Medical Policies
Our medical policies define how MMM Holdings LLC and its subsidiaries identify and evaluate requests for specific services by applying clinical guidelines. Policies adhere to National and Local Coverage Determinations (NCD or LCD) and/or Articles defined by the Centers for Medicare & Medicaid Services (CMS) and/or any other clinical criteria. Policies reflect current scientific research and evidence-based clinical guideline standards.
Policies — Part B Rx
This section contains the clinical criteria for injectable, infused or implanted drugs and therapies covered under the medical benefit that are subject to prior authorization. The clinical criteria are developed to help guide the clinically appropriate use of drugs and therapies, and are reviewed and approved by the Pharmacy & Therapeutics (P&T) Committee: an independent, external committee of practicing physicians, pharmacists and clinicians from leading academic medical centers and clinical practices with expertise in evidence-based medicine.
Brand NameGeneric NameHCPCS CodePolicy NamePolicy Number
- Brand NameAbecmaGeneric NameIdecabtagene vicleucelHCPCS CodeQ2055Policy NameIdecabtagene vicleucel (Abecma®)
- Brand NameAbraxaneGeneric NamePaclitaxelHCPCS CodeJ9264, J9258, J9259Policy NamePaclitaxel, Protein Bound (Abraxane®)Policy NumberMP-RX-FP-69-23
- Brand NameActemraGeneric NameTocilizumabHCPCS CodeJ3262Policy NameMonoclonal Antibodies to Interlukin-6: tocilizumab (Actemra), sarilumab (Kevzara)Policy NumberMP-RX-FP-59-23
- Brand NameAdacelGeneric NameTetanus Toxoid-Diphtheria-Acellular Pertussis Adsorb (Tdap)HCPCS Code90715Policy NameHepatitis B and Tetanus-Containing VaccinesPolicy NumberMP-RX-FP-156-24
- Brand NameAdakveoGeneric NameCrizanlizumab-tmcaHCPCS CodeJ0791Policy NameCrizanlizumab-tmca (Adakveo®)Policy NumberMP-RX-FP-118-24
- Brand NameAdbryGeneric NameTralokinumab-ldrmHCPCS CodeJ3490, J3590, C9399Policy NameTralokinumab-ldrm (Adbry®)Policy NumberMP-RX-FP-149-24
- Brand NameAdcetrisGeneric NameBrentuximabHCPCS CodeJ9042Policy NameBrentuximab vedotin (Adcetris®)Policy NumberMP-RX-FP-01-23
- Brand NameAdvateGeneric NameAntihemophilic Factor (Rcmb) Plasma/Albumin Free (rAHF-PFM)HCPCS CodeJ7192Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameAdynovateGeneric NameAntihemophilic Factor (Recombinant) PegylatedHCPCS CodeJ7207Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameAfstylaGeneric NameAntihemophilic Factor (Recombinant) Single ChainHCPCS CodeJ7210Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameAhzantiveGeneric Nameaflibercept-mrbbHCPCS CodeQ5150Policy NameVascular Endothelial Growth Factor (VEGF) InhibitorsPolicy NumberMP-RX-FP-100-23
- Brand NameAimovigGeneric NameErenumabHCPCS CodeC9399; J3490; J3590Policy NameCGRP Antagonists: Erenumab (Aimovig), Fremanezumab (Ajovy), Galcanezumab (Emgality)Policy NumberMP-RX-FP-17-23
- Brand NameAjovyGeneric NameFremanezumab-vfrmHCPCS CodeJ3031Policy NameCGRP Antagonists: Erenumab (Aimovig), Fremanezumab (Ajovy), Galcanezumab (Emgality)Policy NumberMP-RX-FP-17-23
- Brand NameAkynzeoGeneric NameNetupitant, palonosetronHCPCS CodeJ8655Policy NameOral Antiemetic Drugs (Replacement for Intravenous Antiemetics)
- Brand NameAlhemoGeneric Nameconcizumab-mtciHCPCS CodeJ7173Policy NameSelect Clotting Agents for Bleeding DisordersPolicy NumberMP-RX-FP-82-23
- Brand NameAlimtaGeneric NamePemetrexedHCPCS CodeJ9305Policy NamePemetrexed (Alimta®, Axtle®, Pemfexy®, Pemrydi®)Policy NumberMP-RX-FP-05-23
- Brand NameAlphanateGeneric NameAntihemophilic viii/vwf compHCPCS CodeJ7186Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameAlphaNineGeneric NameCoagulation Factor IXHCPCS CodeJ7193Policy NameAgents for Hemophilia BPolicy NumberMP-RX-FP-03-23
- Brand NameAlprolixGeneric NameCoagulation Factor IX (Recomb) Fc Fusion Protein (rFIXFc)HCPCS CodeJ7201Policy NameAgents for Hemophilia BPolicy NumberMP-RX-FP-03-23
- Brand NameAltuviioGeneric NameFactor VIII/von Willebrand factor complex, recombinantHCPCS CodeJ7214Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameAlymsysGeneric Namebevacizumab-malyHCPCS CodeQ5126Policy NameBevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, Zirabev and Avzivi)Policy NumberMP-RX-FP-13-23
- Brand NameAlymsys intravitrealGeneric Namebevacizumab-malyHCPCS CodeQ5126Policy NameVascular Endothelial Growth Factor (VEGF) InhibitorsPolicy NumberMP-RX-FP-100-23
- Brand NameAmondys 45Generic NameCasimersenHCPCS CodeJ1426Policy NameCasimersen (Amondys 45)Policy NumberMP-RX-FP-181-26
- Brand NameAnktivaGeneric NameNogapendekin alfa inbakicept-pmlnHCPCS CodeJ9028Policy NameAnktiva_PartB_MedPol_2024Policy NumberMP-RX-FP-154-24
- Brand NameApretudeGeneric NameInjection, cabotegravir, 1 mgHCPCS CodeJ0739Policy NamePreexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection
- Brand NameAralastGeneric NameAlpha1-Proteinase Inhibitor (Human)HCPCS CodeJ0256Policy NameAlpha-1 Proteinase Inhibitor Therapy [Aralast, Glassia, Prolastin-C, Zemaira]Policy NumberMP-RX-FP-06-23
- Brand NameAranesp (Albumin Free)Generic NameDarbepoetin alfa, esrd useHCPCS CodeJ0882Policy NameErythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
- Brand NameAranesp (Albumin Free)Generic NameDarbepoetin alfa, non-esrdHCPCS CodeJ0881Policy NameErythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
- Brand NameArzerraGeneric NameOfatumumabHCPCS CodeJ9302Policy NameOfatumumab (Arzerra®)Policy NumberMP-RX-FP-132-24
- Brand NameAscenivGeneric NameImmune Globulin (Human)-slraHCPCS CodeJ1554Policy NameImmunoglobulinsPolicy NumberMP-RX-FP-40-23
- Brand NameAtgamGeneric NameLymphocyte Immune Globulin,Anti-Thymocyte Globulin (Equine)HCPCS CodeJ7504Policy NameAntithymocyte Globulin Equine, (Atgam)Policy NumberMP-RX-FP-08-24
- Brand NameAvastinGeneric NameBevacizumabHCPCS CodeJ9035Policy NameBevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, Zirabev and Avzivi)Policy NumberMP-RX-FP-13-23
- Brand NameAvastin intravitrealGeneric NamebevacizumabHCPCS CodeJ9035Policy NameVascular Endothelial Growth Factor (VEGF) InhibitorsPolicy NumberMP-RX-FP-100-23
- Brand NameAvsolaGeneric NameInfliximab-axxqHCPCS CodeQ5121Policy NameTumor Necrosis Factor AntagonistsPolicy NumberMP-RX-FP-96-23
- Brand NameAvtozmaGeneric NameTocilizumab-anohHCPCS CodeJ3590Policy NameMonoclonal Antibodies to Interlukin-6Policy NumberMP-RX-FP-59-23
- Brand NameAvziviGeneric Namebevacizumab-tnjnHCPCS CodeJ3490, J3590Policy NameBevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, Zirabev and Avzivi)Policy NumberMP-RX-FP-13-23
- Brand NameAxtleGeneric NamePemetrexedHCPCS CodeJ9292Policy NamePemetrexed (Alimta®, Axtle®, Pemfexy®, Pemrydi®)Policy NumberMP-RX-FP-05-23
- Brand NameAzedraGeneric Nameiobenguane I 131HCPCS CodeA9590Policy NameRadioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra®, Lutathera®, Pluvicto®, Zevalin®)Policy NumberMP-RX-FP-137-24
- Brand NameBavencioGeneric NameAvelumabHCPCS CodeJ9023Policy NameAvelumab (Bavencio®)Policy NumberMP-RX-FP-09-23
- Brand NameBelrapzoGeneric NameBendamustineHCPCS CodeJ9036Policy NameBendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®)Policy NumberMP-RX-FP-10-23
- Brand NameBendekaGeneric NameBendamustineHCPCS CodeJ9034, J9058, J9059Policy NameBendamustine Agents (Bendeka®, Treanda®, Belrapzo®, Vivimusta®)Policy NumberMP-RX-FP-10-23
- Brand NameBeneFixGeneric NameCoagulation Factor IX (Recombinant)HCPCS CodeJ7195Policy NameAgents for Hemophilia BPolicy NumberMP-RX-FP-03-23
- Brand NameBenlystaGeneric NameBelimumabHCPCS CodeJ0490Policy NameBenlysta (belimumab)Policy NumberMP-RX-FP-11-23
- Brand NameBeovuGeneric NameBrolucizumab-dbllHCPCS CodeJ0179Policy NameVascular Endothelial Growth Factor (VEGF) InhibitorsPolicy NumberMP-RX-FP-100-23
- Brand NameBEQVEZGeneric NameFidanacogene elaparvovec-dzktHCPCS CodeJ1414Policy NameFidanacogene elaparvovec-dzkt (BEQVEZ)Policy NumberMP-RX-FP-170-25
- Brand NameBerinertGeneric NameC1 Esterase Inhibitor (Human)HCPCS CodeJ0597Policy NameHereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, OrladeyoPolicy NumberMP-RX-FP-36-23
- Brand NameBesponsaGeneric NameInotuzumabHCPCS CodeJ9229Policy NameInotuzumab ozogamicin (Besponsa®)Policy NumberMP-RX-FP-12-23
- Brand NameBildyosGeneric Namedenosumab-bmwoHCPCS CodeQ5162Policy NameIV Biphosphonate and Monoclonal Antibodies for Treatment of OsteoporosisPolicy NumberMP-RX-FP-123-24
- Brand NameBilprevdaGeneric Namedenosumab-bmwoHCPCS CodeQ5162Policy NameIV Biphosphonate and Monoclonal Antibodies for Treatment of OsteoporosisPolicy NumberMP-RX-FP-123-24
- Brand NameBivigamGeneric NameImmune Globulin (Human) IVHCPCS CodeJ1556Policy NameImmunoglobulinsPolicy NumberMP-RX-FP-40-23
- Brand NameBizengriGeneric Namezenocutuzumab-zbcoHCPCS CodeJ9382Policy NameBizengri (zenocutuzumab-zbco)Policy NumberMP-RX-FP-165-25
- Brand NameBkemvGeneric NameeculizumabHCPCS CodeJ3590Policy NameComplement Inhibitors: eculizumab agents (Soliris and biosimilars BKEMV and Epysqli)], Ultomiris [ravulizumab-cwvz], Piasky (crovalimab-aeeb)Policy NumberMP-RX-FP-19-23
- Brand NameBlincytoGeneric NameBlinatumomabHCPCS CodeJ9039Policy NameBlinatumomab (Blyncito®)Policy NumberMP-RX-FP-14-23
- Brand NameBomyntraGeneric Namedenosumab-bnhtHCPCS CodeC9399, J3590Policy NameIV Biphosphonate and Monoclonal Antibodies for Treatment of OsteoporosisPolicy NumberMP-RX-FP-123-24
- Brand NameBonivaGeneric NameIbandronate sodium injectionHCPCS CodeJ1740Policy NameIV Biphosphonate and Monoclonal Antibodies for Treatment of OsteoporosisPolicy NumberMP-RX-FP-123-24
- Brand NameBonivaGeneric NameIbandronate sodium injectionHCPCS CodeJ1740Policy NameBisphosphonates (Intravenous [IV]) and Monoclonal Antibodies in the Treatment of Osteoporosis and Their Other Indications
- Brand NameBonsityGeneric NameTeriparatideHCPCS CodeJ3110Policy NameHuman Parathyroid Hormone Agents: abaloparatide (Tymlos), teriparatide (Forteo, Bonsity)Policy NumberMP-RX-FP-37-23
- Brand NameBoostrixGeneric NameTetanus Toxoid-Diphtheria-Acellular Pertussis Adsorb (Tdap)HCPCS Code90715Policy NameHepatitis B and Tetanus-Containing VaccinesPolicy NumberMP-RX-FP-156-24
- Brand NameBotoxGeneric NameOnabotulinumtoxinAHCPCS CodeJ0585Policy NameBotulinum ToxinsPolicy NumberLCD: L33274 - Botulinum Toxins
- Brand NameBreyanziGeneric NameLisocabtagene maraleucelHCPCS CodeQ2054Policy NameLisocabtagene maraleucel (Breyanzi®)
- Brand NameBriumviGeneric Nameublituximab-xiiyHCPCS CodeJ2329Policy NameUblituximab-xiiy (Briumvi®)Policy NumberMP-RX-FP-151-24
- Brand NameBynfeziaGeneric NameOctreotide AcetateHCPCS CodeJ3490Policy NameOctreotide Agent (Bynfezia Pen, Sandostatin, Sandostatin LAR)Policy NumberMP-RX-FP-65-23
- Brand NameByoovizGeneric Nameranibizumab-nunaHCPCS CodeQ5128Policy NameVascular Endothelial Growth Factor (VEGF) InhibitorsPolicy NumberMP-RX-FP-100-23
- Brand NameCabenuvaGeneric NameCabotegravir & RilpivirineHCPCS CodeJ0741Policy NameCabotegravir extended-release; rilpivirine extended-release (Cabenuva)Policy NumberMP-RX-FP-16-23
- Brand NameCamceviGeneric NameLeuprolide mesylateHCPCS CodeJ1952Policy NameGnRH analogs for non-oncology and oncology-related indicationsPolicy NumberMP-RX-FP-34-23
- Brand NameCamcevi ETMGeneric NameLeuprolide mesylateHCPCS CodeJ9003Policy NameGnRH analogs for non-oncology and oncology-related indicationsPolicy NumberMP-RX-FP-34-23
- Brand NameCarvyktiGeneric NameCiltacabtagene autoleucelHCPCS CodeQ2056Policy NameCiltacabtagene autoleucel (Carvykti®)
- Brand NameCerezymeGeneric NameImigluceraseHCPCS CodeJ1786Policy NameEnzyme Replacement Therapy for Gaucher Disease: Imiglucerase (Cerezyme), Taliglucerase (Elelyso), Velaglucerase (Vpriv)Policy NumberMP-RX-FP-29-23
- Brand NameCimerliGeneric Nameranibizumab-eqrnHCPCS CodeQ5124Policy NameVascular Endothelial Growth Factor (VEGF) InhibitorsPolicy NumberMP-RX-FP-100-23
- Brand NameCinqairGeneric NameReslizumabHCPCS CodeJ2786Policy NameMonoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)]Policy NumberMP-RX-FP-58-23
- Brand NameCinryzeGeneric NameC1 Esterase Inhibitor (Human)HCPCS CodeJ0598Policy NameHereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, OrladeyoPolicy NumberMP-RX-FP-36-23
- Brand NameCoagadexGeneric NameCoagulation Factor X (Human)HCPCS CodeJ7175Policy NameSelect Clotting Agents for Bleeding DisordersPolicy NumberMP-RX-FP-82-23
- Brand NameColumviGeneric NameGlofitamab-gxbmHCPCS CodeJ9286Policy NameGlofitamab-gxbm (Columvi®)Policy NumberMP-RX-FP-122-24
- Brand NameConexxenceGeneric Namedenosumab-bnhtHCPCS CodeC9399, J3590Policy NameIV Biphosphonate and Monoclonal Antibodies for Treatment of OsteoporosisPolicy NumberMP-RX-FP-123-24
- Brand NameCorifactGeneric NameFactor XIII Concentrate (Human)HCPCS CodeJ7180Policy NameSelect Clotting Agents for Bleeding DisordersPolicy NumberMP-RX-FP-82-23
- Brand NameCoselaGeneric NameTrilaciclibHCPCS CodeJ1448Policy NameTrilaciclib (Cosela)Policy NumberMP-RX-FP-173-25
- Brand NameCosentyxGeneric NameSecukinumabHCPCS CodeC9399; J3490; J3590Policy NameMonoclonal Antibodies to Interleukin-17 [Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)]Policy NumberMP-RX-FP-60-23
- Brand NameCutaquigGeneric NameImmune Globulin (Human) IVHCPCS CodeJ1551Policy NameImmunoglobulinsPolicy NumberMP-RX-FP-40-23
- Brand NameCuvitruGeneric NameImmune Globulin (Human) SubcutaneousHCPCS CodeJ3590Policy NameImmunoglobulinsPolicy NumberMP-RX-FP-40-23
- Brand NameCyramzaGeneric NameRamucirumabHCPCS CodeJ9308Policy NameRamucirumab (Cyramza®)Policy NumberMP-RX-FP-20-23
- Brand NameDanyelzaGeneric NameNaxitamab-gqgkHCPCS CodeJ9348Policy NameNaxitamab-gqgk (Danyelza®)Policy NumberMP-RX-FP-129-24
- Brand NameDarzalexGeneric NameDaratumumabHCPCS CodeJ9145Policy NameDaratumumab (Darzalex®) and daratumumab and hyaluronidase-fihj (Darzalex Faspro)Policy NumberMP-RX-FP-21-23
- Brand NameDarzalex FasproGeneric NameDaratumumab and hyaluronidase-fijhHCPCS CodeJ9144Policy NameDaratumumab (Darzalex®) and daratumumab and hyaluronidase-fihj (Darzalex Faspro)Policy NumberMP-RX-FP-21-23
- Brand NameDescovyGeneric NameEmtricitabine 200 mg and tenofovir alafenamide 25 mg, oralHCPCS CodeJ0751Policy NamePreexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection
- Brand NameDodexGeneric NameCyanocobalaminHCPCS CodeJ3420Policy NameVitamin B12 InjectionsPolicy NumberLCD - Vitamin B12 Injections (L33967) (cms.gov)
- Brand NameDuopaGeneric NameCarbidopa-LevodopaHCPCS CodeJ7340Policy NameCarbidopa and levodopa enteral suspension (Duopa)Policy NumberMP-RX-FP-22-23
- Brand NameDupixentGeneric NameDupilumabHCPCS CodeC9399; J3490; J3590Policy NameDupilumab (Dupixent)Policy NumberMP-RX-FP-23-23
- Brand NameDurolaneGeneric NameSodium Hyaluronate (Viscosupplement)HCPCS CodeJ7318Policy NameHyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3]Policy NumberMP-RX-FP-38-23
- Brand NameDurystaGeneric NameBimatoprostHCPCS CodeJ7351Policy NameDurysta [Bimatoprost Implant]Policy NumberMP-RX-FP-24-23
- Brand NameDysportGeneric NameAbobotulinumtoxinAHCPCS CodeJ0586Policy NameBotulinum ToxinsPolicy NumberLCD: L33274 - Botulinum Toxins
- Brand NameEgriftaGeneric NameTesamorelin AcetateHCPCS CodeJ3490; J3590Policy NameTesamorelin (Egrifta SV®, Egrifta WR™)Policy NumberMP-RX-FP-25-23
- Brand NameEgrifta SVGeneric NameTesamorelin AcetateHCPCS CodeJ3490; J3590Policy NameTesamorelin (Egrifta SV®, Egrifta WR™)Policy NumberMP-RX-FP-25-23
- Brand NameEgrifta WRGeneric NameTesamorelin AcetateHCPCS CodeJ3490; J3590Policy NameTesamorelin (Egrifta SV®, Egrifta WR™)Policy NumberMP-RX-FP-25-23
- Brand NameElahereGeneric NameMirvetuximab Soravtansine-gynxHCPCS CodeJ9063Policy NameMirvetuximab soravtansine-gynx (Elahere®)Policy NumberMP-RX-FP-126-24
- Brand NameElelysoGeneric NameTaliglucerase AlfaHCPCS CodeJ3060Policy NameEnzyme Replacement Therapy for Gaucher Disease: Imiglucerase (Cerezyme), Taliglucerase (Elelyso), Velaglucerase (Vpriv)Policy NumberMP-RX-FP-29-23
- Brand NameElevidysGeneric NameDelandistrogene moxeparvovec-roklHCPCS CodeJ1413Policy NameDelandistrogene moxeparvovec-rokl (Elevidys)Policy NumberMP-RX-FP-163-24
- Brand NameEligardGeneric NameLeuprolideHCPCS CodeJ9217Policy NameGnRH analogs for non-oncology and oncology-related indicationsPolicy NumberMP-RX-FP-34-23
- Brand NameEloctateGeneric NameAntihemophilic Factor (Recombinant) Fc Fusion Protein(BDD-rFVIIIFc)HCPCS CodeJ7205Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameElrexfioGeneric NameElranatamab-bcmmHCPCS CodeJ3490, J3590, J9999, C9165Policy NameElranatamab-bcmm (Elrexfio®)Policy NumberMP-RX-FP-120-24
- Brand NameEmendGeneric NameAprepitant, oralHCPCS CodeJ8501Policy NameOral antiemetic drugs: AprepitantPolicy NumberMP-RX-FP-07-23
- Brand NameEmgalityGeneric NameGalcanezumabHCPCS CodeC9399; J3490; J3590Policy NameCGRP Antagonists: Erenumab (Aimovig), Fremanezumab (Ajovy), Galcanezumab (Emgality)Policy NumberMP-RX-FP-17-23
- Brand NameEmpaveliGeneric NamePegcetacoplanHCPCS CodeJ3490, C9399Policy NamePegcetacoplan (Empaveli®)Policy NumberMP-RX-FP-135-24
- Brand NameEmplicitiGeneric NameElotuzumabHCPCS CodeJ9176Policy NameElotuzumab (Empliciti®)Policy NumberMP-RX-FP-26-23
- Brand NameEmrelisGeneric NameTelisotuzumab Vedotin-tllvHCPCS CodeJ9326Policy NameTelisotuzumab vedotin-tllv (Emrelis)Policy NumberMP-RX-FP-175-25
- Brand NameEngerix-BGeneric NameHepatitis B Vaccine (Recomb)HCPCS Code90744Policy NameHepatitis B and Tetanus-Containing VaccinesPolicy NumberMP-RX-FP-156-24
- Brand NameEnhertuGeneric Namefam-trastuzumab deruxtecan-nxkHCPCS CodeJ9358Policy NameFam-trastuzumab deruxtecan-nxki (Enhertu)Policy NumberMP-RX-FP-180-26
- Brand NameEnjaymoGeneric NameSutimlimab-jomeHCPCS CodeJ1302Policy NameSutimlimab-jome (Enjaymo®)Policy NumberMP-RX-FP-141-24
- Brand NameEntyvioGeneric NameVedolizumabHCPCS CodeJ3380Policy NameVedolizumab (Entyvio)Policy NumberMP-RX-FP-28-23
- Brand NameEnzeevuGeneric Nameaflibercept-abzvHCPCS CodeQ5149Policy NameVascular Endothelial Growth Factor (VEGF) InhibitorsPolicy NumberMP-RX-FP-100-23
- Brand NameEpioxaGeneric NameRiboflavin 5'-phosphate ophthalmicHCPCS CodeJ2787Policy NameRiboflavin 5-Phosphate ophthalmic (Epioxa)Policy NumberMP-RX-FP-187-26
- Brand NameEpioxa HDGeneric NameRiboflavin 5'-phosphate ophthalmicHCPCS CodeJ2787Policy NameRiboflavin 5-Phosphate ophthalmic (Epioxa HD)Policy NumberMP-RX-FP-187-26
- Brand NameEpkinlyGeneric NameEpcoritamab-byspHCPCS CodeJ9321Policy NameEpcoritamab-bysp (Epkinly®)Policy NumberMP-RX-FP-121-24
- Brand NameEpogenGeneric NameEpoetin alfa, non-esrdHCPCS CodeJ0885Policy NameErythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
- Brand NameEpogenGeneric NameEpoetin alfa, esrdHCPCS CodeQ4081Policy NameErythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
- Brand NameEpysqliGeneric Nameeculizumab-aaghHCPCS CodeJ3590Policy NameComplement Inhibitors: eculizumab agents (Soliris and biosimilars BKEMV and Epysqli)], Ultomiris [ravulizumab-cwvz], Piasky (crovalimab-aeeb)Policy NumberMP-RX-FP-19-23
- Brand NameErbituxGeneric NameCetuximabHCPCS CodeJ9055Policy NameCetuximab (Erbitux®)Policy NumberMP-RX-FP-30-23
- Brand NameEsperoctGeneric NameAntihemophilic Factor (Recombinant) Glycopegylated-exeiHCPCS CodeJ7204Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameEuflexxaGeneric NameSodium Hyaluronate (Viscosupplement)HCPCS CodeJ7323Policy NameHyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3]Policy NumberMP-RX-FP-38-23
- Brand NameEvenityGeneric NameRomosozumab-aqqgHCPCS CodeJ3111Policy NameRomosozumab (Evenity)Policy NumberMP-RX-FP-32-23
- Brand NameExondys 51Generic NameEteplirsenHCPCS CodeJ1428Policy NameEteplirsen (Exondys 51)Policy NumberMP-RX-FP-182-26
- Brand NameEyleaGeneric NameAfliberceptHCPCS CodeJ0178Policy NameVascular Endothelial Growth Factor (VEGF) InhibitorsPolicy NumberMP-RX-FP-100-23
- Brand NameEylea HDGeneric NameAflibercept hdHCPCS CodeJ0177Policy NameVascular Endothelial Growth Factor (VEGF) InhibitorsPolicy NumberMP-RX-FP-100-23
- Brand NameFasenraGeneric NameBenralizumabHCPCS CodeJ0517Policy NameMonoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)]Policy NumberMP-RX-FP-58-23
- Brand NameFasenra PenGeneric NameBenralizumabHCPCS CodeJ0517Policy NameMonoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)]Policy NumberMP-RX-FP-58-23
- Brand NameFeiba NFGeneric NameAntiinhibitor Coagulant ComplexHCPCS CodeJ7198Policy NameSelect Clotting Agents for Bleeding DisordersPolicy NumberMP-RX-FP-82-23
- Brand NameFensolviGeneric NameLeuprolideHCPCS CodeJ1951Policy NameGnRH analogs for non-oncology and oncology-related indicationsPolicy NumberMP-RX-FP-34-23
- Brand NameFerahemeGeneric NameFerumoxytolHCPCS CodeQ0138Policy NameIron AgentsPolicy NumberMP-RX-FP-44-23
- Brand NameFerrlecitGeneric NameSodium ferric gluconate/sucrose complexHCPCS CodeJ2916Policy NameIron AgentsPolicy NumberMP-RX-FP-44-23
- Brand NameFibrygaGeneric NameFibrinogen Concentrate (Human)HCPCS CodeJ7177Policy NameSelect Clotting Agents for Bleeding DisordersPolicy NumberMP-RX-FP-82-23
- Brand NameFirazyrGeneric NameIcatibant AcetateHCPCS CodeJ1744Policy NameHereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, OrladeyoPolicy NumberMP-RX-FP-36-23
- Brand NameFirmagonGeneric NameFirmagonHCPCS CodeJ9155Policy NameGnRH analogs for non-oncology and oncology-related indicationsPolicy NumberMP-RX-FP-34-23
- Brand NameFirmagon (240 MG Dose)Generic NameDegarelixHCPCS CodeJ9155Policy NameGnRH analogs for non-oncology and oncology-related indicationsPolicy NumberMP-RX-FP-34-23
- Brand NameFlebogamma DIFGeneric NameImmune Globulin (Human) IVHCPCS CodeJ1572Policy NameImmunoglobulinsPolicy NumberMP-RX-FP-40-23
- Brand NameForteoGeneric NameTeriparatide (Recombinant)HCPCS CodeJ3110Policy NameHuman Parathyroid Hormone Agents: abaloparatide (Tymlos), teriparatide (Forteo, Bonsity)Policy NumberMP-RX-FP-37-23
- Brand NameFulphilaGeneric NamePegfilgrastim-jmdbHCPCS CodeQ5108Policy NameColony Stimulating FactorsPolicy NumberMP-RX-FP-18-23
- Brand NameFylnetraGeneric Namepegfilgrastim-pbbkHCPCS CodeQ5130Policy NameColony Stimulating FactorsPolicy NumberMP-RX-FP-18-23
- Brand NameGammagardGeneric NameGammagard liquid injectionHCPCS CodeJ1569Policy NameImmunoglobulinsPolicy NumberMP-RX-FP-40-23
- Brand NameGammagard S/DGeneric NameImmune Globulin (Human) IVHCPCS CodeJ1566Policy NameImmunoglobulinsPolicy NumberMP-RX-FP-40-23
- Brand NameGammakedGeneric NameImmune Globulin (Human) IVHCPCS CodeJ3590Policy NameImmunoglobulinsPolicy NumberMP-RX-FP-40-23
- Brand NameGammaplexGeneric NameImmune Globulin (Human) IVHCPCS CodeJ3590Policy NameImmunoglobulinsPolicy NumberMP-RX-FP-40-23
- Brand NameGamunexGeneric NameImmune Globulin (Human) IVHCPCS CodeJ1561Policy NameImmunoglobulinsPolicy NumberMP-RX-FP-40-23
- Brand NameGazyvaGeneric NameObinutuzumabHCPCS CodeJ9301Policy NameObinutuzumab (Gazyva®)Policy NumberMP-RX-FP-33-23
- Brand NameGel-OneGeneric NameCross-Linked HyaluronateHCPCS CodeJ7326Policy NameHyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3]Policy NumberMP-RX-FP-38-23
- Brand NameGel-SynGeneric NameHyaluronan or derivative, for intra-articular injectionHCPCS CodeJ7328Policy NameHyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3]Policy NumberMP-RX-FP-38-23
- Brand NameGenVisc 850Generic NameSodium Hyaluronate (Viscosupplement)HCPCS CodeJ7320Policy NameHyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3]Policy NumberMP-RX-FP-38-23
- Brand NameGlassiaGeneric NameAlpha1-Proteinase Inhibitor (Human)HCPCS CodeJ0257Policy NameAlpha-1 Proteinase Inhibitor Therapy [Aralast, Glassia, Prolastin-C, Zemaira]Policy NumberMP-RX-FP-06-23
- Brand NameGrafapexGeneric NameTreosulfanHCPCS CodeC9175, J9999Policy NameTreosulfan (Grafapex)Policy NumberMP-RX-FP-174-25
- Brand NameGranixGeneric NameTbo-FilgrastimHCPCS CodeJ1447Policy NameColony Stimulating FactorsPolicy NumberMP-RX-FP-18-23
- Brand NameHaegardaGeneric NameC1 Esterase Inhibitor (Human)HCPCS CodeJ0599Policy NameHereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, OrladeyoPolicy NumberMP-RX-FP-36-23
- Brand NameHalavenGeneric NameEribulinHCPCS CodeJ9179Policy NameEribulin mesylate (Halaven®)Policy NumberMP-RX-FP-35-23
- Brand NameHemlibraGeneric NameEmicizumab-kxwhHCPCS CodeJ7170Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameHemofil-MGeneric NameAntihemophilic Factor (Human)HCPCS CodeJ7190Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameHeplisav-BGeneric NameHepatitis B Vaccine Recombinant AdjuvantedHCPCS Code90739Policy NameHepatitis B and Tetanus-Containing VaccinesPolicy NumberMP-RX-FP-156-24
- Brand NameHerceptinGeneric NameTrastuzumabHCPCS CodeJ9355Policy NameTrastuzumab – Trastuzumab BiologicsPolicy NumberMP-RX-FP-161-24
- Brand NameHerceptin HylectaGeneric NameTrastuzumab, and hyaluronidase-oyskHCPCS CodeJ9356Policy NameTrastuzumab – Trastuzumab BiologicsPolicy NumberMP-RX-FP-161-24
- Brand NameHercessiGeneric Nametrastuzumab-strfHCPCS CodeQ5146Policy NameTrastuzumab – Trastuzumab BiologicsPolicy NumberMP-RX-FP-161-24
- Brand NameHerzumaGeneric NameTrastuzumab-pkrbHCPCS CodeQ5113Policy NameTrastuzumab AgentsPolicy NumberMP-RX-FP-161-24
- Brand NameHizentraGeneric NameImmune Globulin (Human) IVHCPCS CodeJ1559Policy NameImmunoglobulinsPolicy NumberMP-RX-FP-40-23
- Brand NameHumalog®, Humulin®, Novolin®, Novolog®, Insulin Lispro®, Apidra Solostar®Generic NameInsulin Lispro or Aspart for insulin pump useHCPCS CodeJ1817, S5550, S5551Policy NameInfusion PumpsPolicy NumberLCD - External Infusion Pumps (L33794)
- Brand NameHumate-PGeneric NameAntihemophilic Factor/von Willebrand Factor Complex (Human)HCPCS CodeJ7187Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameHyalganGeneric NameSodium Hyaluronate (Viscosupplement)HCPCS CodeJ7321Policy NameHyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3]Policy NumberMP-RX-FP-38-23
- Brand NameHymovisGeneric NameHyaluronanHCPCS CodeJ7322Policy NameHyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3]Policy NumberMP-RX-FP-38-23
- Brand NameHymovis OneGeneric NameHyaluronanHCPCS CodeJ7322Policy NameHyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3]Policy NumberMP-RX-FP-38-23
- Brand NameHympavziGeneric Namemarstacimab-hncqHCPCS CodeJ7172Policy NameSelect Clotting Agents for Bleeding DisordersPolicy NumberMP-RX-FP-82-23
- Brand NameHyqviaGeneric NameImmune Globulin (Human)-Hyaluronidase (Human Recombinant)HCPCS CodeJ1575Policy NameImmunoglobulinsPolicy NumberMP-RX-FP-40-23
- Brand NameIdelvionGeneric NameCoagulation Factor IX Recomb Albumin Fusion Protein (rIX-FP)HCPCS CodeJ7202Policy NameAgents for Hemophilia BPolicy NumberMP-RX-FP-03-23
- Brand NameIlumyaGeneric NameTildrakizumab-asmnHCPCS CodeJ3245Policy NameMonoclonal Antibodies to Interleukin23 [Ilumya (tildrakizumab-asmn), Skyrizi (risankizumab-rzaa), Tremfya (guselkumab)]Policy NumberMP-RX-FP-61-23
- Brand NameIluvienGeneric NameFluocinolone acetonide intravitreal implantHCPCS CodeJ7313Policy NameIntravitreal Corticosteroid Implants: [Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant)]Policy NumberMP-RX-FP-43-23
- Brand NameImaavyGeneric NameNipocalimab-aahuHCPCS CodeJ9256Policy NameNipocalimab-aahu (Imaavy)Policy NumberMP-RX-FP-179-25
- Brand NameImdelltraGeneric NameTarlatamab-dlleHCPCS CodeJ9026Policy NameTarlatamab-dlle (Imdelltra)Policy NumberMP-RX-FP-171-25
- Brand NameImfinziGeneric NameDurvalumabHCPCS CodeJ9173Policy NameDurvalumab (Imfinzi®)Policy NumberMP-RX-FP-39-23
- Brand NameImjudoGeneric NameTremelimumab-actlHCPCS CodeJ9347Policy NameTremelimumab-actl (Imjudo®)Policy NumberMP-RX-FP-150-24
- Brand NameImuldosaGeneric NameUstekinumab, iv inject, 1 mgHCPCS CodeJ3358Policy NameUstekinumab agentsPolicy NumberMP-RX-FP-85-23
- Brand NameInfedGeneric NameIron dextranHCPCS CodeJ1750Policy NameIron AgentsPolicy NumberMP-RX-FP-44-23
- Brand NameInflectraGeneric NameInfliximab-dyybHCPCS CodeQ5103Policy NameTumor Necrosis Factor AntagonistsPolicy NumberMP-RX-FP-96-23
- Brand NameInfliximabGeneric NameInfliximabHCPCS CodeJ1745Policy NameTumor Necrosis Factor AntagonistsPolicy NumberMP-RX-FP-96-23
- Brand NameInjectaferGeneric NameFerric carboxymaltoseHCPCS CodeJ1439Policy NameIron AgentsPolicy NumberMP-RX-FP-44-23
- Brand NameInlexzoGeneric NameGemcitabine intravesical systemHCPCS CodeJ9183Policy NameGemcitabine intravesical system (Inlexzo)Policy NumberMP-RX-FP-185-26
- Brand NameIron sucroseGeneric NameIron sucroseHCPCS CodeJ1756Policy NameIron AgentsPolicy NumberMP-RX-FP-44-23
- Brand NameISTODAXGeneric NameRomidepsinHCPCS CodeJ9319Policy NameRomidepsin (Istodax®)Policy NumberMP-RX-FP-45-23
- Brand NameIXEMPRAGeneric NameIxabepiloneHCPCS CodeJ9207Policy NameIxabepilone (Ixempra®)Policy NumberMP-RX-FP-46-23
- Brand NameIxifiGeneric NameInfliximab-qbtxHCPCS CodeQ5109Policy NameTumor Necrosis Factor AntagonistsPolicy NumberMP-RX-FP-96-23
- Brand NameIxinityGeneric NameCoagulation Factor IX (Recombinant)HCPCS CodeJ7195Policy NameAgents for Hemophilia BPolicy NumberMP-RX-FP-03-23
- Brand NameIzervayGeneric NameAvacincaptad PegolHCPCS CodeC9160Policy NameAvacincaptad pegol intravitreal solution (Izervay®)Policy NumberMP-RX-FP-117-24
- Brand NameJemperliGeneric NameDostarlimab-gxlyHCPCS CodeJ9272Policy NameDostarlimab-gxly (Jemperli®)Policy NumberMP-RX-FP-119-24
- Brand NameJevtanaGeneric NameCabazitaxelHCPCS CodeJ9043, J9064Policy NameCabazitaxel (Jevtana®)Policy NumberMP-RX-FP-47-23
- Brand NameJiviGeneric NameAntihemophilic Factor (Recombinant) PEGylated-aucl (BDD-rFVIII PEG-aucl)HCPCS CodeJ7208Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameJobevneGeneric Namebevacizumab-malyHCPCS CodeQ5160Policy NameBevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, Zirabev and Avzivi)Policy NumberMP-RX-FP-13-23
- Brand NameJubbontiGeneric Namedenosumab-bbdzHCPCS CodeQ5136, J3590Policy NameIV Biphosphonate and Monoclonal Antibodies for Treatment of OsteoporosisPolicy NumberMP-RX-FP-123-24
- Brand NameKadcylaGeneric Nameado-trastuzumab emtansineHCPCS CodeJ9354Policy NameAdo-trastuzumab (Kadcyla®)Policy NumberMP-RX-FP-48-23
- Brand NameKalbitorGeneric NameEcallantideHCPCS CodeJ1290Policy NameHereditary Angioedema Agents: Cinryze, Haegarda, Berinet, Firazyr, Kalbitor, Ruconest, Takhzyro, OrladeyoPolicy NumberMP-RX-FP-36-23
- Brand NameKanjintiGeneric NameTrastuzumabHCPCS CodeQ5117Policy NameTrastuzumab AgentsPolicy NumberMP-RX-FP-161-24
- Brand NameKevzaraGeneric NameSarilumabHCPCS CodeC9399; J3490; J3590Policy NameMonoclonal Antibodies to Interlukin-6: tocilizumab (Actemra), sarilumab (Kevzara)Policy NumberMP-RX-FP-59-23
- Brand NameKeytrudaGeneric NamePembrolizumabHCPCS CodeJ9271Policy NamePembrolizumab (Keytruda®) and Pembrolizumab and Berahyaluronidase alfa-pmph (KEYTRUDA QLEX™)Policy NumberMP-RX-FP-49-23
- Brand NameKeytruda QlexGeneric NamePembrolizumab, berahyaluronidase alfaHCPCS CodeJ9277Policy NamePembrolizumab (Keytruda®) and Pembrolizumab and Berahyaluronidase alfa-pmph (KEYTRUDA QLEX™)Policy NumberMP-RX-FP-49-23
- Brand NameKimmtrakGeneric NameTebentafusp-tebnHCPCS CodeJ9274Policy NameTebentafusp-tebn (Kimmtrak®)Policy NumberMP-RX-FP-143-24
- Brand NamekimyrsaGeneric Nameoritavancin, 10mgHCPCS CodeJ2406Policy NameOritavancin (Orbactiv®, Kimyrsa®)Policy NumberMP-RX-FP-133-24
- Brand NameKisunlaGeneric NameDonanemab-azbtHCPCS CodeJ0175Policy NameDonanemab-azbt (Kisunla)
- Brand NameKoateGeneric NameAntihemophilic Factor (Human)HCPCS CodeJ7190Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameKoate-DVIGeneric NameAntihemophilic Factor (Human)HCPCS CodeJ7190Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameKogenate FSGeneric NameAntihemophilic Factor (Recombinant) (rFVIII)HCPCS CodeJ7192Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameKovaltryGeneric NameAntihemophilic Factor (Recombinant) Plasma/Albumin Free (rAHF-PFM)HCPCS CodeJ7211Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameKrystexxaGeneric NamePegloticaseHCPCS CodeJ2507Policy NameKrystexxa (pegloticase)Policy NumberMP-RX-FP-50-23
- Brand NameKymriahGeneric NameTisagenlecleucelHCPCS CodeQ2042Policy NameTisagenlecleucel (Kymriah®)
- Brand NameKyprolisGeneric NameCarfilzomibHCPCS CodeJ9047Policy NameCarfilzomib (Kyprolis®)Policy NumberMP-RX-FP-51-23
- Brand NameLanreotideGeneric NameLanreotide (cipla)HCPCS CodeJ1932Policy NameLanreotide (Somatuline Depot)Policy NumberMP-RX-FP-83-23
- Brand NameLemtradaGeneric NameAlemtuzumabHCPCS CodeJ0202Policy NameAlemtuzumab [Lemtrada]Policy NumberMP-RX-FP-52-23
- Brand NameLeqembiGeneric NameLecanemab-irmbHCPCS CodeJ0174Policy NameMonoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease (AD)
- Brand NameLeqvioGeneric NameInclisiran, 1 mgHCPCS CodeJ1306Policy NameInclisiran [Leqvio]Policy NumberMP-RX-FP-53-23
- Brand NameLeukineGeneric NameSargramostimHCPCS CodeJ2820Policy NameColony Stimulating FactorsPolicy NumberMP-RX-FP-18-23
- Brand NameLibtayoGeneric Namecemiplimab-rwlcHCPCS CodeJ9119Policy NameCemiplimab-rwlc (Libtayo®)Policy NumberMP-RX-FP-54-23
- Brand NameLoqtorziGeneric NameToripalimab-tpziHCPCS CodeJ3490, J3590, C9399Policy NameToripalimab-tpzi (Loqtorzi®)Policy NumberMP-RX-FP-147-24
- Brand NameLucentisGeneric NameRanibizumabHCPCS CodeJ2778Policy NameVascular Endothelial Growth Factor (VEGF) InhibitorsPolicy NumberMP-RX-FP-100-23
- Brand NameLumizymeGeneric Namealglucosidase alfaHCPCS CodeJ0221Policy NameAlglucosidase alfa (Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme®), and Cipaglucosidase alfa-atga (Pombiliti®)Policy NumberMP-RX-FP-124-24
- Brand NameLunsumioGeneric Namemosunetuzumab-axgbHCPCS CodeJ9350Policy NameMosunetuzumab-axgb (Lunsumio, Lunsumio Velo)Policy NumberMP-RX-FP-55-23
- Brand NameLunsumio VeloGeneric Namemosunetuzumab-axgbHCPCS CodeJ9350Policy NameMosunetuzumab-axgb (Lunsumio, Lunsumio Velo)Policy NumberMP-RX-FP-55-23
- Brand NameLupanetaGeneric NameLeuprolideHCPCS CodeJ1950Policy NameGnRH analogs for non-oncology and oncology-related indicationsPolicy NumberMP-RX-FP-34-23
- Brand NameLupron Depot (1-Month)Generic NameLeuprolideHCPCS CodeJ1950, J9217Policy NameGnRH analogs for non-oncology and oncology-related indicationsPolicy NumberMP-RX-FP-34-23
- Brand NameLupron Depot (3-Month)Generic NameLeuprolideHCPCS CodeJ1950, J9217Policy NameGnRH analogs for non-oncology and oncology-related indicationsPolicy NumberMP-RX-FP-34-23
- Brand NameLupron Depot (6-Month)Generic NameLeuprolideHCPCS CodeJ9217Policy NameGnRH analogs for non-oncology and oncology-related indicationsPolicy NumberMP-RX-FP-34-23
- Brand NameLutatheraGeneric Namelutetium Lu 177 dotatateHCPCS CodeA9513Policy NameRadioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra®, Lutathera®, Pluvicto®, Zevalin®)Policy NumberMP-RX-FP-137-24
- Brand NameLutrateGeneric NameLeuprolideHCPCS CodeJ1954Policy NameGnRH analogs for non-oncology and oncology-related indicationsPolicy NumberMP-RX-FP-34-23
- Brand NameLymphirGeneric NameDenileukin diftitox-cxdlHCPCS CodeC9399; J3490; J9999Policy NameDenileukin diftitox-cxdl (Lymphir)Policy NumberMP-RX-FP-158-24
- Brand NameLynozyficGeneric NameLinvoseltamab-gcptHCPCS CodeJ9201Policy NameLinvoseltamab-gcpt (LYNOZYFIC)Policy NumberMP-RX-FP-178-25
- Brand NameMargenzaGeneric NameMargetuximabHCPCS CodeJ9353Policy NameMargetuximab-cmkb (Margenza®)Policy NumberMP-RX-FP-56-23
- Brand NameMonjuviGeneric NameTafasitamabHCPCS CodeJ9349Policy NameTafasitamab-cxix (Monjuvi®)Policy NumberMP-RX-FP-57-23
- Brand NameMonoferricGeneric NameFerric derisomaltoseHCPCS CodeJ1437Policy NameIron AgentsPolicy NumberMP-RX-FP-44-23
- Brand NameMonoviscGeneric NameHyaluronanHCPCS CodeJ7327Policy NameHyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3]Policy NumberMP-RX-FP-38-23
- Brand NameMozobilGeneric NameplerixaforHCPCS CodeJ2562Policy NamePlerixafor (Mozobil®)Policy NumberMP-RX-FP-128-24
- Brand NameMvasiGeneric NameBevacizumabHCPCS CodeQ5107Policy NameBevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, Zirabev and Avzivi)Policy NumberMP-RX-FP-13-23
- Brand NameMvasi intravitrealGeneric Namebevacizumab-awwbHCPCS CodeQ5107Policy NameVascular Endothelial Growth Factor (VEGF) InhibitorsPolicy NumberMP-RX-FP-100-23
- Brand NameMYCOPHENOLATE MOFETIL ORALGeneric NameMycophenolate mofetilHCPCS CodeJ7517, J7528Policy NameImmunosuppressive DrugsPolicy NumberLCD - Immunosuppressive Drugs (L33824) (cms.gov)
- Brand NameMYCOPHENOLATE SODIUMGeneric NameMycophenolic acidHCPCS CodeJ7518Policy NameImmunosuppressive DrugsPolicy NumberLCD - Immunosuppressive Drugs (L33824) (cms.gov)
- Brand NameMylotargGeneric Namegemtuzumab ozogamicinHCPCS CodeJ9203Policy NameGemtuzumab ozogamicin (Mylotarg®)Policy NumberMP-RX-FP-62-23
- Brand NameMyoblocGeneric NameRimabotulinumtoxinBHCPCS CodeJ0587Policy NameBotulinum ToxinsPolicy NumberLCD: L33274 - Botulinum Toxins
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- Brand NameNeulastaGeneric NamePegfilgrastimHCPCS CodeJ2506Policy NameColony Stimulating FactorsPolicy NumberMP-RX-FP-18-23
- Brand NameNeupogenGeneric NameFilgrastimHCPCS CodeJ1442Policy NameColony Stimulating FactorsPolicy NumberMP-RX-FP-18-23
- Brand NameNexviazymeGeneric Nameavalglucosidase alfa-ngptHCPCS CodeJ0219Policy NameAlglucosidase alfa (Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme®), and Cipaglucosidase alfa-atga (Pombiliti®)Policy NumberMP-RX-FP-124-24
- Brand NameNiktimvoGeneric NameAxatilmab-csfrHCPCS CodeJ3590, C9399Policy NameAxatilmab-csfr (Niktimvo)Policy NumberMP-RX-FP-159-24
- Brand NameNivestymGeneric NameFilgrastim-aafiHCPCS CodeQ5110Policy NameColony Stimulating FactorsPolicy NumberMP-RX-FP-18-23
- Brand NameNovoeightGeneric NameAntihemophilic Factor VIII (Recombinant) BD Truncated (BD trunc-rFVIII)HCPCS CodeJ7182Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameNovoSeven RTGeneric NameCoagulation Factor VIIa (Recombinant)HCPCS CodeJ7189Policy NameSelect Clotting Agents for Bleeding DisordersPolicy NumberMP-RX-FP-82-23
- Brand NameNplateGeneric NameRomiplostimHCPCS CodeJ2796Policy NameRomiplostim (Nplate)Policy NumberMP-RX-FP-63-23
- Brand NameNucalaGeneric NameMepolizumabHCPCS CodeJ2182Policy NameMonoclonal Antibodies to Interleukin-5 [Cinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)]Policy NumberMP-RX-FP-58-23
- Brand NameNuwiqGeneric NameAntihemophilic Factor (Rcmb) Simoctocog alfa(BDD-rFVIII,sim)HCPCS CodeJ7209Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameNypoziGeneric Namefilgrastim-txidHCPCS CodeC9399, J3590Policy NameColony Stimulating FactorsPolicy NumberMP-RX-FP-18-23
- Brand NameNyvepriaGeneric NamePegfilgrastim-apgfHCPCS CodeQ5122Policy NameColony Stimulating FactorsPolicy NumberMP-RX-FP-18-23
- Brand NameObizurGeneric NameAntihemophilic Factor (Recombinant Porcine) (rpFVIII)HCPCS CodeJ7188Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameOcrevusGeneric NameOcrelizumabHCPCS CodeJ2350Policy NameOcrelizumab [Ocrevus®], Ocrelizumab/hyaluronidase-ocsq [Ocrevus Zunovo®]Policy NumberMP-RX-FP-64-23
- Brand NameOcrevus ZunovoGeneric NameOcrelizumab hyaluronidaseHCPCS CodeJ2351Policy NameOcrelizumab [Ocrevus®], Ocrelizumab/hyaluronidase-ocsq [Ocrevus Zunovo®]Policy NumberMP-RX-FP-64-23
- Brand NameOctagamGeneric NameImmune Globulin (Human) IVHCPCS CodePolicy NameImmunoglobulinsPolicy NumberMP-RX-FP-40-23
- Brand NameOctreotide AcetateGeneric NameOctreotide AcetateHCPCS CodeJ2354Policy NameOctreotide Agent (Bynfezia Pen, Sandostatin, Sandostatin LAR)Policy NumberMP-RX-FP-65-23
- Brand NameOgivriGeneric NameTrastuzumab-dkstHCPCS CodeQ5114Policy NameTrastuzumab AgentsPolicy NumberMP-RX-FP-161-24
- Brand NameOMLYCLOGeneric Nameomalizumab-igecHCPCS CodeQ5154Policy NameOmalizumab [Xolair]Policy NumberMP-RX-FP-105-23
- Brand NameOmvohGeneric NameMirikizumab-mrkzHCPCS CodeJ3590Policy NameMonoclonal Antibodies to Interleukin-23 [Ilumya® (tildrakizumab-asmn), Omvoh IV® (mirikizumab-mrkz), Skyrizi IV® (risankizumab-rzaa), Tremfya® IV (guselkumab)]Policy NumberMP-RX-FP-61-23
- Brand NameOntruzantGeneric Nametrastuzumab-dttbHCPCS CodeQ5112Policy NameTrastuzumab AgentsPolicy NumberMP-RX-FP-161-24
- Brand NameOpdivoGeneric NameNivolumabHCPCS CodeJ9299Policy NameNivolumab (Opdivo®) and Nivolumab and hyaluronidase-nvhy (Opdivo Qvantig®)Policy NumberMP-RX-FP-66-23
- Brand NameOpdivo QvantigGeneric NameNivolumab and hyaluronidase-nvhyHCPCS CodeJ9289Policy NameNivolumab (Opdivo®) and Nivolumab and hyaluronidase-nvhy (Opdivo Qvantig®)Policy NumberMP-RX-FP-66-23
- Brand NameOpdualagGeneric Namenivolumab and relatlimab-rmbwHCPCS CodeJ9298Policy NameNivolumab and relatlimab-rmbw (Opdualag®)Policy NumberMP-RX-FP-67-23
- Brand NameOpuvizGeneric NameafliberceptHCPCS CodeQ5153Policy NameVascular Endothelial Growth Factor (VEGF) InhibitorsPolicy NumberMP-RX-FP-100-23
- Brand NameorbactivGeneric Nameoritavancin, 10mgHCPCS CodeJ2407Policy NameOritavancin (Orbactiv®, Kimyrsa®)Policy NumberMP-RX-FP-133-24
- Brand NameOrenciaGeneric NameAbataceptHCPCS CodeJ0129Policy NameOrencia (abatacept)Policy NumberMP-RX-FP-68-23
- Brand NameOrthoviscGeneric NameHyaluronanHCPCS CodeJ7324Policy NameHyaluronan Injections: [Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Sodium hyaluronate , Synvisc/-One, Triluron, TriVisc, Visco-3]Policy NumberMP-RX-FP-38-23
- Brand NameOsenveltGeneric Namedenosumab-bmwoHCPCS CodeC9399, J3590Policy NameIV Biphosphonate and Monoclonal Antibodies for Treatment of OsteoporosisPolicy NumberMP-RX-FP-123-24
- Brand NameOspomyvGeneric Namedenosumab-dssbHCPCS CodeC9399, J3590Policy NameIV Biphosphonate and Monoclonal Antibodies for Treatment of OsteoporosisPolicy NumberMP-RX-FP-123-24
- Brand NameOtulfiGeneric NameUstekinumab-aauzHCPCS CodeQ9999Policy NameUstekinumab agentsPolicy NumberMP-RX-FP-85-23
- Brand NameOzurdexGeneric NameDexamethasone intravitreal implantHCPCS CodeJ7312Policy NameIntravitreal Corticosteroid Implants: [Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant)]Policy NumberMP-RX-FP-43-23
- Brand NamePACLitaxel Protein-Bound PartGeneric NamePaclitaxelHCPCS CodeJ9264, J9258, J9259Policy NamePaclitaxel, Protein Bound (Abraxane®)Policy NumberMP-RX-FP-69-23
- Brand NamePadcevGeneric NameEnfortumabHCPCS CodeJ9177Policy NameEnfortumab vedotin-ejfv (Padcev®)Policy NumberMP-RX-FP-70-23
- Brand NamePanzygaGeneric NameIvig non-lyophilized, nosHCPCS CodeJ1599Policy NameImmunoglobulinsPolicy NumberMP-RX-FP-40-23
- Brand NamePavbluGeneric Nameaflibercept-ayyhHCPCS CodeQ5147Policy NameVascular Endothelial Growth Factor (VEGF) InhibitorsPolicy NumberMP-RX-FP-100-23
- Brand NamePedmarkGeneric NameSodium Thiosulfate (Otoprotective)HCPCS CodeJ0208Policy NameSodium thiosulfate injection (Pedmark)Policy NumberMP-RX-FP-160-24
- Brand NamePemetrexedGeneric NamePemetrexedHCPCS CodeJ9314, J9322, J9323, J9294, J9296, J9297Policy NamePemetrexed (Alimta®, Axtle®, Pemfexy®, Pemrydi®)Policy NumberMP-RX-FP-05-23
- Brand NamePemfexyGeneric NamePemetrexedHCPCS CodeJ9304Policy NamePemetrexed (Alimta®, Axtle®, Pemfexy®, Pemrydi®)Policy NumberMP-RX-FP-05-23
- Brand NamePemrydiGeneric NamePemetrexedHCPCS CodeJ9324Policy NamePemetrexed (Alimta®, Axtle®, Pemfexy®, Pemrydi®)Policy NumberMP-RX-FP-05-23
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- Brand NamePhesgoGeneric Namepertuzumab, trastuzumab, and hyaluronidase-zzxfHCPCS CodeJ9316Policy NameTrastuzumab AgentsPolicy NumberMP-RX-FP-161-24
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- Brand NameXeominGeneric NameIncobotulinumtoxinAHCPCS CodeJ0588Policy NameBotulinum ToxinsPolicy NumberLCD: L33274 - Botulinum Toxins
- Brand NameXgevaGeneric NameDenosumabHCPCS CodeJ0897Policy NameIV Biphosphonate and Monoclonal Antibodies for Treatment of OsteoporosisPolicy NumberMP-RX-FP-123-24
- Brand NameXgevaGeneric NameDenosumabHCPCS CodeJ0897Policy NameBiphosphonates and Monoclonal Antibodies for Treatment of Osteoporosis: Denosumab (Prolia, Xgeva), Ibandronate IV (Boniva)
- Brand NameXiaflexGeneric NameCollagenase Clostridium HistolyticumHCPCS CodeJ0775Policy NameXiaflex (collagenase clostridium histolyticum) injectionPolicy NumberMP-RX-FP-104-23
- Brand NameXipereGeneric NameTriamcinolone acetonideHCPCS CodeJ3299Policy NameTriamcinolone acetonide injectable suspension [Xipere, Triesence]Policy NumberMP-RX-FP-93-23
- Brand NameXolairGeneric NameOmalizumabHCPCS CodeJ2357Policy NameOmalizumab [Xolair]Policy NumberMP-RX-FP-105-23
- Brand NameXynthaGeneric NameAntihemophilic Factor VIII (Recombinant) Moroctocog alfa(BDD-rFVIII,mor)HCPCS CodeJ7185Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameXyntha SolofuseGeneric NameAntihemophilic Factor VIII (Recombinant) Moroctocog alfa(BDD-rFVIII,mor)HCPCS CodeJ7192Policy NameAgents for Hemophilia A and Von Willebrand DiseasePolicy NumberMP-RX-FP-02-23
- Brand NameYartemleaGeneric NameNarsoplimab-wuugHCPCS CodeJ3590Policy NameNarsoplimab-wuug (Yartemlea)Policy NumberMP-RX-FP-188-26
- Brand NameAvlayahGeneric NameTividenofusp alfa-eknmHCPCS CodeJ3590Policy NameTividenofusp alfa-eknm (Avlayah)Policy NumberMP-RX-FP-189-26
- Brand NameDecnupazGeneric NamePivekimab sunirine-pvzyHCPCS CodeJ3490, J3590Policy NamePivekimab sunirine-pvzy (Decnupaz)Policy NumberMP-RX-FP-190-26
- Brand NameLoargysGeneric NamePegzilarginase-nblnHCPCS CodeJ3590Policy NamePegzilarginase-nbln (Loargys)Policy NumberMP-RX-FP-191-26
- Brand NameYervoyGeneric NameIpilimumabHCPCS CodeJ9228Policy NameIpilimumab (Yervoy®)Policy NumberMP-RX-FP-106-23
- Brand NameYesafiliGeneric NameafliberceptHCPCS CodeQ5155Policy NameVascular Endothelial Growth Factor (VEGF) InhibitorsPolicy NumberMP-RX-FP-100-23
- Brand NameYescartaGeneric Nameaxicabtagene ciloleucelHCPCS CodeQ2041Policy NameAxicabtagene ciloleucel (Yescarta®)
- Brand NameYesintekGeneric NameUstekinumab-kfceHCPCS CodeQ5100Policy NameUstekinumab agentsPolicy NumberMP-RX-FP-85-23
- Brand NameYondelisGeneric NameTrabectedinHCPCS CodeJ9352Policy NameTrabectedin (Yondelis®)Policy NumberMP-RX-FP-148-24
- Brand NameYutiqGeneric NameFluocinolone acetonide intravitreal implantHCPCS CodeJ7314Policy NameIntravitreal Corticosteroid Implants: [Iluvien (fluocinolone acetonide intravitreal), Retisert (fluocinolone acetonide intravitreal), Yutiq (fluocinolone acetonide intravitreal), Ozurdex (dexamethasone intravitreal implant)]Policy NumberMP-RX-FP-43-23
- Brand NameZaltrapGeneric NameAfliberceptHCPCS CodeJ9400Policy NameZiv-aflibercept (Zaltrap®)Policy NumberMP-RX-FP-107-23
- Brand NameZarxioGeneric NameFilgrastim-sndzHCPCS CodeQ5101Policy NameColony Stimulating FactorsPolicy NumberMP-RX-FP-18-23
- Brand NameZemairaGeneric NameAlpha1-Proteinase Inhibitor (Human)HCPCS CodeJ0256Policy NameAlpha-1 Proteinase Inhibitor Therapy [Aralast, Glassia, Prolastin-C, Zemaira]Policy NumberMP-RX-FP-06-23
- Brand NameZepzelcaGeneric NameLurbinectedinHCPCS CodeJ9223Policy NameLurbinectedin (Zepzelca®)Policy NumberMP-RX-FP-108-23
- Brand NameZevalin Y-90Generic NameIbritumomab TiuxetanHCPCS CodeA9543Policy NameRadioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra®, Lutathera®, Pluvicto®, Zevalin®)Policy NumberMP-RX-FP-137-24
- Brand NameZiextenzoGeneric NamePegfilgrastim-bmezHCPCS CodeQ5120Policy NameColony Stimulating FactorsPolicy NumberMP-RX-FP-18-23
- Brand NameZiiheraGeneric NameZanidatamab-hriiHCPCS CodeJ9276Policy NameZiihera (Zanidatamab-hrii)Policy NumberMP-RX-FP-167-25
- Brand NameZinplavaGeneric NameBezlotoxumabHCPCS CodeJ0565Policy NameBezlotoxumab (Zinplava)Policy NumberMP-RX-FP-109-23
- Brand NameZirabevGeneric NameBevacizumabHCPCS CodeQ5118Policy NameBevacizumab (Avastin and biosimilars Alymsys, Mvasi, Vegzelma, Zirabev and Avzivi)Policy NumberMP-RX-FP-13-23
- Brand NameZirabev intravitrealGeneric Namebevacizumab-bvzrHCPCS CodeQ5118Policy NameVascular Endothelial Growth Factor (VEGF) InhibitorsPolicy NumberMP-RX-FP-100-23
- Brand NameZoladexGeneric NameGoserelinHCPCS CodeJ9202Policy NameGnRH analogs for non-oncology and oncology-related indicationsPolicy NumberMP-RX-FP-34-23
- Brand NameZolgensmaGeneric NameOnasemnogene abeparvovec-xioiHCPCS CodeJ3399Policy NameOnasemnogene abeparvovec-xioi (Zolgensma)Policy NumberMP-RX-FP-186-26
- Brand NameZometaGeneric NameZoledronicHCPCS CodeJ3489Policy NameZoledronic acid (Zometa®)Policy NumberMP-RX-FP-130-24
- Brand NameZometaGeneric NameZoledronic AcidHCPCS CodeJ3489Policy NameBisphosphonates (Intravenous [IV]) and Monoclonal Antibodies in the Treatment of Osteoporosis and Their Other Indications
- Brand NameZusduriGeneric NameMitomycinHCPCS CodeJ9282Policy NameMitomycin (Zusduri)Policy NumberMP-RX-FP-176-25
- Brand NameZynlontaGeneric Nameloncastuximab tesirine-lpylHCPCS CodeJ9359Policy NameLoncastuximab tesirine-lpyl (Zynlonta®)Policy NumberMP-RX-FP-110-23
- Brand NameZynyzGeneric NameRetifanlimab-dlwrHCPCS CodeJ9345Policy NameRetifanlimab-dlwr (Zynyz®)Policy NumberMP-RX-FP-138-24
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Clinical Utilization Management Policies
The Medical Utilization Policies define how MMM Holdings LLC and its subsidiaries identify and evaluate requests for specific services and facilitate a consistent determination process in accordance with the regulations of the Centers for Medicare and Medicaid Services (CMS).
Medical Policy TitleMedical Policy Number
- Medical Policy TitleAdditional information available – please contact:Medical Policy Numberliz.roman@mso-pr.com and or sindia.Villegas@mso-pr.com
- Medical Policy TitleAntibiotic and Antifungal - Parenteral Therapy in the Home SettingMedical Policy NumberMP-OTHER-FP-01-25
- Medical Policy TitleAntiemetic - Parenteral Administration in Home SettingMedical Policy NumberMP-ME-FP-09-25
- Medical Policy TitleAuthorization of Services Unit - Clinical CriteriaMedical Policy NumberAuthorization of Services Unit - Clinical Criteria
- Medical Policy TitleCorticosteroid – Parenteral Administration in Home SettingMedical Policy NumberMP-ME-FP-08-25
- Medical Policy TitleGMT Medicare Crosswalk 2025Medical Policy NumberGMT Medicare Crosswalk 2025
- Medical Policy TitleH2 Antagonist - Intravenous Administration in Home SettingsMedical Policy NumberMP-ME-FP-06-25
- Medical Policy TitleHeart and Lung TransplantationMedical Policy NumberMP-SU-FP-05-25
- Medical Policy TitlePenile Prosthesis Implantation for Erectile Dysfunction (ED)Medical Policy NumberMP-SU-FP-06-26
- Medical Policy TitleHome Visits - Mental HealthMedical Policy NumberMP-EM-FP-04-25
- Medical Policy TitleMental Health Unit - Clinical CriteriaMedical Policy NumberMental Health Unit - Clinical Criteria
- Medical Policy TitleMolecular Testing Review CriteriaMedical Policy NumberMolecular Testing Review Criteria
- Medical Policy TitleOccupational, Speech and Physical Therapy GuidelinesMedical Policy NumberOccupational, Speech and Physical Therapy Guidelines
- Medical Policy TitleOphthalmic use of Nd YAG Laser for Posterior CapsulotomyMedical Policy NumberMP-SU-FP-04-25
- Medical Policy TitleProton Pump Inhibitors (PPIs) - Intravenous Administration in Home SettingMedical Policy NumberMP-ME-FP-07-25
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