Medical Policies
- Alphabetical
-
Administrative Anesthesiology Allergy/Immunology Behavioral Health Cardiovascular Dermatology Durable Medical Equipment (DME) Ear, Nose, and Throat (ENT) Endocrinology Gastroenterology General Surgery Genetics Genitourinary Hematology/Oncology Infectious Diseases Laboratory/Pathology Nephrology Neurology/Neurosurgery Obstetrics and Gynecology Ophthalmology Oral maxillofacial Orthopedic Pediatrics Pharmacy Physical Medicine Preventive Medicine Pulmonary Radiology, diagnostic Radiation Therapy Transplant Women's Health
Administrative
Reimbursement Policies
Pharmacy
Dental
New Policies
Updated Policies
Upcoming Policies
For Advantage U Part D Requests, please visit: Advantage U Medicare Provider Documents & Forms
| Policy | Name | Effective Date | Revision Date | Next Review Date |
|---|---|---|---|---|
| ALL | ||||
| PHARM-PA | General Pharmacy Prior Authorization Form | N/A | N/A | N/A |
| PHARM-FE | Pharmacy Formulary Exception Request Form | N/A | N/A | N/A |
| PHARM-MHCFE | MHC Formulary Exception Form | N/A | N/A | N/A |
| PHARM-MHCPA | MHC General Pharmacy Prior Authorization Form | N/A | N/A | N/A |
| A | ||||
| pharm-m033 | Abecma | June 1, 2021 | May 19, 2021 | May 19, 2022 |
| Pharm-088 | Acute Migraine Medications | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-001 | Acne Rosacea | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-002 | Alpha-1-Proteinase-Inhibitors | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-003 | Ankylosing Spondylitis | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-m018 | Ankylosing Spondylitis- Medical Infused Drugs | April 1, 2021 | March 24, 2021 | March 24, 2022 |
| pharm-004 | Anthelmintic | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-006 | Antiemetics for Chemotherapy Induced Nausea and Vomiting | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-m028 | Akynzeo | June 01, 2021 | May 19, 2021 | May 19, 2022 |
| pharm-m017 | Antineoplastics - Medical Infused Drugs | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-007 | Antineoplastics - Retail | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-008 | Aranesp | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-009 | Atopic Dermatitis | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| B | ||||
| pharm-011 | Basal Insulin | January 01, 2021 | December 22, 2020 | December 22, 2021 |
| pharm-012 | Biosimilar Policy | May 01, 2021 | April 19, 2021 | April 19, 2022 |
| pharm-013 | Brand Name Medications | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-081 | Benlysta | June 01, 2021 | May 19, 2021 | May 19, 2022 |
| pharm-m006 | Branded Denosumab Products (Prolia, Xgeva) | August 01, 2021 | July 21, 2021 | July 21, 2022 |
| pharm-m034 | Breyanzi | June 1, 2021 | May 19, 2021 | May 19, 2022 |
| pharm-m014 | Brineura | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-m015 | Botulinum Toxins | May 01, 2021 | April 19, 2021 | April 19, 2022 |
| C | ||||
| Pharm-094 | Cablivi | August 01, 2021 | July 21, 2021 | July 21, 2022 |
| pharm-096 | Carisoprodol for Healthy U | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-015 | C. Difficile Drugs | June 01, 2021 | May 19, 2021 | May 19, 2022 |
| pharm-016 | Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists | December 01, 2020 | November 23, 2020 | November 23, 2021 |
| pharm-017 | Constipation | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-108 | Continuous Glucose Monitor (CGM)- Retail Pharmacy | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-018 | Corlanor | April 1, 2021 | March 24, 2021 | March 24, 2022 |
| pharm-019 | Crohn's Disease | June 01, 2021 | May 19, 2021 | May 19, 2022 |
| pharm-m019 | Crohn’s Disease- Medical Infused Drugs | June 01, 2021 | May 19, 2021 | May 19, 2022 |
| pharm-098 | Cuvposa | August 10, 2020 | August 19, 2020 | August 19, 2021 |
| pharm-104 | Cystadrops and Cystaran for Ocular Cystinosis | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-014 | Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Agents | January 23, 2020 | January 22, 2020 | January 23, 2021 |
| D | ||||
| pharm-020 | Daliresp | April 1, 2021 | March 24, 2021 | March 24, 2022 |
| pharm-111 | Descovy | January 01, 2021 | November 23, 2020 | November 23, 2021 |
| pharm-112 | Dojolvy | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-022 | Dupixent | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| E | ||||
| pharm-024 | Epidiolex | August 01, 2020 | May 20, 2019 | May 20, 2021 |
| pharm-091 | Esbriet/OFEV | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-m030 | Evrysdi | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| G | ||||
| pharm-026 | Gonadotropin Releasing Hormone (GnRH) Agonists and Antagonists | June 1, 2021 | May 19, 2021 | May 19, 2022 |
| pharm-027 | Growth Hormones- Adult | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-028 | Growth Hormones- Child | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| H | ||||
| pharm-030 | Hepatitis C Direct Acting Antivirals | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-110 | Hemophilia and Blood Products | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-031 | Hereditary Angioedema | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-032 | Hidradenitis Suppurativa | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-m020 | Hidradenitis Supperativa- Medical Infused Drugs | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-101 | Humira for Uveitis | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-033 | Hyperkalemia | March 01, 2021 | February 24, 2021 | February 24, 2022 |
| pharm-m001 | Hyaluronic Acid for Knee | March 01, 2021 | February 24, 2021 | February 24, 2022 |
| I | ||||
| pharm-034 | Irritable Bowel Syndrome with Diarrhea (IBS-D) | July 01, 2021 | May 01, 2021 | April 19, 2022 |
| pharm-035 | Interleukin-5 Receptor Antagonists for Asthma- IL5 (Eosinophilic asthma) | March 01, 2021 | February 24, 2021 | February 24, 2022 |
| pharm-036 | Increlex | June 1, 2021 | May 19, 2021 | May 19, 2022 |
| pharm-038 | Chronic Insomnia | March 01, 2021 | February 24, 2021 | February 24, 2022 |
| pharm-039 | Interstitial Cystitis | March 01, 2021 | February 24, 2021 | February 24, 2022 |
| pharm-082 | Iron Chelation Therapy | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-091 | Idiopathic Pulmonary Fibrosis | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-m002 | Intravenous Iron | June 01, 2021 | May 19, 2021 | May 19, 2022 |
| pharm-105 | Isturisa | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| J | ||||
| pharm-041 | Juvenile Idiopathic Arthritis | April 1, 2021 | March 24, 2021 | March 24, 2022 |
| pharm-m021 | Juvenile Idiopathic Arthritis - Medical Infused Drugs | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| K | ||||
| pharm-m036 | Ketamine | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-m029 | Krystexxa | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-m003 | Kymriah | August 01, 2021 | July 21, 2021 | July 21, 2022 |
| L | ||||
| pharm-043 | Long Acting Tacrolimus | March 01, 2021 | February 24, 2021 | February 24, 2022 |
| pharm-118 | Lupkynis | June 1, 2021 | May 19, 2021 | May 19, 2022 |
| pharm-m004 | Lutathera | March 01, 2021 | February 24, 2021 | February 24, 2022 |
| pharm-116 | Lyrica CR | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| M | ||||
| pharm-044 | Multiple Sclerosis Agents | June 01, 2021 | May 19, 2021 | May 19, 2022 |
| N | ||||
| pharm-102 | Nayzilam® and Valtoco® Nasal Spray | August 01, 2021 | July 21, 2021 | July 21, 2022 |
| pharm-113 | Nerlynx | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-099 | Nexletol and Nexlizet | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-047 | Neupro | June 1, 2021 | May 19, 2021 | May 19, 2022 |
| pharm-m027 | Neuromyelitis Optica Spectrum Disorder | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| PHARM-048 | Nucala for Eosinophilic Granulomatosis | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-106 | Nucala for Hypereosinophilic Syndrome | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-083 | Nuedexta | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| O | ||||
| pharm-068 | Ocaliva | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-049 | Off Label Use | June 1, 2021 | May 19, 2021 | May 19, 2022 |
| pharm-120 | Omnipod Dash | September 1, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-050 | Opioid Dependence Agents | March 01, 2021 | February 24, 2021 | February 24, 2022 |
| pharm-051 | Opioids - Chronic | June 01, 2021 | May 19, 2021 | May 19, 2022 |
| pharm-052 | Opioids - Limitations | March 01, 2021 | February 24, 2021 | February 24, 2022 |
| pharm-054 | Osteoporosis Medications | May 01, 2021 | April 19, 2021 | April 19, 2022 |
| pharm-m005 | Ophthalmic VEGF Antagonists | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-m035 | Oxlumo | June 1, 2021 | May 19, 2021 | May 19, 2022 |
| P | ||||
| pharm-080 | Pancreatic Enzymes | January 1, 2021 | December 22, 2020 | December 22, 2021 |
| pharm-089 | Parkinson's Agents | September 01, 2020 | August 19, 2020 | August 19, 2021 |
| pharm-057 | Phosphodiesterase Type 5 (PDE-5) Inhibitor | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-103 | Pharmacy Continuity of Care | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-058 | Phenylbutyrates | June 1, 2021 | May 19, 2021 | May 19, 2022 |
| pharm-059 | Phenylketonuria (PKU) | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| Pharm-M026 | Place of Service for Pharmaceutical Infusions | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-100 | Prevymis | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-056 | Prior Authorization and Medical Necessity Policy | August 21, 2019 | April 22, 2019 | August 21, 2020 |
| pharm-060 | Promacta | June 1, 2021 | May 19, 2021 | May 19, 2022 |
| pharm-061 | Psoriasis | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-m022 | Psoriasis- Medical Infused Drugs | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-062 | Psoriatic Arthritis | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-m023 | Psoriatic Arthritis- Medical Infused Drugs | April 1, 2021 | March 24, 2021 | March 24, 2022 |
| pharm-063 | Pulmonary Arterial Hypertension | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-045 | Pulmozyme ® | June 1, 2021 | May 19, 2021 | May 19, 2022 |
| R | ||||
| PHARM-064 | Revcovi | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-065 | Rheumatoid Arthritis | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-m024 | Rheumatoid Arthritis-Medical Infused Drugs | June 1, 2021 | May 19, 2021 | May 19, 2022 |
| pharm-114 | Rocklatan and Rhopressa | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-084 | Ruzurgi- Firdapse | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| S | ||||
| pharm-066 | Sandostation LAR | April 1, 2021 | March 24, 2021 | March 24, 2022 |
| pharm-067 | Savella | March 01, 2021 | February 24, 2021 | February 24, 2022 |
| pharm-109 | Signifor | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-m013 | Soliris & Ultomiris | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-069 | Spravato | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-m007 | Spinraza | April 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-071 | Brand Statins | May 01, 2021 | April 19, 2021 | April 19, 2022 |
| pharm-115 | Step Therapy | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-070 | Subcutaneous Methotrexate | January 23, 2020 | January 22, 2020 | January 23, 2021 |
| pharm-107 | Sunosi | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-073 | Synagis | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| T | ||||
| pharm-m031 | Tecartus | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-m016 | Tepezza | May 01, 2021 | April 19, 2021 | April 19, 2022 |
| pharm-m008 | Testopel | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-074 | Topiramate ER Sprinkle Capsules | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| U | ||||
| pharm-075 | Ulcerative Colitis | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-m025 | Ulcerative Colitis - Medical Infused Drugs | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| V | ||||
| pharm-085 | Vasopressin Receptor Antagonists (VRA) | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-090 | Vascepa | May 01, 2021 | April 26, 2021 | April 26, 2022 |
| pharm-077 | VMAT-2 Inhibitors | August 01, 2021 | July 21, 2021 | July 21, 2022 |
| pharm-119 | Vocabria | September 1, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-m032 | Vyepti | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| X | ||||
| pharm-078 | Xifaxan | July 01, 2021 | May 01, 2021 | April 19, 2022 |
| pharm-079 | Xolair | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-086 | XHANCE | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-m011 | Xiaflex | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| Y | ||||
| pharm-m009 | Yescarta | June 01, 2021 | May 19, 2021 | May 19, 2022 |
| pharm-087 | Yupelri | December 01, 2020 | November 23, 2020 | November 23, 2021 |
| Z | ||||
| pharm-m010 | Zilretta | August 01, 2021 | July 21, 2021 | July 21, 2022 |
| pharm-m012 | Zolgensma | January 01, 2021 | December 22, 2020 | December 22, 2021 |