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 |
November 15, 2022 | |
Acupuncture |
Medical necessity guidelines for acupuncture |
November 15, 2022 | |
Attention Deficit Hyperactivity Disorder Assessment and Treatmentt |
This policy is for use when processing equests for Attention Deficit Hyperactivity Disorder Assessment and Treatment | July 18, 2023 | |
| CP.MP.175 (PDF) | Air Ambulance | Medical necessity guidelines for fixed wing air transportation. | November 15, 2022 |
Allergy Testing and Therapy |
Medical necessity guidelines for allergy testing and treatment |
November 15, 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 |
July 18, 2023 | |
Ambulatory Surgery Center Optimization |
Medical necessity guidelines for the use of ambulatory surgery centers as an alternative to inpatient surgical services |
November 15, 2022 | |
Articular Cartilage Defect Repairs |
Medical necessity guidelines for articular cartilage defect repairs |
July 18, 2023 | |
Assisted Reproductive Technology |
Medical necessity guidelines for assisted reproductive technology |
March 21, 2023 | |
Bariatric Surgery |
Medical necessity guidelines for bariatric surgery for obesity in adolescents and adults |
July 18, 2023 | |
Biofeedback |
Medical necessity guidelines for biofeedback therapyJuly 20, 2021 |
March 21, 2023 | |
Bone-anchored hearing aid |
Medical necessity guidelines for bone-anchored hearing aid |
November 15, 2022 | |
Bronchial Thermoplasty |
Medical necessity guidelines for bronchial thermoplasty |
July 18, 2023 | |
Burn Surgery |
Medical necessity guidelines for burn surgery, including debridement and application of skin substitutes for burns. |
March 21, 2023 | |
Cardiac biomarker testing |
Medical necessity guidelines for cardiac biomarker testing for the evaluation of suspected acute myocardial infarction |
November 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 15, 2022 | |
| CP.CPC.01 (PDF) | Clinical Policy Committee | Clinical Policy Committee process | July 18, 2023 |
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 |
March 21, 2023 | |
Clinical Trials |
Medical necessity guidelines for routine costs of clinical trials |
November 15, 2022 | |
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 |
March 21, 2023 | |
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures |
Medical necessity guidelines for dental anesthesia |
March 21, 2023 | |
| CP.BH.201 (PDF) | Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder | Medical necessity criteria for deep transcranial magnetic stimulation for the treatment of OCD | July 18, 2023 |
| CP.MP.203 (PDF) | Diaphragmatic/Phrenic Nerve Stimulation | Medical necessity guidelines for diaphragmatic/phrenic nerve stimulation | March 21, 2023 |
Digital electroencephalography spike analysis |
Medical necessity guidelines for digital EEG spike analysis |
November 15, 2022 | |
Disc Decompression Procedures |
Medical necessity guidelines for open discectomy, microdiscectomy, and minimally invasive and percutaneous disc decompression |
July 19, 2022 | |
Discography |
Medical necessity guidelines for discography |
November 15, 2022 | |
Donor lymphocyte infusion |
Medical necessity guidelines for donor lymphocyte infusion |
July 18, 2023 | |
Drugs of Abuse: Definitive Testing |
Medical necessity guidelines for confirmatory/definitive lab testing for specific drugs of abuse. |
July 18, 2023 | |
Durable Medical Equipment (DME) |
Medical necessity guidelines for durable medical equipment, orthotics, and prosthetics |
March 21, 2023 | |
Electric Tumor Treating Fields |
Medical necessity guidelines for electric tumor treating fields Optune® (NovoCureTM) |
March 21, 2023 | |
Electroencephalography in the evaluation of headache |
Medical necessity guidelines for the use of electroencephalography (EEG) in the evaluation of headaches |
November 15, 2022 | |
Endometrial ablation |
Medical necessity guidelines for endometrial ablation |
July 18, 2023 | |
Evoked Potential Testing |
Medical necessity guidelines for evoked potential testing |
July 18, 2023 | |
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. |
July 18, 2023 | |
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 |
November 15, 2022 | |
Fecal incontinence treatments |
Medical necessity guidelines for fecal incontinence treatments |
November 15, 2022 | |
Ferriscan R2-MRI |
Medical necessity guidelines for use of the FerriScan R2-MRI |
March 21, 2023 | |
Fertility preservation |
Medical necessity guidelines for fertility preservation when undergoing medical treatments that may transiently or permanently affect fertility |
November 15, 2022 | |
Fetal surgery in utero for prenatally diagnosed malformations |
Medical necessity guidelines for performing fetal surgery in utero |
November 15, 2022 | |
Functional MRI |
Medical necessity guidelines for the use of functional magnetic resonance imaging (fMRI). |
July 18, 2023 | |
Gastric electrical stimulation |
Medical necessity guidelines for gastric electrical stimulation |
July 18, 2023 | |
Gender Affirming Procedures |
Medical necessity guidelines for surgery for the treatment of gender dysphoria |
March 21, 2023 | |
| V2.203 (PDF) | Concert Genetics Genetic Testing: Aortopathies and Connective Tissue Disorders | Medical necessity criteria for Concert Genetics Genetic Testing: Aortopathies and Connective Tissue Disorders | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetic Testing: Cardiac Disorders | Medical necessity criteria for Concert Genetic Testing: Cardiac Disorders | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetic Testing: Dermatologic Conditions | Medical necessity criteria for Concert Genetic Testing: Dermatologic Conditions | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetic Testing: Epilepsy Neurodegenerative and Neuromuscular Disorders | Medical necessity criteria for Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders | Medical necessity criteria for Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetic Testing: Eye Disorders | Medical necessity criteria for Concert Genetic Testing: Eye Disorders | July 18, 2023 |
| V2.2023 (PDF) | Genetic Testing Gastroenterologic Disorders (non-cancerous) | Medical necessity criteria for Genetic Testing: Gastroenterologic Disorders (non-cancerous) | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetic Testing: General Approach to Genetic Testing | Medical necessity criteria for Concert Genetic Testing: General Approach to Genetic Testing | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetic Testing: Hearing Loss | Medical necessity criteria for Concert Genetic Testing: Hearing Loss | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetic Testing: Hematologic Condition (non-cancerous) | Medical necessity criteria for Concert Genetic Testing: Hematologic Conditions (non-cancerous) | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetic Testing: Hereditary Cancer Susceptibility | Concert Genetic Testing: Hereditary Cancer Susceptibility | July 18, 2023 |
| V2.2023 (PDF) | Genetic Testing Immune, Autoimmune, and Rheumatoid Disorders | Medical necessity criteria for Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetic Testing: Kidney Disorders | Medical necessity criteria for Concert Genetic Testing: Kidney Disorders | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetic Testing: Lung Disorders | Medical necessity criteria for Concert Genetic Testing: Lung Disorders | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetic Testing: Metabolic Endocrine and Mitochondrial Disorders | Medical necessity criteria for Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay | Medical necessity criteria for Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetic Testing: for Non-Invasive Prenatal Screening (NIPS) | Medical necessity criteria for Concert Genetic Testing: Non-invasive Prenatal Screening (NIPS) | July 18, 2023 |
| V2.2023 (PDF) | Concert Oncology: Algorithmic Testing | Medical necessity criteria for Concert Oncology: Algorithmic Testing | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetics Oncology: Cancer Screening | Medical necessity criteria for Concert Genetics Oncology: Cancer Screening | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetics Oncology: Cytogenetic Testing | Medical necessity criteria for Concert Genetics Oncology: Cytogenetic Testing | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic | Medical necessity criteria for Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetic Testing: Pharmacogenetics | Medical necessity criteria for Concert Genetic Testing: Pharmacogenetic | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetic Testing: Preimplantation Genetic Testing | Medical necessity criteria for Concert Genetic Testing: Preimplantation Genetic Testing | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetic Testing: Prenatal and Preconception Carrier Screening | Medical necessity criteria for Concert Genetic Testing: Prenatal and Preconception Carrier Screening | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss | Medical necessity criteria for Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss | July 18, 2023 |
| V2.2023 (PDF) | Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders | Medical necessity criteria for Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders | 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 | July 18, 2023 |
H. Pylori serology testing |
Medical necessity guidelines for H. pylori |
November 15, 2022 | |
Heart-Lung Transplant |
Medical necessity guidelines for heart-lung transplantation |
July 18, 2023 | |
Holter Monitors |
Medical necessity guidelines for Holter monitoring, or continuous ambulatory electrocardiogram (ECG) monitoring |
July 18, 2023 | |
Home Birth |
Medical necessity guidelines for planned home birth |
March 21, 2023 | |
Phototherapy for neonatal hyperbilirubinemia |
Medical necessity guidelines for home phototherapy for the treatment of neonatal hyperbilirubinemia |
March 21, 2023 | |
Homocysteine testing |
Medical necessity guidelines for homocysteine testing |
July 18, 2023 | |
Hospice Services |
Medical necessity guidelines for hospice services |
March 21, 2023 | |
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 |
March 21, 2023 | |
| CP.MP.180 (PDF) | Implantable Hypoglossal Nerve Stimulation | Medical necessity criteria for Implantable Hypoglossal Nerve Stimulation (Inspire) for Obstructive Sleep Apnea | March 21, 2023 |
Implantable Intrathecal Pain Pump |
Medical necessity guidelines for preliminary trial and implantation of intrathecal pain pumps |
March 21, 2023 | |
| CP.MP.243 (PDF) | Implantable Loop Recorder | Use this policy when processing requests for implantable loop recorders | July 18, 2023 |
Implantable Wireless Pulmonary Artery Pressure Monitoring |
Medical necessity guidelines for implantable wireless pulmonary artery pressure monitoring |
July 18, 2023 | |
Therapeutic Utilizaton of Inhaled Nitric Oxide |
Medical necessity guidelines for the therapeutic utilization of inhaled nitric oxide (iNO) |
July 18, 2023 | |
Intensity-Modulated Radiotherapy |
Medical necessity guidelines for intensity-modulated radiotherapy (IMRT) |
March 21, 2023 | |
Intestinal and multivisceral transplant |
Medical necessity guidelines for the review of intestinal and multivisceral transplant requests. |
July 19, 2022 | |
Intradiscal Steroid Injections for Pain Management |
Medical necessity criteria for intradiscal steroid injections for pain management |
November 15, 2022 | |
Laser therapy for skin conditions |
Medical necessity guidelines for excimer laser based targeted phototherapy |
July 18, 2023 | |
| CP.MP.244 (PDF) | Liposuction for Lipedema | This policy is for use when processing requests for Liposuction for Lipedema | July 19, 2022 |
Long Term Care Placement Criteria |
Medical necessity guidelines for long term care (LTC) placement |
July 18, 2023 | |
Low-frequency ultrasound and noncontact normothermic wound therapy |
Medical necessity guidelines for low-frequency ultrasound therapy and noncontact normothermic wound therapy. |
July 18, 2023 | |
| CP.MP.57 (PDF) | Lung Transplantation | Medical necessity guidelines for review of lung transplantation requests | July 18, 2023 |
Lysis of Epidural Lesions |
Medical necessity criteria for epidural adhesiolysis, also known as as epidural neuroplasty, lysis of epidural adhesions, or caudal neuroplasty |
July 19, 2022 | |
Measurement of serum 1,25-dihydroxyvitamin D |
Medical necessity guidelines for the measurement of serum 1,25-dihydroxyvitamin D |
November 15, 2022 | |
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. |
March 21, 2023 | |
Medical Necessity Criteria |
This policy identifies the medical necessity guidelines used by the health plan and related definitions. |
November 15, 2022 | |
Multiple Sleep Latency Testing |
Medical necessity criteria for multiple sleep latency testing (MSLT) |
July 18, 2023 | |
Neonatal abstinence syndrome guidelines |
Medical necessity guidelines for managing neonatal abstinence syndrome in the neonatal intensive care unit (NICU) |
July 18, 2023 | |
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 |
July 18, 2023 | |
Nerve Blocks for Pain Management |
Medical necessity criteria for nerve blocks for pain management |
November 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) | November 15, 2022 |
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 |
November 15, 2022 | |
NICU discharge guidelines |
Medical necessity guidelines to assist in comprehensive discharge planning and smooth transition from the neonatal intensive care unit (NICU) to home. |
July 18, 2023 | |
| CP.MP.184 (PDF) | Home Ventilators | Medical necessity guidelines for non-invasive home ventilators | November 15, 2022 |
Non-myeloablative allogeneic stem cell transplants |
Medical necessity guidelines for non-myeloablative allogeneic stem cell transplants |
July 18, 2023 | |
Obstetrical Home Health Care Programs |
Medical necessity guidelines for OB home health programs |
July 18, 2023 | |
| V2.203 (PDF) | Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy | Medical necessity criteria for Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) | July 18, 2023 |
Optic nerve decompression surgery |
Medical necessity guidelines for optic nerve sheath decompression surgery |
November 15, 2022 | |
| CP.MP.202 (PDF) | Orthognathic Surgery | Medical necessity guidelines for Orthognathic Surgery | March 21, 2023 |
Outpatient Cardiac Rehabilitation |
Medical necessity criteria for conventional and intensive outpatient cardiac rehabiliation programs. |
July 19, 2022 | |
| CP.MP.190 (PDF) | Outpatient Oxygen Use | 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. | March 21, 2023 |
Pancreas transplant |
Medical necessity guidelines for pancreas transplant, including simultaneous pancreas kidney transplant, pancreas after kidney transplant, pancreas transplant alone, and islet cell transplant. |
July 18, 2023 | |
Panniculectomy |
Medical necessity guidelines for panniculectomy |
March 21, 2023 | |
Pediatric heart transplant |
Medical necessity guidelines for pediatric heart transplant |
March 21, 2023 | |
| CP.MP.246 (PDF) | Pediatric Kidney Transplant | Use this policy when processing requests for Pediatric Kidney Transplant | November 15, 2022 |
Pediatric Liver Transplant |
Medical necessity guidelines for pediatric liver transplant for end-stage liver disease |
July 18, 2023 | |
Pediatric Oral Function Therapy |
Medical necessity guidelines for pediatric oral function therapy. |
July 19, 2022 | |
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention |
Medical necessity guidelines for left atrial appendage closure devices for stroke prevention. |
July 19, 2022 | |
| CP.MP.181 (PDF) | Polymerase Chain Reaction Respiratory Viral Panel Testing | Medical necessity criteria for multiplex respiratory polymerase chain reaction (PCR) testing. | July 18, 2023 |
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 |
November 15, 2022 | |
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. |
July 18, 2023 | |
Proton and neutron beam therapy |
Medical necessity guidelines for proton beam and neutron beam radiation therapy |
March 21, 2023 | |
| CP.MP.242 (PDF) | Pulmonary Function Testing | Use this policy when processing requests for Pulmonary Function Testing | July 18, 2023 |
Radial Head Implant |
Medical necessity guidelines for radial head implant, also known as arthroplasty |
July 19, 2022 | |
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 15, 2022 | |
Repair of Nasal Valve Compromise |
Medical necessity guidelines for the treatment of Repair of Nasal Valve Compromise |
July 19, 2022 | |
Sacroiliac joint fusion |
Medical necessity guidelines for sacroiliac joint fusion |
November 15, 2022 | |
Sacroiliac Joint Interventions for Pain Management |
Medical necessity criteria for sacroiliac joint interventions for pain management |
November 15, 2022 | |
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins |
Medical necessity guidelines for sclerotherapy for treatment of vericose veins |
July 18, 2023 | |
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy |
Medical necessity criteria for Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy. |
March 21, 2023 | |
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 |
November 15, 2022 | |
| CP.MP.182 (PDF) | Short Inpatient Hospital Stay | Medical necessity criteria for inpatient hospital stay of 2 days or less | March 21, 2023 |
| CP.MP.248 (PDF) | Facility-based Sleep Studies for Obstructive Sleep Apnea | Medical necessity guidelines for sleep center polysomnography and split-night studies for obstructive sleep apnea | July 18, 2023 |
Skilled Nursing Facility Leveling |
Medical necessity criteria for skilled nursing facility levels of care |
November 15, 2022 | |
Skin and Soft Tissue Substitutes for Chronic Wounds |
Medical necessity criteria for skin and soft tissue substitutes in the treatment of chronic wounds. |
July 18, 2023 | |
Spinal Cord Stimulation |
Medical necessity guidelines for spinal cord stimulation for pain management, also known as dorsal column stimulation |
July 18, 2023 | |
State specific clinical policy process |
This policy describes the process for creating, maintaining, and posting state-specific clinical policies |
March 21, 2023 | |
Stereotactic Body Radiation Therapy |
Medical necessity guidelines for stereotactic body radiation therapy |
March 21, 2023 | |
Tandem Transplant |
Medical necessity guidelines for tandem transplant |
July 18, 2023 | |
Testing for select genitourinary conditions |
Medical necessity guidelines for various diagnostic testing methods to identify the etiology of the signs and symptoms of vaginitis |
July 18, 2023 | |
Therapy Services (PT/OT/ST) |
Medical necessity guidelines for outpatient speech therapy, occupational therapy, and/or physical therapy evaluation and treatment. |
November 15, 2022 | |
Thyroid hormones and insulin testing in pediatrics |
Medical necessity guidelines for thyroid hormones and insulin testing in pediatrics |
November 15, 2022 | |
Total artificial heart |
Medical necessity guidelines for a total artificial heart (TAH) |
March 21, 2023 | |
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition |
Medical necessity guidelines for total parenteral nutrition (TPN) and intradialytic parenteral nutrition (IDPN) |
July 18, 2023 | |
Transcatheter closure of patent foramen ovale |
Medical necessity guidelines for transcatheter closure of patent foramen ovale (PFO) with the AmplatzerTM PFO Occluder. |
March 21, 2023 | |
| CP.BH.200 (PDF) | Transcranial Magnetic Stimulation for Treatment Resistant Major Depression | This policy describes medical necessity guidelines for the use of transcranial magnetic stimulation. | July 18, 2023 |
| CP.MP.247 (PDF) | Transplant Service Documentation Requirements | Medical necessity guidelines for transplant service documentation requirements | March 21, 2023 |
Trigger Point Injections for Pain Management |
Medical necessity criteria for trigger point injections for pain management |
November 15, 2022 | |
Ultrasound in Pregnancy |
Medical necessity guidelines for ultrasound use in pregnancy. |
July 18, 2023 | |
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 |
March 21, 2023 | |
Urodynamic testing |
Medical necessity guideines for urodynamic testing as part of the comprehensive evaluation of voiding dysfunction |
July 18, 2023 | |
Vagus Nerve Stimulation |
Medical necessity guidelines for vagus nerve stimulation. |
November 15, 2022 | |
Ventricular Assist Devices |
Medical necessity guidelines for ventricular assist devices. |
July 18, 2023 | |
Wheelchair seating |
Medical necessity guidelines for special wheelchair seating and cushions |
July 18, 2023 | |
Wireless Motility Capsule |
Medical necessity guidelines for wireless motility capsule |
November 15, 2022 | |
| CP.MP.194 (PDF) | Osteogenic Stimulation | Electrical osteogenic stimulation can be performed invasively or non-invasively. | November 15, 2022 |
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 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 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.280 (PDF)
- Brand Name Override; CP.PMN.22 (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 Override and Dose Optimization; 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)
- Ketorolac nasal spray (Sprix); CP.PMN.282 (PDF)
- Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex); CP.PHAR.134 (PDF)
- Nabumatone Double-Strength (Relafen DS); CP.PMN.287 (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 (Sublocade, Brixadi); 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 (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; 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 (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler); 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, Dapzura RT); 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)
- Rifapentine (Priftin); CP.PMN.05 (PDF)
Antivirals
- Acyclovir buccal tab (Sitavig); 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)
- Lenacapavir (Sunlenca); CP.PHAR.622 (PDF)
- Letermovir (Prevymis); CP.PHAR.367 (PDF)
- Maribavir (Livtencity); CP.PMN.271 (PDF)
- Nirmatrelvir-Ritonavir (Paxlovid); CP.PMN.288 (PDF)
- Ombitasvir/Paritaprevir/Ritonavir (Technivie); OR.CP.PHAR.1003 (PDF)
- Peginterferon Alfa-2a (Pegasys); 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 (Alymsys, Avastin, Mvasi, Zirabev); CP.PHAR.93 (PDF)
- Ramucirumab (Cyramza); CP.PHAR.119 (PDF)
- Ziv-aflibercept (Zaltrap); CP.PHAR.325 (PDF)
- Antineoplastic - Anti-HER2 Agents
- Margetuximab-cmkb (Margenza); CP.PHAR.522 (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)
- Epcoritamab-bysp (Epkinly); CP.PHAR.634 (PDF)
- Fam-trastuzumab deruxtecan-nxki (Enhertu); CP.PHAR.456 (PDF)
- Gemtuzumab (Mylotarg); CP.PHAR.358 (PDF)
- Glofitamab-gxbm (Columvi); CP.PHAR.636 (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)
- Mirvetuximab soravtansine-gynx (Elahere); CP.PHAR.617 (PDF)
- Mogamulizumab-kpkc (Poteligeo); CP.PHAR.139 (PDF)
- Mosunetuzumab-axgb (Lunsumio); CP.PHAR.618 (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)
- retifanlimab-dlwr (Zynyz); CP.PHAR.629 (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 (PDF)
- Teclistamab-cqyv (Tecvayli); CP.PHAR.611 (PDF)
- Tisotumab vedotin-tftv (Tivdak); CP.PHAR.561 (PDF)
- Trastuzumab Biosimilars Trastuzumab-Hyaluronidase; CP.PHAR.228 (PDF)
- Tremelimumab-actl (Imjudo); CP.PHAR.612 (PDF)
- Zanubrutinib (Brukinsa); CP.PHAR.467 (PDF)
- Antineoplastic - BCL-2 Inhibitors
- Venetoclax (Venclexta); CP.PHAR.129
- 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)
- Elacestrant (Orserdu); CP.PHAR.623 (PDF)
- Enzalutamide (Xtandi); CP.PHAR.106 (PDF)
- Fulvestrant (Faslodex Injection); CP.PHAR.424 (PDF)
- Goserelin acetate (Zoladex); OR.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); OR.CP.PHAR.175 (PDF)
- Antineoplastic - Hypoxia-Inducible Factor Inhibitors
- Belzutifan (Welireg); CP.PHAR.553 (PDF)
- Antineoplastic - Immunomodulators
- Pomalidomide (Pomalyst); CP.PHAR.116 (PDF)
- Antineoplastic – Kinase Inhibitor
- Mobocertinib (Exkivity); CP.PHAR.559 (PDF)
- 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)
- Nivolumab/Relatlimab-rmbw (Opdualag); CP.PHAR.588 (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)
- Adagrasib (Krazati); CP.PHAR.605 (PDF)
- Afatinib (Gilotrif); CP.PHAR.298 (PDF)
- Alectinib (Alecensa); CP.PHAR.369 (PDF)
- Alpelisib (Piqray, Vijoice); 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)
- Futibatinib (Lytgobi); CP.PHAR.604 (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)
- Olutasidenib (Rezlidhia); CP.PHAR.615 (PDF)
- Osimertinib (Tagrisso); CP.PHAR.294 (PDF)
- Pacritinib (Vonjo); CP.PHAR.583 (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)
- Pirtobrutinib (Jaypirca); CP.PHAR.620 (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)
- Lutetium Lu 177 vipivotide tetraxetan (Pluvicto); CP.PHAR.582 (PDF)
- Antineoplastics Misc.
- Bexarotene (Targretin); CP.PHAR.75 (PDF)
- Interferon Gamma- 1b (Actimmune); CP.PHAR.52 (PDF)
- Nadofaragene Firadenovec-vncg (Adstiladrin); CP.PHAR.461 (PDF)
- Omacetaxine (Synribo); CP.PHAR.108 (PDF)
- Ropeginterferon alfa-2b-njft (BESREMi); CP.PHAR.570
- Chemotherapy Rescue/Antidote Agents
- Dexrazoxane (Zinecard Totect); CP.PHAR.418 (PDF)
- Levoleucovorin (Fusilev, Khapzory); CP.PHAR.151 (PDF)
- Leucovorin Injection; CP.PHAR.393 (PDF)
- Sodium thiosulfate (Pedmark); CP.PHAR.610 (PDF)
- Antineoplastic XPO1 Inhibitors
- Selinexor (Xpovio); CP.PHAR.431 (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)
- Oncolytic Viral Agents
- Talimogene laherparepvec (Imlygic); CP.PHAR.542 (PDF)
- Topoisomerase I Inhibitors
- Irinotecan Liposome (Onivyde); CP.PHAR.304 (PDF)
- Topotecan (Hycamtin); CP.PHAR.64 (PDF)
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)
- Ivabradine (Corlanor); CP.PMN.70 (PDF)
- Macitentan (Opsumit); CP.PHAR.194 (PDF)
- Mavacamten (Camzyos); CP.PMN.272 (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)
- Riociguat (Adempas); CP.PHAR.195 (PDF)
- Sacubitril/valsartan (Entresto); CP.PMN.67 (PDF)
- Selexipag (Uptravi); CP.PHAR.196 (PDF)
- Sildenafil (Revatio, Liqrev); CP.PHAR.197 (PDF)
- Tadalafil (Adcirca, Alyq, Tadliq); CP.PHAR.198 (PDF)
- Tafamidis (Vyndaqel, Vyndamax); CP.PHAR.432 (PDF)
- Treprostinil (Orenitram, Remodulin, Tyvaso); CP.PHAR.199 (PDF)
Diuretics
Vasopressors
- Abrocitinib (Cibinqo); CP.PHAR.578 (PDF)
- Acitretin (Soriatane); 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)
- Clascoterone (Winlevi); CP.PMN.257 (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)
- Deucravacitinib (Sotyktu); CP.PHAR.607 (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)
- Fluorouracil Cream (Tolak); CP.PMN.165 (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); 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)
- Spesolimab-sbzo (Spevigo); CP.PHAR.606 (PDF)
- Tacrolimus (Protopic); OR.CP.PMN.1009 (PDF)
- Tapinarof (Vtama); CP.PMN.283 (PDF)
- Tazarotene (Arazlo, Fabior, Tazorac); CP.PMN.244 (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)
- Exenatide ER (Bydureon, Bydureon BCise); OR.CP.PMN.183 (PDF)
- Exenatide IR (Byetta); OR.CP.PMN.183 (PDF)
- Insulin degludec (Tresiba); CP.PMN.285 (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)
- Teplizumab-mzwv (Tzield) CP.PHAR.492 (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 (Sogroya); OR.CP.PHAR.517 (PDF)
- Somatropin (Genotropin, Humatrope, Norditropin, Nutropin, Qmnitrope, Zomacton, Saizen, Serostim, Zorbtive); OR.CP.PHAR.517 (PDF)
Hormone Receptor Modulators
Insulin-Like Growth Factors
Insulin-Like Growth Factor Receptor Inhibitors
LHRH/GNRH Agonist Analog Pituitary Suppressants
Menopausal Symptoms 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)
- Fosdenopterin (Nulibry); CP.PHAR.471 (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)
- Pegunigalsidase alfa (Elfabrio); CP.PHAR.512 (PDF)
- Pegvaliase-pqpz (Palynziq); CP.PHAR.140 (PDF)
- Sapropterin (Kuvan); CP.PHAR.43 (PDF)
- Sebelipase alfa (Kanuma); CP.PHAR.159 (PDF)
- Sodium phenylbutyrate (Buphenyl, Pheburane, Olpruva); CP.PHAR.208 (PDF)
- Velmanase Alfa-tycv (Lamzede); CP.PHAR.601 (PDF)
- Vestronidase alfa-vjbk (Mepsevii); CP.PHAR.374 (PDF)
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, Signifor LAR); CP.PHAR.332
Vasopressin Receptor Antagonists
Antiemetics
- Amisulpride (Barhemsys); CP.PMN.236 (PDF)
- Aprepitant (Aponvie, Cinvanti, Emend); CP.PMN.19 (PDF)
- Dolasetron (Anzemet); CP.PMN.141 (PDF)
- Dronabinol (Marinol, Syndros); CP.PMN.159 (PDF)
- Fosaprepitant (Emend); CP.PMN.19 (PDF)
- Granisetron (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
Gastrointestinal Agents - Misc.
- Alosetron (Lotronex); CP.PMN.153 (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); CP.PMN.170 (PDF)
- Fecal microbiota spores, live-brpk (Vowst); CP.PHAR.632 (PDF)
- Fecal microbiota, live-jslm (Rebyota); CP.PHAR.613 (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); CP.PMN.224 (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)
- Lumasiran (Oxlumo); CP.PHAR.473 (PDF)
- Pentosan polysulfate sodium (Elmiron); CP.PMN.276 (PDF)
- Sparsentan (Filspari); CP.PHAR.631 (PDF)
- 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)
- Progesterone (Crinone, Endometrin, Milprosa); CP.PMN.243 (PDF)
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)
- Rivaroxaban (Xarelto); CP.PMN.247 (PDF)
Hematological Agents - Misc.
- Anti-inhibitor Coagulant Complex (Feiba); CP.PHAR.217 (PDF)
- Antithrombin III (ATryn, Thrombate III); CP.PHAR.564 (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)
- Etranacogene Dezaparvovec (Hemgenix); CP.PHAR.580 (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, Syfovre); 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)
- Betibeglogene autotemcel (Zynteglo); CP.PHAR.545 (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 maltol (Accrufer); CP.PMN.213 (PDF)
- Ferric Pyrophosphate Citrate (Triferic); CP.PHAR.624 (PDF)
- Ferumoxytol (Feraheme); CP.PHAR.165 (PDF)
- Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastm-aafi (Nivestym), Filgrastim-ayow (Releuko); CP.PHAR.297 (PDF)
- Hydroxyurea (Siklos); CP.PMN.193 (PDF)
- Imiglucerase (Cerezyme); CP.PHAR.154 (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), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo), Pegfilgrastim-apgf (Nyvepria), Pegfilgrastim-pbbk (Fylnetra); 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.
- House Dust Mite Allergen Extract (Odactra); CP.PMN.111 (PDF)
- Mixed pollens allergen extract (Oralair); CP.PMN.85 (PDF)
- Peanut allergen powder (Palforzia); CP.PMN.220 (PDF)
- Short ragweed pollen allergen extract (Ragwitek); CP.PMN.83 (PDF)
- Timothy grass pollen allergen extract (Grastek); CP.PMN.84 (PDF)
Alternative Medicines
Antidotes and Specific Antagonists
- Daprodustat (Jesduvroq); CP.PHAR.628 (PDF)
- Deferasirox (Exjade, Jadenu); CP.PHAR.145 (PDF)
- Deferiprone (Ferriprox); CP.PHAR.147 (PDF)
- Deferoxamine (Desferal); CP.PHAR.146 (PDF)
- Nalmefene (Opvee); CP.PHAR.638 (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
- Leniolisib (Joenja); CP.PHAR.597 (PDF)
- Lenalidomide (Revlimid); CP.PHAR.71 (PDF)
- Thalidomide (Thalomid); CP.PHAR.78 (PDF)
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)
- Ganaxolone (Ztalmy); CP.PMN.278 (PDF)
- Lacosamide (Vimpat, Motpoly XR); 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)
- Topiramate ER (Qudexy XR, Trokendi XR); CP.PMN.281 (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), IR Tablets (Dhivy); 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)
- 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)
- Zavegepant (Zavzpret); CP.PHAR.630 (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)
- Elivaldogene Autotemcel (Skysona); CP.PHAR.556 (PDF)
- Esketamine (Spravato); CP.PMN.199 (PDF)
- Fingolimod (Gilenya, Tascenso ODT); OR.CP.PHAR.251 (PDF)
- Flibanserin (Addyi); CP.PHAR.446 (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)
- Lecanemab-irmb (Leqembi); CP.PHAR.596 (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)
- Ublituximab-xiiy (Briumvi); CP.PHAR.621 (PDF)
- Valbenazine (Ingrezza); OR.CP.PHAR.1004 (PDF)
- Varenicline (Chantix); OR.CP.PMN.1008 (PDF)
- Vutrisiran (Amvuttra); CP.PHAR.550 (PDF)
- AbobotulinumtoxinA (Dysport); CP.PHAR.230 (PDF)
- Casimersen (Amondys 45); CP.PHAR.470 (PDF)
- Delandistrogene Moxeparvovec (Elevidys); CP.PHAR.593 (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)
- Omaveloxolone (Skyclarys); CP.PHAR.590 (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)
- Sodium Phenylbutyrate-Taurursodiol (Relyvrio); CP.PHAR.584 (PDF)
- Tofersen (Qalsody); CP.PHAR.591 (PDF)
- Trofinetide (Daybue); CP.PHAR.600 (PDF)
- Viltolarsen (Viltepso); CP.PHAR.484 (PDF)
- AbobotulinumtoxinA (Dysport); CP.PHAR.230 (PDF)
- Casimersen (Amondys 45); CP.PHAR.470 (PDF)
- Delandistrogene Moxeparvovec (Elevidys); CP.PHAR.593 (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)
- Omaveloxolone (Skyclarys); CP.PHAR.590 (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)
- Sodium Phenylbutyrate-Taurursodiol (Relyvrio); CP.PHAR.584 (PDF)
- Tofersen (Qalsody); CP.PHAR.591 (PDF)
- Trofinetide (Daybue); CP.PHAR.600 (PDF)
- Viltolarsen (Viltepso); CP.PHAR.484 (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, Zoryve); 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.285 (PDF)
- Pirfenidone (Esbriet); OR.CP.PHAR.286 (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 - Scanning Computerized Ophthalmic Diagnostic Imaging (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 - MP.CP.MP.106 Endometrial Ablation (PDF)
Effective: January 01, 2024 - CP.MP.125 DNA Analysis of Stool to Screen for Colorectal Cancer (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.103 FeNO Testing (PDF)
Effective: July 01, 2021 - CP.PP.073 Sepsis Diagnosis (PDF)
Last Review Date: March 2022
- 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 - Scanning Computerized Ophthalmic Diagnostic Imaging (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 - MP.CP.MP.106 Endometrial Ablation (PDF)
Effective: January 01, 2024 - CP.MP.125 DNA Analysis of Stool to Screen for Colorectal Cancer (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.103 FeNO Testing (PDF)
Effective: July 01, 2021 - CP.PP.073 Sepsis Diagnosis (PDF)
Last Review Date: March 2022
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. |
| OR.CM.06 (PDF) | Transition of Care Between CCO's | To ensure the transition of care of a Medicaid member who is enrolled in Trillium Community Health Plan (the CCO) to the receiving CCO immediately after the member is dis-enrolled from the CCO. This transition includes disenrollment from another CCO resulting from termination of the predecessor CCO’s contract, choice or from Medicaid fee-for-service (FFS) to allow for continued access to care. |