Oscar Clinical Guidelines: Archived
Clinical guidelines are developed and adopted to establish evidence-based clinical criteria for utilization management decisions. Oscar may delegate utilization management decisions of certain services to third-party delegates who may develop and adopt their own clinical criteria. The clinical guidelines are applicable to all commercial policies. Coverage of services is subject to the terms, conditions, limitations of a member’s policy and applicable state and federal law. Please reference the member’s policy documents (e.g., Certificate/Evidence of Coverage, Schedule of Benefits) or to confirm coverage contact 855-672-2755 for Oscar Plans and 855-672-2789 for Cigna+Oscar Plans. You can find the active guidelines below:
Archived Summary of Changes
- 2025 Q3 (September) P&T Summary of Changes
- 2025 Q3 (August) P&T Summary of Changes
- 2025 Q3 (July) P&T Summary of Changes
- 2025 Q2 (June) P&T Summary of Changes
- 2025 Q2 Clinical Advisory Subcommittee (CAS) Summary of Changes
- 2025 Q1 Clinical Advisory Subcommittee (CAS) Summary of Changes
- 2025 Q1 Pharmacy & Therapeutics Summary of Changes
- 2025 Q2 (April & May) P&T Summary of Changes
Archived Medical and Pharmacy Policies
- Acupuncture (CG013)
- Acupuncture (CG013, Ver. 10)
- Adefovir Dipivoxil (Hepsera) (PG081)
- Adefovir Dipivoxil (Hepsera) (PG081, Ver. 6)
- Aduhelm (aducanumab-avwa) (PG139)
- albendazole (Albenza) (PG101)
- albendazole (Albenza) (PG101, Ver. 5)
- Allergen Sublingual Immunotherapy (SLIT) (PG093)
- Alvesco (ciclesonide) (PG105)
- Alvesco (ciclesonide) (PG105, Ver. 5)
- Ambulatory Cardiac Event Monitoring (CG032)
- Ambulatory Cardiac Event Monitoring (CG032, Ver. 10)
- Ambulance Services (CG057)
- Amvuttra (vutrisiran) (PG264)
- Amvuttra (vutrisiran) (PG264, Ver. 1)
- Anesthesia and Sedation in Endoscopy (CG041)
- Antidiabetic Agents - Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (PG152, Ver. 5)
- Antidiabetic Agent - SymlinPen (pramlintide acetate) (PG156, Ver 3.)
- Anti-migraine Agents: Calcitonin Gene-Related Peptide (CGRP) Antagonists and Serotonin Receptor 5-HT1F Agonists (PG008)
- Aptiom (eslicarbazepine acetate) (PG174, Ver. 2)
- Aripiprazole oral disintegrating tablet, solution (PG173, Ver. 3)
- Asenapine (Saphris) (PG058, Ver 6.)
- Authorization Duration Exception-REG (PG269, Ver. 1)
- Autonomic Testing (CG026)
- Autonomic Testing (CG026, Ver. 10)
- Auvelity (Dextromethorphan and Bupropion) (PG128, Ver. 3)
- Azelaic acid 15% gel (PG059, Ver. 6)
- Balloon Ostial Dilation (CG018)
- Balloon Ostial Dilation (CG018, Ver. 10)
- Bariatric Surgery (Adolescents) (CG009)
- Bariatric Surgery (Adolescents: Ages 13 - 17) (CG009, Ver. 10)
- Bariatric Surgery (Adults) (CG008)
- Bariatric Surgery (Adults) (CG008, Ver. 10)
- Benign Prostatic Hyperplasia Procedures (CG031)
- Benign Prostatic Hyperplasia Procedures (CG031, Ver. 10)
- Benlysta (belimumab) (PG014, Ver. 7)
- Benzodiazepines for Acute Repetitive Seizures or Seizure Clusters (PG254)
- Benzodiazepines for Acute Repetitive Seizures or Seizure Clusters (PG254, Ver. 4)
- Benzodiazepines for Acute Repetitive Seizures or Seizure Clusters (PG254, Ver. 3)
- Benzodiazepines for Acute Repetitive Seizures or Seizure Clusters (PG254, Ver. 2)
- Beqvez (fidanacogene elaparvovec) (CG118)
- Beyfortus (nirsevimab-alip) (PG180)
- Bioengineered Skin and Soft Tissue Substitutes (CG030)
- Breast Imaging (CG027)
- Breast Imaging (CG027, Ver. 10)
- Breast Procedures (CG036)
- Breast Procedures (CG036, Ver. 11)
- Brimonidine/Timolol (Combigan) (PG103)
- Briumvi (ublituximab) (PG134)
- Briviact (brivaracetam) Tablet, Solution (PG172, Ver. 2)
- Budesonide 3mg Delayed-Release Capsule (Entocort EC) (PG082)
- Budesonide 3mg Delayed-Release Capsule (Entocort EC) (PG082, Ver. 6)
- Caplyta (lumateperone) (PG175)
- Carvykti (ciltacabtagene autoleucel; cilta-cel) (CG067)
- Carvykti (ciltacabtagene autoleucel; cilta-cel) (CG067, Ver. 5)
- Carvykti (ciltacabtagene autoleucel; cilta-cel) (CG067, Ver. 4)
- Casgevy (exagamglogene autotemcel) (CG113)
- Casgevy (exagamglogene autotemcel) (CG113, Ver. 3)
- Casgevy (exagamglogene autotemcel) (CG113, Ver. 2)
- CeQur Simplicity Insulin Delivery System (PG192)
- Cibinqo (abrocitinib) (PG111)
- Cibinqo (abrocitinib) (PG111, Ver. 4)
- Cibinqo (abrocitinib) (PG111, Ver. 3)
- clomiphene (Clomid) (PG104)
- clomiphene (Clomid) (PG104, Ver. 5)
- Collagenase Ointment (Santyl) (PG141)
- Colorectal Cancer Screening (CG024)
- Combination Products for Treatment of Helicobacter pylori (PG199)
- Commercial Preferred Physician-Administered Specialty Drugs (CG052)
- Commercial Preferred Physician-Administered Specialty Drugs (CG052, Ver. 32)
- Commercial Preferred Physician-Administered Specialty Drugs (CG052, Ver. 31)
- Commercial Preferred Physician-Administered Specialty Drugs (CG052, Ver. 29)
- Commercial Preferred Physician-Administered Specialty Drugs (CG052, Ver. 11)
- Contact Lenses and Eyeglasses (CG039)
- Continuous Glucose Monitors (CGMs) Prescription Products (PG121, Ver. 6)
- Coronavirus Disease (COVID-19) Antibody Testing (CG077)
- Cromolyn Sodium Oral Concentrate (PG087, Ver. 6)
- Daybue (trofinetide) (PG148)
- Daybue (trofinetide) (PG148, Ver. 2)
- Deep Brain Stimulation (DBS) and Responsive Neurostimulation (RNS) (CG050)
- Deep Brain Stimulation (DBS) and Responsive Neurostimulation (RNS) (CG050, Ver. 8)
- Diabetes Equipment and Supplies (CG028)
- Diabetes Equipment and Supplies (CG028, Ver. 10)
- Diagnosis and Treatment of Infertility (CG016)
- Diagnosis and Treatment of Infertility (CG016, Ver. 12)
- Dipentum (olsalazine sodium) (PG244, Ver. 1)
- Direct Acting Antiviral Agents for Hepatitis C (PG045, Ver. 6)
- Doxylamine/Pyridoxine (Bonjesta, Diclegis) (PG096, Ver. 5)
- Duaklir (aclidinium/formoterol) (PG107)
- Duaklir (aclidinium/formoterol) (PG107, Ver. 5)
- Dupixent (dupilumab) (PG026)
- Dupixent (dupilumab) (PG026, Ver. 13)
- Durysta (bimatoprost intracameral implant) (CG116)
- Emverm (mebendazole) (PG001)
- Emverm (mebendazole) (PG001, Ver. 6)
- Entecavir (Baraclude) (PG085)
- Entecavir (Baraclude) (PG085, Ver. 6)
- Erectile Dysfunction (CG037)
- Experimental or Investigational Services, Products, Drugs, and Biologicals (CG012)
- Experimental or Investigational Services, Products, Drugs, and Biologicals (CG012, Ver. 11)
- Febuxostat (Uloric) (PG066)
- Febuxostat (Uloric) (PG066, Ver. 6)
- Fetzima (levomilnacipran) (PG063, Ver. 6)
- Fleqsuvy (baclofen oral suspension) (PG112)
- Fleqsuvy (baclofen oral suspension) (PG112, Ver. 3)
- Fycompa (perampanel) (PG176, Ver. 2)
- Glaucoma Surgery (CG034)
- Glaucoma Surgery (CG034, Ver. 10)
- Hearing Aids and Implants (CG001)
- Hemangeol (propranolol hydrochloride oral solution) (PG135)
- Hemangeol (propranolol hydrochloride oral solution) (PG135, Ver. 3)
- Home Births and Birth Centers (CG038)
- Home Care - Home Health Aides (CG022)
- Home Care - Home Health Aides (HHA) (CG022, Ver. 10)
- Home Care - Physical Therapy/Occupational Therapy (CG021)
- Home Care - Physical Therapy (PT) and Occupational Therapy (OT) (CG021, Ver. 10)
- Home Care - Speech-Language Pathology (SLP) Services (CG023)
- Home Care - Speech-Language Pathology (SLP) Services (CG023, Ver. 10)
- Home Care - Skilled Nursing Care (RN, LVN/LPN) (CG020)
- Home Care - Skilled Nursing Care (RN, LVN/LPN) (CG020, Ver. 10)
- Hospital Beds and Accessories (CG006)
- Hyperbaric Oxygen Therapy (CG014)
- Hyperbaric Oxygen Therapy (CG014, Ver. 10)
- Hypoglossal Nerve Stimulation (CG065)
- Hypoglossal Nerve Stimulation (CG065, Ver. 5)
- iDose TR (travoprost intracameral implant) (CG115, Ver. 3)
- Imcivree (setmelanotide) (PG088)
- Imcivree (setmelanotide) (PG088, Ver. 6)
- Injectable Iron Supplements (PG196)
- Injectable Iron Supplements (PG196, Ver. 4)
- Injectable Iron Supplements (PG196, Ver. 3)
- Infertility Injectable Agents (PG119)
- Infertility Injectable Agents (PG119, Ver. 3)
- Insulin Delivery Systems and Continuous Glucose Monitoring (CG029, Ver. 15)
- Intraoperative Neuromonitoring (CG045)
- Intraoperative Neuromonitoring (CG045, Ver. 8)
- Ivermectin 1% Topical Cream (PG239)
- Ivermectin 1% Topical Cream (PG239, Ver. 1)
- Kisunla (donanemab-azbt) (PG238)
- Kisunla (donanemab-azbt) (PG238, Ver. 1)
- Kymriah (tisagenlecleucel) (CG058)
- Kymriah (tisagenlecleucel) (CG058, Ver. 7)
- Lacosamide (Vimpat) (PG056, Ver. 6)
- Lamotrigine ER (Lamictal XR) (PG055, Ver. 6)
- Lamotrigine Orally Disintegrating Tablet (PG083, Ver. 6)
- Lamzede (velmanase alfa-tycv) (PG146, Ver. 2)
- Lanthanum Carbonate Chewable tablet (Fosrenol) (PG177)
- Lanthanum Carbonate Chewable tablet (Fosrenol) (PG177, Ver. 2)
- Lazcluze (lazertinib) (PG251)
- Lazcluze (lazertinib) (PG251, Ver. 1)
- Lemtrada (Alemtuzumab) (PG226)
- Lenmeldy (atidarsagene autotemcel) (CG117)
- Long-Term Acute Care Hospital (LTACH) (CG062)
- lurasidone (Latuda) (PG057)
- lurasidone (Latuda) (PG057, Ver. 6)
- Manual and Electric Breast Pumps (CG002)
- Medical Nutrition Therapy (CG010)
- Medical Nutrition Therapy (Dietary Evaluation & Counseling) (CG010, Ver. 10)
- Memantine (Namenda) (PG213, Ver. 1)
- Methotrexate Injectable Solution (PG249, Ver. 1)
- Miebo (perfluorohexyloctane) (PG166)
- Miebo (perfluorohexyloctane) (PG166, Ver. 2)
- Negative Pressure Wound Therapy and Negative Pressure Infusion/Instillation Therapy in Outpatient and Home Care Settings (CG068)
- Nevanac (nepafenac) ophthalmic suspension (PG078)
- Nevanac (nepafenac) ophthalmic suspension (PG078, Ver. 6)
- NexoBrid (anacaulase-bcdb) (CG112)
- NexoBrid (anacaulase-bcdb) (CG112, Ver. 2)
- Niktimvo (axatilimab) (PG252)
- Noninvasive Positive Pressure Ventilation (CG003)
- Ocrelizumab (Ocrevus, Ocrevus Zunovo) (PG235)
- Ohtuvayre (ensifentrine) (PG237)
- Ohtuvayre (ensifentrine) (PG237, Ver. 1)
- Omisirge (omidubicel-onlv) (PG149)
- Omisirge (omidubicel-onlv) (PG149, Ver. 2)
- Opioids (PG018)
- Opioids (PG018, Ver. 7)
- Optical Coherence Tomography (OCT) (CG025)
- Optical Coherence Tomography (OCT) (CG025, Ver. 10)
- Orgovyx (relugolix) (PG089, Ver. 6)
- Osphena (ospemifene) (PG169)
- Osphena (ospemifene) (PG169, Ver. 2)
- Outpatient Physical Therapy & Occupational Therapy (CG044)
- Outpatient Physical Therapy (PT) and Occupational Therapy (OT) (CG044, Ver. 8)
- Oxbryta (voxelotor) (PG114)
- Oxbryta (voxelotor) (PG114, Ver. 3)
- Oxiconazole (Oxistat 1%) (PG100)
- Oxygen Therapy (CG005)
- Pain Management: Epidural Steroid Injections, Selective Nerve Root Blocks (SNRB), and Intradiscal Steroid Injections (CG048)
- Pain Management: Facet Joint Injections/Medial Branch Blocks and Radiofrequency Facet Denervation (CG047)
- Pain Management: Facet Joint Injections/Medial Branch Blocks and Radiofrequency Facet Denervation (CG047, Ver. 8)
- Pain Management: Sacroiliac Intra-Articular Joint Injections (CG056)
- Phenoxybenzamine (PG054, Ver. 6)
- Pneumatic Compression Devices (CG049)
- Prenatal Testing (CG043)
- Prescription Drugs for Serious Mental Illnesses-REG (PG171, Ver. 2)
- Pressure-Reducing Support Surfaces (CG007)
- Preventive Services Statins Zero Copay Exception-REG (PG159)
- Preventive Services Statins Zero Copay Exception-REG (PG159, Ver. 2)
- Rebyota (fecal microbiota, live - jslm) (PG240, Ver. 1)
- Relyvrio (Sodium Phenylbutyrate/Taurursodiol) (PG129)
- Relyvrio (Sodium Phenylbutyrate/Taurursodiol) (PG129, Ver. 2)
- Restasis (cyclosporine ophthalmic emulsion 0.05%) (PG025, Ver. 7)
- Rexulti (brexpiprazole) (PG074)
- Rexulti (brexpiprazole) (PG074, Ver. 6)
- Rezdiffra (resmetirom) (PG198)
- Rezdiffra (resmetirom) (PG198, Ver. 2)
- Rezdiffra (resmetirom) (PG198, Ver. 1)
- Rivastigmine (Exelon) (PG212, Ver. 1)
- Sancuso (granisetron) Patch (PG007, Ver. 7)
- Savella (milnacipran) (PG062)
- Savella (milnacipran) (PG062, Ver. 6)
- Sex Reassignment Surgery (Gender Affirmation Surgery) and Non-Surgical Services (CG017)
- Sex Reassignment Surgery (Gender Affirmation Surgery) and Non-Surgical Services (CG017, Ver. 14)
- Sirturo (bedaquiline) (PG242)
- Site-of-Service (Site-of-Care) (Infusion Therapy & Physician-Administered Drugs) (CG046)
- Site-of-Service (Site-of-Care) (Infusion Therapy & Physician-Administered Drugs) (CG046, Ver. 10)
- Skilled Nursing Facility Care (CG042)
- Skilled Nursing Facility Care (CG042, Ver. 10)
- Spinal Orthoses (Back Braces) (CG051)
- Skysona (elivaldogene autotemcel) (CG074)
- Skysona (elivaldogene autotemcel) (CG074, Ver. 3)
- Tarpeyo (budesonide delayed release capsules) (PG116)
- Tarpeyo (budesonide delayed release capsules) (PG116, Ver. 4)
- Testosterone Replacement Therapy (PG122)
- Tevimbra (tislelizumab) (PG210)
- Total Hip Arthroplasty (CG070)
- Total Knee Arthroplasty (CG069)
- Total Shoulder Arthroplasty (Replacement) and Reverse Total Shoulder Arthroplasty (CG076)
- Transcranial Doppler (CG035)
- Transcranial Doppler (CG035, Ver. 10)
- Treatment and Removal of Benign Skin Lesions (CG015)
- Treatment and Removal of Benign Skin Lesions (CG015, Ver. 10)
- Tremfya (guselkumab) (PG250)
- Tremfya (guselkumab) (PG250, Ver. 3)
- Tremfya (guselkumab) (PG250, Ver. 4)
- Tysabri (natalizumab) (PG195, Ver. 3)
- Ultomiris (ravulizumab-cwvz) (PG189, Ver. 2)
- Urea Cycle Disorder (UCD) Treatment Agents (PG187)
- Urea Cycle Disorder (UCD) Treatment Agents (PG187, Ver. 2)
- Varicose Vein Treatment (CG004)
- Varubi (rolapitant) (PG178, Ver. 2)
- Velphoro (sucroferric oxyhydroxide) (PG179)
- Vemlidy (tenofovir alafenamide) (PG010)
- Verkazia (cyclosporine ophthalmic emulsion) 0.1% (PG236, Ver. 1)
- Verquvo (vericiguat) (PG091)
- Verquvo (vericiguat) (PG091, Ver. 6)
- Vesicular Monoamine Transporter Type 2 (VMAT2) Inhibitors (PG144)
- Vowst (fecal microbiota spores, live-brpk) (PG241, Ver. 1)
- Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) (PG191)
- Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) (PG191, Ver. 2)
- Wearable Cardioverter-Defibrillator Devices (CG019)
- Weight Loss Agents (PG070)
- Weight Loss Agents (PG070, Ver. 6)
- Xdemvy (lotilaner) (PG161)
- Xifaxan (rifaximin)(PG022)
- Xiidra (lifitegrast) (PG197)
- Xiidra (lifitegrast) (PG197, Ver. 2)
- Ycanth (cantharidin) (PG162)
- Ycanth (cantharidin) (PG162, Ver. 3)
- Yescarta (axicabtagene ciloleucel) (CG063)
- Yescarta (axicabtagene ciloleucel) (CG063, Ver. 7)
Archived Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria
- Agents for Amyloidosis-Associated Polyneuropathy - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG109)
- Agents for Amyloidosis-Associated Polyneuropathy - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG109, Ver. 1)
- Antiemetics - Substance P/Neurokinin 1 (NK1) Antagonist (i.e., Fosaprepitant Products) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG103)
- Antiemetics - Substance P/Neurokinin 1 (NK1) Antagonist (i.e., Fosaprepitant Products) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG103, Ver. 1)
- Antineoplastics - Bendamustine Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG102)
- Antineoplastics - Bendamustine Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG102, Ver. 1)
- Antineoplastics - Bevacizumab for Cancer Indications - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG083)
- Antineoplastics - Bevacizumab for Cancer Indications - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG083, Ver. 3)
- Antineoplastics - Bevacizumab for Cancer Indications - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG083, Ver. 2)
- Antineoplastics - Bevacizumab (Alymsys, Avastin, Avzivi, Mvasi, Vegzelma, Zirabev) for Cancer Indications - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG083)
- Antineoplastics - Cyclophosphamide Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG120)
- Antineoplastics - Cyclophosphamide Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Policy (CG120, Ver. 1)
- Antineoplastics - Gemcitabine Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG104)
- Antineoplastics - Gemcitabine Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG104, Ver. 2)
- Antineoplastics - HER2-Targeted Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG101)
- Antineoplastics - HER2-Targeted Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG101, Ver. 1)
- Antineoplastics - Proteosome Inhibitors (i.e., bortezomib, carfilzomib) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG106)
- Antineoplastics - Proteosome Inhibitors (i.e., bortezomib, carfilzomib) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG106, Ver. 1)
- Antineoplastics - Pemetrexed Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG105, Ver. 2)
- Antineoplastics - Trastuzumab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG082)
- Antineoplastics - Trastuzumab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG082, Ver. 2)
- Trastuzumab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG082)
- Antineoplastic and Immunomodulating Agents - Biologics for Autoimmune and Inflammatory Conditions - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG086)
- Antineoplastic and Immunomodulating Agents - Biologics for Autoimmune and Inflammatory Conditions - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG086, Ver. 7)
- Antineoplastic and Immunomodulating Agents - Biologics for Autoimmune and Inflammatory Conditions - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG086, Ver. 6)
- Antineoplastic and Immunomodulating Agents - Biologics for Autoimmune and Inflammatory Conditions - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG086, Ver. 5)
- Antineoplastic and Immunomodulating Agents - Biologics for Autoimmune and Inflammatory Conditions - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG086, Ver. 4)
- Agents for Autoimmune Conditions - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG086)
- Antineoplastic and Immunomodulating Agents - Infliximab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG087)
- Antineoplastic and Immunomodulating Agents - Infliximab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG087, Ver. 2)
- Antineoplastic and Immunomodulating Agents - Infliximab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG087)
- Antineoplastic and Immunomodulating Agents - Rituximab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG081)
- Antineoplastic and Immunomodulating Agents - Rituximab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG081, Ver. 2)
- Antineoplastic and Immunomodulating Agents - Rituximab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG081)
- Antineoplastic and Immunomodulating Agents - Tocilizumab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG108)
- Antineoplastic and Immunomodulating Agents - Tocilizumab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG108, Ver. 2)
- Antineoplastic and Immunomodulating Agents - Tocilizumab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG108, Ver. 1)
- Biologics for Chronic Respiratory and Allergic Conditions - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG100)
- Biologics for Chronic Respiratory and Allergic Conditions - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG100, Ver. 3)
- Botulinum Toxins - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG088)
- Botulinum Toxins - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG088, Ver. 3)
- Botulinum Toxins - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG088)
- Commercial Preferred Physician-Administered Specialty Drugs (CG052)
- Commercial Preferred Physician-Administered Specialty Drugs (CG052, Ver. 32)
- Commercial Preferred Physician-Administered Specialty Drugs (CG052, Ver. 31)
- Commercial Preferred Physician-Administered Specialty Drugs (CG052, Ver. 29)
- Commercial Preferred Physician-Administered Specialty Drugs (CG052, Ver. 11)
- Complement Inhibitors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG098, Ver. 4)
- Complement Inhibitors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG098)
- Complement Inhibitors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG098, Ver. 4)
- Complement Inhibitors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG098, Ver. 3)
- Complement Inhibitors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG098)
- Erythropoiesis-Stimulating Agent (ESA) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG084)
- Erythropoiesis-Stimulating Agent (ESA) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG084, Ver. 2)
- Erythropoiesis-Stimulating Agent (ESA) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG084)
- Factor IX Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG089)
- Factor IX Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG089, Ver. 2)
- Factor IX Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG089)
- Factor VIII (Long-Acting) Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG090)
- Factor VIII (Long-Acting) Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG090, Ver. 2)
- Factor VIII (Long-Acting) Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG090)
- Factor VIII Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG091)
- Factor VIII Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG091, Ver. 2)
- Factor VIII Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG091, Ver. 1)
- Follicle Stimulating Hormone (FSH) Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG092)
- Follicle Stimulating Hormone (FSH) Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG092, Ver. 2)
- Follicle Stimulating Hormone (FSH) Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG092)
- Gaucher's Disease Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG093)
- Gaucher's Disease Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG093, Ver. 2)
- Gaucher's Disease Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG093)
- Hyaluronate and Derivatives - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG094)
- Hyaluronate and Derivatives - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG094, Ver. 4)
- Hyaluronate and Derivatives - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG094, Ver. 3)
- Hyaluronate and Derivatives - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG094)
- Injectable Iron Supplements - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG107)
- Injectable Iron Supplements - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG107, Ver. 3)
- Injectable Iron Supplements - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG107, Ver. 2)
- Injectable Iron Supplements - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG107)
- Long-Acting Granulocyte Colony-Stimulating Factors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG079)
- Long-Acting Granulocyte Colony-Stimulating Factors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG079, Ver. 2)
- Long-Acting Granulocyte Colony-Stimulating Factors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG079)
- Long-Acting Reversible Contraceptives - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG095)
- Long-Acting Reversible Contraceptives - Medical Benefit Preferred Physician- Administered Drug Exceptions Criteria (CG095, Ver. 3)
- Long-Acting Reversible Contraceptives - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG095, Ver. 2)
- Long-Acting Reversible Contraceptives - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG095)
- Multiple Sclerosis Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG096)
- Multiple Sclerosis Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG096, Ver. 4)
- Multiple Sclerosis Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG096, Ver. 3)
- Multiple Sclerosis Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG096)
- Prostacyclin Analogs/Receptor Agonists for Pulmonary Hypertension (PAH) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG097)
- Prostacyclin Analogs/Receptor Agonists for Pulmonary Hypertension (PAH) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG097, Ver. 2)
- Short-Acting Granulocyte Colony-Stimulating Factors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG080)
- Short-Acting Granulocyte Colony-Stimulating Factors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG080, Ver. 3)
- Short-Acting Granulocyte Colony-Stimulating Factors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG080, Ver. 2)
- Short-Acting Granulocyte Colony-Stimulating Factors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG080)
- Site-of-Service (Site-of-Care) (Infusion Therapy & Physician-Administered Drugs) (CG046)
- Site-of-Service (Site-of-Care) (Infusion Therapy & Physician-Administered Drugs) (CG046, Ver. 10)
- Vascular Endothelial Growth Factor (VEGF) Inhibitor Ophthalmic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG099)
- Vascular Endothelial Growth Factor (VEGF) Inhibitor Ophthalmic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG099, Ver. 4)
- Vascular Endothelial Growth Factor (VEGF) Inhibitor Ophthalmic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG099)