Clinical Coverage Policies

• 1E-1, Hysterectomy
• 1E-2, Therapeutic and Non-therapeutic Abortions
• 1E-3, Sterilization Procedures
• 1E-4, Fetal Surveillance
• 1E-5, Obstetrics
• 1E-6, Pregnancy Medical Home
• 1E-7, Family Planning Service

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

• 1A-2, Preventive Medicine Annual Health Assessment
• 1A-3, Noninvasive Pulse Oximetry
• 1A-4, Cochlear and Auditory Brainstem Implants
• 1A-5, Child Medical Evaluation and Medical Team Conference for Child Maltreatment
• 1A-6, Invasive Electrical Bone Growth Stimulation
• 1A-7, Neonatal and Pediatric Critical and Intensive Care Services
• 1A-8, Hyperbaric Oxygenation Therapy
• 1A-9, Blepharoplasty/Blepharoptosis (Eyelid Repair)
• 1A-11, Extracorporeal Shock Wave Lithotripsy
• 1A-12, Breast Surgeries
• 1A-13, Ocular Photodynamic Therapy
• 1A-14, Surgery for Ambiguous Genitalia
• 1A-15, Surgery for Clinically Severe or Morbid Obesity
• 1A-16, Surgery of the Lingual Frenulum
• 1A-17, Stereotactic Pallidotomy
• 1A-19, Transcranial Doppler Studies
• 1A-20, Sleep Studies and Polysomnography Services
• 1A-21, Endovascular Repair of Aortic Aneurysm
• 1A-22, Medically Necessary Circumcision
• 1A-23, Physician Fluoride Varnish Services
• 1A-24, Diabetes Outpatient Self-Management Education
• 1A-25, Spinal Cord Stimulation
• 1A-26, Deep Brain Stimulation
• 1A-27, Electrodiagnostic Studies
• 1A-28, Visual Evoked Potential (VEP)
• 1A-30, Spinal Surgeries
• 1A-31, Wireless Capsule Endoscopy
• 1A-32, Tympanometry and Acoustic Reflex Testing
• 1A-33, Vagus Nerve Stimulation for the Treatment of Seizures
• 1A-34,  Dialysis Services
• 1A-36, Implantable Bone Conduction Hearing Aids (BAHA)
• 1A-38, Special Services: After Hours
• 1A-39, Routine Costs in Clinical Trial Services for Life Threatening Conditions
• 1A-40, Fecal Microbiota Transplantation
• 1A-41, Office-Based Opioid Treatment: Use of Buprenorphine and Buprenorphine-Naloxone
• 1A-42, Balloon Ostial Dilation

• 1K-1, Breast Imaging Procedures
• 1K-2, Bone Mass Measurement
• 1K-6, Radiation Oncology
• 1K-7, Prior Approval for Imaging Services