Welcome to the Clinical Criteria Page

This page provides the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. The effective dates for using these documents for clinical reviews are communicated through the Provider notification process.
To determine if a code requires authorization, use the Prior Authorization lookup tool
The Nebraska Medicaid state-specific clinical criteria information is alphabetized below. Not all drugs requiring authorization have Nebraska Medicaid State specific criteria. If a code requires authorization and the clinical criteria document is not found in the list below, please utilize the following link for additional criteria.Clinical Criteria

Nebraska Specific Policies

Clinical Criteria
Associated Medications (as applicable) Document Number Coding
Amondys Amondys CC-0189 NE J1426
Human Parathyroid-Bonsity Bonsity CC-0038 NE J3110
Human Parathyroid-Forteo Forteo CC-0038 NE J3110
Human Parathyroid-Tymlos Tymlos CC-0038 NE C9399, J3490
Hyaluronan Durolane, GenVisc 850, Hyalgan, Supartz, Hymovis, Euflexxa, Orthovisc, Synvisc, Synvisc-One, Gel-One, Monovisc, Gel-Syn, trivisc, synojoynt, Triluron CC-0006 NE J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332
Immunomodulators-Cinqair Cinqair CC-0043 NE J2786
Immunomodulators-Fasenra Fasenra CC-0043 NE J0517
Immunomodulators-Nucala Nucala CC-0043 NE J2182
Immunomodulators-Xolair Xolair CC-0033-NE J2357
Infertility and HCG Agents Novarel, Pregnyl, Ovidrel, Lupron, Cetrotide or other injectable for infertility treatment, Clomid, Serophene, Menopur, Gonal-F, Follistim, Antagon, Crinone 8%, Endometrin, Crinone 4% CC-0015 NE J0725, J1950, J3490, J8499, S0122, S0126, S0128, S0132, J3490
Synagis Synagis CC-0007 NE 90378, S9562
Aduhelm Aduhelm CC-0200 NE J0172

(Note: in the case of a clinical criteria document being listed on both sites, please utilize those listed directly above.)
If you have questions or feedback, please contact druglist@carelon.com.