Clinical Criteria

Medical Policies

Criterion Modification Policy

Ambulance Services - Medical Transportation

Adult Sleep Studies

Arthroscopic Knee Surgery

Autologous Chondrocyte Implantation (ACI)

Bariatric Surgery

Cervical Spine

Continuity of Care/Transition of Care

Criterion Modification Policy
‍
Dental Services

Drug Testing

Genetic Testing

Home Health Services

Hospital Stay Requirement SNF

Investigational or Experimental Services and Clinical Trials

Liver Fibrosis Serum Testing

Short Stay Admissions and Outpatient Hospital Observation

Pulsed Dye Laser

Readmission Review

Site of Service

Sacroiliac Joint Infections

Sepsis and Septic Shock

Skilled Nursing Facility Services
‍
Temporomandibular Joint (TMJ) Disorders

Total or Partial Knee Arthroplasty

Tumor Treating Fields - Optune

Varicose Veins (Clinical Criteria Modification)


Step Therapy

Part B Step Therapy Drug List

Antineoplastic – bevacizumab

Antineoplastic - rituximab

Antineoplastic – trastuzumab

Anti-inflammatory infliximab

Colony Stimulating Factors Long Acting

Colony Stimulating Factors – Short Acting

Hyaluronate Injections for Osteoarthritis of the Knee


Medical Pharmacy Policies

Abecma - idecabtagene vicleucel

Actemra - tocilizumab

Adakveo - crizanlizumab-tmca

Aduhelm - aducanumab-avwa

Alimta - pemetrexed

Aloxi - palonosetron

Alpha-1-Proteinase Inhibitors: Aralast/Prolastin/Zemaira/Glassia

Amvuttra

Breyanzi - lisocabtagene maraleucel

Briumvi

Cabenuva - cabotegravir and rilpivirine

Carvykti

Cerezyme (imiglucerase)

Cimzia - certolizumab pegol

Clotting Disorder Therapy

Cosela - trilaciclib

Cresemba - isavuconazonium sulfate

Dalvance - dalbavancin

Duchenne Muscular Dystrophy (DMD)

Elahere

Emend - fosaprepitant dimeglumine

Empaveli - pegcetacoplan

Enjaymo

Entyvio - vedolizumab

Evenity - romosozumab

Evkeeza - evinacumab

Fasenra - benralizumab

Feraheme

Fyarro - sirolimus albumin-bound

Givlaari - givosiran

Hemgenix

Ilaris - canakinumab

Ilumya - tildrakizumab-asmn

Imjudo

Intravenous Immune Globulins (IVIG)

Intravitreal Injections/Implants

Isodax_romidepsin

Jemperli - dostarlimab

Khapzory - levoleucovorin

Kimmtrack - tebentafusp-tebn

Krystexxa - pegloticase

Kymriah - tisagenlecleucel

Leqembi

Leqvio - inclisiran

Lunsumio

Lupron Depot-Lupron Depot-Ped Eligard-Fensolvi-Camcevi - leuprolide

Luxturna - voretigene neparvovec

Mepsevii - vestronidase alfa-vjbk

Nexviazyme - avalglucosidase alfa-ngpt

Nulibry - fosdenopterin hydrobromide

Nulojix - belatacept

Off Label Indications

Opdualag

Orencia - abatacept

Padcev - enfortumab vedotin-ejfv

Pepaxto - melphalan flufenamide

Pulmonary Arterial Hypertension

Reblozyl - luspatercept-aamt

Relizorb - immobilized lipase

Rybrevant - amivantamab

Saphnelo - anifrolumab-fnia

Sarclisa - isatuximab

Signifor LAR - pasireotide

Simponi ARIA - golimumab

Skysona

Somatuline Depot - lanreotide

Spevigo

Spinraza - nusinersen

Stelara - ustekinumab

Subcutaneous Immune Globulins (SCIG)

Sunlenca

Supprelin LA - histrelin

Synagis - palivizumab

Takhyzro - lanadelumab-flyo

Tecartus - brexucabtagene autoleucel

Tecvayli

Tepezza - teprotumumab-trbw

Tezspire - tezepelumab-ekko

Tivdak - tisotumab vedotin

Trelstar

Triptodur - triptorelin

Tzield

Vimizim - elosulfase alfa

Vyepti - eptinezumab-jjmr

Vyvgart - efgartigimod alfa-fcab

Xenpozyme

Yescarta - axicabtagene ciloleucel

Zepzelca - lurbinectedin

Zilretta - triamcinolone acetonide

Zolgensma - onasemnogene abeparvovec-xioi

Zulresso - brexanolone

Zynlonta - loncastuximab tesirine

Zynteglo (betibeglongene autotemcel)