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592598e9-dd9c-443c-a448-dd007cc944c9.aspx
  
5161patisiran(Onpattro®)andvutrisiran(Amvuttra™)08.01.50cPharmacy (08)08.01.50c08.01.50patisiran (Onpattro®) and vutrisiran (Amvuttra™)patisiran (Onpattro®) and vutrisiran (Amvuttra™)3/14/2023 10:00 AM592598e9-dd9c-443c-a448-dd007cc944c9
6/12/2023
5979a682-a590-4d6c-b8ca-cd43008feb8b.aspx
  
5411HydroxyprogesteroneCaproateInjectionasaTechniquetoReducetheRiskofPretermBirthinHigh-RiskPregnancies08.01.00gPharmacy (08)08.01.00g08.01.00Hydroxyprogesterone Caproate Injection as a Technique to Reduce the Risk of Preterm Birth in High-Risk PregnanciesHydroxyprogesterone Caproate Injection as a Technique to Reduce the Risk of Preterm Birth in High-Risk Pregnancies5/31/2023 10:00 AM5979a682-a590-4d6c-b8ca-cd43008feb8b
6/30/2023
7d3b2f6d-9368-46ae-8bf5-d183b24a219a.aspx
  
5410Belantamabmafodotin-blmf(Blenrep)08.01.70bPharmacy (08)08.01.70b08.01.70Belantamab mafodotin-blmf (Blenrep)Belantamab mafodotin-blmf (Blenrep)5/31/2023 10:00 AM7d3b2f6d-9368-46ae-8bf5-d183b24a219a
6/30/2023
91e60963-28a3-45fc-8e93-63edd9a87742.aspx
  
5194InjectableDermalFillersforCosmeticProcedures05.00.62iDME (05)05.00.62i05.00.62Injectable Dermal Fillers for Cosmetic ProceduresInjectable Dermal Fillers for Cosmetic Procedures3/31/2023 1:00 PM91e60963-28a3-45fc-8e93-63edd9a87742
7/1/2023
ce92180b-3b91-4668-af51-0aa525646307.aspx
  
5390CosmeticProcedures12.01.03bMiscellaneous (12)12.01.03b12.01.03Cosmetic ProceduresCosmetic Procedures3/31/2023 11:00 AMce92180b-3b91-4668-af51-0aa525646307
7/1/2023
78e9e21f-7bda-4a27-82af-e44e1699bc5a.aspx
  
5428eviCoreLabManagement(AmeriHealth)06.02.52acPathology and Laboratory (06)06.02.52ac06.02.52eviCore Lab Management (AmeriHealth)eviCore Lab Management (AmeriHealth)6/1/2023 10:00 AM78e9e21f-7bda-4a27-82af-e44e1699bc5a
{"5429": {"Id":5429,"MPAttachmentLetter":"B","Title":"Procedure Codes Requiring Prepayment Reviews","MPPolicyAttachmentInternalSourceId":7401,"PolicyAttachmentPageName":"a8799be1-e1d6-4f70-aa75-d75b029a573e"},"5430": {"Id":5430,"MPAttachmentLetter":"A","Title":"Procedure Codes Requiring Pre-service and Prepayment Reviews","MPPolicyAttachmentInternalSourceId":7403,"PolicyAttachmentPageName":"11dff6fd-c59f-4171-8be1-2cfd76e6a63c"},}
7/1/2023
80b4f5dc-0103-4eb7-8fbb-7e461bc09f3c.aspx
  
5416GPSCancer™TestingbyNantHealth06.02.50Pathology and Laboratory (06)06.02.5006.02.50GPS Cancer™ Testing by NantHealthGPS Cancer™ Testing by NantHealth5/31/2023 1:00 PM80b4f5dc-0103-4eb7-8fbb-7e461bc09f3c
7/1/2023
d89e5108-899a-4c59-93d0-688bf734f0b2.aspx
  
5404LaboratoryServicesforMembersEnrolledinHealthMaintenanceOrganization(HMO)orHealthMaintenanceOrganizationPoint-of-Service(HMO-POS)Products00.03.07akAdministrative (00)00.03.07ak00.03.07Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) ProductsLaboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products4/21/2023 2:00 PMd89e5108-899a-4c59-93d0-688bf734f0b2
{"5405": {"Id":5405,"MPAttachmentLetter":"B2","Title":"SERVICES ELIGIBLE FOR REIMBURSEMENT IN THE OUTPATIENT HOSPITAL LABORATORY","MPPolicyAttachmentInternalSourceId":7221,"PolicyAttachmentPageName":"02dec0be-e1a1-48ee-9b68-8125b0bfda4a"},"5406": {"Id":5406,"MPAttachmentLetter":"B1","Title":"SERVICES ELIGIBLE FOR REIMBURSEMENT WHEN PERFORMED IN THE SPECIALIST OFFICE (THIS INCLUDES THE CERTIFIED REGISTERED NURSE PRACTITIONER (CRNP) AND PHYSICIAN ASSISTANT (PA) PRACTICING WITHIN THE SCOPE OF THEIR SPECIALTY)","MPPolicyAttachmentInternalSourceId":7222,"PolicyAttachmentPageName":"2d45beec-7923-4235-85b0-d13ed7a93769"},"5407": {"Id":5407,"MPAttachmentLetter":"A2","Title":"HCPCS CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE","MPPolicyAttachmentInternalSourceId":7223,"PolicyAttachmentPageName":"cc1477bb-b6ab-4623-a0f5-bd6b1df4de5e"},"5408": {"Id":5408,"MPAttachmentLetter":"A1","Title":"CPT CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE","MPPolicyAttachmentInternalSourceId":7224,"PolicyAttachmentPageName":"0a64a426-a57e-4ba2-bf0d-059b77ed7544"},}
7/31/2023
d5a36339-6212-45cf-b6ca-844d0241b5f5.aspx
  
5397Luspatercept–aamt(Reblozyl®)08.00.10cPharmacy (08)08.00.10c08.00.10Luspatercept–aamt (Reblozyl®)Luspatercept–aamt (Reblozyl®)5/22/2023 12:00 PMd5a36339-6212-45cf-b6ca-844d0241b5f5
8/21/2023