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.

• Durable Medical Equipment Policies
  • Qualified Health Plans (Commercial)
  • MassHealth (Medicaid)
  • Senior Care Options - Contact Northwood directly.
• Radiology Policies
• Fraud, Waste and Abuse Policy
• Administrative Appeals Policy
• Involuntary Member Transfer or Plan Disenrollment Policy

• Medical Policies
• Reimbursement Policies
• Pharmacy Policies

Search

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

Search

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

Search

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