Medical management

• Medical prior authorization service list (PDF)
• Non-covered services (PDF)

• Medical injectables list (PDF)
• Medical drug PA policies/PA form/exception to coverage form
• Drug management policies
• Medicare Part B Prior Authorization list (PDF)
• Policy - Medicare Part B Utilization Management in absence of NCD/LCD (PDF)

For new FDA-approved drugs on the market for less than a year.

• Pharmacy drug-IL (PDF)
• Pharmacy drug-MO (PDF)
• Medical injectable drug-IL (PDF)
• Medical injectable drug-MO (PDF)
• Medicare injectable drug step B therapy (PDF)
• Medicare pharmacy drug step B therapy (PDF)