The Medical Review staff of the Medical Management Department utilize clinical medical policies (CMPs) to guide decisions regarding Neighborhood’s Conditional Benefits.
Through collaboration with Neighborhood’s Associate Medical Director, and our specialty consultants, the policies are developed and/or revised following thorough review of current medical literature and standards of practice. To the extent possible, Neighborhood’s CMPs are developed according to evidence-based outcomes.
To view one of Neighborhood’s approved CMPs, please click the link below:
- Acupuncture
- Adult Day Health
- Ambulance Transportation
- Assisted Living
- Chiropractic Care
- Circulating Cell-free (ccfDNA)
- Cognitive Rehabilitation
- Continuous Glucose Monitoring
- Experimental Investigational
- External Beam/Teletherapy, Brachytherapy, IMRT, SBRT/SRS, IORT, and IGRT
- Gender Affirmation
- Genetic Testing
- Genomic/Genetic/Biomarker/Tumor Marker Tests
- Hasbro Partial Program
- Home Care Services
- Infertility Services
- In Lieu of Services
- Levels of Care
- Neutron Beam and Proton Beam Radiation Therapy
- No Criteria – Use of Evidence Based Medicine
- Non Standard Requests
- Obstetrical Ultrasound
- Out-of-Network & Out-of-Area
- Outpatient PT-OT Special Needs
- Outpatient Speech Special Needs
- Outpatient Rehab Therapies-Adult
- Phototherapy and Photochemotherapy for Dermatologic Conditions
- Plastic Surgery
- Private Duty-Extended Home Care-Skilled Hours
- Relizorb Enzyme Cartridge
- Termination of Pregnancy
Pharmacy Medical Benefit Policies
- Actemra
- Aldurazyme
- Alpha-1-Proteinase Inhibitors: Aralast, Glassia, prolastin, Zemaira
- Amondys45
- Amvuttra
- Apretude
- Bal in Oil and Calcium EDTA
- Benefit Exclusion
- Benlysta
- Beovu
- Berinert
- Botox
- Brineura
- Cerezyme Elelyso VPRIV
- Cimzia
- Cinacalcet
- Cinqair
- Cinryze
- Crysvita
- Diabetic Test Strip/Supplies: Accu-Check, Dexcom, Omnipod, Freestyle
- Duopa
- Durysta
- Dysport
- Elaprase
- Entyvio
- Erythropoiesis stimulating agents Non-Oncology: Epogen, Procrit, Aranesp, Mircera, Retacrit
- Evenity
- Evkeeza
- Exondys51
- Eylea
- Fabrazyme
- Fasenra
- General PA Policy
- Givlaari
- Haegarda
- Hemgenix
- Hemophilia Products – Anti-inhibitor Antibody: Hemlibra
- Hemophilia Products-Anti-inhibitor Coagulant Complex: Feiba NF/Feiba VF
- Hemophilia Products – Factor IX: AlphaNine SD, Alprolix, BeneFIX, Idelvion, Ixinity, Mononine, Profilnine, Rebinyn, and Rixubis
- Hemophilia Products- Factor VIIa: NovoSeven RT, Sevenfact
- Hemophilia Products- Factor VIII: Advate, Adynovate, Afstyla, Eloctate, Hemofil M, Koate DVI,
Kogenate FS, Kovaltry, Novoeight, Nuwiq, Obizur, Recombinate, Xyntha/Xyntha Solofuse, Jivi, Esperoct - Hemophilia Products – Factor X: Coagadex
- Hemophilia Products – Factor XIII: Corifact
- Hemophilia Products – Coagulation Factor XIII A-subunit: Tretten
- Hemophilia Products – Factor VIII/VWF Complex: Alphanate, Humate-P, Wilate
- Hemophilia Products – von Willebrand Factor (Vonvendi)
- H. P. Acthar
- Hyaluronic Acid Intraarticular Injections: Durolane, Euflexxa, Gel-One , Gelsyn, GenVisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/Supartz FX, Synojoynt, Synvisc, Synvisc-One, Triluron, Trivisc, , Visco-3, & sodium hyaluronate 1%
- Ilaris
- Ilumya
- Immune Globulin – Intravenous Non-oncology: Asceniv, Flebogamma 10% DIF, Flebogamma 5% DIF, Gamunex-C , Gammagard Liquid, Gammaked, Gammaplex, Octagam 10%, Octagam 5%, Privigen, Panzyga
- Immune Globulin – Subcutaneous: Hizentra, Gammagard Liquid, Gamunex-C, Gammaked, Hyqvia, Cuvitru, Cutaquig, Xembify
- Infliximab/Remicade/Renflexis/Inflectra/Avsola
- Kalbitor
- Kanuma
- Krystexxa
- Lemtrada
- Leqvio
- Long acting granulocyte colony stimulating factors non-oncology: Fulphila, Neulasta, Nyvepria, Udencya, and Zietenzo
- Lucentis/Byooviz
- Lumizyme
- Luxturna
- Medical Benefit Only Policy
- Mepsevii
- Miacalcin
- Monoferric
- Myobloc
- Naglazyme
- Nexviazyme
- Nipent
- Nucala
- Nulibry
- Ocrevus
- Oncology Hematology Policy
- Onpattro
- Orencia
- Oxlumo
- Parsabiv
- Prevymis
- Probuphine
- Radicava
- Revcovi
- Rituxan Non-Oncology
- Ruconest
- Ryplazim
- Saphnelo
- Scenesse
- Serostim
- Short-Acting Granulocyte Colony Stimulating Factors: Nivestym, Neupogen, Granix, Zarxio
- Signifor LAR
- Simponi Aria
- Skyrizi
- Skysona
- Soliris Ultomiris Non-Hematology Policy
- Somatuline Depot
- Spevigo
- Spinraza
- Stelara
- Step Therapy Part B
- Step Therapy Medicaid and Commercial
- Strensiq
- Sublocade
- Susvimo
- Synagis
- Tepezza
- Testopel
- Tezspire
- Triptodur
- Trogarzo
- Tysabri
- Uplizna
- Vabysmo
- Viltepso
- Vimizim
- Vonvendi
- Vyepti
- Vyondys53
- Vyvgart
- Xenleta
- Xeomin
- Xiaflex
- Xolair
- Zolgensma
- Zulresso
- Zynteglo
- Abecma
- Abraxane
- Adakveo
- Adcetris
- Adstiladrin
- Aliqopa
- Antiemetics: Zofran, Kytril, Anzemet, Aloxi, Sancuso, Susto, Akynzeo, Emend, Cinvanti, Varubi
- Arzerra
- Asparlas
- Azedra
- Bavencio
- Beleodaq
- Besponsa
- Besremi
- Bevacizumab Products
- Blenrep
- Blincyto
- Bone Modifying Agents: Aredia, Zometa, Xgeva/Prolia
- Breyanzi
- Cablivi
- Carvykti
- Clolar
- Cosela
- Cyramza
- Danyelza
- Darzalex and Darzalex Faspro
- Doxil
- Elahere
- Elitek
- Elzonris
- Empaveli
- Empliciti
- Enhertu
- Enjaymo
- Erbitux
- Erwinaze and Rylaze
- Erythropoiesis Stimulating Agents: Epogen, Procrit, Aranesp, Mircera, Retacrit
- Folotyn
- Fusilev/Khapzory
- Fyarro
- Gamifant
- Gazyva
- Generic Drugs
- Halaven
- Imfinzi
- Imjudo
- Imlygic
- Immune Globulin (IG) (IVIG, SCIG, IMIG)
- Iron Products: Infed, Venofer, Ferrlecit, Feraheme, Monferric, Injectafer
- Istodax
- Ixempra
- Jelmyto
- Jemperli
- Jevtana
- Kadcyla
- Keytruda
- Kimmtrak
- Kymriah
- Kyprolis
- LHRH agonists and antagonists: Lupron, Trelstar, Zoladex, Irmagon, Orgovyx
- Libtayo
- Lumoxiti
- Lunsumio
- Lutathera
- Margenza
- Monjuvi
- Myeloid Growth Factors: Neupogen, Granix, Sargramostim, Zarxio, Nivestym, Releuko, Neulasta/Neulasta Onpro, Fulphila, Udenyca, Ziextenzo, Fylnetra, Stimufend, Rolvedon
- Mylotarg
- Nplate
- Oncaspar
- Onivyde
- Opdivo
- Opdualag
- Padcev
- Pedmark
- Photofrin
- Pluvicto
- Polivy
- Poteligeo
- Provenge
- Reblozyl
- Rituxan Products: Rituxan, Rituxan Hycela, Truxima, Ruxience
- Rybrevant
- Sarclisa
- Soliris
- Somatostatin Analog: Sandostatin SQ, LAR depot (Octreotide), and Somatuline (lanreotide)
- Step Therapy Medicare Part B Medications
- Step Therapy Medicaid and Commercial
- Sylvant
- Synribo
- Tecartus
- Tecentriq
- Tecvayli
- Tivdak
- Torisel
- Trastuzumab Products and Phesgo
- Treanda/Bendeka/Belrapzo
- Trodelvy
- Ultomiris
- Unituxin
- Valstar
- Vectibix
- Voraxaze
- Vyxeos
- Xofigo
- Yervoy
- Yescarta
- Yondelis
- Zaltrap
- Zepzelca
- Zevalin
- Zynlonta