Information

Title Medical Specialty Drug Policies: D-F

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:

A-C

G-H

I-K

L-N

O-R

S-U

V-Z

D

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Danyelza (naxitamab-gqgk)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology (eff 3/1/2021)	ARCHIVED - Global Oncology
Darzalex (daratumumab)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Darzalex Faspro (daratumumab)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Datroway (datopotamab deruxtecan-dlnk)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Dawnzera (donidalorsen)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective: 09/12/2025	ARCHIVED - SDRP
Daxxify (daxibotulinumtoxinA-lanm)		04/01/2026	Fax Form QUEST Fax Form Medicare Advantage Fax Form	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY) Effective 1/1/2025 Specialty Drugs Requiring Precertification (SDRP) Effective 1/1/25: Removed from SDRP policy	ARCHIVED - Botulinum Toxins ARCHIVED - SDRP
1. Daxxify (daxibotulinumtoxinA-lanm) (Botulinum Toxins Preferred Drug Program) (Medicare Advantage)		11/21/2025		Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY) Preferred Drug Program	ARCHIVED - Botulinum Toxins Preferred Drug Program MA
2. Daxxify (daxibotulinumtoxinA-lanm)		04/01/2026		Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY) Effective 1/1/2025	ARCHIVED - Botulinum Toxins
1. Dupixent (dupilumab) (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. Dupixent (dupilumab) (Commercial and QUEST)		04/01/2026	Fax Form		ARCHIVED - Dupixent
Dupixent (dupilumab) (QUEST)	60-day provider notice 05/01/2026-06/30/2026, in effect 07/01/2026
1. Durolane (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Durolane Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Durolane (hyaluronic acid) (Commercial and QUEST)		04/12/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI) ARCHIVED - Hyaluronates (drug specific)
1. Durolane (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Durolane Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program (MA)
2. Durolane (hyaluronic acid) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Dysport (abobotulinumtoxinA)		04/01/2026	Fax Form QUEST Fax Form Medicare Advantage Fax Form	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY)	ARCHIVED - Botulinum Toxins
1. Dysport (Botulinum Toxins Preferred Drug Program) (Medicare Advantage)		11/21/2025	Refer below for Dysport Fax Forms	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY) Preferred Drug Program	ARCHIVED - Botulinum Toxins Preferred Drug Program MA
2. Dysport (abobotulinumtoxinA)		04/01/2026	Fax Form QUEST Fax Form Medicare Advantage Fax Form	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY)	ARCHIVED - Botulinum Toxins

E

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
1. Ebglyss (lebrikizumab-lbkz) (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. Ebglyss (lebrikizumab-lbkz) (Commercial and QUEST)		01/01/2026	Commercial Fax Form	Drug-specific policy effective 01/01/2026 Effective 01/01/2026: Removed from SDRP policy	ARCHIVED - Ebglyss ARCHIVED - SDRP
Ebglyss (lebrikizumab-lbkz) (QUEST)	60-day provider notice 05/01/2026-06/30/2026, in effect 07/01/2026
edaravone (generic)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective: 12/16/2024	ARCHIVED - SDRP
Egrifta (tesamorelin acetate)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective: 08/01/2025	ARCHIVED - SDRP
Elahere (mirvetuximab soravtansine-gynx)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Effective 12/02/2022	ARCHIVED - Global Oncology
Elelyso (taliglucerase) (Commercial and QUEST)		03/01/2026	Commercial Fax Form QUEST Fax Form		ARCHIVED - Elelyso (Comm-QUEST) ARCHIVED - Elelyso
Elelyso (taliglucerase) (Medicare Advantage)		09/26/2025	Medicare Advantage Fax Form		ARCHIVED - Elelyso (MA)
Elevidys Kit (delandistrogene moxeparvovec-rokl)	Please contact HMSA at 808-948-6464, option #4, for drug review
Elfabrio (pegunigalsidase alfa-lwxj)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 6/01/2023	ARCHIVED - SDRP
Eligard (leuprolide acetate)	No PA required for Medicare Advantage	04/14/2026	Fax Form	Global Oncology	ARCHIVED - Global Oncology
Eloctate [Factor VIII (Recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Elrexfio (elranatamab-bcmm)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 9/5/2023	ARCHIVED - Global Oncology
Elzonris (tagraxofusp-erzs)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Emgality (galcanezumab-gnlm)		04/14/2026	Commercial Fax Form QUEST Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Empaveli (pegcetacoplan)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Empliciti (elotuzumab)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Emrelis (telisotuzumab vedotin-tllv)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 7/10/2025	ARCHIVED - Global Oncology
1. Enbrel (etanercept) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Enbrel Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Enbrel (etanercept) (Commercial and QUEST)		08/01/2025	Fax Form	Specific drug criteria for Enbrel	ARCHIVED - Enbrel (Comm-QUEST)
Enhertu (fam-trastuzumab deruxtecan-nxki)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Enjaymo (sutimlimab-jome)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 4/1/2022	ARCHIVED - SDRP
Enoby (denosumab-qbde) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Prolia and Biosimilars (Commercial and QUEST)	ARCHIVED - Prolia (Comm-QUEST)
Enspryng (satralizumab-mwge)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
1. Entyvio (vedolizumab) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	See below for Entyvio fax form	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Entyvio (vedolizumab) (Commercial and QUEST)		08/01/2025	Commercial Fax Form QUEST Fax Form	Specific drug criteria for Entyvio	ARCHIVED - Entyvio (Comm-QI) ARCHIVED - Entyviio (Comm-QI-MA)
Entyvio (vedolizumab) (Medicare Advantage)		04/25/2025	Medicare Advantage Fax Form		ARCHIVED - Entyvio (MA)
Epkinly (epcoritamab-bysp)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 7/21/2023	ARCHIVED - Global Oncology
Epogen				No PA required as of 11/23/15
epoprostenol (generic) (Commercial and QUEST)	60-day provider notice 04/01/2026-05/31/2026, in effect 6/1/2026	12/19/2025	Fax Form	Flolan; Veletri; epoprostenol (generic)	ARCHIVED - Flolan-Veletri-epoprostenol (Comm-QI) ARCHIVED - Flolan-Veletri
epoprostenol (generic) (Medicare Advantage)		12/19/2025	Medicare Advantage Fax Form	Flolan; Veletri; epoprostenol (generic) MA	ARCHIVED - Flolan-Veletri-epoprostenol (MA)
Epysqli (eculizumab-aagh) (Commercial and QUEST)		12/19/2025		Soliris	ARCHIVED - Soliris (Comm-QUEST)
Epysqli (eculizumab-aagh) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Soliris-Bkemy-Epysqli	ARCHIVED - Soliris (MA)
Erbitux (cetuximab)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Erythropoiesis Stimulating Agents (ESAs)				No PA required as of 11/23/15
Esperoct [Factor VIII (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
1. Euflexxa® (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Euflexxa Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Euflexxa® (1% sodium hyaluronate) (Commercial and QUEST)		04/12/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI) ARCHIVED - Hyaluronates (drug specific)
1. Euflexxa (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Euflexxa Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program (MA)
2. Euflexxa® (1% sodium hyaluronate) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Evenity (romosozumab-aqqg) (Commercial and QUEST)		12/19/2025	Commerical Fax Form QUEST Fax Form	Effective 4/1/23: Drug specific policy Specialty Drugs Requiring Precertification (SDRP) Effective 4/1/23: Removed from SDRP policy.	ARCHIVED - Evenity (Comm/QI) ARCHIVED - Evenity Refer to policies eff 4/1/2023 and later ARCHIVED - SDRP
Evenity (romosozumab-aqqg) (Medicare Advantage)		06/27/2025	Medicare Advantage Fax Form		ARCHIVED - Evenity (MA)
Evkeeza (evinacumab-dgnb)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Exdensur (depemokimab-ulaa)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Exondys 51 (eteplirsen)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Extavia (interferon beta-1b) (Multiple Sclerosis Preferred Program) (Commercial)		11/21/2025	Commercial Fax Form	Multiple Sclerosis (MS) - Interferons Preferred Drug Program	ARCHIVED - Multiple Sclerosis (MS) – Preferred Drug Program
Eylea (aflibercept) (Commercial and QUEST)	No PA required
Eylea (aflibercept) Medicare Advantage)	No PA required as of 01/01/2024			Retinal Disorders Preferred Drug Program	ARCHIVED - Retinal Disorders Preferred Drug Program (MA)

F

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Fasenra (benralizumab)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Favlyxa (fluorouracil)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 4/14/2026	ARCHIVED - Global Oncology
Feiba [Anti-inhibitor coagulant complex]	Please contact HMSA at 808-948-6464, option #4, for drug review
Fensolvi (leuprolide acetate) (Non-oncology) (Commercial and QUEST)		01/01/2026	Fax Form	Leuprolide-Lupron	ARCHIVED - Leuprolide (Comm-QI)
1. Firazyr (icatibant) (Hereditary Angioedema Preferred Drug Program) (Commercial)		11/21/2025	Refer below for Firazyr Fax Forms	Hereditary Angioedema Preferred Drug Program	ARCHIVED - Hereditary Angioedema Preferred Drug Program
2. Firazyr (icatibant) (Commerical and QUEST)		01/01/2026	Commercial Fax Form QUEST Fax Form	icatibant–Firazir-sajazir	ARCHIVED - Icatibant (Comm-QUEST)
Flebogamma DIF (human immunoglobulin) (Commercial and QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QUEST)
Flebogamma DIF (human immunoglobulin) (Medicare Advantage)		10/01/2025	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Flolan (epoprostenol) (Commercial and QUEST)	60-day provider notice 04/01/2026-05/31/2026, in effect 6/1/2026	12/19/2025	Fax Form	Flolan; Veletri; epoprostenol (generic)	ARCHIVED - Flolan-Veletri-epoprostenol (Comm-QI) ARCHIVED - Flolan-Veletri
Flolan (epoprostenol) (Medicare Advantage)		12/19/2025	Medicare Advantage Fax Form	Flolan; Veletri; epoprostenol (generic) MA	ARCHIVED - Flolan-Veletri-epoprostenol (MA)
Folotyn (pralatrexate)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Forteo (teriparatide)		06/27/2025	Fax Form		ARCHIVED - Forteo
Forzinity (elamipretide)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 11/18/2025	ARCHIVED - SDRP
Fulphila (pegfilgrastim-jmdb) (Commercial)	No PA Required	01/01/2026		Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CSF Long Acting Preferred Drug Program
Fulphila (pegfilgrastim-jmdb) (Medicare Advantage)	No PA Required	01/01/2026		Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CFS Long Acting Preferred Drug Program (MA)
Fyarro (sirolimus protein-bound particles for injectable suspension)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 4/1/2022	ARCHIVED - Global Oncology
Fylnetra (pegfilgrastim-pbbk) (Commercial)		01/01/2026	Commercial Fax Form	Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CSF Long Acting Preferred Drug Program
Fylnetra (pegfilgrastim-pbbk) (Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CFS Long Acting Preferred Drug Program (MA)

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

Change History

Rev#:	Date:	Nature of Change:
6.25	05/07/2026	1100-1677778-1848950 The following 60-day notices effective 7/1/2026 have been posted: Dupixent (dupilumab) (QUEST) Ebglyss (lebrikizumab-lbkz) (QUEST)
6.24	05/04/2026	1100-1677771-1838900 Favlyxa (fluorouracil), a drug covered under the Global Oncology policy, has been added to the table. 1100-1677778-1846250 The fax form links for the following drugs have been updated: Ebglyss (Commercial)
6.23	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Datroway (datopotamab deruxtecan-dlnk) Elahere (mirvetuximab soravtansine-gynx) Eligard - no PA required for Medicare Advantage Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Emrelis (telisotuzumab vedotin-tllv) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Favlyxa (fluorouracil) (NEW) Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension) 1100-1677771-1837550 The SDRP policy eff 04/14/2026 has been posted for the following drugs covered under this policy. Dawnzera (donidalorsen) edaravone (generic) Egrifta (tesamorelin acetate) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exdensur (depemokimab-ulaa) Exondys 51 Fasenra Forzinity (elamipretide)
6.22	04/20/2026	1100-1677771-1831000 The epoprostenol-Flolan-Veletri (Commercial and QUEST) 60-day provider notice 04/01/2026-05/31/2026, in effect 06/01/2026, has been posted for the following drugs covered under this policy: epoprostenol (generic) (Commercial and QUEST) Flolan (epoprostenol) (Commercial and QUEST)
6.21	04/16/2026	1100-1677771-1819705 Updated the spelling of "Enovy (Commercial and QUEST) " to "Enoby (Commercial and QUEST)" and re-alphabetized.
6.20	04/14/2026	1100-1677771-1821700 The QUEST fax form links have been updated for Elelyso and Firazyr. 1100-1677771-0820850 The Hyaluronate Products (Commercial and QUEST) effective 04/12/2026 has been posted for the following drugs covered under this policy:
6.19	04/13/2026	1100-1677771-1819705 The Prolia (denosumab) (Commercial and QUEST) policy effective 04/01/2026 has been posted for the following drug covered under this policy: Enoby (denosumab-qbde) (Commercial and QUEST)
6.18	04/09/2026	1100-1677771-1805800 Effective date for Evkeeza (evinacumab-dgnb) has been updated to 3/27/2026.
6.17	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.
6.16	04/06/2026	1100-1677771-1805800 The SDRP policy eff 03/27/2026 has been posted for the following drugs covered under this policy. Dawnzera (donidalorsen) edaravone (generic) Egrifta (tesamorelin acetate) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exdensur (depemokimab-ulaa) Exondys 51 Fasenra Forzinity (elamipretide)
6.15	04/02/2026	1100-1677764-1798651 The following policies effective 04/01/2026 have been posted: 2. Dupixent (dupilumab) (Commercial and QUEST) 1100-1677764-1802900 The Hyaluronates (MA) policy effective 04/01/2026 has been posted for the following drugs covered under this policy. 2. Durolane (hyaluronic acid) (Medicare Advantage) 2. Euflexxa® (1% sodium hyaluronate) (Medicare Advantage)
6.14	03/31/2026	1100-1677764-1798651 Botulinum Toxins, eff 04/01/2026, has been posted for the following drugs covered under this policy. Daxxify (daxibotulinumtoxinA-lanm) – Note: I noticed 60-Day Provider Notice wasn’t added to the drug. The drug should be part of the full list of drugs for Botulinum Toxins. 2. Daxxify Dysport (abobotulinumtoxinA) 2. Dysport
6.13	03/30/2026	1100-1677764-1798661 Soliris and Biosimilars (Medicare Advantage), effective 04/01/2026, has been posted for the following drug covered under this policy. Epysqli (eculizumab-aagh) (Medicare Advantage)
6.12	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Datroway (datopotamab deruxtecan-dlnk) Elahere (mirvetuximab soravtansine-gynx) Eligard - no PA required for Medicare Advantage Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Emrelis (telisotuzumab vedotin-tllv) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension) 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. Dawnzera (donidalorsen) edaravone (generic) Egrifta (tesamorelin acetate) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exdensur (depemokimab-ulaa) Exondys 51 Fasenra Forzinity (elamipretide)
6.11	02/26/2026	1100-1677757-1758252 The Elelyso (taliglucerase) (Commercial and QUEST) policy effective 3/1/2026 has been posted. ARCHIVED: 60-day notice and policy eff 9/27/2024.
6.10	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. Dawnzera (donidalorsen) edaravone (generic) Egrifta (tesamorelin acetate) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exdensur (depemokimab-ulaa) Exondys 51 Fasenra Forzinity (elamipretide)
6.09	02/23/2026	1100-1677757-1751350 The epoprostenol-Flolan-Veletri (Commercial and QUEST) 60-day provider notice (02/01/2026-03/31/2026), effective 4/01/2026 has been removed. The policy effective 12/19/2025 will continue as the current policy until further notice for the following drugs: epoprostenol (generic) (Commercial and QUEST) Flolan (epoprostenol) (Commercial and QUEST)
6.08	02/20/2026	1100-1677757-1748050 The Evenity (romosozumab-aqqg) (Commercial and QUEST) 60-day provider notice (02/01/2026-03/31/2026), effective 4/01/2026 has been removed. The policy effective 12/19/2025 will continue as the current policy until further notice.
6.07	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. Dawnzera (donidalorsen) edaravone (generic) Egrifta (tesamorelin acetate) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exdensur (depemokimab-ulaa) (NEW) Exondys 51 Fasenra Forzinity (elamipretide)
6.06	02/04/2026	1100-1677757-1723650 The Dupixent (dupilumab) (Commercial and QUEST) 60-day provider notices (02/01/2026-03/31/2026), effective 4/01/2026, has been posted.
6.05	02/03/2026	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: Epysqli (eculizumab-aagh) (Medicare Advantage) (NEW) 1100-1677757-1723601 The Evenity (romosozumab-aqqg) (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: 2. Daxxify (daxibotulinumtoxinA-lanm) 2. Dysport (abobotulinumtoxinA) 1100-1205577-1675357 The epoprostenol-Flolan-Veletri (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: epoprostenol (generic) (Commercial and QUEST) Flolan (epoprostenol) (Commercial and QUEST) 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 drug covered under this policy: Enovy (denosumab-qbde) (Commercial and QUEST) (NEW)
6.04	01/21/2026	1100-1677750-1704852 Updated the policy notes for Daxxify and Dysport.
6.03	01/20/2026	1100-1677750-1699604 Updated missed Global Oncology drugs to effective date 01/13/2026. 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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Datroway (datopotamab deruxtecan-dlnk) Elahere (mirvetuximab soravtansine-gynx) Eligard - no PA required for Medicare Advantage Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Emrelis (telisotuzumab vedotin-tllv) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
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. 1100-1677750-1684314 Added a policy note for Daxxify. 1100-1677750-1684306 Edits to LOB in drug link name. 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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Datroway (datopotamab deruxtecan-dlnk) Elahere (mirvetuximab soravtansine-gynx) Eligard - no PA required for Medicare Advantage Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Emrelis (telisotuzumab vedotin-tllv) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
6.01	01/05/2026	1100-1677750-1684300 Icatibant (Commercial and QUEST), effective 01/01/2026 has been posted for the following drugs covered under this policy. The policy effective 09/27/2024 has been archived. 2. Firazyr (icatibant) (Commercial and QUEST) 1100-1677750-1684306 Leuprolide (Commercial and QUEST) effective 07/26/2024 has been posted for the following drug covered under this policy. Archived: 60-day notice and policy eff 07/26/2024. Fensolvi (leuprolide acetate) (Commercial and QUEST)
6.00	01/01/2026	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 Dawnzera (donidalorsen) 2. Ebglyss (lebrikizumab-lbkz) - Effective 1/1/26: Removed from SDRP policy edaravone (generic) Egrifta (tesamorelin acetate) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra Forzinity (elamipretide) 1100-1677750-1684700 Ebglyss (lebrikizumab-lbkz) effective 01/01/2026 has been posted.
5.58	12/31/2025	1100-1205577-1681552 Colony Stimulating Factors (CSF) – Long Acting Specialty Exceptions (Commercial), effective 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 09/26/2025 Fulphila (pegfilgrastim-jmdb) (Commercial) - No PA required Fylnetra (pegfilgrastim-pbbk) (Commercial) 1100-1205577-1681552 Colony Stimulating Factors (CSF) – Long Acting Specialty Exceptions(Medicare Advantage), effective 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 09/26/2025. Fulphila (pegfilgrastim-jmdb) (Medicare Advantage) - No PA required Fylnetra (pegfilgrastim-pbbk) (Medicare Advantage) 1100-1205577-1681563 The Hyaluronates Specialty Exceptions(Commercial and QUEST) policy effective 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 09/26/2025. 1. Durolane (Commercial and QUEST) 1. Euflexxa (Commercial and QUEST) 1100-1205577-1681563 The Hyaluronates Specialty Exceptions(Medicare Advantage) policy effective 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 09/26/2025. 1. Durolane (Medicare Advantage) 1. Euflexxa (Medicare Advantage) 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. Dupixent (dupilumab) (Atopic Dermatitis Preferred Program) 1. Ebglyss (lebrikizumab-lbkz) (Atopic Dermatitis Preferred Program) 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 1. Enbrel (etanercept) 1. Entyvio (vedolizumab)
5.57	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 Dawnzera (donidalorsen) 2. Ebglyss (lebrikizumab-lbkz) edaravone (generic) Egrifta (tesamorelin acetate) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra Forzinity (elamipretide)
5.56	12/29/2025	1100-1205577-1679550 The Elelyso (Comm-QUEST) 60-day provider notices 01/01/2026-02/28/2026, in effect 03/01/2026 have been posted.
5.55	12/24/2025	1100-1205577-1675357 Evenity (romosozumab-aqqg) (Commercial-QUEST) policy, effective 12/19/2025 has been posted. ARCHIVED: policy effective 7/26/2024. 1100-1205577-1675357 Flolan-Veletri (Commercial and QUEST) effective 12/19/2025, has been posted for the following drugs covered under this policy. ARCHIVED: Policy 10/25/2024. epoprostenol (generic) (Commercial and QUEST) Flolan (epoprostenol) (Commercial and QUEST)
5.54	12/23/2025	1100-1205577-1671755 Flolan-Veletri (Medicare Advantage) effective 12/19/2025, has been posted for the following drugs covered under this policy. ARCHIVED: Policy 10/25/2024. epoprostenol (generic) (Medicare Advantage) Flolan (epoprostenol) (Medicare Advantage) 1100-1205577-1671755 The Hyaluronates Medicare Part B policy effective 12/19/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 12/20/2024. 2. Durolane (hyaluronic acid) (Medicare Advantage) 2. Euflexxa® (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. Epysqli (eculizumab-aagh) (Commercial and QUEST)
5.53	12/03/2025	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Datroway (datopotamab deruxtecan-dlnk) Elahere (mirvetuximab soravtansine-gynx) Eligard - no PA required for Medicare Advantage Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Emrelis (telisotuzumab vedotin-tllv) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
5.52	12/01/2025	1100-1205570-1634455 Corrected effective date of 1. Firazyr (icatibant) (Hereditary Angioedema Preferred Drug Program) (Commercial) to 11/21/2025
5.51	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. Daxxify (daxibotulinumtoxinA-lanm) (Botulinum Toxins Preferred Drug Program) (Medicare Advantage) 1. Dysport (abobotulinumtoxinA) (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. Firazyr (icatibant) (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. Extavia (interferon beta-1b) (Multiple Sclerosis Preferred Program) (Commercial) 1100-1205570-1639569 Ebglyss (Commercial and QUEST) policy effective 1/1/2026 has been posted.
5.50	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 Dawnzera (donidalorsen) 2. Ebglyss (lebrikizumab-lbkz) edaravone (generic) Egrifta (tesamorelin acetate) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra Forzinity (elamipretide) (NEW)
5.49	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Datroway (datopotamab deruxtecan-dlnk) Elahere (mirvetuximab soravtansine-gynx) Eligard - no PA required for Medicare Advantage Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Emrelis (telisotuzumab vedotin-tllv) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
5.48	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 Dawnzera (donidalorsen) Ebglyss (lebrikizumab-lbkz) edaravone (generic) Egrifta (tesamorelin acetate) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
5.47	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 Dawnzera (donidalorsen) (NEW) Ebglyss (lebrikizumab-lbkz) edaravone (generic) Egrifta (tesamorelin acetate) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
5.46	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Datroway (datopotamab deruxtecan-dlnk) Elahere (mirvetuximab soravtansine-gynx) Eligard - no PA required for Medicare Advantage Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Emrelis (telisotuzumab vedotin-tllv) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
5.45	10/29/2025	1100-1205563-1592054 The Atopic Dermatitis (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: 1. Dupixent (dupilumab) (Atopic Dermatitis Preferred Program) (NEW) 1. Ebglyss (lebrikizumab-lbkz) (Atopic Dermatitis Preferred Program) (NEW)
5.44	10/28/2025	1100-1205563-1594410 Leuprolide (Commercial and QUEST) 60-day provider notice 11/01/2025-12/31/2025 effective 01/01/2026, has been posted for the following drug covered under this policy: Fensolvi (leuprolide acetate) (non-oncology) (Commercial and QUEST)
5.43	10/23/2025	1100-1205563-1590053 The icatibant 60-day notice (Commercial and QUEST) has been posted for the following drugs covered under this policy. Provider notification period is 11/01/2025-12/31/2025. Policy effective date is 01/01/2026. 2. Firazyr (icatibant) (Commercial and QUEST) 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: 1. Enbrel (etanercept) 1. Entyvio (vedolizumab)
5.42	10/21/2025	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 for the following drugs covered under this policy. ARCHIVED: Policy eff 01/01/2025 Fulphila (pegfilgrastim-jmdb) (Commercial) Fylnetra (pegfilgrastim-pbbk) (Commercial) 1100-1205563-1574400 Colony Stimulating Factors (CSF) – Long Acting Specialty Exceptions(Medicare Advantage), effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 01/01/2025. Fulphila (pegfilgrastim-jmdb) (Medicare Advantage) Fylnetra (pegfilgrastim-pbbk) (Medicare Advantage)
5.41	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. Ebglyss (lebrikizumab-lbkz) edaravone (generic) Egrifta (tesamorelin acetate) (NEW) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra 1100-1205563-1574400 The Hyaluronates Preferred Drug Program (Commercial and QUEST) policy effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 01/01/2025. 1. Durolane (Commercial and QUEST) 1. Euflexxa (Commercial and QUEST) 1100-1205563-1574400 The Hyaluronates Specialty Exceptions(Medicare Advantage) policy effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 01/01/2025. 1. Durolane (Medicare Advantage) 1. Euflexxa (Medicare Advantage)
5.40	10/02/2025	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. Flebogamma DIF (human immunoglobulin) (Medicare Advantage) 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 1. Enbrel (etanercept) 1. Entyvio (vedolizumab)
5.39	09/30/2025	1100-1205556-1544400 The following policy has been posted: Elelyso (taliglucerase) (Medicare Advantage), 09/26/2025; ARCHIVED policy eff 7/26/24
5.38	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 07/25/2025. Ebglyss (lebrikizumab-lbkz) edaravone (generic) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
5.37	09/19/2025	1100-1205556-1514402 The effective dates for the following drugs covered under the Global Oncology policy have been updated to 09/12/2025. It was inadvertently missed in the last update. Elahere (mirvetuximab soravtansine-gynx) Eligard - no PA required for Medicare Advantage Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Emrelis (telisotuzumab vedotin-tllv) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux
5.36	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Datroway (datopotamab deruxtecan-dlnk) Elahere (mirvetuximab soravtansine-gynx) Eligard - no PA required for Medicare Advantage Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Emrelis (telisotuzumab vedotin-tllv) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
5.35	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. Ebglyss (lebrikizumab-lbkz) edaravone (generic) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
5.34	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Datroway (datopotamab deruxtecan-dlnk) Elahere (mirvetuximab soravtansine-gynx) Eligard - no PA required for Medicare Advantage Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Emrelis (telisotuzumab vedotin-tllv) (NEW) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension) 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: 1. Enbrel (etanercept) 1. Entyvio (vedolizumab)
5.33	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Datroway (datopotamab deruxtecan-dlnk) Elahere (mirvetuximab soravtansine-gynx) Eligard - no PA required for Medicare Advantage Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Emrelis (telisotuzumab vedotin-tllv) (NEW) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension) 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. Ebglyss (lebrikizumab-lbkz) edaravone (generic) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
5.32	09/02/2025	1100-1205549-1486802 The QUEST fax form links for the following drugs have been updated: Emgalitiy, Empaveli, Enjaymo, Enspryng, Evkeeza, Exondys 51, Fasenra
5.31	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Datroway (datopotamab deruxtecan-dlnk) Elahere (mirvetuximab soravtansine-gynx) Eligard - no PA required for Medicare Advantage Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Emrelis (telisotuzumab vedotin-tllv) (NEW) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension) 1100-1205549-1488650 The SDRP policy eff 07/01/2025-v2 has been posted for the following drugs covered under this policy. Ebglyss (lebrikizumab-lbkz) edaravone (generic) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
5.30	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. Ebglyss (lebrikizumab-lbkz) edaravone (generic) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra 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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Datroway (datopotamab deruxtecan-dlnk) Elahere (mirvetuximab soravtansine-gynx) Eligard - no PA required for Medicare Advantage Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Emrelis (telisotuzumab vedotin-tllv) (NEW) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
5.29	08/11/2025	1100-1205549-1463450 Intravenous Immune Globulin (IVIG) (Commercial and QUEST) effective 7/25/2025, has been posted for the following drug covered under this policy. Archived: policy eff 5/23/2025. Flebogamma DIF (Commercial and QUEST)
5.28	08/07/2025	1100-1205549-1457500 2. Entyvio (vedolizumab) (Commercial and QUEST), 8/1/2025 was posted (inadvertently missed in previous update) 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. Flebogamma DIF (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: 1. Enbrel (etanercept) 1. Entyvio (vedolizumab)
5.27	08/05/2025	1100-1205549-1457500 Policies effective 8/1/2025, have been posted for the following drugs. 2. Enbrel (etanercept) (Commercial and QUEST); ARCHIVED: 60-day notice and policy eff 8/01/2024. 2. Entyvio (vedolizumab) (Commercial and QUEST); ARCHIVED: 60-day notice and policy eff 4/26/2024.
5.26	07/28/2025	1100-1205535-1388200 Ebglyss - removed the Medicare Fax form link.
5.25	07/24/2025	1100-1205542-1427101 The following drug policies, effective 6/27/2025 has been posted: Evenity (Medicare Advantage); ARCHIVED: policy eff 7/26/2024 Forteo (teriparatide); ARCHIVED: policy effective 07/26/2024.
5.24	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. Ebglyss (lebrikizumab-lbkz) edaravone (generic) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra 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. Epysqli (eculizumab-aagh) (Commercial and QUEST)
5.23	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. 1. Enbrel (etanercept) (Autoimmune Preferred Drug Program) 1. Entyvio (vedolizumab) (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. Ebglyss (lebrikizumab-lbkz) edaravone (generic) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra The Hyaluronate Products (Commercial and QUEST Integration) effective 5/23/2025, has been posted for the following drugs covered under this policy. Archived: Policy eff 11/29/2024. 2. Durolane (hyaluronic acid) 2. Euflexxa (1% sodium hyaluronate) 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. Flebogamma DIF (Commercial and QUEST)
5.22	06/03/2025	1100-1205535-1358909 60-day notices (6/01/2025-7/31/2025), effective 8/1/2025, have been posted for the following drugs: 2. Enbrel (etanercept) (Commercial and QUEST) 2. Entyvio (vedolizumab) (Commercial and QUEST)
5.21	05/22/2025	1100-1205528-1346450 Fax form links for the following have been update: 2. Entyvio (vedolizumab) (Commercial and QUEST Integration)
5.20	05/19/2025	1100-1205528-1345201 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. Ebglyss (lebrikizumab-lbkz) edaravone (generic) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
5.19	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Datroway (datopotamab deruxtecan-dlnk) Elahere (mirvetuximab soravtansine-gynx) Eligard - no PA required for Medicare Advantage Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
5.18	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. Ebglyss (lebrikizumab-lbkz) edaravone (generic) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
5.17	05/08/2025	1100-1205528-1315150 The following fax form links have been updated or added: Daxxify (daxibotulinumtoxinA-lanm) - QUEST Dysport (abobotulinumtoxinA) - QUEST 2. Dysport (abobotulinumtoxinA) - QUEST Fylnetra (pegfilgrastim-pbbk) (Medicare Advantage) - MA 1100-1205528-1330252 Edited the SDRP current effective date to 04/01/2025 as applicable.
5.16	05/06/2025	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. Ebglyss (lebrikizumab-lbkz) edaravone (generic) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra 1100-1205528-1330255 Entyvio (MA), 4/25/2025 has been posted. ARCHIVED: policy eff 8/1/2024.
5.15	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Datroway (datopotamab deruxtecan-dlnk) Elahere (mirvetuximab soravtansine-gynx) Eligard - no PA required for Medicare Advantage Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
5.14	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. Ebglyss (lebrikizumab-lbkz) edaravone (generic) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
5.13	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Datroway (datopotamab deruxtecan-dlnk) Elahere (mirvetuximab soravtansine-gynx) Eligard - no PA required for Medicare Advantage Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
5.12	04/14/2025	1100-1205521-1305653 Dupixent (dupilumab) (Commercial and QUEST) has been posted; ARCHIVED: 60-day notice and policy eff 4/1/2024 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 Epysqli (eculizumab-aagh) (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. Daxxify 2. Daxxify (Medicare Advantage) Dysport 2. Dysport (Medicare Advantage)
5.11	04/07/2025	1100-1205521-1301650 The SDRP policy eff 02/01/2025 has been posted for the following drugs covered under this policy. Ebglyss (lebrikizumab-lbkz) edaravone (generic) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
5.10	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: Daxxify (daxibotulinumtoxinA-lanm) Dysport (abobotulinumtoxinA) 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. 1. Enbrel (etanercept) 1. Entyvio (vedolizumab)
5.09	03/13/2025	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Datroway (datopotamab deruxtecan-dlnk) (NEW) Elahere (mirvetuximab soravtansine-gynx) Eligard - no PA required for Medicare Advantage Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension) Change history notes from 2020, 2021, and 2022 are archived and have been removed from this article.
5.08	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. Ebglyss (lebrikizumab-lbkz) edaravone (generic) (NEW eff 12/16/2024) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
5.07	03/05/2025	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 drugs covered under this policy: Daxxify (daxibotulinumtoxinA-lanm) Dysport (abobotulinumtoxinA) The following redlined 60-day provider notices (02/01/2025-03/31/2025), effective 04/01/2025 have been posted: Dupixent (dupilumab) (Commercial and QUEST) 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: Epysqli (eculizumab-aagh) (Commercial and QUEST) (NEW)
5.06	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Elahere (mirvetuximab soravtansine-gynx) Eligard - no PA required for Medicare Advantage Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
5.05	02/24/2025	1100-1205507-1238900 Minor typographical edit. 1100-1205507-1254950 Fax form link have been updated for the following drugs: Flebogamma DIF (Commercial & QUEST) Flebogamma DIF (Medicare Advantage)
5.04	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.. Ebglyss (lebrikizumab-lbkz) edaravone (generic) (NEW eff 12/16/2024) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra 1100-1205507-1238900 Botulinum Toxins, eff 01/01/2025, has been posted for the following drug covered under this policy. Daxxify (daxibotulinumtoxinA-lanm) (new)
5.03	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. Daxxify (daxibotulinumtoxinA-lanm) Ebglyss (lebrikizumab-lbkz) edaravone (generic) (NEW eff 12/16/2024) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
5.02	01/15/2025	1100-1205500-1214101The Global Oncology policy effective 12/01/2024 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 11/15/2024. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Elahere (mirvetuximab soravtansine-gynx) Eligard - no PA required for Medicare Advantage Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
5.01	01/09/2025	1100-956557-1197456 Removed policy and fax form link: Fulphilia (Commercial) and Fulphilia (MA)
5.0	01/07/2025	1100-956557-1197456 Added: 2. Daxxify (daxibotulinumtoxinA-lanm) - Botulinum Toxins Added: No PA Required to Fulphilia (Commercial) and Fulphilia (MA)

Rev#:	Date:	Nature of Change:
4.44	11/05/2025	1100-1205570-1607700 The following drug name has been updated to: 1. Firazyr (icatibant) (Hereditary Angioedema Preferred Drug Program) (Commercial)
4.43 (v204)	12/30/2024	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. Daxxify (new eff 1/1/25) Dysport (abobotulinumtoxinA) 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. Daxxify (new eff 1/1/25) 1. Dysport (abobotulinumtoxinA) (Medicare Advantage) 1100-956557-1197456 Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial), effective 1/1/2025, has been posted for the following drugs covered under this policy. The 60-day notice eff 1/1/2025 and policy eff 1/1/2024 have been archived. Fulphila (pegfilgrastim-jmdb) (Commercial) Fylnetra (pegfilgrastim-pbbk) (Commercial) 1100-956557-1197456 Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Medicare Advantage), effective 1/1/2025, has been posted for the following drugs covered under this policy. ARCHIVED: The 60-day notice eff 1/1/2025. Fulphila (pegfilgrastim-jmdb) (Medicare Advantage) Fylnetra (pegfilgrastim-pbbk) (Medicare Advantage) 1100-956557-1197456 The Hyaluronates Preferred Drug Program (Commercial and QUEST) policy effective 1/1/2025, has been posted for the following drugs covered under this policy. Archived: 60-day provider notice effective 1/1/2025 and policy effective 1/1/2024. 1. Durolane (Commercial and QUEST) 1. Euflexxa (Commercial and QUEST) 1100-956557-1197456 The Hyaluronates Medicare Part B Preferred Drug Program 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. Durolane (Medicare Advantage) 1. Euflexxa (Medicare Advantage)
4.42 (v203)	12/20/2024	1100-956557-1204850 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. Firazyr (icatibant) (Commercial) The Hyaluronates Medicare Part B policy effective 12/20/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 5/30/2024. 2. Durolane (hyaluronic acid) (Medicare Advantage) 2. Euflexxa® (1% sodium hyaluronate) (Medicare Advantage) Intravenous Immune Globulin (IVIG) (Commercial and QUEST) effective 12/20/2024, has been posted for the following drug covered under this policy. Archived: policy eff 4/01/2024. Flebogamma DIF (Commercial and QUEST)
4.41 (v202)	12/03/2024	1100-956552-1182203 The current effective dates for the following were corrected to 11/15/2024: Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) 1100-956557-1188100 The Hyaluronate Products (Commercial and QUEST Integration) effective 11/29/2024, has been posted for the following drugs covered under this policy. Archived: Policy eff 4/1/2024. 2. Durolane (hyaluronic acid) 2. Euflexxa (1% sodium hyaluronate)
4.40 (v201)	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. 1. Enbrel (etanercept) 1. Entyvio (vedolizumab) 1100-956552-1182203 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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Elahere (mirvetuximab soravtansine-gynx) Eligard Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
4.39 (v200)	11/12/2024	1100-956552-1168730 Added a link to the archived folder for epoprostenol (generic) (Medicare Advantage) and Flolan (epoprostenol) (Medicare Advantage).
4.38 (v199)	11/04/2024	1100-956552-1168730 Flolan-Veletri (Commercial and QUEST) effective 10/25/2024, has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 4/1/2024. epoprostenol (generic) (Commercial and QUEST) Flolan (epoprostenol) (Commercial and QUEST) Flolan-Veletri (Medicare Advantage) effective 10/25/2024, has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 1/1/2024. epoprostenol (generic) (Medicare Advantage) Flolan (epoprostenol) (Medicare Advantage) 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. Extavia (interferon beta-1b) (Commercial)
4.37 (v198)	11/01/2024	1100-956547-1167950 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: Daxxify (daxibotulinumtoxinA-lanm) (new) Dysport (abobotulinumtoxinA) 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: Daxxify (Medicare Advantage) (new) 1. Dysport (abobotulinumtoxinA) (Medicare Advantage) 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 for the following drugs covered under this policy. Fulphila (pegfilgrastim-jmdb) (Commercial) Fylnetra (pegfilgrastim-pbbk) (Commercial) 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 for the following drugs covered under this policy. Fulphila (pegfilgrastim-jmdb) (Medicare Advantage) Fylnetra (pegfilgrastim-pbbk) (Medicare Advantage) The Hyaluronates Preferred Drug Program (Commercial and QUEST) 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. Durolane (Commercial and QUEST) 1. Euflexxa (Commercial and QUEST) The Hyaluronates Medicare Part B Preferred Drug Program 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. Durolane (Medicare Advantage) 1. Euflexxa (Medicare Advantage)
4.36 (v197)	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Elahere (mirvetuximab soravtansine-gynx) Eligard Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension) The SDRP policy eff 10/3/2024 v2 has been posted for the following drugs covered under this policy. Daxxify (daxibotulinumtoxinA-lanm) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
4.35 (v196)	10/21/2024	1100-956547-1156413 The SDRP policy eff 10/3/2024 has been posted for the following drugs covered under this policy. Ebglyss (lebrikizumab-lbkz) - new eff 10/3/2024
4.34 (v195)	10/11/2024	1100-956547-1156401 Elelyso (taliglucerase) (Commercial and QUEST), 09/27/2024 has been posted. Archived: 1/1/2024. Icatibant, effective 09/27/2024 has been posted for the following drugs covered under this policy. The policy effective 10/27/2023 has been archived. 2. Firazyr (icatibant) (Commercial and QUEST) 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. Daxxify (daxibotulinumtoxinA-lanm) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
4.33 (v194)	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. 1. Enbrel (etanercept) 1. Entyvio (vedolizumab)
4.32 (v193)	10/08/2024	1100-956547-1154187 "No PA Required for Medicare Advantage" has been added to the notices section for Eligard (leuprolide acetate).
4.31 (v192)	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. Daxxify (daxibotulinumtoxinA-lanm) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
4.30 (v191)	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. Daxxify (daxibotulinumtoxinA-lanm) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
4.29 (v190)	09/17/2024	1100-956542-1137967 The Global Oncology policy effective 09/10/2024 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 07/15/2024. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Elahere (mirvetuximab soravtansine-gynx) Eligard Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
4.28 (v189)	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. Daxxify (daxibotulinumtoxinA-lanm) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
4.27 (v188)	08/06/2024	1100-956537-1105000 The following policies have been posted: 2. Enbrel (etanercept) (Commercial and QUEST Integration), 8/1/2024; ARCHIVED: 60-day notice and poicy eff 2/1/2024 Entyvio (vedolizumab) (Medicare Advantage), 8/1/2024; ARCHIVED: 60-day notice and poicy eff 1/1/2024 1100-956537-1104509 The following policy has been posted: Elelyso (taliglucerase) (Medicare Advantage), 07/26/2024. Archived: 1/1/2024 Evenity (romosozumab-aqqg) (Commercial and QUEST Integration):, 07/26/2024. Archived: 1/1/2024 Evenity (romosozumab-aqqg) (Medicare Advantage), 07/26/2024. Archived: 1/1/2024 Forteo (teriparatide), 07/26/2024. Archived: 3/22/2024. Leuprolide (non-oncology) (Commercial and QUEST Integration) effective 07/26/2024 has been posted for the following drug covered under this policy. Archived: policy eff 4/1/2024. Fensolvi (leuprolide acetate) (Commercial and QUEST Integration)
4.26 (v187)	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Elahere (mirvetuximab soravtansine-gynx) Eligard Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension) The SDRP policy eff 7/01/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 6/17/2024. Daxxify (daxibotulinumtoxinA-lanm) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
4.25 (v185)	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. 1. Enbrel (etanercept) 1. Entyvio (vedolizumab)
4.24 (v184)	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. Daxxify (daxibotulinumtoxinA-lanm) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
4.23 (v183)	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Elahere (mirvetuximab soravtansine-gynx) Eligard Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
4.22 (v182)	06/07/2024	1100-956527-1069655 The following redlined 60-day notices (06/01/2024-07/31/2024) has been reposted: 2. Enbrel (etanercept) (Commercial and QUEST Integration)
4.21 (v181)	06/06/2024	1100-956527-1069655 The following redlined 60-day notices (06/01/2024-07/31/2024) have been posted: 2. Enbrel (etanercept) (Commercial and QUEST Integration) Entyvio (vedolizumab) (Medicare Advantage)
4.20 (v180)	05/30/2024	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. 2. Durolane (hyaluronic acid) (Medicare Advantage) 2. Euflexxa® (1% sodium hyaluronate) (Medicare Advantage)
4.19 (v179)	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: #1. Enbrel (etanercept) #1. Entyvio (vedolizumab)
4.18 (v178)	05/23/2024	1100-956522-1060150 The SDRP policy eff 5/27/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 5/12/2024. Daxxify (daxibotulinumtoxinA-lanm) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
4.17 (v177)	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. Daxxify (daxibotulinumtoxinA-lanm) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
4.16 (v176)	05/08/2024	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. Daxxify (daxibotulinumtoxinA-lanm) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
4.15 (v175)	05/06/2024	1100-956522-1046905 Entyvio archived folder link name fix.
4.14 (v174)	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. Enbrel (etanercept) #1. Entyvio (vedolizumab) 1100-956522-1046905 The following policy has been posted: Entyvio (vedolizumab) (Commercial and QUEST Integration), 4/26/2024. Archived: 1/1/2024 Intravenous Immune Globulin (IVIG) (Medicare Advantage) eff 4/26/2024 has been posted for the following drug covered under this policy. Archived: policy eff 12/15/2023. Flebogamma DIF (human immunoglobulin) (Medicare Advantage)
4.13 (v173)	04/15/2024	The Hyaluronates (drug specific policy) effective 2/1/2023 has been archived. The following drugs covered under this policy have been archived and removed from the table Euflexxa (1% sodium hyaluronate) The following link has been revised: Fensolvi 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. Dysport (abobotulinumtoxinA) 2. Dysport (abobotulinumtoxinA)
4.12 (v172)	04/05/2024	Elevidys Kit (delandistrogene moxeparvovec-rokl) has been added to the applicable table.
4.11 (v171)	03/31/2024	The following policy has been posted: Dupixent (Commercial and QUEST Integration), 4/1/2024. Archived: 4/1/2023 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. Dysport (abobotulinumtoxinA) 2. Dysport (abobotulinumtoxinA) Flolan-Veletri (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 1/1/2024 epoprostenol (generic) (Commercial and QUEST Integration) Flolan (epoprostenol) (Commercial and QUEST Integration) The Hyaluronate Products (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 1/1/2024. 2. Durolane (hyaluronic acid) 2. Euflexxa (1% sodium hyaluronate) 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. Flebogamma DIF (Commercial and QUEST Integration) Leuprolide (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: Fensolvi (leuprolide acetate) (Commercial and QUEST Integration)
4.10 (v170)	03/29/2024	Corrected the effective date for Forteo in the drug table.
4.9 (v169)	03/28/2024	Forteo (teriparatide), 3/22/2024 has been posted. The policy eff 7/28/2023 has been archived.
4.8 (v168)	03/21/2024	Added the Medicare fax form link to Daxxify and Elfabrio.
4.7 (v167)	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. Daxxify (daxibotulinumtoxinA-lanm) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
4.6 (v166)	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. Daxxify (daxibotulinumtoxinA-lanm) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
4.5 (v165)	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. Daxxify (daxibotulinumtoxinA-lanm) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
4.4 (v164)	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: Dysport (abobotulinumtoxinA)
4.3 (v163)	02/01/2024	60-day notices have been posted for the following drug. Provider notification period is 2/1/2024-3/31/2024. Dupixent (Commercial and 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: Dysport (abobotulinumtoxinA) Flolan-Veletri (Commercial and 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: epoprostenol (generic) (Commercial and QUEST Integration) Flolan (epoprostenol) (Commercial and QUEST Integration) The Hyaluronate Products (Commercial and 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: 2. Durolane (hyaluronic acid) 2. Euflexxa (1% sodium hyaluronate) 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: Flebogamma DIF (Commercial and QUEST Integration) Leuprolide (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: Fensolvi (leuprolide acetate) (Commercial and QUEST Integration)
4.2 (v162)	01/31/2024	Updated fax form links for the following: Elelyso, Entyvio, epoprostinol, Evenity, Flolan
4.1 (v161)	01/30/2024	The following policy has been posted: 2. Enbrel (etanercept), 2/1/2024; ARCHIVED: 60-day notice eff 2/1/24 and policy eff 9/1/2022
4.0 (v160)	01/12/2024	The following policy has been posted: Evenity (romosozumab-aqqg), 1/1/2024, v2; archived policy eff 1/1/2024 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. Daxxify (daxibotulinumtoxinA-lanm) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra

Rev#:	Date:	Nature of Change:
3.39 (v159)	12/29/2023	Minor typographical edits and updated the link to the Elelyso archived folder. Removed Durolane (all LOBs) row from the table.
3.38 (v158)	12/28/2023	The following policies effective 1/1/2024 have been posted: Elelyso (taliglucerase) (Commercial and QUEST Integration) Elelyso (taliglucerase) (Medicare Advantage) 2. Entyvio (vedolizumab) (Commercial and QUEST Integration) Entyvio (vedolizumab) (Medicare Advantage) Evenity (romosozumab-aqqg) (Commercial and QUEST Integration) Evenity (romosozumab-aqqg) (Medicare Advantage) The following policies have been archived: Elelyso (taliglucerase) 06/23/2023 (for all LOBs) 2. Entyvio (vedolizumab), 12/01/2023 (for all LOBs) Evenity (romosozumab-aqqg), 07/28/2023 (for all LOBs) Flolan-Veletri (Commercial and QUEST Integration), eff 1/1/2024, has been posted for the following drugs covered under this policy. Archived: policy eff 3/1/2023 (all LOBs) has been archived epoprostenol (generic) (Commercial and QUEST Integration) Flolan (epoprostenol) (Commercial and QUEST Integration) Flolan-Veletri (Medicare Advantage), eff 1/1/2024, has been posted for the following drugs covered under this policy. Archived: policy eff 3/1/2023 (all LOBs) has been archived epoprostenol (generic) (Medicare Advantage) Flolan (epoprostenol) (Medicare Advantage) The Hyaluronates (Commercial and QUEST Integration) and (Medicare Advantage) policies effective 01/01/2024 have been posted to the following drugs covered under these policies, as applicable. Archived: Policy effective 2/1/2023 (all LOBs) 2. Durolane (Commercial and QUEST Integration) 2. Durolane (Medicare Advatage) 2. Euflexxa (Commercial and QUEST Integration) 2. Euflexxa (Medicare Advatage) The Retinal Disorders (Medicare Advantage) policy effective 10/01/2023 has been archived for the following drug covered under this policy. No PA is required as of 1/1/2024. 1. Eylea (Medicare Advantage)
3.37 (v157)	12/27/2023	Botulinum Toxins Medicare Part B Preferred Drug Program policy, eff 1/1/2024, has been posted for the following drug covered under this policy. Archived: 60-day notice eff 1/1/2024 and policy eff 10/28/2022. 1. Dysport (abobotulinumtoxinA) (Medicare Advantage) Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial), effective 1/1/2024, has been posted for the following drugs covered under this policy. The 60-day notice eff 1/1/2024 and policy eff 3/1/2023 have been archived. Fulphila (pegfilgrastim-jmdb) (Commercial) Fylnetra (pegfilgrastim-pbbk) (Commercial) The Hyaluronates Preferred Drug Program (Commercial) policy effective 01/01/2024, has been posted for the following drugs covered under this policy. Archived: 60-day provider notice effective 1/1/2024 and policy effective 10/28/2022. 1. Durolane (Commercial) 1. Euflexxa (Commercial) The Hyaluronates Medicare Part B Preferred Drug Program policy effective 1/1/2024, has been posted for the following drugs covered under this policy. Archived: 60-day notice eff 1/1/2024 and policy effective 1/1/2023 1. Durolane (Hyaluronates Preferred Drug Program) (Medicare Advantage) 1. Euflexxa (Hyaluronates Preferred Drug Program) (Medicare Advantage)
3.36 (v156)	12/21/2023	Removed the MA Fax form link from Eligard (Global Oncology)
3.35 (v155)	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Elahere (mirvetuximab soravtansine-gynx) Eligard Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension) 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. Daxxify (daxibotulinumtoxinA-lanm) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
3.34 (v154)	12/18/2023	Intravenous Immune Globulin (IVIG) (Medicare Advantage) eff 12/15/2023 has been posted for the following drug covered under this policy. Archived: policy eff 9/1/2022. Flebogamma DIF (human immunoglobulin) (Medicare Advantage)
3.33 (v153)	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Elahere (mirvetuximab soravtansine-gynx) Eligard Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension) 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. Daxxify (daxibotulinumtoxinA-lanm) (NEW effective 10/01/2023) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
3.32 (v152)	12/11/2023	The following policy has been posted: 2. Enbrel (etanercept) redlined 60-day notice (12/1/23-1/31/24)
3.31 (v151)	12/08/2023	Entyvio (vedolizumab), 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 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. Extavia (interferon beta-1b) (Commercial) 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. Firazyr (icatibant) (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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Elahere (mirvetuximab soravtansine-gynx) Eligard Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
3.30 (v150)	11/202023	Icatibant, effective 10/27/2023 has been posted for the following drugs covered under this policy. The policy effective 02/01/2023 have been archived. 2. Firazyr (icatibant)
3.29 (v149)	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Elahere (mirvetuximab soravtansine-gynx) Eligard Elrexfio (elranatamab-bcmm) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension) 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. Daxxify (daxibotulinumtoxinA-lanm) (NEW effective 10/01/2023) Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra 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.
3.28 (v148)	11/07/2023	Links to the applicable archived folders have been added to the following drugs: 2. Enbrel (etanercept) Extavia (interferon beta-1b) (Commercial) 1. Firazyr (icatibant) (Commercial) Flebogamma DIF (human immunoglobulin) (Commercial & QUEST) Flebogamma DIF (human immunoglobulin) (Medicare Advantage) Typo fixes.
3.27 (v147)	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. Dysport (abobotulinumtoxinA) (Medicare Advantage) The Hyaluronates Preferred Drug Program (Commercial) 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. Durolane (Commercial) 1. Euflexxa (Commercial) The Hyaluronates Medicare Part B 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. Durolane (Hyaluronates Preferred Drug Program) (Medicare Advantage) 1. Euflexxa (Hyaluronates Preferred Drug Program) (Medicare Advantage) 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 drugs covered under this policy: Fulphila (pegfilgrastim-jmdb) (Commercial) Fylnetra (pegfilgrastim-pbbk) (Commercial)
3.26 (v146)	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. Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
3.25 (v145)	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. #1. Enbrel (etanercept) #1. Entyvio (vedolizumab)
3.24 (v144)	10/03/2023	Relinked the Entyvio 60-day provider notice.
3.23 (v143)	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. Entyvio (vedolizumab)
3.22 (v142)	09/28/2023	The Retinal Disorders Preferred Drug Program (Medicare Advantage) policy effective 10/01/2023 has been posted for the following drug covered under this policy. The 60-day notice eff 10/1/23 and policy effective 10/28/22 has been archived. Eylea (Medicare Advantage)
3.21 (v141)	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Elahere (mirvetuximab soravtansine-gynx) Eligard Elrexfio (elranatamab-bcmm) (NEW eff 9/5/2023) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension) 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. Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
3.20 (v140)	08/12/2023	Moved Epkinly and Esperoct into the correct alpha order.
3.19 (v139)	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Elahere (mirvetuximab soravtansine-gynx) Eligard Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Epkinly (epcoritamab-bysp) (NEW eff 7/21/2023) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension) 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. Elfabrio (pegunigalsidase alfa-lwxj) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
3.18 (v138)	08/07/2023	The following drug policies have been posted: Evenity (romosozumab-aqqg), 7/28/2023; archived policy eff 4/1/2023 Forteo (teriparatide), 7/28/2023; archived policy eff 4/1/2023
3.17 (v137)	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 drug covered under this policy: Eylea (Medicare Advantage)
3.16 (v136)	07/11/2023	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.
3.15 (v135)	07/07/2023	Global Oncology 7/1/2023 has been posted for the following drugs covered under this policy. The previous policy effective 5/10/2023 has beeen archived. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Elahere (mirvetuximab soravtansine-gynx) Eligard Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
3.14 (v134)	06/29/2023	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. Elfabrio (pegunigalsidase alfa-lwxj) (NEW eff 6/1/23) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra 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. #1. Enbrel (etanercept) #1. Entyvio (vedolizumab) 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. Eloctate [Factor VIII (Recombinant)] Esperoct [Factor VIII (recombinant)] Feiba [Anti-inhibitor coagulant complex]
3.13 (v133)	06/27/2023	The following policy has been posted: Elelyso (taliglucerase), 6/23/2023; archived policy eff 10/28/2022 Added link to archived folder.
3.12 (v132)	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. Enbrel (etanercept) #1. Entyvio (vedolizumab) 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. Elfabrio (pegunigalsidase alfa-lwxj) (NEW eff 6/1/23) Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
3.11 (v131)	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Elahere (mirvetuximab soravtansine-gynx) Eligard Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension) 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. Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
3.10 (v130)	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. Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
3.9 (v129)	04/28/2023	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: #1. Enbrel (etanercept) #1. Entyvio (vedolizumab)
3.8 (v128)	04/17/2023	Updated the fax form link for Evenity.
3.7 (v127)	04/06/2023	Minor typo fix.
3.6 (v126)	03/31/2023	Minor typo fixes.
3.5 (v125)	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. #1. Enbrel (etanercept) #1. Entyvio (vedolizumab) Lupron-Lupaneta, eff 4/01/2023, has been posted for the following drugs covered under this policy. The 60-day notice and policy eff 4/1/2022 have been archived. Fensolvi (leuprolide acetate) (non-oncology) The following policies have been posted: Dupixent (dupilumab), 4/1/2023; archived 60-day notice and policy eff 8/18/2022 Evenity (romosozumab-aqqg), 4/1/2023; archived the 60-day notice 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. Dysport (abobotulinumtoxinA) 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. Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
3.4 (v124)	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. Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evenity Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
3.3 (v123)	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Elahere (mirvetuximab soravtansine-gynx) Eligard Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
3.2 (v122)	02/24/2023	Flolan-Veletri-epopreostenol, eff 3/01/2023, has been posted for the following drugs covered under this policy. Archived: 60-day notice eff 3/1/23 and policy eff 3/1/2022 have been archived Flolan (epoprostenol) epoprostenol (generic) Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial), effective 3/01/2023, has been posted for the following drugs covered under this policy. The 60-day notice eff 3/1/22 and policy eff 10/01/2021 have been archived. Fulphila (pegfilgrastim-jmdb) Fylnetra (pegfilgrastim-pbbk) - NEW eff 3/1/2023
3.1 (v121)	02/03/2023	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. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Elahere (mirvetuximab soravtansine-gynx) Eligard Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
3.0 (v120)	01/31/2023	Icatibant, effective 02/01/2023 has been posted for the following drugs covered under this policy. The 60-day notice and policy effective 4/1/2022 have been archived. 2. Firazyr (icatibant) The Hyaluronates (drug specific policy) effective 02/01/2023 has been posted to the following drugs covered under this policy. The 60-day notice and the policy effective 7/23/2021 have been archived. 2. Durolane (Commercial, QUEST Integration and Medicare Part B policy) 2. Euflexxa (Commercial, QUEST Integration and Medicare Part B policy) 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: Dysport (abobotulinumtoxinA) The Forteo (teriparatide) 60-day notice has been posted. Provider notification period is 1/1/2023-2/28/2023. Policy effective date is 4/1/2023. Lupron-Lupaneta 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: Fensolvi (leuprolide acetate) (non-oncology) 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: #1. Enbrel (etanercept) #1. Entyvio (vedolizumab) The following redlined 60-day notices effective 4/1/2023 (notification period: 02/01/2023-03/31/2023) have been posted: Dupixent (dupilumab) Evenity (romosozumab-aqqg)
2.49 (v119)	12/30/2022	Hyperlinks to policy archive folders have been updated with the new domain name.
2.48 (v118)	12/27/2022	The Hyaluronates Preferred Drug Program (Medicare Advantage only) policy effective 1/1/2023 has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy effective 1/1/2022. 1. Durolane (Hyaluronates Preferred Drug Program) (Medicare Advantage) 1. Euflexxa (Hyaluronates Preferred Drug Program) (Medicare Advantage) Flolan-Veletri 60-day provider notice (01/01/2023-02/28/2023), effective 3/01/2023, has been posted for the following drugs covered under this policy: Flolan (epoprostenol) epoprostenol (generic)
2.47 (v117)	12/07/2022	Global Oncology (eff 12/2/2022) has been posted for the following drugs covered under this policy. The previous policy effective 11/30/2022 has beeen archived. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Elahere (mirvetuximab soravtansine-gynx) (NEW - effective 12/2/2022) Eligard Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension) SDRP (eff 12/1/2022) has been posted for the following drugs covered under this policy. The SDRP policy effective 10/28/2022 has been archived. Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evenity Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
2.46 (v116)	12/01/2022	Global Oncology (eff 11/30/2022) has been posted for the following drugs covered under this policy. The previous policy effective 10/1/2022 has beeen archived. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Eligard Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
2.45 (v115)	11/30/2022	The icatibant 60-day notice has been posted for the following drug covered under this policy. Provider notification period is 1/1/2023-2/28/2023. Policy effective date is 3/1/2023. Firazyr (icatibant) The Hyaluronates (drug specific policy) 60-day notice has been posted for the following drugs covered under this policy. Provider notification period is 12/1/2022-1/31/2023. Policy effective date is 2/1/2023. Durolane (hyaluronic acid) and #2. Durolane (hyaluronic acid) for preferred drug programs Euflexxa (1% sodium hyaluronate) and #2. Euflexxa (1% sodium hyaluronate) for preferred drug programs
2.44 (v114)	10/31/2022	The Hyaluronates Preferred Drug Program (Medicare Advantage only) redlined 60-day notice (eff 1/1/2023) has been posted to the following drugs: 1. Durolane (Hyaluronates Preferred Drug Program) (Medicare Advantage) 1. Euflexxa (Hyaluronates Preferred Drug Program) (Medicare Advantage) The following policies have been posted: Elelyso (taliglucerase), 10/28/2022; archived policy effective 03/01/2022 The Hyaluronates Preferred Drug Program (Commercial) effective 10/28/2022 has been posted to the following drugs. The policy effective 7/7/2022 has been archived. 1. Durolane (Commercial) 1. Euflexxa (Commercial) The Hereditary Angioedema (HAE) Acute Preferred Drug Program (Commercial) policy effective 10/28/2022 has been posted for the following drug. The policy effective 2/1/2022 has been archived. 1. Firazyr (icatibant) (Commercial) The Botulinum Toxins Preferred Drug Program (Medicare Advantage only) policy effective 10/28/2022 has been posted for the following drug. The policy effective 6/1/2021 has been archived. 1. Dysport (Botulinum Toxins Preferred Drug Program policy) The Retinal Disorders Preferred Drug Program (Medicare Advantage) policy effective 10/28/2022 has been posted for the following drug. The policy effective 2/1/2022 has been archived. 1. Eylea (Medicare Advantage) Multiple Sclerosis (MS) – Interferons Preferred Drug Program (Commercial) effective 10/28/2022, has been posted for the following drugs. The policy eff 7/1/22 has been archived.d. Extavia (interferon beta-1b) (Commercial)
2.43 (v113)	10/27/2022	Tables have been reformatted.
2.42 (v112)	09/30/2022	The Autoimmune Preferred Drug Program policy effective 10/01/2022 has been posted for the following drugs. The policy effective 07/01/2021 has been archived. #1. Enbrel (etanercept) #1. Entyvio (vedolizumab)
2.41 (v111)	09/27/2022	The current policy for Global Oncology (eff 10/1/2022) has been posted for the following drugs. The Global Oncology policy effective 8/1/2022 and 60-day notice eff 10/1/22 have been archived. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Eligard Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
2.40 (v110)	09/07/2022	The Global Oncology redlined 60-day notice (8/1/22-9/30/22) eff 10/1/22, version 2 has been posted for the following drugs: Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Eligard Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension) (new eff 4/1/22)
2.39 (v109)	08/30/2022	The following policies were posted: 2. Enbrel (etanercept), 9/1/2022; archived 60-day notice and policy eff 1/1/2022 2. Entyvio (vedolizumab), 9/1/2022; archived 60-day notice and policy eff 1/1/2022 Intravenous Immune Globulin (IVIG) (Commercial and QUEST Integration), 9/1/2022 has been posted for the following drug. Archived 60-day notice and policy eff 12/17/2021. Flebogamma DIF (human immunoglobulin) (Commercial and QUEST) Intravenous Immune Globulin (IVIG) (Medicare Advantage), 9/1/2022 has been posted for the following drugs. Archived 60-day notice and policy eff 12/17/2021. Flebogamma DIF (human immunoglobulin) (Medicare Advantage)
2.38 (v108)	08/29/2022	The current policy for Global Oncology (eff 8/1/2022) has been posted for the following drugs. The Global Oncology policy effective 7/1/2022 has been archived. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Eligard Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
2.37 (v107)	08/25/2022	The following policy has been posted: Dupixent (dupilumab), 8/18/2022; archived policy eff 3/1/2022
2.36 (v106)	08/17/2022	Removed the "Other" quick link at the beginning of the article. The "Other" article has been archived as the information can be be found on the applicable current and archive articles.
2.35 (v105)	08/10/2022	The current policy for SDRP 8/1/2022 has been posted for the following drugs. (Pharmacy drugs Camzyos and Cibinqo were removed.) The SDRP policy effective 7/17/2022 has been archived. Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evenity Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
2.34 (v104)	07/29/2022	The Global Oncology redlined 60-day notice (8/1/22-9/30/22) eff 10/1/22 has been posted for the following drugs. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Eligard (also removed MA fax form link) Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension) (new eff 4/1/22)
2.33 (v103)	07/14/2022	The current policy for SDRP 7/17/2022 has been posted for the following drugs. The SDRP policy effective 6/1/2022 has been archived. Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evenity Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra The current policy for Global Oncology (eff 7/1/2022) has been posted for the following drugs. The Global Oncology policy effective 5/1/2022 has been archived. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Eligard Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
2.32 (v102)	06/30/2022	The following policies were posted: 2. Enbrel (etanercept) redlined 60-day notice (7/1/22-8/31/22) 2. Entyvio (vedolizumab) redlined 60-day notice (7/1/22-8/31/22) Intravenous Immune Globulin (IVIG) (Commercial and QUEST Integration) redlined 60-day notice (07/01/2022-08/31/2022; eff 9/1/2022) has been posted for the following drugs: Flebogamma DIF (human immunoglobulin) (Commercial and QUEST) Intravenous Immune Globulin (IVIG) (Medicare Advantage)redlined 60-day notice (07/01/2022-08/31/2022; eff 9/1/2022) has been posted for the following drugs: Flebogamma DIF (human immunoglobulin) (Medicare Advantage) The Autoimmune Preferred Drug Program policy effective 07/01/2022 has been posted for the following drugs. The policy effective 11/1/2021 has been archived. #1. Enbrel (etanercept) #1. Entyvio (vedolizumab) Multiple Sclerosis (MS) – Interferons Preferred Drug Program (Commercial) effective 07/01/2022, has been posted for the following drug. The policy eff 10/1/22 has been archived. Extavia (interferon beta-1b) (Commercial)
2.31 (v101)	06/28/2022	The current policy for SDRP 6/1/2022 has been posted for the following drugs. The SDRP policy effective 5/1/2022 (v2) has been archived. Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evenity Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
2.30 (v100)	06/07/2022	The current policy for Global Oncology (eff 5/1/2022) has been posted for the following drugs. The Global Oncology policy effective 4/1/2022 has been archived. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Eligard Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension) The current policy for SDRP 5/1/2022 (v2) has been posted for the following drugs. The SDRP policy effective 5/1/2022 (v1) has been archived. Emgality (drug is not covered under Part B) Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evenity Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
2.29 (v99)	05/26/2022	The current policy for Global Oncology (eff 4/1/2022) has been posted for the following drugs. The Global Oncology policy effective 12/10/2021 has been archived. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Eligard Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Erbitux Folotyn Fyarro (sirolimus protein-bound particles for injectable suspension)
2.28 (v98)	05/23/2022	The current policy for SDRP 5/1/2022 has been posted for the following drugs. The SDRP policy effective 4/1/2022 has been archived. Emgality Empaveli (pegcetacoplan) Enjaymo (sutimlimab-jome) Enspryng (satralizumab-mwge) Evenity Evkeeza (evinacumab-dgnb) Exondys 51 Fasenra
2.27 (v97)	05/11/2022	Emgality - Removed the MA fax form link.
2.26 (v96)	05/03/2022	The current policy for SDRP 4/1/2022 has been posted for the following drugs.The SDRP policy effective 12/10/2020 has been archived. Emgality, Empaveli (pegcetacoplan), Enspryng (satralizumab-mwge), Evenity, Exondys 51, Evkeeza (evinacumab-dgnb), Enjaymo (sutimlimab-jome) (new) Fasenra
2.24 (v95)	04/20/2022	Updated fax form links for Global Oncology and SDRP drugs.
2.23 (v94)	04/07/2022	Updated for clarity: Dysport, Durolane
2.22 (v93)	04/01/2022	Updated the fax form information for 1. Firazyr (icatibant)
2.21 (v92)	03/28/2022	Updated Durolane and Eylea line entries (added QUEST Integration where applicable). The Ictibant policy eff 4/1/2022 has been posted for the following drugs (archived: the policy eff 4/1/2021 and 60-day notice): 2. Firazyr (icatibant) The Lupron-Lupaneta eff 4/1/2022 has been posted for the following drugs (archived: the policy eff 9/1/2020 and 60-day notice): Fensolvi (leuprolide acetate)
2.20 (v91)	03/24/2022	The following policies were posted: Dupixent (dupilumab) eff 3/1/22; archived: policy eff 9/25/20 and 60-day provider notice (1/1/22-2/28/22) Elelyso (taliglucerase) eff 3/1/22; archived: policy eff 1/1/21 and 60-day provider notice (1/1/22-2/28/22) The Flolan-Veletri-epoprostenol policy eff 3/1/22 has been posted for the following drugs and the policy eff 3/1/21 and the 60-day provider notice (1/1/22-2/28/22) were archived. epoprostinol (generic) Flolan (epoprostenol) Updated the Specialty Drugs Requiring Precertification link located at the top of the article.
2.19 (v90)	02/04/2022	The Hyaluronates Preferred Drug Program (Commercial only) policy effective 2/7/2022 has been posted for the following drugs. The policy eff 7/23/2021 has been archived. Durolane (hyaluronic acid) Euflexxa (1% sodium hyaluronate) The Hyaluronate drugs have been reordered.
2.18 (v89)	02/03/2022	Minor link fix.
2.17 (v88)	02/01/2022	The Retinal Disorders Preferred Drug Program (Medicare Advantage) eff 2/1/2022 has been posted for the following drug. The 60-day notice and policy eff 6/1/21 has been archived. Eylea (aflibercept) Medicare Advantage Archived files have been removed from record. They can be accessed from the respective drug policy folder.
2.16 (v87)	01/31/2022	The Icatibant 60-day provider notice (02/01/2022-03/31/2022; eff 4/1/2022) has been posted for the following drug: Firazyr (icatibant) The Lupron-Lupaneta 60-day provider notice (02/01/2022-03/31/2022; eff 4/1/2022) was posted for the following drug: Fensolvi (leuprolide acetate) The Dupixent (dupilumab) 60-day provider notice (1/1/22-2/28/22), eff 3/1/22, Version 2 was posted. Version 1 has been archived. The Hereditary Angioedema (HAE) Acute Preferred Drug Program (Commercial) policy effective 2/1/2022 has been posted for the following drug and the 10/1/21 policy archived. 1. Firazyr (icatibant) (Commercial)
2.15 (v86)	01/07/2022	The following policies were posted: Dupixent (dupilumab) 60-day provider notice (1/1/22-2/28/22), eff 3/1/22 Elelyso (taliglucerase) 60-day provider notice (1/1/22-2/28/22), eff 3/1/22 The Flolan-Veletri-epoprostenol 60-day provider notice (1/1/22-2/28/22) has been posted for the following drugs: epoprostinol (generic) Flolan (epoprostenol)
2.14 (v85)	12/27/2021	The following policies were posted: 2. Enbrel (etanercept); eff 1/1/2022; archived - 10/1/2020 & 60-day notice (11/1/21 - 12/31/21) 2. Entyvio (vedolizumab); eff 1/1/2022; archived - 10/1/2020 & 60-day notice (11/1/21 - 12/31/21) Botulinum Toxins policy effective 1/1/2022 has been posted for the following drugs: Dysport (abobotulinumtoxinA) (Commercial, QUEST Integration) Dysport (abobotulinumtoxinA) (Medicare Advantage) Hyaluronates Preferred Drug Program (Medicare Part B) eff 1/1/2022 has been posted for the following drugs. Archived - 06/1/2021 & 60-day notice (11/1/21 - 12/31/21) 1. Durolane (hyaluronic acid) (Medicare Advantage) 1. Euflexxa (1% sodium hyaluronate) (Medicare Advantage)
2.13 (v84)	12/20/2021	Intravenous Immune Globulin (IVIG) (Commercial and QUEST Integration) policy effective 12/17/2021 has been posted for the following drug. The policy effective 12/18/2020 has been archived. Flebogamma DIF (human immunoglobulin) (Commercial and QUEST) Intravenous Immune Globulin (IVIG) (Medicare Advantage) policy effective 12/17/2021 has been posted for the following drug. The policy effective 12/18/2020 has been archived. Flebogamma DIF (human immunoglobulin) (Medicare Advantage)
2.12 (v83)	12/09/2021	The Retinal Disorders Preferred Drug Program (Medicare Advantage only) 60-day provider notice (12/01/2021-01/31/2022; eff 2/1/2022) has been posted for the following drug(s): Eylea (aflibercept) Medicare Advantage
2.11 (v82)	12/02/2021	The current policy for Global Oncology (12/10/2021) has been posted for the following drugs. The Global Oncology policy effective 10/1/2021 has been archived. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Eligard Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Erbitux Folotyn The current policy for SDRP (12/10/2021) has been posted for the following drugs.The SDRP policy effective 10/1/2020 has been archived. Emgality, Empaveli (pegcetacoplan), Enspryng (satralizumab-mwge), Evenity, Exondys 51, Evkeeza (evinacumab-dgnb) Fasenra
2.10 (v81)	11/02/2021	The Autoimmune Preferred Drug Program policy effective 11/1/2021 has been posted for the following drugs. The policy effective 10/1/2020 has been archived. #1. Enbrel (etanercept) #1. Entyvio (vedolizumab) Botulinum Toxins 60-day provider notice (11/1/21 - 12/31/21) has been posted for the following drug: 2. Dysport (abobotulinumtoxinA) (Medicare Advantage) Minor typo corrections.
2.9 (v80)	10/29/2021	The following 60-day provider notices (11/1/21 - 12/31/21) were posted for the following drugs: Enbrel (etanercept) Entyvio (vedolizumab) Botulinum Toxins 60-day provider notice (11/1/21 - 12/31/21) has been posted for the following drug: Dysport (abobotulinumtoxinA) Hyaluronates Preferred Drug Program (Medicare Part B) 60-day provider notice (11/1/21 - 12/31/21) has been posted for the following drugs: 1. Durolane (hyaluronic acid) (Medicare Advantage) 1. Euflexxa (1% sodium hyaluronate) (Medicare Advantage)
2.7 (v79)	10/26/2021	The current policy for SDRP 10/1/2021 has been posted for the following drugs. Includes the addition of Nexviazyme (avalglucosidase alfa-ngpt). The SDRP policy effective 6/1/2020 has been archived. Emgality, Empaveli (pegcetacoplan), Enspryng (satralizumab-mwge), Evenity, Exondys 51, Evkeeza (evinacumab-dgnb) Fasenra The current policy for Global Oncology (10/1/2021) has been posted for the following drugs; added Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) and Tivdak (tisotumab vedotin-tftv). The Global Oncology policy effective 6/1/2021 has been archived. Danyelza (naxitamab-gqgk) Darzalex (daratumumab) Darzalex Faspro (daratumumab) Eligard Elzonris (tagraxofusp-erzs) Empliciti (elotuzumab) Enhertu (fam-trastuzumab deruxtecan-nxki) Erbitux Folotyn
2.6 (v78)	10/22/2021	The Icatibant policy (formerly Firazyr) eff 4/01/2021 has been posted for the following drug: 2. Firazyr (icatibant) The Firazyr policy eff 4/01/2021 has been archived.
2.5 (v77)	10/01/2021	The following FAX form(s) link(s) were posted: Extavia (interferon beta-1b) (Commercial) Firazyr (icatibant) (QUEST Integration) Fulphila (pegfilgrastim-jmdb) (Commercial)
2.4 (v76)	09/30/2021	Minor formatting revisions to update 2.3 (v75).
2.3 (v75)	09/29/2021	Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial), effective 10/01/2021 has been posted for the following drugs: Fulphila (pegfilgrastim-jmdb) (Commercial) Multiple Sclerosis (MS) – Interferons Preferred Drug Program (Commercial) effective 10/01/2021, has been posted for the following drugs: Extavia (interferon beta-1b) (Commercial) Hereditary Angioedema (HAE) Acute Preferred Drug Program (Commercial) 60-day provider notice effective 10/01/2021 has been posted for the following drug(s): #1. Firazyr (icatibant) (Commercial) No PA required for the following drug(s): Eylea (aflibercept) (Commercial)
2.2 (v74)	08/27/2021	The Hyaluronates Preferred Drug Program (Medicare Advantage only) (effective 6/1/2021, v2) has been posted to the following drug(s): 1. Durolane (Hyaluronates Preferred Drug Program) (Medicare Advantage) 1. Euflexxa (Hyaluronates Preferred Drug Program) (Medicare Advantage) The Lupron-Lupaneta policy effective 9/1/2021 has been posted for the following drugs. The 60-day notice and policy effective 4/1/2021 have been archived. Fensolvi (leuprolide acetate) (Non-oncology)
2.1 (v73)	07/27/2021	The Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial) 60-day provider notice has been posted. Comment period (08/01/2021-09/30/2021); effective 10/01/2021. Fulphila (pegfilgrastim-jmdb) (Commercial) The Multiple Sclerosis (MS) – Interferons Preferred Drug Program (Commercial) 60-day provider notice has been posted. Comment period (08/01/2021-09/30/2021); effective 10/01/2021. Extavia (interferon beta-1b) (Commercial) Retinal Disorders Preferred Drug Program (Commercial) 60-day provider notice has been posted. Comment period (08/01/2021-09/30/2021); effective 10/01/2021. Eylea (aflibercept) (Commercial) Hereditary Angioedema (HAE) Acute Preferred Drug Program (Commercial) 60-day provider notice has been posted. Comment period (08/01/2021-09/30/2021); effective 10/01/2021. #1. Firazyr (icatibant) (Commercial)
2.0 (v72)	07/23/2021	The Hyaluronates Preferred Drug Program (Commercial only) policy effective 0723/2021 has been posted for the following drugs: Durolane (hyaluronic acid) Euflexxa (1% sodium hyaluronate) The Hyaluronates (drug specific) policy effective 0723/2021 has been posted for the following drugs: Durolane (hyaluronic acid) Euflexxa (1% sodium hyaluronate) The Forteo (teriparatide) policy effective 07/23/2021 has been posted.

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