| Abatacept | RX501.113 · Effective Apr 1, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Ablation of Peripheral Nerves to Treat Pain | SUR705.040 · Commercial, Medicaid | 6 | Original policy ↗ |
| Absorbable Nasal Implant for Treatment of Nasal Valve Collapse | SUR706.017 · Effective Dec 15, 2025 · Commercial, Medicaid | 1 | Original policy ↗ |
| Actigraphy | MED201.048 · Commercial, Medicaid | 3 | Original policy ↗ |
| Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast | SUR716.021 · Commercial, Medicaid | 5 | Original policy ↗ |
| Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses | DME103.007 · Effective Jun 15, 2026 · Commercial, Medicaid | 2 | Original policy ↗ |
| Adoptive Immunotherapy | THE801.024 · Commercial, Medicaid | 4 | Original policy ↗ |
| Adult Wellness Guidelines | 22960.0925 · Commercial, Medicaid · IL | — | Original policy ↗ |
| Adult Wellness Guidelines (Spanish) | 23032.0925 · Commercial, Medicaid · IL | — | Original policy ↗ |
| Aflibercept and Associated Biosimilar(s) | OTH903.027 · Commercial, Medicaid | 11 | Original policy ↗ |
| Airway Clearance Devices | DME101.027 · Commercial, Medicaid | 10 | Original policy ↗ |
| Alemtuzumab | RX501.077 · Effective Mar 1, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Allergen Testing | RPLAB013 · Effective Sep 4, 2026 · Commercial, Medicaid · IL | 13 | Original policy ↗ |
| Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms | SUR703.032 · Commercial, Medicaid | 67 | Original policy ↗ |
| Allogeneic Pancreas Transplant | SUR703.013 · Commercial, Medicaid | 5 | Original policy ↗ |
| Allograft Injection for Degenerative Disc Disease | SUR705.049 · Effective Dec 15, 2025 · Commercial, Medicaid | 4 | Original policy ↗ |
| Ambulance and Transport Services | MED201.058 · Commercial, Medicaid | 47 | Original policy ↗ |
| Amniotic Membrane and Amniotic Fluid | SUR704.011 · Effective Dec 15, 2025 · Commercial, Medicaid | 284 | Original policy ↗ |
| Anesthesia Information – Professional Provider | CPCP010 · Effective Nov 1, 2025 · Commercial, Medicaid · IL | 11 | Original policy ↗ |
| Anesthesia Information – Professional Provider | RP010 · Effective Oct 12, 2026 · Commercial, Medicaid · IL | 11 | Original policy ↗ |
| Anesthesia Information – Professional Provider | RP010 · Effective Nov 1, 2026 · Commercial, Medicaid · IL | 11 | Original policy ↗ |
| Anifrolumab-fnia | RX501.138 · Commercial, Medicaid | 1 | Original policy ↗ |
| Annulus Closure After Discectomy | SUR705.045 · Commercial, Medicaid | 3 | Original policy ↗ |
| Antigen Leukocyte Antibody Test | MED206.005 · Commercial, Medicaid | 2 | Original policy ↗ |
| Antineoplaston Cancer Therapy | MED203.002 · Commercial, Medicaid | 2 | Original policy ↗ |
| Applied Behavior Analysis | CPCP011 · Effective Mar 20, 2026 · Commercial, Medicaid · IL | 14 | Original policy ↗ |
| Aqueous Shunts and Stents for Glaucoma | SUR713.034 · Effective Jan 1, 2026 · Commercial, Medicaid | 15 | Original policy ↗ |
| Artificial Intervertebral Disc | SUR712.028 · Effective Jan 1, 2026 · Commercial, Medicaid | 12 | Original policy ↗ |
| Auditory Brainstem Implant | SUR714.009 · Commercial, Medicaid | 6 | Original policy ↗ |
| Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions | SUR705.020 · Effective Sep 15, 2026 · Commercial, Medicaid | 5 | Original policy ↗ |
| Autologous Chondrocyte Implantation (ACI) for Focal Articular Cartilage Lesions | SUR705.035 · Commercial, Medicaid | 11 | Original policy ↗ |
| Automated Percutaneous Discectomy and Percutaneous Endoscopic Discectomy | SUR712.004 · Effective Oct 15, 2025 · Commercial, Medicaid | 3 | Original policy ↗ |
| Autonomic Nervous System (ANS) Testing | MED205.034 · Commercial, Medicaid | 5 | Original policy ↗ |
| Avacincaptad pegol | OTH903.045 · Commercial, Medicaid | 2 | Original policy ↗ |
| Axial Lumbosacral Interbody Fusion | SUR712.038 · Commercial, Medicaid | 2 | Original policy ↗ |
| Axillary Reverse Mapping for Prevention of Breast Cancer- Related Lymphedema | SUR708.002 · Effective Jan 1, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Balloon Dilation of the Eustachian Tube | SUR706.018 · Effective Nov 15, 2025 · Commercial, Medicaid | 2 | Original policy ↗ |
| Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis | SUR706.019 · Effective Sep 15, 2026 · Commercial, Medicaid | 9 | Original policy ↗ |
| Bariatric Surgery | SUR716.003 · Effective Jan 1, 2026 · Commercial, Medicaid | 40 | Original policy ↗ |
| Baroreflex Stimulation Devices | THE801.034 · Commercial, Medicaid | 17 | Original policy ↗ |
| Belatacept | RX501.158 · Commercial, Medicaid | 1 | Original policy ↗ |
| Belimumab | RX501.116 · Effective May 1, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Benralizumab | RX501.100 · Effective Jan 1, 2026 · Commercial, Medicaid | 1 | Original policy ↗ |
| Bioengineered Skin and Soft Tissue Substitutes | SUR704.012 · Effective Jul 1, 2026 · Commercial, Medicaid | 156 | Original policy ↗ |
| Biofeedback as a Treatment of Chronic Pain | PSY301.018 · Effective Jun 15, 2025 · Commercial, Medicaid | 4 | Original policy ↗ |
| Biofeedback as a Treatment of Fecal Incontinence or Constipation | PSY301.017 · Commercial, Medicaid | 6 | Original policy ↗ |
| Biofeedback as a Treatment of Headache | PSY301.019 · Commercial, Medicaid | 4 | Original policy ↗ |
| Biofeedback as a Treatment of Urinary Incontinence | PSY301.016 · Commercial, Medicaid | 7 | Original policy ↗ |
| Biofeedback for Miscellaneous Indications | PSY301.007 · Effective Jan 1, 2026 · Commercial, Medicaid | 4 | Original policy ↗ |
| Bioimpedance Devices for Detection and Management of Lymphedema | MED201.036 · Effective Oct 15, 2025 · Commercial, Medicaid | 1 | Original policy ↗ |
