacaftor-ivacaftor)
     Triptans Step Therapy Policy
     Trodelvy (sacituzumab govitecan-hziy)
     Tukysa (tucatinib)
     Tymlos (abaloparatide)
     Tysabri (natalizumab)
U     - Back to Top -
     Ubrelvy (ubrogepant)
     Ukoniq (umbralisib)
     Ultomiris (ravulizumab-cwvz)
     Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis
     Ultrasound in Pregnancy
     Uplizna (inebilizumab-cdon)
     Upneeq (oxymetazoline hydrochloride ophthalmic solution)
     Urinary Tumor Markers for Bladder Cancer
     Urine Culture Testing for Bacteria
     Use of Common Genetic Variants (single nucleotide polymorphisms) to Predict Risk of Non-Familial Breast Cancer
V     - Back to Top -
     Vagas Nerve Blocking Therapy for Treatment of Obesity
     Vectra DA Blood Test for Rheumatoid Arthritis
     Venous and Arterial Thrombosis Risk Testing
     Verquvo (vericiguat)
     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
     Vitamin B12 and Methylmalonic Acid Testing
     Vitamin D
     Vitrakvi (larotrectinib)
     Vizimpro (dacomitinib)
     VPRIV (velaglucerase alfa)
     Vyepti (eptinezumab)
     Vyndaqel (tafamidis meglumine) and Vyndamax (tafamidis)
     Vyxeos (daunorubicin and cytarabine)
W     - Back to Top -
     Wakix (pitolisant)
     Whole Body Dual X-Ray Absorptiometry (DXA) to Determine Body Composition
     Whole Genome and Whole Exome Sequencing
     Whole Gland Cryoablation of Prostate Cancer
X     - Back to Top -
     Xalkori (crizotanib)
     Xeljanz (tofacitinib)
     Xepi (ozenoxacin)
     Xermelo (telotristat)
     Xgeva (denosumab)
     Xifaxan (rifaximin)
     Xolair (omalizumab)
     Xospata (gilteritinib)
     Xpovio (selinexor)
     Xyrem (sodium oxybate)
     Xywav (calcium, magnesium, potassium, and sodium oxybates)
Y     - Back to Top -
     Yervoy (ipilimumab)
     Yonsa (abiraterone acetate)
Z     - Back to Top -
     Zejula (niraparib)
     Zepzelca (lurbinectedin)
     ZIKA Virus Risk Assessment
     Zinplava (bezlotoxumab)
     Zokinvy (lonafarnib)
Β     - Back to Top -
     β-Hemolytic Streptococcus Testing
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