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Policies and Pre-Authorization Search 



Name Type State Effective/Updated
Bariatric Surgery PA Medicaid Medical  
BCR-ABL1 Genetic Testing in Leukemia Medical Policy PA Medicaid  
BRCA Medical Policy PA Medicaid  
Breast Reconstruction Medical Policy PA Medicaid  
Bronchial Thermoplasty Medical Policy PA Medicaid  
Capsule Endoscopy  Medical Policy PA Medicaid  
Carpal Tunnel Medical Policy PA Medicaid  
Chromosomal Microarray Medical Policy PA Medicaid  
Colorectal Cancer Screening Medical Policy PA Medicaid  
Custom-Made Oral Appliances in the Treatment of Obstructive Sleep Apnea (OSA) Medical Policy PA Medicaid  
Enteral Feeding In-line Cartridge Medical Policy PA Medicaid  
Fetal Aneuploid Medical Policy PA Medicaid  
Gender Transition Services Medical Policy PA Medicaid  
Genetic Disease Testing Medical Policy PA Medicaid  
Genetic Testing for Colorectal Cancer Susceptibility Medical Policy PA Medicaid  
Genetic Testing for Cystic Fibrosis Medical Policy PA Medicaid  
Hyperbaric Oxygen Therapy (HBOT) Medical Policy PA Medicaid  
Implantable Cardioverter Defibrillator (ICD) Medical Policy PA Medicaid  
Long-Term Use Continuous Glucose Monitoring of Interstitial Fluid Medical Policy PA Medicaid  
Negative Pressure Wound Therapy in the Outpatient Setting Medical Policy PA Medicaid  
Noninvasive Assessment of Liver Fibrosis in Chronic Hepatitis C Medical Policy PA Medicaid  
Noninvasive Positive Pressure Intermittent Ventilation(NPPV) Medical Policy PA Medicaid  
Oncotype DX Medical Policy PA Medicaid  
Panniculectomy Medical Policy PA Medicaid  
Passive Oscillatory Devices in the Outpatient Setting Medical Policy PA Medicaid  
Place of Service Medical Policy PA Medicaid  
Skin Replacement Therapy for Chronic Non-healing Wounds in the Outpatient Setting Medical Policy PA Medicaid  
Wearable Cardioverter-Defibrillator in Home Setting Medical Policy PA Medicaid  
Whole Exome and Whole Genome Genetic Testing Medical Policy PA Medicaid  
Bronchial Thermoplasty Medical Policy PA Medicare  
Cataract Extraction Medical Policy PA Medicare  
Fetal Aneuploidy Medical Policy PA Medicare  

BronchialThermoplasty

Medical Policy OH  
Cataract Extraction Medical Policy OH  
Fetal Aneuploidy Medical Policy OH  
Bronchial Thermoplasty Medical Policy KY  
Cataract Extraction Medical Policy KY  
Fetal Aneuploidy Medical Policy KY  
Bronchial Thermoplasty Medical Policy NC  
Cataract Extraction Medical Policy NC  
Fetal Aneuploidy Medical Policy NC  
Adcetris Drug Policy PA Medicaid  
Alimta Drug Policy PA Medicaid  
Avastin Drug Policy PA Medicaid  
Faslodex Drug Policy PA Medicaid  
Herceptin Drug Policy PA Medicaid  
Interleukin-5 Inhibitors Drug Policy PA Medicaid  
Intravenous Immunoglobulin (IVIG) Drug Policy PA Medicaid  
Keytruda Drug Policy PA Medicaid  
Ocrevus Drug Policy PA Medicaid  
Opdivo Drug Policy PA Medicaid  
Perjeta Drug Policy PA Medicaid  
Portrazza Drug Policy PA Medicaid  
Remicade® (Infliximab) Drug Policy PA Medicaid  
Soliris Drug Policy PA Medicaid  
Spinraza Drug Policy PA Medicaid  
Tysabri Drug Policy PA Medicaid  
Vimizim Drug Policy PA Medicaid  

Xolair

Drug Policy PA Medicaid  
Yervoy Drug Policy PA Medicaid  

Adcetris

Drug Policy PA Medicare  

Alimta

Drug Policy PA Medicare  

Botox

Drug Policy PA Medicare  
Exondys 51 Drug Policy PA Medicare  

Faslodex

Drug Policy PA Medicare  

G-CSF

Drug Policy PA Medicare  

Herceptin

Drug Policy PA Medicare  

Interleukin-5 Inhibitors

Drug Policy PA Medicare  
Keytruda Drug Policy PA Medicare  

Kyprolis

Drug Policy PA Medicare  

Ocrevus

Drug Policy PA Medicare  

Perjeta

Drug Policy PA Medicare  

Remicade

Drug Policy PA Medicare  

Rituxan

Drug Policy PA Medicare  
Tysabri Drug Policy PA Medicare  

Vimizim​

Drug Policy PA Medicare  

Xolair

Drug Policy PA Medicare  

Portrazza

Drug Policy PA Medicare  

Soliris

Drug Policy PA Medicare  

Spinraza

Drug Policy PA Medicare  
Velcade Drug Policy PA Medicare  
Adcetris Drug Policy OH  
Exondys 51 Drug Policy OH  
Faslodex Drug Policy OH  
G-CSF Drug Policy OH  
Interleukin-5 Inhibitors Drug Policy OH  
Ocrevus Drug Policy OH  
Perjeta Drug Policy OH  
Spinraza Drug Policy OH  
Tysabri Drug Policy OH  
Velcade Drug Policy OH  
Vimizim Drug Policy OH  
Xolair​ Drug Policy OH  
Yervoy Drug Policy OH  

Adcetris

Drug Policy KY  

Exondys 51

Drug Policy KY  

Faslodex

Drug Policy KY  
G-CSF Drug Policy KY  

Interleukin-5 Inhibitors

Drug Policy KY  

Ocrevus

Drug Policy KY  

Perjeta

Drug Policy KY  

Spinraza

Drug Policy KY  
Tysabri Drug Policy KY  

Velcade

Drug Policy KY  

Vimizim

Drug Policy KY  

Xolair

Drug Policy KY  
Yervoy Drug Policy KY  

Alimta

Drug Policy NC  

Botox

Drug Policy NC  

Exondys 51

Drug Policy NC  

Faslodex

Drug Policy NC  

G-CSF

Drug Policy NC  
Interleukin-5 Inhibitors Drug Policy NC  

Ocrevus

Drug Policy NC  

Perjeta

Drug Policy NC  

Soliris

Drug Policy NC  

Spinraza

Drug Policy NC  

Tysabri

Drug Policy NC  

Vimizim

Drug Policy NC  
Xolair Drug Policy NC  
G-CSF Drug Policy PA Medicaid  
Genetic Testing for Colon CA Medical Policy PA Medicaid  
PA Place of Service Medical Policy PA Medicaid  
Botox Drug Policy PA Medicaid  
Rituxan Drug Policy PA Medicaid  
Erbitux Drug Policy PA Medicaid  
Capsule Endoscopy Medical Policy PA Medicaid  
Continuous Glucose Monitoring Medical Policy PA Medicaid  
Kyprolis Drug Policy PA Medicaid  
Spinraza Drug Policy PA Medicaid  
Cardiac Rehab Medical Policy PA Medicaid  
Pulmonary Rehab Medical Policy PA Medicaid  
Macular Degeneration Medical Policy PA Medicaid  
Avonex Prior Authorization Form PA Medicaid Jan 09, 2014
Copaxone Prior Authorization Form PA Medicaid Jan 09, 2014
Cough and Cold Medications for Children less than 4 Non-Formulary Policies PA Medicaid Sept 22,2017
Elidel Prior Authorization Form PA Medicaid Jan 09, 2014
Enbrel Prior Authorization Form PA Medicaid Jan 09, 2014
Exelon Prior Authorization Form PA Medicaid Jan 09, 2014
First Generation Antipsychotics Prior Authorization Form PA Medicaid Oct 02, 2017
Gleevec Prior Authorization Form PA Medicaid Jan 09, 2014
Hemophilia and Blood Factor Products Prior Authorization Form PA Medicaid Apr 29, 2015
Hepatitis C Treatment Prior Authorization Form PA Medicaid Jul 29, 2017
Hereditary Angioedema Acute Treatment Prior Authorization Form PA Medicaid Apr 15, 2016
Hereditary Angioedema Prophylaxis Prior Authorization Form PA Medicaid Apr 15, 2016
Humira Prior Authorization Form PA Medicaid Jan 09, 2014
Janumet Prior Authorization Form PA Medicaid Jan 09, 2014
Januvia Prior Authorization Form PA Medicaid Jan 09, 2014
Lupron Prior Authorization Form PA Medicaid Jan 09, 2014
Lupron Depot Prior Authorization Form PA Medicaid Jan 09, 2014
Lyrica Prior Authorization Form PA Medicaid Jan 15, 2016
Makena Prior Authorization Form PA Medicaid Dec 08, 2015
Neupogen Prior Authorization Form PA Medicaid Jan 09, 2014
Non-TNF Biologics Non-Formulary Policies PA Medicaid Sept 22, 2017
Norditropin Prior Authorization Form PA Medicaid Jan 09, 2014
PCSK9 Inhibitor Initial Authorization Prior Authorization Form PA Medicaid Dec 18, 2015
PCSK9 Inhibitor Reauthorization Prior Authorization Form PA Medicaid Dec 18, 2015
Peg-Intron Prior Authorization Form PA Medicaid Jan 09, 2014
Pegasys Prior Authorization Form PA Medicaid Jan 09, 2014
Procrit Prior Authorization Form PA Medicaid Jan 09, 2014
Pulmozyme Prior Authorization Form PA Medicaid Jan 09, 2014
Remicade Prior Authorization Form PA Medicaid Jan 09, 2014
Restasis Prior Authorization Form PA Medicaid Jan 09, 2014
Second Generation Antipsychotics for Children less than 18 Prior Authorization Form PA Medicaid Mar 07, 2017
Short-acting and long acting Opioid Analgesics Prior Authorization Form PA Medicaid Sept 15, 2017
Suboxone Film Prior Authorization Form PA Medicaid Jan 09, 2014
Subutex Prior Authorization Form PA Medicaid Jan 09, 2014
Synagis Prior Authorization Form PA Medicaid Jan 09, 2014
Synvisc One Prior Authorization Form PA Medicaid Jan 09, 2014
Vivitrol Prior Authorization Form PA Medicaid Jul 12, 2017
Voltaren Gel Prior Authorization Form PA Medicaid Jan 09, 2014
Xolair Prior Authorization Form PA Medicaid May 21, 2017
Zubsolv Prior Authorization Form PA Medicaid May 18, 2014
Adcetris Non Formulary Policies PA Medicaid  
Alimta Non Formulary Policies PA Medicaid  
Emflaza Non Formulary Policies PA Medicaid  
Entresto Non Formulary Policies PA Medicaid  
Erbitux Non Formulary Policies PA Medicaid  
Esbriet Non Formulary Policies PA Medicaid  
Faslodex Non Formulary Policies PA Medicaid  
Granulocyte Colony Stimulating Factors (G-CSFs) Non Formulary Policies PA Medicaid  
H.P. Acthar Gel Non Formulary Policies PA Medicaid  
Hemophilia and Blood Factor Products Non Formulary Policies PA Medicaid  
Hepatitis B Non Formulary Policies PA Medicaid  
Hepatitis C Non Formulary Policies PA Medicaid  
Herceptin Non Formulary Policies PA Medicaid  
Hereditary Angioedema (HAE) Management Non Formulary Policies PA Medicaid  
Interleukin-5 Inhibitors Non Formulary Policies PA Medicaid  
Intravenous and Subcutaneous Immune Globulin (IVIG & SCIG) Non Formulary Policies PA Medicaid  
Kalydeco and Orkambi Non Formulary Policies PA Medicaid  
Keytruda Non Formulary Policies PA Medicaid  
Kyprolis Non Formulary Policies PA Medicaid  
Makena Non Formulary Policies PA Medicaid  
Ocrevus Non Formulary Policies PA Medicaid  
Ofev Non Formulary Policies PA Medicaid  
Opdivo Non Formulary Policies PA Medicaid  
Opioid Analgesics Non Formulary Policies PA Medicaid  
PCSK9 Inhibitors Non Formulary Policies PA Medicaid  
Perjeta Non Formulary Policies PA Medicaid  
Portrazza Non Formulary Policies PA Medicaid  
Pulmonary Arterial Hypertension(PAH) Agents Non Formulary Policies PA Medicaid  
Rituxan Non Formulary Policies PA Medicaid  
Second Generation Antipsychotics for Children less than 18 Non Formulary Policies PA Medicaid  
Soliris Non Formulary Policies PA Medicaid  
Spinraza Non Formulary Policies PA Medicaid  
Sublingual Immunotherapy Medications Non Formulary Policies PA Medicaid  
Tysabri Non Formulary Policies PA Medicaid  
Velcade Non Formulary Policies PA Medicaid  
Vimizim Non Formulary Policies PA Medicaid  
Xgeva and Prolia Non Formulary Policies PA Medicaid  
Xolair Non Formulary Policies PA Medicaid  
Yervoy Non Formulary Policies PA Medicaid  
Zinbryta Non Formulary Policies PA Medicaid  
Daraprim Non Formulary Policies PA Medicaid  
Exondys-51 Non Formulary Policies PA Medicaid