Pharmacy Services Clinical Coverage Policies

Associated Files

9B.pdf

9B, Hemophilia Specialty Pharmacy Program

PDF • 308.74 KB

9D.pdf

9D, Off Label Antipsychotic Safety Monitoring in Beneficiaries Through Age 17

PDF • 314.6 KB

9E.pdf

9E, Off Label Antipsychotic Safety Monitoring in Beneficiaries 18 and Older

PDF • 300.96 KB

Details

Clinical Coverage Criteria and Prior Approval request forms
Preferred Drug List (PDL)

  • 9, Outpatient Pharmacy Program
  • 9A, Over-The-Counter Products
  • 9B, Hemophilia Specialty Pharmacy Program
  • 9D, Off Label Antipsychotic Safety Monitoring in Beneficiaries Through Age 17
  • 9E, Off Label Antipsychotic Safety Monitoring in Beneficiaries 18 and Older

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