Medicaid Managed Care Policies & Procedures Archive (2020)

"Policy or procedure" shall mean a requirement governing the administration of managed care organizations specific to billing guidelines, medical management and utilization review guidelines, case management guidelines, claims processing guidelines and edits, grievance and appeals procedures and process, other guidelines or manuals containing pertinent information related to operations and pre-processing claims, and core benefits and services.

Below are items previously posted for public comment:

Item Number Policy/Procedure Date Posted Comment Period Closed Status Document Links
2020-PHARM-257 Thrombopoietin Agents PDL 11/16/20 12/31/20 Approved Thrombopoietin Agents PDL
2020-PHARM-256 Sickle Cell Anemia PDL 11/16/20 12/31/20 Approved Sickle Cell Anemia PDL
2020-PHARM-255 PPIs 11/16/20 12/31/20 Approved PPIs
2020-PHARM-254 POS P and T January 2021 Posting 11/16/20 12/31/20 Approved POS P and T January 2021 Posting
2020-PHARM-253 POS Thrombopoiesis Stimulating Proteins 11/16/20 12/31/20 Approved POS Thrombopoiesis Stimulating Proteins
2020-PHARM-252 POS Sickle Cell Anemia Treatments 11/16/20 12/31/20 Approved POS Sickle Cell Anemia Treatments
2020-PHARM-251 POS Movement Disorders VMAT2 Inhibitors 11/16/20 12/31/20 Approved POS Movement Disorders VMAT2 Inhibitors
2020-PHARM-250 POS Methotrexate 11/16/20 12/31/20 Approved POS Methotrexate
2020-PHARM-249 POS Immunomodulators Asthma 11/16/20 12/31/20 Approved POS Immunomodulators Asthma
2020-PHARM-248 POS Immune Globulins 11/16/20 12/31/20 Approved POS Immune Globulins
2020-PHARM-247 POS Idiopathic Pulmonary Fibrosis 11/16/20 12/31/20 Approved POS Idiopathic Pulmonary Fibrosis
2020-PHARM-246 POS Enzyme Replacements 11/16/20 12/31/20 Approved POS Enzyme Replacements
2020-PHARM-245 POS Botulinum Toxins 11/16/20 12/31/20 Approved POS Botulinum Toxins
2020-PHARM-244 POS Antipsychotic Agents Oral 11/16/20 12/31/20 Approved POS Antipsychotic Agents Oral
2020-PHARM-243 POS Anticonvulsants 11/16/20 12/31/20 Approved POS Anticonvulsants
2020-PHARM-242 POS Anti-Allergens Oral 11/16/20 12/31/20 Approved POS Anti-Allergens Oral
2020-PHARM-241 POS Anthelmintics 11/16/20 12/31/20 Approved POS Anthelmintics
2020-PHARM-240 PDL 1.1.21 11/16/20 12/31/20 Approved PDL 1.1.21
2020-PHARM-239 Otic Agents Antibiotics 11/16/20 12/31/20 Approved Otic Agents Antibiotics
2020-PHARM-238 Ophthalmic Disorders Glaucoma Agents Intraocular Pressure Reducers 11/16/20 12/31/20 Approved Ophthalmic Disorders Glaucoma Agents Intraocular Pressure Reducers
2020-PHARM-237 Oncology Agents Oral Renal Cell 11/16/20 12/31/20 Approved Oncology Agents Oral Renal Cell
2020-PHARM-236 Movement Disorders VMAT2 Inhibitors 11/16/20 12/31/20 Approved Movement Disorders VMAT2 Inhibitors
2020-PHARM-235 Methotrexate 11/16/20 12/31/20 Approved Methotrexate
2020-PHARM-234 Immunomodulators Asthma 11/16/20 12/31/20 Approved Immunomodulators Asthma
2020-PHARM-233 Immune Globulin 11/16/20 12/31/20 Approved Immune Globulin
2020-PHARM-232 Idiopathic Pulmonary Fibrosis 11/16/20 12/31/20 Approved Idiopathic Pulmonary Fibrosis
2020-PHARM-231 Enzyme Replacement Agents Gaucher's Disease 11/16/20 12/31/20 Approved Enzyme Replacement Agents Gaucher's Disease
2020-PHARM-230 Dermatology-Atopic Dermatitis Immunomodulators 11/16/20 12/31/20 Approved Dermatology-Atopic Dermatitis Immunomodulators
2020-PHARM-229 Botulinum Toxins 11/16/20 12/31/20 Approved Botulinum Toxins
2020-PHARM-228 Asthma-COPD Inhaled Glucocorticoids 11/16/20 12/31/20 Approved Asthma-COPD Inhaled Glucocorticoids
2020-PHARM-227 Anticonvulsants 11/16/20 12/31/20 Approved Anticonvulsants
2020-PHARM-226 Anthelmintics 11/16/20 12/31/20 Approved Anthelmintics
2020-PHARM-225 Allergen Extracts Oralair Palforzia 11/16/20 12/31/20 Approved Allergen Extracts Oralair Palforzia
2020-PHARM-224 ADHD 11/16/20 12/31/20 Approved ADHD
2020-HB-PHARM-25 Testosterone Injectables 11/12/20 12/27/20 Approved Testosterone Injectables
2020-HB-PHARM-24 Tegsedi 11/12/20 12/27/20 Approved Tegsedi
2020-HB-PHARM-23 Somatuline Depot 11/12/20 12/27/20 Approved Somatuline Depot
2020-HB-PHARM-22 Selected GnRH Analogs 11/12/20 12/27/20 Approved Selected GnRH Analogs
2020-HB-PHARM-21 Polivy 11/12/20 12/27/20 Approved Polivy
2020-HB-PHARM-20 Onpattro 11/12/20 12/27/20 Approved Onpattro
2020-HB-PHARM-19 Ocrevus 11/12/20 12/27/20 Approved Ocrevus
2020-HB-PHARM-18 Lumoxiti 11/12/20 12/27/20 Approved Lumoxiti
2020-HB-PHARM-17 Lumizyme 11/12/20 12/27/20 Approved Lumizyme
2020-HB-PHARM-16 Libtayo 11/12/20 12/27/20 Approved Libtayo
2020-HB-PHARM-15 Jevtana 11/12/20 12/27/20 Approved Jevtana
2020-HB-PHARM-14 Implantable &ER Buprenorphine Products 11/12/20 12/27/20 Approved Implantable &ER Buprenorphine Products
2020-HB-PHARM-13 Fabrazyme 11/12/20 12/27/20 Approved Fabrazyme
2020-HB-PHARM-12 Evenity 11/12/20 12/27/20 Approved Evenity
2020-HB-PHARM-11 Erythropoiesis Stimulating Agents 11/12/20 12/27/20 Approved Erythropoiesis Stimulating Agents
2020-HB-PHARM-10 ERT for Gaucher’s Disease 11/12/20 12/27/20 Approved ERT for Gaucher’s Disease
2020-HB-PHARM-9 Denosumab Agents 11/12/20 12/27/20 Approved Denosumab Agents
2020-HB-PHARM-8 Brineura 11/12/20 12/27/20 Approved Brineura
2020-HB-PHARM-7 Beta Interferons & Glatiramer Acetate 11/12/20 12/27/20 Approved Beta Interferons & Glatiramer Acetate
2020-HB-PHARM-6 Benlysta 11/12/20 12/27/20 Approved Benlysta
2020-HB-PHARM-5.0 Alpha-1 Proteinase Inhibitor Therapy 11/12/20 12/27/20 Approved Alpha-1 Proteinase Inhibitor Therapy
2020-ACLA-PHARM-5 Diabetic Testing Supplies 11/12/20 12/27/20 Approved Diabetic Testing Supplies
2020-ACLA-818 Prior Authorizations Update 11/18/20 1/2/21 Complete Prior Authorizations Update
2020-LDH-1 LDH MCO Manual 11/10/20 12/25/20 Approved LDH MCO Manual
2020-HB-PHARM-5 Avsola Medical Step Therapy 11/4/20 12/18/20 Approved Avsola Medical Step Therapy
2020-LHCC-PHARM-4 Requests for Pharmacy Profiles 10/30/20 12/13/20 Approved Requests for Pharmacy Profiles
2020-LHCC-PHARM-3 PBM Inquiry for Additional Information 10/30/20 12/13/20 Approved PBM Inquiry for Additional Information
2020-LHCC-PHARM-2  Drug Utilization 10/30/20 12/13/20 Approved Drug Utilization
2020-HB-PHARM-4 Anti VEGF Medical Step Therapy 10/27/20 12/10/20 Approved Anti VEGF Medical Step Therapy
2020-HB-PHARM-3 Herceptin Bio Med Step Therapy 10/26/20 12/9/20 Approved Herceptin Bio Med Step Therapy
2020-PHARM-223 Uterine Disorder Treatment 10/26/20 12/9/20 Approved Uterine Disorder Treatment
2020-PHARM-222 Urology Incontinence Bladder Relaxant Preparations 10/26/20 12/9/20 Approved Urology Incontinence Bladder Relaxant Preparations
2020-PHARM-221 Smoking Cessation Products 10/26/20 12/9/20 Approved Smoking Cessation Products
2020-PHARM-220 Sinus Node Inhibitors 10/26/20 12/9/20 Approved Sinus Node Inhibitors
2020-PHARM-219 Prostate Benign Prostatic Hyperplasia Treatment 10/26/20 12/9/20 Approved Prostate Benign Prostatic Hyperplasia Treatment
2020-PHARM-218 Progestational Agents 10/26/20 12/9/20 Approved Progestational Agents
2020-PHARM-217 Pituitary Suppressive Agents 10/26/20 12/9/20 Approved Pituitary Suppressive Agents
2020-PHARM-216 Pediatric Multivitamins 10/26/20 12/9/20 Approved Pediatric Multivitamins
2020-PHARM-215 Parkinsons Antiparkinson Agents Anticholinergic and Other 10/26/20 12/9/20 Approved Parkinsons Antiparkinson Agents Anticholinergic and Other
2020-PHARM-214 Pain Management Skeletal Muscle Relaxants 10/26/20 12/9/20 Approved Pain Management Skeletal Muscle Relaxants
2020-PHARM-213 Pain Management Neuropathic Pain 10/26/20 12/9/20 Approved Pain Management Neuropathic Pain
2020-PHARM-212 Pain Management Narcotic Analgesics Short Acting 10/26/20  12/9/20  Approved Pain Management Narcotic Analgesics Short Acting 
2020-PHARM-211 Pain Management Narcotic Analgesics Long Acting  10/26/20  12/9/20  Approved Pain Management Narcotic Analgesics Long Acting  
2020-PHARM-210 Pain Management Cytokine and CAM Antagonists  10/26/20  12/9/20  Approved Pain Management Cytokine and CAM Antagonists  
2020-PHARM-209 Pain Management Antimigraine Agents Triptans  10/26/20  12/9/20  Approved Pain Management Antimigraine Agents Triptans  
2020-PHARM-208 Pain Management Antimigraine Agents Ergotamine  10/26/20   12/9/20 Approved Pain Management Antimigraine Agents Ergotamine  
2020-PHARM-207 Pain Management Antimigraine Agents CGRP Antagonists 10/26/20 12/9/20 Approved Pain Management Antimigraine Agents CGRP Antagonists
2020-PHARM-206 Otic Agents Anti Infectives and Anesthetics 10/26/20 12/9/20 Approved Otic Agents Anti Infectives and Anesthetics
2020-PHARM-205 Osteoporosis Bone Resorption Suppression Agents 10/26/20 12/9/20 Approved Osteoporosis Bone Resorption Suppression Agents
2020-PHARM-204 Opiate Dependence Agents 10/26/20 12/9/20 Approved Opiate Dependence Agents
2020-PHARM-203 Ophthalmic Disorders Glaucoma Agents Intraocular Pressure Reducers 10/26/20 12/9/20 Approved Ophthalmic Disorders Glaucoma Agents Intraocular Pressure Reducers
2020-PHARM-202 Ophthalmic Disorders Anti-Inflammatory Immunomodulators 10/26/20 12/9/20 Approved Ophthalmic Disorders Anti-Inflammatory Immunomodulators
2020-PHARM-201 Ophthalmic Disorders Anti-Inflammatories 10/26/20 12/9/20 Approved Ophthalmic Disorders Anti-Inflammatories
2020-PHARM-200 Ophthalmic Disorders Antibiotic-Steroid Combinations 10/26/20 12/9/20 Approved Ophthalmic Disorders Antibiotic-Steroid Combinations
2020-PHARM-199 Ophthalmic Disorders Allergic Conjunctivitis 10/26/20 12/9/20 Approved Ophthalmic Disorders Allergic Conjunctivitis
2020-PHARM-198 Oncology Oral Skin 10/26/20 12/9/20 Approved Oncology Oral Skin
2020-PHARM-197 Oncology Oral Renal Cell 10/26/20 12/9/20 Approved Oncology Oral Renal Cell
2020-PHARM-196 Oncology Oral Prostate 10/26/20 12/9/20 Approved Oncology Oral Prostate
2020-PHARM-195 Oncology Oral Other 10/26/20 12/9/20 Approved Oncology Oral Other
2020-PHARM-194 Oncology Oral Lung 10/26/20 12/9/20 Approved Oncology Oral Lung
2020-PHARM-193 Oncology Oral Hematologic 10/26/20 12/9/20 Approved Oncology Oral Hematologic
2020-PHARM-192 Oncology Oral Breast 10/26/20 12/9/20 Approved Oncology Oral Breast
2020-PHARM-191 Multiple Sclerosis Multiple Sclerosis Agents Immunomodulatory Agents 10/26/20 12/9/20 Approved Multiple Sclerosis Multiple Sclerosis Agents Immunomodulatory Agents
2020-PHARM-190 Infectious Disorders Hepatitis C Agents Not Direct Acting Antiviral Agents 10/26/20 12/9/20 Approved Infectious Disorders Hepatitis C Agents Not Direct Acting Antiviral Agents
2020-PHARM-189 Infectious Disorders Hepatitis C Agents Direct Acting Antiviral Agents 10/26/20 12/9/20 Approved Infectious Disorders Hepatitis C Agents Direct Acting Antiviral Agents
2020-PHARM-188 Infectious Disorders Antibiotics Vaginal 10/26/20 12/9/20 Approved Infectious Disorders Antibiotics Vaginal
2020-PHARM-187 Infectious Disorders Antibiotics Streptogramins 10/26/20 12/9/20 Approved Infectious Disorders Antibiotics Streptogramins
2020-PHARM-186 Infectious Disorders Antibiotics Oxazolidinones 10/26/20 12/9/20 Approved Infectious Disorders Antibiotics Oxazolidinones
2020-PHARM-185 Infectious Disorders Antibiotics Nitrofuran Derivatives 10/26/20 12/9/20 Approved Infectious Disorders Antibiotics Nitrofuran Derivatives
2020-PHARM-184 Infectious Disorders Antibiotics Macrolides Ketolides 10/26/20 12/9/20 Approved Infectious Disorders Antibiotics Macrolides Ketolides
2020-PHARM-183 Infectious Disorders Antibiotics Lincosamides 10/26/20 12/9/20 Approved Infectious Disorders Antibiotics Lincosamides
2020-PHARM-182 Infectious Disorders Antibiotics Inhaled Antibiotics 10/26/20 12/9/20 Approved Infectious Disorders Antibiotics Inhaled Antibiotics
2020-PHARM-181 Infectious Disorders Antibiotics Gastrointestinal Antibiotics 10/26/20 12/9/20 Approved Infectious Disorders Antibiotics Gastrointestinal Antibiotics
2020-PHARM-180 Infectious Disorders Antibiotics Fluoroquinolones 10/26/20 12/9/20 Approved Infectious Disorders Antibiotics Fluoroquinolones
2020-PHARM-179 Immunosuppressives Oral 10/26/20 12/9/20 Approved Immunosuppressives Oral
2020-PHARM-178 Hemodialysis Phosphate Binders 10/26/20 12/9/20 Approved Hemodialysis Phosphate Binders
2020-PHARM-177 Hematologic Agents Hematopoietic Agents Erythropoietins 10/26/20 12/9/20 Approved Hematologic Agents Hematopoietic Agents Erythropoietins
2020-PHARM-176 Heart Disease Hyperlipidemia Vasodilators Coronary 10/26/20 12/9/20 Approved Heart Disease Hyperlipidemia Vasodilators Coronary
2020-PHARM-175 Heart Disease Hyperlipidemia Sympatholytics 10/26/20 12/9/20 Approved Heart Disease Hyperlipidemia Sympatholytics
2020-PHARM-174 Heart Disease Hyperlipidemia Statins and Statin Combination Agents 10/26/20 12/9/20 Approved Heart Disease Hyperlipidemia Statins and Statin Combination Agents
2020-PHARM-173 Heart Disease Hyperlipidemia Pulmonary Arterial Hypertension 10/26/20 12/9/20 Approved Heart Disease Hyperlipidemia Pulmonary Arterial Hypertension
2020-PHARM-172 Heart Disease Hyperlipidemia Lipotropics Other 10/26/20 12/9/20 Approved Heart Disease Hyperlipidemia Lipotropics Other
2020-PHARM-171 Heart Disease Hyperlipidemia Hypertension Calcium Channel Blockers 10/26/20 12/9/20 Approved Heart Disease Hyperlipidemia Hypertension Calcium Channel Blockers
2020-PHARM-170 Heart Disease Hyperlipidemia Hypertension Beta Blocker Agents 10/26/20 12/9/20 Approved Heart Disease Hyperlipidemia Hypertension Beta Blocker Agents
2020-PHARM-169 Heart Disease Hyperlipidemia Hypertension Angiotensin Modulators Calcium Channel Blockers Combinations 10/26/20 12/9/20 Approved Heart Disease Hyperlipidemia Hypertension Angiotensin Modulators Calcium Channel Blockers Combinations
2020-PHARM-168 Heart Disease Hyperlipidemia Hypertension ACE Inhibitors and Direct Renin Inhibitors 10/26/20 12/9/20 Approved Heart Disease Hyperlipidemia Hypertension ACE Inhibitors and Direct Renin Inhibitors
2020-PHARM-167 Heart Disease Hyperlipidemia Anticoagulants Platelet Aggregation Inhibitors  10/23/20   12/6/20 Pending  Heart Disease Hyperlipidemia Anticoagulants Platelet Aggregation Inhibitors 
2020-PHARM-166 Heart Disease Hyperlipidemia Anticoagulants  10/23/20  12/6/20  Pending  Heart Disease Hyperlipidemia Anticoagulants  
2020-PHARM-165 H Pylori Treatment  10/23/20  12/6/20  Pending  H Pylori Treatment  
2020-PHARM-164 Growth Deficiency Growth Hormones  10/23/20  12/6/20  Pending  Growth Deficiency Growth Hormones  
2020-PHARM-163 Gout Agents Antihyperuricemics   10/23/20 12/6/20  Pending  Gout Agents Antihyperuricemics  
2020-PHARM-162 Glucocorticoids Oral 10/23/20 12/6/20 Pending Glucocorticoids Oral
2020-PHARM-161 GI Motility Chronic 10/23/20 12/6/20 Pending GI Motility Chronic
2020-PHARM-160 Epinephrine Self Injected 10/23/20 12/6/20 Pending Epinephrine Self Injected
2020-PHARM-159 Digestive Disorders Ulcerative Colitis Agents 10/23/20 12/6/20 Pending Digestive Disorders Ulcerative Colitis Agents
2020-PHARM-158 Digestive Disorders Proton Pump Inhibitors 10/23/20 12/6/20 Pending Digestive Disorders Proton Pump Inhibitors
2020-PHARM-157 Digestive Disorders Pancreatic Enzymes 10/23/20 12/6/20 Pending Digestive Disorders Pancreatic Enzymes
2020-PHARM-156 Digestive Disorders Histamine II Receptor Blockers 10/23/20 12/6/20 Pending Digestive Disorders Histamine II Receptor Blockers
2020-PHARM-155 Digestive Disorders Bile Acid Salts 10/23/20 12/6/20 Pending Digestive Disorders Bile Acid Salts
2020-PHARM-154 Digestive Disorders Antiemetic Antivertigo Agents 10/23/20 12/6/20 Pending Digestive Disorders Antiemetic Antivertigo Agents
2020-PHARM-153 Diabetes Metformins 10/23/20 12/6/20 Pending Diabetes Metformins
2020-PHARM-152 Diabetes Hypoglycemics Thiazolidinediones 10/23/20  12/6/20  Pending  Diabetes Hypoglycemics Thiazolidinediones 
2020-PHARM-151 Diabetes Hypoglycemics Sulfonylureas 10/23/20  12/6/20  Pending  Diabetes Hypoglycemics Sulfonylureas 
2020-PHARM-150 Diabetes Hypoglycemics Sodium Glucose Co Transporter 2 Inhibitors 10/23/20  12/6/20  Pending  Diabetes Hypoglycemics Sodium Glucose Co Transporter 2 Inhibitors 
2020-PHARM-149 Diabetes Hypoglycemics Meglitinides 10/23/20  12/6/20  Pending  Diabetes Hypoglycemics Meglitinides 
2020-PHARM-148 Diabetes Hypoglycemics Insulins and Related Agents 10/23/20   12/6/20 Pending  Diabetes Hypoglycemics Insulins and Related Agents
2020-PHARM-147 Diabetes Hypoglycemics Incretin Mimetics Enhancers 10/23/20 12/6/20 Pending Diabetes Hypoglycemics Incretin Mimetics Enhancers
2020-PHARM-146 Diabetes Alpha Glucosidase Inhibitors 10/23/20 12/6/20 Pending Diabetes Alpha Glucosidase Inhibitors
2020-PHARM-145 Dermatology Steroids Topical Medium Potency 10/23/20 12/6/20 Pending Dermatology Steroids Topical Medium Potency
2020-PHARM-144 Dermatology Steroids Topical Low Potency 10/23/20 12/6/20 Pending Dermatology Steroids Topical Low Potency
2020-PHARM-143 Dermatology Steroids Topical High Potency 10/23/20 12/6/20 Pending Dermatology Steroids Topical High Potency
2020-PHARM-142 Dermatology Immunomodulators Topical 10/23/20 12/6/20 Pending Dermatology Immunomodulators Topical
2020-PHARM-141 Dermatology Emollients 10/23/20 12/6/20 Pending Dermatology Emollients
2020-PHARM-140 Dermatology Atopic Dermatitis Immunomodulators 10/23/20 12/6/20 Pending Dermatology Atopic Dermatitis Immunomodulators
2020-PHARM-139 Dermatology Antiviral Agents Topical 10/23/20 12/6/20 Pending Dermatology Antiviral Agents Topical
2020-PHARM-138 Dermatology Antipsoriatics Topical 10/23/20 12/6/20 Pending Dermatology Antipsoriatics Topical
2020-PHARM-137 Dermatology Antipsoriatics Oral 10/23/20 12/6/20 Pending Dermatology Antipsoriatics Oral
2020-PHARM-136 Dermatology Antiparasitic Agents Topical 10/23/20 12/6/20 Pending Dermatology Antiparasitic Agents Topical
2020-PHARM-135 Cystic Fibrosis Oral 10/23/20 12/6/20 Pending Cystic Fibrosis Oral
2020-PHARM-134 Colony Stimulating Factors 10/23/20 12/6/20 Pending Colony Stimulating Factors
2020-PHARM-133 Asthma COPD Leukotriene Modifiers 10/23/20 12/6/20 Pending Asthma COPD Leukotriene Modifiers
2020-PHARM-132 Asthma COPD Glucocorticoids Inhalation 10/22/20 12/5/20 Approved Asthma COPD Glucocorticoids Inhalation
2020-PHARM-131 Asthma COPD Bronchodilator Beta Adrenergic Oral Agents 10/22/20 12/5/20 Approved Asthma COPD Bronchodilator Beta Adrenergic Oral Agents
2020-PHARM-130 Asthma COPD Bronchodilator Beta Adrenergic Inhalation Agents 10/22/20 12/5/20 Approved Asthma COPD Bronchodilator Beta Adrenergic Inhalation Agents
2020-PHARM-129 Asthma COPD Bronchodilator Anticholinergics COPD Oral 10/22/20 12/5/20 Approved Asthma COPD Bronchodilator Anticholinergics COPD Oral
2020-PHARM-128 Asthma COPD Bronchodilator Anticholinergics COPD Inhalation 10/22/20 12/5/20 Approved Asthma COPD Bronchodilator Anticholinergics COPD Inhalation
2020-PHARM-127 Antivirals Oral 10/22/20 12/5/20 Approved Antivirals Oral
2020-PHARM-126 Androgenic Agents 10/22/20 12/5/20 Approved Androgenic Agents
2020-PHARM-125 Alzheimers Agents 10/22/20 12/5/20 Approved Alzheimers Agents
2020-PHARM-124 Allergy Rhinitis Agents Nasal 10/22/20 12/5/20 Approved Allergy Rhinitis Agents Nasal
2020-PHARM-123 Allergy Antihistamines Minimally Sedating 10/22/20 12/5/20 Approved Allergy Antihistamines Minimally Sedating
2020-PHARM-122 Vyondys  10/22/20 12/5/20   Approved Vyondys  
2020-PHARM-121 Spinraza Form  10/22/20  12/5/20   Approved Spinraza Form 
2020-PHARM-120 Spinraza Criteria  10/22/20  12/5/20   Approved Spinraza Criteria 
2020-PHARM-119 Selected Anti Infective Anti Fungal and Corticosteroid Quantity Limits Plus Criteria  10/22/20  12/5/20   Approved Selected Anti Infective Anti Fungal and Corticosteroid Quantity Limits Plus Criteria  
2020-PHARM-118 POS DUR January 2021 Posting Revised  10/22/20  12/5/20   Approved POS DUR January 2021 Posting Revised 
2020-PHARM-117 POS Sedative Hypnotics  10/22/20  12/5/20   Approved POS Sedative Hypnotics 
2020-PHARM-116 POS Pain Management Nonsteroidal Anti Inflammatory Drugs  10/22/20  12/5/20   Approved POS Pain Management Nonsteroidal Anti Inflammatory Drugs  
2020-PHARM-115 POS Otic Agents Antibiotics  10/22/20  12/5/20   Approved POS Otic Agents Antibiotics  
2020-PHARM-114 POS Opthalmic Disorders Antibiotics 10/22/20  12/5/20   Approved POS Opthalmic Disorders Antibiotics 
2020-PHARM-113 POS Infectious Disorders Antifungals Oral  10/22/20  12/5/20   Approved POS Infectious Disorders Antifungals Oral
2020-PHARM-112 POS Infectious Disorders Antibiotics Tetracyclines  10/22/20  12/5/20   Approved POS Infectious Disorders Antibiotics Tetracyclines  
2020-PHARM-111 POS Infectious Disorders Antibiotics Cephalosporin and Related Antibiotics  10/22/20  12/5/20   Approved POS Infectious Disorders Antibiotics Cephalosporin and Related Antibiotics 
2020-PHARM-110 POS Hemophilia Treatment  10/22/20  12/5/20   Approved POS Hemophilia Treatment  
2020-PHARM-109 POS Document for October DUR  10/22/20  12/5/20   Approved POS Document for October DUR  
2020-PHARM-108 POS Dermatology Steriods Topical Very High Potency  10/22/20  12/5/20   Approved POS Dermatology Steriods Topical Very High Potency 
2020-PHARM-107 POS Dermatology Antifungals Topical  10/22/20  12/5/20   Approved POS Dermatology Antifungals Topical  
2020-PHARM-106 POS Dermatology Antibiotics Topical  10/22/20  12/5/20   Approved POS Dermatology Antibiotics Topical  
2020-PHARM-105 POS Depression Selective Serotonin Reuptake Inhibitors  10/22/20  12/5/20   Approved POS Depression Selective Serotonin Reuptake Inhibitors  
2020-PHARM-104 POS Depression Antidepressants Other  10/22/20  12/5/20   Approved POS Depression Antidepressants Other  
2020-PHARM-103 POS Anxiolytics  10/22/20  12/5/20   Approved POS Anxiolytics 
2020-PHARM-102 POS Antipsychotic Agents Oral  10/22/20  12/5/20   Approved POS Antipsychotic Agents Oral 
2020-PHARM-101 POS Antipsychotic Agents Injectable Agents  10/22/20  12/5/20   Approved POS Antipsychotic Agents Injectable Agents  
2020-PHARM-100 POS ADD-ADHD Stimulants and Related Agents  10/22/20  12/5/20   Approved POS ADD-ADHD Stimulants and Related Agents  
2020-PHARM-99 POS Acne Agents  10/22/20  12/5/20   Approved POS Acne Agents 
2020-PHARM-98 PDL 7-1-20 for 10-7-20 Diabetic Supplies  10/22/20  12/5/20   Approved PDL 7-1-20 for 10-7-20 Diabetic Supplies 
2020-PHARM-97 Pain Management Non Steriodal AntiInflammatory Agents  10/22/20  12/5/20   Approved Pain Management Non Steriodal AntiInflammatory Agents  
2020-PHARM-96 Other Behavioral Health Under 7  10/22/20  12/5/20   Approved Other Behavioral Health Under 7  
2020-PHARM-95 Nocdurna POS  10/22/20  12/5/20   Approved Nocdurna POS 
2020-PHARM-94 Medically Necessary Criteria  10/22/20  12/5/20   Approved Medically Necessary Criteria  
2020-PHARM-93 Louisiana Medicaid ICD-10 Chart with October DUR Updates redline  10/22/20  12/5/20   Approved Louisiana Medicaid ICD-10 Chart with October DUR Updates redline 
2020-PHARM-92 Immune Globulin Criteria  10/22/20  12/5/20   Approved Immune Globulin Criteria 
2020-PHARM-91 Exondys  10/22/20  12/5/20   Approved Exondys  
2020-PHARM-90 Evrysdi  10/22/20  12/5/20   Approved Evrysdi 
2020-PHARM-89 Epidiolex Criteria  10/22/20  12/5/20   Approved Epidiolex Criteria 
2020-PHARM-88 Enzyme Replacement Therapy Diagnosis Code and TD Edits  10/22/20  12/5/20   Approved Enzyme Replacement Therapy Diagnosis Code and TD Edits 
2020-PHARM-87 Diabetes Strips Lancets Quantity Limit  10/22/20  12/5/20   Approved Diabetes Strips Lancets Quantity Limit 
2020-PHARM-86 Depression Antidepressants SSRIs  10/22/20  12/5/20   Approved  Depression Antidepressants SSRIs  
2020-PHARM-85 Depression Antidepressants Other  10/22/20  12/5/20   Approved Depression Antidepressants Other 
2020-PHARM-84 Cytokine and CAM Antagonists  10/22/20  12/5/20   Approved Cytokine and CAM Antagonists 
2020-PHARM-83 Botulinum Toxins Diagnosis Code and Quantity Limits  10/22/20  12/5/20   Approved Botulinum Toxins Diagnosis Code and Quantity Limits  
2020-PHARM-82 Anxiolytics  10/22/20  12/5/20   Approved Anxiolytics  
2020-PHARM-81 Antipsychotics  10/22/20  12/5/20   Approved Antipsychotics 
2020-PHARM-80 Allergen Extracts  10/22/20  12/5/20   Approved Allergen Extracts 
2020-PHARM-79 ADHD  10/22/20 12/5/20  Approved ADHD 
2020-HB-PHARM-2 Avastin Biosimilars Sed Step Therapy Notice 10/22/20 12/5/20 Approved Avastin Biosimilars Sed Step Therapy Notice
2020-UHC-PHARM-26 Benlysta 10/21/20 12/4/20 Approved Benlysta
2020-UHC-PHARM-25 Trogarzo 10/21/20 12/4/20 Approved Trogarzo
2020-UHC-PHARM-24 Testosterone 10/21/20 12/4/20 Approved Testosterone
2020-UHC-PHARM-23   Radicava 10/16/20 11/30/20 Approved Radicava
2020-UHC-PHARM-22   Reblozyl 10/16/20 11/30/20 Approved Reblozyl
2020-UHC-PHARM-21   Parsabiv 10/16/20 11/30/20 Approved Parsabiv
2020-UHC-PHARM-20   Immune Globulins 10/16/20 11/30/20 Approved Immune Globulins
2020-UHC-PHARM-19   Botulinum Toxins 10/16/20 11/30/20 Approved Botulinum Toxins
2020-UHC-PHARM-18   Rituxan 10/16/20 11/30/20 Approved Rituxan
2020-UHC-PHARM-17   Somatostatin Analogs 10/16/20 11/30/20 Approved Somatostatin Analogs
2020-UHC-PHARM-16   Buprenorphine 10/16/20 11/30/20 Approved Buprenorphine
2020-UHC-PHARM-15  Gaucher Disease 10/13/20 11/27/20 Approved Gaucher Disease
2020-UHC-PHARM-14  Vyepti 10/13/20 11/27/20 Approved Vyepti
2020-UHC-PHARM-13  Enzyme Replacement Therapy 10/13/20 11/27/20 Approved Enzyme Replacement Therapy
2020-UHC-PHARM-12  Tepezza 10/13/20 11/27/20 Approved Tepezza
2020-UHC-PHARM-11  Onpattro 10/13/20 11/27/20 Approved Onpattro
2020-UHC-PHARM-10  Complement Inhibitors 10/13/20 11/27/20 Approved Complement Inhibitors
2020-UHC-PHARM-9     IV Iron Replacement Therapy 10/13/20 11/27/20 Approved IV Iron Replacement Therapy
2020-UHC-PHARM-8     Denosumab 10/13/20 11/27/20 Approved Denosumab
2020-UHC-PHARM-7     Brineura 10/13/20 11/27/20 Approved Brineura
2020-UHC-PHARM-6     Crysvita 10/13/20 11/27/20 Approved Crysvita
2020-UHC-PHARM-5     Krystexxa 10/13/20 11/27/20 Approved Krystexxa
2020-UHC-PHARM-4     Sodium Hyaluronate 10/13/20 11/27/20 Approved Sodium Hyaluronate
2020-LHCC-PHARM-1 Pharmacy Prior Authorization and Medical Necessity 9/30/20 11/14/20 Approved Pharmacy Prior Authorization and Medical Necessity
2020-UHC-PHARM-1 Scenesse 9/28/20 11/12/20 Approved Scenesse
2020-UHC-PHARM-2 Uplizna 9/28/20 11/12/20 Approved Uplizna
2020-UHC-PHARM-3 Viltepso 9/28/20 11/12/20 Approved Viltepso
2020-ACLA-PHARM-4 Specialty Drugs PA Criteria 9/15/20 10/30/20 Approved Specialty Drugs PA Criteria
2020-ACLA-PHARM-3 Oncology Drugs PA Criteria 9/8/20 10/24/20 Approved Oncology Drugs PA Criteria
2020-ACLA-PHARM-1 Remdesivir 9/1/20 10/16/20 Approved Remdesivir
2020-ACLA-PHARM-2 Diabetic Testing Supplies 9/1/20 10/16/20 Approved Diabetic Testing Supplies
2020-LHCC-814 Crisis Intervention Policy 8/28/20 10/12/20 Approved Crisis Intervention Policy
2020-LHCC-817 Vitamin D Testing Policy 8/28/20 10/12/20 Approved Vitamin D Testing Policy
2020-ABH-PHARM-2 Compounds 8/25/20 10/9/20 Complete Compounds
2020-ABH-PHARM-1 Quantity Level Limit 8/19/20 10/3/20 Approved Quantity Level Limit
2020-HBL-816 Vitamin D Policy 8/18/20 10/2/20 Approved Vitamin D Policy
2020-ACLA-815 Vitamin D Policy 8/14/20 9/28/20 Approved Vitamin D Policy
2020-ABH-813 Vitamin D Policy 8/14/20 9/28/20 Approved Vitamin D Policy
2020-HPA-3 HPA: Tobacco Cessation for Pregnant Women 8/11/20 9/25/20 Complete HPA: Tobacco Cessation for Pregnant Women
2020-IB-2 IB: Tobacco Cessation for Pregnant Women 8/11/20 9/25/20 Complete IB: Tobacco Cessation for Pregnant Women
2020-UHC-812 Vitamin D Policy 8/7/20 9/21/20 Approved Vitamin D Policy
2020-SCG-3 Tracking of Evidence Based Practices (EBP) 8/6/20 9/20/20 Complete MCO SCG July 2020 pg. 16-17
2020-PHARM-78  Asthma COPD Bronchodilator Anticholinergics Inhalation  7/31/20  9/14/20  Approved Asthma COPD Bronchodilator Anticholinergics Inhalation 
2020-PHARM-77  Cytokineand CAM Antagonists  7/31/20   9/14/20  Approved Cytokineand CAM Antagonists 
2020-PHARM-76  Dermatology Atopic Dermatitis Immunomodulators  7/31/20   9/14/20  Approved Dermatology Atopic Dermatitis Immunomodulators  
2020-PHARM-75  Diabetes Hypoglycemics Incretin Mimetics Enhancers  7/31/20   9/14/20  Approved Diabetes Hypoglycemics Incretin Mimetics Enhancers  
2020-PHARM-74  Esbriet  7/31/20   9/14/20  Approved Esbriet
2020-PHARM-73  Fetroja  7/31/20   9/14/20  Approved Fetroja 
2020-PHARM-72  Givlaari  7/31/20   9/14/20  Approved Givlaari 
2020-PHARM-71  Hepatitis C DAA  7/31/20   9/14/20  Approved Hepatitis C DAA 
2020-PHARM-70  Infectious Disorders Hepatitis C Agents Direct Acting Antiviral Agents  7/31/20   9/14/20  Approved Infectious Disorders Hepatitis C Agents Direct Acting Antiviral Agents 
2020-PHARM-69 Koselugo   7/31/20   9/14/20  Approved Koselugo 
2020-PHARM-68 Ofev  7/31/20   9/14/20  Approved Ofev 
2020-PHARM-67 Oxbryta  7/31/20   9/14/20  Approved Oxbryta 
2020-PHARM-66 POS DUR October 2020  7/31/20   9/14/20  Approved POS DUR October 2020  
2020-PHARM-65 Sedative Hypnotics  7/31/20   9/14/20  Approved Sedative Hypnotics  
2020-PHARM-64 Tikosyn  7/31/20   9/14/20  Approved Tikosyn 
2020-PHARM-63 VMAT2 Inhibitors 7/31/20   9/14/20  Approved VMAT2 Inhibitors 
2020-PHARM-62 Xenleta  7/31/20   9/14/20  Approved Xenleta 
2020-HBL-366 Out-of-Area, Out-of-Network Care 7/24/20  9/7/20  Approved  Out-of-Area, Out-of-Network Care
2020-HBL-542.1 2020-HBL-542.2 Anesthesia Services for Interventional Pain Management Procedures and Clinical Guidelines 7/24/20  9/7/20  Completed Anesthesia Services for Interventional Pain Management Procedures Clinical Guidelines
2020-UHC-564 Benlysta 7/24/20  9/7/20  Approved Benlysta
2020-UHC-565 Crysvita 7/24/20  9/7/20  Approved Crysvita
2020-UHC-567 Maximum Dosage 7/24/20  9/7/20  Approved Maximum Dosage
2020-UHC-568 Ocrevus 7/24/20  9/7/20  Approved Ocrevus
2020-UHC-569 Off Label Unproven  7/24/20  9/7/20  Approved Off Label Unproven
2020-UHC-572 Reblozyl  7/24/20  9/7/20  Approved Reblozyl
2020-UHC-574 Testosterone Replacement  7/24/20  9/7/20  Approved Testosterone Replacement
2020-LHCC-610 Authorization Error Correction Process  7/24/20  9/7/20  Completed  Authorization Error Correction Process
2020-LHCC-636 Authorization for Second Clinical Opinions  7/24/20  9/7/20  Completed  Authorization for Second Clinical Opinions 
2020-LHCC-682 Active Procedures in Physical Medicine  7/24/20  9/7/20  Approved Active Procedures in Physical Medicine
2020-LHCC-683 Chiro Infant Care Policy  7/24/20  9/7/20  Approved Chiro Infant Care Policy
2020-LHCC-684 Chiro Infant Care Policy  7/24/20  9/7/20  Approved Chiro Infant Care Policy
2020-LHCC-685 Experimental, Unproven, or Investigational Services  7/24/20  9/7/20  Approved Experimental, Unproven, or Investigational Services
2020-HBL-318 Clinical Information for Utilization Review 7/16/20 8/30/20 Approved Clinical Information for Utilization Review
2020-HBL-328 Pre-Certification of Requested Services 7/16/20 8/30/20 Approved Pre-Certification of Requested Services
2020-UHC-535 Nat'l Drug Code (NDC) Requirement Policy 7/16/20 8/30/20 Approved Nat'l Drug Code (NDC) Requirement Policy
2020-ACLA-538 PCP Assignment 7/16/20 8/30/20 Approved PCP Assignment
2020-HBL-588 Retrospective Review 7/16/20 8/30/20 Approved Retrospective Review
2020-LHCC-609 Court Ordered Services Louisiana PP   7/16/20 8/30/20 Approved Court Ordered Services Louisiana PP  
2020-HBL-677 SPOT AIM Rehab Transition Bulletin 7/16/20 8/30/20 Approved SPOT AIM Rehab Transition Bulletin
2020-HB-PHARM-1   Louisiana Compound Coverage 7/21/20 9/4/20 Approved Louisiana Compound Coverage
2020-HBL-316 Associates Performing Utilization Review 7/9/20 8/23/20 Approved Associates Performing Utilization Review
2020-HBL-576 AIM Musculoskeletal Prog Clinical Appropriateness Guidelines 7/9/20 8/23/20 Approved AIM Musculoskeletal Prog Clinical Appropriateness Guidelines
2020-LHCC-329 Adverse Determinations 7/9/20 8/23/20 Approved Adverse Determinations
2020-LHCC-429 UM Program Description  7/9/20 8/23/20 Approved UM Program Description 
2020-LHCC-498 Mental Health Rehab MNC Policy 7/9/20 8/23/20 Approved Mental Health Rehab MNC Policy
2020-LHCC-532 Appropriate UM Professionals 7/9/20 8/23/20 Approved Appropriate UM Professionals
2020-LHCC-607 Inpatient Leveling of Care WP 7/9/20 8/23/20 Completed Inpatient Leveling of Care WP
2020-UHC-557 Transcranial Magnetic Stimulation 7/9/20 8/23/20 Approved Transcranial Magnetic Stimulation
2020-UHC-558 Knee Replacement Surgery (Arthroplasty), Total and Partial 7/9/20 8/23/20 Approved Knee Replacement Surgery (Arthroplasty), Total and Partial
2020-UHC-559 Implantable Beta-Emitting Microspheres 7/9/20 8/23/20 Approved Implantable Beta-Emitting Microspheres
2020-UHC-560 Home Hemodialysis 7/9/20 8/23/20 Approved Home Hemodialysis
2020-UHC-561 Cognitive Rehabilitation 7/9/20 8/23/20 Approved Cognitive Rehabilitation
2020-HBL-602.1 Medical drug Clinical Criteria updates 7/2/20 8/16/20 Approved Medical drug Clinical Criteria updates
2020-HBL-602.2 Faslodex Criteria 7/2/20 8/16/20 Approved Faslodex Criteria
2020-HBL-602.3 Gazyva Criteria 7/2/20 8/16/20 Approved Gazyva Criteria
2020-HBL-602.4 Immunoglobulins Criteria 7/2/20 8/16/20 Approved Immunoglobulins Criteria
2020-HBL-602.5 Intravitreal Corticosteroid Implants Criteria 7/2/20 8/16/20 Approved Intravitreal Corticosteroid Implants Criteria
2020-HBL-602.6 Keytruda Criteria 7/2/20 8/16/20 Approved Keytruda Criteria
2020-HBL-602.7 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications Criteria 7/2/20 8/16/20 Approved Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications Criteria
2020-LHCC-505 New Follow-Up After Hospitalization Policy 7/2/20 8/16/20 Approved New Follow-Up After Hospitalization Policy
2020-LHCC-611 Appeals Process 7/2/20 8/16/20 Completed Appeals Process
2020-UHC-563 Actemra Criteria 7/2/20 8/16/20 Approved Actemra Criteria
2020-UHC-570 Orencia Criteria 7/2/20 8/16/20 Approved Orencia Criteria
2020-LHCC-331   Provider Manual 6/25/20 8/10/20 Approved Provider Manual
2020-UHC-585  Chelation Therapy 6/25/20 8/10/20 Approved Chelation Therapy
2020-PHARM-61 Hepatitis C DAA 6/22/20 8/7/20 Approved Hepatitis C DAA
2020-ACLA-325 Provider Manual 6/18/20  8/3/20 Approved Provider Manual
2020-HBL-115 Multiple Bilateral Article and Policy 6/18/20  8/3/20 Approved Multiple Bilateral Article and Policy 1Multiple Bilateral Article and Policy 2
2020-HBL-120 Psychiatris Res Trmt Fac PRTF Gde, Med Gde and Withdrawal Gde 6/18/20  8/3/20 Approved Psychiatris Res Trmt Fac PRTF Gde Med Gde Withdrawal Gde
2020-HBL-250 Provider Manual 6/18/20  8/3/20 Denied Provider Manual
2020-UHC-324 Provider Manual 6/18/20  8/3/20 Approved Provider Manual
2020-UHC-513 Epidural Steroid and Facet Injections for Spinal Pain (for Louisiana Only) 6/18/20  8/3/20 Approved Epidural Steroid and Facet Injections for Spinal Pain (for Louisiana Only)
2020-UHC-516 Reimbursement Policy: Obstetrical Services Policy 6/18/20  8/3/20 Approved Reimbursement Policy: Obstetrical Services Policy
2020-UHC-518 Reimbursement Policy: Global Days Policy 6/18/20  8/3/20 Approved Reimbursement Policy: Global Days Policy
2020-UHC-519 Reimbursement Policy: Vaccines for Children 6/18/20  8/3/20 Approved Reimbursement Policy: Vaccines for Children
2020-UHC-529 AIM Advanced Imaging Clinical Appropr. Guidelines 6/18/20  8/3/20 Approved AIM Advanced Imaging Clinical Appropr. Guidelines 1

AIM Advanced Imaging Clinical Appropr. Guidelines 2

AIM Advanced Imaging Clinical Appropr. Guidelines 3

AIM Advanced Imaging Clinical Appropr. Guidelines 4
2020-UHC-531 AIM Advanced Imaging Clinical Appropr. Guidelines 6/18/20  8/3/20 Approved AIM Advanced Imaging Clinical Appropr. Guidelines
2020-UHC-534 Add On Codes Policy 6/18/20 8/3/20 Approved Add On Codes Policy 1

Add On Codes Policy 2
2020-PHARM-60 Multiple Sclerosis Agents for August 2020 6/15/20 7/30/20 Approved Multiple Sclerosis Agents
2020-UHC-511 Manipulation Under Anesthesia 6/10/20 7/25/20 Approved Manipulation Under Anesthesia
2020-UHC-512 Glaucoma Surgical Treatment 6/10/20 7/25/20 Approved Glaucoma Surgical Treatment
2020-ABH-114 Limitations on Abortions 6/9/20 7/24/20 Approved Limitations on Abortions
2020-ABH-496 Community Psychiatric Support and Treatment (CPST) and Psychosocial Rehabilitation (PSR) Services 6/9/20 7/24/20 Approved Community Psychiatric Support and Treatment (CPST) and Psychosocial Rehabilitation (PSR) Services
2020-ACLA-368 Split Surgery Care 6/9/20 7/24/20 Approved Split Surgery Care
2020-ACLA-380 Assistant Surgery Care 6/9/20 7/24/20 Approved Assistant Surgery Care
2020-ACLA-381 Co-Surgery 6/9/20 7/24/20 Approved Co-Surgery
2020-ACLA-484 Prior Authorization Requirements 6/9/20 7/24/20 Completed Prior Authorization Requirements
2020-ACLA-495 Anesthesia Services for Gastrointestinal Endoscopy 6/9/20 7/24/20 Approved Anesthesia Services for Gastrointestinal Endoscopy
2020-ACLA-507 Site of Care Medical Pharmacy 6/9/20 7/24/20 Approved Site of Care Medical Pharmacy
2020-ACLA-508 Outpatient Surgical Procedures 6/9/20 7/24/20 Approved Outpatient Surgical Procedures
2020-HBL-257 Pediatric Day Health Care and Personal Care Services 6/9/20 7/24/20 Approved Pediatric Day Health Care and Personal Care Services
2020-HBL-319 Unlisted Unspecified Misc Codes Newsletter 6/9/20 7/24/20 Completed Unlisted Unspecified Misc Codes Newsletter
2020-HBL-327 Distinct Procedural 6/9/20 7/24/20 Completed Distinct Procedural
2020-HBL-359 Justice Involved Case Management 6/9/20 7/24/20 Approved Justice Involved Case Management
2020-HBL-360 Durable Medical Equipment 6/9/20 7/24/20 Approved Durable Medical Equipment
2020-HBL-415 Case Management Face to Face Intervention 6/9/20 7/24/20 Approved Case Management Face to Face Intervention
2020-HBL-416 Unlisted Unspecified Misc Codes Policy 6/9/20 7/24/20 Completed Unlisted Unspecified Misc Codes Policy
2020-HBL-485 Standing Referral 6/9/20 7/24/20 Completed Standing Referral
2020-HBL-515 Louisiana Provider Payment Suspension (Hold) 6/9/20 7/24/20 Completed Louisiana Provider Payment Suspension (Hold)
2020-LHCC-314 Infusion Therapy Site Of Care Optimization 6/9/20 7/24/20 Approved Infusion Therapy Site Of Care Optimization
2020-LHCC-315  Testing Select GU Conditions 6/9/20 7/24/20 Approved Testing Select GU Conditions
2020-LHCC-334 Disease Management Policies 6/9/20 7/24/20 Approved Disease Management Policies
2020-LHCC-335 Quality Program Description 6/9/20 7/24/20 Approved Quality Program Description
2020-LHCC-336 Care Management Program Description 6/9/20 7/24/20 Completed Care Management Program Description
2020-LHCC-338 Perinatal Substance Use Disorder Care Management Program 6/9/20 7/24/20 Approved Perinatal Substance Use Disorder Care Management Program
2020-LHCC-342 Medical Record Review 6/9/20 7/24/20 Completed Medical Record Review
2020-LHCC-419 Provider Termination 6/9/20 7/24/20 Completed Provider Termination
2020-LHCC-421 Provider Relations Demographic Provider Roster Affiliation Verification 6/9/20 7/24/20 Completed Provider Relations Demographic Provider Roster Affiliation Verification
2020-LHCC-422 Network Development and Management 6/9/20 7/24/20 Completed Network Development and Management
2020-LHCC-423 EPSDT 6/9/20 7/24/20 Approved EPSDT
2020-LHCC-424 PASRR 6/9/20 7/24/20 Approved PASRR
2020-LHCC-426 Adverse Incidents 6/9/20 7/24/20 Approved Adverse Incidents
2020-LHCC-430 Covered Benefits and Services 6/9/20 7/24/20 Approved Covered Benefits and Services
2020-LHCC-431 Monitoring Utilization 6/9/20 7/24/20 Approved Monitoring Utilization
2020-LHCC-432 Psychiatric Treatment Facility 6/9/20 7/24/20 Approved Psychiatric Treatment Facility
2020-LHCC-497 Emergency Services Policy 6/9/20 7/24/20 Completed Emergency Services Policy
2020-LHCC-499 Retrospective Review For Services Requiring Authorizations 6/9/20 7/24/20 Completed Retrospective Review For Services Requiring Authorizations
2020-LHCC-500 Policy, Procedure and Job Description Guidelines Policy 6/9/20 7/24/20 Completed Policy, Procedure and Job Description Guidelines Policy
2020-LHCC-501 Access to Non-Emergency Transportation policy 6/9/20 7/24/20 Approved Access to Non-Emergency Transportation policy
2020-LHCC-502 Clinical Information and Documentation Policy 6/9/20 7/24/20 Completed Clinical Information and Documentation Policy
2020-LHCC-503 Evaluation of the Accessibility of services 6/9/20 7/24/20 Completed Evaluation of the Accessibility of services
2020-LHCC-504 Quality PIPs policy 6/9/20 7/24/20 Approved Quality PIPs policy
2020-LHCC-525 Remote Field Staff Quarterly HIPPA and Equipment audit policy 6/9/20 7/24/20 Completed Remote Field Staff Quarterly HIPPA and Equipment audit policy
2020-LHCC-526 TruCare Standards for Documentation policy 6/9/20 7/24/20 Completed TruCare Standards for Documentation policy
2020-LHCC-527 Organizational Cultural Competency policy 6/9/20 7/24/20 Completed Organizational Cultural Competency policy
2020-LHCC-528 Public Records Request policy 6/9/20 7/24/20 Completed Public Records Request policy
2020-UHC-374 Electrical and Ultrasound Bone Growth Stimulators 6/9/20 7/24/20 Completed Electrical and Ultrasound Bone Growth Stimulators
2020-UHC-382 Benlysta (Belimumab) 6/9/20 7/24/20 Completed Benlysta (Belimumab)
2020-UHC-383 Oncology Medication Clinical Coverage 6/9/20 7/24/20 Completed Oncology Medication Clinical Coverage
2020-UHC-384 Intravenous Iron Replacement Therapy (Feraheme & Injectafer) 6/9/20 7/24/20 Completed Intravenous Iron Replacement Therapy (Feraheme & Injectafer)
2020-UHC-385 Ketalar (Ketamine) and Spravato (Esketamine) 6/9/20 7/24/20 Completed Ketalar (Ketamine) and Spravato (Esketamine)
2020-UHC-386 Luxturna (Voretigene Neparvovec-rzyl) 6/9/20 7/24/20 Completed Luxturna (Voretigene Neparvovec-rzyl)
2020-UHC-387 Review At Launch For New To Market Medications 6/9/20 7/24/20 Completed Review At Launch For New To Market Medications
2020-UHC-389 Somatostatin Analogs 6/9/20 7/24/20 Completed Somatostatin Analogs
2020-UHC-390 Vyondys 53 (Golodirsen) 6/9/20 7/24/20 Completed Vyondys 53 (Golodirsen)
2020-UHC-391 Zulresso (Brexanolone) 6/9/20 7/24/20 Completed Zulresso (Brexanolone)
2020-UHC-392 Alpha1-Proteinase Inhibitors 6/9/20 7/24/20 Completed Alpha1-Proteinase Inhibitors
2020-UHC-393 Botulinum Toxins A and B 6/9/20 7/24/20 Completed Botulinum Toxins A and B
2020-UHC-394 Denosumab (Prolia & Xgeva) 6/9/20 7/24/20 Completed Denosumab (Prolia & Xgeva)
2020-UHC-396 Exondys 51 (Eteplirsen) 6/9/20 7/24/20 Approved Exondys 51 (Eteplirsen)
2020-UHC-397 Ilaris (Canakinumab) 6/9/20 7/24/20 Completed Ilaris (Canakinumab)
2020-UHC-398 Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease 6/9/20 7/24/20 Completed Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease
2020-UHC-399 Buprenorphine (Probuphine & Sublocade) 6/9/20 7/24/20 Approved Buprenorphine (Probuphine & Sublocade)
2020-UHC-400 Compliment Inhibitors (SOLIRIS & ULTOMIRIS) 6/9/20 7/24/20 Completed Compliment Inhibitors (SOLIRIS & ULTOMIRIS)
2020-UHC-401 Crysvita (BUROSUMAB-TWZA) 6/9/20 7/24/20 Completed Crysvita (BUROSUMAB-TWZA)
2020-UHC-402 Denied Drug Codes - Pharmacy Benefit Drugs 6/9/20 7/24/20 Approved Denied Drug Codes - Pharmacy Benefit Drugs
2020-UHC-403 Enzyme Replacement Therapy 6/9/20 7/24/20 Completed Enzyme Replacement Therapy
2020-UHC-404 Erythropoiesis Stimulating Agents 6/9/20 7/24/20 Completed Erythropoiesis Stimulating Agents
2020-UHC-405 Gonadatropin Releasing Hormones 6/9/20 7/24/20 Approved Gonadatropin Releasing Hormones
2020-UHC-406 Immune Globulin (IVIG and SCIG) 6/9/20 7/24/20 Approved Immune Globulin (IVIG and SCIG)
2020-UHC-407 Krystexxa 6/9/20 7/24/20 Completed Krystexxa
2020-UHC-408 Maximum Dosage 6/9/20 7/24/20 Approved Maximum Dosage
2020-UHC-409 Opthalmologic VEGF Inhibitors 6/9/20 7/24/20 Approved Opthalmologic VEGF Inhibitors
2020-UHC-410 Sodium Hyaluronate 6/9/20 7/24/20 Approved Sodium Hyaluronate
2020-UHC-411 Tysabri 6/9/20 7/24/20 Approved Tysabri
2020-UHC-412 WBC-CSF 6/9/20 7/24/20 Approved WBC-CSF
2020-UHC-413 Addendum to BH Utilization Management 6/9/20 7/24/20 Approved Addendum to BH Utilization Management
2020-UHC-417 Prior Authorization Requirements 6/9/20 7/24/20 Completed Prior Authorization Requirements
2020-UHC-479 Cardiac Event Monitoring -Annual CPT/HCPCS Code Updates and MCG 6/9/20 7/24/20 Completed Cardiac Event Monitoring -Annual CPT/HCPCS Code Updates and MCG
2020-UHC-481 CPT/HCPCS Updates     Prosthetic Devices 6/9/20 7/24/20 Approved CPT/HCPCS Updates     Prosthetic Devices
2020-UHC-482 CPT / HCPCS Updates   Molecular Oncology Testing 6/9/20 7/24/20 Approved CPT / HCPCS Updates   Molecular Oncology Testing
2020-UHC-483 CPT/HCPCS Updates  Genetic Testing for Hereditary Cancer 6/9/20 7/24/20 Approved CPT/HCPCS Updates  Genetic Testing for Hereditary Cancer
2020-UHC-493 Surgical Treatment for Spine Pain 6/9/20 7/24/20 Completed Surgical Treatment for Spine Pain
2020-UHC-509 Breast Reconstruction Post Mastectomy 6/9/20 7/24/20 Approved Breast Reconstruction Post Mastectomy
2020-UHC-510 COLLAGEN CROSSLINKS AND BIOCHEMICAL MARKERS OF BONE TURNOVER 6/9/20 7/24/20 Approved COLLAGEN CROSSLINKS AND BIOCHEMICAL MARKERS OF BONE TURNOVER
2020-UHC-520 Panniculectomy Body Contouring Procedures 6/9/20 7/24/20 Approved Panniculectomy Body Contouring Procedures
2020-UHC-521 Gastrointestinal Motility Disorders Diagnosis and Treatment 6/9/20 7/24/20 Approved Gastrointestinal Motility Disorders Diagnosis and Treatment
2020-UHC-523 Intrauterine Fetal Surgery 6/9/20 7/24/20 Approved Intrauterine Fetal Surgery
2020-UHC-524 DME Repairs and Replacements 6/9/20 7/24/20 Approved DME Repairs and Replacements
2020-UHC-530 Reimbursement Policy: DRUG TESTING POLICY 6/9/20 7/24/20 Approved Reimbursement Policy: DRUG TESTING POLICY
2020-PHARM-59 Acne Agents 5/29/20 7/13/20 Approved Acne Agents 
2020-PHARM-58 Acne Criteria  5/29/20 7/13/20 Approved Acne Criteria 
2020-PHARM-57 Adakveo  5/29/20 7/13/20 Approved Adakveo 
2020-PHARM-56 CGRP Antagonists  5/29/20 7/13/20 Approved CGRP Antagonists 
2020-PHARM-55 Colony Stimulating Factors  5/29/20 7/13/20 Approved Colony Stimulating Factors  
2020-PHARM-54 Diabetes Hypoglycemics Incretin Mimetics Enhancers  5/29/20 7/13/20 Approved Diabetes Hypoglycemics Incretin Mimetics Enhancers 
2020-PHARM-53 Egrifta  5/29/20 7/13/20 Approved Egrifta 
2020-PHARM-52 Keveyis  5/29/20 7/13/20 Approved Keveyis  
2020-PHARM-51 Multiple Sclerosis Agents Immunomodulatory Agents  5/29/20 7/13/20 Approved Multiple Sclerosis Agents Immunomodulatory Agents 
2020-PHARM-50 Multiple Sclerosis Agents  5/29/20 7/13/20 Approved Multiple Sclerosis Agents  
2020-PHARM-49 Other Behavioral Health Under 6  5/29/20 7/13/20 Approved Other Behavioral Health Under 6  
2020-PHARM-48 Otrexup Rasuvo  5/29/20 7/13/20 Approved Otrexup Rasuvo 
2020-PHARM-47 Pain Management Antimigraine Agents CGRP Antagonists  5/29/20 7/13/20 Approved Pain Management Antimigraine Agents CGRP Antagonists  
2020-PHARM-46 Pain Management Antimigraine Agentss Triptans 5/27/20  5/29/20 7/13/20 Approved Pain Management Antimigraine Agentss Triptans 5/27/20 
2020-PHARM-45 Pain Management Antimigraine Agents Triptans 5/26/20  5/29/20 7/13/20 Approved Pain Management Antimigraine Agents Triptans 5/26/20  
2020-PHARM-44 POS Document for May DUR  5/29/20 7/13/20 Approved POS Document for May DUR 
2020-PHARM-43 Ranexa  5/29/20 7/13/20 Approved Ranexa 

 

Surgeon General Ralph L. Abraham, M.D.

Secretary Bruce D. Greenstein

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