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Clinical & Payment Policies

Clinical Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules.  They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies.  Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

All policies found in the PA Health & Wellness Clinical Policy Manual apply to PA Health & Wellness members. Policies in the PA Health & Wellness Clinical Policy Manual may have either a PA Health & Wellness or a “Centene” heading.  PA Health & Wellness utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a PA Health & Wellness clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling PA Health & Wellness. In addition, PA Health & Wellness may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or  InterQual®criteria is payable by PA Health & Wellness.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

A-H I-Q R-Z
Acupuncture (PDF) Intestinal and Multivisceral Transplant (PDF) Radial Head Implant (PDF)
Allergy Testing and Therapy (PDF) Intensity-modulated Radiotherapy (PDF) Reduction Mammoplasty and Gynecomastia Surgery (PDF)
Allogenic Hematopoietic Cell Transplants for Sickle Cell (PDF) Injections and Radiofrequency Neurotomy for Pain Management (PDF) Stereotactic Body Radiation Therapy (PDF)
Ambulatory Surgery Center Optimization (PDF) Laser Therapy for Skin Conditions (PDF) Spinal Cord Stimulation (PDF)
Balloon Sinus Ostial Dilation for Treatment of Chronic Sinusitis (PDF) Lysis of Epidural Lesions (PDF) Testing for Rupture of Fetal Membranes (PDF)
Bariatric Surgery (PDF) Non-Myeloablative Allogeneic Stem Cell Transplants (PDF) Ultrasound in Pregnancy (PDF)
Biofeedback (PDF) Medical Necessity Guidelines (PDF) Urinary Incontinence Devices and Treatments (PDF)
Cardiac Biomarker Testing (PDF) Multiple Sleep Latency Testing (PDF) Urodynamic Testing (PDF)
Carrier Screening in Pregnancy (PDF) Obstetrical Home Care Programs (PDF) Vagus Nerve Stimulation (PDF)
Cell-free Fetal DNA Testing (PDF) Optic Nerve Decompression Surgery (PDF) Ventricular Assist Devices (PDF)
Clinical Trials (PDF) Outpatient Testing for Drugs of Abuse (PDF) Ventriculectomy and Cardiomyoplasty (PDF)
Cochlear Implant Replacements (PDF) Pancreas Transplantation (PDF)  
Cosmetic and Reconstructive Surgery (PDF) Panniculectomy (PDF)  
Dental Anesthesia (PDF) Pediatric Heart Transplant (PDF)  
Digital EEG Spike Analysis (PDF) Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)  
Disc Decompression Procedures (PDF) Proton and Neutron Beam Therapy (PDF)  
Discography (PDF)    
DME and O&P Criteria (PDF)    
Donor Lymphocyte Infusion (PDF)    
EEG in the Evaluation of Headache (PDF)    
Electric Tumor Treating Fields (Optune) (PDF)    
Endometrial Ablation (PDF)    
EpiFix Wound Treatment (PDF)    
Essure Removal (PDF)    
Fecal Incontinence Treatments (PDF)    
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)    
Functional MRI (PDF)    
Gastric Electrical Stimulation (PDF)    
Gender Confirmation Surgery (PDF)    
Heart-Lung Transplant (PDF)    
Helicobacter Pylori Serology Testing (PDF)    
Holter Monitors (PDF)    
Home Sleep Testing (PDF)    
Homocysteine Testing (PDF)    
Hospice Services (PDF)    
Hyperemesis Gravidarum Treatment (PDF)    
A - H I - Q R - Z
Abaloparatide (Tymlos) (PDF) Ibandronate Oral (Boniva) (PDF) Ranolazine (Ranexa) (PDF)
Abemaciclib (Verzenio) (PDF) Ibandronate Sodium (Boniva) (PDF) Ranibizumab (Lucentis) (PDF)
Abiraterone (Zytiga) (PDF) Icatibant (Firazyr) (PDF) Ramucirumab (Cyramza) (PDF)
AbobotulinumtoxinA (Dysport) (PDF) IncobotulinumtoxinA (Xeomin) (PDF) Regorafenib (Stivarga) (PDF)
Acalabrutinib (Calquence) (PDF) Interferon beta-1b (Betaseron, Extavia) (PDF) Repository Corticotropin Injection (H.P. Acthar Gel) (PDF)
Adalimumab (Humira) (PDF) Iloprost (Ventavis) (PDF) Reslizumab (Cinqair) (PDF)
Ado-Trastuzumab (Kadcyla) (PDF) Infliximab (Remicade, Inflectra, Renflexis) (PDF) Ribociclib (Kisqali) (PDF)
Agalsidase Beta (Fabrazyme) (PDF) Inhaled Combination Long-acting Anticholinergic & Beta-2-agonist Agents (PDF) Riociguat (Adempas) (PDF)
Afatinib (Gilotrif) (PDF) Inotuzumab Ozogamicin (Besponsa) (PDF) Riociguat (Adempas) (PDF)
Aflibercept (Eylea) (PDF) Interferon beta-1a (Avonex, Rebif) (PDF) Rifapentine (Priftin) (PDF)
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) Interferon Gamma-1b (Actimmune) (PDF) Rifaximin (Xifaxan) (PDF)
Alectinib (Alecensa) (PDF) Imatinib (Gleevec) (PDF) Rilonacept (Arcalyst) (PDF)
Alemtuzumab (Lemtrada) (PDF) Immune Globulins (PDF) RimabotulinumtoxinB (Myobloc) (PDF)
Alglucosidase Alfa (Lumizyme) (PDF) Ipilimumab (Yervoy) (PDF) Riociguat (Adempas) (PDF)
Alirocumab (Praluent) (PDF) Irinotecan Liposome Injection (Onivyde) (PDF) Risedronate (Actonel Atelvia) (PDF)
Alpha-1 Proteinase Inhibitors (Aralast NP, Glassia,Prolastin-C, Zemaira) (PDF) Isotretinoin (Claravis, Absorica, Myorisan, Zenatane) (PDF)
Rituximab (Rituxan) (PDF)
Amantadine ER (Gocovri) (PDF) Iron Sucrose (Venofer) (PDF) Rivastigmine (Exelon) (PDF)
Anakinra (Kineret) (PDF) Ivabradine (Corlanor) (PDF) Rolapitant (Varubi) (PDF)
Anti-Allergy Ophthalmics (PDF) Ivacaftor (Kalydeco) (PDF) Romidepsin (Istodax) (PDF)
Anti-Inhibitor Coagulant Complex (Human - Feiba) (PDF) Ixazomib (Ninlaro) (PDF) Roflumilast (Daliresp) (PDF)
Antipsychotics (PDF) Ixekizumab (Taltz) (PDF) Romiplostim (Nplate) (PDF)
Ambrisentan (Letairis) (PDF) Lapatinib (Tykerb) (PDF) Rucaparib (Rubraca) (PDF)
Apalutamide (Erleada) (PDF) Latanoprostene Bunod (Vyzulta) (PDF) Ruxolitinib (Jakafi) (PDF)
Apremilast (Otezla) (PDF) Ledipasvir/Sofosbuvir (Harvoni) (PDF) Sacubitril-Valsartan (Entresto) (PDF)
Armodafinil (Nuvigil) (PDF) Lenalidomide (Revlimid) (PDF) Sapropterin Dihydrochloride (Kuvan) (PDF)
Asfotase Alfa (Strensiq) (PDF) Letermovir (Prevymis) (PDF) Sargramostim (Leukine) (PDF)
Atezolizumab (Tecentriq) (PDF) Lidocaine transdermal (Lidoderm) (PDF) Sebelipase Alfa (Kanuma) (PDF)
Atomoxetine (Strattera) (PDF) Lifitegrast (Xiidra) (PDF) Secnidazole (Solosec) (PDF)
Axicabtagene Ciloleucel (Yescarta) (PDF) Lindane Shampoo (PDF) Secukinumab (Cosentyx) (PDF)
Axitinib (Inlyta) (PDF) Linezolid (Zyvox) (PDF) Selexipag (Uptravi) (PDF)
Avelumab (Bavencio) (PDF) Lomitapide (Juxtapid) (PDF) Short Acting Narcotic Analgesics (PDF)
Aztreonam (Cayston) (PDF) Long Acting Narcotic Analgesics (PDF) Sildenafil (Revatio) (PDF)
Becaplermin (Regranex) (PDF) Lisdexamfetamine (Vyvanse) (PDF) Siltuximab (Sylvant) (PDF)
Belatacept (Nulojix) (PDF) Lumacaftor-Ivacaftor (Orkambi) (PDF) Simeprevir (Olysio) (PDF)
Belinostat (Beleodaq) (PDF) Nafarelin Acetate (Synarel) (PDF) Sipuleucel-T (Provenge) (PDF)
Belimumab (Benlysta) (PDF) Naltrexone (Vivitrol) (PDF) Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF)
Bendamustine (Bendeka, Treanda) (PDF) Natalizumab (Tysabri) (PDF) Sodium phenylbutyrate (Buphenyl) (PDF)
Benznidazole (PDF) Nilotinib (Tasigna) (PDF) Sodium Oxybate (Xyrem) (PDF)
Bevacizumab (Avastin) (PDF) Nintedanib (Ofev) (PDF) Sofosbuvir (Sovaldi) (PDF)
Bexarotene (Targretin) Capsules (PDF) Nivolumab (Opdivo) (PDF) Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (PDF)
Bezlotoxumab (Zinplava) (PDF) Nusinersen (Spinraza) (PDF) Sonidegib (Odomzo) (PDF)
Blinatumomab (Blincyto) (PDF) Macitentan (Opsumit) (PDF) Sorafenib (Nexavar) (PDF)
Bosentan (Tracleer) (PDF) Mecasermin (Increlex) (PDF) Suvorexant (Belsomra) (PDF)
Bosutinib (Bosulif) (PDF) Mepolizumab (Nucala) (PDF) Tadalafil (Adcirca) (PDF)
Brand Name Override (PDF) Mesalamine Oral Therapy (PDF) Taliglucerase Alfa (Elelyso) (PDF)
Brentuximab Vedotin (Adcetris) (PDF) Metformin ER (Glumetza) (PDF) Tasimelteon (Hetlioz) (PDF)
Brigatinib (Alunbrig) (PDF) Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) Tavaborole (Kerydin) (PDF)
Buprenorphine (Subutex) (PDF) Mifepristone (Korlym) (PDF) Tazarotene (Tazorac) (PDF)
Buprenorphine HCL (Probuphine Implant) (PDF) Miglustat (Zavesca) (PDF) Tedizolid (Sivextro) (PDF)
Buprenorphine-Naloxone (Suboxone, Bunavail, Zubsolv) (PDF) Minocycline (Solodyn) and Microspheres (Arestin) (PDF) Teduglutide (Gattex) (PDF)
C1 Esterase Inhibitors (Berinert, Cinryze, Ruconest) (PDF) Mipomersen (Kynamro) (PDF) Temsirolimus (Torisel) (PDF)
Cabazitaxel (Jevtana) (PDF) Modafinil (Provigil) (PDF) Teriflunomide (Aubagio) (PDF)
Cabozantinib (Cometriq, Cabometyx) (PDF) Obeticholic acid (Ocaliva) (PDF) Teriparatide (Forteo) (PDF)
Canakinumab (Ilaris) (PDF) Obinutuzumab (Gazyva) (PDF) Tesamorelin (Egrifta) (PDF)
Capecitabine (Xeloda) (PDF) Octreotide Acetate (Sandostatin Injection, Sandostatin LAR Depot) (PDF) Thalidomide (Thalomid) (PDF)
Carbamazepine ER (Equetro) (PDF) Off-Label Use (PDF) Tiludronate (Skelid) (PDF)
Carglumic acid (Carbaglu) (PDF) Olaparib (Lynparza) (PDF) Thyrotropin alfa (Thyrogen) (PDF)
Celecoxib (Celebrex) (PDF) Olaratumab (Lartruvo) (PDF) Tobramycin (Bethkis Inhalation Solution, Kitabis Pak, TOBI Inhalation Solution, TOBI Podhaler) (PDF)
Cerliponasa alfa (Brineura) (PDF) OnabotulinumtoxinA (Botox) (PDF) Tocilizumab (Actemra) (PDF)
Certolizumab (Cimzia) (PDF) Omacetaxine (Synribo) (PDF) Tofacitinib (Xeljanz/Xeljanz XR) (PDF)
Cetuximab (Erbitux) (PDF) Ombitasvir/Paritaprevir/Ritonavir (Technivie) (PDF) Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
Cinacalcet (Sensipar) (PDF) Omalizumab (Xolair) (PDF) Trabectedin (Yondelis) (PDF)
Clobazam (Onfi) (PDF) Omega-3-Acid Ethyl Esters (Lovaza) (PDF) Trametinib (Mekinist) (PDF)
Colchicine (Colcrys) (PDF) Oral Antiemetics (5-HT3 Antagonists) (PDF) Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF)
Collagenase Clostridium Histolyticum (Xiaflex) (PDF) Oral Bisphosphonates (PDF) Triptorelin Pamoate (Trelstar) (PDF)
Copanlisib (Aliqopa) (PDF) Ozenoxacin (Xepi) (PDF) Velaglucerase Alfa (VPRIV) (PDF)
Cosyntropin (Cortrosyn) (PDF) Palbociclib (Ibrance) (PDF) Vemurafenib (Zelboraf) (PDF)
Crizotinib (Xalkori) (PDF) Palivizumab (Synagis) (PDF) Vilazodone (Viibryd) (PDF)
Cyclosporine (Restasis) (PDF) Peginterferon Alfa-2b (PegIntron, Sylatron) (PDF) Vincristine Sulfate Liposome Injection (Marqibo) (PDF)
Dabigatran (Pradaxa) (PDF) Pembrolizumab (Keytruda) (PDF)  
Daclatasvir (Daklinza) (PDF) Pertuzumab (Perjeta) (PDF)  
Daclizumab (Zinbryta) (PDF) Pimavanserin (Nuplazid) (PDF)  
Dalfampridine (Ampyra) (PDF) Pirfenidone (Esbriet) (PDF)  
Dalteparin (Fragmin) (PDF) Plecanatide (Trulance) (PDF)  
Daratumumab (Darzalex) (PDF) Ponatinib (Iclusig) (PDF)  
Darbepoetin alfa (Aranesp) (PDF) Pralatrexate (Folotyn) (PDF)  
Dasabuvir, Ombitasvir, Paritaprevir, Ritonavir (Viekira XR, Viekira Pak) (PDF) Pramlintide (Symlin) (PDF)  
Deferoxamine (Desferal) (PDF) Prasterone (Intrarosa) (PDF)  
Deflazacort (Emflaza) (PDF) Protein C Concentrate, Human (Ceprotin) (PDF)  
Degarelix Acetate (Firmagon) (PDF) Pyrimethamine (Daraprim) (PDF)  
Denosumab (Prolia, Xgeva) (PDF)    
Desmopressin Acetate (DDAVP Injection) (PDF)    
Deutetrabenazine (Austedo) (PDF)    
Dexmethylphenidate ER (Focalin XR) (PDF)    
Dextromethorphan-Quinidine (Nuedexta) (PDF)    
Dimethyl fumarate (Tecfidera) (PDF)    
Dipeptidyl Peptidase - 4 (DPP-4) Inhibitors (PDF)    
Dornase Alfa (Pulmozyme) (PDF)    
Doxycline (Doryx, Oracea) (PDF)    
Droxidopa (Northera™) (PDF)    
Dupilumab (Dupixent) (PDF)    
Ecallantide (Kalbitor) (PDF)    
Eculizumab (Soliris) (PDF)    
Edaravone (Radicava) (PDF)    
Elbasvir/Grazoprevir (Zepatier) (PDF)    
Elosulfase Alfa (Vimizim) (PDF)    
Elotuzumab (Empliciti) (PDF)    
Eltrombopag (Promacta) (PDF)    
Enfuvirtide (Fuzeon) (PDF)    
Enzalutamide (Xtandi) (PDF)    
Epinephrine (EpiPen and EpiPen Jr) (PDF)    
Epoetin alfa (Epogen and Procrit) (PDF)    
Epoprostenol Sodium (Flolan, Veletri) (PDF)    
Eribulin Mesylate (Halaven) (PDF)    
Erwinia Asparaginase (Erwinaze) (PDF)    
Etanercept (Enbrel) (PDF)    
Eteplirsen (PDF)    
Etidronate (Didronel) (PDF)    
Everolimus (Afinitor, Afinitor Disperz) (PDF)    
Evolocumab (Repatha) (PDF)    
Exemestane (Aromasin) (PDF)    
Ezetimibe (Zetia) (PDF)    
Ezetimibe and Simvastain (Vytorin) (PDF)    
Factor IX (Human - Bebulin, Profilnine) (PDF)    
Factor IX (Human - AlphaNine SD, Mononine; Recombinant - Alprolix, BeneFIX, Ixinity, Rixubis) (PDF)    
Factor IX (Human, Recombinant) (PDF)    
Factor XIII (Human - Corifact) (PDF)    
Factor XIII A-Subunit (Recombinant - Tretten) (PDF)    
Factor VIII/von Willebrand Factor Complex (Human - Alphanate, Humate-P, Wilate) (PDF)    
Factor VIII (Human, Recombinant) (PDF)    
Factor VIIa (Recombinant - NovoSeven RT) (PDF)    
Febuxostat (Uloric) (PDF)    
Ferric Carboxymaltose (Injectafer) (PDF)    
Ferric Gluconate (Ferrlecit) (PDF)    
Ferumoxytol (Feraheme) (PDF)    
Filgrastim, Filgrastim-sndz, Tbo-filgrastim (PDF)    
Fluticasone/Salmeterol (Advair Diskus, Advair HFA) (PDF)    
Fingolimod (Gilenya) (PDF)    
Fondaparinux (Arixtra) (PDF)    
Galsulfase (Naglazyme) (PDF)    
Gefitinib (Iressa) (PDF)    
Gemtuzumab (Mylotarg) (PDF)    
Glatiramer Acetate (Copaxone, Glatopa) (PDF)    
Glecaprevir/Pibrentasvir (Mavyret) (PDF)    
Global Biopharm Criteria (PDF)    
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonistst (PDF)    
Glucagon-like peptide-1 receptor agonists for type 2 diabetes (PDF)    
Glycerol phenylbutyrate (Ravicti) (PDF)    
Golimumab (Simponi, Simponi Aria) (PDF)    
Goserelin Acetate (Zoladex) (PDF)    
Granisetron (Sancuso) (PDF)    
Hemin (Panhematin) (PDF)    
Histrelin Acetate (Vantas, Supprelin LA) (PDF)    
Hyaluronate Derivatives (PDF)    
Hydroxyprogesterone Caproate (Makena/compound) (PDF)