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dda832ee-a0b1-49f2-80de-061c0f3edee9.aspx
  
Golimumab(SimponiAria®)Intravenous(IV)Injection08.01.15g08.01.15gPharmacy (08)Golimumab (Simponi Aria®) Intravenous (IV) Injectiondda832ee-a0b1-49f2-80de-061c0f3edee95471Golimumab (Simponi Aria®) Intravenous (IV) Injection08.01.158/1/2023 10:00 AM
{"5472": {"Id":5472,"MPAttachmentLetter":"A","Title":"Medically Necessary ICD-10 Codes","MPPolicyAttachmentInternalSourceId":7466,"PolicyAttachmentPageName":"ef2c976b-9f8e-44ff-8555-fd0fc5eb38df"},}
10/30/2023
15d4fdbe-af50-4e4b-9b1c-6d8ee491d0ab.aspx
  
Tocilizumab(Actemra®)forIntravenousInfusion08.00.85n08.00.85nPharmacy (08)Tocilizumab (Actemra®) for Intravenous Infusion15d4fdbe-af50-4e4b-9b1c-6d8ee491d0ab5483Tocilizumab (Actemra®) for Intravenous Infusion08.00.858/16/2023 10:00 AM
{"5484": {"Id":5484,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":7468,"PolicyAttachmentPageName":"d13aec89-9dd0-4ddd-a6f9-d8a787664e9d"},}
11/13/2023
1a6bddc6-a618-4287-8360-450516d7023b.aspx
  
Daratumumab(Darzalex®),DaratumumabandHyaluronidase-fihj(DarzalexFaspro®)08.01.29k08.01.29kPharmacy (08)Daratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®)1a6bddc6-a618-4287-8360-450516d7023b5514Daratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®)08.01.298/29/2023 2:00 PM
11/27/2023
b54e7ec4-dc44-418c-8fd0-1e1c2ad712f5.aspx
  
Abatacept(Orencia®)forInjectionforIntravenousUse08.00.62p08.00.62pPharmacy (08)Abatacept (Orencia®) for Injection for Intravenous Useb54e7ec4-dc44-418c-8fd0-1e1c2ad712f55543Abatacept (Orencia®) for Injection for Intravenous Use08.00.629/12/2023 11:00 AM
{"5544": {"Id":5544,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":7512,"PolicyAttachmentPageName":"8208ab03-d005-451f-8bf2-5e1cfee36282"},}
12/11/2023
4f4f2c65-9768-43af-81cf-7b151317458c.aspx
  
NebulizersandInhalationSolutions05.00.15t05.00.15tDME (05)Nebulizers and Inhalation Solutions4f4f2c65-9768-43af-81cf-7b151317458c5588Nebulizers and Inhalation Solutions05.00.159/29/2023 11:00 AM
1/1/2024