Information

Title Medical Specialty Drug Policies: A-C

Content

Precertification is required for designated new-to market specialty drugs. Precertification of the drug will be required on the market launch date of the drug. For details, please refer to Specialty Drugs Requiring Precertification.

Existing Policies

HMSA medical policies rely on the use of evidence-based medicine, which typically comes from peer-reviewed literature. Physicians submitting comments should include citation source material to support their positions. Inclusion of this material will help HMSA's pharmacy benefit manager and HMSA's medical directors evaluate the comment or proposed change.

Physicians may contact HMSA's pharmacy benefit manager by email to HMSAPAReview@caremark.com or by fax at 1-866-237-5512 for questions/comments.

Current Policies:

D-F

G-H

I-K

L-N

O-R

S-U

V-Z

#

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
1% sodium hyaluronate (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (MA)

A

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Abecma (idecabtagene vicleucel)	Please contact HMSA at 808-948-6464, option #4, for drug review
1. Abrilada (adalimumab-afzb)(Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Abrilada (adalimumab-afzb) (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 12/1/2023	ARCHIVED - Adalimumab (Humira)
Abrilada (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
1. Actemra (tocilizumab) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Actemra Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Actemra (tocilizumab) (Commercial)		04/01/2026	Commercial Fax Form QUEST Fax Form	Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (COMM-QUEST) ARCHIVED - Actemra
Actemra (tocilizumab) (QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (COMM-QUEST) ARCHIVED - Actemra
Actemra (tocilizumab) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form		ARCHIVED - Actemra (MA)
Actimmune (interferon gamma-1b)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Adakveo (crizanlizumab-tmca)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Adalimumab Preferred Drug Program + Drug Specific Criteria (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
1. adalimumab-aacf (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for adalimumab-aacf Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. adalimumab-aacf (Commercial)		05/25/2025		Humira (adalimumab) Effective 7/1/2024	ARCHIVED - Humira
Adalimumab-aacf (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
1. adalimumab-aaty (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for adalimumab-aaty Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. adalimumab-aaty (Commercial)		05/25/2025		Humira (adalimumab) Effective 7/1/2024	ARCHIVED - Adalimumab (Humira)
Adalimumab-aaty (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
1. adalimumab-adaz (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for adalimumab-adaz Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. adalimumab-adaz (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 7/1/2024	ARCHIVED - Adalimumab (Humira)
adalimumab-adaz (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
1. adalimumab-adbm (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for adalimumab-adbm Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. adalimumab-adbm (Commercial)		05/25/2025		Humira (adalimumab) Effective 7/1/2024	ARCHIVED - Adalimumab (Humira)
adalimumab-adbm (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
adalimumab-bwwd (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
1. adalimumab-fkjp (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for adalimumab-fkjp Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. adalimumab-fkjp (Commercial)		05/25/2025		Humira (adalimumab) Effective 7/1/2024	ARCHIVED - Adalimumab (Humira)
adalimumab-fkjp (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
1. adalimumab-ryvk (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for adalimumab-ryvk Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. adalimumab-ryvk (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 7/1/2024	ARCHIVED - Adalimumab (Humira)
adalimumab-ryvk (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
1. Adbry (tralokinumab-idrm) (Atopic Dermatitis Preferred Program) (Commercial)		01/01/2026		Atopic Dermatitis Preferred Program Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Atopic Dermatitis (Commercial)
2. Adbry (tralokinumab-idrm) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Effective 7/1/23: Drug specific policy Specialty Drugs Requiring Precertification (SDRP) eff 4/1/2022; eff 7/1/2023 - removed from SDRP policy	ARCHIVED - Adbry ARCHIVED - SDRP
Adbry (QUEST)	60-day provider notice 05/01/2026-06/30/2026, in effect 07/01/2026
Adstiladrin (nadofaragene firadenovec-vncg)	Please contact HMSA at 808-948-6464, option #4, for drug review
Aduhelm (aducanumab-avwa)	Please contact HMSA at 808-948-6464, option #4, for questions
Advate [Factor VIII (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Adynovate [Factor VIII (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Adzynma (ADAMTS13, recombinant-krhn)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 12/01/2023	ARCHIVED - SDRP
Afstyla [Factor VIII (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Aimovig (erenumab-aooe)		04/14/2026	Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Ajovy (fremanezumab-vfrm)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Alhemo [Tissue Factor Pathway Inhibitor (concizumab-mtci)]	Please contact HMSA at 808-948-6464, option #4, for drug review.
Alimta (Pemetrexed)	Alimta discontinued as of 04/01/2026			Global Oncology	ARCHIVED - Global Oncology
Aliqopa (copanlisib)				Aliqopa was removed from the market. Global Oncology	ARCHIVED - Global Oncology
Alphanate [Factor VIII (plasma derived)]	Please contact HMSA at 808-948-6464, option #4, for drug review
AlphaNine SD [Factor IX (plasma derived)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Alprolix [Factor IX (Recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Altuviiio [Factor VIII (Recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Alyglo (Commercial and QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG) - Comm-QUEST	ARCHIVED - IVIG (Comm-QUEST)
Alyglo (Medicare Advantage)		10/01/2025	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
1. Alymsys (bevacizumab-maly) (Bevacizumab Preferred Drug Program policy Commercial)		01/01/2026	Commercial Fax Form	Bevacizumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Bevacizumab Products (Commercial)
2. Alymsys (bevacizumab-maly) (Commercial)		04/14/2026		Global Oncology Effective 10/11/2023	ARCHIVED - Global Oncology
1. Alymsys (bevacizumab-maly) (Bevacizumab Preferred Drug Program policy Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Bevacizumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Bevacizumab Products (MA)
2. Alymsys (bevacizumab-maly) (Medicare Advantage)		04/14/2026		Global Oncology Effective 10/11/2023	ARCHIVED - Global Oncology
1. Alymsys (bevacizumab-maly) (Bevacizumab Preferred Drug Program policy QUEST)		01/01/2026		Bevacizumab Products - Preferred Drug Program QUEST Effective 1/1/2025	ARCHIVED - Bevacizumab Products (QUEST)
2. Alymsys (bevacizumab-maly) (QUEST)		04/14/2026	QUEST Fax Form	Global Oncology Effective 10/11/2023	ARCHIVED - Global Oncology
1. Amjevita (adalimumab-atto) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Amjevita (adalimumab-atto) (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 12/1/2023	ARCHIVED - Adalimumab (Humira)
Amjevita (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
Amondys 45 (casimersen)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Amtagvi (lifileucel)	Please contact HMSA at 808-948-6464, option #4, for drug review
Amvuttra (vutrisiran)	Effective 02/15/2024: Please contact HMSA at 808-948-6464, option #4, for drug review			Effective 2/15/2024 PA review for Amvuttra is moved from CVS to HMSA review
Andembry (garadacimab-gxii)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 07/01/2025	ARCHIVED - SDRP
Anktiva (nogapendekin alfa inbakicept-pmln)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Effective 5/17/2024	ARCHIVED - Global Oncology
Aphexda (motixafortide)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 10/01/2023	ARCHIVED - SDRP
Apligraf (graftskin)	Please contact HMSA at 808-948-6464, option #4, for drug review
Aranesp				No PA required as of 11/23/2015
Arcalyst (rilonacept) (Commercial and QUEST)	No PA required for Medicare Advantage effective 1/1/2024	04/01/2026	Commercial Fax Form QUEST Fax Form		ARCHIVED - Arcalyst
arsenic trioxide (generic)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Asceniv (immune globulin intravenous, human – slra) (Commerical & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG) - Comm-QUEST	ARCHIVED - IVIG (Comm-QUEST)
Asceniv (immune globulin intravenous, human – slra) (Medicare Advantage)		10/01/2025	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Asparlas (calaspargase pegol-mknl)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Atopic Dermatitis Preferred Program (Commercial)		01/01/2026		Atopic Dermatitis Preferred Program	ARCHIVED - Atopic Dermatitis (Commercial)
Autoimmune Preferred Drug Program (Commercial)		01/01/2026			ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
1. Avastin (bevacizumab) (Bevacizumab Preferred Drug Program policy Commercial)		01/01/2026	Commercial Fax Form	Bevacizumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Bevacizumab Products (Commercial)
2. Avastin (bevacizumab) (Commercial)		04/14/2026		Global Oncology	ARCHIVED - Global Oncology
1. Avastin (bevacizumab) (Bevacizumab Preferred Drug Program policy Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Bevacizumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Bevacizumab Products (MA)
2. Avastin (bevacizumab) (Medicare Advantage)		04/14/2026		Global Oncology	ARCHIVED - Global Oncology
1. Avastin (bevacizumab) (Bevacizumab Preferred Drug Program policy QUEST)		01/01/2026		Bevacizumab Products - Preferred Drug Program QUEST Effective 1/1/2025	ARCHIVED - Bevacizumab Products (QUEST)
2. Avastin (bevacizumab) (QUEST)		04/14/2026	QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
Avastin (bevacizumab) (Retinal Disorders) (Commercial and QUEST) (non-oncology)	No PA required				ARCHIVED - Retinal Disorders Preferred Drug Program (Commercial)
Avastin (bevacizumab) (Retinal Disorders) (Medicare Advantage) (non-oncology)	No PA required as of 01/01/2024			Retinal Disorders Preferred Drug Program Effective 6/1/2021	ARCHIVED - Retinal Disorders Preferred Drug Program (MA)
Avlayah (tividenofusp alfa-eknm)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 10/01/2023	ARCHIVED - SDRP
Avonex (interferon beta-1a) (Commercial)	No PA required as of 7/1/2022	11/21/2025		Multiple Sclerosis (MS) - Interferons Preferred Drug Program	ARCHIVED - Multiple Sclerosis (MS) – Preferred Drug Program
1. Avsola (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	See below for Avsola Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Avsola (infliximab-axxq) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Infliximab-Avsola-Inflectra-Remicade-Renflexis-Zymfentra	ARCHIVED - Infliximab (Comm-QUEST) ARCHIVED - Infliximab
Avsola (infliximab-axxq) (QUEST)	60-day provider notice 05/01/2026-06/30/2026, in effect 07/01/2026			Infliximab-Avsola-Inflectra-Renflexis-Zymfentra (QUEST)
Avsola (infliximab-axxq) (Medicare Advantage)		12/19/2025	Medicare Advantage Fax Form	Infliximab-Avsola-Inflectra-Remicade-Renflexis MA	ARCHIVED - Infliximab (MA)
Avtozma (tocilizumab-anoh) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (COMM-QUEST)
Avtozma (tocilizumab-anoh) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (MA)
Azedra	No PA required			No PA required as of 3/1/2019

B

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Bavencio (avelumab)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Beizray (docetaxel)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added eff 11/18/2025	ARCHIVED - Global Oncology
Benefix [Factor IX (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Benlysta (belimumab) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form		ARCHIVED - Benlysta (Comm-QUEST) ARCHIVED - Benlysta
Benlysta (belimumab) (Medicare Advantage)		06/27/2025	Medicare Advantage Fax Form		ARCHIVED - Benlysta (MA)
1. Beovu (brolucizumab-dbll) (Medicare Advantage)	No PA required as of 01/01/2024 for Retinal Disorders			Retinal Disorders Preferred Drug Program	ARCHIVED - Retinal Disorders Preferred Drug Program (MA)
2. Beovu (brolucizumab-dbll)	No PA required as of 01/11/2024			Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
1. Berinert (C1 esterase inhibitor [human]) (Hereditary Angioedema Preferred Drug Program) (Commercial)		11/21/2025	Refer below for Berinert Fax Forms	Hereditary Angioedema Preferred Drug Program	ARCHIVED - Hereditary Angioedema Preferred Drug Program
2. Berinert (C1 esterase inhibitor [human]) (Commercial and QUEST)		01/19/2026	Commercial Fax Form QUEST Fax Form		ARCHIVED - Berinert (Comm-QUEST) ARCHIVED - Berinert
Berinert (C1 esterase inhibitor [human]) (Medicare Advantage)		12/19/2025	Medicare Advantage Fax Form		ARCHIVED - Berinert (MA)
Besponsa (inotuzumab ozogamicin)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Besremi ropeginterferon alfa-2b-njft)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Betaseron (interferon beta-1b) (Commercial)	No PA required	11/21/2025		Multiple Sclerosis (MS) - Interferons Preferred Drug Program	ARCHIVED - Multiple Sclerosis (MS) – Preferred Drug Program
Bevacizumab Preferred Drug Program (Commercial)		01/01/2026		Bevacizumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Bevacizumab Products (Commercial)
Bevacizumab Preferred Drug Program (Medicare Advantage)		01/01/2026		Bevacizumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Bevacizumab Products (MA)
Bevacizumab Preferred Drug Program (QUEST)		01/01/2026		Bevacizumab Products - Preferred Drug Program MA Effective 1/1/2025	ARCHIVED - Bevacizumab Products (QUEST)
Bildyos (denosumab-nxxp) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Prolia and Biosimilars (Commercial and QUEST)	ARCHIVED - Prolia (Comm-QUEST)
1. Bimzelx (bimekizumab-bkzx) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Bimzelx Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Bimzelx (bimekizumab-bkzx) (Commercial and QUEST)		02/01/2026	Commercial Fax Form QUEST Fax Form	Drug-specific policy in effect 2/1/2026 Specialty Drugs Requiring Precertification (SDRP) Removed effective 2/1/2026	ARCHIVED - Bimzelx ARCHIVED - SDRP
Bimzelx (bimekizumab-bkzx) (Medicare Advantage)		04/14/2026	Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Bivigam (human immunoglobulin) (Commercial & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QUEST)
Bivigam (human immunoglobulin) (Medicare Advantage)		10/01/2025	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Bizengri (zenocutuzumab-zbco)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Bkemv (eculizumab-aeeb) (Commercial and QUEST)		12/19/2025		Soliris	ARCHIVED - Soliris (Comm-QUEST)
Bkemv (eculizumab-aeeb) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Soliris-Bkemy-Epysqli	ARCHIVED - Soliris (MA)
Blenrep (belantamab mafodotin-blmf)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Bomyntra (denosumab-bnht) (Commercial and QUEST)		06/27/2025	Commercial Fax Form QUEST Fax Form	Xgeva and Biosimilars (Commercial and QUEST) Added eff 6/27/2025	ARCHIVED - Xgeva (Comm-QUEST)
Bomyntra (denosumab-bnht) (Medicare Advantage)		06/27/2025	Medicare Advantage Fax Form	Xgeva and Biosimilars (Medicare Advantage) Added eff 6/27/2025	ARCHIVED - Xgeva (MA)
Bonsity (teriparatide)		06/27/2025	Fax Form	Forteo (teriparatide) Effective 4/1/2023	ARCHIVED - Forteo
bortezomib (generic)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Boruzu (bortezomib)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Bosaya (denosumab-kyqq) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Prolia and Biosimilars (Commercial and QUEST)	ARCHIVED - Prolia (Comm-QUEST)
Botox (Botulinum Toxins)		04/01/2026	Fax Form QUEST Fax Form Medicare Advantage Fax Form	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY)	ARCHIVED - Botulinum Toxins
1. Botox (Botulinum Toxins Preferred Drug Program) (Medicare Advantage)		11/21/2025	Refer below for Botox Fax Forms	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY) Preferred Drug Program	ARCHIVED - Botulinum Toxins Preferred Drug Program MA
2. Botox (onabotulinumtoxinA)		04/01/2026	Fax Form QUEST Fax Form Medicare Advantage Fax Form	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY)	ARCHIVED - Botulinum Toxins
Botulinum Toxins Preferred Drug Program (Medicare Advantage)		11/21/2025	Refer below for Botulinum Toxins Fax Forms	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY) Preferred Drug Program	ARCHIVED - Botulinum Toxins Preferred Drug Program MA
Botulinum Toxins		04/01/2026		Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY)	ARCHIVED - Botulinum Toxins
Breyanzi (lisocabtagene maraleucel)	Please contact HMSA at 808-948-6464, option #4, for drug review
Brineura (cerliponase alfa)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Briumvi (ublituximab-xiiy)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 3/1/2023	ARCHIVED - SDRP
Brixadi (buprenorphine)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 9/1/2023	ARCHIVED - SDRP
Byooviz (ranibizumab-nuna) (Medicare Advantage)	No PA required as of 01/01/2024			Retinal Disorders Preferred Drug Program	ARCHIVED - Retinal Disorders Preferred Drug Program (MA)

C

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Cablivi Kit (caplacizumab-yhdp)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Camcevi (leuprolide mesylate)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Carimune NF (human immunoglobulin) (Commercial & QUEST)				Carimune NF (Commercial and QUEST) inactive and removed as of 09/01/2022. Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG Refer to archived policies eff through 8/31/2022
Carimune NF (human immunoglobulin) (Medicare Advantage)				Carimune NF (Medicare Advantage) inactive and removed as of 09/01/2022. Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA) Refer to archived policies eff through 8/31/2022
Carvykti (ciltacabtagene autoleucel)	Please contact HMSA at 808-948-6464, option #4, for drug review
Casgevy (exagamglogene autotemcel)	Please contact HMSA at 808-948-6464, option #4, for drug review
Cerezyme (imiglucerase) (Commercial and QUEST)		05/23/2025	Fax Form		ARCHIVED - Cerezyme (Commerical-QUEST) ARCHIVED - Cerezyme
Cerezyme (imiglucerase) (Medicare Advantage)		05/23/2025	Medicare Advantage Fax Form		ARCHIVED - Cerezyme (MA)
1. Cimzia (certolizumab pegol) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Cimzia Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Cimzia (certolizumab pegol) (Commercial and QUEST)		08/01/2025	Commercial Fax Form QUEST Fax Form	Specific drug criteria for Cimzia	ARCHIVED - Cimzia (Comm-QUEST) ARCHIVED - Cimzia
Cimzia (certolizumab pegol) (Medicare Advantage)		03/27/2026	Medicare Advantage Fax Form		ARCHIVED - Cimzia (MA)
Cinqair (reslizumab)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Cinryze (C1 esterase inhibitor) (Commercial and QUEST)		01/19/2026	Commercial Fax Form QUEST Fax Form		ARCHIVED - Cinryze (Comm-QUEST) ARCHIVED - Cinryze
Cinryze (C1 esterase inhibitor) (Medicare Advantage)		01/19/2026	Medicare Advantage Fax Form		ARCHIVED - Cinryze (MA)
Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial)		01/01/2026		Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial)	ARCHIVED - CFS Long Acting Preferred Drug Program
Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Medicare Advantage)		01/01/2026		Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (MA)	ARCHIVED - CFS Long Acting Preferred Drug Program (MA)
Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program (Commercial and QUEST)		11/21/2025		Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program	ARCHIVED - CFS Short Acting Preferred Drug Program
Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program (Medicare Advantage)		11/21/2025		CSF–Short Acting Preferred Drug Program MA	ARCHIVED - CSF Short Acting (Preferred Drug Program) (MA)
Columvi (glofitamab-gxbm)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Eff 7/1/2023	ARCHIVED - SDRP
Conexxence (denosumab-bnht) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Prolia and Biosimilars (Commercial and QUEST)	ARCHIVED - Prolia (Comm-QUEST)
Conexxence (denosumab-bnht) (Medicare Advantage)		06/27/2025	Medicare Advantage Fax Form	Prolia and Biosimilars (Medicare Advantage) Added eff 6/27/2025	ARCHIVED - Prolia (MA)
Cosela (trilaciclib)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
1. Cosentyx (secukinumab) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Cosentyx Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Cosentyx (secukinumab) (Commercial and QUEST)		10/01/2025	Commercial Fax Form QUEST Fax Form	Specific drug criteria for Cosentyx eff 10/1/2020	ARCHIVED - Cosentyx (Comm-QUEST)
Criteria Exception (Commercial and QUEST)		01/01/2026			ARCHIVED - Criteria Exception (Comm-QUEST)
Crysvita (burosumab-twza)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Cutaquig (Immune Globulin Subcutaneous [Human] – hipp) (Commercial and QUEST)		10/01/2025	Commercial Fax Form QUEST Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED - SCIG (Comm-QUEST)
Cutaquig (Immune Globulin Subcutaneous [Human] – hipp) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED SCIG (MA)
Cuvitru (Immune Globulin Subcutaneous [Human], 20% Solution) (Commercial and QUEST)		10/01/2025	Commercial Fax Form QUEST Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED - SCIG (Comm-QUEST)
Cuvitru (Immune Globulin Subcutaneous [Human], 20% Solution) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED - SCIG (MA)
1. Cyltezo (adalimumab-adbm) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Cyltezo (adalimumab-adbm) (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 12/1/2023	ARCHIVED - Adalimumab (Humira)
Cyltezo (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
Cyramza (ramucirumab)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology

CVS Caremark^® is an independent company providing pharmacy benefit management services on behalf of HMSA.

Change History

Rev#:	Date:	Nature of Revision:
6.22	05/07/2026	1100-1677778-1848950 The Adbry (QUEST) 60-day notice effective 7/1/2026 has been posted. 1100-1677778-1848950 Infliximab (QUEST) 60-day provider notice (05/01/2026-06/30/2026) in effect 07/01/2026 has been posted for the following drug: Avsola (infliximab-axxq) (QUEST)
6.21	05/04/2026	1100-1677778-1846250 The fax form links for the following drugs have been updated: 2. Adbry (Commercial and QUEST) Benlysta (Commercial and QUEST) Cutaquig (Medicare Advantage) Cuvitru (Medicare Advantage)
6.20	04/29/2026	1100-1677771-1838900 The Global Oncology policy effective 04/14/2026 has been posted for the following drugs covered under this policy. Alimta (pemetrexed) (Discontinued as of 04/01/2026) 2. Alymsys (bevacizumab-maly)(Commercial) 2. Alymsys (bevacizumab-maly)(Medicare Advantage) 2. Alymsys (bevacizumab-maly)(QUEST) Anktiva (nogapendekin alfa inbakicept-pmln) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin(Commercial) 2. Avastin(Medicare Advantage) 2. Avastin(QUEST) Bavencio (avelumab) Beizray (docetaxel) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) Bizengri (zenocutuzumab-zbco) Blenrep (belantamab mafodotin-blmf)(NEW) bortezomib (generic) Boruzu (bortezomib) Camcevi (leuprolide mesylate) Cyramza 1100-1677771-1837550 The SDRP policy eff 04/14/2026 has been posted for the following drugs covered under this policy. Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Andembry (garadacimab-gxii) Aphexda (motixafortide) Avlayah (tividenofusp alfa-eknm) (NEW) Bimzelx (bimekizumab-bkzx) (Medicare Advantage) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
6.19	04/13/2026	1100-1677771-1819704 The following drug has been added: Alhemo [Tissue Factor Pathway Inhibitor (concizumab-mtci)] 1100-1677771-1819705 The Prolia (denosumab) (Commercial and QUEST) policy effective 04/01/2026 has been posted for the following drugs covered under this policy: Bildyos (denosumab-nxxp) (Commercial and QUEST) Bosaya (denosumab-kyqq) (Commercial and QUEST) Conexxence (denosumab-bnht) (Commercial and QUEST)
6.18	04/07/2026	1100-1677764-1802900: The effective date for drugs covered under the Hyaluronates (MA) policy has been corrected from 4/1/2026 to 03/13/2026.
6.17	04/06/2026	1100-1677771-1805800 Cimzia (certolizumab pegol) (Medicare Advantage), 3/27/2026 has been posted. 1100-1677771-1805800 The SDRP policy eff 03/27/2026 has been posted for the following drugs covered under this policy. Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Andembry (garadacimab-gxii) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) (Medicare Advantage) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
6.16	04/02/2026	1100-1677764-1802900 The Hyaluronates (MA) policy effective 04/01/2026 has been posted for the following drug covered under this policy. 1% sodium hyaluronate (Medicare Advantage)
6.15	03/31/2026	1100-1677764-1798651 The Actemra (Commercial and QUEST) policy, effective 04/01/2026, has been posted for the following drugs covered under this policy. 2. Actemra (tocilizumab) (Commercial and QUEST) Avtozma (tocilizumab-anoh) (Commercial and QUEST) 1100-1677764-1798651 The Actemra (Medicare Advantage) policy, effective 04/01/2026, has been posted for the following drugs covered under this policy. 2. Actemra (tocilizumab) (Medicare Advantage) Avtozma (tocilizumab-anoh) (Medicare Advantage) 1100-1677764-1798651 The following policies effective 04/01/2026 have been posted: Adbry (tralokinumab-ldrm) (Commercial and QUEST) Arcalyst (rilonacept) (Commercial and QUEST) Benlysta (belimumab) (Commercial and QUEST) 1100-1677764-1798651 Botulinum Toxins, eff 04/01/2026, has been posted for the following drugs covered under this policy. Botox (onabotulinumtoxinA) 2. Botox Botulinum Toxins 1100-1677764-1802500 Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST) effective 04/01/2026, has been posted for the following drugs covered under this policy. Abrilada (Adalimumab Preferred Drug Program + Drug Specific Criteria)) (QUEST) Adalimumab Preferred Drug Program + Drug Specific Criteria)) (QUEST) adalimumab-aacf (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST) adalimumab-aaty (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST) adalimumab-adaz (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST) adalimumab-adbm (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST) adalimumab-bwwd (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST) adalimumab-fkjp (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST) adalimumab-ryvk (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST) Amjevita (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST) Cyltezo (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)
6.14	03/30/2026	1100-1677764-1798661 Infliximab (Commercial and QUEST) effective 04/01/2026 has been posted to the following drug covered under this policy: 2. Avsola (infliximab-axxq) (Commercial and QUEST) 1100-1677764-1798661 Subcutaneous Immunoglobulin (SCIG) (Medicare Advantage) effective 04/01/2026 has been posted for the following drugs. Cutaquig (Immune Globulin Subcutaneous [Human] – hipp) (Medicare Advantage) Cuvitru (Immune Globulin Subcutaneous [Human], 20% Solution) (Medicare Advantage) 1100-1677764-1798661 Soliris and Biosimilars (Medicare Advantage), effective 04/01/2026, has been posted for the following drug covered under this policy. Bkemv (eculizumab-aeeb) (Medicare Advantage)
6.16	03/23/2026	1100-1677764-1784003 The Global Oncology policy effective 03/13/2026 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 01/13/2026. Alimta (pemetrexed) 2. Alymsys (bevacizumab-maly)(Commercial) 2. Alymsys (bevacizumab-maly)(Medicare Advantage) Alymsys (bevacizumab-maly)(QUEST) Anktiva (nogapendekin alfa inbakicept-pmln) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin(Commercial) 2. Avastin(Medicare Advantage) Avastin(QUEST) Bavencio (avelumab) Beizray (docetaxel) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) Bizengri (zenocutuzumab-zbco) Blenrep (belantamab mafodotin-blmf)(NEW) bortezomib (generic) Boruzu (bortezomib) Camcevi (leuprolide mesylate) Cyramza 1100-1677764-1784000 The SDRP policy eff 03/13/2026 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 02/23/2026. Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Andembry (garadacimab-gxii) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) (Medicare Advantage) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
6.15	02/26/2026	1100-1677757-1758252 The Cimzia (certolizumab pegol) (Medicare Advantage) policy effective 3/1/2026 has been posted. ARCHIVED: 60-day notice and policy eff 1/1/2025.
6.14	02/24/2026	1100-1677757-1754350 The SDRP policy eff 02/23/2026 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 02/09/2026. Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Andembry (garadacimab-gxii) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) (Medicare Advantage) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
6.13	02/17/2026	1100-1677757-1743054 Products Specialty Exceptions (Commercial) policy, effective 01/01/2026 v2, has been posted for the following drugs covered under this policy. 1. Alymsys (bevacizumab-maly) (Commercial) 1. Avastin (bevacizumab) (Commercial) Bevacizumab Preferred Drug Program (Commercial) 1100-1677757-1743054 Products Specialty Exceptions (Medicare Advantage) policy, effective 01/01/2026 v2, has been posted for the following drugs covered under this policy. 1. Alymsys (bevacizumab-maly) (Medicare Advantage) 1. Avastin (bevacizumab) (Medicare Advantage) Bevacizumab Preferred Drug Program (Medicare Advantage) 1100-1677757-1743054 Products Specialty Exceptions (QUEST) policy, effective 01/01/2026 v2, has been posted for the following drugs covered under this policy. 1. Alymsys (bevacizumab-maly) (QUEST) 1. Avastin (bevacizumab) (QUEST) Bevacizumab Preferred Drug Program (QUEST)
6.12	02/12/2026	1100-1677757-1739560 The SDRP policy eff 02/09/2026 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 01/01/2026. Bimzelx (bimekizumab-bkzx) (Medicare Advantage) (NEW) 2. Bimzelx (bimekizumab-bkzx) (Commercial and QUEST) - drug-specific policy effective 2/1/2026. Effective date updated.
6.11	02/10/2026	1100-1677757-1734651 The SDRP policy eff 02/09/2026 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 01/01/2026. Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Andembry (garadacimab-gxii) Aphexda (motixafortide) 2. Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
6.10	02/06/2026	1100-1677757-1723650 Policy notes updated for 2. Avsola (infliximab-axxq) (Commercial and QUEST)
6.09	02/05/2026	1100-1677757-1721600 The Actemra and Biosimilars (Medicare Advantage) policy, redlined 60-day notice effective 04/01/2026, has been posted for the following drugs covered under this policy. Actemra (tocilizumab) (Medicare Advantage) - (Link missed in original update)
6.08	02/04/2026	1100-1677757-1723650 The following 60-day provider notices (02/01/2026-03/31/2026), effective 4/01/2026, have been posted. Adbry (tralokinumab-ldrm) (Commercial and QUEST) Arcalyst (rilonacept) (Commercial and QUEST) 1100-1677757-1723650 Infliximab (Commercial and QUEST) 60-day provider notice (02/01/2026-03/31/2026), effective 04/01/2026, has been posted for the following drug covered under this policy: 2. Avsola (infliximab-axxq) (Commercial and QUEST)
6.07	02/03/2026	1100-1677757-1721600 The Actemra (Commercial and QUEST) policy, redlined 60-day notice effective 04/01/2026, has been posted for the following drugs covered under this policy. 2. Actemra (tocilizumab) (Commercial and QUEST) Avtozma (tocilizumab-anoh) (Commercial and QUEST) (NEW) 1100-1677757-1721600 The Actemra and Biosimilars (Medicare Advantage) policy, redlined 60-day notice effective 04/01/2026, has been posted for the following drugs covered under this policy. Actemra (tocilizumab) (Medicare Advantage) Avtozma (tocilizumab-anoh) (Medicare Advantage) (NEW) 1100-1677757-1721600 The Adalimumab Preferred Drug Program (QUEST) redlined 60-day provider notice (02/01/2026-03/31/2026), effective 04/01/2026, has been posted for the following drugs covered under this policy: Abrilada (adalimumab-afzb) (Preferred Drug Program) QUEST adalimumab-aacf (QUEST) adalimumab-aaty (QUEST) adalimumab-adaz (QUEST) adalimumab-adbm (QUEST) adalimumab-adbm (QUEST) adalimumab-bwwd (QUEST) (NEW) adalimumab-fkjp (QUEST) adalimumab-ryvk (QUEST) (NEW) Amjevita (adalimumab-atto) (Adalimumab Preferred Drug Program) (QUEST) Cyltezo (adalimumab-adbm)(Adalimumab Preferred Drug Program) (QUEST) 1100-1677757-1721600 The Soliris (Medicare Advantage) redlined 60-day provider notice (02/01/2026-03/31/2026), effective 4/01/2026, has been posted for the following drug covered under this policy: Bkemv (eculizumab-aeeb) (Medicare Advantage) (NEW) 1100-1677757-1723601 The Benlysta (belimumab) (Commercial and QUEST) 60-day provider notice (02/01/2026-03/31/2026), effective 4/01/2026, has been posted. 1100-1677757-1723601 Botulinum Toxins (Comm-QUEST-MA) 60-day provider notice 02/01/2026-03/31/2026, in effect 04/01/2026, has been posted for the following drug covered under this policy: Botox (onabotulinumtoxinA) 1100-1677757-1721607 Subcutaneous Immunoglobulin (SCIG) (Medicare Advantage) 60-day provider notice 02/01/2026-03/31/2026, in effect 04/01/2026 has been posted for the following drugs covered under this policy: Cutaquig (Immune Globulin Subcutaneous [Human] – hipp) (Medicare Advantage) Cuvitru (Immune Globulin Subcutaneous [Human], 20% Solution) (Medicare Advantage) 1100-1677757-1721150 The Prolia (denosumab) (Commercial and QUEST) 60-day provider notice 02/01/2026-03/31/2026, in effect 04/01/2026 has been posted for the following drugs covered under this policy: Bildyos (denosumab-nxxp) (Commercial and QUEST) (NEW) Bosaya (denosumab-kyqq) (Commercial and QUEST) (NEW) Conexxence (denosumab-bnht) (Commercial and QUEST)
6.06	02/02/2026	1100-1677750-1720806 Posted 2. Bimzelx (bimekizumab-bkzx) (Commercial and QUEST), 2/1/2026 has been posted. ARCHIVED: 60-day notice.
6.05	01/21/2026	1100-1677750-1704852 Removed the Botulinum Toxins Preferred Provider Program row. Updated the policy notes for Botulinum Toxins and Botox.
6.04	01/20/2026	1100-1677750-1702005 The following policies effective 01/19/2026 have been posted: 2. Berinert (C1 esterase inhibitor [human]) (Commercial and QUEST); ARCHIVED: policy eff 4/1/2024 Cinryze (C1 esterase inhibitor [human]) (Commercial and QUEST); ARCHIVED: policy eff 4/1/2024 Cinryze (C1 esterase inhibitor [human]) (Medicare Advantage); ARCHIVED: policy eff 3/20/2025 1100-1677750-1702005 Updated all instances of QUEST Integration to QUEST.
6.03	01/16/2026	1100-1677750-1699604 The Global Oncology policy effective 01/13/2026 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 12/23/2025. Alimta (pemetrexed) 2. Alymsys (bevacizumab-maly)(Commercial) 2. Alymsys (bevacizumab-maly)(Medicare Advantage) Alymsys (bevacizumab-maly)(QUEST) Anktiva (nogapendekin alfa inbakicept-pmln) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin(Commercial) 2. Avastin(Medicare Advantage) Avastin(QUEST) Bavencio (avelumab) Beizray (docetaxel) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) Bizengri (zenocutuzumab-zbco) Blenrep (belantamab mafodotin-blmf)(NEW) bortezomib (generic) Boruzu (bortezomib) Camcevi (leuprolide mesylate) Cyramza
6.02	01/08/2026	1100-1205577-1682553 Atopic Dermatitis Preferred Program has been added to the policy notes for the drugs covered under this policy. 1100-1677750-1690700 The Global Oncology policy effective 12/23/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 11/21/2025. Alimta (pemetrexed) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Beizray (docetaxel) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) Bizengri (zenocutuzumab-zbco) bortezomib (generic) Boruzu (bortezomib) Camcevi (leuprolide mesylate) Cyramza
6.01	01/05/2026	1100-1677750-1684300 The Criteria Exception (Commercial and QUEST) policy eff 01/01/2026 has been posted. ARCHIVED: 60-day notice and policy eff 9/27/2024.
6.00	01/02/2026	1100-1677750-1684314 The SDRP policy eff 01/01/2026 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 12/23/2025 Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Andembry (garadacimab-gxii) Aphexda (motixafortide) 2. Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
5.60	12/31/2025	1100-1205577-1681552 Colony Stimulating Factors (CSF) – Long Acting Specialty Exceptions (Commercial), effective 01/01/2026, has been posted. ARCHIVED: Policy eff 09/26/2025 1100-1205577-1681552 Colony Stimulating Factors (CSF) – Long Acting Specialty Exceptions (Medicare Advantage), effective 01/01/2026, has been posted. ARCHIVED: Policy eff 09/26/2025. 1100-1205577-1681556 Bevacizumab Products Specialty Exceptions (Commercial) policy, effective 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 09/26/2025 1. Alymsys (bevacizumab-maly) (Commercial) 1. Avastin (bevacizumab) (Commercial) Bevacizumab Preferred Drug Program (Commercial) 1100-1205577-1681556 Bevacizumab Products Specialty Exceptions (Medicare AdvantageMedicare Advantage) policy, effective 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 09/26/2025 1. Alymsys (bevacizumab-maly) (Medicare Advantage) 1. Avastin (bevacizumab) (Medicare Advantage) Bevacizumab Preferred Drug Program (Medicare Advantage) 1100-1205577-1681556 Bevacizumab Products Specialty Exceptions (QUEST) policy, effective 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 09/26/2025 1. Alymsys (bevacizumab-maly) (QUEST) 1. Avastin (bevacizumab) (QUEST) Bevacizumab Preferred Drug Program (QUEST) 1100-1205577-1682553 The Atopic Dermatitis (Commercial) 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: 60-day notice. 1. Adbry (tralokinumab-idrm) (Atopic Dermatitis Preferred Program) Atopic Dermatitis (Commercial) 1100-1205577-1682550 The Autoimmune Preferred Drug Program (Commercial) policy effective 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: 60-day notice and policy effective 10/01/2025 Autoimmune Preferred Drug Program 1. Abrilada (adalimumab-afzb) 1. Actemra (tocilizumab) 1. adalimumab-aacf (Autoimmune Preferred Drug Program) 1. adalimumab-aaty (Autoimmune Preferred Drug Program) 1. adalimumab-adaz (Autoimmune Preferred Drug Program) 1. adalimumab-adbm (Autoimmune Preferred Drug Program) 1. adalimumab-fkjp (Autoimmune Preferred Drug Program) 1. adalimumab-ryvk (Autoimmune Preferred Drug Program) 1. Amjevita (adalimumab-atto) (Autoimmune Preferred Drug Program) 1. Avsola (infliximab) Infliximab (Autoimmune Preferred Drug Program) 1. Bimzelx (bimekizumab-bkzx) (Autoimmune Preferred Drug Program) 1. Cimzia (certolizumab pegol) (Autoimmune Preferred Drug Program) 1. Cosentyx (secukinumab) (Autoimmune Preferred Drug Program) 1. Cyltezo (adalimumab-adbm) (Autoimmune Preferred Drug Program)
5.59	12/30/2025	1100-1205577-1680803 The SDRP policy eff 12/23/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 11/18/2025 Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Andembry (garadacimab-gxii) Aphexda (motixafortide) 2. Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
5.58	12/29/2025	1100-1205577-1679550 The Cimzia (Medicare Advantage) 60-day provider notices 01/01/2026-02/28/2026, in effect 03/01/2026 have been posted.
5.57	12/23/2025	1100-1205577-1671755 Berinert (MA) effective 12/19/2025 has been posted. Archived: policy eff 11/29/2024. 1100-1205577-1671755 Infliximab (Medicare Advantage) policies effective 12/19/2025 have been posted to the following drug covered under these policies, as applicable. Archived: Policy effective 11/15/2024. Avsola (infliximab-axxq) (Medicare Advantage) 1100-1205577-1671755 The Hyaluronates (MA) policy effective 12/19/2025 has been posted for the following drug covered under this policy. ARCHIVED: policy effective 12/20/2024. 1% sodium hyaluronate (Medicare Advantage) 1100-1205577-1672050 Soliris and Biosimilars (Commercial and QUEST), effective 12/19/2025, has been posted for the following drug covered under this policy. ARCHIVED: policy eff 4/01/2025 v2. Bkemv (eculizumab-aeeb) (Commercial and QUEST)
5.56	12/03/2025	1100-1205577-1642506 Colony Stimulating Factors (CSF) – Short Acting Commercial and QUEST Preferred Drug Program effective 11/21/2025, has been posted. Archived: policy effective 01/01/2025. 1100-1205577-1642506 Colony Stimulating Factors (CSF) – Short-Acting Medicare Advantage Preferred Drug Program effective 11/21/2025, has been posted. Archived: Policy effective 1/1/2025. 1100-1205577-1642610 The Global Oncology policy effective 11/21/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 11/18/2025. Alimta (pemetrexed) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Beizray (docetaxel) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) Bizengri (zenocutuzumab-zbco) bortezomib (generic) Boruzu (bortezomib) Camcevi (leuprolide mesylate) Cyramza
5.55	11/26/2025	1100-1205570-1634452 Botulinum Toxins Preferred Drug Program (Medicare Advantage) policy, eff 11/21/2025, has been posted for the following drugs covered under this policy. Archived: Policy eff 1/1/2025. 1. Botox (onabotulinumtoxinA) (Botulinum Toxins Preferred Drug Program) (Medicare Advantage) 1. Botulinum Toxins Preferred Drug Program (Medicare Advantage) 1100-1205570-1634455 The Hereditary Angioedema (HAE) Preferred Drug Program (Commercial) policy effective 11/21/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 12/20/2024. 1. Berinert (C1 esterase inhibitor [human]) (Hereditary Angioedema Preferred Drug Program) (Commercial) 1100-1205570-1634458 Multiple Sclerosis (MS) Preferred Drug Program (Commercial) effective 11/21/2025, has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 10/25/2024. Avonex (interferon beta-1a) (Commercial) - No PA required Betaseron (interferon beta-1b) (Commercial) - No PA required 1100-1205570-1636950 The information in the following rows have been updated: Adalimumab Preferred Program (QUEST) Atopic Dermatitis Preferred Program (Commercial) Autoimmune Preferred Drug Program (Commercial) Botulinum Toxins Preferred Program Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial) 1100-1205570-1642602 2. Bimzelx (bimekizumab-bkzx) 60-day notice eff 2/1/2026 has been posted.
5.54	11/24/2025	1100-1205570-1631470 The SDRP policy eff 11/18/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 10/10/2025 Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Andembry (garadacimab-gxii) Aphexda (motixafortide) 2. Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
5.53	11/20/2025	1100-1205570-1631260 The Global Oncology policy effective 11/18/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 09/18/2025. Alimta (pemetrexed) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Beizray (docetaxel) (NEW) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) Bizengri (zenocutuzumab-zbco) bortezomib (generic) Boruzu (bortezomib) Camcevi (leuprolide mesylate) Cyramza
5.52	11/10/2025	1100-1205570-1613562 The SDRP policy eff 10/10/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 09/12/2025 Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Andembry (garadacimab-gxii) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
5.51	11/05/2025	1100-1205570-1607700 The following drug name has been updated to: 1. Berinert (C1 esterase inhibitor [human]) (Hereditary Angioedema Preferred Drug Program) (Commercial)
5.50	11/03/2025	1100-1205563-1603251 The SDRP policy eff 09/12/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 08/01/2025 v2 Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Andembry (garadacimab-gxii) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
5.49	10/30/2025	1100-1205563-1597750 The Global Oncology policy effective 09/18/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 09/12/2025. Alimta (pemetrexed) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) Bizengri (zenocutuzumab-zbco) bortezomib (generic) Boruzu (bortezomib) Camcevi (leuprolide mesylate) Cyramza
5.48	10/28/2025	1100-1205563-1594400 Criteria Exception 60-day provider notice 11/01/2025-12/31/2025 effective 01/01/2026 has been posted.
5.47	10/23/2025	1100-1205563-1589400 The Autoimmune Preferred Drug Program (Commercial) 60-day provider notice (11/01/2025-12/31/2025) effective 01/01/2026, has been posted for the following drugs covered under this policy: Autoimmune Preferred Drug Program 1. Abrilada (adalimumab-afzb) 1. Actemra (tocilizumab) 1. adalimumab-aacf (Autoimmune Preferred Drug Program) 1. adalimumab-aaty (Autoimmune Preferred Drug Program) 1. adalimumab-adaz (Autoimmune Preferred Drug Program) 1. adalimumab-adbm (Autoimmune Preferred Drug Program) 1. adalimumab-fkjp (Autoimmune Preferred Drug Program) 1. adalimumab-ryvk (Autoimmune Preferred Drug Program) 1. Amjevita (adalimumab-atto) (Autoimmune Preferred Drug Program) 1. Avsola (infliximab) Infliximab (Autoimmune Preferred Drug Program) 1. Bimzelx (bimekizumab-bkzx) (Autoimmune Preferred Drug Program) 1. Cimzia (certolizumab pegol) (Autoimmune Preferred Drug Program) 1. Cosentyx (secukinumab) (Autoimmune Preferred Drug Program) 1. Cyltezo (adalimumab-adbm) (Autoimmune Preferred Drug Program) Revision# from 5.40 were reconciled.
5.46	10/21/2025	1100-1205563-1574400 The following effective dates were updated to 09/26/2025: Colony Stimulating Factors (CSF) – Long Acting Specialty Exceptions (Commercial), Colony Stimulating Factors (CSF) – Long Acting Specialty Exceptions (Medicare Advantage) The following were posted on 10/17/2025: 1100-1205563-1574400 Colony Stimulating Factors (CSF) – Long Acting Specialty Exceptions (Commercial), effective 09/26/2025, has been posted. ARCHIVED: Policy eff 01/01/2025 1100-1205563-1574400 Colony Stimulating Factors (CSF) – Long Acting Specialty Exceptions (Medicare Advantage), effective 09/26/2025, has been posted. ARCHIVED: Policy eff 01/01/2025.
5.45	10/17/2025	1100-1205563-1579050 The SDRP policy eff 08/01/2025 v2 has been posted for the following drugs covered under this policy. Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Andembry (garadacimab-gxii) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita 1100-1205563-1574454 The Prolia fax form links have been updated for Conexxence (Commercial and QUEST) 1100-1205563-1574400 Bevacizumab Products Specialty Exceptions (Commercial) policy, effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 01/01/2025 1. Alymsys (bevacizumab-maly) (Commercial) 1. Avastin (bevacizumab) (Commercial) Bevacizumab Preferred Drug Program (Commercial) 1100-1205563-1574400 Bevacizumab Products Specialty Exceptions (Medicare AdvantageMedicare Advantage) policy, effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 01/01/2025 1. Alymsys (bevacizumab-maly) (Medicare Advantage) 1. Avastin (bevacizumab) (Medicare Advantage) Bevacizumab Preferred Drug Program (Medicare Advantage) 1100-1205563-1574400 Bevacizumab Products Specialty Exceptions (QUEST) policy, effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 01/01/2025 1. Alymsys (bevacizumab-maly) (QUEST) 1. Avastin (bevacizumab) (QUEST) Bevacizumab Preferred Drug Program (QUEST)
5.44	10/02/2025	1100-1205563-1551406 2. Cosentyx (secukinumab) (Commercial and QUEST), 10/1/2025 has been posted; ARCHIVED: 60-day notice and policy eff 4/1/2025 1100-1205563-1551406 The Prolia (denosumab) (Commercial and QUEST) policy effective 10/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: 60-day notice and policy eff 7/26/2024. Conexxence (denosumab-bnht) (Commercial and QUEST) 1100-1205563-1551406 Intravenous Immune Globulin (IVIG) (Medicare Advantage) eff 10/01/2025 has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy eff 4/26/2024. Alyglo (Medicare Advantage) Asceniv (immune globulin intravenous, human - slra) (Medicare Advantage) Bivigam (human immunoglobulin) (Medicare Advantage) 1100-1205563-1551406 Subcutaneous Immunoglobulin (SCIG) (Commercial and QUEST) eff 10/01/2025 has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy eff 4/26/2024. Cutaquig (Immune Globulin Subcutaneous [Human] – hipp) (Commercial and QUEST) Cuvitru (Immune Globulin Subcutaneous [Human], 20% Solution) (Commercial and QUEST) 1100-1205563-1551406 The Autoimmune Preferred Drug Program (Commercial) policy effective 10/1/2025, has been posted for the following drugs covered under this policy. ARCHIVED: 60-day notice and policy effective 6/7/2025 Autoimmune Preferred Drug Program 1. Abrilada (adalimumab-afzb) 1. Actemra (tocilizumab) 1. adalimumab-aacf (Autoimmune Preferred Drug Program) 1. adalimumab-aaty (Autoimmune Preferred Drug Program) 1. adalimumab-adaz (Autoimmune Preferred Drug Program) 1. adalimumab-adbm (Autoimmune Preferred Drug Program) 1. adalimumab-fkjp (Autoimmune Preferred Drug Program) 1. adalimumab-ryvk (Autoimmune Preferred Drug Program) 1. Amjevita (adalimumab-atto) (Autoimmune Preferred Drug Program) 1. Avsola (infliximab) Infliximab (Autoimmune Preferred Drug Program) 1. Bimzelx (bimekizumab-bkzx) (Autoimmune Preferred Drug Program) 1. Cimzia (certolizumab pegol) (Autoimmune Preferred Drug Program) 1. Cosentyx (secukinumab) (Autoimmune Preferred Drug Program) 1. Cyltezo (adalimumab-adbm) (Autoimmune Preferred Drug Program)
5.43	09/30/2025	1100-1205556-1544400 The following policy has been posted: Criteria Exception, 09/26/2025; ARCHIVED policy eff 9/27/24
5.42	09/22/2025	1100-1205556-1528353 The SDRP policy eff 08/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 07/23/2025. Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Andembry (garadacimab-gxii) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
5.41	09/17/2025	1100-1205556-1514402 The Global Oncology policy effective 09/12/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 07/30/2025. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) (Removed from the market.) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) Bizengri (zenocutuzumab-zbco) bortezomib (generic) Boruzu (bortezomib) Camcevi (leuprolide mesylate) Cyramza
5.40	09/16/2025	1100-1205556-1518355 The SDRP policy eff 07/25/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 07/11/2025. Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Andembry (garadacimab-gxii) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
5.39	09/15/2025	1100-1205556-1514402 The Global Oncology policy effective 07/30/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 07/28/2025. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) (Removed from the market.) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) Bizengri (zenocutuzumab-zbco) bortezomib (generic) Boruzu (bortezomib) Camcevi (leuprolide mesylate) Cyramza 1100-1205556-1518352 The Autoimmune Preferred Drug Program (Commercial) 60-day provider notice (8/01/2025-9/30/2025) effective 10/1/2025 v2, has been posted for the following drugs covered under this policy: Autoimmune Preferred Drug Program 1. Abrilada (adalimumab-afzb) 1. Actemra (tocilizumab) 1. adalimumab-aacf (Autoimmune Preferred Drug Program) 1. adalimumab-aaty (Autoimmune Preferred Drug Program) 1. adalimumab-adaz (Autoimmune Preferred Drug Program) 1. adalimumab-adbm (Autoimmune Preferred Drug Program) 1. adalimumab-fkjp (Autoimmune Preferred Drug Program) 1. adalimumab-ryvk (Autoimmune Preferred Drug Program) 1. Amjevita (adalimumab-atto) (Autoimmune Preferred Drug Program) 1. Avsola (infliximab) Infliximab (Autoimmune Preferred Drug Program) 1. Bimzelx (bimekizumab-bkzx) (Autoimmune Preferred Drug Program) 1. Cimzia (certolizumab pegol) (Autoimmune Preferred Drug Program) 1. Cosentyx (secukinumab) (Autoimmune Preferred Drug Program) 1. Cyltezo (adalimumab-adbm) (Autoimmune Preferred Drug Program)
5.38	09/03/2025	1100-1205556-1499704 The Global Oncology policy effective 07/28/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 07/17/2025. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) Bizengri (zenocutuzumab-zbco) bortezomib (generic) Boruzu (bortezomib) Camcevi (leuprolide mesylate) Cyramza 1100-1205556-1499704 The SDRP policy eff 07/11/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 07/01/2025-v2. Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Andembry (garadacimab-gxii) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
5.37	09/02/2025	1100-1205549-1486802 The QUEST fax form links for the following drugs have been updated: Alymsys, Avastin, Bomyntra, Adakveo, Adzynma, Ajovy, Amondys 45, Aphexda, Bimzelx, Brineura, Briumvi, Cablivi, Cinqair, Columzi, Cosela, Crysvita
5.36	08/26/2025	1100-1205549-1488650 The Global Oncology policy effective 07/17/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 07/10/2025. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) Bizengri (zenocutuzumab-zbco) bortezomib (generic) Boruzu (bortezomib) Camcevi (leuprolide mesylate) Cyramza 1100-1205549-1488650 The SDRP policy eff 07/01/2025-v2 has been posted for the following drugs covered under this policy. Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Andembry (garadacimab-gxii) (NEW) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
5.35	08/18/2025	1100-1205549-1463454 Andembry (garadacimab-gxii) - revised policy note to "Added Effective 07/01/2025"
5.34	08/12/2025	1100-1205549-1463454 The SDRP policy eff 07/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 06/01/2025. Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Andembry (garadacimab-gxii) (NEW) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita 1100-1205549-1463454 The Global Oncology policy effective 07/10/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 05/08/2025. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) Bizengri (zenocutuzumab-zbco) bortezomib (generic) Boruzu (bortezomib) Camcevi (leuprolide mesylate) Cyramza
5.33	08/11/2025	1100-1205549-1463450 Intravenous Immune Globulin (IVIG) (Commercial and QUEST) effective 7/25/2025, has been posted for the following drugs covered under this policy. Archived: policy eff 5/23/2025. Alyglo (Commercial and QUEST) Asceniv (Commercial and QUEST) Bivigam (Commercial and QUEST)
5.32	08/07/2025	1100-1205549-1463400 The Cosentyx (Commercial and QUEST) 60-day provider notice (8/1/2025-9/30/2025) eff 10/1/2025 has been posted. 1100-1205549-1463400 The Prolia (denosumab) (Commercial and QUEST) 60-day provider notice (08/01/2025-09/30/2025) eff 10/01/2025 has been posted for the following drugs covered under this policy: Conexxence (denosumab-bnht) (Commercial and QUEST) (NEW) 1100-1205549-1463400 The Subcutaneous Immunoglobulin (SCIG) (Commercial and QUEST) 60-day provider notice (8/01/2025-9/30/2025) effective 10/01/2025 has been posted for the following drugs covered under this policy: Cutaquig (Commercial and QUEST) Cuvitru (Commercial and QUEST) 1100-1205549-1463400 The Intravenous Immune Globulin (IVIG) (Medicare Advantage) 60-day provider notice (08/01/2025-09/30/2025) eff 10/01/2025 has been posted for the following drugs covered under this policy. Alyglo (Medicare Advantage) Asceniv (immune globulin intravenous, human - slra) (Medicare Advantage) Bivigam (human immunoglobulin) (Medicare Advantage) 1100-1205549-1463400 The Autoimmune Preferred Drug Program (Commercial) 60-day provider notice (8/01/2025-9/30/2025) effective 10/1/2025, has been posted for the following drugs covered under this policy: Autoimmune Preferred Drug Program 1. Abrilada (adalimumab-afzb) 1. Actemra (tocilizumab) 1. adalimumab-aacf (Autoimmune Preferred Drug Program) 1. adalimumab-aaty (Autoimmune Preferred Drug Program) 1. adalimumab-adaz (Autoimmune Preferred Drug Program) 1. adalimumab-adbm (Autoimmune Preferred Drug Program) 1. adalimumab-fkjp (Autoimmune Preferred Drug Program) 1. adalimumab-ryvk (Autoimmune Preferred Drug Program) 1. Amjevita (adalimumab-atto) (Autoimmune Preferred Drug Program) 1. Avsola (infliximab) Infliximab (Autoimmune Preferred Drug Program) 1. Bimzelx (bimekizumab-bkzx) (Autoimmune Preferred Drug Program) 1. Cimzia (certolizumab pegol) (Autoimmune Preferred Drug Program) 1. Cosentyx (secukinumab) (Autoimmune Preferred Drug Program) 1. Cyltezo (adalimumab-adbm) (Autoimmune Preferred Drug Program)
5.31	08/05/2025	1100-1205549-1457500 2. Cimzia (Commercial and QUEST) effective 8/1/2025, has been posted. ARCHIVED: 60-day notice and policy eff 8/01/2
5.30	07/27/2025	1100-1205542-1427101 The following drug policy effective 6/27/2025 has been posted: Benlysta (belimumab) (Medicare Advantage); ARCHIVED: policy eff 7/26/2024 Bonsity - hyperlink has been removed. 1100-1205542-1427101 Prolia and Biosimilars (Medicare Advantage), 6/27/2025 has been posted for the following drug covered under this policy: Conexxence (denosumab-bnht) (Medicare Advantage) (NEW) 1100-1205542-1427101 Xgeva and Biosimilars (Commercial and QUEST), 6/27/2025 has been posted for the following drug covered under this policy: Bomyntra (denosumab-bnht) (Commercial and QUEST) (NEW) 1100-1205542-1427101 Xgeva and Biosimilars (Medicare Advantage), 6/27/2025 has been posted for the following drug covered under this policy: Bomyntra (denosumab-bnht) (Medicare Advantage) (NEW)
5.29	06/30/2025	1100-1205535-1366050 The SDRP policy eff 06/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 05/23/2025. Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita 1100-1205535-138830 Soliris (Commercial and QUEST), effective 4/01/2025 v2, has been posted for the following drug covered under this policy. ARCHIVED: policy eff 4/01/2025. Bkemv (eculizumab-aeeb) (Commercial and QUEST)
5.28	06/10/2025	1100-1205535-1368400 Autoimmune (AI) Preferred Drug Program (Commercial) effective 6/07/2025 has been posted for the following drugs covered under this policy. ARCHVIED: Policy effective 2/14/2025. Autoimmune Preferred Drug Program 1. Abrilada (adalimumab-afzb) 1. Actemra (tocilizumab) 1. adalimumab-aacf (Autoimmune Preferred Drug Program) (NEW) 1. adalimumab-aaty (Autoimmune Preferred Drug Program) (NEW) 1. adalimumab-adaz (Autoimmune Preferred Drug Program) 1. adalimumab-adbm (Autoimmune Preferred Drug Program) (NEW) 1. adalimumab-fkjp (Autoimmune Preferred Drug Program) (NEW) 1. adalimumab-ryvk (Autoimmune Preferred Drug Program) 1. Amjevita (adalimumab-atto) (Autoimmune Preferred Drug Program) 1. Avsola (infliximab) Infliximab (Autoimmune Preferred Drug Program) 1. Bimzelx (bimekizumab-bkzx) (Autoimmune Preferred Drug Program) 1. Cimzia (certolizumab pegol) (Autoimmune Preferred Drug Program) 1. Cosentyx (secukinumab) (Autoimmune Preferred Drug Program) 1. Cyltezo (adalimumab-adbm) (Autoimmune Preferred Drug Program) 1100-1205535-1366050 The SDRP policy eff 05/23/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 05/15/2025, v2. Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita Intravenous Immune Globulin (IVIG) (Commercial and QUEST) effective 5/23/2025, has been posted for the following drugs covered under this policy. Archived: policy eff 12/20/2024. Alyglo (Commercial and QUEST) Asceniv (Commercial and QUEST) Bivigam (Commercial and QUEST) The following policies have been posted effective 5/23/2025: Cerezyme (imiglucerase) (Commercial and QUEST), Archived: 11/29/2024 Cerezyme (imiglucerase) (Medicare Advantage), Archived: 5/24/2024
5.27	06/03/2025	1100-1205535-1358903 Linked Actimmune (interferon gamma-1b) to the SDRP policy, eff 5/15/2025. 1100-1205535-1358909 2. Cimzia (Commercial and QUEST) 60-day notice (6/01/2025-7/31/2025), effective 8/1/2025, has been posted.
5.26	05/22/2025	1100-1205528-1346450 The following fax form links have been updated. Avsola (QUEST) 2. Abrilada (adalimumab-afzb) (Commercial) 2. adalimumab-adaz (Commercial) adalimumab-ryvk (Commercial) (NEW) 2. Amjevita (adalimumab-atto) (Commercial) 2. Avsola (infliximab-axxq) (Commercial and QUEST) 2. Cyltezo (adalimumab-adbm) (Commercial)
5.25	05/21/2025	1100-1205528-1349251 Adalimumab (Commercial) effective 5/25/2025, has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy eff 4/01/2025. 2. Abrilada (adalimumab-afzb) (Commercial) adalimumab-aacf (Commercial) adalimumab-aaty (Commercial) 2. adalimumab-adaz (Commercial) adalimumab-adbm (Commercial) adalimumab-fkjp (Commercial) 2. Amjevita (adalimumab-atto) (Commercial) 2. Cyltezo (adalimumab-adbm) (Commercial)
5.24	05/19/2025	1100-1205528-1345201 Updated Actimmune (interferon gamma-1b). Added: PA in effect on 05/01/2025 The SDRP policy eff 05/15/2025, v2 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 04/01/2025, v2. Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
5.23	05/15/2025	1100-1205528-1344351 Fax form links for Cinryze (C1 esterase inhibitor) (Commercial and QUEST Integration) have been updated.
5.22	05/14/2025	1100-1205528-1340903 The Global Oncology policy effective 05/08/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 03/23/2025. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) Bizengri (zenocutuzumab-zbco) bortezomib (generic) Boruzu (bortezomib) Camcevi (leuprolide mesylate) Cyramza
5.21	05/12/2025	1100-1205528-1336050 The SDRP policy eff 04/01/2025, v2 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 04/01/2025. Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
5.20	05/08/2025	1100-1205528-1315150 The following fax form links have been updated or added: Bimzelx (bimekizumab-bkzx) - Commercial Botox (Botulinum Toxins) - QUEST 2. Botox (onabotulinumtoxinA) - QUEST Botulinum Toxins - QUEST 2. Botulinum Toxins - QUEST 1100-1205528-1330252 Edited the SDRP current effective date to 04/01/2025 as applicable.
5.19	05/06/2025	1100-1205528-1332100 Cinryze (C1 esterase inhibitor [human]) (Medicare Advantage), 3/20/2025 has been posted. ARCHIVED: policy eff 12/20/2024 1100-1205528-1330252 The SDRP policy eff 04/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 03/01/2025. Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
5.18	04/23/2025	1100-1205521-1317159 The Global Oncology policy effective 03/23/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 02/28/2025. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) Bizengri (zenocutuzumab-zbco) bortezomib (generic) Boruzu (bortezomib) Camcevi (leuprolide mesylate) Cyramza
5.17	04/22/2025	1100-1205521-1316800 The SDRP policy eff 03/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 02/01/2025. Actimmune (interferon gamma-1b) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
5.16	04/21/2025	1100-1205521-1305653 The following edits were applied: Abrilada (adalimumab-afzb) (QUEST) - removed the 60-day provider notice and update the Current Effective Date to 04/01/2025. Adalimumab (QUEST) - updated the Current Effective Date to 04/01/2025.
5.15	04/15/2025	1100-1205521-1305678 The Global Oncology policy effective 02/28/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 02/03/2025. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) Bizengri (zenocutuzumab-zbco) bortezomib (generic) Boruzu (bortezomib) Camcevi (leuprolide mesylate) Cyramza
5.14	04/14/2025	1100-1205521-1305653 The Actemra (Commercial and QUEST) policy, effective 04/01/2025, has been posted for the following drug covered under this policy. ARCHIVED: 60-day notice and policy eff 2/1/2024. 2. Actemra (tocilizumab) (Commercial and QUEST) Adalimumab (Commercial) effective 04/01/2025, has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy eff 7/01/2024. 2. Abrilada (adalimumab-afzb) (Commercial) adalimumab-aacf (Commercial) adalimumab-aaty (Commercial) 2. adalimumab-adaz (Commercial) adalimumab-adbm (Commercial) adalimumab-fkjp (Commercial) 2. Amjevita (adalimumab-atto) (Commercial) 2. Cyltezo (adalimumab-adbm) (Commercial) Adalimumab (QUEST) effective 04/01/2025, has been posted for the following drugs covered under this policy. ARCHIVED: 60-day notice and policy 5/03/2024. Abrilada (adalimumab-afzb) (QUEST) adalimumab-aacf (QUEST) adalimumab-aaty (QUEST) adalimumab-adaz (QUEST) adalimumab-adbm (QUEST) adalimumab-fkjp (QUEST) Amjevita (adalimumab-atto) (QUEST) Cyltezo (adalimumab-adbm) (QUEST) The following policies effective 04/01/2025 have been posted: 2. Berinert (C1 esterase inhibitor [human]) (Commercial and QUEST); ARCHIVED: 60-day notice and policy eff 1/1/2024 Cinryze (C1 esterase inhibitor [human]) (Commercial and QUEST); ARCHIVED: 60-day notice and policy eff 1/1/2024 Cosentyx (secukinumab) (Commercial and QUEST); ARCHIVED: 60-day notice and policy eff 2/1/2024 Soliris (Commercial and QUEST), effective 4/01/2025, has been posted for the following drug covered under this policy. ARCHIVED: 60-day notice and policy eff 1/01/2024 Bkemv (eculizumab-aeeb) (Commercial and QUEST) Botulinum Toxins, eff 04/01/2025, has been posted for the following drug covered under this policy. ARCHIVED: 60-day notice and policy eff 1/1/2025. Botox 2. Botox (Medicare Advantage) Botulinum Toxins
5.13	04/07/2025	1100-1205521-1301650 The SDRP policy eff 02/01/2025 has been posted for the following drugs covered under this policy. Actimmune (interferon gamma-1b) (NEW) Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
5.12	03/24/2025	1100-1205514-1272756 Added the Infliximab (Comm-QUEST) archived folder for 2. Avsola (infliximab-axxq) (Commercial and QUEST)
5.11	03/14/2025	1100-1205514-1265700 Corrected the link titles for Botulinum Toxins (Comm-QUEST-MA) redlined 60-day provider notice (02/01/2025-03/31/2025), effective 4/01/2025, and for the following drug covered under this policy: Botox (onabotulinumtoxinA) 1100-1205514-1280502 Autoimmune (AI) Preferred Drug Program (Commercial) effective 2/14/2025 has been posted for the following drugs covered under this policy. ARCHVIED: Policy effective 11/18/2024. Autoimmune Preferred Drug Program 1. Abrilada (adalimumab-afzb) 1. Actemra (tocilizumab) 1. adalimumab-adaz (Autoimmune Preferred Drug Program) 1. adalimumab-ryvk (Autoimmune Preferred Drug Program) (new) 1. Amjevita (adalimumab-atto) 1. Avsola (infliximab) Infliximab (Autoimmune Preferred Drug Program) 1. Bimzelx (bimekizumab-bkzx) 1. Cimzia (certolizumab pegol) 1. Cosentyx (secukinumab) 1. Cyltezo (adalimumab-adbm)
5.10	03/13/2025	1100-1205514-1279100 Updated Cosentyx fax form links. 1100-1205514-1278952 The Global Oncology policy effective 02/03/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 01/15/2025. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) (new eff 5/17/2024) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) Bizengri (zenocutuzumab-zbco) (NEW) bortezomib (generic) Boruzu (bortezomib) (NEW) Camcevi (leuprolide mesylate) Cyramza Change history notes from 2020, 2021, and 2022 are archived and have been removed from this article.
5.09	03/10/2025	1100-1205514-1272761 The SDRP policy eff 01/01/2025, v2 has been posted for the following drugs covered under this policy. Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita 1100-1205514-1272756 Infliximab (Commercial and QUEST) effective 3/1/2025 has been posted to the following drug covered under these policies, as applicable. ARCHIVED: 60-day notice and policy effective 1/1/2024. 2. Avsola (infliximab-axxq) (Commercial and QUEST)
5.08	03/05/2025	1100-1205514-1265700 The Actemra (Commercial and QUEST) redlined 60-day provider notice (02/01/2025-03/31/2025), effective 04/01/2025, has been posted for the following drug covered under this policy: 2. Actemra (tocilizumab) (Commercial and QUEST) The Adalimumab redlined 60-day provider notice (02/01/2025-03/31/2025), effective 04/01/2025, has been posted for the following drugs covered under this policy: 2. Abrilada (adalimumab-afzb) (Commercial) 2. adalimumab-aacf (Commercial) 2. adalimumab-aaty (Commercial) 2. adalimumab-adaz (Commercial) 2. adalimumab-adbm (Commercial) 2. adalimumab-fkjp (Commercial) 2. Amjevita (adalimumab-atto) (Commercial) 2. Cyltezo (adalimumab-adbm) (Commercial) The Adalimumab (QUEST) redlined 60-day provider notice (02/01/2025-03/31/2025), effective 04/01/2025, has been posted for the following drugs covered under this policy: Abrilada (adalimumab-afzb) (QUEST) adalimumab-aacf (QUEST) adalimumab-aaty (QUEST) adalimumab-adaz (QUEST) adalimumab-adbm (QUEST) adalimumab-fkjp (QUEST) Amjevita (adalimumab-atto) (QUEST) Cyltezo (adalimumab-adbm) (QUEST) The following redlined 60-day provider notices (02/01/2025-03/31/2025), effective 04/01/2025 have been posted: 2. Berinert (C1 esterase inhibitor [human]) (Commercial and QUEST) Cinryze (C1 esterase inhibitor [human]) (Commercial and QUEST) Cosentyx (secukinumab) (Commercial and QUEST) Botulinum Toxins (Comm-QUEST-MA) redlined 60-day provider notice (02/01/2025-03/31/2025), effective 4/01/2025, has been posted for the following drug covered under this policy: Botox (onabotulinumtoxinA) The Soliris (Commercial and QUEST) redlined 60-day provider notice (02/01/2025-03/31/2025), effective 4/01/2025, has been posted for the following drug covered under this policy: Bkemv (eculizumab-aeeb) (Commercial and QUEST) (NEW)
5.07	03/03/2025	1100-1205514-1261250 The Global Oncology policy effective 01/15/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 12/01/2024. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) (new eff 5/17/2024) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) Bizengri (zenocutuzumab-zbco) (NEW) bortezomib (generic) Boruzu (bortezomib) (NEW) Camcevi (leuprolide mesylate) Cyramza
5.06	02/24/2025	1100-1205507-1254950 Fax form link have been updated for the following drugs: Alyglo (Commercial & QUEST) Alyglo (Medicare Advantage)Asceniv (Commercial & QUEST) Asceniv (Medicare Advantage)Bivigam (Commercial & QUEST) Bivigam (Medicare Advantage)
5.05	02/10/2025	1100-1205507-1238900 The SDRP policy eff 01/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 12/16/2024. Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
5.04	02/05/2025	1100-1205507-1235400 The SDRP policy eff 12/16/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 10/3/2024. Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
5.03	02/04/2025	1100-1205507-1235752 Updated the fax form links for the following drugs: Cutaquig (Commercial/QUEST/Medicare Advantage) Cuvitru (Commercial/QUEST/Medicare Advantage)
5.02	01/30/2025	1100-1205500-1214101 Formatting edits.
5.01	01/14/2025	1100-1205500-1214101 The Global Oncology policy effective 12/01/2024 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 11/15/2024. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) (new eff 5/17/2024) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) bortezomib (generic) Boruzu (bortezomib) (NEW) Camcevi (leuprolide mesylate) Cyramza
5.0	01/07/2025	1100-956557-1197451 Edit 2. Avsola link to 60-day provider notice (01/01/2025-02/28/2025) eff 03/01/2025
3.44 (v188)	12/18/2023	Updated the MA fax form link for Bimzelx Intravenous Immune Globulin (IVIG) (Medicare Advantage) eff 12/15/2023 has been posted for the following drugs covered under this policy. Archived: policy eff 9/1/2022. Asceniv (immune globulin intravenous, human - slra) (Medicare Advantage) Bivigam (human immunoglobulin) (Medicare Advantage)

Rev#:	Date:	Nature of Revision:
4.43 (v236)	12/30/2024	1100-956557-1197451 Infliximab (Commercial and QUEST) 60-day provider notice (02/01/2023-03/31/2023), effective 12/01/2023, has been posted for the following drug covered under this policy: 2. Avsola (infliximab-axxq) 1100-956557-1197456 Bevacizumab Products - Commercial Preferred Drug Program policy, effective 01/01/2025, has been posted for the following drugs covered under this policy. Archived: policy eff 1/1/24 and 60-day notice eff 1/1/25 1. Alymsys (bevacizumab-maly) (Commercial) 1. Avastin (bevacizumab) (Commercial) Bevacizumab Preferred Drug Program (Commercial) 1100-956557-1197456 Bevacizumab Products - Medicare Part B Preferred Drug Program policy effective 01/01/2025, has been posted for the following drugs covered under this policy. Archived: policy eff 1/1/24 and 60-day notice eff 1/1/25 1. Alymsys (bevacizumab-maly) (Medicare Advantage) 1. Avastin (bevacizumab) (Medicare Advantage) Bevacizumab Preferred Drug Program (Medicare Advantage) 1100-956557-1197456 Bevacizumab Products - QUEST Preferred Drug Program policy, effective 01/01/2025, has been posted for the following drugs covered under this policy. Archived: 60-day notice eff 1/1/25 1. Alymsys (bevacizumab-maly) (QUEST) 1. Avastin (bevacizumab) (QUEST) Bevacizumab Preferred Drug Program (QUEST) 1100-956557-1197456 Botulinum Toxins, eff 01/01/2025, has been posted for the following drug covered under this policy. Archived: 60-day notice eff 1/1/25 and policy eff 4/1/24, v2. Botox (onabotulinumtoxinA) 1100-956557-1197456 Botulinum Toxins Medicare Part B Preferred Drug Program policy, eff 1/1/2025, has been posted for the following drugs covered under this policy. Archived: 60-day notice eff 1/1/2025 and policy eff 1/1/2024. 1. Botox (onabotulinumtoxinA) (Medicare Advantage) 1. Botulinum Toxins (Medicare Advantage) 1100-956557-1197456 The following policy has been posted: Cimzia (Medicare Advantage), 1/1/2025; ARCHIVED: 60-day notice effective 1/1/2025 and policy effective 1/1/2024 1100-956557-1197456 Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial), effective 1/1/2025, has been posted. The 60-day notice eff 1/1/2025 and policy eff 1/1/2024 have been archived. 1100-956557-1197456 Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Medicare Advantage), effective 1/1/2025, has been posted. ARCHIVED: The 60-day notice eff 1/1/2025. 1100-956557-1197456 Colony Stimulating Factors (CSF) – Short Acting Commercial and QUEST Preferred Drug Program effective 01/01/2025, has been posted. Archived: 60-day provider notice effective 1/1/2025 and policy effective 11/17/2023. 1100-956557-1197456 Colony Stimulating Factors (CSF) – Short-Acting Medicare Advantage Preferred Drug Program effective 01/01/2025, has been posted. Archived: 60-day provider notice effective 1/1/2025 and policy effective 1/1/2024. Subcutaneous Immunoglobulin (SCIG) (Medicare Advantage) effective 1/1/2025 has been posted for the following drugs. Archived: 60-day notice eff 1/1/25 and policy eff 1/1/24. Cutaquig (Immune Globulin Subcutaneous [Human] – hipp) (Medicare Advantage) Cuvitru (Immune Globulin Subcutaneous [Human], 20% Solution) (Medicare Advantage)
4.42 (v235)	12/27/2024	1100-956557-1204850 The following revisions were made: Cinryze (MA) - Reposted the policy; Bivigam (Comm-QUEST) - Updated the current effective date to 12/20/2024
4.41 (v234)	12/23/2024	1100-956557-1204850 The Actemra (tocilizumab) (Medicare Advantage) policy effective 12/20/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 1/1/2024 Actemra (tocilizumab) (Medicare Advantage) The following policy has been posted: Cinryze (C1 esterase inhibitor [human]) (Medicare Advantage), 12/20/2024; ARCHIVED: policy eff 1/1/2024 The Hereditary Angioedema (HAE) Preferred Drug Program (Commercial) policy effective 12/20/2024 has been posted for the following drug covered under this policy. ARCHIVED: policy effective 11/17/2023. 1. Berinert (C1 esterase inhibitor [human]) (Commercial) The Hyaluronates Medicare Part B policy effective 12/20/2024 has been posted for the following drug covered under this policy. ARCHIVED: policy effective 5/30/2024. 1% sodium hyaluronate (Medicare Advantage) Intravenous Immune Globulin (IVIG) (Commercial and QUEST) effective 12/20/2024, has been posted for the following drugs covered under this policy. Archived: policy eff 4/01/2024. Alyglo (Commercial and QUEST) (new) Asceniv (Commercial and QUEST) Bivigam (Commercial and QUEST)
4.40 (v233)	12/11/2024	1100-956552-1182200 Updated the Autoimmune (AI) Preferred Drug Program (Commercial) link name
4.39 (v232)	12/04/2024	1100-956552-1182200 Updated the Autoimmune (AI) Preferred Drug Program (Commercial) link name 1100-956557-1188100 Added links to applicable archived folders for Berinert (MA) and Cerezyme (Comm-QUEST)
4.38 (v231)	12/03/2024	1100-956557-1188100 The following policies have been posted: Berinert (C1 esterase inhibitor [human]) (Medicare Advantage), 11/29/2024; ARCHIVED: policy eff 1/1/2024 Cerezyme (imiglucerase) (Commercial and QUEST), 11/29/2024; ARCHIVED: policy eff 1/1/2024
4.37 (v230)	11/21/2024	1100-956552-1182200 Autoimmune (AI) Preferred Drug Program (Commercial) effective 11/18/2024 has been posted for the following drugs covered under this policy. ARCHVIED: Policy effective 10/03/2024. Autoimmune Preferred Drug Program 1. Abrilada (adalimumab-afzb) 1. Actemra (tocilizumab) 1. adalimumab-adaz (Autoimmune Preferred Drug Program) 1. adalimumab-ryvk (Autoimmune Preferred Drug Program) (new) 1. Amjevita (adalimumab-atto) 1. Avsola (infliximab) 1. Bimzelx (bimekizumab-bkzx) 1. Cimzia (certolizumab pegol) 1. Cosentyx (secukinumab) 1. Cyltezo (adalimumab-adbm) 1100-956552-1182203 Infliximab (Medicare Advantage) policies effective 11/15/2024 have been posted to the following drugs covered under these policies, as applicable. Archived: Policy effective 1/1/2024. 2. Avsola (infliximab-axxq) (Medicare Advantage) The Global Oncology policy effective 11/15/2024 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 10/23/2024. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) (new eff 5/17/2024) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) bortezomib (generic) Camcevi (leuprolide mesylate) Cyramza
4.36 (v229)	11/04/2024	1100-956552-1168730 Multiple Sclerosis (MS) Preferred Drug Program (Commercial) effective 10/25/2024, has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 11/17/2023. Avonex (interferon beta-1a) (Commercial) Betaseron (interferon beta-1b) (Commercial)
4.35 (v228)	11/01/2024	1100-956547-1167950 Bevacizumab Products - Commercial Preferred Drug Program 60-day provider notice (11/01/2024-12/31/20234), effective 01/01/2025, has been posted for the following drugs covered under this policy: 1. Alymsys (bevacizumab-maly) (Commercial) 1. Avastin (bevacizumab) (Commercial) Bevacizumab Preferred Drug Program (Commercial) Bevacizumab Products - Medicare Part B Preferred Drug Program 60-day provider notice (11/01/2024-12/31/20234), effective 01/01/2025, has been posted for the following drugs covered under this policy: 1. Alymsys (bevacizumab-maly) (Medicare Advantage) 1. Avastin (bevacizumab) (Medicare Advantage) Bevacizumab Preferred Drug Program (Medicare Advantage) Bevacizumab Products - QUEST Preferred Drug Program 60-day provider notice (11/01/2024-12/31/20234), effective 01/01/2025, has been posted for the following drugs covered under this policy: 1. Alymsys (bevacizumab-maly) (Bevacizumab Preferred Drug Program Policy QUEST) (new) 1. Avastin (bevacizumab) (Bevacizumab Preferred Drug Program Policy QUEST) (new) Bevacizumab Preferred Drug Program (QUEST) (new) Botulinum Toxins (Comm-QUEST-MA) 60-day provider notice (11/01/2024-12/31/2024) eff 1/1/2025, has been posted for the following drug covered under this policy: Botox (onabotulinumtoxinA) Botulinum Toxins Preferred Drug Program (Medicare Advantage) 60-day provider notice (11/01/2024-12/31/2024), effective 01/01/2025, has been posted for the following drugs covered under this policy: 1. Botox (onabotulinumtoxinA) (Medicare Advantage) 1. Botulinum Toxins (Medicare Advantage) Cimzia (Medicare Advantage) 60-day provider notice (11/01/2024-12/31/2024) eff 1/1/2025 has been posted. Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial) 60-day provider notice (11/01/2024-12/31/2024) eff 1/1/2025, has been posted. Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Medicare Advantage) 60-day provider notice (11/01/2024-12/31/2024) eff 1/1/2025, has been posted. Colony Stimulating Factors (CSF) – Short Acting Commercial and QUEST Preferred Drug Program 60-day provider notice 60-day provider notice (11/01/2024-12/31/2024) eff 1/1/2025, has been posted. Colony Stimulating Factors (CSF) – Short-Acting Medicare Advantage Preferred Drug Program 60-day provider notice 60-day provider notice (11/01/2024-12/31/2024) eff 1/1/2025, has been posted. Subcutaneous Immunoglobulin (SCIG) (Medicare Advantage) (11/01/2024-12/31/2024) eff 1/1/2025 has been posted for the following drugs covered under this policy: Cutaquig (Immune Globulin Subcutaneous [Human] – hipp) (Medicare Advantage) Cuvitru (Immune Globulin Subcutaneous [Human], 20% Solution) (Medicare Advantage)
4.34 (v227)	10/28/2024	1100-956547-1165170 The Global Oncology policy effective 10/23/2024 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 09/10/2024. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) bortezomib (generic) Camcevi (leuprolide mesylate) Cyramza The SDRP policy eff 10/3/2024 v2 has been posted for the following drugs covered under this policy. Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
4.33 (v226)	10/11/2024	1100-956547-1156401 Criteria Exception (Commercial and QUEST) eff 9/27/2024 has been posted. ARCHIVED: policy eff 2/1/2024. 1100-956547-1156413 The SDRP policy eff 10/3/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 9/27/2024. Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
4.32 (v225)	10/10/2024	1100-956547-1152003 Autoimmune (AI) Preferred Drug Program (Commercial) effective 10/03/2024 has been posted for the following drugs covered under this policy. ARCHVIED: The 60-day notice and policy effective 07/01/2024. Autoimmune Preferred Drug Program 1. Abrilada (adalimumab-afzb) 1. Actemra (tocilizumab) 1. adalimumab-adaz (Autoimmune Preferred Drug Program) 1. adalimumab-ryvk (Autoimmune Preferred Drug Program) (new) 1. Amjevita (adalimumab-atto) 1. Avsola (infliximab) 1. Bimzelx (bimekizumab-bkzx) 1. Cimzia (certolizumab pegol) 1. Cosentyx (secukinumab) 1. Cyltezo (adalimumab-adbm) The following rows were removed: 1. adalimumab-aacf 1. adalimumab-aaty 1. adalimumab-adaz 1. adalimumab-adbm
4.31 (v224)	10/02/2024	1100-956547-1150004 The SDRP policy eff 9/27/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 9/10/2024. Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
4.30 (v223)	09/25/2024	1100-956542-1145350 The SDRP policy eff 9/10/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 8/23/2024. Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
4.29 (v222)	09/17/2024	1100-956542-1137967 The Global Oncology policy effective 09/10/2024 has been posted for the following drugs. ARCHIVED: Policy eff 07/15/2024. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) bortezomib (generic) Camcevi (leuprolide mesylate) Cyramza
4.28 (v221)	09/12/2024	1100-956537-1131400 Corrected the effective date for Aimovig.
4.27 (v220)	09/10/2024	1100-956537-1131400 The SDRP policy eff 8/23/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 7/1/2024. Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
4.26 (v219)	08/06/2024	1100-956537-1105000 The following policies have been posted: 2. Cimzia (certolizumab pegol) (Commercial and QUEST Integration), 8/1/2024; ARCHIVED: 60-day notice and poicy eff 1/1/2024 1100-956537-1104509 The following policy has been posted: Benlysta (Commercial and QUEST Integration), 07/26/2024. Archived: 4/1/2024 Benlysta (Medicare Advantage), 07/26/2024. Archived: 1/1/2024 Forteo (teriparatide), 07/26/2024 has been posted for the following drug covered under this policy. Archived: 3/22/2024. Bonsity (teriparatide)
4.25 (v218)	07/16/2024	1100-956532-1092301 Global Oncology 07/15/2024 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 05/17/2024. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) bortezomib (generic) Camcevi (leuprolide mesylate) Cyramza The SDRP policy eff 7/01/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 6/17/2024. Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
4.24 (v217)	06/25/2024	1100-956527-1081006 Autoimmune (AI) Preferred Drug Program (Commercial) effective 07/01/2024 has been posted for the following drugs covered under this policy. ARCHVIED: The 60-day notice and policy effective 09/01/2023. Autoimmune Preferred Drug Program1. Abrilada (adalimumab-afzb)(new) 1. Actemra (tocilizumab) 1. adalimumab-aacf (new) 1. adalimumab-aaty (new) 1. adalimumab-adaz (new) 1. adalimumab-adbm (new) 1. adalimumab-fkjp (new) 1. Amjevita (adalimumab-atto) (new) 1. Avsola (infliximab) 1. Bimzelx (bimekizumab-bkzx) (new) 1. Cimzia (certolizumab pegol) 1. Cosentyx (secukinumab) 1. Cyltezo (adalimumab-adbm) (new) Humira (adalimumab) (Commercial) effective 07/01/2024, has been posted for the following drugs covered under this policy. Archived: policy eff 04/01/2024. 2. Abrilada (adalimumab-afzb) (Commercial) 2. adalimumab-aacf (Commercial) (new) 2. adalimumab-aaty (Commercial) (new) 2. adalimumab-adaz (Commercial) 2. adalimumab-adbm (Commercial) (new) 2. adalimumab-fkjp (Commercial) 2. Amjevita (adalimumab-atto) (Commercial) 2. Cyltezo (adalimumab-adbm) (Commercial)
4.23 (v216)	06/24/2024	1100-956527-1079102 The SDRP policy eff 6/17/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 5/27/2024. Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
4.22 (v215)	06/10/2024	1100-956527-1071521 Global Oncology 05/17/2024 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 12/12/2023. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) 2. Alymsys (bevacizumab-maly) Anktiva (nogapendekin alfa inbakicept-pmln) (new eff 5/17/2024) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) bortezomib (generic) Camcevi (leuprolide mesylate) Cyramza
4.21 (v214)	06/06/2024	1100-956527-1069655 The following redlined 60-day notices (06/01/2024-07/31/2024) have been posted: 2. Cimzia (certolizumab pegol) (Commercial and QUEST Integration)
4.20 (v213)	05/31/2024	1100-956522-1060957 Formatting and minor typographical edit.
4.19 (v212)	05/30/2024	1100-956522-1064600 The following policies have been posted: Arcalyst (rilonacept) (Commercial and QUEST Integration), 5/24/2024. Archived: 1/1/2024 Cerezyme (imiglucerase) (Medicare Advantage), 5/24/2024. Archived: 1/1/2024 1100-956522-1064200 The Hyaluronates Medicare Part B policy effective 5/30/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 1/1/2024. 1% sodium hyaluronate (Medicare Advantage) (new)
4.18 (v211)	05/28/2024	1100-956522-1060957 Autoimmune Preferred Drug Program (Commercial) revised redlined 60-day notice effective 7/1/2024, v2 (notification period: 05/01/2024-06/30/2024) has been posted for the following drugs covered under this policy: Autoimmune Preferred Drug Program #1. Abrilada (adalimumab-afzb) (Autoimmune Preferred Drug Program)(new) #1. Actemra (tocilizumab) #1. adalimumab-adaz (Autoimmune Preferred Drug Program)(new) #1. Amjevita (adalimumab-atto) (Autoimmune Preferred Drug Program)(new) #1. Avsola (infliximab) #1. Bimzelx (bimekizumab-bkzx) (Autoimmune Preferred Drug Program)(new) #1. Cimzia (certolizumab pegol) #1. Cosentyx (secukinumab) #1. Cyltezo (adalimumab-adbm) (Autoimmune Preferred Drug Program)(new)
4.17 (v210)	05/23/2024	1100-956522-1060150 The Adbry policy eff 5/27/2024 has been posted. ARCHIVED: policy eff 7/1/2023. The SDRP policy eff 5/27/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 5/12/2024. Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
4.16 (v209)	05/15/2024	1100-956522-1055200 The SDRP policy eff 5/12/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 4/1/2024. Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
4.15 (v208)	05/10/2024	1100-956522-1050250 Updated the Adalimumab Preferred Drug Program (QUEST Integration) archived folder links.
4.14 (v207)	05/08/2024	1100-956522-1050250 Adalimumab Preferred Drug Program (QUEST Integration) effective 5/03/2024, has been posted for the following drugs covered under this policy. Archived: policy eff 4/1/2024 Abrilada (adalimumab-afzb) (QUEST Integration) Adalimumab (QUEST Integration) (new eff 5/1/2024) Adalimumab-aacf (QUEST Integration) (new eff 5/3/2024) Adalimumab-aaty (QUEST Integration) (new eff 5/3/2024) adalimumab-adbm (QUEST Integration) (new eff 5/3/2024) adalimumab-adaz (QUEST Integration) adalimumab-fkjp (QUEST Integration) Amjevita (adalimumab-atto) (QUEST Integration) Cyltezo (adalimumab-adbm) (QUEST Integration) 1100-956522-1049457 The SDRP policy eff 4/1/2024 has been posted for the following drugs covered under this policy. The SDRP policy effective 3/1/2024 has been archived. Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
4.13 (v206)	05/06/2024	1100-956522-1046905 Intravenous Immune Globulin (IVIG) (Medicare Advantage) eff 4/26/2024 has been posted for the following drugs covered under this policy. Alyglo (Medicare Advantage) (new)
4.12 (v205)	05/02/2024	1100-956522-1046900 Autoimmune Preferred Drug Program (Commercial) revised redlined 60-day notice effective 7/1/2024 (notification period: 05/01/2024-06/30/2024) has been posted for the following drugs covered under this policy: #1. Actemra (tocilizumab) Autoimmune Preferred Drug Program #1. Avsola (infliximab) #1. Cimzia (certolizumab pegol) #1. Cosentyx (secukinumab) 1100-956522-1046905 Intravenous Immune Globulin (IVIG) (Medicare Advantage) eff 4/26/2024 has been posted for the following drugs covered under this policy. Archived: policy eff 12/15/2023. Asceniv (immune globulin intravenous, human - slra) (Medicare Advantage) Bivigam (human immunoglobulin) (Medicare Advantage) Subcutaneous Immunoglobulin (SCIG) (Commercial and QUEST Integration) effective 4/26/2024 has been posted for the following drugs covered under this policy. Archived: 4/1/2024. Cutaquig (Immune Globulin Subcutaneous [Human] – hipp) (Commercial and QUEST Integration) Cuvitru (Immune Globulin Subcutaneous [Human], 20% Solution) (Commercial and QUEST Integration)
4.11 (v204)	04/15/2024	Humira (adalimumab) (Commercial) effective 04/01/2024, has been posted for the following drugs covered under this policy. Archived: policy eff 12/1/2023 Abrilada (adalimumab-afzb) (Commercial) adalimumab-adaz (Commercial) (new eff 4/1/24) adalimumab-fkjp (Commercial) (new eff 4/1/24) Amjevita (adalimumab-atto) (Commercial) Cyltezo (adalimumab-adbm) (Commercial) *Drug numbering has been removed. Botulinum Toxins (drug specific), eff 4/01/2024 v2, has been posted for the following drug covered under this policy. Archived: policy eff 4/01/2024. Botox (onabotulinumtoxinA) 2. Botox (onabotulinumtoxinA) Botulinum Toxins (drug specific policy) 2. Botulinum Toxins
4.10 (v203)	04/05/2023	The following drugs were added to the applicable tables: Adstiladrin (nadofaragene firadenovec-vncg) Amtagvi (lifileucel) Apligraf (graftskin) Casgevy (exagamglogene autotemcel)
4.9 (v202)	03/31/2024	Adalimumab Preferred Drug Program (QUEST Integration) effective 4/01/2024, has been posted for the following drugs covered under this policy. Archived: 60-day notice. 1. Abrilada (adalimumab-afzb) (QUEST Integration) 1. adalimumab-adaz (QUEST Integration) (new eff 4/1/2024) 1. adalimumab-fkjp (QUEST Integration) (new eff 4/1/2024) 1. Amjevita (adalimumab-atto) (QUEST Integration) 1. Cyltezo (adalimumab-adbm) (QUEST Integration) The following policy has been posted: Benlysta (Commercial and QUEST Integration), 4/1/2024. Archived: 1/1/2024 Botulinum Toxins (drug specific), eff 4/01/2024, has been posted for the following drug covered under this policy. Archived: 60-day notice and policy eff 4/01/2023. Botox (onabotulinumtoxinA) 2. Botox (onabotulinumtoxinA) Botulinum Toxins (drug specific policy) Intravenous Immune Globulin (IVIG) (Commercial and QUEST Integration) effective 4/01/2024, has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy eff 9/1/2022. Asceniv (Commercial and QUEST Integration) Bivigam (Commercial and QUEST Integration) Subcutaneous Immunoglobulin (SCIG) (Commercial and QUEST Integration) effective 4/1/2024 has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy eff 9/1/2022. Cutaquig (Immune Globulin Subcutaneous [Human] – hipp) (Commercial and QUEST Integration) Cuvitru (Immune Globulin Subcutaneous [Human], 20% Solution) (Commercial and QUEST Integration)
4.8 (v201)	03/28/2024	Forteo (teriparatide), 3/22/2024 has been posted for the following drug covered under this policy. The policy eff 7/28/2023 has been archived. Bonsity (teriparatide)
4.7 (v200)	03/20/2024	The SDRP policy eff 3/1/2024 has been posted for the following drugs covered under this policy. Omvoh is not covered under Part B. The SDRP policy effective 2/1/2024 has been archived. Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
4.6 (v199)	02/15/2024	The SDRP policy eff 2/1/2024, v2 has been posted for the following drugs covered under this policy. Amvuttra, Givlaari, Onpattro, and Oxlumo have been removed. The SDRP policy effective 1/1/2024, v2 has been archived. Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amvuttra - Effective 2/15/2024 PA review for Amvuttra is moved from CVS to HMSA review Amondys 45 (casimersen) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
4.5 (v198)	02/09/2024	The SDRP policy eff 1/1/2024, v2 has been posted for the following drugs covered under this policy. The SDRP policy effective 1/1/2024 has been archived. Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Amvuttra (vutrisiran) Aphexda (motixafortide) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
4.4 (v197)	02/08/2024	The following has been posted and moved to a new row: Botulinum Toxins (Commercial and QUEST Integration) 60-day provider notice (02/01/2024-03/31/2024), effective 4/01/2024 v2, has been posted for the following drug covered under this policy: Botox (onabotulinumtoxinA) (Commercial and QUEST Integration) Botulinum Toxins (Commerical and QUEST Integration) Adalimumab Preferred Drug Program (QUEST Integration) 60-day provider notice (02/01/2024-03/31/2024), effective 4/01/2024 has been added to a new row.
4.3 (v196)	02/01/2024	60-day notices have been posted for the following drug. Provider notification period is 2/1/2024-3/31/2024. Benlysta (Commercial and QUEST Integration) Adalimumab Preferred Drug Program (QUEST Integration) 60-day provider notice (02/01/2024-03/31/2024), effective 4/01/2024, has been posted for the following drugs covered under this policy: 1. Abrilada (adalimumab-afzb) (QUEST Integration) 1. Amjevita (adalimumab-atto) (QUEST Integration) 1. Cyltezo (adalimumab-adbm) (QUEST Integration) Botulinum Toxins (Commercial and QUEST Integration) 60-day provider notice (02/01/2024-03/31/2024), effective 4/01/2024, has been posted for the following drug covered under this policy: Botox (onabotulinumtoxinA) Intravenous Immune Globulin (IVIG) (Commercial and QUEST Integration) 60-day provider notice (02/01/2024-03/31/2024), effective 4/01/2024, has been posted for the following drug covered under this policy: Asceniv (Commercial and QUEST Integration) Bivigam (Commercial and QUEST Integration) Intravenous Immune Globulin (SCIG) (Commercial and QUEST Integration) 60-day provider notice (02/01/2024-03/31/2024), effective 4/01/2024, has been posted for the following drug covered under this policy: Cutaquig (Commercial and QUEST Integration) Cuvitru (Commercial and QUEST Integration)
4.2 (v195)	01/31/2024	Updated fax form links for the following: Avastin (new line for QI), Benlysta, Cerezyme, Cinryze
4.1 (v194)	01/30/2024	Updated fax form links for the following: Alymsys (new line for QI), Arcalyst The following policies have been posted: 2. Actemra (tocilizumab), 2/1/2024; ARCHIVED: 60-day notice eff 2/1/24 and policy eff 1/1/2024; linked new COMM-QI archive folder 2. Cosentyx (secukinumab), 2/1/2024; ARCHIVED: 60-day notice eff 2/1/24 and policy eff 9/1/2022 Criteria Exception (Commercial and QUEST Integration), 2/1/2024; ARCHIVED: 60-day notice eff 2/1/24 and policy eff 7/1/2023
4.0 (v193)	01/12/2024	The SDRP policy eff 1/1/2024 has been posted for the following drugs covered under this policy. The SDRP policy effective 12/1/2023 has been archived. Adakveo Adzynma (ADAMTS13, recombinant-krhn) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Amvuttra (vutrisiran) Aphexda (motixafortide) #2. Beovu (No PA required as of 1/11/2024) Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
3.48 (v192)	12/29/2023	Updated notice statement for Beovu (Medicare Advantage): No PA required as of 01/01/2024 for Retinal Disorders
3.47 (v191)	12/28/2023	The following policies effective 1/1/2024 have been posted: 2. Actemra (tocilizumab) (Commercial and QUEST Integration) Actemra (tocilizumab) (Medicare Advantage) Benlysta (belimumab) (Commercial and QUEST Integration) Benlysta (belimumab) (Medicare Advantage) 2. Berinert (C1 esterase inhibitor [human]) (Commercial and QUEST Integration) Berinert (C1 esterase inhibitor [human]) (Medicare Advantage) Cerezyme (imiglucerase) (Commercial and QUEST Integration) Cerezyme (imiglucerase) (Medicare Advantage) 2. Cimzia (certolizumab pegol) (Commercial and QUEST Integration) Cimzia (certolizumab pegol) (Medicare Advantage) Cinryze (C1 esterase inhibitor [human]) (Commercial and QUEST Integration) Cinryze (C1 esterase inhibitor [human]) (Medicare Advantage) The following policies have been archived: Actemra (tocilizumab), 11/01/2023 (for all LOBs) Benlysta (belimumab), 12/2/2022 (for all LOBs) Berinert (C1 esterase inhibitor [human]), 10/27/2023 (for all LOBs) Cerezyme (imiglucerase), 06/23/2023 (for all LOBs) Cimzia (certolizumab pegol), 12/01/2023 (for all LOBs) Cinryze (C1 esterase inhibitor [human]), 10/27/2023 (for all LOBs) Infliximab (Commercial and QUEST Integration) and (Medicare Advantage) policies effective 1/1/2024 have been posted to the following drugs covered under these policies, as applicable. Archived: The policy effective 12/1/2023 (all LOBs) has been archived. 2. Avsola (infliximab-axxq) (Commercial and QUEST Integration) 2. Avsola (infliximab-axxq) (Medicare Advantage) Subcutaneous Immunoglobulin (SCIG) (Medicare Advantage) effective 1/1/2024 has been posted for the following drugs. Archived: Policy effective 9/1/2022. Cutaquig (Immune Globulin Subcutaneous [Human] – hipp) (Medicare Advantage) Cuvitru (Immune Globulin Subcutaneous [Human], 20% Solution) (Medicare Advantage) Arcalyst (rilonacept), 1/1/2024 has been posted. (No PA required for Medicare Advantage effective 1/1/2024). ARCHIVED: Arcalyst (rilonacept), 2/1/2023 The Retinal Disorders (Medicare Advantage) policy effective 10/01/2023 has been archived for the following drugs covered under this policy. No PA is required as of 1/1/2024. Avastin (Medicare Advantage) 1. Byooviz (Medicare Advantage) 1. Beovu (Medicare Advantage)
3.46 (v190)	12/27/2023	Bevacizumab Products - Commercial Preferred Drug Program policy, effective 01/01/2024, has been posted for the following drugs covered under this policy. Archived: redlined 60-day provider notice effective 1/1/24. 1. Alymsys (bevacizumab-maly) (Commercial) (new) 1. Avastin (bevacizumab) (Commercial) (new) Bevacizumab Preferred Drug Program (Commercial) (new) Bevacizumab Products - Medicare Part B Preferred Drug Program policy effective 01/01/2024, has been posted for the following drugs covered under this policy. Archived: redlined 60-day provider notice effective 1/1/24. 1. Alymsys (bevacizumab-maly) (Medicare Advantage) (new) 1. Avastin (bevacizumab) (Medicare Advantage) (new) Bevacizumab Preferred Drug Program (Medicare Advantage) (new) Botulinum Toxins Medicare Part B Preferred Drug Program policy, eff 1/1/2024, has been posted for the following drugs covered under this policy. Archived: 60-day notice eff 1/1/2024 and policy eff 10/28/2022. 1. Botox (onabotulinumtoxinA) (Medicare Advantage) 1. Botulinum Toxins (Medicare Advantage) Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial), effective 1/1/2024, has been posted. The 60-day notice eff 1/1/2024 and policy eff 3/1/2023 have been archived. Colony Stimulating Factors (CSF) - Short Acting - Medicare Part B Preferred Drug Program effective 01/01/2024, has been posted. Archived: 60-day provider notice effective 1/1/2024 and policy effective 2/1/2023.
3.45 (v189)	12/19/2023	Global Oncology 12/12/2023 has been posted for the following drugs covered under this policy. The policy effective 11/28/2023 has been archived. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) 2. Alymsys (bevacizumab-maly) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) bortezomib (generic) Camcevi (leuprolide mesylate) Cyramza The SDRP policy eff 12/1/2023 has been posted for the following drugs covered under this policy. The SDRP policy effective 11/1/2023 has been archived. Adakveo Adzynma (ADAMTS13, recombinant-krhn) (NEW eff 12/1/2023) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Amvuttra (vutrisiran) Aphexda (motixafortide) #2. Beovu Bimzelx (bimekizumab-bkzx) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
3.44 (v188)	12/18/2023	Updated the MA fax form link for Bimzelx Intravenous Immune Globulin (IVIG) (Medicare Advantage) eff 12/15/2023 has been posted for the following drugs covered under this policy. Archived: policy eff 9/1/2022. Asceniv (immune globulin intravenous, human - slra) (Medicare Advantage) Bivigam (human immunoglobulin) (Medicare Advantage)
3.43 (v187)	12/13/2023	Global Oncology 11/28/2023 has been posted for the following drugs covered under this policy. The previous policy effective 11/17/2023 has been archived. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) 2. Alymsys (bevacizumab-maly) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) bortezomib (generic) Camcevi (leuprolide mesylate) Cyramza The SDRP policy eff 11/1/2023 has been posted for the following drugs covered under this policy. The SDRP policy effective 10/1/2023 v2 has been archived. Adakveo Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Amvuttra (vutrisiran) Aphexda (motixafortide) #2. Beovu Bimzelx (bimekizumab-bkzx) (new effective 11/1/2023) Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
3.42 (v186)	12/12/2023	Minor typographical edits.
3.41 (v185)	12/11/2023	The following policies have been posted: 2. Actemra (tocilizumab) redlined 60-day notice (12/1/23-1/31/24) 2. Cosentyx (secukinumab) redlined 60-day notice (12/1/23-1/31/24) Criteria Exception (Commercial and QUEST Integration) redlined 60-day notice (12/1/23-1/31/24)
3.40 (v184)	12/08/2023	Cimzia (certolizumab pegol), 12/1/2023 has been posted. Archived: Redlined 60-day provider notice (10/01/2023-11/30/2023), effective 12/1/2023 and policy effective 9/1/2022. Humira (adalimumab) effective 12/01/2023, has been posted for the following drugs covered under this policy. Archived: 60-day provider notice (10/01/2023-11/30/2023) Abrilada (adalimumab-afzb) (new eff 12/1/23) Amjevita (adalimumab-atto) (new eff 12/1/23) Cyltezo (adalimumab-adbm) (new eff 12/1/23) Infliximab effective 12/01/2023, has been posted for the following drugs covered under this policy. Archived: 60-day provider notice (10/01/2023-11/30/2023) and policy eff 9/1/2022 2. Avsola (infliximab-axxq) Multiple Sclerosis (MS) Preferred Drug Program (Commercial) effective 11/17/2023, has been posted for the following drugs covered under this policy. Archived: policy effective 10/28/2022. Avonex (interferon beta-1a) (Commercial) Betaseron (interferon beta-1b) (Commercial) Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program (Commercial), 11/17/2023 has been posted. Archived: policy effective 10/1/2022. The Hereditary Angioedema (HAE) Preferred Drug Program (Commercial) policy effective 11/17/2023 has been posted for the following drug covered under this policy. The policy effective 10/28/2022 has been archived. 1. Berinert (C1 esterase inhibitor [human]) (Commercial) Global Oncology 11/17/2023 has been posted for the following drugs covered under this policy. The previous policy effective 10/11/2023 has been archived. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) 2. Alymsys (bevacizumab-maly) (NEW effective 10/11/2023) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) bortezomib (generic) Camcevi (leuprolide mesylate) Cyramza
3.39 (v183)	11/22/2023	Formatting revisions and link fixes for Alymsys Reconciled revision version number from entry 3.22
3.38 (v182)	11/20/2023	The following policies have been posted: 2. Berinert (C1 esterase inhibitor [human]), 10/27/2023; archived policy eff 2/1/2023 Cinryze (C1 esterase inhibitor [human]), 10/27/2023; archived policy eff 2/1/2023
3.37 (v181)	11/14/2023	Global Oncology 10/11/2023 has been posted for the following drugs covered under this policy. The previous policy effective 9/5/2023 has been archived. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) 2. Alymsys (bevacizumab-maly) (NEW effective 10/11/2023) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) 2. Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) bortezomib (generic) Camcevi (leuprolide mesylate) Cyramza The SDRP policy eff 10/1/2023 v2 has been posted for the following drugs covered under this policy. The SDRP policy effective 10/1/2023 has been archived. No change to the policy - two drugs added: Aphexda and Daxxify. Adakveo Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Amvuttra (vutrisiran) Aphexda (motixafortide) (NEW effective 10/01/2023) #2. Beovu Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita Effective 11/14/2023, Medical Specialty Archived policy articles will no longer be updated. The quick links to the archived policy pages have been removed. Archived policies can be accessed via the applicable links on this page, found in the Archived Policies column.
3.36 (v180)	11/07/2023	Links to applicable archived folders have been added to the following drugs: 2. Actemra (tocilizumab) Asceniv (immune globulin intravenous, human – slra) (Commerical & QUEST) Asceniv (immune globulin intravenous, human – slra) (Medicare Advantage) Avastin (bevacizumab) (Retinal Disorders) (Commercial and QUEST Integration)(non-oncology) Avastin (bevacizumab) (Retinal Disorders) (Medicare Advantage) (non-oncology) Avonex(interferon beta-1a) (Commercial) 2.Avsola (infliximab-axxq) Benlysta (belimumab) 1. Berinert (C1 esterase inhibitor [human]) (Commercial) Bivigam (human immunoglobulin) (Commercial & QUEST) Bivigam (human immunoglobulin) (Medicare Advantage) Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program (Commercial) 2. Cosentyx (secukinumab) Cutaquig (Immune Globulin Subcutaneous [Human] – hipp)(Commercial & QUEST) Cutaquig Immune Globulin Subcutaneous [Human] – hipp) (Medicare Advantage) Cuvitru Immune Globulin Subcutaneous [Human], 20% Solution)(Commercial & QUEST) Cuvitru Immune Globulin Subcutaneous [Human], 20% Solution)(Medicare Advantage) Added row 2. Avastin (bevacizumab) - Global Oncology
3.35 (v179)	11/01/2023	Botulinum Toxins Medicare Part B Preferred Drug Program redlined 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024, has been posted for the following drugs covered under this policy: 1. Botox (onabotulinumtoxinA) (Medicare Advantage) 1. Botulinum Toxins (Medicare Advantage) Bevacizumab Products - Commercial Preferred Drug Program 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024, has been posted for the following drugs covered under this policy: 1. Alymsys (bevacizumab-maly) (Commercial) (new) 1. Avastin (bevacizumab) (Commercial) (new) Bevacizumab Preferred Drug Program (Commercial) (new) Bevacizumab Products - Medicare Part B Preferred Drug Program redlined 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024, has been posted for the following drugs covered under this policy: 1. Alymsys (bevacizumab-maly) (Medicare Advantage) (new) 1. Avastin (bevacizumab) (Medicare Advantage) (new) Bevacizumab Preferred Drug Program (Medicare Advantage) (new) Short-Acting Colony Stimulating Factors (CSF) - Medicare Part B Preferred Drug Program redlined 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024, has been posted. Long-Acting Colony Stimulating Factors (CSF) – Commercial Preferred Drug Program 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024, has been posted for the following drug covered under this policy: Colony Stimulating Factors (CSF) – Long-Acting (Commercial)
3.34 (v178)	10/31/2023	Actemra, 11/1/2023 has been posted. Archived policy eff 10/28/2022 and the 60-day notice eff 11/1/2023.
3.33 (v177)	10/23/2023	The SDRP policy eff 10/1/2023 has been posted for the following drugs covered under this policy. The SDRP policy effective 9/1/2023 has been archived. Adakveo Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Amvuttra (vutrisiran) #2. Beovu Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
3.32 (v176)	10/09/2023	Autoimmune (AI) Preferred Drug Program (Commercial) effective 09/01/2023 has been posted for the following drugs covered under this policy. The policy effective 07/01/2023 have been archived. Autoimmune Preferred Drug Program #1. Actemra (tocilizumab) #1. Avsola #1. Cimzia (certolizumab pegol) #1. Cosentyx (secukinumab)
3.31 (v175)	10/03/2023	The Retinal Disorders Preferred Drug Program (Medicare Advantage) policy effective 10/01/2023 has been posted for the following drugs covered under this policy. The 60-day notice eff 10/1/23 and policy effective 10/28/22 has been archived. Byooviz (ranibizumab-nuna) (Medicare Advantage) - no PA required
3.30 (v174)	10/01/2023	Minor type fix.
3.29 (v173)	09/29/2023	Redlined 60-day provider notice (10/01/2023-11/30/2023), effective 12/1/2023 has been posted for the following drug: 2. Cimzia (certolizumab pegol) Humira (adalimumab) redlined 60-day provider notice (10/01/2023-11/30/2023), effective 12/01/2023, has been posted for the following drugs covered under this policy: Abrilada (adalimumab-afzb) (new eff 12/1/23) Amjevita (adalimumab-atto) (new eff 12/1/23) Cyltezo (adalimumab-adbm) (new eff 12/1/23) Infliximab redlined 60-day provider notice (02/01/2023-03/31/2023), effective 12/01/2023, has been posted for the following drug covered under this policy: 2. Avsola (infliximab-axxq)
3.28 (v172)	09/28/2023	The Retinal Disorders Preferred Drug Program (Medicare Advantage) policy effective 10/01/2023 has been posted for the following drugs covered under this policy. The 60-day notice eff 10/1/23 and policy effective 10/28/22 has been archived. Avastin (Medicare Advantage) - no PA required 1. Beovu (Medicare Advantage)
3.27 (v171)	09/11/2023	Global Oncology 9/5/2023 has been posted for the following drugs covered under this policy. The previous policy effective 7/21/2023 has been archived. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) bortezomib (generic) Camcevi (leuprolide mesylate) Cyramza The SDRP policy eff 9/1/2023 has been posted for the following drugs covered under this policy. The SDRP policy effective 7/1/2023 (v2) has been archived. Adakveo Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Amvuttra (vutrisiran) #2. Beovu Brineura Briumvi (ublituximab-xiiy) Brixadi (buprenorphine) (NEW eff 9/1/2023) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) Cosela (trilaciclib) Crysvita
3.26 (v170)	08/30/2023	The following policy has been posted: Actemra, redlined 60-day provider notice (9/1/23-10/31/23) eff 11/1/2023
3.25 (v169)	08/08/2023	Global Oncology 7/21/2023 has been posted for the following drugs covered under this policy. The previous policy effective 7/1/2023 has been archived. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) bortezomib (generic) Camcevi (leuprolide mesylate) Cyramza The SDRP policy eff 7/1/2023, v2 has been posted for the following drugs covered under this policy. The SDRP policy effective 7/1/2023 has been archived. Adakveo Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Amvuttra (vutrisiran) #2. Beovu Brineura Briumvi (ublituximab-xiiy) Cablivi Kit Cinqair Columvi (glofitamab-gxbm) (NEW eff 7/1/2023) Cosela (trilaciclib) Crysvita
3.24 (v168)	08/07/2023	Forteo (teriparatide), 7/28/2023 has been posted for the following drug covered under this policy. The policy eff 4/1/2023 has been archived. Bonsity (teriparatide)
3.23 (v167)	07/31/2023	The Retinal Disorders Preferred Drug Program (Medicare Advantage) redlined 60-day notice effective 10/1/2023 (notification period: 08/01/2023-09/30/2023) has been posted for the following drugs covered under this policy: Avastin (Medicare Advantage) - no PA required 1. Beovu (Medicare Advantage) Byooviz (ranibizumab-nuna) (Medicare Advantage)
3.22 (v166)	07/11/2023	Minor copy fixes. References to CVS and/or CVS Caremark have been removed or updated to "HMSA's pharmacy benefit manager" or "the pharmacy benefit manager." Minor proofreading edits, which did not affect context, were also applied.
3.21 (v164)	07/03/2023	Minor copy fixes.
3.20 (v163)	06/30/2023	Updated the fax form for Adbry, effective 7/1/2023.
3.19 (v162)	06/29/2023	The following policies have been posted: Adbry (tralokinumab-ldrm), 7/1/2023; archived 60-day notice Criteria Exception, 7/1/2023; archived 60-day notice The SDRP policy eff 7/1/2023 has been posted for the following drugs covered under this policy. The SDRP policy effective 6/1/2023 has been archived. Adakveo Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Amvuttra (vutrisiran) #2. Beovu Brineura Briumvi (ublituximab-xiiy) Cablivi Kit Cinqair Cosela (trilaciclib) Crysvita Autoimmune Preferred Drug Program (Commercial) effective 07/01/2023 has been posted for the following drugs covered under this policy. The 60-day notice and policy effective 04/01/2023 have been archived. Autoimmune Preferred Drug Program #1. Actemra (tocilizumab) #1. Avsola #1. Cimzia (certolizumab pegol) #1. Cosentyx (secukinumab) The following drugs are part of the Hemophilia Preferred Drug Program and have been added to the drug tables. It applies only to Commercial and QUEST Integration members. Advate [Factor VIII (recombinant)] Adynovate [Factor VIII (recombinant)] Afstyla [Factor VIII (recombinant)] Alphanate [Factor VIII (plasma derived)] AlphaNine SD [Factor IX (plasma derived)] Alprolix [Factor IX (Recombinant)] Altuviiio [Factor VIII (Recombinant)] Benefix [Factor IX (recombinant)]
3.18 (v161)	06/27/2023	The following policy has been posted: Cerezyme (imiglucerase), 6/23/2023; archived policy eff 2/1/2023
3.17 (v160)	06/14/2023	Autoimmune Preferred Drug Program (Commercial) revised redlined 60-day notice effective 7/1/2023, v2 (notification period: 05/01/2023-06/30/2023) has been posted for the following drugs covered under this policy: #1. Actemra (tocilizumab) Autoimmune Preferred Drug Program #1. Avsola (infliximab) #1. Cimzia (certolizumab pegol) #1. Cosentyx (secukinumab) The SDRP policy eff 6/1/2023 has been posted for the following drugs covered under this policy. The SDRP policy effective 5/1/2023 has been archived. Adakveo Adbry (tralokinumab-idrm) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Amvuttra (vutrisiran) #2. Beovu Brineura Briumvi (ublituximab-xiiy) Cablivi Kit Cinqair Cosela (trilaciclib) Crysvita
3.16 (v159)	05/25/2023	Fixed broken link for Aimovig (erenumab-aooe).
3.15 (v158)	05/19/2023	Global Oncology 5/10/2023 has been posted for the following drugs covered under this policy. The previous policy effective 3/6/2023 has beeen archived. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) bortezomib (generic) Camcevi (leuprolide mesylate) Cyramza The SDRP policy eff 5/1/2023 has been posted for the following drugs covered under this policy. The SDRP policy effective 4/1/2023, v2 has been archived. Adakveo Adbry (tralokinumab-idrm) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Amvuttra (vutrisiran) #2. Beovu Brineura Briumvi (ublituximab-xiiy) Cablivi Kit Cinqair Cosela (trilaciclib) Crysvita
3.13 (v157)	05/11/2023	Minor formatting edit.
3.12 (v156)	05/10/2023	The SDRP policy eff 4/1/2023, version 2 has been posted for the following drugs covered under this policy. The SDRP policy effective 4/1/2023 has been archived. Adakveo Adbry (tralokinumab-idrm) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) Amvuttra (vutrisiran) - added eff 11/1/2022 #2. Beovu Brineura Briumvi (ublituximab-xiiy) - added eff 3/1/2023 Cablivi Kit Cinqair Cosela (trilaciclib) Crysvita Removed from table: Briumvi, Global Oncology.
3.11 (v155)	04/28/2023	The following policies were posted: Adbry (tralokinumab-ldrm) 60-day notice effective 7/1/2023 (notification period: 05/01/2023-06/30/2023) Criteria Exception [Formerly Off-Label (Commercial and QUEST)] redlined 60-day notice effective 7/1/2023 (notification period: 05/01/2023-06/30/2023) Autoimmune Preferred Drug Program (Commercial) redlined 60-day notice effective 7/1/2023 (notification period: 05/01/2023-06/30/2023) has been posted for the following drugs covered under this policy: Autoimmune Preferred Drug Program #1. Actemra (tocilizumab) #1. Avsola (infliximab) #1. Cimzia (certolizumab pegol) #1. Cosentyx (secukinumab)
3.10 (v154)	04/06/2023	Removed the 60-day notice link for #1. Actemra (tocilizumab) and updated the current effective date to 4/1/2023, as it was missed in the previous update.
3.9 (v153)	03/30/2023	Autoimmune Preferred Drug Program (Commercial) effective 04/01/2023 has been posted for the following drugs covered under this policy. The 60-day notice and policy effective 10/1/2022 has been archived. Autoimmune Preferred Drug Program #1. Actemra (tocilizumab) #1. Avsola #1. Cimzia (certolizumab pegol) #1. Cosentyx (secukinumab) Forteo (teriparatide), 4/1/2023 has been posted for the following drug covered under this policy. The 60-day notice and policy eff 7/23/2021 have been archived. Bonsity (teriparatide) (new) Botulinum Toxins, eff 4/01/2023, has been posted for the following drug covered under this policy. Archived: 60-day notice and policy eff 1/1/2022. Botox (onabotulinumtoxinA) Botulinum Toxins The SDRP policy eff 4/1/2023 has been posted for the following drugs covered under this policy. The SDRP policy effective 3/1/2023 has been archived. Adakveo Adbry (tralokinumab-idrm) Aimovig (drug is not covered under Part B) Ajovy Amondys 45 (casimersen) #2. Beovu Brineura Cablivi Kit Cinqair Cosela (trilaciclib) Crysvita
3.8 (v152)	03/27/2023	Added the link to the Global Oncology archived folder for Briumvi (ublituximab-xiiy).
3.7 (v151)	03/21/2023	The SDRP policy eff 3/1/2023 has been posted for the following drugs covered under this policy. The SDRP policy effective 12/1/2022 has been archived. Adakveo Adbry (tralokinumab-idrm) Aimovig Ajovy Amondys 45 (casimersen) #2 Beovu Brineura Cablivi Kit Cinqair Cosela (trilaciclib) Crysvita
3.6 (v150)	03/20/2023	Global Oncology 3/6/2023 has been posted for the following drugs covered under this policy. The previous policy effective 1/20/2023 has been archived. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) bortezomib (generic) Briumvi (ublituximab-xiiy) (new) Camcevi (leuprolide mesylate) Cyramza
3.5 (v149)	03/09/2023	The following were noted: Carimune NF (Commercial and QUEST Integration) inactive and removed as of 09/01/2022. Carimune NF (Medicare Advantage) inactive and removed as of 09/01/2022.
3.4 (v148)	02/24/2023	Updated the link for Briumvi (ublituximab-xiiy).
3.3 (v147)	02/03/2023 (published on 2/8/23)	Global Oncology 1/20/2023 has been posted for the following drugs covered under this policy. The previous policy effective 12/2/2022 has beeen archived. Alimta (pemetrexed) Aliqopa (copanlisib dihydrochloride) arsenic trioxide (generic) Asparlas (calaspargase pegol-mknl) Avastin Bavencio (avelumab) Besponsa (inotuzumab ozogamicin) Besremi (ropeginterferon alfa-2b-njft) bortezomib (generic) Briumvi (ublituximab-xiiy) (new) Camcevi (leuprolide mesylate) Cyramza
3.2 (v146)	01/31/2023	The following policies effective 2/1/2023 have been posted: Arcalyst (rilonacept); archived 60-day notice effective 2/1/23 and policy effective 2/1/22 2. Berinert (C1 esterase inhibitor [human]); archived 60-day notice effective 2/1/23 and policy effective 4/1/22 Cerezyme (imiglucerase); archived 60-day notice effective 2/1/23 and policy effective 3/1/22 Cinryze (C1 esterase inhibitor [human]); archived 60-day notice effective 2/1/23 and policy effective 4/1/22 Colony Stimulating Factors (CSF) – Short-Acting Preferred Drug Program (Medicare Advantage) effective 02/01/2023 has been posted. The 60-day notice and policy effective 06/01/2021 have been archived. Botulinum Toxins 60-day provider notice (02/01/2023-03/31/2023), effective 4/01/2023, has been posted for the following drug covered under this policy: Botox (onabotulinumtoxinA) The Forteo (teriparatide) 60-day notice has been posted for the following drugs covered under this policy. Provider notification period is 1/1/2023-2/28/2023. Policy effective date is 4/1/2023. Bonsity (teriparatide) (new) Autoimmune Preferred Drug Program (Commercial) redlined 60-day notice effective 4/1/2023 (notification period: 02/01/2023-03/31/2023) has been posted for the following drugs covered under this policy: Autoimmune Preferred Drug Program #1. Actemra (tocilizumab) #1. Avsola #1. Cimzia (certolizumab pegol) #1. Cosentyx (secukinumab)
2.41 (v145)	01/19/2023	Update to Adbry (tralokinumab-idrm) (SDRP) - removed Medicare Advantage fax form link
2.40 (v144)	01/17/2023	Updated the notice for Aduhelm.

Details

URL Name Medical-Specialty-Drug-Policies-A-C