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-088 | Acute Migraine Medications | June 01, 2020 | June 01, 2020 | May 20, 2021 |
| pharm-001 | Acne Rosacea | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| PHARM-002 | Alpha-1-Proteinase-Inhibitors | September 01, 2020 | November 01, 2020 | August 19, 2021 |
| pharm-003 | Ankylosing Spondylitis | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-m018 | Ankylosing Spondylitis- Medical Infused Drugs | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-004 | Anthelmintic | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-005 | Antidepressants | March 26, 2020 | March 25, 2020 | March 25, 2021 |
| pharm-006 | Antiemetics for Chemotherapy Induced Nausea and Vomiting | September 01, 2020 | August 19, 2020 | August 19, 2021 |
| pharm-m028 | Antiemetics for Chemotherapy Induced Nausea and Vomiting- Medical Infused Drugs | August 27, 2020 | August 19, 2020 | August 19, 2021 |
| pharm-m017 | Antineoplastics - Medical Infused Drugs | June 30, 2020 | July 6, 2020 | June 30, 2021 |
| pharm-007 | Antineoplastics - Retail | July 06, 2020 | June 30, 2020 | June 30, 2021 |
| pharm-008 | Aranesp | September 01, 2020 | August 19, 2020 | August 19, 2021 |
| pharm-009 | Atopic Dermatitis | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| B | ||||
| pharm-010 | Brand Atypical Antipsychotics | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-011 | Basal Insulin | January 01, 2021 | December 22, 2020 | December 22, 2021 |
| pharm-012 | Biosimilar Policy | June 01, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-013 | Brand Name Medications | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-081 | Benlysta | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-095 | Brand Anticonvulsants | February 27, 2020 | March 25, 2020 | March 25, 2021 |
| pharm-m014 | Brineura | January 01, 2021 | December 22, 2020 | December 22, 2021 |
| pharm-m015 | Botulinum Toxins | January 10, 2020 | March 25, 2020 | March 25, 2021 |
| C | ||||
| Pharm-094 | Cablivi | June 01, 2020 | April 15, 2020 | May 20, 2021 |
| pharm-096 | Carisoprodol for Healthy U | September 01, 2020 | August 19, 2020 | August 19, 2021 |
| pharm-015 | C. Difficile Drugs | February 20, 2019 | February 13, 2019 | February 20, 2020 |
| 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 | March 26, 2020 | March 25, 2020 | March 25, 2021 |
| pharm-019 | Crohn's Disease | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-m019 | Crohn’s Disease- Medical Infused Drugs | June 30, 2020 | July 6, 2020 | June 30, 2021 |
| 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 | March 26, 2020 | March 25, 2020 | March 25, 2021 |
| pharm-111 | Descovy | January 01, 2021 | November 23, 2020 | November 23, 2021 |
| pharm-022 | Dupixent | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| E | ||||
| pharm-023 | Entresto | March 26, 2020 | March 25, 2020 | March 25, 2021 |
| 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 |
| G | ||||
| pharm-026 | Gonadotropin Releasing Hormone (GnRH) Agonists and Antagonists | March 26, 2020 | March 25, 2020 | March 25, 2021 |
| pharm-027 | Growth Hormones- Adult | June 1, 2020 | May 29, 2020 | May 29, 2021 |
| pharm-028 | Growth Hormones- Child | June 1, 2020 | May 29, 2020 | May 29, 2021 |
| H | ||||
| pharm-030 | Hepatitis C Direct Acting Antivirals | September 01, 2020 | August 19, 2020 | August 19, 2021 |
| pharm-110 | Hemophilia and Blood Products | January 01, 2021 | November 23, 2020 | November 23, 2021 |
| pharm-031 | Hereditary Angioedema | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-032 | Hidradenitis Suppurativa | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-m020 | Hidradenitis Supperativa- Medical Infused Drugs | June 30, 2020 | July 6, 2020 | June 30, 2021 |
| pharm-101 | Humira for Uveitis | June 18, 2020 | August 19, 2020 | August 19, 2021 |
| pharm-033 | Hyperkalemia | January 23, 2020 | January 22, 2020 | January 23, 2021 |
| pharm-m001 | Hyaluronic Acid | September 01, 2020 | August 19, 2020 | August 19, 2021 |
| I | ||||
| pharm-034 | Irritable Bowel Syndrome with Diarrhea (IBS-D) | March 26, 2020 | March 25, 2020 | March 25, 2021 |
| pharm-035 | Interleukin-5 Receptor Antagonists for Asthma- IL5 (Eosinophilic asthma) | January 23, 2020 | January 22, 2020 | January 23, 2021 |
| pharm-036 | Increlex | August 01, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-038 | Chronic Insomnia | January 23, 2020 | January 22, 2020 | January 23, 2021 |
| pharm-039 | Interstitial Cystitis | January 23, 2020 | January 22, 2020 | January 23, 2021 |
| 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 | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-105 | Isturisa | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| J | ||||
| pharm-041 | Juvenile Idiopathic Arthritis | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-m021 | Juvenile Idiopathic Arthritis - Medical Infused Drugs | June 30, 2020 | July 6, 2020 | June 30, 2021 |
| K | ||||
| pharm-m029 | Krystexxa | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-m003 | Kymriah | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| L | ||||
| pharm-043 | Long Acting Tacrolimus | January 23, 2020 | January 22, 2020 | January 23, 2021 |
| pharm-m004 | Lutathera | January 23, 2020 | January 22, 2020 | January 23, 2021 |
| M | ||||
| pharm-044 | Multiple Sclerosis Agents | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-045 | Mucolytics | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-046 | Myrbetriq | February 27, 2019 | February 20, 2019 | February 27, 2020 |
| N | ||||
| pharm-102 | Nayzilam® and Valtoco® Nasal Spray | June 01, 2020 | May 20, 2020 | May 21, 2021 |
| pharm-099 | Nexletol and Nexlizet | August 10, 2020 | August 19, 2020 | August 19, 2021 |
| pharm-047 | Neupro | August 01, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-m027 | Neuromyelitis Optica Spectrum Disorder | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| PHARM-048 | Nucala | September 01, 2020 | November 01, 2020 | August 19, 2021 |
| 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 | January 23, 2020 | January 22, 2020 | January 23, 2021 |
| pharm-049 | Off Label Use | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-050 | Opioid Dependence Agents | January 23, 2020 | January 22, 2020 | January 23, 2021 |
| pharm-051 | Opioids - Chronic | March 5, 2020 | January 23, 2021 | March 5, 2020 |
| pharm-052 | Opioids - Limitations | September 01, 2020 | August 19, 2020 | August 19, 2021 |
| pharm-054 | Osteoprosis | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-m005 | Ophthalmic VEGF Antagonists | May 9, 2019 | May 6, 2019 | May 9, 2020 |
| pharm-097 | Overactive Bladder | April 29, 2020 | June 28, 2020 | April 29, 2021 |
| P | ||||
| Pharm-M026 | Place of Service for Pharmaceutical Infusions | March 24, 2020 | June 24, 2020 | August 24, 2020 |
| pharm-056 | Prior Authorization and Medical Necessity Policy | August 21, 2019 | April 22, 2019 | August 21, 2020 |
| pharm-057 | Phosphodiesterase Type 5 (PDE-5) Inhibitor | September 01, 2020 | August 19, 2020 | August 19, 2021 |
| pharm-058 | Phenylbutyrates | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-059 | Phenylketonuria (PKU) | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-100 | Prevymis | August 05, 2020 | August 19, 2020 | August 19, 2021 |
| pharm-060 | Promacta | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-061 | Psoriasis | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-m022 | Psoriasis- Medical Infused Drugs | June 30, 2020 | July 6, 2020 | June 30, 2021 |
| pharm-062 | Psoriatic Arthritis | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-m023 | Psoriatic Arthritis- Medical Infused Drugs | June 30, 2020 | July 6, 2020 | June 30, 2021 |
| pharm-063 | Pulmonary Arterial Hypertension | September 01, 2020 | August 19, 2020 | August 19, 2021 |
| 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-m006 | Branded Denosumab Products (Prolia, Xgeva) | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| R | ||||
| PHARM-064 | Revcovi | September 01, 2020 | November 01, 2020 | August 19, 2021 |
| pharm-065 | Rheumatoid Arthritis | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-m024 | Rheumatoid Arthritis-Medical Infused Drugs | June 30, 2020 | July 6, 2020 | June 30, 2021 |
| pharm-084 | Ruzurgi- Firdapse | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| S | ||||
| pharm-066 | Sandostatin | March 1, 2020 | February 27, 2020 | February 27, 2021 |
| pharm-067 | Savella | January 23, 2020 | January 22, 2020 | January 23, 2021 |
| 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 | Spavato-Ketamine | September 01, 2020 | August 19, 2020 | August 19, 2021 |
| pharm-m007 | Spinraza | November 06, 2019 | November 01, 2019 | November 06, 2020 |
| pharm-071 | Brand Statins | June 28, 2020 | March 25, 2020 | March 25, 2021 |
| 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 | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| T | ||||
| pharm-m031 | Tecartus | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-m016 | Tepezza | March 25, 2020 | March 25, 2020 | March 25, 2021 |
| pharm-m008 | Testopel | September 01, 2020 | August 19, 2020 | August 19, 2021 |
| pharm-074 | Topiramate ER Sprinkle Capsules | September 01, 2020 | August 19, 2020 | August 19, 2021 |
| U | ||||
| pharm-075 | Ulcerative Colitis | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-m025 | Ulcerative Colitis - Medical Infused Drugs | June 30, 2020 | July 6, 2020 | June 30, 2021 |
| V | ||||
| pharm-077 | VMAT-2 Inhibitors | August 01, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-085 | Vasopressin Receptor Antagonists (VRA) | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-m032 | Vyepti | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| X | ||||
| pharm-078 | Xifaxan | June 28, 2020 | March 25, 2020 | March 25, 2021 |
| pharm-079 | Xolair | September 01, 2020 | August 19, 2020 | August 19, 2021 |
| pharm-086 | XHANCE | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-m011 | Xiaflex | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| Y | ||||
| pharm-m009 | Yescarta | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-087 | Yupelri | December 01, 2020 | November 23, 2020 | November 23, 2021 |
| Z | ||||
| pharm-m010 | Zilretta | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-m012 | Zolgensma | January 01, 2021 | December 22, 2020 | December 22, 2021 |