| Ambetter Health Texas Wellcare Allwell Medicare Clinical | Continuous Insulin Delivery Systems | 2020-11-01 |
| Ambetter Health Texas Wellcare Allwell Medicare Clinical | Pralsetinib | 2020-11-01 |
| Ambetter Health Texas Wellcare Allwell Medicare Clinical | Budesonide/Glycopyrrolate/Formoterol Fumarate | 2020-11-01 |
| Meridian Michigan Medicaid Clinical | CC.PP.067 Renal Hemodialysis | 2020-11-01 |
| Buckeye Health Plan Ohio Medicaid Clinical | Extended Ophthalmoscopy | 2020-11-01 |
| Buckeye Health Plan Ohio Medicaid Clinical | Fluorescein Angiography | 2020-11-01 |
| Buckeye Health Plan Ohio Medicaid Clinical | Fundus Photography | 2020-11-01 |
| Buckeye Health Plan Ohio Medicaid Clinical | Gonioscopy | 2020-11-01 |
| Buckeye Health Plan Ohio Medicaid Clinical | Scanning Computerized Opthalmic Diagnostic | 2020-11-01 |
| Buckeye Health Plan Ohio Medicaid Clinical | Visual Field Testing | 2020-11-01 |