Molina Clinical Policy
Molina has established Molina Clinical Policies (MCP) that function as one of the sets of guidelines for coverage decisions or determinations. Note: These MCPs do not constitute plan authorization, nor are they an explanation of benefits. The MCPs are applicable to all lines of business including Medicaid, Marketplace, and Medicare unless superseded by National Coverage Determination (Medicare) or one of the state Medicaid Plans.
The policies below are specific to the state of Mississippi. Providers should also refer to molinaclinicalpolicy.com, where MCPs are housed.
Behavioral Health Policies
Please visit MolinaClinicalPolicy.com for Behavioral Health policies.
Medical Policies
Please visit MolinaClinicalPolicy.com for Medical policies.
- Gender Affirmation Treatment and Procedures (Medicaid): Policy No. 216a
- Zolgensma (onasemnogene abeparvovec): Policy No. 348
The Molina Clinical Policy Committee (MCPC) periodically reviews and updates policies to stay in compliance with current medical practice and to ensure the best outcomes for patients. Policy updates require a 30-day notification period until they are effective. The following policies are being revised and are currently still in effect:
- MCP-045: Kidney Transplantation
- MCP-118: Hematopoietic Stem Cell Transplantations for Acute Lymphoblastic Leukemia_ALL
- MCP-187: Hematopoietic Stem Cell Transplantations for Chronic Myelogenous Leukemia_CML
- MCP-204: Blepharoplasty
- MCP-209: Hematopoietic Stem Cell Transplantations for Sickle Cell Anemia
- MCP-218: Bone Graft Substitutes for Bone Fusion (formerly Recombinant Human Bone Morphogenetic Protein)
- MCP-256: Hematopoietic Stem Cell Transplantations for Mucopolysaccharidoses_MPS
- MCP-265: Hematopoietic Stem Cell Transplantations for Immunodeficiency Disorders
- MCP-272: Hematopoietic Stem Cell Transplantations for Ewings Sarcoma
- MCP-283: Hematopoietic Stem Cell Transplantations for Wilms Tumor
- MCP-309: Hematopoietic Stem Cell Transplantations for Myelodysplastic Syndromes_MDS
- MCP-323: Pre-Transplant Evaluation
- MCP-324: Hematopoietic Stem Cell Transplantations for Primary Myelofibrosis
- MCP-362: Haploidentical Allogeneic Hematopoietic Cell Transplantation
- MCP-378: Tecartus (brexucabtagene autoleucel)
- MCP-395: Kymriah (tisagenlecleucel)
- MCP-396: Yescarta (axicabtagene ciloleucel)
- MCP-400: Breyanzi (lisocabtagene maraleucel)
- MCP-402: Plantar Fasciitis Surgery
- MCP-403: Abecma (idecabtagene vicleucel)
- MCP-413: Carvykti (ciltacabtagene autoleucel)
- MCP-432: Developmental Testing
The following policy is scheduled to be retired but is currently in effect:
Payment Policies
- Outpatient Definitive Drug Testing Marketplace_PI_33
- Outpatient Definitive Drug Testing Medicare Medicaid_PI_33
Pharmacy Policies
Providers should also refer to molinaclinicalpolicy.com, as some medications are categorized under Medical Policies.
Healthcare Administered Drug/ Physician Administered Drugs Phone Number: 844-826-4335
Healthcare Administered Drug/ Physician Administered Drugs Fax Number: 844-312-6371
Abilify MyCite Kit (aripiprazole with biosensor) MNR MHI
Abrysvo IL Medicaid Only C27393-A
Actemra (tocilizumab) MHI
Acthar gel (repository corticotropin injection) MHI
Adakveo (crizanlizumab-tcma) MHI
Adbry (tralokinumab) MHI
Adcetris (brentuximab vedotin) MHI
Aduhelm (aducanumab) MHI
Adzynma (ADAMTS13, recombinant-krhn) MHI
Aldara_Zyclara (imiquimod) MHI
Alpha-1 Antitrypsin Deficiency [Aralast NP, Glassia, Prolastin, Zemaira] MHI
Amondys 45 (casimersen) MNR MHI
Ampyra (dalfampridine) MHI
Amvuttra MHI
Anticonvulsants IL Medicaid Only C21453-A
Antidiabetic Agents IL Medicaid Only C21858-A
Antiemetics MHI
Antimalarial agents MHI
Aphexda (motixafortide) MHI
Apokyn, Kynmobi (apomorphine) MHI
Arcalyst (rilonacept) MHI
Arixtra (fondaparinox) MHI
Atopic Dermatitis Eucrisa Elidel Protopic IL Medicaid Only C21052-A
Atypical Antipsychotics MHI
Austedo (deutetrabenazine) IL Medicaid Only C25216-A
Azactam (aztreonam) MHI
Baxdela (delafloxacin) MHI
Benlysta (belimumab) MHI
Beovu (brolucizumab-dbll) MHI
Benzodiazepine Global Criteria IL Medicaid Only C24664-A
Bimzelx (bimekizumab) MHI
Botulinum Toxin MHI
Brineura (cerliponase alfa) MHI
Briumvi (ublituximab) MHI
Brixadi (buprenorphine) MHI
Bylvay (odevixebant) MHI
Cabenuva IL Medicaid Only C21979-A
Cablivi (caplacizumab) MHI
Camzyos (mavacamten) MHI
Cancidas (caspofungin) MHI
Carisoprodol MHI
Cayston (aztreonam) MHI
Cerdelga (eliglustat) MHI
CGRP Antagonists IL Medicaid Only C17186-C
Cholbam (cholic acid) MHI
Cibinqo (abrocitinib) MHI
Cimzia (certolizumab pegol) MHI
Cinqair (reslizumab) MHI
CNS Stimulants IL Medicaid Only C21108-A
Colcrys, Mitigare, Gloperba (colchicine) MHI
Constipation Agents MHI
Continous Glucose Monitoring (CGM) IL Medicaid Only C22081-A
Copaxone/Glatopa (glatiramer acetate) MHI
Cosela (trilaciclib) MHI
Cosentyx (secukinumab) MHI
Crysvita (Burosumab-twza) MHI
Cubicin (daptomycin) MHI
Cuvposa (glycopyrrolate) Oral Solution MHI
Cystic Fibrosis Agents (Kalydeco, Orkambi, Symdeko, Trikafta) MHI
Cytogam (cytomegalovirus immune globulin) MHI
Dalvance (dalbavancin) MHI
Daraprim (pyrimethamine) MHI
Daybue (trofinetide) MHI
Desmopressin Nasal and Oral (DDAVP) MHI
Dextenza (dexamethasone intracanalicular insert) MHI
Dexycu (dexamethasone intraocular suspension) MHI
Diabetic Testing Supplies MHI
Diclofenac topical MHI
Direct Oral Anticoagulants MHI
Disposable Insulin Delivery Device MHI
Doptelet (avatrombopag) MHI
Dry Eye Therapies MHI
Dupixent IL Medicaid Only C22067-A
Duplication of Therapy/High Risk Combination MHI
Durysta (bimatoprost implant) MHI
Egrifta (tesamorelin) MNR MHI
Elaprase (idursulfase) MHI
Eliquis IL Medicaid Only C18476-A
Emflaza (deflazacort) MNR MHI
Empaveli (pegcetacoplan) MHI
Enbrel (etanercept) MHI
Endari (L-glutamine) MNR MHI
Enjaymo (sutimlimab) MHI
Enspryng (satralizmab) MHI
Entyvio (vedolizumab) MHI
Enzyme Replacement Therapy for Gaucher Disease [Cerezyme, Elelyso, Vpriv] MHI
Enzyme Replacement Therapy for Lysosomal Storage Disorders (MPS I, VI) [Aldurazyme, Naglayzme] MHI
Erythropoiesis-stimulating agents (ESAs) MHI
Esbriet (pirfenidone) MHI
Evenity (romosozumab-aqqg) MHI
Evkeeza MHI
Evrysdi (risdiplam) MHI
Exondys 51 (eteplirsen) MNR MHI
Eylea (aflibercept) MHI
Fabrazyme (agalsidase beta) MHI
Fasenra IL Medicaid Only C22068-A
Filgrastim MHI
Filspari MHI
Firdapse (amifampridine) MHI
Forteo (teriparatide) MHI
Furoscix (furosemide injection) MHI
Fuzeon (enfuvirtide) MHI
Galafold (migalastat) MHI
Gamifant (Emapalumab-lzsg) MHI
Gattex (teduglutide [rDNA origin]) MHI
Gender Dysphoria Hormone Therapy IL Medicaid Only C23809-A
Givlaari (givosiran) MHI
Gocovri/Osmolex (amantadine ER caps/tabs) MHI
Growth Hormone Therapy IL Medicaid Only C22969-A
Hemangeol IL Medicaid Only C21109-A
Hemophilia and Blood Factor Products MHI
Hemostatic Agents MHI
Hepatitis B Immune Globulin MHI
Hepatitis C Antiviral Therapy IL Medicaid Only C18433-A
Hereditary Angioedema Agents MHI
Hetlioz (tasimelteon) MHI
High-Cost Outlier Targeted (HOT) Drug Exception MHI
Humira (adalimumab) MHI
Hyaluronic Acid (HA) Injections MHI
Igalmi (dexmedetomidine) MHI
Ilaris (canakinumab) MHI
Ilumya (tildrakizumab) MHI
Iluvien (fluocinolone acetonide intravitreal implant) MHI
Imcivree (setmelanotide) MNR MHI
Immunoglobulin (SCIg, IVIg) MHI
Increlex (mecasermin) MHI
Infliximab (Remicade_Renflexis_Ixifi_Avsola_Inflectra) MHI
Ingrezza IL Medicaid Only C25457-A
Inpefa (sotagliflozin) MHI
InPen (Insulin Smart Pen) MNR MHI
Inrebic (fedratinib) MHI
Insulin Patch MNR MHI
Intravenous Bisphophonates MHI
Iron chelating Agents (Desferal, Exjade, Ferriprox, Jadenu) MHI
Iron Deficiency Anemia Agents MHI
Isotretinoin MHI
Isturisa (osilodrostat) MHI
Izervay (avacincaptad intravitreal) MHI
Jesduvroq (daprodustat) MHI
Joenja (leniolisib) MHI
Juxtapid (lomitapide) MHI
Kanuma (sebelipase alfa) MHI
Kerendia (finerenone) MHI
Kesimpta (ofatumumab) MHI
Keveyis (dichlorphenamide) MHI
Kevzara (sarilumab) MHI
Kineret (anakinra) MHI
Korlym (mifepristone) MHI
Korsuva (difelikefalin) MHI
Koselugo (selumetinib) MHI
Krystexxa (pegloticase) MHI
Kuvan (sapropterin dihydrochloride) MHI
Lamzede (velmanase alfa) MHI
Lemtrada (alemtuzumab) MHI
Leqembi (lecanemab-irmb) MHI
Leqvio (inclisiran) MHI
Leukine (sagramostim) MHI
Leuprolide long acting (Lupron Depot, Eligard, Lupaneta, Lupron Depot Ped, Fensolvi) MHI
Lidocaine Patch MHI
Linezolid MHI
Litfulo (ritlecitinib) MNR MHI
Livmarli (maralixibat) MHI
Livtencity (maribavir) MHI
Long-Acting Injectable Antipsychotic Agents IL Medicaid Only C27179-A
Lucemyra (lofexidine) MHI
Lumizyme, Myozyme (Alglucosidase alfa) MHI
Lupkynis (voclosporin) MHI
Lyrica.Lyrica CR (pregabalin.pregabalin ER) MHI
Medical Necessity Review IL Medicaid Only C22913-A
Mepron (atovaquone) MHI
Mepsevii (vestronidase alfa-vjbk) MHI
Mozobil (plerixafor injection) MHI
Mulpleta (lusutrombopag) MHI
Multiple Sclerosis Agents- Interferons MHI
Myalept (metreleptin) MHI
Mycamine (micafungin) MHI
Nasal Steroids MHI
Natpara (parathyroid hormone) MHI
Nexletol (bempedoic acid) Nexlizet (bempedoic acid and ezetimibe) MHI
NexoBrid (anacaulase gel) MHI
Nexviazyme (avalglucosidase alfa-ngpt) MHI
Northera (droxidopa) MHI
Nplate (romiplostim) MHI
Nucala (mepolizumab) MHI
Nuedexta (dextromethorphan/quinidine) MHI
Nulibry (fosdenopterin) MHI
Nulojix (belatacept) MHI
Nuplazid (pimavanserin) MHI
Nuzyra (omadacycline) MHI
Ocaliva (obeticholic acid) MHI
Ocrevus (ocrelizumab) MHI
Octreotide MHI
Ofev (nintedanib) MHI
Off-Label Use of Drugs and Biologic Agents MHI
Ojjaara (momelotinib) MHI
Olumiant (baricitinib) MHI
Omega-3 Fatty Acids IL Medicaid Only C4708-A
Omvoh (mirikizumab) MHI
Onpattro (patisiran) and Tegsedi (inotersen) MHI
Opfolda (miglustat) MHI
Opioid Global Criteria IL Medicaid Only C24663-A
Opioid Induced Constipation Agents MHI
Opzelura IL Medicaid Only C24359-A
Oral MS Disease-Modifying Therapies MHI
Orencia (abatacept) MHI
Orgovyx (relugolix), Myfembree (relugolix, estradiol, and norethindrone) MHI
Orilissa Oriahnn IL Medicaid Only C24157-A
Orladeyo (berotralstat) MHI
Otezla (apremilast) MHI
Otrexup, Rasuvo, RediTrex (methotrexate) MHI
Oxbryta (voxelotor) MHI
Oxervate (cenegermin) MHI
Oxlumo (lumasiran) MHI
Ozurdex (dexamethasone intravitreal implant) MHI
Palforzia [peanut (Arachis hypogaea) allergen powder-dnfp] MHI
Palynziq (pegvaliase-pqpz) MHI
Parsabiv (etelcalcetide) MHI
PCSK9 Inhibitors MHI
Physician Administered Drugs MHI
Pombiliti (cipaglucosidase alfa) MHI
Prescription Compound Products MHI
Prescription Digital Therapeutics MHI
Prevymis (letermovir) MHI
Procysbi_Cystagon (cysteamine bitartrate) MHI
Prolia (denosumab) MHI
Promacta (eltrombopag) MHI
Pulmicort Respules (budesonide) MHI
Pulmonary Arterial Hypertension IL Medicaid Only C17185-A
Pulmozyme (dornase alfa) MHI
Pyrukynd (mitapivat) MHI
Qalsody (tofersen) MHI
Qutenza (capsaicin) MHI
Radicava (edaravone) MHI
Ranibizumab and Biosimilars (Lucentis, Byooviz, Cimerli) MHI
Ravicti (glycerol phenylbutyrate) MHI
Reblozyl (luspatercept-aamt) MHI
Rebyota (fecal microbiota) MHI
Recorlev (levoketoconazole) MHI
Regranex (becaplermin) MHI
Relizorb (immobilized lipase cartridge) MNR MHI
Revcovi (elapegademase) MHI
Reyvow (lasmiditan) MHI
Rezurock (belumosudil) MHI
Rezzayo (rezafungin) MHI
Riluzole (Rilutek_Tiglutik_Exservan) MHI
Rinvoq (Upadacitinib) MHI
Rituxan (rituximab) and Biosimilars MHI
Rolvedon, Neulasta and Related Biosimilars MHI
Ryplazim (plasminogen, human) MHI
Rystiggo (rozanolixizumab) MHI
Santyl (collagenase) MHI
Saphnelo (anifrolumab) MHI
Savella (milnacipran) MHI
Sensipar (cinacalcet) MHI
Serotonin-Norepinephrine Reuptake Inhibitors (SNRI) MHI
Sexual Dysfunction Criteria- Non-Coverage MHI
Seysara (sarecyline) MHI
Signifor (pasireotide diaspartate) MHI
Siliq (brodalumab) MHI
Simponi/Simponi Aria (golimumab) MHI
Sivextro (tedizolid) MHI
Skyclarys (omaveloxolone) MHI
Skyrizi (risankizumab-rzaa) MHI
Sodium Oxybate (Lumryze, Xyrem, Xywav) MHI
Sohonos (palvarotene) MHI
Soliris_Ultomiris (eculizumab_ravulizumab) MHI
Sotyktu (deucravacitinib) MHI
Spevigo (spesolimab-sbzo) MHI
Spiriva (tiotropium) MHI
Sporanox, Tolsura (itraconazole) MHI
Spravato (esketamine) MHI
Standard Oncology Criteria MHI
Stelara (ustekinumab) MHI
Strensiq (asfotase alfa) MHI
Sunlenca (lenacapavir) MHI
Sunosi (solriamfetol) MHI
Supprelin (histrelin) MHI
Syfovre (pegcetacoplan) MHI
Symlin (pramlintide) MHI
Synagis (palivizumab) MHI
Synarel (nafarelin acetate, nasal solution) MHI
Tadalafil and combinations for BPH MHI
Taltz (ixekizumab) MHI
Tarpeyo MHI
Tavalisse (fostamatinib) MHI
Tavneos (avacopan) MHI
Tepezza (teprotumumab-trbw) MHI
Testosterone MHI
Tezspire (tezepelumab) MHI
Thiola (tiopronin) MHI
Tobramycin for inhalation MHI
Tolvaptan MHI
Topical Acne And Topical Rosacea IL Medicaid Only C21454-A
Topical Antibacterials MHI
Tremfya (guselkumab) MHI
Triptodur (triptorelin pamoate) MHI
Trogarzo (ibalizumab-uiyk) MHI
Tymlos (abaloparatide) MHI
Tysabri (natalizumab) MHI
Uplizna (inebilizumab) MHI
Vabysmo (faricimab) MHI
Valcyte (valganciclovir) MHI
Vancocin (vancomycin) Capsules MHI
Veklury (remdesivir) MHI
Velsipity (etrasimod) MHI
Veopoz (pozelimab) MHI
Veozah (fezolinetant) MHI
Verquvo IL Medicaid Only C22082-A
Vibativ (telavancin) MHI
Vibrant (transient device for constipation capsule) MNR MHI
Vijoice (alpelisib) MHI
Viltepso (viltolarsen) MNR MHI
Vimizim (elosulfase alfa) MHI
Vonjo (pacritinib) MHI
Voxzogo (vosoritide) MHI
Vtama (tapinarof) cream MHI
Vyndaqel_Vyndamax (tafamidis) MHI
Vyondys 53 (golodirsen) MNR MHI
Vyvgart (efgartigimiod alfa) MHI
Wakix (pitolisant) MHI
Wegovy (semaglutide) MNR MHI
Xacduro (sulbactam and durlobactam) MHI
Xeljanz IL Medicaid Only C22209-A
Xenazine (tetrabenazine) MHI
Xenpozyme (olipudase alfa-rpcp) MHI
Xermelo (telotristat ethyl) MHI
Xgeva (denosumab) MHI
Xiaflex (collagenase clostridium histolyticum) MHI
Xifaxan (rifaximin)_Aemcolo (rifamycin) MHI
Xipere (triamcinolone acetonide ocular inj)
Xolair (Omalizumab) MHI
Xphozah (tenapanor) MHI
Zavesca (miglustat) MHI
Zemplar (paricalcitol) MHI
Zilretta (Triamcinolone ER Injection) MHI
Zinplava (bexlotoxumab) MHI
Zokinvy (lonafarnib) MHI
Zoladex (goserelin acetate) MHI
Zortress (everolimus) MHI
Zoryve MHI
Zoryve (roflumilast) MHI
Zovirax (acyclovir) Topical MHI
Ztalmy MHI
Zulresso (brexanolone) MHI
Zurzuvae (zuranolone) MHI
Radiology Medical Policies
Please visit MolinaClinicalPolicy.comfor Radiology Medical policies.
Utilization Management Policies
Please visit MolinaClinicalPolicy.com for Utilization Management policies.
Evolent (NCH) Policies
Molina Healthcare partners with Evolent (New Century Health) to administer cardiology and oncology services for members ages 18 and over. For clinical policies related to cardiology and oncology, please visit the New Century Health website or log into the NCH provider portal