Policies

The policies below summarize BMC HealthNet Plan's medical coverage criteria and claims payment guidelines for specific services. You will also find policies related to administrative services.

The policies are used as a guide by the Plan to make clinical determinations regarding health care coverage and reimbursement. The Plan's policies undergo regular updates; check back often for the most up-to-date information. Providers are reminded that member eligibility is determined before medical coverage policies and reimbursement guidelines are applied to any claim. As a result, the Plan cannot guarantee payment when a member is ineligible or a non-covered benefit is rendered.

Type Title
Actigraphy Testing (Policy OCA 3.712), Effective 12/01/21
Acupuncture (Policy OCA 3.17), Effective 01/01/22
Administratively Necessary Days (Policy OCA 3.102), Effective 11/01/21
Ambulance and Transportation Services (Policy OCA 3.191), Effective 12/01/21 And Retired 04/30/22
Ambulatory Cardiac Monitors (Excluding Holter Monitors) (Policy OCA 3.35), Effective 01/01/22
Autism Spectrum Disorders Medical Diagnosis and Treatment (Policy OCA 3.724), Effective 05/01/22
Autism Spectrum Disorders Medical Diagnosis and Treatment (Policy OCA 3.724), Effective 12/01/21 And Retired 04/30/22
Balloon Sinus Ostial Dilation (Policy OCA 3.706), Effective 12/01/21
Biofeedback in an Outpatient Setting to Treat Incontinence or Constipation (Policy OCA 3.969), Effective 01/01/22
Breast Reconstruction (Policy OCA 3.43), Effective 05/01/22
Breast Reconstruction (Policy OCA 3.43), Effective 12/01/21 And Retired 04/30/22
Breast Reduction Surgery (Policy OCA 3.44), Effective 05/01/22
Breast Reduction Surgery (Policy OCA 3.44), Effective 12/01/21 And Retired 04/30/22
Cardiac Rehabilitation, Outpatient (Policy OCA 3.61) Used with InterQual Criteria, Effective 11/01/21
CAR T-Cell Therapy to Treat Hematological Malignancies (Policy OCA 3.22), Effective 01/01/22
Chromosomal Microarray Analysis (Policy OCA 3.573) Used with InterQual Criteria Effective 02/01/22
Clinical Review Criteria (Policy OCA 3.201), Effective 12/01/21
Clinical Technology Evaluation (Policy OCA 3.13), Effective 12/01/21
Clinical Trials (Policy OCA 3.192), Effective 12/01/21
Cochlear Implants (Policy OCA 3.301) Used with InterQual Criteria for Pediatric Members, Effective 12/01/21
Complementary and Alternative Medicine (Policy OCA 3.194), Effective 01/01/22
Contact Lens and Scleral Lens (Policy OCA 3.28), Effective 04/01/22
Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices (Policy OCA 3.966), Effective 03/01/22 And Retired 04/30/22
Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices (Policy OCA 3.966), Effective 05/01/22
Cosmetic Reconstructive, and Restorative Services (Policy OCA 3.69), Effective 12/01/21
Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances (Policy OCA 3.98), Effective 04/01/22
Electric Tumor Treatment Fields ( Policy OCA 3.29), Effective 01/01/22
Endoscopic Procedures or Magnetic Esophageal Sphincter Augmentation to Treat Gastrointestinal Reflux Disease (GERD) in the Outpatient Setting (Policy OCA 3.46), Effective 12/01/21
Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Policy OCA 3.37), Effective 12/01/21
Experimental and Investigational Treatment (Policy OCA 3.12), Effective 12/01/21
Facet Joint Nerve Injections (Policy OCA 3.9641), Effective 03/01/22
Gender Affirmation Services (Policy OCA 3.11), Effective 01/01/22
Genetic/Genomic Testing and Pharmacogenetics (Policy OCA 3.727) Used with InterQual Criteria, Effective 04/01/22 And Retired 04/30/22
Genetic/Genomic Testing and Pharmacogenetics (Policy OCA 3.727) Used with InterQual Criteria, Effective 05/01/22
Genetic Testing for Fragile X-Associated Disorders (Policy OCA 3.571) Used with InterQual Criteria, Effective 02/01/22
Genetic Testing for Hereditary Thrombophilia (Policy OCA 3.728), Effective 02/01/22
Gynecomastia Surgery (Policy OCA 3.48), Effective 05/01/22
Gynecomastia Surgery (Policy OCA 3.48), Effective 12/01/21 And Retired 04/30/22
Home Health Care (Policy OCA 3.719 MassHealth and SCO) Used with InterQual Criteria, Effective 02/01/22 And Retired 05/31/22
Home Health Care (Policy OCA 3.719 MassHealth and SCO) Used with InterQual Criteria, Effective 06/01/22
Home Health Care (Policy OCA 3.732 QHP) Used with InterQual Criteria, Effective 12/01/21
Home Prothrombin Time Monitoring Devices (Policy OCA 3.27), Effective 01/01/22
Hyperbaric Oxygen Therapy (HBOT) or Topical Oxygen Therapy (TOT) (Policy OCA 3.75) Used with InterQual Criteria, Effective 12/01/21
Implantable Bone-Conduction (Bone-Anchored) Hearing Aids (Policy OCA 3.30), Effective 01/01/22
Infertility Services (Policy OCA 3.725), Effective 12/01/21
Inpatient Readmission (Policy OCA 3.16), Effective 02/01/22 And Retired 07/31/22
Inpatient Readmission (Policy OCA 3.16), Effective 08/01/22
Intensity Modulated Radiation Therapy, Outpatient (Policy OCA 3.81), Effective 12/01/21
Mastopexy (Policy OCA 3.717), Effective 05/01/22
Mastopexy (Policy OCA 3.717), Effective 12/01/21 And Retired 04/30/22
Mechanized Spinal Distraction Therapy (Policy OCA 3.84), Effective 03/01/22
Medically Necessary (Policy OCA 3.14), Effective 12/01/21
Medically Necessary Facility/Hospital Services for Non-Covered Dental Services (Due to a Serious Medical Condition) (Policy OCA 3.723), Effective 05/01/22
Medically Necessary Facility/Hospital Services for Non-Covered Dental Services (Due to a Serious Medical Condition) (Policy OCA 3.723), Effective 11/01/21 And Retired 04/30/22
Medical Nutrition Therapy in the Outpatient Setting or Office Setting (Policy OCA 3.66), Effective 12/01/21
Minimally Invasive Procedures and Associated Devices Used to Treat Back Pain (Policy OCA 3.713) Used with InterQual Criteria, Effective 03/01/22
Nerve Repairs for Peripheral Nerve Injuries Using Allografts and Conduits (Policy OCA 3.701), Effective 03/01/22
Non-Emergency Transportation Services (Policy OCA 3.191), Effective 05/01/22
Occipital Nerve Stimulation (Policy OCA 3.501), Effective 02/01/22
Occupational Therapy in the Outpatient Setting (Policy OCA 3.53) Used with InterQual Criteria, Effective 12/01/21
Osteochondral Treatments for Defects of the Knee, Talus, and Other Joints (Policy OCA 3.965), Effective 03/01/22
Out-of-Network Services (Policy OCA 3.18), Effective 06/01/22
Panniculectomy and Related Redundant Skin Surgery (Policy OCA 3.722), Effective 02/01/22
Pelvic Floor Stimulation for the Treatment of Incontinence and/or Overactive Bladder (Policy OCA 3.561), Effective 11/01/21
Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting (Policy OCA 3.39), Effective 02/01/22
Physical Therapy in the Outpatient Setting (Policy OCA 3.54) Used with InterQual Criteria, Effective 12/01/21
Posterior Tibial Nerve Stimulation (Percutaneous or Transcutaneous) (Policy OCA 3.562), Effective 11/01/21
Preimplantation Genetic Testing (Policy OCA 3.726) Effective 12/01/21
Private Duty Nursing Services (Policy OCA 3.715), Effective 04/01/22
Prolotherapy (Policy OCA 3.707), Effective 12/01/21
Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions (Policy OCA 3.563), Effective 01/01/22
Sacroiliac Joint Injections (Policy OCA 3.9642), Effective 05/01/22
Sacroiliac Joint Injections (Policy OCA 3.9642), Effective 12/01/21 and Retired 04/30/22
Skin Substitutes in the Outpatient Setting (Policy OCA 3.710), Effective 01/01/22 And Retired 04/30/22
Skin Substitutes in the Outpatient Setting (Policy OCA 3.710), Effective 05/01/22
Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation in the Outpatient Setting (Policy OCA 3.551) Used with InterQual Criteria, Effective 02/01/22
Temporomandibular Joint Disorder Treatment (Policy OCA 3.968), Effective 12/01/21
Transplant Administration (Policy OCA 3.10), Effective 12/01/21
Transplantation of Lung or Lobar Lung (Policy OCA 3.24), Effective 06/01/22
Transplantation of Lung or Lobar Lung (Policy OCA 3.24), Effective 12/01/21 And Retired 05/31/22
Transplantation of Small Bowel, Small Bowel-Liver, or Multivisceral Organs (Policy OCA 3.26), Effective 06/01/22
Transplantation of Pancreas or Pancreas-Kidney (Policy OCA 3.25), Effective 12/01/21 And Retired 05/31/22
Transplantation of Small Bowel, Small Bowel-Liver, or Multivisceral Organs (Policy OCA 3.26), Effective 06/01/22
Transplantation of Small Bowel, Small Bowel-Liver, or Multivisceral Organs (Policy OCA 3.26), Effective 12/01/21 And Retired 05/31/22
Video Electroencephalography (EEG) Facility-Based Monitoring (Policy OCA 3.38), Effective 12/01/21 And Retired 04/30/22
Video Electroencephalography (EEG) Monitoring (Policy OCA 3.38), Effective 05/01/22
Vision Therapy (Policy OCA 3.40), Effective 02/01/22
Whole Body Integumentary Photography (Policy OCA 3.702), Effective 12/01/21
Type Title Plan Type
Acupuncture Services (Policy 4.4), Effective 04/01/2021
MassHealth or QHP
Bilateral and Multiple Procedure Reductions – Professional, 2099, Effective 4/1/2022
MassHealth or QHP
Chemotherapy (Policy 4.11), Effective 04/01/21
MassHealth or QHP
Chiropractic Services, 2109, Effective 05/01/2022
MassHealth or QHP
Chronic Maintenance Dialysis performed in Freestanding Dialysis Clinics (Policy 4.95), Effective 11/01/21
MassHealth or QHP
Clinical Trials (Policy 4.134), Effective 07/01/21
MassHealth or QHP
Community Health Center and Federally Qualified Health Center, 2112, Effective 4/1/2022
MassHealth or QHP
Dental Services (Policy 4.15), Effective 05/15/21
MassHealth or QHP
Diabetes Self-Management Training / Medical Nutrition Therapy (Policy 4.32), Effective 04/01/21
MassHealth or QHP
Drug Screening/Testing (DS/T): Drugs of Abuse (Policy 4.94), Effective 07/01/21
MassHealth or QHP
Early Intervention (Policy 4.3), Effective 11/01/21
MassHealth or QHP
General Billing and Coding Guidelines, 2119, Effective 4/1/2022
MassHealth or QHP
Home Health (Policy 4.7), Effective 11/01/21
MassHealth or QHP
Home Infusion including Parenteral/Tube Fed Enteral Nutritional Therapy (Policy 4.121), Effective 06/01/21
MassHealth or QHP
Hospice, (Policy 4.8), Effective 9/1/2021
MassHealth or QHP
Immunizations, 2125, Effective 4/1/2022
MassHealth or QHP
Infertility Services (Policy 4.34), Effective 06/01/21
MassHealth or QHP
Inpatient Hospital, 2087, Effective 08/01/2022
MassHealth or QHP
Inpatient Hospital (Policy 4.110), Effective 11/01/21, Retired 07/31/2022
MassHealth or QHP
Anesthesia, 4.103; Effective 3/1/2022
MassHealth or QHP
Family Planning, 4.115 effective 1/1/2022
MassHealth or QHP
Freestanding Ambulatory Surgical Center, 4.114; Effective 02/01/22
MassHealth or QHP
General Clinical Editing and Payment Accuracy, SCO 4.108; Effective 02/01/22
MassHealth or QHP
Hearing Aid, 4.111, Effective 3/1/2022
MassHealth or QHP
Non-Reimbursed Codes, 4.48, Effective 3/1/2022
MassHealth or QHP
Physician and Non-Physician Services, 4.608, Effective 3/1/2022
MassHealth or QHP
Physical Therapy, Occupational Therapy, and Speech/Language Therapy Services, 4.609 effective 1/1/2022
MassHealth or QHP
Telemedicine Services, 2102, Effective 10/16/2021
MassHealth or QHP
Transportation, 4.113; Effective 02/01/22
MassHealth or QHP
Urgent Care, 4.96, Effective 3/1/2022
MassHealth or QHP
Modifiers (Policy 4.23), Effective 08/01/21
MassHealth or QHP
Newborn and Neonatal Intensive Care Unit (NICU) Services (Policy 4.106), Effective 05/15/21
MassHealth or QHP
Non-Priced Codes (Policy 4.37), Effective 11/01/21
MassHealth or QHP
Observation Services (Policy 4.36), Effective 11/01/2021
MassHealth or QHP
Obstetrics, 2093, Effective 4/1/2022
MassHealth or QHP
Outpatient Hospital, 4.17, Effective 11/01/2021
MassHealth or QHP
Preventive Services, 2097, Effective 4/1/2022
MassHealth or QHP
Private Duty Nursing, 2217, Effective 4/1/2022
MassHealth or QHP
Provider Preventable Conditions and Serious Reportable Events (Policy 4.610), Effective 07/01/21
MassHealth or QHP
Sleep Studies (Policy 4.5), Effective 11/01/2021
MassHealth or QHP
Vision Services (Policy 4.38), Effective 08/01/21
MassHealth or QHP
Adult Foster Care and Group Adult Foster Care, 2127, Effective 05/01/2022
SCO
Adult Day Health, 2126, Effective 05/01/2022
SCO
Aging Service Access Points, 2128, Effective 05/01/2022
SCO
Bilateral and Multiple Procedure Reductions – Professional, 2154, Effective 4/1/2022
SCO
Clinical Trials (SCO 4.134), Effective 07/01/21
SCO
Day Habilitation, 2133, Effective 05/01/2022
SCO
End-Stage Renal Disease -Dialysis (SCO 4.95), Effective 09/01/21
SCO
Home Health Agency Services: Medicare-Certified (SCO 4.7), Effective 01/01/2021: Episodes beginning on or after 01/01/2021, Retires 12/31/2021
SCO
Home Health Agency Services: Medicare-Certified (SCO 4.7), Effective 01/01/2020 and Retired: Episodes beginning on or after 01/01/2020 and before 12/31/2020
SCO
Home Health Agency Services: Non-Medicare Certified (SCO 4.6), Effective 08/01/21
SCO
Hospice (SCO 4.8), Effective 09/01/21, Retired 05/31/2022
SCO
Hospice – Dual Eligible Members, 2421, Effective 06/01/2022
SCO
Hospice – Medicaid-Only Members, 2142, Effective 06/01/2022
SCO
Inpatient Hospital (SCO 4.110), Effective 04/01/21
SCO
Inpatient Rehabilitation Hospital (SCO 4.71), Effective 09/01/21
SCO
Modifiers, (SCO 4.23) Effective 05/15/21
SCO
Non-Participating Provider, (SCO 4.5) Effective 11/01/21
SCO
Nursing Facility – Patient Paid Amount, 2422, Effective 07/01/2022
SCO
Outpatient Hospital, SCO 4.17, Effective 12/01/21
SCO
Personal Care Attendant, 2148, Effective 05/01/2022
SCO
Personal Care Management, 2149, Effective 05/01/2022
SCO
Physician / Non-Physician Practitioner Services (SCO 4.608), Effective 08/01/21
SCO
Podiatry Services (SCO 4.72), Effective 09/01/21
SCO
Private Duty Nursing, 2153, Effective 4/1/2022
SCO
Provider Preventable Conditions (PPC) and Serious Reportable Events (SRE) (SCO 4.610), Effective 07/01/21
SCO
Chiropractic Services, 2131, Effective 05/01/2022
SCO
Home Health Agency Services: Medicare-Certified, SCO 4.7 Effective 01/01/2022: Periods of Care beginning or continuing on or after 01/01/2022
SCO
Medicare Certified Home Infusion Therapy Services, SCO 4.121, Effective 1/1/2022
SCO
Physical Therapy, Occupational Therapy, and Speech/Language Therapy Services, SCO 4.609, Effective 1/1/2022
SCO
Ambulatory Surgical Center, SCO 4.114; Effective 02/01/22
SCO
Anesthesia, SCO 4.103, Effective 03/01/2022
SCO
Emergent Transportation, SCO 4.113; Effective 02/01/22
SCO
General Billing and Coding Guidelines, SCO 4.31, Effective 03/01/2022
SCO
General Clinical Editing and Payment Accuracy, SCO 4.108; Effective 02/01/22
SCO
Hearing Aid, SCO 4.111, Effective 03/01/2022
SCO
Type Title Plan Type
Medical- Asthma Monoclonal Antibodies (Policy MA9.109), Effective 05/01/2022
Mass Health
Medical- Infliximab Products (Policy MA9.123), Effective 05/01/2022
Mass Health
Medical- Complement Inhibitors (Policy MA9.134), Effective 05/01/2022
Mass Health
Medical- Erythropoiesis-Stimulating Agents (Policy MA9.609), Effective 05/01/2022
Mass Health
Medical- Filgrastim Products (Policy MA9.631), Effective 05/01/2022
Mass Health
Medical- Rituximab (Policy MA9.704), Effective 05/01/2022
Mass Health
Age & Quantity Limitation Program Policy (Policy MA9.050), Effective 01/01/2022
Mass Health
Non-Formulary Exceptions (Policy MA9.051), Effective 01/01/2022
Mass Health
Prescription Compounds (Policy MA9.054), Effective 01/01/2022
Mass Health
Hereditary Angioedema (Policy MA9.101), Effective 01/01/2022
Mass Health
Topical Immunomodulators (Policy MA9.103), Effective 01/01/2022
Mass Health
Sublingual Immunotherapy (SLIT) Medications (Policy MA9.104), Effective 01/01/2022
Mass Health
Esbriet (Policy MA9.105), Effective 01/01/2022
Mass Health
Nplate (Policy MA9.106), Effective 01/01/2022
Mass Health
Promacta (Policy MA9.107), Effective 01/01/2022
Mass Health
Kyrstexxa (Pegloticase) (Policy MA9.108), Effective 01/01/2022
Mass Health
Immune Globulin (Policy MA9.110), Effective 01/01/2022
Mass Health
Daliresp (Policy MA9.111), Effective 01/01/2022
Mass Health
Acthar H.P. Gel (Policy MA9.112), Effective 01/01/2022
Mass Health
Benlysta (Belimumab) (Policy MA9.115), Effective 01/01/2022
Mass Health
Entyvio (Policy MA9.120), Effective 01/01/2022
Mass Health
Infliximab Products (Policy MA9.123), Effective 01/01/2022
Mass Health
Methotrexate (Policy MA9.125), Effective 01/01/2022
Mass Health
Ofev (Policy MA9.133), Effective 01/01/2021
Mass Health
Ofev (Policy MA9.133), Effective 01/01/2022
Mass Health
Complement Inhibitors (Policy MA9.134), Effective 03/01/2022
Mass Health
Lambert Eaton Myasthenic Syndrome (Policy MA9.135), Effective 01/01/2022
Mass Health
Tavalisse (Policy MA9.136), Effective 01/01/2022
Mass Health
Step Therapy Policy - Gout (Policy MA9.137), Effective 01/01/2022
Mass Health
Step Therapy Policy - Pulmonary Agents (Policy MA9.138), Effective 01/01/2022
Mass Health
Immune Suppressants - Topical - Unified Formulary (Policy MA9.139), Effective 01/01/2022
Mass Health
Respiratory Agents - Unified Formulary (Policy MA9.141), Effective 01/01/2022
Mass Health
Step Therapy Policy - Oral and Nasal Allergy Agents (Policy MA9.142), Effective 01/01/2021
Mass Health
Step Therapy Policy - Oral and Nasal Allergy Agents (Policy MA9.142), Effective 01/01/2022
Mass Health
Asthma and Allergy Monoclonal Antibodies- Unified Formulary (Policy MA9.143), Effective 09/01/2021
Mass Health
Asthma and Allergy Monoclonal Antibodies - Unified Formulary (Policy MA9.143), Effective 01/01/2022
Mass Health
Targeted Immunomodulators- United Formulary (Policy MA9.144), Effective 09/01/2021
Mass Health
Targeted Immunomodulators (TIMs) - Unified Formulary (Policy MA9.144), Effective 07/01/2021
Mass Health
Arcalyst and Ilaris - Unified Formulary (Policy MA9.145), Effective 01/01/2022
Mass Health
Levalbuterol Nebulizer Solution (Policy MA9.147), Effective 01/01/2022
Mass Health
Cystic Fibrosis-CFTR Modulators- Unified Formulary (Policy MA9.148), Effective 01/01/2022
Mass Health
Lupkynis (Policy MA9.153), Effective 01/01/2022
Mass Health
Nuedexta (Policy MA9.200), Effective 06/01/2021
Mass Health
Diacomit (Policy MA9.201), Effective 01/01/2021
Mass Health
Diacomit (Policy MA9.201), Effective 06/01/2021
Mass Health
Savella (Policy MA9.202), Effective 06/01/2021
Mass Health
Cuvposa (Glycopyrrolate) (Policy MA9.203), Effective 06/01/2021
Mass Health
VMAT 2 Inhibitors (Policy MA9.204), Effective 06/01/2021
Mass Health
Calcitonin Gene-Related Peptide Antagonist (CGRP) (Policy MA9.205), Effective 06/01/2021
Mass Health
Pregabalin (Policy MA9.206), Effective 01/01/2021
Mass Health
Tramadol ER (Policy MA9.207), Effective 06/01/2021
Mass Health
Narcolepsy (Policy MA9.208), Effective 06/01/2021
Mass Health
Botox (Policy MA9.209), Effective 06/01/2021
Mass Health
Opioids (Policy MA9.210), Effective 06/01/2021
Mass Health
Insomnia Agents (Policy MA9.211), Effective 06/01/2021
Mass Health
Multiple Sclerosis (Policy MA9.212), Effective 01/01/2022
Mass Health
Inbrija (Policy MA9.213), Effective 06/01/2021
Mass Health
Step Therapy Policy - Anticonvulsant Agents (Policy MA9.214), Effective 07/01/2021
Mass Health
Step Therapy Policy - Migraine Agents (Policy MA9.215), Effective 06/01/2021
Mass Health
Step Therapy Policy - Anti-Parkinson Agents (Policy MA9.217), Effective 06/01/2021
Mass Health
Step Therapy Policy - NSAIDS (Policy MA9.218), Effective 06/01/2021
Mass Health
Multiple Sclerosis - Unified Formulary (Policy MA9.219), Effective 01/01/2022
Mass Health
Calcitonin-Gene Related Peptide (CGRP) Inhibitors - Unified Formulary (Policy MA9.220), Effective 06/01/2021
Mass Health
Epidiolex (Policy MA9.222), Effective 06/01/2021
Mass Health
Fintepla (Policy MA9.224), Effective 06/01/2021
Mass Health
Kynmobi (Policy MA9.225), Effective 06/01/2021
Mass Health
Valtoco-Nayzilam (Policy MA9.226), Effective 06/01/2021
Mass Health
Amyloidosis Therapies - Unified Formulary (Policy MA9.227), Effective 01/01/2022
Mass Health
Spinraza (Policy MA9.229), Effective 09/01/2021
Mass Health
Anticonvulsants (Policy MA9.230), Effective 09/01/2021
Mass Health
Anticonvulsants - Unified Formulary (Policy MA9.230), Effective 07/01/2021
Mass Health
Dojolvi (Policy MA9.231), Effective 09/01/2021
Mass Health
Evrysdi (Policy MA9.232), Effective 09/01/2021
Mass Health
Isturisa (Policy MA9.233), Effective 09/01/2021
Mass Health
Zeposia -United Formulary (Policy MA9.234), Effective 01/01/2022
Mass Health
Osphena (Policy MA9.300), Effective 03/01/2022
Mass Health
Brineura (Policy MA9.301), Effective 01/01/2021
Mass Health
Brineura (Policy MA9.301), Effective 09/01/2021
Mass Health
Duchenne Muscular Dystrophy Agents (Policy MA9.302), Effective 01/01/2021
Mass Health
Duchenne Muscular Dystrophy (Policy MA9.302), Effective 09/01/2021
Mass Health
Korlym (Policy MA9.303), Effective 01/01/2021
Mass Health
Korlym (Policy MA9.303), Effective 09/01/2021
Mass Health
Egrifta (Policy MA9.304), Effective 01/01/2021
Mass Health
Urea Cycle Disorder Agents (Policy MA9.305), Effective 01/01/2021
Mass Health
Urea Cycle Disorder Agents (Policy MA9.305), Effective 09/01/2021
Mass Health
Signifor (Policy MA9.306), Effective 01/01/2021
Mass Health
Myalept (Policy MA9.307), Effective 01/01/2021
Mass Health
Cholbam (Policy MA9.308), Effective 03/01/2022
Mass Health
Natpara (Policy MA9.309), Effective 01/01/2021
Mass Health
Natpara (Policy MA9.309), Effective 09/01/2021
Mass Health
Trientine (Syprine) (Policy MA9.310), Effective 01/01/2021
Mass Health
Kanuma (Policy MA9.311), Effective 01/01/2021
Mass Health
Kanuma (Policy MA9.311), Effective 09/01/2021
Mass Health
Strensiq (Policy MA9.312), Effective 01/01/2021
Mass Health
Strensiq (Policy MA9.312), Effective 09/01/2021
Mass Health
Cerdelga (Policy MA9.313), Effective 01/01/2021
Mass Health
Rayaldee (Policy MA9.314), Effective 01/01/2021
Mass Health
Rayaldee (Policy MA9.314), Effective 09/01/2021
Mass Health
Spinraza (Policy MA9.315), Effective 01/01/2021
Mass Health
Mepsevii (Policy MA9.316), Effective 01/01/2021
Mass Health
Mepsevii (Policy MA9.316), Effective 09/01/2021
Mass Health
Increlex (Policy MA9.317), Effective 01/01/2021
Mass Health
Increlex (Policy MA9.317), Effective 09/01/2021
Mass Health
Metabolic Bone Disease Agents (Policy MA9.318), Effective 01/01/2021
Mass Health
Metabolic Bone Disease Agents (Policy MA9.318), Effective 09/01/2021
Mass Health
Samsca (Policy MA9.319), Effective 01/01/2021
Mass Health
Samsca/Tolvaptan (Policy MA9.319), Effective 09/01/2021
Mass Health
Vyndaqel, Vyndamax (Policy MA9.323), Effective 01/01/2021
Mass Health
Crysvita (Policy MA9.324), Effective 01/01/2021
Mass Health
Crysvita (Policy MA9.324), Effective 09/01/2021
Mass Health
Step Therapy Policy - Bisphosphonates (Policy MA9.329), Effective 01/01/2021
Mass Health
Step Therapy Bisphosphonates (Policy MA9.329), Effective 09/01/2021
Mass Health
Spinal Muscular Atrophy (SMA) Agents - Unified Formulary (Policy MA9.331), Effective 01/01/2021
Mass Health
Spinal Muscular Atrophy (SMA) Agents (Policy MA9.331), Effective 09/01/2021
Mass Health
Antidiabetic Agents - Unified Formulary (Policy MA9.332), Effective 07/01/2021
Mass Health
Antidiabetic Agents - United Formulary (Policy MA9.332), Effective 01/01/2022
Mass Health
Glucagon Products - Unified Formulary (Policy MA9.333), Effective 09/01/2021
Mass Health
Growth Hormone Agents - Unified Formulary (Policy MA9.334), Effective 01/01/2022
Mass Health
Insulin Products - Unified Formulary (Policy MA9.335), Effective 01/01/2022
Mass Health
Diabetic Testing Supplies - United Formulary (Policy MA9.336), Effective 07/01/2021
Mass Health
Diabetic Testing Supplies- United Formulary (Policy MA9.336), Effective 09/01/2021
Mass Health
Continuous Glucose Monitoring - Unified Formulary (Policy MA9.337), Effective 01/01/2022
Mass Health
Continuous Glucose Monitoring- United Formulary (Policy MA9.337), Effective 07/01/2021
Mass Health
Givlaari - Unified Formulary (Policy MA9.338), Effective 07/01/2021
Mass Health
Givlaari- United Formulary (Policy MA9.338), Effective 09/01/2021
Mass Health
Continuous Subcutaneous Insulin Infusion- United Formulary (Policy MA9.339), Effective 09/01/2021
Mass Health
Continuous Subcutaneous Insulin Infusion - Unified Formulary (Policy MA9.339), Effective 01/01/2022
Mass Health
Fabrazyme (Policy MA9.341), Effective 09/01/2021
Mass Health
Pyrimethamine (Daraprim) (Policy MA9.401), Effective 06/01/2021
Mass Health
Impavido (Policy MA9.402), Effective 06/01/2021
Mass Health
Systemic Antibiotics (Policy MA9.403), Effective 06/01/2021
Mass Health
Synagis (Policy MA9.405), Effective 06/01/2021
Mass Health
Antifungal Agents (Policy MA9.406), Effective 06/01/2021
Mass Health
Step Therapy Policy - Pediculicides (Policy MA9.408), Effective 06/01/2021
Mass Health
Hepatitis Antiviral Agents- United Formulary (Policy MA9.409), Effective 09/01/2021
Mass Health
Hepatitis Antiviral Agents - Unified Formulary (Policy MA9.409), Effective 06/01/2021
Mass Health
Pediatric Behavioral Health Medication Initiative (Policy MA9.500), Effective 06/01/2021
Mass Health
Lucemyra (Policy MA9.501), Effective 06/01/2021
Mass Health
Antidepressants (Policy MA9.502), Effective 06/01/2021
Mass Health
Antipsychotics (Policy MA9.503), Effective 09/01/2021
Mass Health
Buprenorphine and Naloxone Products (Policy MA9.504), Effective 06/01/2021
Mass Health
Clonidine ER (Policy MA9.505), Effective 01/01/2022
Mass Health
Step Therapy Policy - Antidepressant and Antipsychotic Agents (Policy MA9.506), Effective 06/01/2021
Mass Health
Antipsychotics- United Formulary (Policy MA9.507), Effective 09/01/2021
Mass Health
Antipsychotics - Unified Formulary (Policy MA9.507), Effective 01/01/2022
Mass Health
Cerebral Stimulants and ADHD Medications - Unified Formulary (Policy MA9.508), Effective 01/01/2022
Mass Health
Opioid Dependence and Reversal Agents- United Formulary (Policy MA9.509), Effective 09/01/2021
Mass Health
Opioid Dependence - Unified Formulary (Policy MA9.509), Effective 01/01/2022
Mass Health
Pulmonary Hypertension (Policy MA9.600), Effective 3/01/2022
Mass Health
ACEIs and ARBs (Policy MA9.601), Effective 03/01/2022
Mass Health
Beta Blockerss (Policy MA9.602), Effective 3/01/2022
Mass Health
Homozygous Familial Hypercholesterolemia (Policy MA9.603), Effective 03/01/2022
Mass Health
Droxidopa (Policy MA9.604), Effective 03/01/2022
Mass Health
PCSK9 Inhibitors (Policy MA9.605), Effective 03/01/2022
Mass Health
Entresto (Policy MA9.606), Effective 01/01/2021
Mass Health
Omega Fatty Acids (Policy MA9.607), Effective 03/01/2022
Mass Health
Ranolazine ER (Policy MA9.608), Effective 03/01/2022
Mass Health
Blood Clotting Disorder Medications (Policy MA9.610), Effective 03/01/2022
Mass Health
Adakveo (Policy MA9.611), Effective 03/01/2022
Mass Health
Oxbryta (Policy MA9.612), Effective 03/01/2022
Mass Health
Reblozyl (Policy MA9.613), Effective 03/01/2022
Mass Health
Step Therapy Policy - Antihypertensive Agents (Policy MA9.615), Effective 03/01/2022
Mass Health
Erythropoiesis Stimulating Agents (ESAs) - Unified Formulary (Policy MA9.617), Effective 03/01/2022
Mass Health
Step Therapy Policy - Anti-Platelet Agents (Policy MA9.618), Effective 03/01/2022
Mass Health
Anticoagulants- United Formulary (Policy MA9.619), Effective 01/01/2022
Mass Health
Granulocyte Stimulating Agents - Unified Formulary (Policy MA9.621), Effective 03/01/2022
Mass Health
Iron Chelating Agents (Policy MA9.625), Effective 03/01/2022
Mass Health
Sapropterin (Policy MA9.626), Effective 09/01/2021
Mass Health
Verquvo (Policy MA9.630), Effective 03/01/2022
Mass Health
Antineoplastic Agents (Policy MA9.700), Effective 01/01/2021
Mass Health
Antineoplastic Agents (Policy MA9.700), Effective 01/01/2022
Mass Health
Xermelo (Policy MA9.701), Effective 01/01/2021
Mass Health
Xermelo (Policy MA9.701), Effective 09/01/2021
Mass Health
Mozobil (Policy MA9.702), Effective 01/01/2021
Mass Health
Mozobil (Policy MA9.702), Effective 09/01/2021
Mass Health
GnRH Agents (Policy MA9.703), Effective 03/01/2022
Mass Health
Rituximab (Policy MA9.704), Effective 01/01/2021
Mass Health
Rituximab (Policy MA9.704), Effective 09/01/2021
Mass Health
Tepezza (Policy MA9.705), Effective 01/01/2021
Mass Health
Tepezza (Policy MA9.705), Effective 09/01/2021
Mass Health
Enhertu (Policy MA9.706), Effective 01/01/2021
Mass Health
Enhertu (Policy MA9.706), Effective 09/01/2021
Mass Health
Padcev (Policy MA9.707), Effective 01/01/2021
Mass Health
Padcev (Policy MA9.707), Effective 09/01/2021
Mass Health
Breast Cancer Therapies - Unified Formulary (Policy MA9.708), Effective 01/01/2021
Mass Health
Breast Cancer Therapies- United Formulary (Policy MA9.708), Effective 01/01/2022
Mass Health
Chronic Myelogenous Leukemia (CML) Agents - Unified Formulary (Policy MA9.709), Effective 01/20/2021
Mass Health
Colorectal Cancer Agents - Unified Formulary (Policy MA9.710), Effective 01/01/2021
Mass Health
Colorectal Cancer Agents- United Formulary (Policy MA9.710), Effective 09/01/2021
Mass Health
Kinase Inhibitors- United Formulary (Policy MA9.711), Effective 09/01/2021
Mass Health
Kinase Inhibitors - Unified Formulary (Policy MA9.711), Effective 01/01/2022
Mass Health
Lung Cancer Agents- United Formulary (Policy MA9.712), Effective 09/01/2021
Mass Health
Lung Cancer Agents - Unified Formulary (Policy MA9.712), Effective 01/01/2022
Mass Health
Lymphoma and Leukemia Agents - Unified Formulary (Policy MA9.713), Effective 01/01/2021
Mass Health
Lymphoma and Leukemia Agents (Policy MA9.713), Effective 09/01/2021
Mass Health
Melanoma Agents - Unified Formulary (Policy MA9.714), Effective 01/01/2022
Mass Health
Melanoma Agents (Policy MA9.714), Effective 09/01/2021
Mass Health
Medullary Thyroid Cancer Agents - Unified Formulary (Policy MA9.715), Effective 01/01/2021
Mass Health
Medullary Thyroid Cancer Agents- United Formulary (Policy MA9.715), Effective 09/01/2021
Mass Health
Neurotrophic Receptor Tyrosine Kinase Inhibitors (NRTK) Inhibitors - Unified Formulary (Policy MA9.716), Effective 01/01/2021
Mass Health
Turalio - Unified Formulary (Policy MA9.717), Effective 01/01/2021
Mass Health
Turalio- United Formulary (Policy MA9.717), Effective 09/01/2021
Mass Health
JAK Inhibitors- United Formulary (Policy MA9.718), Effective 09/01/2021
Mass Health
JAK Inhibitors - Unified Formulary (Policy MA9.718), Effective 01/01/2022
Mass Health
Gavreto (Policy MA9.719), Effective 09/01/2021
Mass Health
Inqovi (Policy MA9.720), Effective 09/01/2021
Mass Health
Monjuvi (Policy MA9.721), Effective 09/01/2021
Mass Health
Onureg (Policy MA9.722), Effective 09/01/2021
Mass Health
Pepaxto/Blenrep (Policy MA9.723), Effective 09/01/2021
Mass Health
Uplinza (Policy MA9.725), Effective 09/01/2021
Mass Health
Xpovio (Policy MA9.726), Effective 09/01/2021
Mass Health
Ayvakit (Policy MA9.727), Effective 09/01/2021
Mass Health
Jelmyto (Policy MA9.731), Effective 09/01/2021
Mass Health
Pemazyre (Policy MA9.732), Effective 09/01/2021
Mass Health
Qinlock (Policy MA9.733), Effective 09/01/2021
Mass Health
Trodelvy (Policy MA9.735), Effective 09/01/2021
Mass Health
Zepzelca (Policy MA9.737), Effective 09/01/2021
Mass Health
Hydroxyprogesterone Caproate (Policy MA9.800), Effective 03/01/2022
Mass Health
Tranexamic Acid (Policy MA9.801), Effective 03/01/2022
Mass Health
Gattex (Policy MA9.802), Effective 03/01/2022
Mass Health
Ocaliva (Policy MA9.803), Effective 03/01/2022
Mass Health
Gastrointestinal Agents (Policy MA9.804), Effective 03/01/2022
Mass Health
Benign Prostatic Hyperplasia (BPH) Medications (Policy MA9.805), Effective 03/01/2022
Mass Health
Step Therapy Policy - Proton Pump Inhibitors (Policy MA9.806), Effective 03/01/2022
Mass Health
Step Therapy Policy - Urinary Antispasmodic Agents (Policy MA9.807), Effective 03/01/2022
Mass Health
Phexxi (Policy MA9.811), Effective 03/01/2022
Mass Health
Oriahnn and Myfembree (Policy MA9.812), Effective 03/01/2022
Mass Health
Bylvay (Policy MA9.814), Effective 03/01/2022
Mass Health
Ophthalmic Antibodies (Policy MA9.901), Effective 03/01/2022
Mass Health
Restasis, Xiidra (Policy MA9.902), Effective 03/01/2022
Mass Health
Mytesi (Policy MA9.903), Effective 030/01/2022
Mass Health
Luxterna (Policy MA9.904), Effective 03/01/2022
Mass Health
Antiemetics (Policy MA9.905), Effective 03/01/2022
Mass Health
Topical Medications (MISC) (Policy MA9.906), Effective 03/01/2022
Mass Health
Anabolic Steroids - Anadrol, Oxandrolone (Policy MA9.907), Effective 03/01/2022
Mass Health
Acne and Rosacea Agents (Policy MA9.908), Effective 03/01/2022
Mass Health
Viscosupplements (Policy MA9.909), Effective 03/01/2022
Mass Health
Bile Acid Sequestrants (Policy MA9.910), Effective 03/01/2022
Mass Health
Xiaflex (Policy MA9.911), Effective 03/01/2022
Mass Health
Rhopressa (Netrasudil) (Policy MA9.912), Effective 03/01/2022
Mass Health
Step Therapy Policy - Glaucoma (Policy MA9.913), Effective 03/01/2022
Mass Health
Step Therapy Policy - Miscellaneous Ophthalmic Policy (Policy MA9.915), Effective 03/01/2022
Mass Health
Step Therapy Policy - Topical Acne Agents (Policy MA9.916), Effective 03/01/2022
Mass Health
Step Therapy Policy - Topical Lidocaine (Policy MA9.917), Effective 03/01/2022
Mass Health
Step Therapy Policy - Topical Steroids (Policy MA9.918), Effective 03/01/2022
Mass Health
Vyndaqel, Vyndamax (Policy MA9.323), Effective 09/01/2021
Mass Health
Chronic Myelogenous Leukemia (CML) Agents- United Formulary (Policy MA9.709), Effective 09/01/2021
Mass Health
Neurotrophic Receptor Tyrosine Kinase (NRTK) Inhibitors- United Formulary (Policy MA9.716), Effective 09/01/2021
Mass Health
QHP9.212_Multiple-Sclerosis_Rev2021
Mass Health
Zokinvy (Policy MA9.340), Effective 09/01/2021
Mass Health
Medical- Asthma Monoclonal Antibodies (Policy QHP9.109), Effective 05/01/2022
Qualified Health Plan
Medical- Infliximab Products (Policy QHP9.123), Effective 05/01/2022
Qualified Health Plan
Medical- Complement Inhibitors (Policy QHP9.134), Effective 05/01/2022
Qualified Health Plan
Medical- Erythropoiesis-Stimulating Agents (Policy QHP9.609), Effective 05/01/2022
Qualified Health Plan
Medical- Filgrastim Products (Policy QHP9.631), Effective 05/01/2022
Qualified Health Plan
Medical- Rituximab (Policy QHP9.704), Effective 05/01/2022
Qualified Health Plan
Age & Quantity Limitation Program Policy (Policy QHP9.050), Effective 01/01/2022
Qualified Health Plan
Non-Formulary Exceptions (Policy QHP9.051), Effective 01/01/2022
Qualified Health Plan
Prescription Compounds (Policy QHP9.054), Effective 01/01/2022
Qualified Health Plan
Cystic Fibrosis Agents (Policy QHP9.100), Effective 01/01/2022
Qualified Health Plan
Hereditary Angioedema (Policy QHP9.101), Effective 01/01/2022
Qualified Health Plan
Rinvoq (Policy QHP9.102), Effective 05/01/2022
Qualified Health Plan
Topical Immunomodulators (Policy QHP9.103), Effective 01/01/2022
Qualified Health Plan
Sublingual Immunotherapy (SLIT) Medications (Policy QHP9.104), Effective 01/01/2022
Qualified Health Plan
Esbriet (Policy QHP9.105), Effective 01/01/2022
Qualified Health Plan
Promacta (Policy QHP9.107), Effective 01/01/2022
Qualified Health Plan
Asthma-Allergy Monoclonal Antibodies (Policy QHP9.109), Effective 01/01/2022
Qualified Health Plan
Immune Globulin (Policy QHP9.110), Effective 01/01/2022
Qualified Health Plan
Acthar H.P. Gel (Policy QHP9.112), Effective 01/01/2022
Qualified Health Plan
Acterma (Tocilizumab) (Policy QHP9.113), Effective 03/01/2022
Qualified Health Plan
Arcalyst (Rilonacept) (Policy QHP9.114), Effective 01/01/2022
Qualified Health Plan
Benlysta (Belimumab) (Policy QHP9.115), Effective 01/01/2022
Qualified Health Plan
Cimzia (Certolizumab pegol) (Policy QHP9.116), Effective 04/01/2022
Qualified Health Plan
Cosentyx (Secukinumab) (Policy QHP9.117), Effective 04/01/2022
Qualified Health Plan
Dupixent (Dupilumab) (Policy QHP9.118), Effective 01/01/2022
Qualified Health Plan
Enbrel (Etanercept) (Policy QHP9.119), Effective 11/01/2021
Qualified Health Plan
Entyvio (Policy QHP9.120), Effective 01/01/2022
Qualified Health Plan
Humira (Policy QHP9.121), Effective 01/01/2022
Qualified Health Plan
Infliximab Products (Policy QHP9.123), Effective 01/01/2022
Qualified Health Plan
Methotrexate (Policy QHP9.125), Effective 01/01/2022
Qualified Health Plan
Orencia SC (Policy QHP9.126), Effective 04/01/2022
Qualified Health Plan
Otezla (Policy QHP9.127), Effective 01/01/2022
Qualified Health Plan
Simponi (Policy QHP9.128), Effective 04/01/2022
Qualified Health Plan
Stelara (Policy QHP9.129), Effective 01/01/2022
Qualified Health Plan
Taltz (Policy QHP9.130), Effective 01/01/2022
Qualified Health Plan
Xeljanz (Policy QHP9.131), Effective 04/05/2022
Qualified Health Plan
Ofev (Policy QHP9.133), Effective 01/01/2022
Qualified Health Plan
Complement Inhibitors (Policy QHP9.134), Effective 03/01/2022
Qualified Health Plan
Tavalisse (Policy QHP9.136), Effective 01/01/2022
Qualified Health Plan
Step Therapy - Gout Agents (Policy QHP9.137), Effective 01/01/2022
Qualified Health Plan
Step Therapy- Pulmonary Agents (Policy QHP9.138), Effective 01/01/2022
Qualified Health Plan
Skyrizi (risankizumab-rzaa) (Policy QHP9.140), Effective 04/01/2022
Qualified Health Plan
Actimmune (Policy QHP9.146), Effective 01/01/2022
Qualified Health Plan
Ilumya (Policy QHP9.149), Effective 03/01/2022
Qualified Health Plan
Tremfya (Policy QHP9.150), Effective 01/01/2022
Qualified Health Plan
Kevzara (Policy QHP9.151), Effective 03/01/2022
Qualified Health Plan
Siliq (Policy QHP9.152), Effective 03/01/2022
Qualified Health Plan
Lupkynis (Policy QHP9.153), Effective 01/01/2022
Qualified Health Plan
Actemra-IV (Policy QHP9.156), Effective 01/01/2022
Qualified Health Plan
Orencia IV (Policy QHP9.158), Effective 04/01/2022
Qualified Health Plan
Nuedexta (Policy QHP9.200), Effective 06/01/2021
Qualified Health Plan
Diacomit (Policy QHP9.201), Effective 06/01/2021
Qualified Health Plan
Savella (Policy QHP9.202), Effective 06/01/2021
Qualified Health Plan
VMAT 2 Inhibitors (Policy QHP9.204), Effective 06/01/2021
Qualified Health Plan
Calcitonin-Gene Related Peptide Antagonist (CGRP) (Policy QHP9.205), Effective 06/01/2021
Qualified Health Plan
Pregabalin (Policy QHP9.206), Effective 06/01/2021
Qualified Health Plan
Narcolepsy (Policy QHP9.208), Effective 06/01/2021
Qualified Health Plan
Botox (Policy QHP9.209), Effective 06/01/2021
Qualified Health Plan
Opioids (Policy QHP9.210), Effective 06/01/2021
Qualified Health Plan
Insomnia Agents (Policy QHP9.211), Effective 06/01/2021
Qualified Health Plan
Multiple Sclerosis (Policy QHP9.212), Effective 11/01/2021
Qualified Health Plan
Step Therapy - Anticonvulsants (Policy QHP9.214), Effective 06/01/2021
Qualified Health Plan
Step Therapy - Migraine Agents (Policy QHP9.215), Effective 06/01/2021
Qualified Health Plan
Step Therapy - Sleep Disorder Agents (Policy QHP9.216), Effective 06/01/2021
Qualified Health Plan
Epidolex (Policy QHP9.222), Effective 06/01/2021
Qualified Health Plan
Vigabatrin (Policy QHP9.223), Effective 06/01/2021
Qualified Health Plan
Fintepla (Policy QHP9.224), Effective 06/01/2021
Qualified Health Plan
Dojolvi (Policy QHP9.231), Effective 09/01/2021
Qualified Health Plan
Isturisa (Policy QHP9.233), Effective 09/01/2021
Qualified Health Plan
Zeposia (Policy QHP9.234), Effective 3/01/2022
Qualified Health Plan
Egrifta (Policy QHP9.304), Effective 01/01/2021
Qualified Health Plan
Egrifta (Policy QHP9.304), Effective 09/01/2021
Qualified Health Plan
Signifor (Policy QHP9.306), Effective 01/01/2021
Qualified Health Plan
Signifor (Policy QHP9.306), Effective 09/01/2021
Qualified Health Plan
Myalept (Policy QHP9.307), Effective 01/01/2021
Qualified Health Plan
Myalept (Policy QHP9.307), Effective 09/01/2021
Qualified Health Plan
Rayaldee (Policy QHP9.314), Effective 01/01/2021
Qualified Health Plan
Rayaldee (Policy QHP9.314), Effective 09/01/2021
Qualified Health Plan
Increlex (Policy QHP9.317), Effective 01/01/2021
Qualified Health Plan
Increlex (Policy QHP9.317), Effective 09/01/2021
Qualified Health Plan
Metabolic Bone Disease Agents (Policy QHP9.318), Effective 01/01/2021
Qualified Health Plan
Metabolic Bone Disease Agents (Policy QHP9.318), Effective 09/01/2021
Qualified Health Plan
Samsca (Policy QHP9.319), Effective 01/01/2021
Qualified Health Plan
Samsca/Tolvaptan (Policy QHP9.319), Effective 09/01/2021
Qualified Health Plan
Non-Preferred Blood Glucose Testing Products (Policy QHP9.320), Effective 09/01/2021
Qualified Health Plan
Givlaari (Policy QHP9.321), Effective 01/01/2021
Qualified Health Plan
Givlaari (Policy QHP9.321), Effective 09/01/2021
Qualified Health Plan
Anti-Obesity Medications (Policy QHP9.322), Effective 07/01/2021
Qualified Health Plan
Anti-Obesity Medications (Policy QHP9.322), Effective 01/01/2022
Qualified Health Plan
Genotropin (Policy QHP9.325), Effective 01/01/2021
Qualified Health Plan
Genotropin (Policy QHP9.325), Effective 09/01/2021
Qualified Health Plan
Step Therapy - Antidiabetic Agents (Policy QHP9.327), Effective 01/01/2021
Qualified Health Plan
Step Therapy - Antidiabetic Agents (Policy QHP9.327), Effective 01/01/2022
Qualified Health Plan
Somavert (Pegvisomant) (Policy QHP9.328), Effective 01/01/2021
Qualified Health Plan
Somavert (pegvisomant) (Policy QHP9.328), Effective 09/01/2021
Qualified Health Plan
QHP9.340_Zokinvy_Rev2021_NEW
Qualified Health Plan
Zokinvy (Policy QHP9.340), Effective 09/01/2021
Qualified Health Plan
Systemic Antibiotics (Policy QHP9.403), Effective 06/01/2021
Qualified Health Plan
Hepatitis C (Policy QHP9.404), Effective 06/01/2021
Qualified Health Plan
Synagis (Policy QHP9.405), Effective 06/01/2021
Qualified Health Plan
Antifungal Agents (Policy QHP9.406), Effective 06/01/2021
Qualified Health Plan
Step Therapy - Pediculicide Agents (Policy QHP9.408), Effective 06/01/2021
Qualified Health Plan
Chloroquine and Hydroxychloroquine (Policy QHP9.410), Effective 06/01/2021
Qualified Health Plan
Descovy (Policy QHP9.411), Effective 06/01/2021
Qualified Health Plan
Antimycobaterial Agents (Policy QHP9.412), Effective 06/01/2021
Qualified Health Plan
Antidepressants (Policy QHP9.502), Effective 09/01/2021
Qualified Health Plan
Antipsychotics (Policy QHP9.503), Effective 06/01/2021
Qualified Health Plan
Buprenorphine and Naloxone Products (Policy QHP9.504), Effective 07/01/2021
Qualified Health Plan
ADHD Medications (Policy QHP9.505), Effective 06/01/2021
Qualified Health Plan
Step Therapy - Anti-Depressant / Anti-Psychotic Agents (Policy QHP9.506), Effective 06/01/2021
Qualified Health Plan
Pulmonary Hypertension (Policy QHP9.600), Effective 03/01/2022
Qualified Health Plan
ACEIs and ARBSs (Policy QHP9.601), Effective 03/01/2022
Qualified Health Plan
Homozygous Familial Hypercholesterolemia (Policy QHP9.603), Effective 03/01/2022
Qualified Health Plan
Droxidopa (Policy QHP9.604), Effective 03/01/2022
Qualified Health Plan
PCSK9 Inhibitors (Policy QHP9.605), Effective 03/01/2022
Qualified Health Plan
Entresto (Policy QHP9.606), Effective 01/01/2021
Qualified Health Plan
Erythropoiesis Stimulating Agents (Policy QHP9.609), Effective 03/01/2022
Qualified Health Plan
Adakveo (Policy QHP9.611), Effective 03/01/2022
Qualified Health Plan
Oxbryta (Policy QHP9.612), Effective 03/01/2022
Qualified Health Plan
Reblozyl (Policy QHP9.613), Effective 03/01/2022
Qualified Health Plan
Step Therapy - Antihypertensive Agents (Policy QHP9.615), Effective 03/01/2022
Qualified Health Plan
Step Therapy- Dyslipidemia Agents (Policy QHP9.616), Effective 03/01/2022
Qualified Health Plan
Corlanor (Policy QHP9.620), Effective 03/01/2022
Qualified Health Plan
Pegfilgrastim Agents (Policy QHP9.622), Effective 03/01/2022
Qualified Health Plan
Iron Chelating Agents (Policy QHP9.625), Effective 03/01/2022
Qualified Health Plan
Kuvan (Policy QHP9.626), Effective 01/01/2021
Qualified Health Plan
Sapropterin (Policy QHP9.626), Effective 09/01/2021
Qualified Health Plan
Mulpleta (Policy QHP9.627), Effective 03/01/2022
Qualified Health Plan
Pradaxa (Policy QHP9.628), Effective 01/01/2021
Qualified Health Plan
Colony Stimulating Agents Filgrastim Agents (Policy QHP9.629), Effective 03/01/2022
Qualified Health Plan
Verquvo (Policy QHP9.630), Effective 03/01/2022
Qualified Health Plan
Antineoplastic Agents (Policy QHP9.700), Effective 01/01/2021
Qualified Health Plan
Antineoplastic Agents (Policy QHP9.700), Effective 09/01/2021
Qualified Health Plan
GnRH Agents (Policy QHP9.703), Effective 03/01/2022
Qualified Health Plan
Rituximab (Policy QHP9.704), Effective 01/01/2021
Qualified Health Plan
Rituximab (Policy QHP9.704), Effective 09/01/2021
Qualified Health Plan
Tepezza (Policy QHP9.705), Effective 01/01/2021
Qualified Health Plan
Tepezza (Policy QHP9.705), Effective 09/01/2021
Qualified Health Plan
Enhertu (Policy QHP9.706), Effective 01/01/2021
Qualified Health Plan
Enhertu (Policy QHP9.706), Effective 09/01/2021
Qualified Health Plan
Padcev (Policy QHP9.707), Effective 01/01/2021
Qualified Health Plan
Padcev (Policy QHP9.707), Effective 09/01/2021
Qualified Health Plan
Gavreto (Policy QHP9.719), Effective 09/01/2021
Qualified Health Plan
Inqovi (Policy QHP9.720), Effective 09/01/2021
Qualified Health Plan
Monjuvi (Policy QHP9.721), Effective 09/01/2021
Qualified Health Plan
Onureg (Policy QHP9.722), Effective 09/01/2021
Qualified Health Plan
Pepaxto/Blenrep (Policy QHP9.723), Effective 09/01/2021
Qualified Health Plan
Tabrecta (Policy QHP9.724), Effective 09/01/2021
Qualified Health Plan
Uplinza (Policy QHP9.725), Effective 09/01/2021
Qualified Health Plan
Xpovio (Policy QHP9.726), Effective 09/01/2021
Qualified Health Plan
Ayvakit (Policy QHP9.727), Effective 09/01/2021
Qualified Health Plan
Ibrance (Policy QHP9.728), Effective 09/01/2021
Qualified Health Plan
Imbruvica (Policy QHP9.729), Effective 09/01/2021
Qualified Health Plan
Jakafi (Policy QHP9.730), Effective 09/01/2021
Qualified Health Plan
Jelmyto (Policy QHP9.731), Effective 09/01/2021
Qualified Health Plan
Pemazyre (Policy QHP9.732), Effective 09/01/2021
Qualified Health Plan
Qinlock (Policy QHP9.733), Effective 09/01/2021
Qualified Health Plan
Tagrisso (Policy QHP9.734), Effective 09/01/2021
Qualified Health Plan
Trodelvy (Policy QHP9.735), Effective 09/01/2021
Qualified Health Plan
Tukysa (Policy QHP9.736), Effective 09/01/2021
Qualified Health Plan
Zepzelca (Policy QHP9.737), Effective 09/01/2021
Qualified Health Plan
Benign Prostatic Hyperplasia (BPH) Medications (Policy QHP9.805), Effective 03/01/2022
Qualified Health Plan
Step Therapy - Proton Pump Inhibitors (Policy QHP9.806), Effective 03/01/2022
Qualified Health Plan
Infertility Medications (Policy QHP9.808), Effective 03/01/2022
Qualified Health Plan
Oriahnn & Myfembree (Policy QHP9.812), Effective 03/01/2022
Qualified Health Plan
Bylvay (Policy QHP9.814), Effective 03/01/2022
Qualified Health Plan
Xiidra (Policy QHP9.902), Effective 03/01/2022
Qualified Health Plan
Mytesi (Policy QHP9.903), Effective 03/01/2022
Qualified Health Plan
Antiemetics (Policy QHP9.905), Effective 03/01/2022
Qualified Health Plan
Topical Corticosteroids (Policy QHP9.906), Effective 03/01/2022
Qualified Health Plan
Anabolic Steroids (Policy QHP9.907), Effective 03/01/2022
Qualified Health Plan
Acne and Rosacea Agents (Policy QHP9.908), Effective 03/01/2022
Qualified Health Plan
Viscosupplements (Policy QHP9.909), Effective 03/01/2022
Qualified Health Plan
Rhopressa (Policy QHP9.912), Effective 03/01/2022
Qualified Health Plan
Step Therapy - Glaucoma (Policy QHP9.913), Effective 03/01/2022
Qualified Health Plan
Anti-Allergy Ophthalmic Agents (Policy QHP9.914), Effective 03/01/2022
Qualified Health Plan

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