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
Aduhelm Injection.pdf
PA Criteria Aduhelm Injection
Agents for Duchenne Muscular Dystrophy.pdf
Prior Approval Criteria: Agents for Duchenne Muscular Dystrophy
Antifungal-Agents-Vusion.pdf
Prior Approval Criteria: Antifungal-Agents Vusion
Antinarcolepsy-Antihyperkinesis-Agents.pdf
Prior Approval Criteria: Antinarcolepsy / Antihyperkinesis Agents
Antiparkinsons Agents.pdf
Antiparkinsons 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
PA 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
Ivermectin PA Criteria.pdf
Prior Approval Criteria: Ivermectin
Juxtapid.pdf
Prior Approval Criteria: Juxtapid
Lupus Medications.pdf
Prior Approval Criteria: Lupus Medications
Migraine Therapy.pdf
PA Criteria Migraine Therapy
Monoclonal Antibody.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
Opioid Analgesics.pdf
Prior Approval Criteria Opioid Analgesics
Opioid-Dependence-Therapy-Agents.pdf
Prior Approval Criteria: Opioid Dependence Therapy Agents
PCSK9.pdf
Prior Approval Criteria PCSK9 Inhibitors
Sedative-Hypnotics.pdf
Prior Approval Criteria: Sedative Hypnotics
Systemic Immumodulators.pdf
Prior Approval Criteria: Systemic Immunomodulators
Continuous Glucose Monitoring System and Related Supplies.pdf
PA Criteria CGM 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
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