Clinical Coverage Policies

  • 5A-1, Physical Rehabilitation Equipment and Supplies
  • 5A-2, Respiratory Equipment and Supplies
  • 5A-3, Nursing Equipment and Supplies
  • 5B, Orthotics & Prosthetics
  • 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
  • 1T-1, General Ophthalmological Services
  • 1T-2, Special Ophthalmological Services

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
  • 1C-1, Podiatry Services
  • 1C-2, Medically Necessary Routine Foot Care
  • 1K-1, Breast Imaging Procedures
  • 1K-2, Bone Mass Measurement
  • 1K-6, Radiation Oncology
  • 1K-7, Prior Approval for Imaging Services
  • 1-O-1, Reconstructive and Cosmetic Surgery
  • 1-O-2, Craniofacial Surgery
  • 1-O-3, Keloid Excision and Scar Revision
  • 1-O-5, Rhinoplasty and/or Septorhinoplasty
  • 1D-1, Refugee Health Assessments Provided in Health Departments
  • 1D-2, Sexually Transmitted Disease Treatment Provided in Health Departments
  • 1D-3, Tuberculosis Control and Treatment Provided in Health Departments
  • 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics