Adult Sleep Studies Ambulance Services - Medical Transportation Arthroscopic Knee Surgery Autologous Chondrocyte Implantation Bariatric Surgery Continuity of Care and Transition of Care Criteria Modification Policy Dental Services Drug Testing Genetic Testing Home Health Services Hospital Stay Requirements for Skilled Nursing Facility Admission (MA) Investigational or Experimental Services and Clinical Trials Knee Arthroplasty (Total or Partial) Liver Fibrosis Serum Testing Pulsed Dye Laser Therapy for Port Wine Stain Readmission Review Sacroiliac Joint Pain Management Sepsis and Septic Shock Short Stay Admissions and Outpatient Hospital Observation Site of Service Utilization Review Skilled Nursing Facility Services Temporomandibular Joint (TMJ) Disorders Tumor Treating Fields (Optune®)
Part B Step Therapy Drug List Antineoplastic – bevacizumab Antineoplastic - rituximab Antineoplastic – trastuzumab Anti-inflammatory infliximab Colony Stimulating Factors Long Acting Colony Stimulating Factors – Short Acting Hyaluronate Injections for Osteoarthritis of the Knee
Abecma - idecabtagene vicleucel Actemra - tocilizumab Adakveo - crizanlizumab-tmca Aduhelm - aducanumab-avwa Alimta - pemetrexed Aloxi - palonosetron Alpha-1-Proteinase Inhibitors: Aralast/Prolastin/Zemaira/Glassia Amvuttra Breyanzi - lisocabtagene maraleucel Briumvi Cabenuva - cabotegravir and rilpivirine Carvykti Cerezyme (imiglucerase)) Cimzia - certolizumab pegol Clotting Disorder Therapy Cosela - trilaciclib Cresemba - isavuconazonium sulfate Dalvance - dalbavancin Duchenne Muscular Dystrophy (DMD) Elahere Emend - fosaprepitant dimeglumine Empaveli - pegcetacoplan Enjaymo Entyvio - vedolizumab Evenity - romosozumab Evkeeza - evinacumab Fasenra - benralizumab Feraheme Fyarro - sirolimus albumin-bound Givlaari - givosiran Hemgenix Ilaris - canakinumab Ilumya - tildrakizumab-asmn Imjudo Intravenous Immune Globulins (IVIG) Intravitreal Injections/Implants Isodax_romidepsin Jemperli - dostarlimab Khapzory - levoleucovorin Kimmtrack - tebentafusp-tebn Krystexxa - pegloticase Kymriah - tisagenlecleucel Leqembi Leqvio - inclisiran Lunsumio Lupron Depot-Lupron Depot-Ped Eligard-Fensolvi-Camcevi - leuprolide Luxturna - voretigene neparvovec Mepsevii - vestronidase alfa-vjbk Nexviazyme - avalglucosidase alfa-ngpt Nulibry - fosdenopterin hydrobromide Nulojix - belatacept Off Label Indications Opdualag Orencia - abatacept Padcev - enfortumab vedotin-ejfv Pepaxto - melphalan flufenamide Pulmonary Arterial Hypertension Reblozyl - luspatercept-aamt Relizorb - immobilized lipase Rybrevant - amivantamab Saphnelo - anifrolumab-fnia Sarclisa - isatuximab Signifor LAR - pasireotide Simponi ARIA - golimumab Skysona Somatuline Depot - lanreotide Spevigo Spinraza - nusinersen Stelara - ustekinumab Subcutaneous Immune Globulins (SCIG) Sunlenca Supprelin LA - histrelin Synagis - palivizumab Takhyzro - lanadelumab-flyo Tecartus - brexucabtagene autoleucel Tecvayli Tepezza - teprotumumab-trbw Tezspire - tezepelumab-ekko Tivdak - tisotumab vedotin Trelstar Triptodur - triptorelin Tzield Vimizim - elosulfase alfa Vyepti - eptinezumab-jjmr Vyvgart - efgartigimod alfa-fcab Xenpozyme Yescarta - axicabtagene ciloleucel Zepzelca - lurbinectedin Zilretta - triamcinolone acetonide Zolgensma - onasemnogene abeparvovec-xioi Zulresso - brexanolone Zynlonta - loncastuximab tesirine Zynteglo (betibeglongene autotemcel)
For additional clinical criteria please register by entering your name and email address. The same email address associated with your Central Health plan.
For Apollo Criteria please click the link below: https://hsmso.apollomanagedcare.com
Our business hours are 7 days a week
from 8:00am to 8:00pm (PT).
Our business hours are 7 days a week from 8:00am to 8:00pm (PT).
TTY/TDD: 711
PO Box 14244, Orange, CA 92863
