Policies & Criteria
Clinical Policies
Trillium Community Health Plan (Trillium) uses the following guidelines (listed in order of significance) to make OHP/Medicaid medical necessity decisions on a case-by-case basis, based on the information submitted with the request.
State/Federally Developed
- Oregon Administrative Rules, Oregon Health Authority Health Systems Division, Chapter 410
- Oregon Health Plan (OHP) Prioritized LIst and Guideline Notes
- Oregon Health Evidence Review Commission (HERC) Completed Guidances
- Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)
Non-State or Federally Developed
- InterQual Clinical Decision Support Criteria (Attachment 1 2017 Summary of Changes)
- American College of Radiology (ACR) Appropriateness Criteria
- National Comprehensive Cancer Network (NCCN) Practice Guidelines in Oncology
See OR.CP.MP.500 Requests for Authorization – Oregon Health Plan (OHP) for authorization hierarchy.
If you have any questions regarding these policies, please contact Provider Services at 877-600-5472.
| Code | Title | Description | Date Adopted |
|---|---|---|---|
| OR.CP.MP.500 (PDF) | Requests for Authorization - Oregon Health Plan (OHP) | Oregon Health Plan Prioritized List and subsequent policies/criteria/guidelines hierarchy to make medical necessity decisions. | 9/12/2019 |
25-hydroxyvitamin D testing in children and adolescents |
Medical necessity guidelines for 25-hydroxyvitamin D testing in children and adolescents |
5/19/2020 | |
Acupuncture |
Medical necessity guidelines for acupuncture |
2/18/2020 | |
ADHD Assessment and Treatment |
Medical necessity guidelines for the assessment and treatment of attention deficit hyperactivity disorder (ADHD) |
5/19/2020 | |
Allergy Testing and Therapy |
Medical necessity guidelines for allergy testing and treatment |
2/18/2020 | |
Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia |
Medical necessity guidelines for allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia |
2/18/2020 | |
Ambulatory EEG |
Medical necessity guidelines for the use of ambulatory electroencephalogram (EEG) testing in the outpatient setting |
7/21/2020 | |
Ambulatory Surgery Center Optimization |
Medical necessity guidelines for the use of ambulatory surgery centers as an alternative to inpatient surgical services |
2/18/2020 | |
| CP.MP.179 (PDF) | Antithrombin III (Thrombate III, Atryn) | Medical necessity criteria for Antithrombin III (Thrombate III, Atryn) | 2/18/2020 |
Applied Behavioral Analysis for Autism |
Medical necessity guidelines for applied behavioral analysis for autism |
10/1/2019 | |
Articular Cartilage Defect Repairs |
Medical necessity guidelines for articular cartilage defect repairs |
10/1/2019 | |
Assisted Reproductive Technology |
Medical necessity guidelines for assisted reproductive technology |
10/1/2019 | |
Balloon sinus ostial dilation |
Medical necessity guidelines for balloon sinus ostial dilation for chronic rhinosinusitus and recurrent acute rhinosinusitis |
7/21/2020 | |
Bariatric Surgery |
Medical necessity guidelines for bariatric surgery for obesity in adolescents and adults |
10/1/2019 | |
Biofeedback |
Medical necessity guidelines for biofeedback therapy |
10/1/2019 | |
Bone-anchored hearing aid |
Medical necessity guidelines for bone-anchored hearing aid |
10/1/2019 | |
Bronchial Thermoplasty |
Medical necessity guidelines for bronchial thermoplasty |
7/21/2020 | |
Cardiac biomarker testing |
Medical necessity guidelines for cardiac biomarker testing for the evaluation of suspected acute myocardial infarction |
5/19/2020 | |
Carrier Screening in Pregnancy |
Medical necessity guidelines for carrier screening in pregnancy |
10/1/2019 | |
Caudal or Interlaminar Epidural Steroid Injections for Pain Management |
Medical necessity criteria for caudal or interlaminar epidural steroid injections for pain management |
10/1/2019 | |
Cell-free Fetal DNA Testing |
Medical necessity guidelines for cell-free fetal DNA testing |
10/1/2019 | |
Clinical Policy Web Posting |
Corporate and health plan responsibilities for initial posting and maintenance of clinical, payment, and specialty drug policies to public health plan websites |
2/18/2020 | |
Clinical Trials |
Medical necessity guidelines for routine costs of clinical trials |
10/1/2019 | |
Cochlear Implant Replacements |
Medical necessity guidelines for the replacement of cochlear implants and/or cochlear implant components. |
10/1/2019 | |
Cosmetic and Reconstructive Surgery |
Medical necessity guidelines for cosmetic and reconstructive surgery |
10/1/2019 | |
Dental Anesthesia |
Medical necessity guidelines for dental anesthesia |
10/1/2019 | |
| CP.MP.183 (PDF) | Diagnostic Testing Guidelines for 2019-Novel Coronavirus | Medical necessity criteria for diagnosing coronavirus disease 2019 (COVID-19). COVID-19 is caused by the virus SARS-CoV-2. | 7/21/2020 |
Digital electroencephalography spike analysis |
Medical necessity guidelines for digital EEG spike analysis |
5/19/2020 | |
Disc Decompression Procedures |
Medical necessity guidelines for open discectomy, microdiscectomy, and minimally invasive and percutaneous disc decompression |
10/1/2019 | |
Discography |
Medical necessity guidelines for discography |
10/1/2019 | |
DNA analysis of stool to screen for colorectal cancer |
Medical necessity guidelines for DNA analysis of stool for colorectal cancer |
2/18/2020 | |
Donor lymphocyte infusion |
Medical necessity guidelines for donor lymphocyte infusion |
2/18/2020 | |
Durable Medical Equipment (DME) |
Medical necessity guidelines for durable medical equipment, orthotics, and prosthetics |
5/19/2020 | |
Electric Tumor Treating Fields |
Medical necessity guidelines for electric tumor treating fields Optune® (NovoCureTM) |
5/19/2020 | |
Electroencephalography in the evaluation of headache |
Medical necessity guidelines for the use of electroencephalography (EEG) in the evaluation of headaches |
7/21/2020 | |
Endometrial ablation |
Medical necessity guidelines for endometrial ablation |
2/18/2020 | |
EpiFix Wound Treatment |
Medical necessity guidelines for EpiFix® wound treatment |
10/1/2019 | |
Essure Removal |
Medical necessity guidelines for removal of Essure®, a permanent birth control device |
2/18/2020 | |
Evoked Potential Testing |
Medical necessity guidelines for evoked potential testing |
5/19/2020 | |
Experimental Technologies |
General medical necessity guidelines to use in determining coverage of experimental or investigational or potentially experimental or investigational medical and behavioral health technologies. These guidlines are to be used only when there is no other policy, criteria, or coverage statement available. |
5/19/2020 | |
Facet Joint Interventions for pain management |
Medical necessity guidelines for facet joint injections and facet joint radiofrequency neurotomy (ablation) for lumbar, thoracic, and cervical pain management |
2/18/2020 | |
Fecal incontinence treatments |
Medical necessity guidelines for fecal incontinence treatments |
2/18/2020 | |
Ferriscan R2-MRI |
Medical necessity guidelines for use of the FerriScan R2-MRI |
10/1/2019 | |
Fertility preservation |
Medical necessity guidelines for fertility preservation when undergoing medical treatments that may transiently or permanently affect fertility |
7/21/2020 | |
Fetal surgery in utero for prenatally diagnosed malformations |
Medical necessity guidelines for performing fetal surgery in utero |
10/1/2019 | |
Fixed Wing Air Transportation |
Medical necessity guidelines for fixed wing air transportation |
5/19/2020 | |
Fractional exhaled nitric oxide |
Medical necessity guidelines for use of fractional exhaled nitric oxide (FeNO) in asthma diagnosis and care |
2/18/2020 | |
Functional MRI |
Medical necessity guidelines for the use of functional magnetic resonance imaging (fMRI). |
10/1/2019 | |
Gastric electrical stimulation |
Medical necessity guidelines for gastric electrical stimulation |
10/1/2019 | |
Gender Affirming Procedures |
Medical necessity guidelines for surgery for the treatment of gender dysphoria |
7/21/2020 | |
Genetic Testing |
Medical necessity criteria for genetic testing |
10/1/2019 | |
H. Pylori serology testing |
Medical necessity guidelines for H. pylori |
2/18/2020 | |
Heart-Lung Transplant |
Medical necessity guidelines for heart-lung transplantation |
10/1/2019 | |
Holter Monitors |
Medical necessity guidelines for Holter monitoring, or continuous ambulatory electrocardiogram (ECG) monitoring |
7/21/2020 | |
Home Birth |
Medical necessity guidelines for planned home birth |
10/1/2019 | |
Home phototherapy for neonatal hyperbilirubinemia |
Medical necessity guidelines for home phototherapy for the treatment of neonatal hyperbilirubinemia |
2/18/2020 | |
Homocysteine testing |
Medical necessity guidelines for homocysteine testing |
10/1/2019 | |
Hospice Services |
Medical necessity guidelines for hospice services |
7/21/2020 | |
Hyperemesis gravidarum treatment |
Medical necessity guidelines for the treatment of hyperemesis gravidarum, including intravenous and subcutaneous infusions of ondansetron and metoclopramide, enteral therapy, and total parenteral nutrition (TPN) |
5/19/2020 | |
Hyperhidrosis treatments |
Medical necessity guidelines for the treatment of hyperhidrosis, including iontophoresis, endoscopic thoracic sympathectomy, and surgical excision of axillary sweat glands |
5/19/2020 | |
| CP.MP.180 (PDF) | Implantable Hypoglossal Nerve Stimulation | Medical necessity criteria for Implantable Hypoglossal Nerve Stimulation (Inspire) for Obstructive Sleep Apnea | 2/18/2020 |
Implantable Intrathecal Pain Pump |
Medical necessity guidelines for preliminary trial and implantation of intrathecal pain pumps |
5/19/2020 | |
Implantable Wireless Pulmonary Artery Pressure Monitoring |
Medical necessity guidelines for implantable wireless pulmonary artery pressure monitoring |
7/21/2020 | |
Infusion Therapy Site of Care Optimization |
Medical necessity criteria for IV or injectable therapy services in an outpatient setting. |
2/18/2020 | |
Inhaled nitric oxide |
Medical necessity guidelines for the use of inhaled nitric oxide (iNO) |
10/1/2019 | |
Intensity-Modulated Radiotherapy |
Medical necessity guidelines for intensity-modulated radiotherapy (IMRT) |
5/19/2020 | |
Intestinal and multivisceral transplant |
Medical necessity guidelines for the review of intestinal and multivisceral transplant requests. |
10/1/2019 | |
Intradiscal Steroid Injections for Pain Management |
Medical necessity criteria for intradiscal steroid injections for pain management |
10/1/2019 | |
Laser therapy for skin conditions |
Medical necessity guidelines for excimer laser based targeted phototherapy |
10/1/2019 | |
Long Term Care Placement Criteria |
Medical necessity guidelines for long term care (LTC) placement |
7/21/2020 | |
Low-frequency ultrasound therapy for wound management |
Medical necessity guidelines for low-frequency ultrasound therapy for wound management |
2/18/2020 | |
| CP.MP.57 (PDF) | Lung Transplantation | Medical necessity guidelines for review of lung transplantation requests | 5/19/2020 |
Lysis of Epidural Lesions |
Medical necessity criteria for epidural adhesiolysis, also known as as epidural neuroplasty, lysis of epidural adhesions, or caudal neuroplasty |
10/1/2019 | |
Measurement of serum 1,25-dihydroxyvitamin D |
Medical necessity guidelines for the measurement of serum 1,25-dihydroxyvitamin D |
2/18/2020 | |
Mechanical Stretching Devices for Joint Stiffness and Contracture |
Medical necessity guidelines for mechanical stretch devices, including low-load prolonged-duration stretch (LLPS) devices/dynamic stretch devices, static progressive (SP) stretch devices, and patient-actuated serial stretch devices. |
7/21/2020 | |
Medical Necessity Criteria |
This policy identifies the medical necessity guidelines used by the health plan and related definitions. |
7/21/2020 | |
Multiple Sleep Latency Testing |
Medical necessity criteria for multiple sleep latency testing (MSLT) |
7/21/2020 | |
Neonatal abstinence syndrome guidelines |
Medical necessity guidelines for managing neonatal abstinence syndrome in the neonatal intensive care unit (NICU) |
2/18/2020 | |
Neonatal sepsis management |
Medical necessity guidelines for neonates requiring comprehensive assessment, treatment, and discharge planning for neonatal intensive care unit (NICU) stays related to sepsis management |
5/19/2020 | |
Nerve Blocks for Pain Management |
Medical necessity criteria for nerve blocks for pain management |
5/19/2020 | |
NICU Apnea Bradycardia Guidelines |
Medical necessity guidelines to assist with continuing care, discharge planning, and the transition to outpatient and home care of babies affected by ongoing neonatal apnea and bradycardia events |
10/1/2019 | |
NICU discharge guidelines |
Medical necessity guidelines to assist in comprehensive discharge planning and smooth transition from the neonatal intensive care unit (NICU) to home. |
10/1/2019 | |
| CP.MP.184 (PDF) | Non-Invasive Home Ventilators | Medical necessity guidelines for non-invasive home ventilators | 5/19/2020 |
Non-myeloablative allogeneic stem cell transplants |
Medical necessity guidelines for non-myeloablative allogeneic stem cell transplants |
5/19/2020 | |
Obstetrical Home Health Care Programs |
Medical necessity guidelines for OB home health programs |
5/19/2020 | |
Optic nerve decompression surgery |
Medical necessity guidelines for optic nerve sheath decompression surgery |
10/1/2019 | |
Outpatient Cardiac Rehabilitation |
Medical necessity criteria for conventional and intensive outpatient cardiac rehabiliation programs. |
10/1/2019 | |
Outpatient testing for drugs of abuse |
Medical necessity guidelines for confirmatory/definitive lab testing for specific drugs of abuse. |
10/1/2019 | |
Pancreas transplant |
Medical necessity guidelines for pancreas transplant, including simultaneous pancreas kidney transplant, pancreas after kidney transplant, pancreas transplant alone, and islet cell transplant. |
5/19/2020 | |
Panniculectomy |
Medical necessity guidelines for panniculectomy |
5/19/2020 | |
Pediatric heart transplant |
Medical necessity guidelines for pediatric heart transplant |
5/19/2020 | |
Pediatric Liver Transplant |
Medical necessity guidelines for pediatric liver transplant for end-stage liver disease |
5/19/2020 | |
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention |
Medical necessity guidelines for left atrial appendage closure devices for stroke prevention. |
10/1/2019 | |
Posterior tibial nerve stimulation for voiding dysfunction |
Medical necessity guidelines for posterior tibial nerve stimulation for the treatment of voiding dysfunction, including urinary incontinence and overactive bladder |
5/19/2020 | |
Preventive Health and Clinical Practice Guideline Policy |
The process by which the Plan adopts/develops and distributes preventive health and clinical practice guidelines to assist practitioners and members in making decisions about appropriate health care for specific clinical circumstances. |
7/21/2020 | |
Proton and neutron beam therapy |
Medical necessity guidelines for proton beam and neutron beam radiation therapy |
5/19/2020 | |
Radial Head Implant |
Medical necessity guidelines for radial head implant, also known as arthroplasty |
10/1/2019 | |
Reduction mammoplasty and gynecomastia surgery |
Medical necessity guidelines for reduction mammoplasty in women and gynecomastia surgery in men |
10/1/2019 | |
Sacroiliac joint fusion |
Medical necessity guidelines for sacroiliac joint fusion |
10/1/2019 | |
Sacroiliac Joint Interventions for Pain Management |
Medical necessity criteria for sacroiliac joint interventions for pain management |
5/19/2020 | |
Sclerotherapy for Varicose Veins |
Medical necessity guidelines for sclerotherapy for treatment of vericose veins |
7/31/2020 | |
Selective Dorsal Rhizotomy |
Medical necessity criteria for Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy. |
5/19/2020 | |
Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management |
Medical necessity criteria for selective nerve root blocks and transforaminal epidural injections for pain management |
2/18/2020 | |
| CP.MP.182 (PDF) | Short Inpatient Hospital Stay | Medical necessity criteria for inpatient hospital stay of 2 days or less | 7/21/2020 |
Sickle cell disease observation |
Medical necessity criteria for observation stay for sickle cell disease |
5/19/2020 | |
Spinal Cord Stimulation |
Medical necessity guidelines for spinal cord stimulation for pain management, also known as dorsal column stimulation |
5/19/2020 | |
State specific clinical policy process |
This policy describes the process for creating, maintaining, and posting state-specific clinical policies |
2/18/2020 | |
Stereotactic Body Radiation Therapy |
Medical necessity guidelines for stereotactic body radiation therapy |
10/1/2019 | |
Tandem Transplant |
Medical necessity guidelines for tandem transplant |
10/1/2019 | |
Testing for rupture of fetal membranes |
Medical necessity guidelines for testing for rupture of fetal membranes |
10/1/2019 | |
Testing for select genitourinary conditions |
Medical necessity guidelines for various diagnostic testing methods to identify the etiology of the signs and symptoms of vaginitis |
10/1/2019 | |
Therapy Services (PT/OT/ST) |
Medical necessity guidelines for outpatient speech therapy, occupational therapy, and/or physical therapy evaluation and treatment. |
5/19/2020 | |
| CP.MP.189 (PDF) | Thymus Transplantation | Complete DiGeorge anomaly is a disorder in which a person has no thymus function. Without thymus function, bone marrow stem cells do not develop into T cells, which results in immunodeficiency. Without successful treatment, patients usually die by 2 years of age. Thymus transplantation with and without immunosuppression has resulted in the development good T cell function in complete DiGeorge anomaly subjects. | 7/21/2020 |
Thyroid hormones and insulin testing in pediatrics |
Medical necessity guidelines for thyroid hormones and insulin testing in pediatrics |
2/18/2020 | |
Total artificial heart |
Medical necessity guidelines for a total artificial heart (TAH) |
2/18/2020 | |
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition |
Medical necessity guidelines for total parenteral nutrition (TPN) and intradialytic parenteral nutrition (IDPN) |
7/21/2020 | |
Transcatheter closure of patent foramen ovale |
Medical necessity guidelines for transcatheter closure of patent foramen ovale (PFO) with the AmplatzerTM PFO Occluder. |
2/18/2020 | |
Transcranial magnetic stimulation |
This policy describes medical necessity guidelines for the use of transcranial magnetic stimulation |
10/1/2019 | |
Trigger Point Injections for Pain Management |
Medical necessity criteria for trigger point injections for pain management |
7/21/2020 | |
Ultrasound in Pregnancy |
Medical necessity guidelines for ultrasound use in pregnancy. |
10/1/2019 | |
Urinary Incontinence Devices and Treatments |
Medical necessity guidelines for treatments and devices for urinary incontinence including sacral neuromodulation (sacral nerve stimulation) and urethral bulking agents |
5/19/2020 | |
Urodynamic testing |
Medical necessity guideines for urodynamic testing as part of the comprehensive evaluation of voiding dysfunction |
10/1/2019 | |
Vagus Nerve Stimulation |
Medical necessity guidelines for vagus nerve stimulation. |
10/1/2019 | |
Ventricular Assist Devices |
Medical necessity guidelines for ventricular assist devices. |
10/1/2019 | |
Ventriculectomy and cardiomyoplasty |
Medical necessity guidelines for ventriculectomy and cardiomyoplasty procedures |
7/21/2020 | |
| CP.MP.177 (PDF) | Video Electorencephalographic (VEEG) Monitoring | Medical necessity criteria for video electroencephalographic (EEG) monitoring. | 7/21/2020 |
Wheelchair seating |
Medical necessity guidelines for special wheelchair seating and cushions |
2/18/2020 | |
Wireless Motility Capsule |
Medical necessity guidelines for wireless motility capsule |
5/19/2020 |
| Code | Title | Description | Date Adopted |
|---|---|---|---|
| OR.CP.MP.500 (PDF) | Requests for Authorization - Oregon Health Plan (OHP) | Oregon Health Plan Prioritized List and subsequent policies/criteria/guidelines hierarchy to make medical necessity decisions. | 9/12/2019 |
25-hydroxyvitamin D testing in children and adolescents |
Medical necessity guidelines for 25-hydroxyvitamin D testing in children and adolescents |
5/19/2020 | |
Acupuncture |
Medical necessity guidelines for acupuncture |
2/18/2020 | |
ADHD Assessment and Treatment |
Medical necessity guidelines for the assessment and treatment of attention deficit hyperactivity disorder (ADHD) |
5/19/2020 | |
Allergy Testing and Therapy |
Medical necessity guidelines for allergy testing and treatment |
2/18/2020 | |
Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia |
Medical necessity guidelines for allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia |
2/18/2020 | |
Ambulatory EEG |
Medical necessity guidelines for the use of ambulatory electroencephalogram (EEG) testing in the outpatient setting |
7/21/2020 | |
Ambulatory Surgery Center Optimization |
Medical necessity guidelines for the use of ambulatory surgery centers as an alternative to inpatient surgical services |
2/18/2020 | |
| CP.MP.179 (PDF) | Antithrombin III (Thrombate III, Atryn) | Medical necessity criteria for Antithrombin III (Thrombate III, Atryn) | 2/18/2020 |
Applied Behavioral Analysis for Autism |
Medical necessity guidelines for applied behavioral analysis for autism |
10/1/2019 | |
Articular Cartilage Defect Repairs |
Medical necessity guidelines for articular cartilage defect repairs |
10/1/2019 | |
Assisted Reproductive Technology |
Medical necessity guidelines for assisted reproductive technology |
10/1/2019 | |
Balloon sinus ostial dilation |
Medical necessity guidelines for balloon sinus ostial dilation for chronic rhinosinusitus and recurrent acute rhinosinusitis |
7/21/2020 | |
Bariatric Surgery |
Medical necessity guidelines for bariatric surgery for obesity in adolescents and adults |
10/1/2019 | |
Biofeedback |
Medical necessity guidelines for biofeedback therapy |
10/1/2019 | |
Bone-anchored hearing aid |
Medical necessity guidelines for bone-anchored hearing aid |
10/1/2019 | |
Bronchial Thermoplasty |
Medical necessity guidelines for bronchial thermoplasty |
7/21/2020 | |
Cardiac biomarker testing |
Medical necessity guidelines for cardiac biomarker testing for the evaluation of suspected acute myocardial infarction |
5/19/2020 | |
Carrier Screening in Pregnancy |
Medical necessity guidelines for carrier screening in pregnancy |
10/1/2019 | |
Caudal or Interlaminar Epidural Steroid Injections for Pain Management |
Medical necessity criteria for caudal or interlaminar epidural steroid injections for pain management |
10/1/2019 | |
Cell-free Fetal DNA Testing |
Medical necessity guidelines for cell-free fetal DNA testing |
10/1/2019 | |
Clinical Policy Web Posting |
Corporate and health plan responsibilities for initial posting and maintenance of clinical, payment, and specialty drug policies to public health plan websites |
2/18/2020 | |
Clinical Trials |
Medical necessity guidelines for routine costs of clinical trials |
10/1/2019 | |
Cochlear Implant Replacements |
Medical necessity guidelines for the replacement of cochlear implants and/or cochlear implant components. |
10/1/2019 | |
Cosmetic and Reconstructive Surgery |
Medical necessity guidelines for cosmetic and reconstructive surgery |
10/1/2019 | |
Dental Anesthesia |
Medical necessity guidelines for dental anesthesia |
10/1/2019 | |
| CP.MP.183 (PDF) | Diagnostic Testing Guidelines for 2019-Novel Coronavirus | Medical necessity criteria for diagnosing coronavirus disease 2019 (COVID-19). COVID-19 is caused by the virus SARS-CoV-2. | 7/21/2020 |
Digital electroencephalography spike analysis |
Medical necessity guidelines for digital EEG spike analysis |
5/19/2020 | |
Disc Decompression Procedures |
Medical necessity guidelines for open discectomy, microdiscectomy, and minimally invasive and percutaneous disc decompression |
10/1/2019 | |
Discography |
Medical necessity guidelines for discography |
10/1/2019 | |
DNA analysis of stool to screen for colorectal cancer |
Medical necessity guidelines for DNA analysis of stool for colorectal cancer |
2/18/2020 | |
Donor lymphocyte infusion |
Medical necessity guidelines for donor lymphocyte infusion |
2/18/2020 | |
Durable Medical Equipment (DME) |
Medical necessity guidelines for durable medical equipment, orthotics, and prosthetics |
5/19/2020 | |
Electric Tumor Treating Fields |
Medical necessity guidelines for electric tumor treating fields Optune® (NovoCureTM) |
5/19/2020 | |
Electroencephalography in the evaluation of headache |
Medical necessity guidelines for the use of electroencephalography (EEG) in the evaluation of headaches |
7/21/2020 | |
Endometrial ablation |
Medical necessity guidelines for endometrial ablation |
2/18/2020 | |
EpiFix Wound Treatment |
Medical necessity guidelines for EpiFix® wound treatment |
10/1/2019 | |
Essure Removal |
Medical necessity guidelines for removal of Essure®, a permanent birth control device |
2/18/2020 | |
Evoked Potential Testing |
Medical necessity guidelines for evoked potential testing |
5/19/2020 | |
Experimental Technologies |
General medical necessity guidelines to use in determining coverage of experimental or investigational or potentially experimental or investigational medical and behavioral health technologies. These guidlines are to be used only when there is no other policy, criteria, or coverage statement available. |
5/19/2020 | |
Facet Joint Interventions for pain management |
Medical necessity guidelines for facet joint injections and facet joint radiofrequency neurotomy (ablation) for lumbar, thoracic, and cervical pain management |
2/18/2020 | |
Fecal incontinence treatments |
Medical necessity guidelines for fecal incontinence treatments |
2/18/2020 | |
Ferriscan R2-MRI |
Medical necessity guidelines for use of the FerriScan R2-MRI |
10/1/2019 | |
Fertility preservation |
Medical necessity guidelines for fertility preservation when undergoing medical treatments that may transiently or permanently affect fertility |
7/21/2020 | |
Fetal surgery in utero for prenatally diagnosed malformations |
Medical necessity guidelines for performing fetal surgery in utero |
10/1/2019 | |
Fixed Wing Air Transportation |
Medical necessity guidelines for fixed wing air transportation |
5/19/2020 | |
Fractional exhaled nitric oxide |
Medical necessity guidelines for use of fractional exhaled nitric oxide (FeNO) in asthma diagnosis and care |
2/18/2020 | |
Functional MRI |
Medical necessity guidelines for the use of functional magnetic resonance imaging (fMRI). |
10/1/2019 | |
Gastric electrical stimulation |
Medical necessity guidelines for gastric electrical stimulation |
10/1/2019 | |
Gender Affirming Procedures |
Medical necessity guidelines for surgery for the treatment of gender dysphoria |
7/21/2020 | |
Genetic Testing |
Medical necessity criteria for genetic testing |
10/1/2019 | |
H. Pylori serology testing |
Medical necessity guidelines for H. pylori serology testing |
2/18/2020 | |
Heart-Lung Transplant |
Medical necessity guidelines for heart-lung transplantation |
10/1/2019 | |
Holter Monitors |
Medical necessity guidelines for Holter monitoring, or continuous ambulatory electrocardiogram (ECG) monitoring |
7/21/2020 | |
Home Birth |
Medical necessity guidelines for planned home birth |
10/1/2019 | |
Home phototherapy for neonatal hyperbilirubinemia |
Medical necessity guidelines for home phototherapy for the treatment of neonatal hyperbilirubinemia |
2/18/2020 | |
Homocysteine testing |
Medical necessity guidelines for homocysteine testing |
10/1/2019 | |
Hospice Services |
Medical necessity guidelines for hospice services |
7/21/2020 | |
Hyperemesis gravidarum treatment |
Medical necessity guidelines for the treatment of hyperemesis gravidarum, including intravenous and subcutaneous infusions of ondansetron and metoclopramide, enteral therapy, and total parenteral nutrition (TPN) |
5/19/2020 | |
Hyperhidrosis treatments |
Medical necessity guidelines for the treatment of hyperhidrosis, including iontophoresis, endoscopic thoracic sympathectomy, and surgical excision of axillary sweat glands |
5/19/2020 | |
| CP.MP.180 (PDF) | Implantable Hypoglossal Nerve Stimulation | Medical necessity criteria for Implantable Hypoglossal Nerve Stimulation (Inspire) for Obstructive Sleep Apnea | 2/18/2020 |
Implantable Intrathecal Pain Pump |
Medical necessity guidelines for preliminary trial and implantation of intrathecal pain pumps |
5/19/2020 | |
Implantable Wireless Pulmonary Artery Pressure Monitoring |
Medical necessity guidelines for implantable wireless pulmonary artery pressure monitoring |
7/21/2020 | |
Infusion Therapy Site of Care Optimization |
Medical necessity criteria for IV or injectable therapy services in an outpatient setting. |
2/18/2020 | |
Inhaled nitric oxide |
Medical necessity guidelines for the use of inhaled nitric oxide (iNO) |
10/1/2019 | |
Intensity-Modulated Radiotherapy |
Medical necessity guidelines for intensity-modulated radiotherapy (IMRT) |
5/19/2020 | |
Intestinal and multivisceral transplant |
Medical necessity guidelines for the review of intestinal and multivisceral transplant requests. |
10/1/2019 | |
Intradiscal Steroid Injections for Pain Management |
Medical necessity criteria for intradiscal steroid injections for pain management |
10/1/2019 | |
Laser therapy for skin conditions |
Medical necessity guidelines for excimer laser based targeted phototherapy |
10/1/2019 | |
Long Term Care Placement Criteria |
Medical necessity guidelines for long term care (LTC) placement |
7/21/2020 | |
Low-frequency ultrasound therapy for wound management |
Medical necessity guidelines for low-frequency ultrasound therapy for wound management |
2/18/2020 | |
Lung Transplantation |
Medical necessity guidelines for review of lung transplantation requests |
5/19/2020 | |
Lysis of Epidural Lesions |
Medical necessity criteria for epidural adhesiolysis, also known as as epidural neuroplasty, lysis of epidural adhesions, or caudal neuroplasty |
10/1/2019 | |
Measurement of serum 1,25-dihydroxyvitamin D |
Medical necessity guidelines for the measurement of serum 1,25-dihydroxyvitamin D |
2/18/2020 | |
Mechanical Stretching Devices for Joint Stiffness and Contracture |
Medical necessity guidelines for mechanical stretch devices, including low-load prolonged-duration stretch (LLPS) devices/dynamic stretch devices, static progressive (SP) stretch devices, and patient-actuated serial stretch devices. |
7/21/2020 | |
Medical Necessity Criteria |
This policy identifies the medical necessity guidelines used by the health plan and related definitions. |
7/21/2020 | |
Multiple Sleep Latency Testing |
Medical necessity criteria for multiple sleep latency testing (MSLT) |
7/21/2020 | |
Neonatal abstinence syndrome guidelines |
Medical necessity guidelines for managing neonatal abstinence syndrome in the neonatal intensive care unit (NICU) |
2/18/2020 | |
Neonatal sepsis management |
Medical necessity guidelines for neonates requiring comprehensive assessment, treatment, and discharge planning for neonatal intensive care unit (NICU) stays related to sepsis management |
5/19/2020 | |
Nerve Blocks for Pain Management |
Medical necessity criteria for nerve blocks for pain management |
5/19/2020 | |
NICU Apnea Bradycardia Guidelines |
Medical necessity guidelines to assist with continuing care, discharge planning, and the transition to outpatient and home care of babies affected by ongoing neonatal apnea and bradycardia events |
10/1/2019 | |
NICU discharge guidelines |
Medical necessity guidelines to assist in comprehensive discharge planning and smooth transition from the neonatal intensive care unit (NICU) to home. |
10/1/2019 | |
| CP.MP.184 (PDF) | Non-Invasive Home Ventilators | Medical necessity guidelines for non-invasive home ventilators | 5/19/2020 |
Non-myeloablative allogeneic stem cell transplants |
Medical necessity guidelines for non-myeloablative allogeneic stem cell transplants |
5/19/2020 | |
Obstetrical Home Health Care Programs |
Medical necessity guidelines for OB home health programs |
5/19/2020 | |
Optic nerve decompression surgery |
Medical necessity guidelines for optic nerve sheath decompression surgery |
10/1/2019 | |
Outpatient Cardiac Rehabilitation |
Medical necessity criteria for conventional and intensive outpatient cardiac rehabiliation programs. |
10/1/2019 | |
Outpatient testing for drugs of abuse |
Medical necessity guidelines for confirmatory/definitive lab testing for specific drugs of abuse. |
10/1/2019 | |
Pancreas transplant |
Medical necessity guidelines for pancreas transplant, including simultaneous pancreas kidney transplant, pancreas after kidney transplant, pancreas transplant alone, and islet cell transplant. |
5/19/2020 | |
Panniculectomy |
Medical necessity guidelines for panniculectomy |
5/19/2020 | |
Pediatric heart transplant |
Medical necessity guidelines for pediatric heart transplant |
5/19/2020 | |
Pediatric Liver Transplant |
Medical necessity guidelines for pediatric liver transplant for end-stage liver disease |
5/19/2020 | |
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention |
Medical necessity guidelines for left atrial appendage closure devices for stroke prevention. |
10/1/2019 | |
Posterior tibial nerve stimulation for voiding dysfunction |
Medical necessity guidelines for posterior tibial nerve stimulation for the treatment of voiding dysfunction, including urinary incontinence and overactive bladder |
5/19/2020 | |
Preventive Health and Clinical Practice Guideline Policy |
The process by which the Plan adopts/develops and distributes preventive health and clinical practice guidelines to assist practitioners and members in making decisions about appropriate health care for specific clinical circumstances. |
7/21/2020 | |
Proton and neutron beam therapy |
Medical necessity guidelines for proton beam and neutron beam radiation therapy |
5/19/2020 | |
Radial Head Implant |
Medical necessity guidelines for radial head implant, also known as arthroplasty |
10/1/2019 | |
Reduction mammoplasty and gynecomastia surgery |
Medical necessity guidelines for reduction mammoplasty in women and gynecomastia surgery in men |
10/1/2019 | |
Sacroiliac joint fusion |
Medical necessity guidelines for sacroiliac joint fusion |
10/1/2019 | |
Sacroiliac Joint Interventions for Pain Management |
Medical necessity criteria for sacroiliac joint interventions for pain management |
5/19/2020 | |
Sclerotherapy for Varicose Veins |
Medical necessity guidelines for sclerotherapy for treatment of vericose veins |
7/21/2020 | |
Selective Dorsal Rhizotomy |
Medical necessity criteria for Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy. |
5/19/2020 | |
Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management |
Medical necessity criteria for selective nerve root blocks and transforaminal epidural injections for pain management |
2/18/2020 | |
| CP.MP.182 (PDF) | Short Inpatient Hospital Stay | Medical necessity criteria for inpatient hospital stays of 2 days or less | 7/21/2020 |
Sickle cell disease observation |
Medical necessity criteria for observation stay for sickle cell disease |
5/19/2020 | |
Spinal Cord Stimulation |
Medical necessity guidelines for spinal cord stimulation for pain management, also known as dorsal column stimulation |
5/19/2020 | |
State specific clinical policy process |
This policy describes the process for creating, maintaining, and posting state-specific clinical policies |
2/18/2020 | |
Stereotactic Body Radiation Therapy |
Medical necessity guidelines for stereotactic body radiation therapy |
10/1/2019 | |
Tandem Transplant |
Medical necessity guidelines for tandem transplant |
10/1/2019 | |
Testing for rupture of fetal membranes |
Medical necessity guidelines for testing for rupture of fetal membranes |
10/1/2019 | |
Testing for select genitourinary conditions |
Medical necessity guidelines for various diagnostic testing methods to identify the etiology of the signs and symptoms of vaginitis |
10/1/2019 | |
Therapy Services (PT/OT/ST) |
Medical necessity guidelines for outpatient speech therapy, occupational therapy, and/or physical therapy evaluation and treatment. |
5/19/2020 | |
| CP.MP.189 (PDF) | Thymus Transplantation | Complete DiGeorge anomaly is a disorder in which a person has no thymus function. Without thymus function, bone marrow stem cells do not develop into T cells, which results in immunodeficiency. Without successful treatment, patients usually die by 2 years of age. Thymus transplantation with and without immunosuppression has resulted in the development good T cell function in complete DiGeorge anomaly subjects. | 7/21/2020 |
Thyroid hormones and insulin testing in pediatrics |
Medical necessity guidelines for thyroid hormones and insulin testing in pediatrics |
2/18/2020 | |
Total artificial heart |
Medical necessity guidelines for a total artificial heart (TAH) |
2/18/2020 | |
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition |
Medical necessity guidelines for total parenteral nutrition (TPN) and intradialytic parenteral nutrition (IDPN) |
7/21/2020 | |
Transcatheter closure of patent foramen ovale |
Medical necessity guidelines for transcatheter closure of patent foramen ovale (PFO) with the AmplatzerTM PFO Occluder. |
2/18/2020 | |
Transcranial magnetic stimulation |
This policy describes medical necessity guidelines for the use of transcranial magnetic stimulation |
10/1/2019 | |
Trigger Point Injections for Pain Management |
Medical necessity criteria for trigger point injections for pain management |
7/21/20 | |
Ultrasound in Pregnancy |
Medical necessity guidelines for ultrasound use in pregnancy. |
10/1/2019 | |
Urinary Incontinence Devices and Treatments |
Medical necessity guidelines for treatments and devices for urinary incontinence including sacral neuromodulation (sacral nerve stimulation) and urethral bulking agents |
5/19/2020 | |
Urodynamic testing |
Medical necessity guideines for urodynamic testing as part of the comprehensive evaluation of voiding dysfunction |
10/1/2019 | |
Vagus Nerve Stimulation |
Medical necessity guidelines for vagus nerve stimulation. |
10/1/2019 | |
Ventricular Assist Devices |
Medical necessity guidelines for ventricular assist devices. |
10/1/2019 | |
Ventriculectomy and cardiomyoplasty |
Medical necessity guidelines for ventriculectomy and cardiomyoplasty procedures |
2/18/2020 | |
| CP.MP.177 (PDF) | Video Electorencephalographic (VEEG) Monitoring | Medical necessity criteria for video electroencephalographic (EEG) monitoring. | 7/21/2020 |
Wheelchair seating |
Medical necessity guidelines for special wheelchair seating and cushions |
2/18/2020 | |
Wireless Motility Capsule |
Medical necessity guidelines for wireless motility capsule |
5/19/2020 |
Pharmacy Criteria
Trillium Community Health Plan’s goal is to offer the right drug coverage to our members. Trillium Oregon Health Plan (OHP) covers prescription and some over the counter drugs when they are ordered by a licensed prescriber registered with the state of Oregon to provide services to OHP members. The pharmacy program does not cover all drugs. Some drugs need prior approval and some have a limit on the amount of drug that can be given.
Clinical policies are one set of guidelines used to assist in administering health plan benefits. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information.
The Trillium Pharmacy and Therapeutics (P&T) Committee is comprised of community doctors and pharmacists. Together we work to offer drugs used to treat many conditions and illnesses. All clinical policies are reviewed annually by the Trillium P&T Committee, which meets quarterly. Approved criteria and revisions made by the P&T Committee go into effect the first day of the month the start of the following quarter. All medications newly approved by the FDA (Food and Drug Administration) require prior approval until reviewed by our P&T Committee.
All policies found in the Trillium Community Health Plan Clinical Policy Manual apply to Trillium Community Health Plan members. Policies in the Trillium Community Health Plan Clinical Policy Manual may have either a Trillium Community Health Plan or a “Centene” heading. Polices listed as being approved for the Medicaid and/or Oregon Health Plan lines of business apply to prior authorization requests for Trillium OHP members.
All prior authorization requests are subject to the Oregon Health Plan’s Prioritized List and Guideline Notes in addition to applicable clinical policy coverage guidelines. Requests for non-preferred medications not listed on Trillium OHP’s Preferred Drug List (PDL) require trial and failure of preferred options prior to approval unless submitted documentation can support the medical necessity of the non-preferred medication.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Pharmacy department.
- Compounded Medications TCHP.PHAR.18000 (PDF)
- Brand Name Override; CP.PMN.22 (PDF)
- Dose Optimization/ CP.PMN.13 (PDF)
- No Coverage Criteria-Off Label Use CP.PMN.53 (PDF)
- Quantity Limit Overrides CP.PMN.59 (PDF)
- Request for Medically Necessary Drug not on the PDL TCHP. PHAR.1905 (PDF)
- Request for Medically Necessary Drug on the PDL TCHP. PHAR.1906 (PDF)
- Supplement, Herbal and Vitamin Products TCHP.PHAR.18001 (PDF)
Anti-Inflammatory Agents
- Abatacept (Orencia); CP.PHAR.241 (PDF)
- Adalimumab (Humira), Humira Biosimilars; CP.PHAR.242 (PDF)
- Anakinra (Kineret); CP.PHAR.244 (PDF)
- Apremilast (Otezla); CP.PHAR.245 (PDF)
- Baricitinib (Olumiant); CP.PHAR.135 (PDF)
- Canakinumab (Ilaris); CP.PHAR.246 (PDF)
- Celecoxib (Celebrex); CP.PMN.122 (PDF)
- Etanercept (Enbrel); CP.PHAR.250 (PDF)
- Golimumab (Simponi, Simponi Aria); CP.PHAR.253 (PDF)
- Ibuprofen-famotidine (Duexis); CP.PMN.120 (PDF)
- Methotrexate (Otrexup, Rasuvo, Xatmep); CP.PHAR.134 (PDF)
- Naproxen and esomeprazole magnesium (Vimovo); CP.PMN.117 (PDF)
- Rilonacept (Arcalyst); CP.PHAR.266 (PDF)
- Sarilumab (Kevzara); CP.PHAR.346 (PDF)
- Tocilizumab (Actemra); CP.PHAR.263 (PDF)
- Tofacitinib (Xeljanz, Xeljanz XR); CP.PHAR.267 (PDF)
- Upadacitinib (Rinvoq); CP.PHAR.443 (PDF)
Musculoskeletal Therapy Agents
Opioid Agents
- Acetaminophen/codeine (Tylenol no. 3, Tylenol no. 4); CP.PMN.97 (PDF)
- Age Limit Override (Codeine, Tramadol, Hydrocodone); CP.PMN.138 (PDF)
- Buprenorphine (Probuphine, Sublocade); CP.PHAR.289 (PDF)
- Buprenorphine (Subutex); CP.PMN.82 (PDF)
- Buprenorphine-Naloxone (Suboxone, Bunavail, Zubsolv); TCHP.PHAR.1903 (PDF)
- Codeine Sulfate; CP.PMN.97 (PDF)
- Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys); CP.PMN.127 (PDF)
- Fentanyl Patch (Duragesic Patch); CP.PMN.97 (PDF)
- Hydrocodone Bitartrate/Acetaminophen elixir (Hycet); CP.PMN.97 (PDF)
- Hydrocodone Bitartrate/Acetaminophen (Lorcet HD, Lorcet, Lorcet Plus, Lortab, Norco, Verdrocet, Xodol); CP.PMN.97 (PDF)
- Hydromorphone (Dilaudid, Exalgo); CP.PMN.97 (PDF)
- Meperidine (Demerol); CP.PMN.97 (PDF)
- Methadone (Dolophine); TCHP.PHAR.1901 (PDF)
- Morphine sulfate ER (MS Contin, Kadian); CP.PMN.97 (PDF)
- Morphine Sulfate tablets and oral solution; CP.PMN.97 (PDF)
- Oxycodone CR (Oxycontin, Xtampza); CP.PMN.97 (PDF)
- Oxycodone IR (Oxy IR, Oxaydo, Roxicodone, Roxybond); CP.PMN.97 (PDF)
- Oxycodone oral solution; CP.PMN.97 (PDF)
- Oxycodone/Acetaminophen (Endocet, Percocet, Roxicet); CP.PMN.97 (PDF)
- Oxymorphone (Opana); CP.PMN.97 (PDF)
- Tramadol (Ultram); CP.PMN.97 (PDF)
Amebicides
Amnoglycosides
- Amikacin (Arikayce); CP.PHAR.401 (PDF)
- Tobramycin ( Kitabis pack, TOBI podhale, Bethkis, TOBI); CP.PHAR.211 (PDF)
Antifungals
- Butenafine (Mentax); TCHP.PHAR.1814 (PDF)
- Ciclopirox (Loprox, Ciclodan, Penlac); TCHP.PHAR.1814 (PDF)
- Clotrimazole; TCHP.PHAR.1814 (PDF)
- Econazole nitrate (Ecoza); TCHP.PHAR.1814 (PDF)
- Efinaconazole (Jublia); TCHP.PHAR.1814 (PDF)
- Fluconazole (Diflucan); TCHP.PHAR.1814 (PDF)
- Flucytosine (Ancobon); TCHP.PHAR.1814 (PDF)
- Griseofulvin (Grifulvin, Gris-Peg); TCHP.PHAR.1814 (PDF)
- Isavuconazonium sulfate (Cresemba); TCHP.PHAR.1814 (PDF)
- Itraconazole (Sporanox, Onmel); TCHP.PHAR.1814 (PDF)
- Ketoconazole (Extina, Nizoral, Xolegel); TCHP.PHAR.1814 (PDF)
- Luliconazole (Luzu); TCHP.PHAR.1814 (PDF)
- Miconazole (Oravig); TCHP.PHAR.1814 (PDF)
- Miconazole Nitrate; TCHP.PHAR.1814 (PDF)
- Naftifine (Naftin); TCHP.PHAR.1814 (PDF)
- Nystatin (Nyamyc, Nyata, Nystop); TCHP.PHAR.1814 (PDF)
- Nystatin/Triamcinolone (Myconel); TCHP.PHAR.1814 (PDF)
- Oxiconazole (Oxistat); TCHP.PHAR.1814 (PDF)
- Posaconazole (Noxafil); TCHP.PHAR.1814 (PDF)
- Sertaconazole (Ertaczo); TCHP.PHAR.1814 (PDF)
- Sulconazole (Exelderm); TCHP.PHAR.1814 (PDF)
- Tavaborole (Kerydin); TCHP.PHAR.1814 (PDF)
- Terbinafine; TCHP.PHAR.1814 (PDF)
- Tolnaftate; TCHP.PHAR.1814 (PDF)
- Voriconazole (Vfend); TCHP.PHAR.1814 (PDF)
Antihelmintics
- Benznidazole; CP.PMN.90 (PDF)
- Moxidectin; CP.PMN.162 (PDF)
- Triclabendazole (Egaten); CP.PMN.207 (PDF)
Anti-Infective Agents - Misc.
- Aztreonam (Cayston); CP.PHAR.209 (PDF)
- Chloramphenicol; CP.PHAR.388 (PDF)
- Daptomycin (Cubicin, Cubicin RF); CP.PHAR.351 (PDF)
- Lefamulin (Xenleta); CP.PMN.219 (PDF)
- Linezolid (Zyvox); CP.PMN.27 (PDF)
- Rifamycin (Aemcolo); CP.PMN.196 (PDF)
- Rifaximin (Xifaxan); CP.PMN.47 (PDF)
- Tedizolid (Sivextro); CP.PMN.62 (PDF)
Antimalarials
Antimycobacterial Agents
- Bedaquiline (Sirturo); CP.PMN.212 (PDF)
- Rifapentine (Priftin); CP.PMN.05 (PDF)
- Pretomanid; CP.PMN.222 (PDF)
- Rifabutin (Mycobutin); CP.PMN.223 (PDF)
- Rifabutin-Omeprazole-Amoxicillin (Talicia); CP.PMN.223 (PDF)
Antivirals
- Acyclovir buccal tab (Sitavig); CP.PMN.210 (PDF)
- Acyclovir ophthalmic ointment (Avaclyr); CP.PMN.210 (PDF)
- Adefovir (Hepsera); CP.PHAR.142 (PDF)
- Bolaxavir marboxil (Xofluza); CP.PMN.185 (PDF)
- Daclatasvir (Daklinza); TCHP.PHAR.1801 (PDF)
- Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Vikira XR, Viekira Pak); TCHP.PHAR.1801 (PDF)
- Elbasvir-Grazoprevir (Zepatier); TCHP.PHAR.1801 (PDF)
- Enfuvirtide (Fuzeon); CP.PHAR.41 (PDF)
- Glecaprevir/Pibrentasvir (Mavyret); TCHP.PHAR.1801 (PDF)
- Ibalizumab-uiyk (Trogarzo); CP. PHAR.378 (PDF)
- Ledipasvir/Sofosbuvir (Harvoni); TCHP.PHAR.1801 (PDF)
- Letermovir (Prevymis); CP.PHAR.367 (PDF)
- Ombitasvir/Paritaprevir/Ritonavir (Technivie); TCHP.PHAR.1801 (PDF)
- Peginterferon Alfa-2a (Pegasys); CP.PHAR.89 (PDF)
- Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere); CP.PHAR.141 (PDF)
- Simeprevir (Olysio); TCHP.PHAR.1801 (PDF)
- Sofosbuvir (Sovaldi); TCHP.PHAR.1801 (PDF)
- Sofosbuvir/Velpatasvir (Epclusa); TCHP.PHAR.1801 (PDF)
- Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi); TCHP.PHAR.1801 (PDF)
Fluoroqunolones
Passive Immunizing and Treatment Agents
- Bezlotoxumab (Zinplava); CP.PHAR.300 (PDF)
- Cytomegalovirus Immune Globulin (CytoGam); CP.PHAR.277 (PDF)
- Immune Globulin (Gammagard S/D; Gammaked; Gammaplex; Gamunex-C; Hizentra; HyQvia; Octagam; Privigen); CP.PHAR.103 (PDF)
- Palivizumab (Synagis); TCHP.PHAR.1811 (PDF)
Tetracyclines
Alkylating Agents
- Bendamustine (Bendeka, Treanda); CP.PHAR.307 (PDF)
- Temozolomide (Temodar); CP.PHAR.77 (PDF)
- Trabectedin (Yondelis); CP.PHAR.204 (PDF)
Antimetabolites
- Azacitidine (Vidaza); CP.PHAR.387 (PDF)
- Capecitabine (Xeloda); CP.PHAR.60 (PDF)
- Mercaptopurine (Purixan); CP.PHAR.447 (PDF)
- Pemetrexed (Alimta); CP.PHAR.368 (PDF)
- Pralatrexate (Folotyn); CP.PHAR.313 (PDF)
- Thioguanine (Tabloid); CP.PHAR.437 (PDF)
Antineoplastic - Angiogenesis Inhibitors
- Bevacizumab (Avastin, Mvasi, Zirabev); CP.PHAR.93 (PDF)
- Ramucirumab (Cyramza); CP.PHAR.119 (PDF)
- Ziv-aflibercept (Zaltrap); CP.PHAR.325 (PDF)
Antineoplastic - Antibodies
- Ado-Trastuzumab Emtansine (Kadcyla); CP.PHAR.229 (PDF)
- Atezolizumab (Tecentriq); CP.PHAR.235 (PDF)
- Avapritinib (Ayvakit); CP.PHAR.454 (PDF)
- Avelumab (Bavencio); CP.PHAR.333 (PDF)
- Belantamab mafodotin; CP.PHAR.469 (PDF)
- Blinatumomab (Blincyto); CP.PHAR.312 (PDF)
- Brentuximab Vedotin (Adcetris); CP.PHAR.303 (PDF)
- Cemiplimab-rwlc (Libtayo); CP.PHAR.397 (PDF)
- Cetuximab (Erbitux); CP.PHAR.317 (PDF)
- Daratumumab (Darzalex); CP.PHAR.310 (PDF)
- Durvalumab (Imfinzi); CP.PHAR.339 (PDF)
- Elotuzumab (Empliciti); CP.PHAR.308 (PDF)
- Enfortumab Vedotin-ejfv (Padcev); CP.PHAR.455 (PDF)
- Gemtuzumab ozogamicin (Mylotarg); CP.PHAR.358 (PDF)
- Inotuzumab ozogamicin (Besponsa); CP.PHAR.359 (PDF)
- Ipilimumab (Yervoy); CP.PHAR.319 (PDF)
- Mogamulizumab-kpkc (Poteligeo); CP.PHAR.139 (PDF)
- Moxetumomab pasudotox-tdfk (Lumoxiti); CP.PHAR.398 (PDF)
- Necitumumab (Portrazza); CP.PHAR.320 (PDF)
- Nivolumab (Opdivo); CP.PHAR.121 (PDF)
- Obinutuzumab (Gazyva); CP.PHAR.305 (PDF)
- Ofatumumab (Arzerra); CP.PHAR.306 (PDF)
- Olaratumab (Lartruvo); CP.PHAR.326 (PDF)
- Panitumumab (Vectibix); CP.PHAR.321 (PDF)
- Pembrolizumab (Keytruda); CP.PHAR.322 (PDF)
- Pertuzumab (Perjeta); CP.PHAR.227 (PDF)
- Rituximab (Rituxan, Ruxience, Truxima, Rituxan Hycela); CP.PHAR.260 (PDF)
- Sacituzumab govitecan (Trodelvy); CP.PHAR.475 (PDF)
- Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri); CP.PHAR.228 (PDF)
- Zanubrutinib (Brukinsa); CP.PHAR.467 (PDF)
Antineoplastic - BCL-2 Inhibitors
Antineoplastic - Cellular Immunotherapy
- Axicabtagene ciloleucel (Yescarta); CP.PHAR.362
- KTE-X19; CP.PHAR.472 (PDF)
- Sipuleucel-T (Provenge); CP.PHAR.120
- Tisagenlecleucel (Kymriah); CP.PHAR.361
Antineoplastic - Hedgehog Pathway Inhibitors
- Glasdegib (Daurismo); CP.PHAR.413 (PDF) effective 7/1/2019
- Sonidegib (Odomzo); CP.PHAR.272 (PDF)
- Vismodegib (Erivedge); CP.PHAR.273 (PDF)
Antineoplastic - Hormonal and Related Agents
- Abiraterone (Zytiga, Yonsa); CP.PHAR.84 (PDF)
- Apalutamide (Erleada); CP.PHAR.376 (PDF)
- Darolutamide (Nubeqa); CP.PHAR.435 (PDF)
- Degarelix Acetate (Firmagon); CP.PHAR.170 (PDF)
- Enzalutamide (Xtandi); CP.PHAR.106 (PDF)
- Fulvestrant (Faslodex Injection); CP.PHAR.424 (PDF)
- Goserelin acetate (Zoladex); CP.PHAR.171 (PDF)
- Histrelin acetate (Vantas, Supprelin LA); CP.PHAR.172 (PDF)
- Leuprolide acetate (Eligard, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped); CP.PHAR.173 (PDF)
- Toremifene (Fareston); CP.PMN.126 (PDF)
- Triptorelin pamoate (Trelstar, Triptodur); CP.PHAR.175 (PDF)
Antineoplastic - Immunomodulators
Antineoplastic Antibiotics
Antineoplastic Combinations
- Daunorubicin/cytarabine (Vyxeos); CP.PHAR.352 (PDF)
- Rituximab/Hyaluronidase (Rituxan Hycela); CP.PHAR.260 (PDF)
- Trifluridine/Tipiracil (Lonsurf); CP.PHAR.383 (PDF)
Antineoplastic Enzyme Inhibitors
- Abemaciclib (Verzenio); CP.PHAR.355 (PDF)
- Acalabrutinib (Calquence); CP.PHAR.366 (PDF)
- Afatinib (Gilotrif); CP.PHAR.298 (PDF)
- Alectinib (Alecensa); CP.PHAR.369 (PDF)
- Axitinib (Inlyta); CP.PHAR.100 (PDF)
- Belinostat (Beleodaq); CP.PHAR.311 (PDF)
- Binimetinib (Mektovi); CP.PHAR.50 (PDF)
- Bortezomib (Velcade); CP.PHAR.410 (PDF)
- Brigatinib (Alunbrig); CP.PHAR.342 (PDF)
- Bosutinib (Bosulif); CP.PHAR.105 (PDF)
- Cabozantinib (Cabometyx, Cometriq); CP.PHAR.111 (PDF)
- Carfilzomib (Kyprolis); CP.PHAR.309 (PDF)
- Ceritinib (Zykadia); CP.PHAR.349 (PDF)
- Cobimetinib (Cotellic); CP.PHAR.380 (PDF)
- Copanlisib (Aliqopa); CP.PHAR.357 (PDF)
- Crizotinib (Xalkori); CP.PHAR.90 (PDF)
- Dabrafenib (Tafinlar); CP.PHAR.239 (PDF)
- Dacomitinib (Vizimpro); CP.PHAR.399 (PDF)
- Dasatinib (Sprycel); CP.PHAR.72 (PDF)
- Duvelisib (Copiktra); CP.PHAR.400 (PDF)
- Enasidenib (Idhifa); CP.PHAR.363 (PDF)
- Encorafenib (Braftovi); CP.PHAR.127 (PDF)
- Entrectinib (Rozlytrek); CP.PHAR.441 (PDF)
- Erdafitinib (Balversa); CP.PHAR.423 (PDF)
- Erlotinib (Tarceva); CP.PHAR.74 (PDF)
- Everolimus (Afinitor, Afinitor Disperz, Zortress); CP.PHAR.63 (PDF)
- Fedratinib (Inrebic); CP.PHAR.442 (PDF)
- Gefitinib (Iressa); CP.PHAR.68 (PDF)
- Gilteritinib (Xospata); CP.PHAR.412 (PDF)
- Larotrectinib (Vitrakvi); CP.PHAR.414 (PDF)
- Lorlatinib (Lorbrena); CP.PHAR.406 (PDF)
- Ibrutinib (Imbruvica); CP.PHAR.126 (PDF)
- Idelalisib (Zydelig); CP.PHAR.133 (PDF)
- Imatinib mesylate (Gleevec); CP.PHAR.65 (PDF)
- Ivosidenib (Tibsovo); CP.PHAR.137 (PDF)
- Ixazomib (Ninlaro); CP.PHAR.302 (PDF)
- Lapatinib (Tykerb); CP.PHAR.79 (PDF)
- Larotrectinib (Vitrakvi); CP.PHAR.414 (PDF)
- Lenvatinib (Lenvima); CP.PHAR.138 (PDF)
- Midostaurin (Rydapt); CP.PHAR.344 (PDF)
- Neratinib (Nerlynx); CP.PHAR.365 (PDF)
- Nilotinib (Tasigna); CP.PHAR.76 (PDF)
- Niraparib (Zejula); CP.PHAR.408 (PDF)
- Olaparib (Lynparza); CP.PHAR.360 (PDF)
- Osimertinib (Tagrisso); CP.PHAR.294 (PDF)
- Palbociclib (Ibrance); CP.PHAR.125 (PDF)
- Panobinostat (Farydak); CP.PHAR.382 (PDF)
- Pexidartinib (Turalio); CP.PHAR.436 (PDF)
- Ponatinib (Iclusig); CP.PHAR.112 (PDF)
- Pazopanib (Votrient); CP.PHAR.81 (PDF)
- Regorafenib (Stivarga); CP.PHAR.107 (PDF)
- Ribociclib (Kisqali); CP.PHAR.334 (PDF)
- Ribociclib-Letrozole (Kisqali Femara); CP.PHAR.334 (PDF)
- Romidepsin (Istodax); CP.PHAR.314 (PDF)
- Rucaparib (Rubraca); CP.PHAR.350 (PDF)
- Ruxolitinib (Jakafi); CP.PHAR.98 (PDF)
- Selpercatinib (Retevmo); CP.PHAR.478 (PDF)
- Selumetinib (Koselugo); CP.PHAR.464 (PDF)
- Sorafenib (Nexavar); CP.PHAR.69 (PDF)
- Sunitinib (Sutent); CP.PHAR.73 (PDF)
- Talazoparib (Talzenna); CP.PHAR.409 (PDF)
- Tazemetostat (Tazverik); CP.PHAR.452 (PDF)
- Temsirolimus (Torisel); CP.PHAR.324 (PDF)
- Trametinib (Mekinist); CP.PHAR.240 (PDF)
- Vandetanib (Caprelsa); CP.PHAR.80 (PDF)
- Vemurafenib (Zelboraf); CP.PHAR.91 (PDF)
- Vorinostat (Zolinza); CP.PHAR.83 (PDF)
Antineoplastic Enzymes
Antineoplastic Radiopharmaceuticals
- Lobenguane I 131 (Azedra); CP.PHAR.459 (PDF)
- Lutetium Lu 177 dotatate (Lutathera); CP.PHAR.384 (PDF)
Antineoplastics Misc.
- Bexarotene (Targretin); CP.PHAR.75 (PDF)
- Interferon Gamma- 1b (Actimmune); CP.PHAR.52 (PDF)
- Nadofaragene firadenovec (Instiladrin); CP.PHAR.461 (PDF)
- Omacetaxine (Synribo); CP.PHAR.108 (PDF)
- Peginterferon Alfa-2b (PegIntron, Sylatron); CP.PHAR.89 (PDF)
Chemotherapy Rescue/Antidote Agents
- Dexrazoxane (Zinecard Totect); CP.PHAR.418 (PDF)
- Levoleucovorin (Fusilev); CP.PHAR.151 (PDF)
- Leucovorin Injection; CP.PHAR.393 (PDF)
Mitotic Inhibitors
- Cabazitaxel (Jevtana); CP.PHAR.316 (PDF)
- Eribulin Mesylate (Halaven); CP.PHAR.318 (PDF)
- Paclitaxel, protein-bound (Abraxane); CP.PHAR.176 (PDF)
- Vincristine sulfate liposome injection (Marqibo); CP.PHAR.315 (PDF)
Topoisomerase I Inhibitors
Antianginal Agents
Antihyperlipidemics
- Alirocumab (Praluent); CP.PHAR.124 (PDF)
- Evolocumab (Repatha); CP.PHAR.123 (PDF)
- Ezetimibe-Simvastatin (Vytorin); CP.PMN.77 (PDF)
- Ezetimibe (Zetia); CP.PMN.78 (PDF)
- Icosapent ethyl (Vascepa); CP.PMN.187 (PDF)
- Lomitapide (Juxtapid); CP.PHAR.283 (PDF)
- Mipomersen (Kynamro); CP.PHAR.284 (PDF)
- Omega-3-Acid Ethyl Esters (Lovaza); CP.PMN.52 (PDF)
- Rosuvastatin (Crestor); TCHP.PHAR.18005 (PDF)
Antihypertensives
- ACEI and ARB Duplicate Therapy; CP.PMN.61 (PDF) effective 7/1/2019
- Mecamylamine (Vecamyl); CP.PMN.136 (PDF)
- Perindopril-amlodipine (Prestalia); CP.PMN.174 (PDF)
Beta Blockers
Cardiovascular Agents - Misc.
- Ambrisentan (Letairis); CP.PHAR.190 (PDF)
- Amlodipine-atorvastatin (Caduet); CP.PMN.176 (PDF)
- Bosentan (Tracleer); CP.PHAR.191 (PDF)
- Epoprostenol (Flolan, Veletri); CP.PHAR.192 (PDF)
- Iloprost (Ventavis); CP.PHAR.193 (PDF)
- Ivabradine (Corlanor); CP.PMN.70 (PDF)
- Macitentan (Opsumit); CP.PHAR.194 (PDF)
- Riociguat (Adempas); CP.PHAR.195 (PDF)
- Sacubitril/valsartan (Entresto); CP.PMN.67 (PDF)
- Selexipag (Uptravi); CP.PHAR.196 (PDF)
- Sildenafil (Revatio); CP.PHAR.197 (PDF)
- Tadalafil (Adcirca, Alyq); CP.PHAR.198 (PDF)
- Tafamidis (Vyndaqel, Vyndamax); CP.PHAR.432 (PDF)
- Treprostinil (Orenitram, Remodulin, Tyvaso); CP.PHAR.199 (PDF)
Vasopressors
- Acitretin (Soratane); TCHP.PHAR.1802 (PDF)
- Adapalene (Differin, Plixda); TCHP.PHAR.1902 (PDF)
- Adapalene - Benzoyl peroxide (Epiduo, Epiduo Fote); TCHP.PHAR.1902 (PDF)
- Afamelanotide (Scenesse); CP.PHAR.444 (PDF)
- Azelaic acid (Azelex, Finacea, Finevin); TCHP.PHAR.1902 (PDF)
- Becaplermin (Regranex); CP.PMN.21 (PDF)
- Benzoyle peroxide (Benzac); TCHP.PHAR.1902 (PDF)
- Benzyl alcohol (Ulesfia); CP.PMN.202 (PDF)
- Betamethasone dipropionate (Sernivo); CP.PMN.182 (PDF)
- Brodalumab (Siliq); CP.PHAR.375 (PDF)
- Calcipotriene/Betamethasone Dipropionate Foam (Enstilar); CP.PMN.181 (PDF)
- Clindamycin phosphate (Cleocin, Clindacin); TCHP.PHAR.1902 (PDF)
- Clindamycin phosphate-Benzoyle peroxide (Benzaclin); TCHP.PHAR.1902 (PDF)
- Clindamycin phosphate-Tretinoin (Ziana); TCHP.PHAR.1902 (PDF)
- Crisaborole (Eucrisa); TCHP.PHAR.18004 (PDF)
- Dapsone (Aczone); TCHP.PHAR.1902 (PDF)
- Doxycycline Hyclate (Acticlate, Doryx); TCHP.PHAR.1902 (PDF)
- Doxycycline monohydrate (Oracea); TCHP.PHAR.1902 (PDF)
- Dupilumab (Dupixent); CP.PHAR.336 (PDF)
- Erythromycin; TCHP.PHAR.1902 (PDF)
- Erythromycin-Benzoyl peroxide (Benzamycin); TCHP.PHAR.1902 (PDF)
- Fluorouracil Cream (Tolak); CP.PMN.165 (PDF)
- Glycopyrronium (Qbrexza); CP.PMN.177 (PDF)
- Guselkumab (Tremfya); CP.PHAR.364 (PDF)
- Halobetasol Propionate Lotion (Ultravate); CP.PMN.180 (PDF)
- Halobetasol-Tazarotene (Duobrii); CP.PMN.208 (PDF)
- Isotretinoin (Claravi, Absorica, Myorisan, Zenatane); TCHP.PHAR.1902 (PDF)
- Ixekizumab (Taltz); CP.PHAR.257 (PDF)
- Lidocaine-prilocaine (EMLA); TCHP.PHAR.1808 (PDF)
- Lidocaine Transdermal (Lidoderm); TCHP.PHAR.1805 (PDF)
- Lindane Shampoo; CP.PMN.09 (PDF)
- Mechlorethamine (Valchlor); CP.PHAR.381 (PDF)
- Neomycin/Fluocinolone Cream (Neo-Synalar); CP.PMN.167 (PDF)
- Ozenoxacin (Xepi); CP.PMN.119 (PDF)
- Pimecrolimus (Elidel); TCHP.PHAR.18004 (PDF)
- Risankizumab-rzaa (Skyrizi); CP.PHAR.426 (PDF)
- Secukinumab (Cosentyx); CP.PHAR.261 (PDF)
- Tacrolimus (Protopic); TCHP.PHAR.18004 (PDF)
- Tazarotene (Tazorac); TCHP.PHAR.18004 (PDF)
- Tildrakizumab-asmn (Ilumya); CP.PHAR.386 (PDF)
- Tretinoin (Retin-A); TCHP.PHAR.1902 (PDF)
- Trifarotene (Aklief); CP.PMN.225 (PDF)
- Ustekinumab (Stelara); CP.PHAR.264 (PDF)
Androgen
Antidiabetics
- Albiglutide (Tanzeum); TCHP.PHAR.2003 (PDF)
- Alogliptin (Nesina); TCHP.PHAR.2001 (PDF)
- Alogliptin/metformin (Kazano); TCHP.PHAR.2001 (PDF)
- Alogliptin/pioglitazone (Oseni); TCHP.PHAR.2001 (PDF)
- Canagliflozin (Invokana); TCHP.PHAR.2002 (PDF)
- Canagliflozin/metformin (Invokamet, Invokamet XR); TCHP.PHAR.2002 (PDF)
- Dapagliflozin propanediol (Farxiga); TCHP.PHAR.2002 (PDF)
- Dapagliflozin/metformin (Xigduo XR); TCHP.PHAR.2002 (PDF)
- Dapagliflozin/saxagliptin (Qtern); TCHP.PHAR.2002 (PDF)
- Dulaglutide (Trulicity); TCHP.PHAR.2003 (PDF)
- Empagliflozin (Jardiance); TCHP.PHAR.2002 (PDF)
- Empagliflozin/linagliptin (Glyxambi); TCHP.PHAR.2002 (PDF)
- Empagliflozin/metformin (Synjardy, Synjardy XR); TCHP.PHAR.2002 (PDF)
- Ertugliflozin (Steglatro); TCHP.PHAR.2002 (PDF)
- Exenatide ER (Bydureon, Bydureon BCise); TCHP.PHAR.2003 (PDF)
- Exenatide IR (Byetta); TCHP.PHAR.2003 (PDF)
- Linagliptin (Tradjenta); TCHP.PHAR.2001 (PDF)
- Linagliptin/metformin (Jentadueto, Jentadueto XR); TCHP.PHAR.2001 (PDF)
- Liraglutide (Victoza); TCHP.PHAR.2003 (PDF)
- Lixisenatide (Adlyxin); TCHP.PHAR.2003 (PDF)
- Lixisenatide/insulin glargine (Soliqua); TCHP.PHAR.2003 (PDF)
- Metformin ER (Glumetza Fortamet); CP.PMN.72 (PDF)
- Pramlintide (Symlin); CP.PMN.129 (PDF)
- Saxagliptin (Onglyza); TCHP.PHAR.2001 (PDF)
- Saxagliptin/metformin (Kombiglyze XR); TCHP.PHAR.2001 (PDF)
- Semaglutide (Ozempic); TCHP.PHAR.2003 (PDF)
- Sitagliptin (Januvia); TCHP.PHAR.2001 (PDF)
- Sitagliptin/metformin (Janumet, Janumet XR); TCHP.PHAR.2001 (PDF)
Bone Density Regulators
- Abaloparatide (Tymlos); CP.PHAR.345 (PDF)
- Denosumab (Prolia, Xgeva); CP.PHAR.58 (PDF)
- Etidronate (Didronel); CP.PMN.94 (PDF)
- Ibandronate injection (Boniva); CP.PHAR.189 (PDF)
- Ibandronate oral (Boniva); CP.PMN.96 (PDF)
- Parathyroid hormone (Natpara); CP.PHAR.282 (PDF)
- Risedronate (Actonel, Atelvia); CP.PMN.100 (PDF)
- Romosozumab-aqqg (Evenity); CP.PHAR.428 (PDF)
- Teriparatide (Forteo); CP.PHAR.188 (PDF)
- Zoledronic Acid (Reclast, Zometa); CP.PHAR.59 (PDF)
Corticosteroids
Corticotropin
Gender Dysphoria Treatment Agents
- Estradiol (Alora, Climara, Divigel, Dotti, Elestrin, Estrace, EstroGel, Evamist, Gynodiol, Imvexxy, Menostar, Minivelle, Vivelle-Dot, Yuvafem); TCHP.PHAR.1907 (PDF)
- Goserelin (Zoladex); TCHP.PHAR.1907 (PDF)
- Histrelin Acetate (Supprelin LA, Vantas); TCHP.PHAR.1907 (PDF)
- Leuprolide Acetate (Eligard, Lupron Depot, Lupron Depot-Ped); TCHP.PHAR.1907 (PDF)
- Nafarelin Acetate (Synarel); TCHP.PHAR.1907 (PDF)
- Testosterone (Androderm, Androge, Aveed, Axiron, Delatestryl, Depo-Testosterone, Fortesta, Natesto, Striant, Testim, Testopel, Vogelxo, Xyosted); TCHP.PHAR.1907 (PDF)
- Triptorelin Pamoate (Trelstar, Triptodur); TCHP.PHAR.1907 (PDF)
GNRH/LHRH Antagonists
Growth Hormone Receptor Antagonists
Growth Hormones
Insulin-Like Growth Factors
- Lanreotide (Somatuline Depot); CP.PHAR.391 (PDF)
- Mecasermin (Increlex); CP.PHAR.150 (PDF)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot); CP.PHAR.40 (PDF)
- Pasireotide (Signifor LAR); CP.PHAR.332 (PDF)
- Teprotumumab (Tepezza); CP.PHAR.465 (PDF)
LHRH/GNRH Agonist Analog Pituitary Suppressants
Metabolic Modifiers
- Agalsidase beta (Fabrazyme); CP.PHAR.158 (PDF)
- Alglucosidase alfa (Lumizyme); CP.PHAR.160 (PDF)
- Asfotase alfa (Strensiq); CP.PHAR.328 (PDF)
- Betaine (Cystadane); CP.PHAR.143 (PDF)
- Burosumab-twza (Crysvita); CP.PHAR.11 (PDF)
- Calcifediol (Rayaldee); CP.PMN.76 (PDF)
- Carglumic acid (Carbaglu); CP.PHAR.206 (PDF)
- Cerliponase alfa (Brineura); CP.PHAR.338 (PDF)
- Cinacalcet (Sensipar); CP.PHAR.61 (PDF)
- Elapegademase-lvlr (Revcovi); CP.PHAR.419 (PDF)
- Elosulfase alfa (Vimizim); CP.PHAR.162 (PDF)
- Etelcalcetide (Parsabiv); CP.PHAR.379 (PDF)
- Galsulfase (Naglazyme); CP.PHAR.161 (PDF)
- Glycerol phenylbutyrate (Ravicti); CP.PHAR.207 (PDF)
- Idursulfase (Elaprase); CP.PHAR.156 (PDF)
- Laronidase (Aldurazyme); CP.PHAR.152 (PDF)
- Metreleptin (Myalept); CP.PHAR.425 (PDF)
- Migalastat (Galafold); CP.PHAR.394 (PDF)
- Nitisinone (Orfadin, Nityr); CP.PHAR.132 (PDF)
- Paricalcitol Injection (Zemplar); CP.PHAR.270 (PDF)
- Pegvaliase-pqpz (Palynziq); CP.PHAR.140 (PDF)
- Sapropterin (Kuvan); CP.PHAR.43 (PDF)
- Sebelipase alfa (Kanuma); CP.PHAR.159 (PDF)
- Sodium phenylbutyrate (Buphenyl); CP.PHAR.208 (PDF)
- Vestronidase alfa-vjbk (Mepsevii); CP.PHAR.374 (PDF)
Miscellaneous Endocrine agents
Posterior Pituitary Hormones
Progesterone Receptor Antagonists
Progestins and Combined Contraceptives
- Hydroxyprogesterone caproate (Makena); CP.PHAR.14 (PDF)
- Megestrol Acetate Oral Suspension (Megace ES); CP.PMN.179 (PDF)
- Segesterone-Ethinyl Estradiol (Annovera); CP.PMN.190 (PDF)
Somatostatic Agents
- Lanreotide (Somatuline Depot); CP.PHAR.391
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot); CP.PHAR.40
- Pasireotide (Signifor LAR); CP.PHAR.332
Vasopressin Receptor Antagonists
Antiemetics
- Aprepitant (Emend); CP.PMN.19 (PDF)
- Dolasetron (Anzemet); CP.PMN.141 (PDF)
- Dronabinol (Marinol, Syndros); CP.PMN.159 (PDF)
- Granisetron (Kytril, Sancuso, Sustol); CP.PMN.74 (PDF)
- Nabilone (Cesamet); CP.PMN.160 (PDF)
- Netupitant/palonosetron (Akynzeo); CP.PMN.158 (PDF)
- Ondansetron (Zuplenz); CP.PMN.45 (PDF)
- Rolapitant (Varubi); CP.PMN.102 (PDF)
Digestive Aids
Gastrointestinal Agents - Misc.
- Alosetron (Lotronex); TCHP.PHAR.185 (PDF)
- Alvimopan (Entereg); TCHP.PHAR.185 (PDF)
- Certolizumab (Cimzia); CP.PHAR.247 (PDF)
- Cholic Acid (Cholbam); CP.PHAR.390 (PDF)
- Dalfampridine (Ampyra); CP.PHAR.248 (PDF)
- Eluxadoline (Viberzi); TCHP.PHAR.185 (PDF)
- Ferric citrate (Auryxia); CP.PMN.04 (PDF)
- Infliximab (Remicade, Inflectra, Renflexis); CP.PHAR.254 (PDF)
- Lanthanum carbonate (Fosrenol); CP.PMN.04 (PDF)
- Linaclotide (Linzess); TCHP.PHAR.185 (PDF)
- Lubiprostone (Amitiza); TCHP.PHAR.185 (PDF)
- Methylnaltrexone (Relistor); TCHP.PHAR.185 (PDF)
- Naldemedine (Symproic); TCHP.PHAR.185 (PDF)
- Naloxegol (Movantik); TCHP.PHAR.185 (PDF)
- Obeticholic acid (Ocaliva); CP.PHAR.287 (PDF)
- Plecanatide (Trulance); TCHP.PHAR.185 (PDF)
- Sevelamer carbonate (Renvela); CP.PMN.04 (PDF)
- Sevelamer hydrochloride (Renagel); CP.PMN.04 (PDF)
- Sucroferric oxyhydroxide (Velphoro); CP.PMN.04 (PDF)
- Teduglutide (Gattex); CP.PHAR.114 (PDF)
- Tegaserod (Zelnorm); TCHP.PHAR.185 (PDF)
- Telotristat ethyl (Xermelo); CP.PHAR.337 (PDF)
- Tenapanor (Ibsrela); TCHP.PHAR.185 (PDF)
- Vedolizumab (Entyvio); CP.PHAR.265 (PDF)
Genitourinary Agents - Misc.
- Cysteamine oral bitartrate (Cystagon, Procysbi); CP.PHAR.155 (PDF)
- Dutasteride (Avodart); CP.PMN.128 (PDF)
- Dutasteride/tamsulosin (Jalyn); CP.PMN.128 (PDF)
- Tadalafil (Cialis); CP.PMN.132 (PDF)
Gout Agents
- Colchcine (Colcrys, Mitigare); CP.PMN.123 (PDF)
- Febuxostat (Uloric); CP.PMN.57 (PDF)
- Lesinurad (Zurampic); CP.PMN.150 (PDF)
- Lesinurad-allopurinol (Duzallo); CP.PMN.150 (PDF)
- Pegloticase (Krystexxa); CP.PHAR.115 (PDF)
Urinary Antispasmodics
- Fesoterodine (Toviaz); CP.PMN.198 (PDF)
- Mirabegron (Myrbetriq); CP.PMN.198 (PDF)
- Solifenacin (Vesicare); CP.PMN.198 (PDF)
Vaginal Products
Anticoagulants
- Dalteparin (Fragmin); CP.PHAR.225 (PDF)
- Dabigatran (Pradaxa);CP.PMN.49 (PDF)
- Edoxaban (Savaysa); CP.PMN.227 (PDF)
- Enoxaparin (Lovenox); CP.PHAR.224 (PDF)
- Fondaparinux (Arixtra); CP.PHAR.226 (PDF)
Hematological Agents - Misc.
- Anti-inhibitor Coagulant Complex (Feiba); CP.PHAR.217 (PDF)
- Aspirin-dipyridamole (Aggrenox); CP.PMN.20 (PDF)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest); CP.PHAR.202 (PDF)
- Caplacizumab-yhdp (Cablivi); CP.PHAR.416 (PDF)
- Ecallantide (Kalbitor); CP.PHAR.177 (PDF)
- Eculizumab (Soliris); CP.PHAR.97 (PDF)
- Emicizumab-kxwh (Hemlibra); CP.PHAR.370 (PDF)
- Factor VIII (Advate, Adynovate, Afstyla, Eloctate, Helixate, Hemofil M, Jivi, Koate, Kogenate, Kovaltry, NovoEight, Nuwiq, Monoclate-P, Obizur, Recombinate, Re-Facto, Xyntha); CP.PHAR.215 (PDF)
- Factor VIII-von Willebrand_Human (Includes: Alphanate, Humate-P, Wilate); CP.PHAR.216 (PDF)
- Factor IX_Human Recombinant (AlphaNine, Alprolix, BeneFIX, Idelvion, Ixinity, Mononine, Rebinyn, Rixubis); CP.PHAR.218 (PDF)
- Factor IX Complex, Human (Bebulin, Profiline); CP.PHAR.219 (PDF)
- Factor VIIa Recombinant (NovoSeven); CP.PHAR.220 (PDF)
- Factor XIII Human (Corifact); CP.PHAR.221 (PDF)
- Factor XIIIa_Recombinant (Tretten); CP.PHAR.222 (PDF)
- Fostamatinib (Tavalisse); CP.PHAR.24 (PDF)
- Givosiran (Givlaari); CP.PHAR.457 (PDF)
- Hemin (Panhematin); CP.PHAR.181 (PDF)
- Icatibant (Firazyr); CP.PHAR.178 (PDF)
- Lanadelumab-fylo (Takhzyro); CP.PHAR.396 (PDF)
- Protein C Concentrate Human (Ceprotin); CP.PHAR.330 (PDF)
- Ravulizumab-cwvz (Ultomiris); CP.PHAR.415 (PDF)
- Valoctocogene Roxaparvovec; CP.PHAR.466 (PDF)
Hematopoietic Agents
- Avatrombopag (Doptelet); CP.PHAR.130 (PDF)
- Crizanlizumab-tmca (Adakveo); CP.PHAR.449 (PDF)
- Darbepoetin alfa (Aranesp); CP.PHAR.236 (PDF)
- Eliglustat (Cerdelga); CP.PHAR.153 (PDF)
- Eltrombopag (Promacta); CP.PHAR.180 (PDF)
- Epoetin Alfa (Epogen, Procrit); CP.PHAR.237 (PDF)
- Epoetin Alfa-epbx (Retacrit); CP.PHAR.237 (PDF)
- Ferric Carboxymaltose (Injectafer); CP.PHAR.234 (PDF)
- Ferric Gluconate (Ferrlecit); CP.PHAR.166 (PDF)
- Ferumoxytol (Feraheme); CP.PHAR.165 (PDF)
- Filgrastim (Neupogen, Zarxio, Granix, Nivestym); CP.PHAR.297 (PDF)
- Hydroxyurea (Siklos); CP.PMN.193 (PDF)
- Imiglucerase (Cerezyme); CP.PHAR.154 (PDF)
- Iron Sucrose (Venofer); CP.PHAR.167 (PDF)
- L-glutamine (Endari); CP.PMN.116 (PDF)
- Lusutrombopag (Mulpleta); CP.PHAR.407 (PDF)
- Luxpatercept-aamt (Reblozyl); CP.PHAR.450 (PDF)
- Methoxy polyethylene glycol-epoetin beta (Mircera); CP.PHAR.238 (PDF)
- Miglustat (Zavesca); CP.PHAR.164 (PDF)
- Pegfilgrastim (Neulasta, Fulphia, Udenyca); CP.PHAR.296 (PDF)
- Plerixafor (Mozobil); CP.PHAR.323 (PDF)
- Romiplostim (Nplate); CP.PHAR.179 (PDF)
- Sargramostim (Leukine); CP.PHAR.295 (PDF)
- Taliglucerase alfa (Elelyso); CP.PHAR.157 (PDF)
- Velaglucerase alfa (VPRIV); CP.PHAR.163 (PDF)
- Voxelotor (Oxbryta); CP.PHAR.451 (PDF)
Allergenic Extracts/Biologicals Misc.
Alternative Medicines
Antidotes and Specific Antagonists
- Deferasirox (Exjade, Jadenu); CP.PHAR.145 (PDF)
- Deferiprone (Ferriprox); CP.PHAR.147 (PDF)
- Deferoxamine (Desferal); CP.PHAR.146 (PDF)
- Naloxone (Evzio); CP.PMN.139 (PDF)
- Naltrexone (Vivitrol); CP.PHAR.96 (PDF)
Diagnostic Products
- Cosyntropin (Cortrosyn); CP.PHAR.203 (PDF)
- Diabetic Test Strip Quantity Limit - Not Receiving Insulin; TCHP.PHAR.2004 (PDF)
- Insulin Infusion Pump (Omnipod, Omnipod DASH); CP.PHAR.420 (PDF)
- Non-preferred blood glucose monitors and test strips; CP.PMN.215 (PDF)
- Thyrotropin Alfa (Thyrogen); CP.PHAR.95 (PDF)
Enzymes
Immunological Agent
Immunomodulators
Immunosuppressive Agents
- Belatacept (Nulojix); CP.PHAR.201 (PDF)
- Emapalumab-lzsg (Gamifant); CP.PHAR.402 (PDF)
- Remestemcel-L (Prochymal); CP.PHAR.474 (PDF)
Potassium Removing Agents
Systemic Lupus Erythematosus Agents
ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants
- Amphetamine-dextroamphetamine extended-release (Mydayis); CP.PMN.92 (PDF)
- Amphetamine extended-release oral suspension (Dyanavel XR); CP.PMN.92 (PDF)
- Amphetamine extended-release orally disintegrating tablets (Adzenys XR-ODT); CP.PMN.92 (PDF)
- Dexmethylphenidate ER (Focalin XR); TCHP.PHAR.1904 (PDF)
- Lisdexamfetamine (Vyvanse); CP.PMN.121 (PDF)
- Methylphenidate extended-release orally disintegrating tablets (Cotempla XR-ODT); CP.PMN.92 (PDF)
- Methylphenidate extended-release oral suspension (Quillivant XR); CP.PMN.92 (PDF)
- Methylphnidate extended-release chewable tablets (Quillichew ER); CP.PMN.92 (PDF)
- Methylphenidate transdermal system (Daytrana); CP.PMN.92 (PDF)
- Methylphenidate extended-release (Aptensio XR); CP.PMN.92 (PDF)
- Pitolisant (Wakix); CP.PMN.221 (PDF)
- Solriamfetol (Sunosi); CP.PMN.209 (PDF)
Anticonvulsants
- Cannabidiol (Epidiolex); CP.PMN.164 (PDF)
- Cenobamate (Xcopri); CP.PMN.231 (PDF)
- Clobazam (Onfi, Sympazan); CP.PMN.54 (PDF)
- Diazepam nasal spray (Valtoco); CP.PMN.216 (PDF)
- Lacosamide (Vimpat); CP.PMN.155 (PDF)
- Perampanel (Fycompa); CP.PMN.156 (PDF)
- Pregabalin (Lyrica); TCHP.PHAR.1807 (PDF)
- Rufinamide (Banzel); CP.PMN.157 (PDF)
- Stiripentol (Diacomit); CP.PMN.184 (PDF)
- Vigabatrin (Sabril); CP.PHAR.169 (PDF)
AntiMyasthenic/Cholinergic Agents
Antiparkinson and Related Therapy Agents
- Amantadine ER (Gocovri, Osmolex ER); CP.PMN.89 (PDF)
- Istradefylline (Nourianz); CP.PMN.217 (PDF)
- Safinamide (Xadago); CP.PMN.113 (PDF)
Hypnotics/Sedatives/Sleep Disorder Agents
- Eszopiclone (Lunesta); TCHP.PHAR.18003 (PDF)
- Lemborexant (Dayvigo); CP.PMN.233 (PDF)
- Ramelteon (Rozerem); TCHP.PHAR.18003 (PDF)
- Suvorexant (Belsomra); TCHP.PHAR.18003 (PDF)
- Tasimelteon (Hetlioz); TCHP.PHAR.18003 (PDF)
- Temazepam (Restoril); TCHP.PHAR.18003 (PDF)
- Triazolam (Halcion); TCHP.PHAR.18003 (PDF)
- Zaleplon (Sonata); TCHP.PHAR.18003 (PDF)
- Zolpidem (Ambien, Ambien CR, Edluar, Intermezzo, Zolpimist); TCHP.PHAR.18003 (PDF)
Migraine Products
- Erenumab-aaoe (Aimovig); CP.PHAR.128 (PDF)
- Fremanezumab-vfrm (Ajovy); CP.PHAR.403 (PDF)
- Galcanezumab-gnlm (Emgality); CP.PHAR.404 (PDF)
- Lasmiditan (Reyvow); CP.PMN.218 (PDF)
- Ubrogepant (Ubrelvy); CP.PHAR.476 (PDF)
Psychotherapeutic and Neurological Agents - Misc.
- Aducanumab; CP.PHAR.468 (PDF)
- Alemtuzumab (Lemtrada); CP.PHAR.243 (PDF)
- Bremelanotide (Vyleesi); CP.PHAR.434 (PDF)
- Bupropion (Zyban); TCHP.PHAR.18002 (PDF)
- Cladribine (Mavenclad); CP.PHAR.422 (PDF)
- Deutetrabenazine (Austedo); TCHP.PHAR.181 (PDF)
- Dextromethorphan-Quinidine (Nuedexta); CP.PMN.93 (PDF)
- Dimethyl fumarate (Tecfidera); CP.PHAR.249 (PDF)
- Diroximel fumarate (Vumerity); CP.PHAR.249 (PDF)
- Fingolimod (Gilenya); CP.PHAR.251 (PDF)
- Fosdenopterin; CP.PHAR.471 (PDF)
- Glatiramer (Copaxone, Glatopa); CP.PHAR.252 (PDF)
- Inebilizumab; CP.PHAR.458 (PDF)
- Interferon beta-1a (Avonex, Rebif); CP.PHAR.255 (PDF)
- Interferon beta-1b (Betaseron, Extavia); CP.PHAR.256 (PDF)
- Inotersen (Tegsedi); CP.PHAR.405 (PDF)
- Lofexidine (Lucemyra); CP.PMN.152 (PDF)
- Milnacipran (Savella); CP.PMN.125 (PDF)
- Monomethyl fumarate (Bifiertam); CP.PHAR.460 (PDF)
- Natalizumab (Tysabri); CP.PHAR.259 (PDF)
- Nicotine Cartridge (Nicotrol); TCHP.PHAR.18002 (PDF)
- Nicotine Gum (Nicorette, Nicorelief); TCHP.PHAR.18002 (PDF)
- Nicotine Lozenge (Nicorettte, Commit); TCHP.PHAR.18002 (PDF)
- Nicotine Patch (Nicoderm, NTS); TCHP.PHAR.18002 (PDF)
- Nicotine Spray (Nicotrol NS); TCHP.PHAR.18002 (PDF)
- Ocrelizumab (Ocrevus); CP.PHAR.335 (PDF)
- Ozanimod (Zeposia); CP.PHAR.462 (PDF)
- Patisiran (Onpattro); CP.PHAR.395 (PDF)
- Peginterferon beta-1a (Plegridy); CP.PHAR.271 (PDF)
- Rivastigmine (Exelon); CP.PMN.101 (PDF)
- Satralizumab; CP.PHAR.463 (PDF)
- Sodium oxybate (Xyrem); CP.PMN.42 (PDF)
- Siponimod (Mayzent); CP.PHAR.427 (PDF)
- Teriflunomide (Aubagio); CP.PHAR.262 (PDF)
- Tetrabenazine (Xenazine); TCHP.PHAR.181 (PDF)
- Valbenazine (Ingrezza); TCHP.PHAR.181 (PDF)
- Varenicline (Chantix); TCHP.PHAR.18002 (PDF)
- AbobotulinumtoxinA (Dysport); CP.PHAR.230 (PDF)
- Casimersen; CP.PHAR.470 (PDF)
- Edaravone (Radicava); CP.PHAR.343 (PDF)
- Eteplirsen (Exondys 51); CP.PHAR.288 (PDF)
- Golodirsen (Vyondys 53); CP.PHAR.453 (PDF)
- IncobotulinumtoxinA (Xeomin); CP.PHAR.231 (PDF)
- OnabotulinumtoxinA (Botox); CP.PHAR.232 (PDF)
- Onasemnogene abeparvovec (Zolgensma); CP.PHAR.421 (PDF)
- Nusinersen (Spinraza); CP.PHAR.327 (PDF)
- RimabotulinumtoxinB (Myobloc); CP.PHAR.233 (PDF)
- Risdiplam; CP.PHAR.477 (PDF)
- Aflibercept (Eylea); CP.PHAR.184 (PDF)
- Brimonidine (Mirvaso); CP.PMN.192 (PDF)
- Brolucizumab (Beovu); CP.PHAR.445 (PDF)
- Cenegermin-bkbj (Oxervate); CP.PMN.186 (PDF)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq); CP.PHAR.385 (PDF)
- Cyclosporine (Restasis); CP.PMN.48 (PDF)
- Cysteamine ophthalmic (Cystaran); CP.PMN.130 (PDF)
- Lantanoprostene Bunod (Vyzulta); CP.PMN.108 (PDF)
- Netarsudil (Rhopressa); CP.PMN.118 (PDF)
- Netarsudil-Latanoprost (Rocklatan); CP.PMN.118 (PDF)
- Oxymetazoline (Rhofade); CP.PMN.86 (PDF)
- Pegaptanib (Macugen); CP.PHAR.185 (PDF)
- Ranibizumab (Lucentis); CP.PHAR.186 (PDF)
- Verteporfin (Visudyne); CP.PHAR.187 (PDF)
- Voretigene neparvovec-rzyl (Luxturna); CP.PHAR.372 (PDF)
Antiasthmatic and Bronchodilator Agents
- Arformoterol tartrate (Brovana); CP.PMN.201 (PDF)
- Benralizumab (Fasenra); CP.PHAR.373 (PDF)
- Budesonide-formoterol (Symbicort); CP.PMN.228 (PDF)
- Fluticasone/salmeterol (Advair Diskus, Advair HFA); CP.PMN.31 (PDF)
- Fluticasone-umeclidinium-vilanterol (Trelegy Ellipta); CP.PMN.146 (PDF)
- Fluticasone-vilanterol (Breo Ellipta); CP.PMN.229 (PDF)
- Indacaterol (Arcapta Neohaler); CP.PMN.203 (PDF)
- Indacaterol-glycopyrrolate (Utibron Neohaler); CP.PMN.147 (PDF)
- Levalbuterol (Xopenex); CP.PMN.07 (PDF)
- Mepolizumab (Nucala); CP.PHAR.200 (PDF)
- Mometasone-formoterol (Dulera); CP.PMN.230 (PDF)
- Olodaterol (Striverdi Respimat); CP.PMN.204 (PDF)
- Omalizumab (Xolair); CP.PHAR.01 (PDF)
- Reslizumab (Cinqair); CP.PHAR.223 (PDF)
- Revefenacin (Yupelri); CP.PMN.195 (PDF)
- Roflumilast (Daliresp); CP.PMN.46 (PDF)
- Tiotropium-olodaterol (Stiolto Respimat); CP.PMN.148 (PDF)
- Umeclidinium-vilanterol (Anoro Ellipta); CP.PMN.149 (PDF)
Respiratory Agents - Misc.
- Aclidinium-formoterol (Duaklir Pressair); CP.PMN.200 (PDF)
- Alpha-1 Proteinase Inhibitor (Aralast NP, Glassia, Prolastin-C, Zemaira); CP.PHAR.94 (PDF)
- Dornase alfa (Pulmozyme); CP.PHAR.212 (PDF)
- Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta); CP.PHAR.440 (PDF)
- Ivacaftor (Kalydeco); CP.PHAR.210 (PDF)
- Lumacaftor-ivacaftor (Orkambi); CP.PHAR.213 (PDF)
- Nintedanib esylate (Ofev); TCHP.PHAR.1806 (PDF)
- Pirfenidone (Esbriet); TCHP.PHAR.1806 (PDF)
- Tezacaftlor-Ivacaflor (Symdeko); CP.PHAR.377 (PDF)
Payment Policies
Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.
All policies found in the Trillium Community Health Plan Payment Policy Manual apply with respect to Trillium Community Health Plan members. Policies in the Trillium Community Health Plan Payment Policy Manual may have either a Trillium Community Health Plan or a “Centene” heading. In addition, Trillium Community Health Plan may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Trillium Community Health Plan.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
- CC.PP.065 Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF)
Effective Date: 10/01/20 - 30-Day Readmission (PDF)
Effective Date: 4/15/18 - 3-Day Payment Window (PDF)
Effective Date: 4/15/18 - Add on Code Billed Without Primary Code (PDF)
effective Date: 1/1/18 - Allergy Testing (PDF)
Effective Date: 10/1/19 - Assistant Surgeon (PDF)
Effective Date: 1/1/18 - Bilateral Procedures (PDF)
Effective Date: 1/1/18 - Cerumen Removal (PDF)
Effective Date: 1/1/18 - Clean Claims (PDF)
Effective Date: 1/1/18 - CLIA Number (PDF)
Effective Date: 1/1/18 - Coding Overview (PDF)
Effective Date: 1/1/18 - Distinct Procedural Modifiers (PDF)
Effective Date: 1/1/18 - Duplicate Primary Code Billing (PDF)
Effective Date: 1/1/18 - E&M Medical Decision-Making (PDF)
Effective Date: 1/1/18 - EM Bundling Edits (PDF)
Effective Date: 1/1/18 - EpiFix Wound Treatment (PDF)
Effective Date: 10/1/19 - Global Maternity Billing (PDF)
Effective Date: 1/1/18 - Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/18 - Inpatient Consultation (PDF)
Effective Date: 1/1/18 - Inpatient Only Procedures (PDF)
Effective Date: 1/1/18 - IV Hydration (PDF)
Effective Date: 1/1/18 - Leveling of ED Services (PDF)
Effective Date: 10/1/2019 - Maximum Units (PDF)
Effective Date: 1/1/18 - Moderate Conscious Sedation (PDF)
Effective Date: 1/1/18 - Modifier -25 clinical validation (PDF)
Effective Date: 1/1/18 - Modifier -59 clinical validation (PDF)
Effective Date: 1/1/18 - Modifier DOS Validation (PDF)
Effective Date: 1/1/18 - Modifier to Procedure Code Validation (PDF)
Effective Date: 1/1/18 - Multiple CPT Code Replacement (PDF)
- Effective Date: 1/1/18
- NCCI Unbundling (PDF)
Effective Date: 1/1/18 - Never Paid Events (PDF)
Effective Date: 1/1/18 - New Patient (PDF)
Effective Date: 1/1/18 - Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 10/1/18 - Outpatient Consultation (PDF)
Effective Date: 1/1/18 - Physician Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/18 - Physician's Consultation Services (PDF)
Effective Date: 4/15/18 - Place of Service Mismatch (PDF)
Effective Date: 10/1/18 - Post-Operative Visits (PDF)
Effective Date: 1/1/18 - Pre-Operative Visits (PDF)
Effective Date: 1/1/18 - Problem Oriented Visits with Preventive Visits (PDF)
Effective Date: 1/1/18 - Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: 10/1/19 - Professional Component (PDF)
Effective Date: 1/1/18 - PROM Testing (PDF)
Effective Date: 1/1/18 - Pulse Oximetry (PDF)
Effective Date: 1/1/18 - Same Day Visits (PDF)
Effective Date: 1/1/18 - Status "B" Bundled Services (PDF)
Effective Date: 1/1/18 - Status "P" Bundled Services (PDF)
Effective Date: 10/1/19 - Supplies Billed on Same Day As Surgery (PDF)
Effective Date: 1/1/18 - Transgender Related Services (PDF)
Effective Date: 1/1/18 - Unbundled Professional Services (PDF)
Effective Date: 1/1/18 - Unbundled Surgical Procedures (PDF)
Effective Date: 1/1/18 - Unlisted Procedure Codes (PDF)
Effective Date: 1/1/18 - Urodynamic Testing (PDF)
Effective Date: 10/1/19 - Urine Specimen Validity Testing (PDF)
Effective Date: 4/15/18
- CC.MP.50 Outpatient Testing for Drugs of Abuse (PDF)
Effective Date: 10/01/20 - CC.PP.065 Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF)
Effective Date: 10/01/20 - 30-Day Readmission (PDF)
Effective Date: 4/15/18 - 3-Day Payment Window (PDF)
Effective Date: 4/15/18 - Add on Code Billed Without Primary Code (PDF)
effective Date: 1/1/18 - Allergy Testing (PDF)
Effective Date: 10/1/19 - Assistant Surgeon (PDF)
Effective Date: 1/1/18 - Bilateral Procedures (PDF)
Effective Date: 1/1/18 - Cerumen Removal (PDF)
Effective Date: 1/1/18 - Clean Claims (PDF)
Effective Date: 1/1/18 - CLIA Number (PDF)
Effective Date: 1/1/18 - Coding Overview (PDF)
Effective Date: 1/1/18 - Distinct Procedural Modifiers (PDF)
Effective Date: 1/1/18 - Duplicate Primary Code Billing (PDF)
Effective Date: 1/1/18 - E&M Medical Decision-Making (PDF)
Effective Date: 1/1/18 - EM Bundling Edits (PDF)
Effective Date: 1/1/18 - EpiFix Wound Treatment (PDF)
Effective Date: 10/1/19 - Global Maternity Billing (PDF)
Effective Date: 1/1/18 - Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/18 - Inpatient Consultation (PDF)
Effective Date: 1/1/18 - Inpatient Only Procedures (PDF)
Effective Date: 1/1/18 - IV Hydration (PDF)
Effective Date: 1/1/18 - Leveling of ED Services (PDF)
Effective Date: 10/1/2019 - Maximum Units (PDF)
Effective Date: 1/1/18 - Moderate Conscious Sedation (PDF)
Effective Date: 1/1/18 - Modifier -25 clinical validation (PDF)
Effective Date: 1/1/18 - Modifier -59 clinical validation (PDF)
Effective Date: 1/1/18 - Modifier DOS Validation (PDF)
Effective Date: 1/1/18 - Modifier to Procedure Code Validation (PDF)
Effective Date: 1/1/18 - Multiple CPT Code Replacement (PDF)
- Effective Date: 1/1/18
- NCCI Unbundling (PDF)
Effective Date: 1/1/18 - Never Paid Events (PDF)
Effective Date: 1/1/18 - New Patient (PDF)
Effective Date: 1/1/18 - Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 10/1/18 - Outpatient Consultation (PDF)
Effective Date: 1/1/18 - Physician Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/18 - Physician's Consultation Services (PDF)
Effective Date: 4/15/18 - Place of Service Mismatch (PDF)
Effective Date: 10/1/18 - Post-Operative Visits (PDF)
Effective Date: 1/1/18 - Pre-Operative Visits (PDF)
Effective Date: 1/1/18 - Problem Oriented Visits with Preventive Visits (PDF)
Effective Date: 1/1/18 - Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: 10/1/19 - Professional Component (PDF)
Effective Date: 1/1/18 - PROM Testing (PDF)
Effective Date: 1/1/18 - Pulse Oximetry (PDF)
Effective Date: 1/1/18 - Same Day Visits (PDF)
Effective Date: 1/1/18 - Status "B" Bundled Services (PDF)
Effective Date: 1/1/18 - Status "P" Bundled Services (PDF)
Effective Date: 10/1/19 - Supplies Billed on Same Day As Surgery (PDF)
Effective Date: 1/1/18 - Transgender Related Services (PDF)
Effective Date: 1/1/18 - Unbundled Professional Services (PDF)
Effective Date: 1/1/18 - Unbundled Surgical Procedures (PDF)
Effective Date: 1/1/18 - Unlisted Procedure Codes (PDF)
Effective Date: 1/1/18 - Urodynamic Testing (PDF)
Effective Date: 10/1/19 - Urine Specimen Validity Testing (PDF)
Effective Date: 4/15/18
Behavioral Health Policies
| Policy Reference Number | Policy Name | Description |
|---|---|---|
| OR.MM.BH.112 (PDF) | Involuntary Psychiatric Care | Trillium provides psychiatric care as outlined in our contract with Oregon Health Authority (OHA) and Oregon Administrative Rules (OAR). Trillium makes reasonable effort to provide covered services on a voluntary basis consistent with current Declaration for Mental Health Treatment in lieu of involuntary treatment. |
Other Policies
| Policy Reference Number | Policy Name | Description |
|---|---|---|
| OR.MM.117 (PDF) | Advance Directives | To provide opportunity for and educate members about their right to be involved in decisions regarding their care including documentation of advance directives and allowance of the member’s representative to facilitate care or make treatment decisions when the member is unable to do so. |