Pharmacy Services Clinical Coverage Policies
Files
9.pdf
9, Outpatient Pharmacy Program
9A.pdf
9A, Over-The-Counter Products
9B.pdf
9B, Hemophilia Specialty Pharmacy Program
9D.pdf
9D, Off Label Antipsychotic Safety Monitoring in Beneficiaries Through Age 17
9E.pdf
9E, Off Label Antipsychotic Safety Monitoring in Beneficiaries 18 and Older
Agents-Duchenne-Muscular-Dystrophy.pdf
Prior Approval Criteria: Agents Duchenne Muscular Dystrophy
Antifungal-Agents-Vusion.pdf
Prior Approval Criteria: Antifungal-Agents Vusion
Antinarcolepsy-Antihyperkinesis-Agents.pdf
Prior Approval Criteria: Antinarcolepsy / Antihyperkinesis Agents
Cialis.pdf
Prior Approval Criteria: Cialis
Crinone.pdf
Prior Approval Criteria: Crinone
Cystic-Fibrosis.pdf
Prior Approval Criteria: Cystic Fibrosis
Emend-Antiemetic-Agents.pdf
Prior Approval Criteria: Emend Antiemetic Agents
Emflaza.pdf
Prior Approval Criteria: Emflaza
Entresto.pdf
Prior Approval Criteria: Entresto
Epidiolex.pdf
Prior Approval Criteria: Epidiolex
Epinephrine-Auto-Injectors.pdf
Prior Approval Criteria: Epinephrine Auto Injectors
Evrysedi.pdf
Prior Approval Criteria: Evrysedi
Gattex.pdf
Prior Approval Criteria: Gattex
Gocovri-Osmolex.pdf
Prior Approval Criteria: Gocovri & Osmolex
Growth-Hormone.pdf
Prior Approval Criteria: Growth Hormone
Hematinics.pdf
Prior Approval Criteria: Hematinics
Hepatitis-C.pdf
Prior Approval Criteria: Hepatitis C Medications
Hetlioz.pdf
Prior Approval Criteria: Hetlioz
Immumodulators.pdf
Prior Approval Criteria: Immunomodulators
Juxtapid.pdf
Prior Approval Criteria: Juxtapid
Migraine-Therapy-Calcitonin-Gene-Related.pdf
Prior Approval Criteria: Migraine Therapy - Calcitonin Gene Related Inhibitors
Monoclonal-Antibodies.pdf
Prior Approval Criteria: Monoclonal Antibodies
Movement-Disorders.pdf
Prior Approval Criteria: Movement Disorders
Mu-Opioid-Receptor-Antagonists-Relistor.pdf
Prior Approval Criteria: Mu-Opioid Receptor Antagonists
Neuromuscular-Blocking-Agents.pdf
Prior Approval Criteria: Neuromuscular Blocking Agents
Opioid-Analgesics.pdf
Prior Approval Criteria: Opioid Analgesics
Opioid-Dependence-Therapy-Agents.pdf
Prior Approval Criteria: Opioid Dependence Therapy Agents
PCSK9-Inhibitors.pdf
Prior Approval Criteria: PCSK9 Inhibitors
Sedative-Hypnotics.pdf
Prior Approval Criteria: Sedative Hypnotics
Synagis.pdf
Prior Approval Criteria: Synagis
Therapeutic-CGM.pdf
Prior Approval Criteria: Therapeutic Continuous Glucose Monitoring Systems and Related Supplies
Topical-Antihistamines.pdf
Prior Approval Criteria: Topical Antihistamines
Topical-Anti-Inflammatory-Medications.pdf
Prior Approval Criteria: Topical Anti-Inflammatories
Topical-Local-Anesthetics.pdf
Prior Approval Criteria: Topical Local Anesthetics
Triptans.pdf
Prior Approval Criteria: Triptans
Zolgensma.pdf
Prior Approval Criteria: Zolgensma
Share this page: