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LAST MODIFIED 09.01.2019

Effective 09.01.2019 – This policy addresses surgical and non-surgical treatment for gender dysphoria.

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LAST MODIFIED 03.01.2019

Effective Date: 03.01.2019 – This policy addresses gonadotropin releasing hormone analog (GnRH analog) drug products, including Firmagon (degarelix), Lupaneta Pack (leuprolide acetate injection and norethindrone acetate tablets), Lupron Depot ...

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LAST MODIFIED 07.23.2019

Lupron Depot (leuprolide), Eligard (leuprolide acetate), Trelstar (triptorelin pamoate), Lupaneta pack (leuprolide acetate inj; norethindrone acetate tablets), Triptodur (triptorelin)

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LAST MODIFIED 07.26.2018

This list contains prior authorization review requirements for UnitedHealthcare Community Plan of California participating care providers for inpatient and outpatient services.

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LAST MODIFIED 07.26.2018

This list contains prior authorization requirements for UnitedHealthcare Community Plan in California participating care providers for inpatient and outpatient services.

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LAST MODIFIED 07.26.2018

This list contains prior authorization review requirements for UnitedHealthcare Community Plan of California participating care providers for inpatient and outpatient services.

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LAST MODIFIED 06.26.2019

Some standard drugs require prior authorization. Use these guidelines to help determine prior authorization requirements for all non-specialty pharmacy drugs. Drugs are listed by drug classification.

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LAST MODIFIED 06.26.2019

Use these guidelines to identify the specific prior authorization guidelines for specialty pharmacy drugs.

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LAST MODIFIED 07.23.2019

Preferred product: Testosterone (T gel and pump) Non-preferred products: Androderm (testosterone [T] patch), Androgel (T gel and pump), Axiron (T topical solution), Fortesta (T gel), Natesto (T nasal gel), Striant (T buccal system), Testim (T ...

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LAST MODIFIED 07.23.2019

Testosterone (T gel and pump) Androderm (testosterone [T] patch), Androgel (T gel and pump), Axiron (T topical solution), Fortesta (T gel), Natesto (T nasal gel), Striant (T buccal system), Testim (T gel), and Vogelxo (T gel and pump), Xyosted ...

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LAST MODIFIED 07.15.2019

Effective Date: 07.01.2019 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.

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LAST MODIFIED 01.01.2019

Effective 01.01.2019 – This policy addresses cosmetic, reconstructive, and plastic surgical procedures.

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LAST MODIFIED 08.01.2019

Effective 08.01.2019 – This policy addresses injectable drugs, off-label drug use, tobacco cessation medications, and outpatient drugs and prescription medications.

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LAST MODIFIED 02.01.2019

Effective 02.01.2019 – This policy addresses post mastectomy surgery.

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LAST MODIFIED 08.13.2019

Effective Date: 08.09.2019 – This policy addresses breast repair/reconstruction not following mastectomy. Applicable Procedure Codes: 19328, 19330, 19355, 19370, 19371, 19380.

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LAST MODIFIED 08.09.2019

Effective Date: 08.09.2019 – This policy addresses breast reconstruction post-mastectomy. Applicable Procedure Codes: 11920, 11921, 11922, 11970, 11971, 15271, 15272, 15777, 19301, 19302, 19303, 19304, 19305, 19306, 19307, 19316, 19318, 19324, ...