| HealthPartners | Tofersen (Qalsody™) | 2025-07-01 |
| Ambetter Health Illinois Clinical | Intradiscal Steroid Injections for Pain Management | 2025-07-01 |
| Ambetter Health Illinois Clinical | Sacroiliac Joint Interventions for Pain Management | 2025-07-01 |
| Ambetter Health Michigan Meridian Clinical | Sacroiliac Joint Interventions for Pain Management | 2025-07-01 |
| Sentara Health Plans | Ambulatory Devices, DME 40 - Commercial | 2025-07-01 |
| Sentara Health Plans | Ambulatory Devices, DME 40 - Medicaid | 2025-07-01 |
| Sentara Health Plans | ASAM Level 2.1 Intensive Outpatient Services - Medicaid | 2025-07-01 |
| Sentara Health Plans | ASAM Level 2.1 Intensive Outpatient Services - Medicaid | 2025-07-01 |
| Sentara Health Plans | ASAM Level 2.1 Adult (Concurrent) Intensive - Medicaid | 2025-07-01 |
| Sentara Health Plans | ASAM Level 2.1 Intensive Outpatient Services - Medicaid | 2025-07-01 |