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.