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 | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| 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 | 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 | November 01, 2020 | October 28, 2020 | October 28, 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 | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-007 | Antineoplastics - Retail | July 06, 2020 | June 30, 2020 | June 30, 2021 |
| 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 | 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 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-m014 | Brineura | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| 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 | April 01, 2021 | March 24, 2021 | March 24, 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 | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-m019 | Crohn’s Disease- Medical Infused Drugs | February 01, 2021 | January 27, 2021 | January 27, 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 | 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 | March 11, 2021 | December 31, 2020 | December 31, 2021 |
| 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 | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-101 | Humira for Uveitis | June 18, 2020 | August 19, 2020 | August 19, 2021 |
| 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) | March 26, 2020 | March 25, 2020 | March 25, 2021 |
| pharm-035 | Interleukin-5 Receptor Antagonists for Asthma- IL5 (Eosinophilic asthma) | March 01, 2021 | February 24, 2021 | February 24, 2022 |
| pharm-036 | Increlex | August 01, 2020 | May 20, 2020 | May 20, 2021 |
| 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 | 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 | 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-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 | March 01, 2021 | February 24, 2021 | February 24, 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 | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-045 | Mucolytics | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| N | ||||
| pharm-102 | Nayzilam® and Valtoco® Nasal Spray | June 01, 2020 | May 20, 2020 | May 21, 2021 |
| pharm-113 | Nerlynx | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| 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 | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| 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 | March 01, 2021 | February 24, 2021 | February 24, 2022 |
| pharm-049 | Off Label Use | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-050 | Opioid Dependence Agents | March 01, 2021 | February 24, 2021 | February 24, 2022 |
| pharm-051 | Opioids - Chronic | March 01, 2021 | February 24, 2021 | February 24, 2022 |
| pharm-052 | Opioids - Limitations | March 01, 2021 | February 24, 2021 | February 24, 2022 |
| 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 |
| 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 | March 01, 2021 | February 24, 2021 | February 24, 2022 |
| pharm-103 | Pharmacy Continuity of Care | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| 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-M026 | Place of Service for Pharmaceutical Infusions | March 24, 2020 | June 24, 2020 | August 24, 2020 |
| pharm-100 | Prevymis | August 05, 2020 | August 19, 2020 | August 19, 2021 |
| pharm-056 | Prior Authorization and Medical Necessity Policy | August 21, 2019 | April 22, 2019 | August 21, 2020 |
| pharm-m006 | Branded Denosumab Products (Prolia, Xgeva) | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| pharm-060 | Promacta | June 1, 2020 | May 20, 2020 | May 20, 2021 |
| 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 | March 01, 2021 | February 24, 2021 | February 24, 2022 |
| R | ||||
| PHARM-064 | Revcovi | September 01, 2020 | November 01, 2020 | August 19, 2021 |
| pharm-065 | Rheumatoid Arthritis | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-m024 | Rheumatoid Arthritis-Medical Infused Drugs | April 1, 2021 | March 24, 2021 | March 24, 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 | Spavato-Ketamine | September 01, 2020 | August 19, 2020 | August 19, 2021 |
| pharm-m007 | Spinraza | April 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-071 | Brand Statins | June 28, 2020 | March 25, 2020 | March 25, 2021 |
| pharm-115 | Step Therapy | April 1, 2021 | March 24, 2021 | March 24, 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 | 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 | 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-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 | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| 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 |