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 1-877-600-5472.
| Code | Title | Description | Date Adopted |
|---|---|---|---|
25-hydroxyvitamin D testing in children and adolescents |
Medical necessity guidelines for 25-hydroxyvitamin D testing in children and adolescents |
February 15, 2022 | |
Acupuncture |
Medical necessity guidelines for acupuncture |
September 21, 2021 | |
ADHD Assessment and Treatment |
Medical necessity guidelines for the assessment and treatment of attention deficit hyperactivity disorder (ADHD) |
May 17, 2022 | |
| CP.MP.175 (PDF) | Air Ambulance | Medical necessity guidelines for fixed wing air transportation. | September 21, 2021 |
Allergy Testing and Therapy |
Medical necessity guidelines for allergy testing and treatment |
May 17, 2022 | |
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 |
February 15, 2022 | |
Ambulatory Surgery Center Optimization |
Medical necessity guidelines for the use of ambulatory surgery centers as an alternative to inpatient surgical services |
November 21, 2021 | |
| CP.MP.179 (PDF) | Antithrombin III (Thrombate III, Atryn) | Medical necessity criteria for Antithrombin III (Thrombate III, Atryn) | February 15, 2022 |
Articular Cartilage Defect Repairs |
Medical necessity guidelines for articular cartilage defect repairs |
May 17, 2022 | |
Assisted Reproductive Technology |
Medical necessity guidelines for assisted reproductive technology |
February 15, 2022 | |
Bariatric Surgery |
Medical necessity guidelines for bariatric surgery for obesity in adolescents and adults |
September 21, 2021 | |
Biofeedback |
Medical necessity guidelines for biofeedback therapyJuly 20, 2021 |
February 15, 2022 | |
Bone-anchored hearing aid |
Medical necessity guidelines for bone-anchored hearing aid |
September 21, 2021 | |
Bronchial Thermoplasty |
Medical necessity guidelines for bronchial thermoplasty |
July 20, 2021 | |
Burn Surgery |
Medical necessity guidelines for burn surgery, including debridement and application of skin substitutes for burns. |
February 15, 2022 | |
Cardiac biomarker testing |
Medical necessity guidelines for cardiac biomarker testing for the evaluation of suspected acute myocardial infarction |
February 15, 2022 | |
Caudal or Interlaminar Epidural Steroid Injections for Pain Management |
Medical necessity criteria for caudal or interlaminar epidural steroid injections for pain management |
November 21, 2021 | |
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 |
February 15, 2022 | |
Clinical Trials |
Medical necessity guidelines for routine costs of clinical trials |
September 21, 2021 | |
Cochlear Implant Replacements |
Medical necessity guidelines for the replacement of cochlear implants and/or cochlear implant components. |
September 21, 2021 | |
Cosmetic and Reconstructive Surgery |
Medical necessity guidelines for cosmetic and reconstructive surgery |
February 15, 2022 | |
Dental Anesthesia |
Medical necessity guidelines for dental anesthesia |
February 15, 2022 | |
| CP.MP.203 (PDF) | Diaphragmatic/Phrenic Nerve Stimulation | Medical necessity guidelines for diaphragmatic/phrenic nerve stimulation | February 15, 2022 |
Digital electroencephalography spike analysis |
Medical necessity guidelines for digital EEG spike analysis |
February 15, 2022 | |
Disc Decompression Procedures |
Medical necessity guidelines for open discectomy, microdiscectomy, and minimally invasive and percutaneous disc decompression |
July 20, 2021 | |
Discography |
Medical necessity guidelines for discography |
September 21, 2021 | |
Donor lymphocyte infusion |
Medical necessity guidelines for donor lymphocyte infusion |
February 15, 2022 | |
Drugs of Abuse: Definitive Testing |
Medical necessity guidelines for confirmatory/definitive lab testing for specific drugs of abuse. |
May 17, 2022 | |
Durable Medical Equipment (DME) |
Medical necessity guidelines for durable medical equipment, orthotics, and prosthetics |
February 15, 2022 | |
Electric Tumor Treating Fields |
Medical necessity guidelines for electric tumor treating fields Optune® (NovoCureTM) |
February 15, 2022 | |
Electroencephalography in the evaluation of headache |
Medical necessity guidelines for the use of electroencephalography (EEG) in the evaluation of headaches |
February 15, 2022 | |
| CP.MP.211 (PDF) | Electromyography and Nerve Conduction Studies | Medical necessity criteria for EMG and NCS | July 20, 2021 |
Endometrial ablation |
Medical necessity guidelines for endometrial ablation |
May 17, 2022 | |
Essure Removal |
Medical necessity guidelines for removal of Essure®, a permanent birth control device |
February 15, 2022 | |
Evoked Potential Testing |
Medical necessity guidelines for evoked potential testing |
August 31, 2021 | |
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. |
May 17, 2022 | |
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 |
September 21, 2021 | |
Fecal incontinence treatments |
Medical necessity guidelines for fecal incontinence treatments |
September 21, 2021 | |
Ferriscan R2-MRI |
Medical necessity guidelines for use of the FerriScan R2-MRI |
February 15, 2022 | |
Fertility preservation |
Medical necessity guidelines for fertility preservation when undergoing medical treatments that may transiently or permanently affect fertility |
November 16, 2021 | |
Fetal surgery in utero for prenatally diagnosed malformations |
Medical necessity guidelines for performing fetal surgery in utero |
September 21, 2021 | |
Functional MRI |
Medical necessity guidelines for the use of functional magnetic resonance imaging (fMRI). |
May 17, 2022 | |
Gastric electrical stimulation |
Medical necessity guidelines for gastric electrical stimulation |
May 17, 2022 | |
Gender Affirming Procedures |
Medical necessity guidelines for surgery for the treatment of gender dysphoria |
February 15, 2022 | |
| CP.MP.215 (PDF) | Genetic Testing Aortopathies and Connective Tissue Disorders | Hereditary connective tissue disorders are a group of disorders that affect the connective tissues that support the skin, bones, joints, heart, blood vessels, eyes, and other organs. | May 17, 2022 |
| CP.MP.216 (PDF) | Genetic Testing Cardiac Disorders | This document addresses genetic testing for cardiac disorders, focusing on cardiomyopathy, arrhythmia, congenital heart defects, and cholesterol disorders. | May 17, 2022 |
| CP.MP.217 (PDF) | Genetic Testing Dermatologic Conditions | This document addresses genetic testing for dermatologic conditions. | May 17, 2022 |
| CP.MP.218 (PDF) | Genetic Testing Epilepsy Neurodegenerative and Neuromuscular Disorders | This document addresses genetic testing for neurodegenerative and neuromuscular genetic diseases. | May 17, 2022 |
| CP.MP.219 (PDF) | Genetic Testing Exome and Genome Sequencing for the Diagnosis of Genetic Disorders | Rapid exome sequencing (rES) and rapid genome (rGS) sequencing involves sequencing of the exome or genome, respectively, in an accelerated time frame. | May 17, 2022 |
| CP.MP.220 (PDF) | Genetic Testing Eye Disorders | Age-related macular degeneration (AMD) is an eye condition that causes damage to the central portion of the retina (the macula), affecting the ability to see objects straight ahead. | May 17, 2022 |
| CP.MP.221 (PDF) | Genetic Testing Gastroenterologic Disorders (non-cancerous) | This document addresses genetic testing for common gastroenterologic (non-cancerous) conditions. | May 17, 2022 |
| CP.MP.222 (PDF) | Genetic Testing General Approach to Genetic Testing | Genetic testing refers to the use of technologies that identify genetic variation, which include genomic, transcriptional, proteomic, and epigenetic alterations, for the prevention, diagnosis, and treatment of disease. | May 17, 2022 |
| CP.MP.223 (PDF) | Genetic Testing Hearing Loss | This policy primarily focuses on the use of genetic testing to identify a cause of suspected hereditary hearing loss. | May 17, 2022 |
| CP.MP.224 (PDF) | Genetic Testing Hematologic Condition (non-cancerous) | This document addresses genetic testing for common hematologic (non-cancerous) conditions | May 17, 2022 |
| CP.MP.225 (PDF) | Genetic Testing Hereditary Cancer Susceptibility | Genetic testing for hereditary cancer susceptibility is a germline test and can be performed on individual genes (e.g., BRCA1) or on many genes simultaneously (i.e., multi-gene panels). | May 17, 2022 |
| CP.MP.226 (PDF) | Genetic Testing Immune, Autoimmune, and Rheumatoid Disorders | Immunodeficiency disorders impair the immune system’s ability to defend the body against foreign substances, such as bacteria, viruses, and cancer cells. | May 17, 2022 |
| CP.MP.227 (PDF) | Genetic Testing Kidney Disorders | Inherited kidney disorders and inherited disorders that indirectly affect the kidneys can be more common, such as autosomal dominant polycystic kidney disease, or more rare, such as Lowe syndrome and Fabry disease. | May 17, 2022 |
| CP.MP.228 (PDF) | Genetic Testing Lung Disorders | One of the most common forms of inherited lung disorders is alpha-1 antitrypsin deficiency (AATD) is an autosomal recessive genetic disorder that results in decreased production of the alpha-1 antitrypsin (AAT) protein, or production of abnormal types of the protein that are functionally deficient. | May 17, 2022 |
| CP.MP.229 (PDF) | Genetic Testing Metabolic Endocrine and Mitochondrial Disorders | Genetic testing for metabolic, endocrine, and mitochondrial disorders aids in identifying the specific disorder that is present, so that proper treatment (if any) can be initiated, and at-risk family member/enrollee can be identified. | May 17, 2022 |
| CP.MP.230 (PDF) | Genetic Testing Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay | This document addresses genetic testing for rare genetic conditions that impact multiple body systems. | May 17, 2022 |
| CP.MP.231 (PDF) | Genetic Testing for Non-Invasive Prenatal Screening (NIPS) | Non-invasive prenatal screening (NIPS) is a sequencing test performed on placental cell-free DNA found in maternal serum and is most commonly used to screen for fetal aneuploidy (trisomy 21, trisomy 13, and trisomy 18); sex chromosomes are also screened for fetal sex determination and sex chromosome aneuploidy. | May 17, 2022 |
| CP.MP.237 (PDF) | Genetic Testing Oncology Algorithmic Testing | Oncology prognostic and algorithmic tests are developed to aid in determining the likelihood that an individual has cancer, the prognosis for a patient diagnosed with cancer, and/or surveillance for recurrence. | May 17, 2022 |
| CP.MP.238 (PDF) | Genetic Testing Oncology Cancer Screening | This policy relates to genetic and biomarker tests that aim to screen for specific cancers in individuals who are at risk to develop them. | May 17, 2022 |
| CP.MP.240 (PDF) | Genetic Testing Oncology Cytogenetic Testing | Cytogenetic analysis of solid tumors and hematologic malignancies aims to both classify the type of tumor or cancer present and also to identify somatic oncogenic mutations in cancer. | May 17, 2022 |
| CP.MP.241 (PDF) | Genetic Testing Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies | The molecular analysis of solid tumors and hematologic malignancies aims to identify somatic oncogenic mutations in cancer. | May 17, 2022 |
| CP.MP.232 (PDF) | Genetic Testing Pharmacogenetics | Pharmacogenetic tests are germline genetic tests that are developed to aid in assessing an individual's response to a drug treatment or to predict the risk of toxicity from a specific drug treatment. | May 17, 2022 |
| CP.MP.233 (PDF) | Genetic Testing Preimplantation Genetic Testing | Preimplantation genetic testing involves analysis of biopsied cells from an embryo as a part of an assisted reproductive procedure. | May 17, 2022 |
| CP.MP.234 (PDF) | Genetic Testing Prenatal and Preconception Carrier Screening | Carrier screening is performed to identify individuals at risk of having offspring with inherited recessive or X-linked single-gene disorders. | May 17, 2022 |
| CP.MP.235 (PDF) | Genetic Testing Prenatal Diagnosis | Prenatal diagnostic testing for genetic disorders is performed on fetal cells derived from amniotic fluid, and/or percutaneous umbilical blood sampling (PUBS) (cordocentesis) or from placental cells via chorionic villus sampling (CVS). | May 17, 2022 |
| CP.MP.236 (PDF) | Genetic Testing Skeletal Dysplasia and Rare Bone Disorders | Genetic testing has allowed for gene identification in more than two thirds of the skeletal dysplasias. | May 17, 2022 |
| CP.MP.209 (PDF) | GI Pathogen Nucleic Acid Detection Panel Testing | Medical necessity guidelines for GI Pathogen Nucleic Acid Detection Panel Testing | May 17, 2022 |
H. Pylori serology testing |
Medical necessity guidelines for H. pylori |
February 15, 2022 | |
Heart-Lung Transplant |
Medical necessity guidelines for heart-lung transplantation |
May 17, 2022 | |
Holter Monitors |
Medical necessity guidelines for Holter monitoring, or continuous ambulatory electrocardiogram (ECG) monitoring |
February 15, 2022 | |
Home Birth |
Medical necessity guidelines for planned home birth |
May 17, 2022 | |
Home phototherapy for neonatal hyperbilirubinemia |
Medical necessity guidelines for home phototherapy for the treatment of neonatal hyperbilirubinemia |
February 15, 2022 | |
Homocysteine testing |
Medical necessity guidelines for homocysteine testing |
May 17, 2022 | |
Hospice Services |
Medical necessity guidelines for hospice services |
February 15, 2022 | |
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) |
May 17, 2022 | |
Hyperhidrosis treatments |
Medical necessity guidelines for the treatment of hyperhidrosis, including iontophoresis, endoscopic thoracic sympathectomy, and surgical excision of axillary sweat glands |
May 17, 2022 | |
| CP.MP.180 (PDF) | Implantable Hypoglossal Nerve Stimulation | Medical necessity criteria for Implantable Hypoglossal Nerve Stimulation (Inspire) for Obstructive Sleep Apnea | February 15, 2022 |
Implantable Intrathecal Pain Pump |
Medical necessity guidelines for preliminary trial and implantation of intrathecal pain pumps |
May 17, 2022 | |
Implantable Wireless Pulmonary Artery Pressure Monitoring |
Medical necessity guidelines for implantable wireless pulmonary artery pressure monitoring |
May 17, 2022 | |
Inhaled nitric oxide |
Medical necessity guidelines for the use of inhaled nitric oxide (iNO) |
September 21, 2021 | |
Intensity-Modulated Radiotherapy |
Medical necessity guidelines for intensity-modulated radiotherapy (IMRT) |
February 15, 2022 | |
Intestinal and multivisceral transplant |
Medical necessity guidelines for the review of intestinal and multivisceral transplant requests. |
May 17, 2022 | |
Intradiscal Steroid Injections for Pain Management |
Medical necessity criteria for intradiscal steroid injections for pain management |
September 21, 2021 | |
Laser therapy for skin conditions |
Medical necessity guidelines for excimer laser based targeted phototherapy |
May 17, 2022 | |
Long Term Care Placement Criteria |
Medical necessity guidelines for long term care (LTC) placement |
July 20, 2021 | |
Low-frequency ultrasound and noncontact normothermic wound therapy |
Medical necessity guidelines for low-frequency ultrasound therapy for wound management |
May 17, 2022 | |
| CP.MP.57 (PDF) | Lung Transplantation | Medical necessity guidelines for review of lung transplantation requests | May 17, 2022 |
Lysis of Epidural Lesions |
Medical necessity criteria for epidural adhesiolysis, also known as as epidural neuroplasty, lysis of epidural adhesions, or caudal neuroplasty |
July 20, 2021 | |
Measurement of serum 1,25-dihydroxyvitamin D |
Medical necessity guidelines for the measurement of serum 1,25-dihydroxyvitamin D |
October 31, 2021 | |
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. |
February 15, 2022 | |
Medical Necessity Criteria |
This policy identifies the medical necessity guidelines used by the health plan and related definitions. |
September 21, 2021 | |
Multiple Sleep Latency Testing |
Medical necessity criteria for multiple sleep latency testing (MSLT) |
July 20, 2021 | |
Neonatal abstinence syndrome guidelines |
Medical necessity guidelines for managing neonatal abstinence syndrome in the neonatal intensive care unit (NICU) |
May 17, 2022 | |
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 |
September 21, 2021 | |
Nerve Blocks for Pain Management |
Medical necessity criteria for nerve blocks for pain management |
February 15, 2022 | |
| CP.MP.48 (PDF) | Neuromuscular Electrical Stimulation (NMES) | Medical necessity requirements for the use of neuromuscular electrical stimulation (NMES) and functional electrical stimulation (FES) | September 21, 2021 |
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 |
July 20, 2021 | |
NICU discharge guidelines |
Medical necessity guidelines to assist in comprehensive discharge planning and smooth transition from the neonatal intensive care unit (NICU) to home. |
September 21, 2021 | |
| CP.MP.184 (PDF) | Non-Invasive Home Ventilators | Medical necessity guidelines for non-invasive home ventilators | July 20, 2021 |
Non-myeloablative allogeneic stem cell transplants |
Medical necessity guidelines for non-myeloablative allogeneic stem cell transplants |
May 17, 2022 | |
Obstetrical Home Health Care Programs |
Medical necessity guidelines for OB home health programs |
February 15, 2022 | |
| CP.MP.239 (PDF) | Oncology Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) | Genetic tests performed on cell-free circulating tumor DNA (ctDNA), also referred to as a liquid biopsy, potentially offer a noninvasive alternative to tissue biopsy for detection of “driver mutations”, or acquired genetic mutations that may guide targeted therapy, and may also be used to track progression of disease. | May 17, 2022 |
Optic nerve decompression surgery |
Medical necessity guidelines for optic nerve sheath decompression surgery |
September 21, 2021 | |
| CP.MP.202 (PDF) | Orthognathic Surgery | Medical necessity guidelines for Orthognathic Surgery | February 15, 2022 |
Outpatient Cardiac Rehabilitation |
Medical necessity criteria for conventional and intensive outpatient cardiac rehabiliation programs. |
July 20, 2021 | |
| CP.MP.190 (PDF) | Oxygen Use and Concentrators | Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxemia. | May 17, 2022 |
Pancreas transplant |
Medical necessity guidelines for pancreas transplant, including simultaneous pancreas kidney transplant, pancreas after kidney transplant, pancreas transplant alone, and islet cell transplant. |
May 17, 2022 | |
Panniculectomy |
Medical necessity guidelines for panniculectomy |
February 15, 2022 | |
Pediatric heart transplant |
Medical necessity guidelines for pediatric heart transplant |
May 17, 2022 | |
Pediatric Liver Transplant |
Medical necessity guidelines for pediatric liver transplant for end-stage liver disease |
May 17, 2022 | |
Pediatric Oral Function Therapy |
Medical necessity guidelines for pediatric oral function therapy. |
July 20, 2021 | |
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention |
Medical necessity guidelines for left atrial appendage closure devices for stroke prevention. |
July 20, 2021 | |
| CP.MP.181 (PDF) | Polymerase Chain Reaction Respiratory Viral Panel Testing | Medical necessity criteria for multiplex respiratory polymerase chain reaction (PCR) testing. | May 17, 2022 |
Post-Acute Care |
Medical necessity criteria for Post-Acute Care |
May 17, 2022 | |
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 |
September 21, 2021 | |
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. |
February 15, 2022 | |
Proton and neutron beam therapy |
Medical necessity guidelines for proton beam and neutron beam radiation therapy |
February 15, 2022 | |
Radial Head Implant |
Medical necessity guidelines for radial head implant, also known as arthroplasty |
July 20, 2021 | |
Radiofrequency Ablation of Uterine Fibroids |
Medical necessity criteria for radiofrequency ablation of uterine fibroids. |
May 17, 2022 | |
Reduction mammoplasty and gynecomastia surgery |
Medical necessity guidelines for reduction mammoplasty in women and gynecomastia surgery in men |
November 21, 2021 | |
Repair of Nasal Valve Compromise |
Medical necessity guidelines for the treatment of Repair of Nasal Valve Compromise |
July 20, 2021 | |
Sacroiliac joint fusion |
Medical necessity guidelines for sacroiliac joint fusion |
September 21, 2021 | |
Sacroiliac Joint Interventions for Pain Management |
Medical necessity criteria for sacroiliac joint interventions for pain management |
September 21, 2021 | |
Sclerotherapy for Varicose Veins |
Medical necessity guidelines for sclerotherapy for treatment of vericose veins |
September 21, 2021 | |
Selective Dorsal Rhizotomy |
Medical necessity criteria for Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy. |
February 15, 2022 | |
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 |
September 21, 2021 | |
| CP.MP.182 (PDF) | Short Inpatient Hospital Stay | Medical necessity criteria for inpatient hospital stay of 2 days or less | February 15, 2022 |
Skilled Nursing Facility Leveling |
Medical necessity criteria for skilled nursing facility levels of care |
May 17, 2022 | |
Skin Substitutes for Chronic Wounds |
Medical necessity criteria for skin substitutes in the treatment of chronic wounds. |
July 20, 2021 | |
Spinal Cord Stimulation |
Medical necessity guidelines for spinal cord stimulation for pain management, also known as dorsal column stimulation |
May 17, 2022 | |
State specific clinical policy process |
This policy describes the process for creating, maintaining, and posting state-specific clinical policies |
February 15, 2022 | |
Stereotactic Body Radiation Therapy |
Medical necessity guidelines for stereotactic body radiation therapy |
May 17, 2022 | |
Tandem Transplant |
Medical necessity guidelines for tandem transplant |
May 17, 2022 | |
Testing for select genitourinary conditions |
Medical necessity guidelines for various diagnostic testing methods to identify the etiology of the signs and symptoms of vaginitis |
May 17, 2022 | |
Therapy Services (PT/OT/ST) |
Medical necessity guidelines for outpatient speech therapy, occupational therapy, and/or physical therapy evaluation and treatment. |
February 16, 2021 | |
Thyroid hormones and insulin testing in pediatrics |
Medical necessity guidelines for thyroid hormones and insulin testing in pediatrics |
February 15, 2022 | |
Total artificial heart |
Medical necessity guidelines for a total artificial heart (TAH) |
February 15, 2022 | |
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition |
Medical necessity guidelines for total parenteral nutrition (TPN) and intradialytic parenteral nutrition (IDPN) |
July 20, 2021 | |
Transcatheter closure of patent foramen ovale |
Medical necessity guidelines for transcatheter closure of patent foramen ovale (PFO) with the AmplatzerTM PFO Occluder. |
February 15, 2022 | |
Trigger Point Injections for Pain Management |
Medical necessity criteria for trigger point injections for pain management |
September 21, 2021 | |
Ultrasound in Pregnancy |
Medical necessity guidelines for ultrasound use in pregnancy. |
May 17, 2022 | |
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 |
February 15, 2022 | |
Urodynamic testing |
Medical necessity guideines for urodynamic testing as part of the comprehensive evaluation of voiding dysfunction |
May 17, 2022 | |
Vagus Nerve Stimulation |
Medical necessity guidelines for vagus nerve stimulation. |
September 21, 2021 | |
Ventricular Assist Devices |
Medical necessity guidelines for ventricular assist devices. |
May 17, 2022 | |
Wheelchair seating |
Medical necessity guidelines for special wheelchair seating and cushions |
May 17, 2022 | |
Wireless Motility Capsule |
Medical necessity guidelines for wireless motility capsule |
February 15, 2022 | |
| CP.MP.194 (PDF) | Osteogenic Stimulation | Electrical osteogenic stimulation can be performed invasively or non-invasively. | November 16, 2021 |
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; OR.CP.PMN.1006 (PDF)
- Brand Name Override; CP.PMN.22 (PDF)
- Dose Optimization; CP.PMN.13 (PDF)
- EPSDT Benefit for Pediatric Members; OR.CP.PMN.234 (PDF)
- No Coverage Criteria; CP.PMN.255 (PDF)
- Off Label Use; CP.PMN.53 (PDF)
- Quantity Limit Overrides; CP.PMN.59 (PDF)
- Request for Medically Necessary Drug not on the PDL; OR.CP.PMN.1001 (PDF)
- Request for Medically Necessary Drug on the PDL; OR.CP.PMN.1002 (PDF)
- Supplement, Herbal and Vitamin Products; OR.CP.PMN.1007 (PDF)
- Step Therapy; CP.PST.01 (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, Elyxyb); CP.PMN.122 (PDF)
- Dicolfenac (Pennsaid); CP.PMN.274 (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, Reditrex); 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 (Bunavail, Cassipa, Suboxone, Zubsolv); OR.CP.PMN.81 (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); OR.CP.PMN.161 (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); OR.CP.PMN.1011 (PDF)
- Ciclopirox (Loprox, Ciclodan, Penlac); OR.CP.PMN.1011 (PDF)
- Clotrimazole; OR.CP.PMN.1011 (PDF)
- Econazole nitrate (Ecoza); OR.CP.PMN.1011 (PDF)
- Efinaconazole (Jublia); OR.CP.PMN.1011 (PDF)
- Fluconazole (Diflucan); OR.CP.PMN.1011 (PDF)
- Flucytosine (Ancobon); OR.CP.PMN.1011 (PDF)
- Griseofulvin (Grifulvin, Gris-Peg); OR.CP.PMN.1011 (PDF)
- Isavuconazonium sulfate (Cresemba); OR.CP.PMN.1011 (PDF)
- Itraconazole (Sporanox, Onmel); OR.CP.PMN.1011 (PDF)
- Ketoconazole (Extina, Nizoral, Xolegel); OR.CP.PMN.1011 (PDF)
- Luliconazole (Luzu); OR.CP.PMN.1011 (PDF)
- Miconazole (Oravig); OR.CP.PMN.1011 (PDF)
- Miconazole Nitrate; OR.CP.PMN.1011 (PDF)
- Naftifine (Naftin); OR.CP.PMN.1011 (PDF)
- Nystatin (Nyamyc, Nyata, Nystop); OR.CP.PMN.1011 (PDF)
- Nystatin/Triamcinolone (Myconel);; OR.CP.PMN.1011 (PDF)
- Oxiconazole (Oxistat); OR.CP.PMN.1011 (PDF)
- Posaconazole (Noxafil); OR.CP.PMN.1011 (PDF)
- Sertaconazole (Ertaczo); OR.CP.PMN.1011 (PDF)
- Sulconazole (Exelderm); OR.CP.PMN.1011 (PDF)
- Tavaborole (Kerydin); OR.CP.PMN.1011 (PDF)
- Terbinafine; OR.CP.PMN.1011 (PDF)
- Tolnaftate; OR.CP.PMN.1011 (PDF)
- Voriconazole (Vfend); OR.CP.PMN.1011 (PDF)
Antihelmintics
- Benznidazole; CP.PMN.90 (PDF)
- Ivermectin (Stromectol, Sklice); CP.PMN.269 (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)
- Nifurtimox (Lampit); CP.PMN.256 (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)
- Pretomanid; CP.PMN.222 (PDF)
- Rifabutin (Mycobutin); CP.PMN.223 (PDF)
- Rifabutin-Omeprazole-Amoxicillin (Talicia); CP.PMN.223 (PDF)
- Rifapentine (Priftin); CP.PMN.05 (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)
- Cabotegravir, Cabotegravir-Rilpivirine (Apretude, Cabenuva); CP.PHAR.573
- Daclatasvir (Daklinza); OR.CP.PHAR.1003 (PDF)
- Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Vikira XR, Viekira Pak); OR.CP.PHAR.1003 (PDF)
- Elbasvir-Grazoprevir (Zepatier); OR.CP.PHAR.1003 (PDF)
- Emtricitabine/Tenofovir Alafenamide (Descovy); CP.PMN.235 (PDF)
- Enfuvirtide (Fuzeon); CP.PHAR.41 (PDF)
- Fostemsavir (Rukobia); CP.PHAR.516 (PDF)
- Glecaprevir/Pibrentasvir (Mavyret); OR.CP.PHAR.1003 (PDF)
- Ibalizumab-uiyk (Trogarzo); CP. PHAR.378 (PDF)
- Ledipasvir/Sofosbuvir (Harvoni); OR.CP.PHAR.1003 (PDF)
- Letermovir (Prevymis); CP.PHAR.367 (PDF)
- Maribavir (Livtencity); CP.PMN.271 (PDF)
- Ombitasvir/Paritaprevir/Ritonavir (Technivie); OR.CP.PHAR.1003 (PDF)
- Peginterferon Alfa-2a (Pegasys, PegIntron, Sylatron); CP.PHAR.89 (PDF)
- Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere); CP.PHAR.141 (PDF)
- Simeprevir (Olysio); OR.CP.PHAR.1003 (PDF)
- Sofosbuvir (Sovaldi); OR.CP.PHAR.1003 (PDF)
- Sofosbuvir/Velpatasvir (Epclusa); OR.CP.PHAR.1003 (PDF)
- Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi); OR.CP.PHAR.1003 (PDF)
- Tenofovir Alafenamide Fumarate (Vemlidy); CP.PMN.268 (PDF)
Fluoroqunolones
Passive Immunizing and Treatment Agents
- Bezlotoxumab (Zinplava); CP.PHAR.300 (PDF)
- Cytomegalovirus Immune Globulin (CytoGam); CP.PHAR.277 (PDF)
- Immune Globulins; CP.PHAR.103 (PDF)
- Palivizumab (Synagis); OR.CP.PHAR.16 (PDF)
Tetracyclines
Alkylating Agents
- Bendamustine (Belrapzo, Bendeka, Treanda); CP.PHAR.307 (PDF)
- Chlorambucil (Leukeran); CP.PHAR.554
- Lomustine (Gleostine); CP.PHAR.507 (PDF)
- Lurbinectedin (Zepzelca); CP.PHAR.500 (PDF)
- Melphalan flufenamide (Pepaxto); CP.PHAR.535 (PDF)
- Temozolomide (Temodar); CP.PHAR.77 (PDF)
- Trabectedin (Yondelis); CP.PHAR.204 (PDF)
Antimetabolites
- Azacitidine (Vidaza, Onureg); CP.PHAR.387 (PDF)
- Capecitabine (Xeloda); CP.PHAR.60 (PDF)
- Mercaptopurine (Purixan); CP.PHAR.447 (PDF)
- Pemetrexed (Alimta, Pemfexy); 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)
- Amivantamab-vmjw (Rybrevant); CP.PHAR.544 (PDF)
- Atezolizumab (Tecentriq); CP.PHAR.235 (PDF)
- Avapritinib (Ayvakit); CP.PHAR.454 (PDF)
- Avelumab (Bavencio); CP.PHAR.333 (PDF)
- Belantamab mafodotin (Blenrep); 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, Daratumumab-Hyaluronidase-fihj (Darzalex, Darzalex Faspro); CP.PHAR.310 (PDF)
- Dostarlimab-gxly (Jemperli); CP.PHAR.540 (PDF)
- Durvalumab (Imfinzi); CP.PHAR.339 (PDF)
- Elotuzumab (Empliciti); CP.PHAR.308 (PDF)
- Enfortumab Vedotin-ejfv (Padcev); CP.PHAR.455 (PDF)
- Fam-trastuzumab deruxtecan-nxki (Enhertu); CP.PHAR.456 (PDF)
- Gemtuzumab (Mylotarg); CP.PHAR.358 (PDF)
- Inotuzumab ozogamicin (Besponsa); CP.PHAR.359 (PDF)
- Ipilimumab (Yervoy); CP.PHAR.319 (PDF)
- Isatuximab-irfc (Sarclisa); CP.PHAR.482 (PDF)
- Loncastuximab tesirine-lpyl (Zynlonta); CP.PHAR.539 (PDF)
- Margetuximab-cmkb (Margenza); CP.PHAR.522 (PDF)
- Mogamulizumab-kpkc (Poteligeo); CP.PHAR.139 (PDF)
- Moxetumomab pasudotox-tdfk (Lumoxiti); CP.PHAR.398 (PDF)
- Naxitamab-gqgk (Danyelza); CP.PHAR.523 (PDF)
- Necitumumab (Portrazza); CP.PHAR.320 (PDF)
- Nivolumab (Opdivo); CP.PHAR.121 (PDF)
- Obinutuzumab (Gazyva); CP.PHAR.305 (PDF)
- Ofatumumab (Arzerra, Kesimpta); 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)
- Polatuzumab vedotin-piiq (Polivy); CP.PHAR.433 (PDF)
- Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan, Hycela); CP.PHAR.260 (PDF)
- Sacituzumab govitecan-hziy (Trodelvy); CP.PHAR.475 (PDF)
- Tafasitamab-cxix (Monjuvi); CP.PHAR.508 (PDF)
- Tebentaufusp-tebn (Kimmtrak); CP.PHAR.575
- Tisotumab vedotin-tftv (Tivdak); CP.PHAR.561 (PDF)
- Trastuzumab Biosimilars Trastuzumab-Hyaluronidase; CP.PHAR.228 (PDF)
- Zanubrutinib (Brukinsa); CP.PHAR.467 (PDF)
Antineoplastic - BCL-2 Inhibitors
Antineoplastic - Cellular Immunotherapy
- Axicabtagene ciloleucel (Yescarta); CP.PHAR.362 (PDF)
- Brexucabtagene autoleucel (Tecartus); CP.PHAR.472 (PDF)
- Ciltacabtagene Autoleucel (Carvykti); CP.PHAR.553
- Lisocabtagene maraleucel (Breyanzi); CP. PHAR.483 (PDF)
- Sipuleucel-T (Provenge); CP.PHAR.120 (PDF)
- Tisagenlecleucel (Kymriah); CP.PHAR.361 (PDF)
Antineoplastic - Hedgehog Pathway Inhibitors
- Glasdegib (Daurismo); CP.PHAR.413 (PDF)
- 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 (Vantas, Supprelin LA); CP.PHAR.172 (PDF)
- Leuprolide Acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi); CP.PHAR.173 (PDF)
- Relugolix (Orgovyx) relugolix-estradiol-northindrone (Myfembree); CP.PHAR.529 (PDF)
- Toremifene (Fareston); CP.PMN.126 (PDF)
- Triptorelin pamoate (Trelstar, Triptodur); CP.PHAR.175 (PDF)
Antineoplastic - Immunomodulators
Antineoplastic – Kinase Inhibitor
Antineoplastic Antibiotics
- Mitomycin for Pyelocalyceal Solution (Jelmyto); CP.PHAR.495 (PDF)
- Mitoxantrone; OR.CP.PHAR.258 (PDF)
- Valrubicin (Valstar); CP.PHAR.439 (PDF)
Antineoplastic Combinations
- Decitabine-Cedazuridine (Inqovi); CP.PHAR.479 (PDF)
- Daunorubicin/cytarabine (Vyxeos); CP.PHAR.352 (PDF)
- Pertuzumab-trastuzumab-hyaluronidase-zzxf (Phesgo); CP.PHAR.501 (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)
- Alpelisib (Piqray); CP. PHAR.430 (PDF)
- Asciminib (Scemblix); CP.PHAR.565 (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)
- Capmatinib (Tabrecta); CP. PHAR.494 (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)
- Ibrutinib (Imbruvica); CP.PHAR.126 (PDF)
- Idecabtagene vicleucel (Abecma); CP.PHAR.481 (PDF)
- Idelalisib (Zydelig); CP.PHAR.133 (PDF)
- Imatinib (Gleevec); CP.PHAR.65 (PDF)
- Infigratinib (Truseltiq); CP.PHAR.547 (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)
- Lorlatinib (Lorbrena); CP.PHAR.406 (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)
- Pazopanib (Votrient); CP.PHAR.81 (PDF)
- Pemigatinib (Pemazyre); CP.PHAR.496 (PDF)
- Pexidartinib (Turalio); CP.PHAR.436 (PDF)
- Ponatinib (Iclusig); CP.PHAR.112 (PDF)
- Pralsetinib (Gavreto); CP.PHAR.514 (PDF)
- Regorafenib (Stivarga); CP.PHAR.107 (PDF)
- Ribociclib (Kisqali); CP.PHAR.334 (PDF)
- Ribociclib-Letrozole (Kisqali Femara); CP.PHAR.334 (PDF)
- Ripretinib (Qinlock); CP.PHAR.502 (PDF)
- Romidepsin (Istodax); CP.PHAR.314 (PDF)
- Rucaparib (Rubraca); CP.PHAR.350 (PDF)
- Ruxolitinib (Jakafi, Opzelura); CP.PHAR.98 (PDF)
- Selpercatinib (Retevmo); CP.PHAR.478 (PDF)
- Selumetinib (Koselugo); CP.PHAR.464 (PDF)
- Sirolimus Protein-Bound Particles (Fyarro), Topical Gel, (Hyftor); CP.PHAR.574
- Sorafenib (Nexavar); CP.PHAR.69 (PDF)
- Sotorasib (Lumakras); CP.PHAR.549 (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)
- Tepotinib (Tepmetko); CP.PHAR.530 (PDF)
- Tivozanib (Fortivda); CP.PHAR.538 (PDF)
- Trametinib (Mekinist); CP.PHAR.240 (PDF)
- Tucatinib (Tukysa); CP.PHAR.497 (PDF)
- Umbralisib (Ukoniq); CP.PHAR.531 (PDF)
- Vandetanib (Caprelsa); CP.PHAR.80 (PDF)
- Vemurafenib (Zelboraf); CP.PHAR.91 (PDF)
- Vorinostat (Zolinza); CP.PHAR.83 (PDF)
Antineoplastic Enzymes
- Calaspargase pegol-mknl (Asparlas); CP.PHAR.353 (PDF)
- Erwinia Asparaginase (Erwinaze, Rylaze); CP.PHAR.301 (PDF)
- Pegaspargase (Oncaspar); CP.PHAR.353 (PDF)
Antineoplastic Radiopharmaceuticals
- Iobenguane I 131 (Azedra); CP.PHAR.459 (PDF)
- Lutetium Lu 177 dotatate (Lutathera); CP.PHAR.384 (PDF)
Antineoplastics Misc.
- Belzutifan (Welireg); CP.PHAR.553 (PDF)
- Bexarotene (Targretin); CP.PHAR.75 (PDF)
- Interferon Gamma- 1b (Actimmune); CP.PHAR.52 (PDF)
- Omacetaxine (Synribo); CP.PHAR.108 (PDF)
- Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron); CP.PHAR.89 (PDF)
- Talimogene laherparepvec (Imlygic); CP.PHAR.542 (PDF)
Chemotherapy Rescue/Antidote Agents
- Dexrazoxane (Zinecard Totect); CP.PHAR.418 (PDF)
- Levoleucovorin (Fusilev, Khapzory); CP.PHAR.151 (PDF)
- Leucovorin Injection; CP.PHAR.393 (PDF)
Antineoplastic XPO1 Inhibitors
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)
- Bempedoic acid (Nexletol); CP.PMN.237 (PDF)
- Bempedoic acid-ezetimibe (Nexlizet); CP.PMN.237 (PDF)
- Colesevelam (Welchol); CP.PMN.250 (PDF)
- Evinacumab-dgnb (Evkeeza); CP.PHAR.511 (PDF)
- Evolocumab (Repatha); CP.PHAR.123 (PDF)
- Icosapent ethyl (Vascepa); OR.CP.PMN.187 (PDF)
- Inclisiran (Leqvio); OR.PHAR.568 (PDF)
- Lomitapide (Juxtapid); CP.PHAR.283 (PDF)
- Omega-3-Acid Ethyl Esters (Lovaza); CP.PMN.52 (PDF)
Antihypertensives
- ACEI and ARB Duplicate Therapy; CP.PMN.61 (PDF)
- 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)
- Camzyos (mavacamten); CP.PMN.272
- 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 (Soriatane); OR.CP.PMN.40 (PDF)
- Abametapir (Xeglyze); CP.PMN.253 (PDF)
- Adapalene (Differin, Plixda); OR.CP.PMN.1012 (PDF)
- Adapalene - Benzoyl peroxide (Epiduo, Epiduo Fote); OR.CP.PMN.1012 (PDF)
- Afamelanotide (Scenesse); CP.PHAR.444 (PDF)
- Azelaic acid (Azelex, Finacea, Finevin); OR.CP.PMN.1012 (PDF)
- Benzoyle peroxide (Benzac); OR.CP.PMN.1012 (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); OR.CP.PMN.1012 (PDF)
- Clindamycin phosphate-Benzoyle peroxide (Benzaclin); OR.CP.PMN.1012 (PDF)
- Clindamycin phosphate-Tretinoin (Ziana); OR.CP.PMN.1012 (PDF)
- Crisaborole (Eucrisa); OR.CP.PMN.1009 (PDF)
- Dapsone (Aczone); OR.CP.PMN.1012 (PDF)
- Dicolfenac (Pennsaid); CP.PMN.274
- Doxycycline Hyclate (Acticlate, Doryx); OR.CP.PMN.1012 (PDF)
- Doxycycline monohydrate (Oracea); OR.CP.PMN.1012 (PDF)
- Dupilumab (Dupixent); CP.PHAR.336 (PDF)
- Erythromycin; OR.CP.PMN.1012 (PDF)
- Erythromycin-Benzoyl peroxide (Benzamycin); OR.CP.PMN.1012 (PDF)
- Guselkumab (Tremfya); CP.PHAR.364 (PDF)
- Halobetasol Propionate Lotion (Bryhali, Lexette, Ultravate); CP.PMN.180 (PDF)
- Halobetasol-Tazarotene (Duobrii); CP.PMN.208 (PDF)
- Isotretinoin (Claravis, Absorica, Absorica LD, Myorisan, Zenatane, Amnesteem); OR.CP.PMN.1012 (PDF)
- Ixekizumab (Taltz); CP.PHAR.257 (PDF)
- Lidocaine-prilocaine (EMLA); OR.CP.PMN.1004 (PDF)
Lidocaine Transdermal (Lidoderm, ZTlido); OR.CP.PMN.08
(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); OR.CP.PMN.1009 (PDF)
- Risankizumab-rzaa (Skyrizi); CP.PHAR.426 (PDF)
- Secukinumab (Cosentyx); CP.PHAR.261 (PDF)
- Tacrolimus (Protopic); OR.CP.PMN.1009 (PDF)
- Tazarotene (Arazlo, Fabior, Tazorac); OR.CP.PMN.1009 (PDF)
- Tildrakizumab-asmn (Ilumya); CP.PHAR.386 (PDF)
- Tralokinumab-ldrm (Adbry); CP.PHAR.577 (PDF)
- Tretinoin (Retin-A); OR.CP.PMN.1012 (PDF)
- Trifarotene (Aklief); CP.PMN.225 (PDF)
- Ustekinumab (Stelara); CP.PHAR.264 (PDF)
Adrenal Steroid Inhibitors
Aldosterone Receptor Antagonists
Androgen
Antidiabetics
- Albiglutide (Tanzeum); OR.CP.PMN.183 (PDF)
- Alogliptin (Nesina); OR.CP.PMN.03 (PDF)
- Alogliptin/metformin (Kazano); OR.CP.PMN.03 (PDF)
- Alogliptin/pioglitazone (Oseni); OR.CP.PMN.03 (PDF)
- Canagliflozin (Invokana); OR.CP.PMN.14 (PDF)
- Canagliflozin/metformin (Invokamet, Invokamet XR); OR.CP.PMN.14 (PDF)
- Dapagliflozin propanediol (Farxiga); OR.CP.PMN.14 (PDF)
- Dapagliflozin/metformin (Xigduo XR); OR.CP.PMN.14 (PDF)
- Dapagliflozin/saxagliptin (Qtern); OR.CP.PMN.14 (PDF)
- Dulaglutide (Trulicity); OR.CP.PMN.183 (PDF)
- Empagliflozin (Jardiance); OR.CP.PMN.14 (PDF)
- Empagliflozin/linagliptin (Glyxambi); OR.CP.PMN.14 (PDF)
- Empagliflozin/metformin (Synjardy, Synjardy XR); OR.CP.PMN.14 (PDF)
- Ertugliflozin (Steglatro); OR.CP.PMN.14 (PDF)
- Exenatide ER (Bydureon, Bydureon BCise); OR.CP.PMN.183 (PDF)
- Exenatide IR (Byetta); OR.CP.PMN.183 (PDF)
- Linagliptin (Tradjenta); OR.CP.PMN.03 (PDF)
- Linagliptin/metformin (Jentadueto, Jentadueto XR); OR.CP.PMN.03 (PDF)
- Liraglutide (Victoza); OR.CP.PMN.183 (PDF)
- Lixisenatide (Adlyxin); OR.CP.PMN.183 (PDF)
- Lixisenatide/insulin glargine (Soliqua); OR.CP.PMN.183 (PDF)
- Metformin ER (Glumetza Fortamet); CP.PMN.72 (PDF)
- Pramlintide (Symlin); CP.PMN.129 (PDF)
- Saxagliptin (Onglyza); OR.CP.PMN.03 (PDF)
- Saxagliptin/metformin (Kombiglyze XR); OR.CP.PMN.03 (PDF)
- Semaglutide (Ozempic); OR.CP.PMN.183 (PDF)
- Sitagliptin (Januvia); OR.CP.PMN.03 (PDF)
- Sitagliptin/metformin (Janumet, Janumet XR); OR.CP.PMN.03 (PDF)
Bone Density Regulators
- Abaloparatide (Tymlos); CP.PHAR.345 (PDF)
- Alendronate (Binosto, Fosamax plus D); CP.PMN.88 (PDF)
- Denosumab (Prolia, Xgeva); CP.PHAR.58 (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
- Budesonide (Tarpeyo); CP.PHAR.572 (PDF)
- Deflazacort (Emflaza); CP.PHAR.331 (PDF)
- Triamcinolone ER Injection (Zilretta); CP.PHAR.371 (PDF)
Corticotropin
Estrogen Combinations
Gender Dysphoria Treatment Agents
- Estradiol (Alora, Climara, Divigel, Dotti, Elestrin, Estrace, EstroGel, Evamist, Gynodiol, Imvexxy, Menostar, Minivelle, Vivelle-Dot, Yuvafem); OR.CP.PHAR.1002 (PDF)
- Goserelin (Zoladex); OR.CP.PHAR.1002 (PDF)
- Histrelin Acetate (Supprelin LA, Vantas); OR.CP.PHAR.1002 (PDF)
- Leuprolide Acetate (Eligard, Lupron Depot, Lupron Depot-Ped); OR.CP.PHAR.1002 (PDF)
- Nafarelin Acetate (Synarel); OR.CP.PHAR.1002 (PDF)
- Testosterone (Androderm, Androge, Aveed, Axiron, Delatestryl, Depo-Testosterone, Fortesta, Natesto, Striant, Testim, Testopel, Vogelxo, Xyosted); OR.CP.PHAR.1002 (PDF)
- Triptorelin Pamoate (Trelstar, Triptodur); OR.CP.PHAR.1002 (PDF)
GNRH/LHRH Antagonists
Growth Hormone Receptor Antagonists
Growth Hormone Releasing Hormones
Growth Hormones
- Somapacitan-beco (Sogrova); OR.CP.PHAR 517 (PDF)
- Somatropin (Genotropin, Humatrope, Norditropin, Nutropin, Qmnitrope, Zomacton, Saizen, Serostim, Zorbtive); OR.CP.PHAR.517 (PDF)
Insulin-Like Growth Factors
- Lanreotide (Somatuline Depot); CP.PHAR.391 (PDF)
- Mecasermin (Increlex); CP.PHAR.150 (PDF)
- Octreotide Acetate (Sandostatin, Sandostatin LAR, Bynfezia, Mycapssa); CP.PHAR.40 (PDF)
- Pasireotide (Signifor, 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)
- Avalglucosidase alfa-ngpt (Nexviazyme); CP.PHAR.521 (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
Natriuretic Peptides
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)
Somatostatic Agents
- Lanreotide (Somatuline Depot); CP.PHAR.391 (PDF)
- Octreotide Acetate (Sandostatin, Sandostatin LAR, Bynfezia, Mycapssa); CP.PHAR.40 (PDF)
- Pasireotide (Signifor LAR); CP.PHAR.332
Vasopressin Receptor Antagonists
Antiemetics
- Amisulpride (Barhemsys); CP.PMN.236 (PDF)
- 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)
- Netupitant/palonosetron (Akynzeo); CP.PMN.158 (PDF)
- Ondansetron (Zuplenz); CP.PMN.45 (PDF)
- Rolapitant (Varubi); CP.PMN.102 (PDF)
Digestive Aids
Diuretics
Gastrointestinal Agents - Misc.
- Alosetron (Lotronex); OR.CP.PMN.1005 (PDF)
- Alvimopan (Entereg); OR.CP.PMN.1005 (PDF)
- Certolizumab (Cimzia); CP.PHAR.247 (PDF)
- Chenodiol (Chenodal); CP.PMN.239 (PDF)
- Cholic Acid (Cholbam); CP.PHAR.390 (PDF)
- Dalfampridine (Ampyra); CP.PHAR.248 (PDF)
- Eluxadoline (Viberzi); OR.CP.PMN.1005 (PDF)
- Ferric citrate (Auryxia); CP.PMN.04 (PDF)
- Infliximab (Avsola, Inflectra, Remicade, Renflexis); CP.PHAR.254 (PDF)
- Lanthanum carbonate (Fosrenol); CP.PMN.04 (PDF)
- Linaclotide (Linzess); OR.CP.PMN.1005 (PDF)
- Lubiprostone (Amitiza); OR.CP.PMN.1005 (PDF)
- Maralixibat (Livmarli); CP.PHAR.543 (PDF)
- Methylnaltrexone (Relistor); OR.CP.PMN.1005 (PDF)
- Metoclopramide (Gimoti); CP.PMN.252 (PDF)
- Naldemedine (Symproic); OR.CP.PMN.1005 (PDF)
- Naloxegol (Movantik); OR.CP.PMN.1005 (PDF)
- Obeticholic acid (Ocaliva); CP.PHAR.287 (PDF)
- Odevixibat (Bylvay); CP.PHAR.528 (PDF)
- Plecanatide (Trulance); OR.CP.PMN.1005 (PDF)
- Prucalopride (Motegrity); OR.CP.PMN.1005 (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); OR.CP.PMN.1005 (PDF)
- Telotristat ethyl (Xermelo); CP.PHAR.337 (PDF)
- Tenapanor (Ibsrela); OR.CP.PMN.1005 (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)
- Pentosan polysulfate sodium (Elmiron); CP.PMN.276
- Tadalafil (Cialis); CP.PMN.132 (PDF)
Gout Agents
- Colchcine (Colcrys, Mitigare); CP.PMN.123 (PDF)
- Febuxostat (Uloric); CP.PMN.57 (PDF)
- Pegloticase (Krystexxa); CP.PHAR.115 (PDF)
Ulcer Drugs
Urinary Antispasmodics
- Fesoterodine (Toviaz); CP.PMN.198 (PDF)
- Mirabegron (Myrbetriq); CP.PMN.198 (PDF)
- Solifenacin (Vesicare); CP.PMN.198 (PDF)
Vaginal Products
- Estradiol (Femring); CP.PMN.263 (PDF)
- Lactic acid-citric acid-potassium bitartrate (Phexxi); CP.PMN.251 (PDF)
- Prasterone (Intrarosa); CP.PMN.99 (PDF)
Anticoagulants
- Antithrombin III (ATryn, Thrombate III); CP.PHAR.564 (PDF)
- 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)
- Rivaroxaban (Xarelto); CP.PMN.247 (PDF)
Hematological Agents - Misc.
- Anti-inhibitor Coagulant Complex (Feiba); CP.PHAR.217 (PDF)
- Aspirin-dipyridamole (Aggrenox); CP.PMN.20 (PDF)
- Avacopan (Tavneos); CP.PHAR.515 (PDF)
- Berotralstat; CP.PHAR.485 (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)
- Fibrinogen concentrate (human) (Fibryga, RiaSTAP); CP.PHAR.526 (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)
- Mitapivat (Pyrukynd); CP.PHAR.558 (PDF)
- Pegcetacoplan (Empaveli); CP.PHAR.524 (PDF)
- Plasminogen, human-tvmh (Ryplazim); CP.PHAR.513 (PDF)
- Protein C Concentrate Human (Ceprotin); CP.PHAR.330 (PDF)
- Ravulizumab-cwvz (Ultomiris); CP.PHAR.415 (PDF)
- Sutimlimab-jome (Enjaymo); CP.PHAR.503 (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 Derisomaltose (Monoferric); CP.PHAR.480 (PDF)
- Ferric Gluconate (Ferrlecit); CP.PHAR.166 (PDF)
- Ferric maltol (Accrufer); CP.PMN.213 (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, Fulphila, Udenyca, Ziextenzo); 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)
Chelating Agents
Diabetic Supplies
- Continuous Glucose Monitors; OR.CP.PMN.214 (PDF)
- Insulin Delivery Systems (V-Go, Omnipod, InPen); CP.PHAR.534 (PDF)
- Diabetic Test Strip Quantity Limit – Not Receiving Insulin; OR.CP.PMN.151 (PDF)
- Non-preferred blood glucose monitors and test strips; CP.PMN.215 (PDF)
Diagnostic Products
Endocrine-Metabolic Agent
Enzymes
Immunological Agent
Immunomodulators
Immunosuppressive Agents
- Antithymocyte Globulin (Atgam, Thymoglobulin); CP.PHAR.506 (PDF)
- Belatacept (Nulojix); CP.PHAR.201 (PDF)
- Belumosudil (Rezurock); CP.PHAR.552 (PDF)
- Emapalumab-lzsg (Gamifant); CP.PHAR.402 (PDF)
- Inebilizumab-cdon (Uplizna) CP.PHAR.458 (PDF)
- Satralizumab (Enspryng); CP.PHAR.463 (PDF)
- Voclosporin (Lupkynis); CP.PHAR.504 (PDF)
Nutrients
Potassium Removing Agents
Other Misc. Drugs
Systemic Lupus Erythematosus Agents
Tissue Products
Wound Care Products
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)
- 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)
- Setmelanotide (Imcivree); CP.PHAR.491 (PDF)
- Solriamfetol (Sunosi); CP.PMN.209 (PDF)
- Viloxazine (Qelbree); CP.PMN.264 (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)
- Fenfluramine (Fintepla); CP.PMN.246 (PDF)
- Lacosamide (Vimpat); CP.PMN.155 (PDF)
- Midazolam (Nayzilam); CP.PMN.211 (PDF)
- Perampanel (Fycompa); CP.PMN.156 (PDF)
- Pregabalin (Lyrica, Lyrica CR); OR.CP.PMN.33
- 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)
- Apomorphine (Apokyn, Kynmobi); CP.PHAR.488 (PDF)
- Carbidopa-Levodopa ER Capsules (Rytary), Enteral Suspension (Duopa); CP.PHAR.238 (PDF)
- Istradefylline (Nourianz); CP.PMN.217 (PDF)
- Levodopa Inhalation Powder (Inbrija); CP.PMN.267 (PDF)
- Opicapone (Ongentys); CP.PMN.245 (PDF)
- Safinamide (Xadago); CP.PMN.113 (PDF)
Hypnotics/Sedatives/Sleep Disorder Agents
- Doxepin (Silenor); OR.CP.PMN.1003 (PDF)
- Eszopiclone (Lunesta); OR.CP.PMN.1003 (PDF)
- Lemborexant (Dayvigo); CP.PMN.233 (PDF)
- Ramelteon (Rozerem); OR.CP.PMN.1003 (PDF)
- Suvorexant (Belsomra); OR.CP.PMN.1003 (PDF)
- Tasimelteon (Hetlioz); OR.CP.PMN.1003 (PDF)
- Temazepam (Restoril); OR.CP.PMN.1003 (PDF)
- Triazolam (Halcion); OR.CP.PMN.1003 (PDF)
- Zaleplon (Sonata); OR.CP.PMN.1003 (PDF)
- Zolpidem (Ambien, Ambien CR, Edluar, Intermezzo, Zolpimist); OR.CP.PMN.1003 (PDF)
Migraine Products
- Atogepant (Qulipta); CP.PHAR.566 (PDF)
- Eptinezumab (Vyepti); CP.PHAR.489 (PDF)
- 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)
- Rimegepant (Nurtec ODT); CP.PHAR.490 (PDF)
- Ubrogepant (Ubrelvy); CP.PHAR.476 (PDF)
Psychotherapeutic and Neurological Agents - Misc.
- Aducanumab (Aduhelm); CP.PHAR.468 (PDF)
- Alemtuzumab (Lemtrada); OR.CP.PHAR.243 (PDF)
- Bremelanotide (Vyleesi); CP.PHAR.434 (PDF)
- Bupropion (Zyban); OR.CP.PMN.1008 (PDF)
- Cladribine (Mavenclad); OR.CP.PHAR.422 (PDF)
- Deutetrabenazine (Austedo); OR.CP.PHAR.1004 (PDF)
- Dextromethorphan-Quinidine (Nuedexta); CP.PMN.93 (PDF)
- Dimethyl fumarate (Tecfidera); OR.CP.PHAR.249 (PDF)
- Diroximel fumarate (Vumerity); OR.CP.PHAR.249 (PDF)
- Esketamine (Spravato); CP.PMN.199 (PDF)
- Fingolimod (Gilenya); OR.CP.PHAR.251 (PDF)
- Fosdenopterin (Nulibry); CP.PHAR.471 (PDF)
- Gabapentin ER (Gralise, Horizant); CP.PMN.240 (PDF)
- Glatiramer (Copaxone, Glatopa); OR.CP.PHAR.252 (PDF)
- Interferon beta-1a (Avonex, Rebif); OR.CP.PHAR.255 (PDF)
- Interferon beta-1b (Betaseron, Extavia); OR.CP.PHAR.256 (PDF)
- Inotersen (Tegsedi); CP.PHAR.405 (PDF)
- Lofexidine (Lucemyra); CP.PMN.152 (PDF)
- Milnacipran (Savella); CP.PMN.125 (PDF)
- Monomethyl fumarate (Bafiertam); OR.CP.PHAR.249 (PDF)
- Natalizumab (Tysabri); OR.CP.PHAR.259 (PDF)
- Nicotine Cartridge (Nicotrol); OR.CP.PMN.1008 (PDF)
- Nicotine Gum (Nicorette, Nicorelief); OR.CP.PMN.1008 (PDF)
- Nicotine Lozenge (Nicorettte, Commit); OR.CP.PMN.10082 (PDF)
- Nicotine Patch (Nicoderm, NTS); OR.CP.PMN.1008 (PDF)
- Nicotine Spray (Nicotrol NS); OR.CP.PMN.1008 (PDF)
- Ocrelizumab (Ocrevus); OR.CP.PHAR.335 (PDF)
- Ozanimod (Zeposia); CP.PHAR.462 (PDF)
- Patisiran (Onpattro); CP.PHAR.395 (PDF)
- Peginterferon beta-1a (Plegridy); OR.CP.PHAR.271 (PDF)
- Ponesimod (Ponvory); OR.CP.PHAR.537 (PDF)
- Rivastigmine (Exelon); CP.PMN.101 (PDF)
- Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, Sodium Oxybate (Xywav); CP.PMN.42 (PDF)
- Siponimod (Mayzent); OR.CP.PHAR.427 (PDF)
- Teriflunomide (Aubagio); OR.CP.PHAR.262 (PDF)
- Tetrabenazine (Xenazine); OR.CP.PHAR.1004 (PDF)
- Valbenazine (Ingrezza); OR.CP.PHAR.1004 (PDF)
- Varenicline (Chantix); OR.CP.PMN.1008 (PDF)
- AbobotulinumtoxinA (Dysport); CP.PHAR.230 (PDF)
- Casimersen (Amondys 45); 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 (Evrysdi); CP.PHAR.477 (PDF)
- Viltolarsen (Viltepso); CP.PHAR.484 (PDF)
- Aflibercept (Eylea); CP.PHAR.184 (PDF)
- Bimatoprost Implant (Durysta); CP.PHAR.486 (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, Xipere, Yutiq); CP.PHAR.385 (PDF)
- Cyclosporine ophthalmic emulsion (Cequa, Restasis, Verkazia); CP.PMN.48 (PDF)
- Cysteamine ophthalmic (Cystaran, Cystadrops); CP.PMN.130 (PDF)
- Lantanoprostene Bunod (Vyzulta); CP.PMN.108 (PDF)
- Netarsudil (Rhopressa); CP.PMN.118 (PDF)
- Netarsudil-Latanoprost (Rocklatan); CP.PMN.118 (PDF)
- Ophthalmic Riboflavin (Photrexa, Photrexa Viscous); CP.PHAR.536 (PDF)
- Oxymetazoline (Rhofade, Upneeq); CP.PMN.86 (PDF)
- Pegaptanib (Macugen); CP.PHAR.185 (PDF)
- Pilocarpine (Vuity); CP.PMN.270
- Ranibizumab (Lucentis); CP.PHAR.186 (PDF)
- Verteporfin (Visudyne); CP.PHAR.187 (PDF)
- Voretigene neparvovec-rzyl (Luxturna); CP.PHAR.372 (PDF)
Antiasthmatic and Bronchodilator Agents
- Aclidinium-formoterol (Duaklir Pressair); CP.PMN.259 (PDF)
- Albuterol (ProAir Digihaler); CP.PMN.259 (PDF)
- Arformoterol tartrate (Brovana); CP.PMN.259 (PDF)
- Benralizumab (Fasenra); CP.PHAR.373 (PDF)
- Budesonide (Pulmicort Respules, Pulmicort Flexhaler); CP.PMN.259 (PDF)
- Budesonide-formoterol (Symbicort); CP.PMN.259 (PDF)
- Budesonide-glycopyrrolate-formoterol fumarat (Breztri Aerosphere); CP.PMN.259 (PDF)
- Ciclesonide (Alvesco); CP.PMN.259 (PDF)
- Fluticasone (Armonair Digihaler, Flovent Diskus); CP.PMN.259 (PDF)
- Fluticasone/salmeterol (Advair Diskus, Advair HFA); CP.PMN.259 (PDF)
- Fluticasone-umeclidinium-vilanterol (Trelegy Ellipta); CP.PMN.259 (PDF)
- Fluticasone-vilanterol (Breo Ellipta); CP.PMN.259 (PDF)
- Formoterol (Perforormist); CP.PMN.259 (PDF)
- Glycopyrrolate (Seebri Neohaler, Lonhala Magnair); CP.PMN.259 (PDF)
- Glycopyrrolate/formoterol (Bevespi Aerosphere); CP.PMN.259 (PDF)
- Indacaterol (Arcapta Neohaler); CP.PMN.259 (PDF)
- Indacaterol-glycopyrrolate (Utibron Neohaler); CP.PMN.259 (PDF)
- Levalbuterol (Xopenex); CP.PMN.259 (PDF)
- Mepolizumab (Nucala); CP.PHAR.200 (PDF)
- Mometasone (Asmanex HFA, Asmanex Twisthaler); CP.PMN.259 (PDF)
- Mometasone-formoterol (Dulera); CP.PMN.259 (PDF)
- Olodaterol (Striverdi Respimat); CP.PMN.259 (PDF)
- Omalizumab (Xolair); CP.PHAR.01 (PDF)
- Reslizumab (Cinqair); CP.PHAR.223 (PDF)
- Revefenacin (Yupelri); CP.PMN.259 (PDF)
- Roflumilast (Daliresp); CP.PMN.46 (PDF)
- Tezepelumab (Tezspire); CP.PHAR.576 (PDF)
- Tiotropium bromide monohydrate (Spiriva Handihaler, Spiriva Respimat); CP.PMN.259 (PDF)
- Tiotropium-olodaterol (Stiolto Respimat); CP.PMN.259 (PDF)
- Umeclidinium-vilanterol (Anoro Ellipta); CP.PMN.259 (PDF)
Respiratory Agents - Misc
- 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)
- Mannitol (Bronchitol); CP.PHAR.518; (PDF)
- Nintedanib esylate (Ofev); OR.CP.PHAR.1001 (PDF)
- Pirfenidone (Esbriet); OR.CP.PHAR.1001 (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: October 01, 2020 - CP.PP.501 30-Day Readmission (PDF)
Effective: February 15, 2022 - 3-Day Payment Window (PDF)
Effective: April 15, 2018 - Add on Code Billed Without Primary Code (PDF)
Effective: January 01, 2018 - Allergy Testing (PDF)
Effective: May 15, 2021 - Digital EEG Spike Analysis (PDF)
Effective: May 15, 2021 - Bronchial Thermoplasty (PDF)
Effective: May 15, 2021 - Laser Therapy for Skin Conditions (PDF)
Effective: May 15, 2021 - Cardiac Biomarker Testing (PDF)
Effective: May 15, 2021 - Ambulatory EEG (PDF)
Effective: May 15, 2021 - Wheelchair Seating (PDF)
Effective: May 15, 2021 - Scanning Computerized Ophthalmic Diagnostic Imaging (PDF)
Effective: May 15, 2021 - Fundus Photography (PDF)
Effective: May 15, 2021 - Visual Field Testing (PDF)
Effective: May 15, 2021 - Assistant Surgeon (PDF)
Effective: January 01, 2018 - Bilateral Procedures (PDF)
Effective: January 01, 2018 - Cerumen Removal (PDF)
Effective: January 01, 2018 - Clean Claims (PDF)
Effective: January 01, 2018 - CLIA Number (PDF)
Effective: January 01, 2018 - Code Editing Overview (PDF)
Effective: February 15, 2021 - Coding Overview (PDF)
Effective: January 01, 2018 - Distinct Procedural Modifiers (PDF)
Effective: January 01, 2018 - Duplicate Primary Code Billing (PDF)
Effective: January 01, 2018 - E&M Medical Decision-Making (PDF)
Effective: January 01, 2018 - EM Bundling Edits (PDF)
Effective: January 01, 2018 - Global Maternity Billing (PDF)
Effective: January 01/18 - Hospital Visit Codes Billed with Labs (PDF)
Effective: January 01, 2018 - Inpatient Consultation (PDF)
Effective: January 01, 2018 - Inpatient Only Procedures (PDF)
Effective: January 01, 2018 - IV Hydration (PDF)
Effective: January 01, 2018 - Leveling of ED Services (PDF)
Effective: October 01, 2019 - Maximum Units (PDF)
Effective: January 01, 2018 - Moderate Conscious Sedation (PDF)
Effective: January 01, 2018 - Modifier -25 clinical validation (PDF)
Effective: January 01, 2018 - Modifier -59 clinical validation (PDF)
Effective: January 01, 2018 - Modifier DOS Validation (PDF)
Effective: January 01, 2018 - Modifier to Procedure Code Validation (PDF)
Effective: January 01, 2018 - Multiple CPT Code Replacement (PDF)
- Effective: January 01, 2018
- NCCI Unbundling (PDF)
Effective: January 01, 2018 - Never Paid Events (PDF)
Effective: January 01, 2018 - New Patient (PDF)
Effective: January 01, 2018 - Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective: October 01, 2018 - Outpatient Consultation (PDF)
Effective: January 01, 2018 - Physician Visit Codes Billed with Labs (PDF)
Effective: January 01, 2018 - Physician's Consultation Services (PDF)
Effective: April 15, 18 - Place of Service Mismatch (PDF)
Effective: October 01, 2018 - Post-Operative Visits (PDF)
Effective: January 01, 2018 - Pre-Operative Visits (PDF)
Effective: January 01, 2018 - Professional Component (PDF)
Effective: January 01, 2018 - PROM Testing (PDF)
Effective: January 01, 2018 - Pulse Oximetry (PDF)
Effective: January 01, 2018 - Same Day Visits (PDF)
Effective: January 01, 2018 - Status "B" Bundled Services (PDF)
Effective: January 01, 2018 - Status "P" Bundled Services (PDF)
Effective: October 01, 2019 - Supplies Billed on Same Day As Surgery (PDF)
Effective: January 01, 2018 - Transgender Related Services (PDF)
Effective: January 01, 2018 - Unbundled Professional Services (PDF)
Effective: January 01, 2018 - Unbundled Surgical Procedures (PDF)
Effective: January 01, 2018 - Unlisted Procedure Codes (PDF)
Effective: January 01, 2018 - Urine Specimen Validity Testing (PDF)
Effective: April 15, 2018 - Sleep Studies POS (PDF)
Effective: January 15, 2021 - Robotic Surgery (PDF)
Effective: January 15, 2021 - 3-Day Payment Window (PDF)
Effective: January 15, 2021 - Lab Quantity Limits (PDF)
Effective: January 15, 2021 - Renal Hemodialysis (PDF)
Effective: January 15, 2021 - CP.MP.38 Ultrasound in Pregnancy (PDF)
Effective: April 01, 2021 - CP.MP.97 Testing for Select GU Conditions (PDF)
Effective: April 01, 2021-June 23, 2022 - CP.MP.97 Testing for Select GU Conditions (PDF)
Effective: June 24, 2022 - CP.MP.106 Endometrial Ablation (PDF)
Effective: April 01, 2021 - CP.MP.113 Holter Monitors (PDF)
Effective: April 01, 2021 - CP.MP.125 DNA Analysis of Stool to Screen for Colorectal Cancer (PDF)
Effective: April 01, 2021 - CP.MP.149 Testing for Rupture of Fetal Membranes (PDF)
Effective: April 01, 2021 - CP.MP.152 Measurement of Serum 1,25-dihydroxyvitamin D (PDF)
Effective: April 01, 2021 - CP.MP.153 H Pylori Serology Testing (PDF)
Effective: April 01, 2021 - CP.MP.154 Thyroid Hormones and Insulin Testing in Pediatrics (PDF)
Effective: April 01, 2021 - CP.MP.156 Cardiac Biomarker Testing for Acute Myocardial Infarction (PDF)
Effective: April 01, 2021 - CP.MP.157 25-hydroxyvitamin D Testing in Children and Adolescents (PDF)
Effective: April 01, 2021 - CP.PP.070 340B Drug Payment Reduction (PDF)
Effective: July 01, 2021 - CP.MP.208 Outpatient Testing for Drugs of Abuse: Presumptive Frequency Edits (PDF)
Effective: July 01, 2021 - CP.MP.155 EEG in the Evaluation of Headache (PDF)
Effective: July 01, 2021-June 23, 2022 - CP.MP.155 EEG in the Evaluation of Headache (PDF)
Effective: June 24, 2022 - OC.UM.CP.0026 Extended Ophthalmoscopy (PDF)
Effective: July 01, 2021 - OC.UM.CP.0043 External Ocular Photography (PDF)
Effective: July 01, 2021 - CP.MP.103 FeNO Testing (PDF)
Effective: July 01, 2021 - OC.UM.CP.0028 Flourescein Angiography (PDF)
Effective: July 01, 2021
- CC.MP.50 Outpatient Testing for Drugs of Abuse (PDF)
Effective: October 01, 2020 - CC.PP.065 Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF)
Effective: October 01, 2020 - CC.PP.501 30-Day Readmission (PDF)
Effective: February 15, 2022 - 3-Day Payment Window (PDF)
Effective: April 15, 2018 - Add on Code Billed Without Primary Code (PDF)
Effective: January 01, 2018 - Allergy Testing (PDF)
Effective: May 15, 2021 - Digital EEG Spike Analysis (PDF)
Effective: May 15, 2021 - Bronchial Thermoplasty (PDF)
Effective: May 15, 2021 - Laser Therapy for Skin Conditions (PDF)
Effective: May 15, 2021 - Cardiac Biomarker Testing (PDF)
Effective: May 15, 2021 - Ambulatory EEG (PDF)
Effective: May 15, 2021 - Wheelchair Seating (PDF)
Effective: May 15, 2021 - Scanning Computerized Ophthalmic Diagnostic Imaging (PDF)
Effective: May 15, 2021 - Fundus Photography (PDF)
Effective: May 15, 2021 - Visual Field Testing (PDF)
Effective: May 15, 2021 - Assistant Surgeon (PDF)
Effective: January 01, 2018 - Bilateral Procedures (PDF)
Effective: January 01, 2018 - Cerumen Removal (PDF)
Effective: January 01, 2018 - Clean Claims (PDF)
Effective: January 01, 2018 - CLIA Number (PDF)
Effective: January 01, 2018 - Code Editing Overview (PDF)
Effective: February 15, 2021 - Coding Overview (PDF)
Effective: January 01, 2018 - Distinct Procedural Modifiers (PDF)
Effective: January 01, 2018 - Duplicate Primary Code Billing (PDF)
Effective: January 01, 2018 - E&M Medical Decision-Making (PDF)
Effective: January 01, 2018 - EM Bundling Edits (PDF)
Effective: January 01, 2018 - Global Maternity Billing (PDF)
Effective: January 01, 2018 - Hospital Visit Codes Billed with Labs (PDF)
Effective: January 01, 2018 - Inpatient Consultation (PDF)
Effective: January 01, 2018 - Inpatient Only Procedures (PDF)
Effective: January 01, 2018 - IV Hydration (PDF)
Effective: January 01, 2018 - Leveling of ED Services (PDF)
Effective: October 01, 2019 - Maximum Units (PDF)
Effective: January 01, 2018 - Moderate Conscious Sedation (PDF)
Effective: January 01, 2018 - Modifier -25 clinical validation (PDF)
Effective: January 01, 2018 - Modifier -59 clinical validation (PDF)
Effective: January 01, 2018 - Modifier DOS Validation (PDF)
Effective: January 01, 2018 - Modifier to Procedure Code Validation (PDF)
Effective: January 01, 2018 - Multiple CPT Code Replacement (PDF)
- Effective: January 01, 2018
- NCCI Unbundling (PDF)
Effective: January 01, 2018 - Never Paid Events (PDF)
Effective: January 01, 2018 - New Patient (PDF)
Effective: January 01, 2018 - Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective: October 01, 2018 - Outpatient Consultation (PDF)
Effective: January 01, 2018 - Physician Visit Codes Billed with Labs (PDF)
Effective: January 01, 2018 - Physician's Consultation Services (PDF)
Effective: April 15, 2018 - Place of Service Mismatch (PDF)
Effective: October 01, 2018 - Post-Operative Visits (PDF)
Effective: January 01, 2018 - Pre-Operative Visits (PDF)
Effective: January 01, 2018 - Professional Component (PDF)
Effective: January 01, 2018 - PROM Testing (PDF)
Effective: January 01, 2018 - Pulse Oximetry (PDF)
Effective: January 01, 2018 - Same Day Visits (PDF)
Effective: January 01, 2018 - Status "B" Bundled Services (PDF)
Effective: January 01, 2018 - Status "P" Bundled Services (PDF)
Effective: October 01, 2019 - Supplies Billed on Same Day As Surgery (PDF)
Effective: January 01, 2018 - Transgender Related Services (PDF)
Effective: January 01, 2018 - Unbundled Professional Services (PDF)
Effective: January 01, 2018 - Unbundled Surgical Procedures (PDF)
Effective: January 01, 2018 - Unlisted Procedure Codes (PDF)
Effective: January 01, 2018 - Urodynamic Testing (PDF)
Effective: October 01, 2019 - Urine Specimen Validity Testing (PDF)
Effective: April 15, 2018 - Sleep Studies POS (PDF)
Effective: January 15, 2021 - Robotic Surgery (PDF)
Effective: January 15, 2021 - 3-Day Payment Window (PDF)
Effective: January 15, 2021 - Lab Quantity Limits (PDF)
Effective: January 15, 2021 - Renal Hemodialysis (PDF)
Effective: January 15, 2021 - CP.MP.38 Ultrasound in Pregnancy (PDF)
Effective: April 01, 2021 - CP.MP.97 Testing for Select GU Conditions (PDF)
Effective: April 01, 2021-June 23, 2022 - CP.MP.97 Testing for Select GU Conditions (PDF)
Effective: June 24, 2022 - CP.MP.106 Endometrial Ablation (PDF)
Effective: April 01, 2021 - CP.MP.113 Holter Monitors (PDF)
Effective: April 01, 2021 - CP.MP.125 DNA Analysis of Stool to Screen for Colorectal Cancer (PDF)
Effective: April 01, 2021 - CP.MP.149 Testing for Rupture of Fetal Membranes (PDF)
Effective: April 01, 2021 - CP.MP.152 Measurement of Serum 1,25-dihydroxyvitamin D (PDF)
Effective: April 01, 2021 - CP.MP.153 H Pylori Serology Testing (PDF)
Effective: April 01, 2021 - CP.MP.154 Thyroid Hormones and Insulin Testing in Pediatrics (PDF)
Effective: April 01, 2021 - CP.MP.156 Cardiac Biomarker Testing for Acute Myocardial Infarction (PDF)
Effective: April 01, 2021 - CP.MP.157 25-hydroxyvitamin D Testing in Children and Adolescents (PDF)
Effective: April 01, 2021 - CP.MP.121 Homocysteine Testing (PDF)
Effective: April 01, 2021 - CP.MP.208 Outpatient Testing for Drugs of Abuse: Presumptive Frequency Edits (PDF)
Effective: July 01, 2021 - CP.MP.155 EEG in the Evaluation of Headache (PDF)
Effective: July 01, 2021-June 23, 2022 - CP.MP.155 EEG in the Evaluation of Headache (PDF)
Effective: June 24, 2022 - OC.UM.CP.0026 Extended Ophthalmoscopy (PDF)
Effective: July 01, 2021 - OC.UM.CP.0043 External Ocular Photography (PDF)
Effective: July 01, 2021 - CP.MP.103 FeNO Testing (PDF)
Effective: July 01, 2021 - OC.UM.CP.0028 Flourescein Angiography (PDF)
Effective: July 01, 2021 - OC.UM.CP.0031 Gonioscopy (PDF)
Effective: July 01, 2021 - CP.MP.139 Low-Frequency Ultrasound Wound Therapy (PDF)
Effective: July 01, 2021 - CC.PP.056 Urine Specimen Validity Testing (PDF)
Effective: July 01, 2021 - CC.PP.502 Wheelchair Accessories (PDF)
Effective: July 01, 2021
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. |
| OR.CP.MP.500 (PDF) | Requests for Authorization - Oregon Health Plan (OHP) | To ensure that Trillium staff and any delegated entities making Utilization Management decisions for Oregon Health Plan (OHP) members follow the Oregon Health Plan Prioritized List and subsequent policies/criteria/guidelines to make medical necessity decisions. |
| OR.CP.MP.501 (PDF) | Applying National Comprehensive Cancer Network Guidelines | To provide Trillium staff and any delegated entities making Utilizaton Management decisions for Oregon Health Plan (OHP) members the use of the most up to date NCCN guidelines when the Health Evidence Review Commission's HERC is behind in posting. |