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Acthar Gel, Purified Cortrophin Gel) (CP.PHAR.168) (RETIRED - Ambetter August 1, 2023 (PDF) Durable Medical Equipment (TX.CP.MP.552) (RETIRED - Medicaid July 19, 2023) (PDF) Selpercatinib (Retevmo) (CP.PHAR.478) (RETIRED Medicaid June 1, 2023) (PDF) Sodium Phenylbutyrate-Taurursodiol (Relyvrio) (RETIRED Medicaid June 1, 2023) (CP.PHAR.584) (PDF) Ferric Gluconate (Ferrlecit) (CP.PHAR.166) (RETIRED Medicaid and Ambetter June 1, 2023) (PDF) Iron Sucrose (Venofer) (CP.PHAR.167) (RETIRED Medicaid and Ambetter June 1, 2023) (PDF) Casirivimab and imdevimab (REGN-COV2) (RETIRED Medicaid and Ambetter June 1, 2023) (CP.PHAR.520) (PDF) Bamlanivimab-etesevimab (LY-CoV555-LY-CoV016) (CP.PHAR.532) (RETIRED Medicaid and Ambetter June 1, 2023) (PDF) Sotrovimab (VIR-7831) (CP.PHAR.541) (RETIRED Medicaid and Ambetter June 1, 2023) (PDF) Tixagevimab-Cilgavimab (Evusheld) (CP.PHAR.571) (RETIRED Medicaid and Ambetter June 1, 2023) (PDF) Ultrasound in Pregnancy (CP.MP.38) (RETIRED Ambetter May 17, 2023) (PDF) Testing for Select Genitourinary Conditions (CP.MP.97) (RETIRED Ambetter and Medicaid May 17, 2023) (PDF) Endometrial Ablation (CP.MP.106) (RETIRED Ambetter May 17, 2023) (PDF) Bronchial Thermoplasty (CP.MP.110) (RETIRED Ambetter and Medicaid May 17, 2023) (PDF) Homocysteine Testing (CP.MP.121) (PDF) Laser Therapy for Skin Conditions (CP.MP.123) (RETIRED Ambetter May 17, 2023) (PDF) Low-frequency Ultrasound and Noncontact Wound Therapy (CP.MP.139) (RETIRED Ambetter and Medicaid May 17, 2023) (PDF) Polymerase Chain Reaction Respiratory Viral Panel Testing (CP.MP.181) (RETIRED Ambetter May 17, 2023) (PDF) Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (CP.MP.209) (RETIRED Ambetter and Medicaid May 17, 2023) (PDF) Pulmonary Function Testing (CP.MP.242) (RETIRED Ambetter May 17, 2023) (PDF) Holter Monitors (CP.MP.113) (RETIRED Ambetter May 17, 2023) (PDF) Evoked Potentials (CP.MP.134) (RETIRED Ambetter May 17, 2023) (PDF) Incontinence Supplies (TX.CP.MP.508) (RETIRED Medicaid June 1, 2023) (PDF) Allergy Testing and Therapy (TX.CP.MP.100) (RETIRED Ambetter and Medicaid May 4, 2023) (PDF) Antithrombin III (Thrombate III, Atryn) (CP.MP.179) (RETIRED Ambetter and Medicaid May 4, 2023) (PDF) Burn Surgery (CP.MP.186) (RETIRED Ambetter and Medicaid May 4, 2023) (PDF) Cell-free Fetal DNA Testing (CP.MP.84) (RETIRED Ambetter and Medicaid May 4, 2023) (PDF) Drugs of Abuse: Presumptive Testing (CP.MP.208) (RETIRED Ambetter and Medicaid May 4, 2023) (PDF) EpiFix Wound Treatment (CP.MP.140) (RETIRED Medicaid May 4, 2023) (PDF) Essure Removal (CP.MP.131) (RETIRED Ambetter May 4, 2023) (PDF) Evinacumab-dgnb (Evkeeza) (CP.PHAR.511) (PDF) Fertility Preservation (CP.MP.130) (PDF) Fixed Wing Air Transportation (CP.MP.175) (RETIRED Medicaid May 4, 2023) (PDF) Fractional Exhaled Nitric Oxide (CP.MP.103) (RETIRED Medicaid May 4, 2023) (PDF) Global Maternity Billing (CC.PP.016) (RETIRED Medicaid May 4, 2023) (PDF) Functional MRI (CP.MP.43) (RETIRED Ambetter May 4, 2023) (PDF) Home Births (CP.MP.136) (RETIRED Ambetter and Medicaid May 4, 2023) (PDF) Hyperemesis Gravidarum Treatment (CP.MP.34) (RETIRED Ambetter May 4, 2023) (PDF) Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (CP.MP.180) (RETIRED Medicaid May 4, 2023) (PDF) Long Term Care Placement Criteria (CP.MP.71) (RETIRED Medicaid May 4, 2023) (PDF) Multiple Sleep Latency Testing (CP.MP.24) (RETIRED Ambetter and Medicaid May 4, 2023) (PDF) Neuromuscular Electrical Stimulation (CP.MP.48) (RETIRED Medicaid May 4, 2023) (PDF) Non-Invasive Home Ventilator (CP.MP.184) - for CHIP only (RETIRED Medicaid May 4, 2023) (PDF) Private Duty Nursing (TX.CP.MP.520) (RETIRED Ambetter May 4, 2023) (PDF) Proton and Neutron Beam Therapy (CP.MP.70) (RETIRED Medicaid May 4, 2023) (PDF) Radiofrequency Ablation of Uterine Fibroids (CP.MP.187) (RETIRED Ambetter May 4, 2023) (PDF) Renal Hemodialysis (CC.PP.067) (RETIRED Ambetter and Medicaid May 4, 2023) (PDF) Selective Dorsal Rhizotomy (RETIRED Ambetter May 4, 2023) (CP.MP.174) (PDF) Short Inpatient Hospital Stay (TX.CP.MP.582) (RETIRED Ambetter May 4, 2023) (PDF) Sickle Cell Disease Observation (CP.MP.88) (RETIRED Ambetter and Medicaid May 4, 2023) (PDF) Therapy Services (PT, OT, ST) (CP.MP.49) (RETIRED Medicaid May 4, 2023) (PDF) Transcatheter Closure of Patent Foramen Ovale (CP.MP.151) (RETIRED Ambetter and Medicaid May 4, 2023) (PDF) Wheelchair Seating (CP.MP.99) (RETIRED Medicaid May 4, 2023) (PDF)Hydroxyprogesterone caproate (Makena) (CP.PHAR.14) - RETIRED (Ambetter April 10, 2022) (PDF) Makena Clinical Criteria for Authorization via Medical Benefit (TX.PHAR.15) - RETIRED (Medicaid April 10, 2022) (PDF) Hyperemesis Gravidarum Treatment (CP.MP.34) - RETIRED (Medicaid and Ambetter March 22, 2023 (PDF) Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) - RETIRED (Medicaid March 1, 2023) (CP.PHAR.211) (PDF) Protein C Concentrate Human (Ceprotin) (CP.PHAR.330) - RETIRED (Medicaid March 1, 2023) (PDF) Enzalutamide (Xtandi) (HIM.PA.164) - RETIRED (Ambetter March 1, 2023) (PDF) Evinacumab-dgnb (Evkeeza) (CP.PHAR.511) - RETIRED (Ambetter March 1, 2023) (PDF) Latanoprostene Bunod (Vyzulta) (CP.PMN.108)- RETIRED (Ambetter March 1, 2023) (PDF) Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan) (CP.PMN.118)- RETIRED (Ambetter March 1, 2023) (PDF) Pegaptanib (Macugen) (CP.PHAR.185)- RETIRED (Medicaid and Ambetter March 1, 2023) (PDF) Genetic and Pharmacogenetic Testing (CP.MP.89) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing: Aortopathies and Connective Tissue Disorders (CP.MP.215) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing Cardiac Disorders (CP.MP.216) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing: Dermatologic Conditions (CP.MP.217) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing Epilepsy, Neurodegenerative, and Neuromuscular Disorders (CP.MP.218) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (CP.MP.219) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing Eye Disorders (CP.MP.220) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing Gastroenterologic Disorders (non-cancerous) (CP.MP.221) Genetic Testing General Approach to Genetic Testing (CP.MP.222) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing Hearing Loss (CP.MP.223) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing Hematologic Condition (non-cancerous) (CP.MP.224) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing Hereditary Cancer Susceptibility (CP.MP.225) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing Immune, Autoimmune, and Rheumatoid Disorders (CP.MP.226) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing Lung Disorders (CP.MP.228) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing Metabolic, Endocrine, and Mitochondrial Disorders (CP.MP.229) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (CP.MP.230) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing for Non-Invasive Prenatal Screening (NIPS) (CP.MP.231) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing Pharmacogenetics (CP.MP.232) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing Preimplantation Genetic Testing (CP.MP.233) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing Prenatal and Preconception Carrier Screening (CP.MP.234) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing Prenatal Diagnosis (Via Amniocentises, CVS, or PUBS) and Pregnancy Loss (CP.MP.235) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Genetic Testing Skeletal Dysplasia and Rare Bone Disorders (CP.MP.236) - RETIRED (Medicaid and Ambetter February 20, 2023 (PDF) Patisiran (Onpattro) (CP.PHAR.395) - RETIRED (Medicaid February 7, 2023) (PDF) PROM Testing (CP.MP.149) - RETIRED (Medicaid and Ambetter January 16, 2023) (PDF) Ambulatory EEG (CP.MP.96) - RETIRED (Medicare January 16, 2023) (PDF) Measure Serum 1,25 Vitamin D (CP.MP.152) - RETIRED (Medicare January 16, 2023) (PDF) Holter Monitors (CP.MP.113) - RETIRED (Medicare January 16, 2023) (PDF) Genetic Testing (TX.CP.MP.531) - RETIRED (Medicaid January 1, 2023) (PDF) Pharmacogenetic Testing - RETIRED (Medicaid January 1, 2023) (TX.CP.MP.528) (PDF) Podiatry Services (TX.CP.MP.527) - RETIRED (Medicaid October 17, 2022) (PDF) Compounded Medications (CP.PCH.27) - RETIRED (Ambetter September 1, 2022) (PDF) Lactitol (Pizensy) (CP.PMN.241) - RETIRED (Ambetter September 1, 2022) (PDF) Valproate (Depacon) (CP.PHAR.429) -- RETIRED (Medicaid and Ambetter September 1, 2022) (PDF) Home Cardiorespiratory Monitors (TX.CP.MP.501) - RETIRED (Medicaid August 15, 2022)(PDF) Nebivolol (Bystolic) (HIM.PA.131) - RETIRED (Ambetter June 1, 2022) (PDF) Natalizumab (Tysabri) (HIM.PA.SP17) - RETIRED (Ambetter June 1, 2022) (PDF) Lorcaserin (Belviq, Belviq XR) (CP.PCH.03) - RETIRED (Ambetter June 1, 2022) (PDF) Thymus Transplantation (CP.MP.189) - RETIRED (Medicaid and Ambetter April 28, 2022)(PDF) Ambulatory EEG (CP.MP.96) (Medicaid and Ambetter April 28, 2022) (PDF) Lesinurad (Zurampic), Lesinurad-allopuriNol (Duzallo) (CP.PMN.150) - RETIRED (Ambetter March 1, 2022) (PDF) Cerliponase alfa (Brineura) (TX.PHAR.46) - RETIRED (Medicaid January 24, 2022)(PDF) Ivermectin (Sklice) (HIM.PA.124) - RETIRED (Ambetter February 1, 2022) (PDF) Velaglucerase Alfa (VPRIV) (CP.PHAR.163) - RETIRED (Ambetter February 1, 2022) (PDF) Taliglucerase Alfa (Elelyso) (CP.PHAR.157) - Effective January 15, 2021 (PDF) Chlorambucil (Leukeran) (HIM.PA.SP59) - RETIRED (Ambetter February 1, 2022) (PDF) Anifrolumab-fnia (Saphnelo) (CP.PHAR.551) - RETIRED (Medicaid February 1, 2022) Fractional Exhaled Nitric Oxide (CP.MP.103) (PDF) - RETIRED (Medicaid January 26, 2022) Pegademase Bovine (Adagen) (CP.PHAR.392) - RETIRED (Medicaid and Ambetter December 1, 2021 (PDF) Human Growth Hormone (Somapacitan, Somatropin) (CP.PCH.39) - RETIRED (Ambetter December 1, 2021) (PDF) Bremelanotide (Vyleesi) (CP.PHAR.434) - RETIRED (Ambetter December 1, 2021) (PDF) DNA Analysis of Stool (CP.MP.125) - RETIRED (Medicaid and Ambetter November 18, 2021) (PDF) Handling Authorizations for Transportation (TX.UM.10.07) - RETIRED (Medicaid November 1, 2021 (PDF) Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (CP.PHAR.385) (PDF) - RETIRED (Medicaid October 18, 2021) Abatacept (Orencia) (CP.PHAR.241) (PDF) - RETIRED (Medicaid October 18, 2021) Alglucosidase Alfa (Lumizyme) (CP.PHAR.160) (PDF) - RETIRED (Medicaid October 18, 2021) Benralizumab (Fasenra) (CP.PHAR.373) (PDF) - RETIRED (Medicaid October 18, 2021) Brexucabtagene Autoleucel (Tecartus) (CP.PHAR.472) (PDF) - RETIRED (Medicaid October 18, 2021) Brexucabtagene Autoleucel (Tecartus) (CP.PHAR.472) (PDF) - RETIRED (Medicaid October 18, 2021) Crizanlizumab-tmca (Adakveo) (CP.PHAR.449) (PDF) - RETIRED (Medicaid October 18, 2021) Emapalumab-lzsg (Gamifant) (CP.PHAR.402) - RETIRED (Medicaid October 18, 2021) (PDF) Treprostinil (Orenitram, Remodulin, Tyvaso) (CP.PHAR.199) - RETIRED (Medicaid October 18, 2021) (PDF) Ibalizumab-uiyk (Trogarzo) (CP.PHAR.378) - RETIRED (Medicaid October 18, 2021) (PDF) Inebilizumab-cdon (Uplizna) (CP.PHAR.458) - RETIRED (Medicaid October 18, 2021) (PDF) Luspatercept-aamt (Reblozyl) (CP.PHAR.450) - RETIRED (Medicaid October 18, 2021)(PDF) Mepolizumab (Nucala) (CP.PHAR.200) - RETIRED (Medicaid October 18, 2021) (PDF) Mogamulizumab-kpkc (Poteligeo) (CP.PHAR.139) - RETIRED (Medicaid October 18, 2021) (PDF) Moxetumomab Pasudotox-tdfk (Lumoxiti) (CP.PHAR.398) - RETIRED (Medicaid October 18, 2021)(PDF) Omalizumab (Xolair) (CP.PHAR.01) - RETIRED (Medicaid October 18, 2021) (PDF) Patisiran (Onpattro) (CP.PHAR.395) - RETIRED (Medicaid October 18, 2021) (PDF) Reslizumab (Cinqair) (CP.PHAR.223) - RETIRED (Medicaid October 18, 2021) (PDF) Teprotumumab (Tepezza) (CP.PHAR.465) - Effective 9/16/2020 (PDF) Vestronidase alfa-vjbk (Mepsevii) (CP.PHAR.374) - Effective January 9, 2018 (PDF) Plecanatide (Trulance) (CP.PMN.87) - RETIRED (Ambetter Septebmer 23, 2021) Sipuleucel-T (Provenge) (CP.PHAR.120) - RETIRED (Ambetter August 2, 2021) Carrier Screening in Pregnancy (CP.MP.83) (PDF) - RETIRED (Medicaid July 30, 2021) Evolocumab (Repatha) (CP.PHAR.123) - Effective 10/1/2015 (PDF) RETIRED (Ambetter June 1, 2021) Continuous Insulin Delivery Systems (V-Go, Omnipod) (CP.PHAR.505) - Effective 12/1/2020 (PDF) RETIRED (Ambetter June 1, 2021) Prucalopride (Motegrity) (CP.PMN.194) - Effective January 29, 2019 (PDF) RETIRED (Ambetter June 1, 2021) Pralsetinib (Gavreto) (CP.PHAR.514) - Effective 2/1/2021 (PDF) RETIRED (Ambetter June 1, 2021) Lemborexant (Dayvigo) (CP.PMN.233) - Effective 6/1/2020 (PDF) RETIRED (Ambetter June 1, 2021) Budesonide (Pulmicort Respules) (HIM.PA.48) - Effective 9/1/2018 (PDF) RETIRED (Ambetter May 3, 2021) Budesonide/Glycopyrrolate/Formoterol Fumarate (Breztri Aerosphere) (HIM.PA.150) - Effective 12/1/2020 (PDF) RETIRED (Ambetter May 3, 2021) Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone) (HIM.PA.35) - Effective 2/1/2017 (PDF) RETIRED (Ambetter May 3, 2021) Ciclesonide (Alvesco) (HIM.PA.65) - Effective 11/17/2020 (PDF) RETIRED (Ambetter May 3, 2021) Indacaterol/Glycopyrrolate (Utibron Neohaler) (HIM.PA.102) - Effective 1/1/2021 (PDF) RETIRED (Ambetter May 3, 2021) Aclidinium/Formoterol (Duaklir Pressair) (CP.PCH.23) - Effective 9/16/2020 (PDF) RETIRED (Ambetter 3/1/2021) Eptinezumab (Vyepti) (CP.PCH.29) - Effective 6/1/2011 (PDF) RETIRED (Ambetter 1/1/2021) Fremanezumab-vfrm (Ajovy) (CP.PCH.17) - Effective 3/1/2020 (PDF) RETIRED (Ambetter 1/1/2021) Applied Behavioral Analysis for Autism (CP.MP.104) (PDF) RETIRED (Ambetter 12/30/2020) Cell-free Fetal DNA Testing (CP.MP.84) (PDF) RETIRED (Ambetter 12/30/2020) Neonatal Abstinence Syndrome Guidelines (CP.MP.86) (PDF) RETIRED (Ambetter 12/30/2020) Genetic Testing (TX.CP.MP.531) (PDF) RETIRED (Medicaid and CHIP 12/30/2020) Enteral Nutrition (TX.CP.MP.550) (PDF) RETIRED (Medicaid and CHIP 12/30/2020) Magnetoencephalography (TX.CP.MP.570) RETIRED (Medicaid and CHIP 12/30/2020) Antithymocyte Globulin (Thymoglobulin, Atgam) (HIM.PA.16) - RETIRED (Ambetter - 12/1/2020) Ciprofloxacin/Dexamethasone (Ciprodex) (HIM.PA.120) - Effective 12/1/2017 (PDF) - RETIRED (Ambetter - 12/1/2020) Ciprofloxacin/Fluocinolone (Otovel) (HIM.PA.14) - Effective 9/4/2018 (PDF) - RETIRED (Ambetter - 12/1/2020) Clindamycin (Evoclin) (HIM.PA.21) - Effective 8/28/2018 (PDF) - RETIRED (Ambetter - 12/1/2020) Clindamycin Phosphate/Benzoyl Peroxide (BenzaClin) (HIM.PA.31) - Effective 12/1/2018 (PDF) - RETIRED (Ambetter - 12/1/2020) Colesevelam (WelChol) (HIM.PA.121) - Effective 12/1/2017 (PDF) - RETIRED (Ambetter - 12/1/2020) Insulin Infusion Pump (Omnipod, Omnipod DASH) (CP.PHAR.420) - Effective 4/23/2019 (PDF) - RETIRED (Ambetter - 12/1/2020) Lomustine (Gleostine) (HIM.PA.19) - Effective 8/28/2018 (PDF) - RETIRED (Ambetter - 12/1/2020) Mesalamine (Apriso) (HIM.PA.42) - Effective 9/4/2018 (PDF) - RETIRED (Ambetter - 12/1/2020) Topical Diclofenac (Solaraze, Flector) (HIM.PA.123) (PDF) - RETIRED (Ambetter - 12/1/2020) Apomorphine (Apokyn) (CP.PCH.14) (PDF) - RETIRED (Ambetter - 11/17/2020) Brivaracetam (Briviact) (HIM.PA.07) (PDF) - RETIRED (Ambetter - 11/17/2020) Daclatasvir (Daklinza) (CP.PCH.15) (PDF) - RETIRED (Ambetter - 11/17/2020) Elbasvir/Grazoprevir (Zepatier) (CP.PCH.16) (PDF) - RETIRED (Ambetter - 11/17/2020) Ledipasvir/Sofosbuvir (Harvoni) (CP.PCH.19) (PDF) - RETIRED (Ambetter - 11/17/2020) Sofosbuvir (Sovaldi) (CP.PCH.20) (PDF) - RETIRED (Ambetter - 11/17/2020) Topical Diclofenac (Solaraze, Flector) (HIM.PA.123) (PDF) - RETIRED (Ambetter - 11/17/2020) Trigger Point Injections for Pain Management (CP.MP.169) (PDF) - RETIRED (Ambetter - 10/30/2020) Facet Joint Interventions for Pain Management (CP.MP.171) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 10/1/2020) Fecal Incontinence Treatments (CP.MP.137) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 10/1/2020) Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 10/1/2020) Neonatal Sepsis Management Guidelines (CP.MP.85) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 10/1/2020) Physicians Office Lab Testing (CC.PP.055) (PDF) IMPLEMENTATION CANCELLED Monitored Anesthesia Care for Gastrointestinal Endoscopy - Effective 1/15/19 (CP.MP.161) PDF) - RETIRED (Medicaid and CHIP - 7/18/2019, Medicare - 7/22/2019, MarketPlace - 7/22/2019) Rituximab - Effective 11/1/2017 (CP.PHAR.260) (PDF) - RETIRED (Medicaid and CHIP, Medicare, Ambetter - 1/1/ 2019) Halobetasol-Tazarotene (Duobrii) (CP.PMN.208) (PDF) - RETIRED (Ambetter - 6/1/2020) Naloxone (Evzio) (CP.PMN.139) (PDF) - RETIRED (Ambetter - 6/1/2020) Sodium Zirconium Cyclosilicate (Lokelma) (CP.PMN.163) (PDF) - RETIRED (Ambetter - 6/1/2020) Digital Breast Tomosynthesis (DBT) (CP.MP.90) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 10/5/2018) Fecal Calprotectin Assay (CP.MP.135) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 12/14/2018) Assertive Community Treatment (TX.CP.MP.548) (PDF) - RETIRED (Medicaid and CHIP - 3/20/2020) Home Telemonitoring Services (TX.CP.MP.547) (PDF) - RETIRED (Medicaid and CHIP - 3/18/2020) Standard Manual Wheelchair or Standard Power Wheeled Mobility Systems (TX.CP.MP.519) (PDF) - RETIRED (Medicaid and CHIP - 4/15/2020) Emtricitabine-Tenofovir (Truvada) (HIM.PA.78) - RETIRED (Ambetter - 9/16/2020) Glecaprevir/Pibrentasvir (Mavyret) (CP.PCH.18) - RETIRED (Ambetter - 9/16/2020) Sofosbuvir/Velpatasvir (Epclusa) (CP.PCH.21) - RETIRED (Ambetter - 9/16/2020) Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (CP.PCH.22) - RETIRED (Ambetter - 9/16/2020) Erenumab-aaoe (Aimovig) (CP.PHAR.128) - Effective 7/10/2018 (PDF) - RETIRED (Ambetter - 10/6/2020) Galcanezumab-gnlm (Emgality) (CP.PCH.24) - Effective 1/1/2020 (PDF) - RETIRED (Ambetter - 10/6/2020) Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (CP.MP.241) (PDF) - RETIRED (Ambetter, Medicaid and CHIP 02/26/2024) Oncology Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (CP.MP.239) (PDF) - RETIRED (Ambetter, Medicaid and CHIP 02/26/2024) Oncology Algorithmic Testing (CP.MP.237) (PDF) - RETIRED (Ambetter, Medicaid and CHIP 02/26/2024) Oncology Cytogenetic Testing (CP.MP.240) (PDF) - RETIRED (Ambetter, Medicaid and CHIP 02/26/2024) Oncology Cancer Screening (CP.MP.238) (PDF) - RETIRED (Ambetter, Medicaid and CHIP 02/26/2024) Hyaluronate Derivatives (CP.PHAR.05) (PDF) - RETIRED (Medicaid and CHIP - 03/01/2024) Goserelin Acetate (Zoladex) (CP.PHAR.171) (PDF) - RETIRED (Medicaid and CHIP - 03/01/2024) Hyperemesis Gravidarum Treatment (TX.CP.MP.534)(PDF) - RETIRED (Medicaid and CHIP - 03/20/2024) Cranial Remolding Orthosis (TX.CP.MP.516) (PDF) - RETIRED (Medicaid and CHIP - 04/15/2024) Home Phototherapy (TX.CP.MP.510) (PDF) - RETIRED (Medicaid and CHIP - 04/15/2024) H Pylori Testing (CP.MP.153) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 06/01/2024) Testing for Select Genitourinary Conditions (CP.MP.97) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 06/01/2024) Polymerase Chain Reaction Respiratory Viral Panel Testing (CP.MP.181) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 06/01/2024) Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (CP.MP.209) (PDF) - RETIRED (Ambetter, Medicaid and CHIP - 06/01/2024) Transcatheter Closure of Patent Foramen Ovale (CP.MP.151) (PDF) - RETIRED (Medicaid and CHIP - 11/20/2024) Burn Surgery (CP.MP.186) (PDF) - RETIRED (Medicaid and CHIP - 12/10/2024) Discography (CP.MP.115) (PDF) - RETIRED (Medicaid and CHIP - 12/10/2024) Gender-Affirming Procedures (CP.MP.95) (PDF) - RETIRED (Medicaid and CHIP - 12/10/2024) (Ambetter - 5/14/2026) Home Birth (CP.MP.136) (PDF) - RETIRED (Medicaid and CHIP - 12/10/2024) Intensity-Modulated Radiotherapy (CP.MP.69) (PDF) - RETIRED (Medicaid and CHIP - 12/10/2024) Intradiscal Steroid Injections for Pain Management (CP.MP.167) (PDF) - RETIRED (Medicaid and CHIP - 12/10/2024) Kidney Disorders (CP.MP.227) - RETIRED (Medicaid and CHIP - 12/10/2024) Multiple Sleep Latency Testing (CP.MP.24) (PDF) - RETIRED (Medicaid and CHIP - 12/10/2024) Renal Hemodialysis (CC.PP.067) (PDF) - RETIRED (Medicaid and CHIP - 12/10/2024) Repair of Nasal Valve Compromise (CP.MP.210) (PDF) - RETIRED (Medicaid and CHIP - 12/10/2024) Wireless Motility Capsule (CP.MP.143) (PDF) - RETIRED (Medicaid December 30, 2024) Flibanserin (Addyi) (CP.PHAR.446) (PDF) - RETIRED (Ambetter February 10, 2025) Influenza Testing (TX.CP.MP.115) (PDF) - RETIRED (Medicaid February 14, 2025) Erenumab-aooe (Aimovig) (CP.PHAR.128) (PDF) - RETIRED (Mediciad March 01, 2025) EpiFix Wound Treatment (CP.MP.140) (PDF) - RETIRED (Ambetter March 27, 2025) Bariatric Surgery (CP.MP.37) (PDF) - RETIRED (MEDICIAD December 18, 2025) Leveling of Emergency Room Services - Professional (CC.PP.053) (PDF) - RETIRED (AMBETTER, MEDICAID and CHIP Febuary 2, 2026) Intensity-Modulated Radiotherapy (CP.MP.69) (PDF) - RETIRED (Ambetter March 31, 2026) Oxygen Use and Concentrators (CP.MP.190) (PDF) - RETIRED (Medicaid March 31, 2026) Cochlear Implant Replacements (CP.MP.14) (PDF) - RETIRED (Ambetter and Medicaid June 30, 2026) Eladocagene Exuparvovec-tneq (Kebilidi) (CP.PHAR.595) (PDF) - RETIRED (Medicaid July 17, 2026)
