Disclaimer
VCHCP Medical Management utilizes Milliman Care Guidelines in addition to below Plan specific Medical Policies.
Medical Policies
- 4K Score Testing
- Airway Pressure Management In Sleep Apnea
- Ambulance And Medical Transport
- Autism And Autism Spectrum Disorders Diagnosis And Treatment
- Balloon Dilatation Of Sinuses
- Biomarker Testing
- Breast Pump
- Chemical Peel
- Clinical Trials Coverage
- Complimentary and Alternative Medicine
- Compression Stockings And Garments
- Contact Lens And Eyeglass Coverage
- Continuous Glucose Monitor
- Cooling Devices In The Outpatient Setting
- Cosmetic Surgery
- Cranial Remodeling Band
- DEXA Scan
- Direct Access OB/GYN Services
- Direct Specialty Referral
- DME Replacement
- Durable Medical Equipment
- Early Intervention Programs
- Experimental And Investigational Procedures
- External Breast Prostheses And Prosthetic Brassiere
- Fertility Preservation Services for Latrogenic Infertility
- Gender Affirming Procedures
- Genetic Information Confidentiality And Use
- Home Enteral Nutrition
- Hospice Care Program
- Hospital Beds And Accessories
- Human Milk
- Infertility Treatment Of
- Injectable Medication Coverage
- Inspire Upper Airway Stimulation (UAS) Device
- Low Dose Computed Tomography
- Maternity Home Care
- Medical Weight Loss Program
- Nail Laser Therapy for Onychomycosis
- Nebulizers
- Non-Invasive Prenatal Testing for Fetal Aneuploidy (NIPT)
- Nutritional Counseling
- Obesity Severe Surgery
- Optometry Examinations (Simple Refraction)
- Organ/Tissue Donation
- Orthotics, Foot
- Osteopathic OMM
- Ostomy Supplies
- Palliative Care Program
- Peak Flow Meters
- Pediatric Tonsillectomy for Obstructive Sleep Apnea
- PKU (Phenylketonuria) Coverage of Testing and Treatment
- Policy for Outpatient Monitored Anesthesia Care
- Policy for Pain Management Procedures
- Prostheses and Orthotics
- Physical Therapy and Occupational Therapy for Pediatric Developmental Delay and Developmental Coordination Disorder
- Pulse Oximetry for Home Use
- Skilled Home Health Services
- Skilled Nursing Facility (SNF)
- Stretching Devices for the Treatment of Joint Stiffness and Contracture
- Subacute Care, Extended Care, & Acute
- Superion Interspinous Spacer for Spinal Stenosis
- The Morning After Pill (TMAP)
- Treatment of Cancer
- Universal Carrier Screening Testing Specific to Parents
- Vaccinations
- Vaginal Birth After Cesarean Section (VBAC)
- VCHCP Policy Guideline for Reviews
- Weight Reduction Medications and Programs
- Wigs
Cardiac Definition Of Emergency Elective Services
Clinical Criteria For UM Decisions
DecisionTimeliness: Processing Medication Requests
Lithium Toxicity Appropriate Regimen
Nurse Practitioner And Physician Assistant PCP’s Practice
Optometry Exam Simple Refraction
Pancreaticoduodenectomy (Whipple Resection) For Zollinger Ellison
Pneumococcal Polysaccharide Vaccine
Treatment Authorization Request
ABA Medical Necessity Criteria Worksheet
Drug Policies – Medical Benefit
- Abecma
- Abraxane
- Actemra
- Acthar
- Adagen
- Adakveo
- Adcetris
- Adstiladrin
- Aduhelm
- Advate
- Adynovate
- Adzynma
- Afstyla
- Aimovig
- Aldurazyme
- Alimta
- Aliqopa
- Alymsys
- Alphanate
- AlphaNine SD
- Alprolix
- Altuviiio
- Alyglo
- Amifostine
- Amondys 45
- Amtagvi
- Amvuttra
- Andembry
- Anktiva
- Aphexda
- Aralast NP
- Aranesp
- Arsenic Trioxide
- Arzerra
- Asceniv
- Asparlas
- Atgam
- Aucatzyl
- Avastin
- Aveed
- Avsola
- Azedra
- Azmiro
- Bavencio
- Beleodaq
- Belrapzo
- Bendamustine
- Bendeka
- BeneFix
- Benlysta IV
- Beovu
- Beqvez
- Berinert
- Besponsa
- Bivigam
- Bizengri
- Bkemv
- Blincyto
- Boniva IV (Ibandronate IV)
- Boruzu
- Bortezomib
- Botox
- Breyanzi
- Brineura
- Briumvi
- Byooviz
- Cablivi
- Camcevi
- Carimune
- Carmustine
- Carvykti
- Casgevy
- Ceprotin
- Cerezyme
- Cimerli
- Cimzia
- Cinqair
- Cinryze
- Coagadex
- Columvi
- Corifact
- Cortrophin Gel
- Cosela
- Cosentyx
- Crysvita
- Cutaquig
- Cuvitru
- Cyramza
- Cytogam
- Dacogen
- Danyelza
- Darzalex Faspro
- Darzalex IV
- Datroway
- Daxxify
- Decitabine
- Delatestryl
- Depo Testosterone
- Docefrez
- Durolane
- Durysta
- Dysport
- Edaravone IV
- Elahere
- Elaprase
- Elelyso
- Elevidys
- Elfabrio
- Eligard
- Elrexfio
- Epkinly
- Eloctate
- Elzonris
- Empliciti
- Emrelis
- Encelto
- Enhertu
- Enjaymo
- Entyvio
- Epogen
- Epoprostenol
- Epysqli
- Erbitux
- Esperoct
- Euflexxa
- Evenity
- Evkeeza
- Exjade
- Exondys 51
- Eylea
- Eylea HD
- Fabrazyme
- Fasenra
- Faslodex
- Fyarro
- FEIBA
- Fensolvi
- Feraheme
- Ferrlecit
- Fibryga
- Firazyr
- Firmagon
- Flebogamma
- Flolan
- Folotyn
- Fulphila
- Fulvestrant
- Fusilev
- Fylnetra
- Gamifant
- Gammagard Liquid IV
- Gammagard SD IV
- Gammagard SubQ
- Gammaked IV
- Gammaked SubQ
- Gammaplex IV
- Gamunex-C IV
- Gamunex-C SubQ
- Gazyva
- Gel-One
- Gelsyn 3
- GenVisc
- Givlaari
- Glassia
- Grafapex
- Granix
- Haegarda
- Halaven
- Helixate
- Hemgenix
- Hemlibra
- Hemofil
- Herceptin
- Herceptin Hylecta
- Hercessi
- Herzuma
- Hizentra
- Humate-P
- Hyalgan
- Hycamtin
- Hymovis
- HyQvia
- Ibandronate IV
- Icatibant
- Idelvion
- iDose TR
- Ilaris
- Ilumya
- Imaavy
- Imcivree
- Imdelltra
- Imfinzi
- Imjudo
- Imlygic
- Imuldose IV
- INFeD
- Inflectra
- Infliximab IV
- Injectafer
- Istodax
- Ixempra
- Ixinity
- Izervay
- Jadenu
- Jadenu Sprinkle
- Jelmyto
- Jemperli
- Jevtana
- Jivi
- Jubbonti
- Kadcyla
- Kalbitor
- Kanjinti
- Kanuma
- Kebilidi
- Keytruda
- Khapzory
- Kimmtrak
- Kisunla
- Koate
- Kogenate
- Kovaltry
- Krystexxa
- Kymriah
- Kynamro
- Kyprolis
- Lamzede
- Lanreotide SC
- Lartruvo
- Leqembi
- Leqvio
- Lemtrada
- Lenmeldy
- Leukine
- Leuprolide Depot
- Levoleucovorin IV
- Libtayo
- Loqtorzi
- Lucentis
- Lumizyme
- Lunsumio
- Lupaneta
- Lupron Depot
- Lupron Depot Ped
- Lutathera
- Luxturna
- Lyfgenia
- Lymphir
- Margenza
- Mepsevii
- Mircera
- Monjuvi
- Monoferric
- Mononine
- Monovisc
- Mvasi
- Mylotarg
- Myobloc
- Naglazyme
- Neulasta
- Neupogen
- Nexviazyme
- Niktimvo
- Nipent
- Nivestym
- Novoeight
- NovoSeven RT
- Nplate
- Nucala
- Nulibry
- Nulojix
- Nuwiq
- Nyvepria
- Ocrevus
- Ocrevus Zunovo
- Octagam
- Ogivri
- Omisirge
- Omvoh IV
- Onapgo
- Oncaspar
- Onivyde
- Onpattro
- Ontruzant
- Opdivo
- Opdivo Qvantig
- Opdualag
- Orencia IV
- Orthovisc
- Osenvelt
- Otulfi IV
- Oxlumo
- Paclitaxel Albumin-Bound
- Padcev
- Palonosetron IV
- Panhematin
- Panzyga
- Pavblu
- Pedmark
- Pemetrexed
- Pemfexy
- Pemrydi RTU
- Perjeta
- Phesgo
- PiaSky
- Pluvicto
- Polivy
- Pombiliti
- Portrazza
- Posfrea IV
- Poteligeo
- Pralatrexate
- Privigen Liquid
- Procrit
- Profilnine
- Prolastin C and Prolastin C Liquid
- Proleukin
- Prolia
- Provenge
- Pyzchiva IV
- Qalsody
- Radicava
- Rebinyn
- Reblozyl
- Reclast
- Recombinate
- Releuko
- Remicade
- Remodulin
- Renflexis
- Retacrit
- Revcovi
- Riabni IV
- RiaSTAP
- Rituxan Hycela
- Rituxan IV
- Rivfloza
- Rixubis
- Roctavian
- Rolvedon
- Romidepsin injection IV
- Ruconest
- Ruxience IV
- Rybrevant IV
- Rylaze
- Ryoncil
- Ryplazim
- Rystiggo
- Rytelo
- Ryzneuta
- Sajazir
- Sandostatin LAR Depot
- Sandostatin
- Saphnelo
- Sarclisa
- Scenesse
- Selarsdi IV
- Sevenfact
- Signifor LAR
- Simponi Aria
- Skyrizi
- Skysona
- Sodium hyaluronate 1% injection
- Soliris
- Somatuline Depot
- Spevigo
- Spinraza
- Spravato
- Stelara IV
- Steqeyma IV
- Stimufend
- Stoboclo
- Supartz FX
- Supprelin LA
- Susvimo
- Syfovre
- Sylatron
- Sylvant
- Synagis
- Synercid
- SynoJoynt
- Synribo
- Synvisc
- Synvisc-One
- Takhzyro
- Talvey
- Taxotere
- Tecartus
- Tecelra
- Tecentriq
- Tecentriq Hybreza
- Tecvayli
- Tegsedi
- Temodar
- Temozolomide IV
- Tepadina
- Tepezza
- Tepylute
- Testopel
- Testosterone enanthate intramuscular injection
- Tevimbra
- Tezspire
- Thiotepa
- Tivdak
- Tofidence IV
- Topetocan IV
- Torisel
- Trazimera
- Treanda
- Trelstar
- Tremfya IV
- Tretten
- Triluron
- Triptodur
- Trisenox
- TriVisc
- Trodelvy
- Truxima IV
- Tyenne IV
- Tysabri
- Tzield
- Udenyca
- Ultomiris
- Unituxin
- Unloxcyt
- Uplizna
- Ustekinumab IV
- Vabysmo
- Valrubicin
- Valstar
- Vantas
- Vectibix
- Vegzelma
- Velcade
- Veletri
- Veopoz
- Venofer
- Viltepso
- Vimizim
- Vivimusta
- Visco-3
- Vonvendi
- Vpriv
- Vyalev
- Vyepti
- Vyjuvek
- Vyloy
- Vyondys 53
- Vyvgart Hytrulo
- Vyvgart IV
- Vyxeos
- Wezlana
- Wilate
- Wyost
- Xembify
- Xenpozyme
- Xeomin
- Xgeva
- Xiaflex
- Xolair
- Xyntha/Xyntha Solfuse
- Xyosted
- Ycanth
- Yervoy
- Yescarta
- Yesintek IV
- Yimmugo
- Yondelis
- Zaltrap
- Zarxio
- Zemaira
- Zepzelca
- Zevaskyn
- Ziextenzo
- Ziihera
- Zilretta
- Zirabev
- Zoladex
- Zoledronic Acid
- Zolgensma
- Zulresso
- Zusduri
- Zynlonta
- Zynteglo
- Zynyz
VCHCP Custom Drug Policies – Medical Benefit