Information

Title Medical Specialty Drug Policies: G-H

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

D-F

I-K

L-N

O-R

S-U

V-Z

G

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Gamifant (emapalumab-lzsg)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Gammagard ERC [immune globulin infusion (human)] (Commercial and QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QUEST)
Gammagard Liquid (human immunoglobulin) (Commercial & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QUEST)
Gammagard Liquid (human immunoglobulin) (Medicare Advantage)		10/01/2025	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Gammagard S/D (immune globulin) (Commercial & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QUEST)
Gammagard S/D (immune globulin) (Medicare Advantage)		10/01/2025	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Gammaked (immune globulin) (Commercial & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QUEST)
Gammaked (immune globulin) (Medicare Advantage)		10/01/2025	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Gammaplex (human immunoglobulin) (Commercial & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QUEST)
Gammaplex (human immunoglobulin) (Medicare Advantage)		10/01/2025	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Gamunex (Medicare Advantage)		10/01/2025	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Gamunex-C (human immunoglobulin) (Commercial & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QUEST)
Gamunex-C (human immunoglobulin) (Medicare Advantage)		10/01/2025	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Gattex (teduglutide) (Commercial and QUEST)	No PA required for Medicare Advantage effective 1/1/2024	04/01/2026	Fax Form		ARCHIVED - Gattex
Gazyva (obinutuzumab)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Gazyva (obinutuzumab) (Non-oncology) (Commercial and QUEST)	60-day provider notice 05/01/2026-06/30/2026, in effect 07/01/2026
1. Gel-One® (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Gel-One® Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Gel-One® (cross-linked hyaluronate) (Commercial and QUEST)		04/12/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QUEST) ARCHIVED - Hyaluronates (drug specific)
1. Gel-One (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Gel-One® Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program) (MA)
2. Gel-One® (cross-linked hyaluronate) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
1. Gelsyn-3 (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Gelsyn-3 Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Gelsyn-3 (sodium hyaluronate 0.84%) (Commercial and QUEST)		04/12/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QUEST) ARCHIVED - Hyaluronates (drug specific)
1. Gelsyn-3 (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Gelsyn-3 Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program) (MA)
2. Gelsyn-3 (sodium hyaluronate 0.84%) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Genotropin (somatropin) (Commercial and QUEST)		01/01/2026	Fax Form	Growth Hormone	ARCHIVED - Growth Hormone
1. Genvisc 850 (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Genvisc 850 Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Genvisc 850 (sodium hyaluronate) (Commercial and QUEST)		04/12/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QUEST) ARCHIVED - Hyaluronates (drug specific)
1. GenVisc 850 (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Genvisc 850 Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program) (MA)
2. Genvisc 850 (sodium hyaluronate) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Givlaari (givosiran)	Effective 02/15/2024: Please contact HMSA at 808-948-6464, option #4, for drug review			Effective 2/15/2024 PA review for Givlaari is moved from CVS to HMSA review	ARCHIVED - SDRP
Glassia (alpha-1 proteinase inhibitor)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 07/01/2025	ARCHIVED - SDRP
Global Oncology		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Gonal-f (Commercial)		12/19/2025	Fax Form		ARCHIVED - Gonal-f (Comm)
Granix (TBO-filgrastim) (CSF Short Acting Preferred Drug Program Commercial and QUEST)		11/21/2025	Commercial Fax Form QUEST Fax Form	Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program	ARCHIVED - CSF Short Acting Preferred Drug Program
Granix (TBO-filgrastim) (CSF Short Acting Preferred Drug Program Medicare Advantage)		11/21/2025	Medicare Advantage Fax Form	CSF–Short Acting Preferred Drug Program	ARCHIVED - CSF Short Acting (Preferred Drug Program) (MA)
Grafapex (treosulfan)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 02/28/2025	ARCHIVED - Global Oncology
Growth Hormone (Commercial and QUEST)		01/01/2026		Growth Hormone	ARCHIVED - Growth Hormone

H

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
1. Hadlima (adalimumab-bwwd) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Hadlima (adalimumab-bwwd) (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 12/01/2023	ARCHIVED - Adalimumab (Humira)
Hadlima (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
Haegarda (C1 esterase inhibitor [human])		04/14/2026	Commercial Fax Form QUEST Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Hemgenix (etranacogene dezaparvovec-drlb)	Please contact HMSA at 808-948-6464, option #4, for drug review
Hemlibra (emicizumab)	Please contact HMSA at 808-948-6464, option #4, for drug review
Hemofil M [Factor VIII (plasma derived)]	Please contact HMSA at 808-948-6464, option #4, for drug review
1. Herceptin (trastuzumab) (Trastuzumab Preferred Drug Program Commercial and QUEST)		01/01/2026	Refer below for Herceptin fax forms	Trastuzumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Trastuzumab Products (Commercial)
2. Herceptin (trastuzumab) (Commercial and QUEST)		04/14/2026	Commercial Fax Form QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Herceptin (trastuzumab) (Trastuzumab Preferred Drug Program Medicare Advantage)		01/01/2026	Refer below for Herceptin fax forms	Trastuzumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Trastuzumab Products (MA)
2. Herceptin (trastuzumab) (Medicare Advantage)		04/14/2026	Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Trastuzumab Preferred Drug Program Commercial and QUEST)		01/01/2026	Refer below for Herceptin Hylecta fax forms	Trastuzumab Products - Preferred Drug Program Commercial	ARCHIVED - Trastuzumab Products (Commercial)
2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Commercial and QUEST)		04/14/2026	Commercial Fax Form QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Trastuzumab Preferred Drug Program Medicare Advantage)		01/01/2026	Refer below for Herceptin Hylecta fax forms	Trastuzumab Products - Preferred Drug Program MA	ARCHIVED - Trastuzumab Products (MA)
2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Medicare Advantage)		04/14/2026	Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Hercessi (trastuzumab-stfr)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Hereditary Angioedema (HAE) Acute Preferred Drug Program (Commercial)		11/21/2025		Hereditary Angioedema (HAE) Acute Preferred Drug Program	ARCHIVED - Hereditary Angioedema Preferred Drug Program
1. Herzuma (trastuzumab-pkrb) (Trastuzumab Preferred Drug Program Commercial and QUEST)		01/01/2026	Refer below for Herzuma fax forms	Trastuzumab Products - Preferred Drug Program Commercial	ARCHIVED - Trastuzumab Products (Commercial)
2. Herzuma (trastuzumab-pkrb) (Commercial and QUEST)		04/14/2026	Commercial Fax Form QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Herzuma (trastuzumab-pkrb) (Trastuzumab Preferred Drug Program Medicare Advantage)		01/01/2026	Refer below for Herzuma fax forms	Trastuzumab Products - Preferred Drug Program MA	ARCHIVED - Trastuzumab Products (MA)
2. Herzuma (trastuzumab-pkrb) (Medicare Advantage)		04/14/2026	Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Hizentra (Immune Globulin Subcutaneous [Human], 20% Liquid) (Commercial and QUEST)		10/01/2025	Commercial Fax Form QUEST Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED - SCIG (Comm-QUEST)
Hizentra (Immune Globulin Subcutaneous [Human], 20% Liquid) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED - SCIG (MA)
HP Acthar Gel (repository corticotropin injection) (Commercial and QUEST)		12/19/2025	Fax Form		ARCHIVED - HP Acthar Gel (Comm-QUEST)
1. Hulio (adalimumab-fkjp) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Hulio (adalimumab-fkjp) (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 12/01/2023	ARCHIVED - Adalimumab (Humira)
Hulio (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
Humate P [Factor VIII (plasma derived)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Humatrope (somatropin) (Commercial and QUEST)				Discontinued as of 12/31/2025	ARCHIVED - Growth Hormone
1. Humira (adalimumab) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Humira Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Humira (adalimumab) (Commerical)		05/25/2025	Commercial Fax Form	Adalimumab (Humira)	ARCHIVED - Adalimumab (Humira)
Humira (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
1. Hyalgan® (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Hyalgan® Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Hyalgan® (sodium hyaluronate) (Commercial and QUEST)		04/12/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QUEST) ARCHIVED - Hyaluronates (drug specific)
1. Hyalgan (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Hyalgan® Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program) (MA)
2. Hyalgan® (sodium hyaluronate) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Hyaluronates Preferred Drug Program (Commercial and QUEST)		01/01/2026		Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
Hyaluronates (Commercial and QUEST)		04/12/2026		Hyaluronates	ARCHIVED - Hyaluronates (Comm-QUEST) ARCHIVED - Hyaluronates (drug specific)
Hyaluronates Preferred Drug Program (Medicare Advantage)		01/01/2026		Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program) (MA)
Hyaluronates (Medicare Advantage)		03/13/2026		Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
hydroxyprogesterone caproate (generic)				Makena (hydroxyprogesterone caproate injection)	ARCHIVED - Makena
1. Hymovis (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Hymovis Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Hymovis (high molecular weight viscoelastic hyaluronan) (Commercial and QUEST)		04/12/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QUEST) ARCHIVED - Hyaluronates (drug specific)
1. Hymovis (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Hymovis Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program) (MA)
2. Hymovis (high molecular weight viscoelastic hyaluronan) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Hymovis One (high molecular weight viscoelastic hyaluronan) (Commercial and QUEST)		04/12/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QUEST)
Hymovis One (high molecular weight viscoelastic hyaluronan) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Hympavzi [Tissue Factor Pathway Inhibitor (marstacimab-hncq)]	Please contact HMSA at 808-948-6464, option #4, for drug review.
HyQvia (Immune Globulin Infusion 10% [Human] with Recombinant Human Hyaluronidase)(Commercial and QUEST)		10/01/2025	Commercial Fax Form QUEST Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED - SCIG (Comm-QUEST)
HyQvia (Immune Globulin Infusion 10% [Human] with Recombinant Human Hyaluronidase) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED - SCIG (MA
1. Hyrimoz (adalimumab-adaz) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Hyrimoz (adalimumab-adaz) (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 12/01/2023	ARCHIVED - Adalimumab (Humira)
Hyrimoz (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)

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

Change History

Rev#:	Date:	Nature of Change:
6.21	05/07/2026	1100-1677778-1848950 The Gazyva (obinutuzumab) (Non-oncology) (Commercial and QUEST) 60-day provider notice (05/01/2026-06/30/2026) in effect 07/01/2026 has been posted.
6.20	05/04/2026	1100-1677778-1846250 The fax form links for the following drugs have been updated: Hizentra (Medicare Advantage) HyQvia (Medicare Advantage)
6.19	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. Gazyva Global Oncology Grafapex (treosulfan) 2. Herceptin (trastuzumab)(Commercial) 2. Herceptin (trastuzumab)(Medicare Advantage) 2. Herceptin (trastuzumab)(QUEST) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)(Commercial and QUEST) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)(Medicare Advantage) Hercessi (trastuzumab-stfr) 2. Herzuma (trastuzumab-pkrb)(Commercial and QUEST) 2. Herzuma (trastuzumab-pkrb)(Medicare Advantage) 1100-1677771-1837550 The SDRP policy eff 04/14/2026 has been posted for the following drugs covered under this policy. Gamifant Glassia (alpha-1 proteinase inhibitor) Haegarda (drug is not covered under Part B)
6.18	04/14/2026	1100-1677771-0820850 The Hyaluronate Products (Commercial and QUEST) effective 04/12/2026 has been posted for the following drugs covered under this policy: 2. Gel-One® (cross-linked hyaluronate) (Commercial and QUEST) 2. Gelsyn-3 (sodium hyaluronate 0.84%) (Commercial and QUEST) 2. Genvisc 850 (sodium hyaluronate) (Commercial and QUEST) 2. Hyalgan® (sodium hyaluronate) (Commercial and QUEST) 2. Hymovis (high molecular weight viscoelastic hyaluronan) (Commercial and QUEST) Hymovis One (high molecular weight viscoelastic hyaluronan) (Commercial and QUEST) (NEW)
6.17	04/13/2026	1100-1677771-1819704 The following drug has been added: Hympavzi [Tissue Factor Pathway Inhibitor (marstacimab-hncq)]
6.16	04/09/2026	1100-1677764-1802900 Minor edits: Removed #1 from Hyaluronates Preferred Drug Program (Medicare Advantage) and #2 from Hyaluronates (Medicare); removed the fax form link for Hyaluronates (Medicare Advantage); removed #1 from Hyaluronates Preferred Drug Program (Commercial) and #2 from Hyaluronates (Commercial).
6.15	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.
6.14	04/06/2026	1100-1677771-1805800 The SDRP policy eff 03/27/2026 has been posted for the following drugs covered under this policy. Gamifant Glassia (alpha-1 proteinase inhibitor) Haegarda (drug is not covered under Part B)
6.13	04/02/2026	1100-1677764-1798651 The following policies effective 04/01/2026 have been posted: Gattex (teduglutide) (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. Gel-One® (cross-linked hyaluronate) (Medicare Advantage) 2. Gelsyn-3 (sodium hyaluronate 0.84%) (Medicare Advantage) 2. Genvisc 850 (sodium hyaluronate) (Medicare Advantage) 2. Hyalgan® (sodium hyaluronate) (Medicare Advantage) 2. Hyaluronates (Medicare Advantage) 2. Hymovis (high molecular weight viscoelastic hyaluronan) (Medicare Advantage) Hymovis One (high molecular weight viscoelastic hyaluronan) (Medicare Advantage) (NEW)
6.12	03/31/2026	1100-1677764-1802500 Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST) effective 04/01/2026, has been posted for the following drugs covered under this policy. Hadlima (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST) Hulio (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST) Humira (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST) Hyrimoz (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)
6.11	03/30/2026	1100-1677764-1798661 Subcutaneous Immunoglobulin (SCIG) (Medicare Advantage) effective 04/01/2026 has been posted for the following drugs. Hizentra (Immune Globulin Subcutaneous [Human], 20%) (Medicare Advantage) HyQvia (Immune Globulin Infusion 10% [Human] with Recombinant Human Hyaluronidase) (Medicare Advantage)
6.10	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. Gazyva Global Oncology Grafapex (treosulfan) 2. Herceptin (trastuzumab)(Commercial) 2. Herceptin (trastuzumab)(Medicare Advantage) Herceptin (trastuzumab)(QUEST) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)(Commercial) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)(Medicare Advantage) Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)(QUEST) Hercessi (trastuzumab-stfr) 2. Herzuma (trastuzumab-pkrb)(Commercial) 2. Herzuma (trastuzumab-pkrb)(Medicare Advantage) Herzuma (trastuzumab-pkrb)(QUEST)(QUEST) 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.. Gamifant Glassia (alpha-1 proteinase inhibitor) Haegarda (drug is not covered under Part B)
6.09	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. Gamifant Glassia (alpha-1 proteinase inhibitor) Haegarda (drug is not covered under Part B)
6.08	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. Gamifant Glassia (alpha-1 proteinase inhibitor) Haegarda (drug is not covered under Part B)
6.07	02/03/2026	1100-1677757-1721600 The Adalimumab Preferred Drug Program (QUEST) redlined 60-day provider notice (02/01/2026-03/31/2026), effective 04/01/2026, has been posted for the following drugs covered under this policy: Hadlima (adalimumab-bwwd) (Adalimumab Preferred Drug Program) (QUEST) Hulio (adalimumab-fkjp) (Adalimumab Preferred Drug Program) (QUEST) Humira (adalimumab) (Adalimumab Preferred Drug Program) (QUEST) Hyrimoz (adalimumab-adaz) (Adalimumab Preferred Drug Program) (QUEST) 1100-1677757-1723601 The Gattex (teduglutide) (Commercial and QUEST) 60-day provider notice (02/01/2026-03/31/2026), effective 4/01/2026, has been posted. 1100-1677757-1721607 Subcutaneous Immunoglobulin (SCIG) (Medicare Advantage) 60-day provider notice 02/01/2026-03/31/2026, in effect 04/01/2026 has been posted for the following drugs covered under this policy: Hizentra (Immune Globulin Subcutaneous [Human], 20%) (Medicare Advantage) HyQvia (Immune Globulin Infusion 10% [Human] with Recombinant Human Hyaluronidase) (Medicare Advantage)
6.06	01/30/2026	1100-1677750-1720704 Removed "Growth Hormone Preferred Drug Program" from the following drug links: Growth Hormone (Commercial and QUEST) Genotropin (somatropin) (Commercial and QUEST) Humatrope (somatropin) (Commercial and QUEST) - discontinued as of 12/31/2025. Updated content accordingly.
6.05	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. Gazyva Global Oncology Grafapex (treosulfan) 2. Herceptin (trastuzumab)(Commercial) 2. Herceptin (trastuzumab)(Medicare Advantage) Herceptin (trastuzumab)(QUEST) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)(Commercial) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)(Medicare Advantage) Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)(QUEST) Hercessi (trastuzumab-stfr) 2. Herzuma (trastuzumab-pkrb)(Commercial) 2. Herzuma (trastuzumab-pkrb)(Medicare Advantage) Herzuma (trastuzumab-pkrb)(QUEST)(QUEST)
6.04	01/13/2026	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. Gazyva Global Oncology Grafapex (treosulfan) 2. Herceptin (trastuzumab)(Commercial) 2. Herceptin (trastuzumab)(Medicare Advantage) Herceptin (trastuzumab)(QUEST) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)(Commercial) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)(Medicare Advantage) Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)(QUEST) Hercessi (trastuzumab-stfr) 2. Herzuma (trastuzumab-pkrb)(Commercial) 2. Herzuma (trastuzumab-pkrb)(Medicare Advantage) Herzuma (trastuzumab-pkrb)(QUEST)(QUEST)
6.03	01/15/2026	1100-1677750-1694000 Growth Hormone Therapy, 01/01/2026 v2, has been posted for the following drugs covered under this policy. Archived: policy effective 01/01/2026 Growth Hormone Therapy (Growth Hormone Preferred Drug Program) (Commercial and QUEST) Genotropin (somatropin) (Growth Hormone Preferred Drug Program) (Commercial and QUEST) Humatrope (somatropin) (Growth Hormone Preferred Drug Program) (Commercial and QUEST)
6.02	01/08/2026	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. Gazyva Global Oncology Grafapex (treosulfan) 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Hercessi (trastuzumab-stfr) 2. Herzuma (trastuzumab-pkrb)
6.01	01/05/2026	1100-1677750-1684300 Growth Hormone Therapy (Commercial and QUEST), 01/01/2026, has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy effective 4/01/2025. Growth Hormone Therapy (Commercial and QUEST) Genotropin (somatropin) (Commercial and QUEST) Humatrope (somatropin) (Commercial and QUEST)
6.00	01/02/2026	1100-1677750-1684314 The SDRP policy eff 01/01/2026 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 12/23/2025 Gamifant Glassia (alpha-1 proteinase inhibitor) Haegarda (drug is not covered under Part B)
5.69	12/31/2025	1100-1205577-1681556 The Trastuzumab Products 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. Herceptin (trastuzumab) (Commercial and QUEST) 1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Commercial and QUEST) 1. Herzuma (trastuzumab-pkrb) (Commercial and QUEST) 1100-1205577-1681556 The Trastuzumab Products 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. Herceptin (trastuzumab) (Medicare Advantage) 1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Medicare Advantage) 1. Herzuma (trastuzumab-pkrb) (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. Gel-One (Commercial and QUEST) 1. Gelsyn-3 (Commercial and QUEST) 1. Genvisc 850 (Commercial and QUEST) 1. Hyalgan (Commercial and QUEST) 1. Hyaluronates Preferred Drug Program (Commercial and QUEST) 1. Hymovis (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. Gel-One (Medicare Advantage) 1. Gelsyn-3 (Medicare Advantage) 1. GenVisc 850 (Medicare Advantage) 1. Hyalgan (Medicare Advantage) Hyaluronates Preferred Drug Program (Medicare Advantage) 1. Hymovis (Medicare Advantage) 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. Hadlima (adalimumab-bwwd) (Autoimmune Preferred Drug Program) 1. Hulio (adalimumab-fkjp) (Autoimmune Preferred Drug Program) 1. Humira (adalimumab) 1. Hyrimoz (adalimumab-adaz) (Autoimmune Preferred Drug Program)
5.68	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 Gamifant Glassia (alpha-1 proteinase inhibitor) Haegarda (drug is not covered under Part B)
5.67	12/23/2025	1100-1205577-1671755 Gonal-f (follitropin-alfa) (Comm), 12/19/2025, has been posted. ARCHIVED: policy effective 10/25/2024. 1100-1205577-1671755 HP Acthar Gel (repository corticotropin injection) (Commercial and QUEST), effective 12/19/2025 has been posted. ARCHIVED: policy effective 9/27/2024 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. Gel-One® (cross-linked hyaluronate) (Medicare Advantage) 2. Gelsyn-3 (sodium hyaluronate 0.84%) (Medicare Advantage) 2. Genvisc 850 (sodium hyaluronate) (Medicare Advantage) 2. Hyalgan® (sodium hyaluronate) (Medicare Advantage) 2. Hyaluronates (Medicare Advantage) 2. Hymovis (high molecular weight viscoelastic hyaluronan) (Medicare Advantage)
5.66	12/03/2025	1100-1205577-1642506 Colony Stimulating Factors (CSF) – Short Acting Commercial and QUEST Preferred Drug Program effective 11/21/2025, has been posted for the following drug covered under this policy. Archived: policy effective 1/1/2025. Granix (TBO-filgrastim) (Commercial and QUEST) 1100-1205577-1642506 Colony Stimulating Factors (CSF) – Short-Acting Medicare Advantage Preferred Drug Program effective 11/21/2025, has been posted for the following drug covered under this policy. Archived: policy effective 1/1/2025. Granix (TBO-filgrastim) 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. Gazyva Global Oncology Grafapex (treosulfan) 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Hercessi (trastuzumab-stfr) 2. Herzuma (trastuzumab-pkrb)
5.65	11/26/2025	1100-1205570-1634455 The Hereditary Angioedema (HAE) Preferred Drug Program (Commercial) policy effective 11/21/2025 has been posted. ARCHIVED: policy effective 12/20/2024. 1100-1205570-1636950 The information in the following rows have been updated: Growth Hormone Therapy Preferred Program (Commercial and QUEST) 1. Hyaluronates Preferred Drug Program (Commercial and QUEST) 2. Hyaluronates (Commercial and QUEST) 1. Hyaluronates Preferred Drug Program (Medicare Advantage)
5.64	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 Gamifant Glassia (alpha-1 proteinase inhibitor) Haegarda (drug is not covered under Part B)
5.63	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. Gazyva Global Oncology Grafapex (treosulfan) 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Hercessi (trastuzumab-stfr) 2. Herzuma (trastuzumab-pkrb)
5.62	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 Gamifant Glassia (alpha-1 proteinase inhibitor) Haegarda (drug is not covered under Part B)
5.61	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 Gamifant Glassia (alpha-1 proteinase inhibitor) Haegarda (drug is not covered under Part B)
5.60	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. Gazyva Global Oncology Grafapex (treosulfan) 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Hercessi (trastuzumab-stfr) 2. Herzuma (trastuzumab-pkrb)
5.59	10/23/2025	1100-1205563-1590050 Growth Hormone Therapy (Commercial and QUEST) 60-day provider notice (11/01/25-12/31/25), effective 01/01/2025, have been posted for the following drug covered under this policy: Genotropin (somatropin) Growth Hormone Therapy Humatrope (somatropin) 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. Hadlima (adalimumab-bwwd) (Autoimmune Preferred Drug Program) 1. Hulio (adalimumab-fkjp) (Autoimmune Preferred Drug Program) 1. Humira (adalimumab) 1. Hyrimoz (adalimumab-adaz) (Autoimmune Preferred Drug Program)
5.58	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. Gamifant Glassia (alpha-1 proteinase inhibitor) Haegarda (drug is not covered under Part B) 1100-1205563-1574400 The Trastuzumab Products Specialty Exceptions (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. Herceptin (trastuzumab) (Commercial and QUEST) 1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Commercial and QUEST) 1. Herzuma (trastuzumab-pkrb) (Commercial and QUEST) 1100-1205563-1574400 The Trastuzumab Products 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. Herceptin (trastuzumab) (Medicare Advantage) 1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Medicare Advantage) 1. Herzuma (trastuzumab-pkrb) (Medicare Advantage) 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. Gel-One (Commercial and QUEST) 1. Gelsyn-3 (Commercial and QUEST) 1. Genvisc 850 (Commercial and QUEST) 1. Hyalgan (Commercial and QUEST) 1. Hyaluronates Preferred Drug Program (Commercial and QUEST) 1. Hymovis (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. Gel-One (Medicare Advantage) 1. Gelsyn-3 (Medicare Advantage) 1. GenVisc 850 (Medicare Advantage) 1. Hyalgan (Medicare Advantage) Hyaluronates Preferred Drug Program (Medicare Advantage) 1. Hymovis (Medicare Advantage)
5.57	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. Gammagard Liquid (human immunoglobulin) (Medicare Advantage) Gammagard S/D (immune globulin) (Medicare Advantage) Gammaked (immune globulin) (Medicare Advantage) Gammaplex (human immunoglobulin) (Medicare Advantage) Gamunex (Medicare Advantage) (NEW) Gamunex-C (human immunoglobulin) (Medicare Advantage) 1100-1205563-1551406 Subcutaneous Immunoglobulin (SCIG) (Commercial and QUEST) effective 10/01/2025 has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy eff 4/26/2024. Hizentra (Immune Globulin Subcutaneous [Human], 20% Liquid) (Commercial and QUEST) HyQvia (Immune Globulin Infusion 10% [Human] with Recombinant Human Hyaluronidase) (Commercial and QUEST) 1100-1205563-1551406 The Autoimmune Preferred Drug Program (Commercial) policy effective 10/1/2025, has been posted for the following drugs covered under this policy. ARCHIVED: 60-day notice and policy effective 6/7/2025 1. Hadlima (adalimumab-bwwd) (Autoimmune Preferred Drug Program) 1. Hulio (adalimumab-fkjp) (Autoimmune Preferred Drug Program) 1. Humira (adalimumab) 1. Hyrimoz (adalimumab-adaz) (Autoimmune Preferred Drug Program)
5.56	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. Gamifant Glassia (alpha-1 proteinase inhibitor) Haegarda (drug is not covered under Part B)
5.55	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. Gazyva Global Oncology Grafapex (treosulfan) 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Hercessi (trastuzumab-stfr) 2. Herzuma (trastuzumab-pkrb)
5.34	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. Gamifant Glassia (alpha-1 proteinase inhibitor) Haegarda (drug is not covered under Part B)
5.33	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. Gazyva Global Oncology Grafapex (treosulfan) 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Hercessi (trastuzumab-stfr) 2. Herzuma (trastuzumab-pkrb) 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. Hadlima (adalimumab-bwwd) (Autoimmune Preferred Drug Program) 1. Hulio (adalimumab-fkjp) (Autoimmune Preferred Drug Program) 1. Humira (adalimumab) 1. Hyrimoz (adalimumab-adaz) (Autoimmune Preferred Drug Program)
5.32	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. Gazyva Global Oncology Grafapex (treosulfan) 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Hercessi (trastuzumab-stfr) 2. Herzuma (trastuzumab-pkrb) 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. Gamifant Glassia (alpha-1 proteinase inhibitor) Haegarda (drug is not covered under Part B)
5.31	09/02/2025	1100-1205549-1486802 The QUEST fax form links for the following drugs have been updated: Gamifant, Haegarda
5.30	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. Gazyva Global Oncology Grafapex (treosulfan) 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Hercessi (trastuzumab-stfr) 2. Herzuma (trastuzumab-pkrb) 1100-1205549-1488650 The SDRP policy eff 07/01/2025-v2 has been posted for the following drugs covered under this policy. Gamifant Glassia (alpha-1 proteinase inhibitor) Haegarda (drug is not covered under Part B)
5.29	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. Gamifant Glassia (alpha-1 proteinase inhibitor) (NEW) Haegarda (drug is not covered under Part B) 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. Gazyva Global Oncology Grafapex (treosulfan) 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Hercessi (trastuzumab-stfr) 2. Herzuma (trastuzumab-pkrb)
5.28	08/11/2025	1100-1205549-1463450 Intravenous Immune Globulin (IVIG) (Commercial and QUEST) effective 7/25/2025, has been posted for the following drugs covered under this policy. Archived: policy eff 5/23/2025. Gammagard ERC [immune globulin infusion (human)] (Commercial and QUEST) (NEW) Gammagard Liquid (Commercial and QUEST) Gammagard S/D (Commercial and QUEST) Gammaked (Commercial and QUEST) Gammaplex (Commercial and QUEST) Gamunex-C (Commercial and QUEST)
5.27	08/07/2025	The Subcutaneous Immunoglobulin (SCIG) (Commercial and QUEST) 60-day provider notice (8/01/2025-9/30/2025) effective 10/01/2025 has been posted for the following drugs covered under this policy: Hizentra (Commercial and QUEST) Hyqvia (Commercial and QUEST) 1100-1205549-1463400 The Intravenous Immune Globulin (IVIG) (Medicare Advantage) 60-day provider notice (08/01/2025-09/30/2025) eff 10/01/2025 has been posted for the following drugs covered under this policy. Gammagard Liquid (human immunoglobulin) (Medicare Advantage) Gammagard S/D (immune globulin) (Medicare Advantage) Gammaked (immune globulin) (Medicare Advantage) Gammaplex (human immunoglobulin) (Medicare Advantage) Gamunex (Medicare Advantage) (NEW) Gamunex-C (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. Hadlima (adalimumab-bwwd) (Autoimmune Preferred Drug Program) 1. Hulio (adalimumab-fkjp) (Autoimmune Preferred Drug Program) 1. Humira (adalimumab) 1. Hyrimoz (adalimumab-adaz) (Autoimmune Preferred Drug Program)
5.26	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. Gamifant Haegarda (drug is not covered under Part B)
5.25	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. Hadlima (adalimumab-bwwd) (Autoimmune Preferred Drug Program) 1. Hulio (adalimumab-fkjp) (Autoimmune Preferred Drug Program) 1. Humira (adalimumab (Autoimmune Preferred Drug Program)) 1. Hyrimoz (adalimumab-adaz) (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. Gamifant Haegarda (drug is not covered under Part B) 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. Gel-One® (cross-linked hyaluronate) (Commercial and QUEST Integration) 2. Gelsyn-3 (sodium hyaluronate 0.84%) (Commercial and QUEST Integration) 2. Genvisc 850 (sodium hyaluronate) (Commercial and QUEST Integration) 2. Hyalgan® (sodium hyaluronate) (Commercial and QUEST Integration) 2. Hymovis (high molecular weight viscoelastic hyaluronan) (Commercial and QUEST Integration) 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. Gammagard Liquid (Commercial and QUEST) Gammagard S/D (Commercial and QUEST) Gammaked (Commercial and QUEST) Gammaplex (Commercial and QUEST) Gamunex-C (Commercial and QUEST)
5.24	05/22/2025	1100-1205528-1346450 Fax form links for the following have been updated: 1. Herceptin (trastuzumab) (Trastuzumab Preferred Drug Program Commercial and QUEST) 1. Herceptin (trastuzumab) (Trastuzumab Preferred Drug Program Medicare Advantage) 2. Herceptin (trastuzumab) (Commercial and QUEST) 2. Herceptin (trastuzumab) (Medicare Advantage) 1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Trastuzumab Preferred Drug Program Commercial and QUEST) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Commercial and QUEST) 1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Trastuzumab Preferred Drug Program Medicare Advantage) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Medicare Advantage) 1. Herzuma (trastuzumab-pkrb) (Trastuzumab Preferred Drug Program Commercial and QUEST) 2. Herzuma (trastuzumab-pkrb) (Commercial and QUEST) 1. Herzuma (trastuzumab-pkrb) (Trastuzumab Preferred Drug Program Medicare Advantage) 2. Hadlima (adalimumab-bwwd) (Commercial) 2. Hulio (adalimumab-fkjp) (Commercial) 2. Hyrimoz (adalimumab-adaz) (Commercial)
5.23	05/21/2025	1100-1205528-1349251 Adalimumab (Commercial) effective 5/25/2025, has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy eff 4/01/2025. 2. Hadlima (adalimumab-bwwd) (Commercial) 2. Hulio (adalimumab-fkjp) (Commercial) 2. Humira (adalimumab) (Commercial) 2. Hyrimoz (adalimumab-adaz) (Commercial)
5.22	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. Gamifant Haegarda (drug is not covered under Part B)
5.21	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. Gazyva Global Oncology Grafapex (treosulfan) 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Hercessi (trastuzumab-stfr) 2. Herzuma (trastuzumab-pkrb)
5.20	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. Gamifant Haegarda (drug is not covered under Part B)
5.19	05/08/2025	1100-1205528-1315150 The following fax form link has been updated or added: Granix (TBO-filgrastim) (CSF Short Acting Preferred Drug Program Commercial and QUEST) - QUEST
5.18	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. Gamifant Haegarda (drug is not covered under Part B)
5.17	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. Gazyva Global Oncology Grafapex (treosulfan) 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Hercessi (trastuzumab-stfr) 2. Herzuma (trastuzumab-pkrb)
5.16	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. Gamifant Haegarda (drug is not covered under Part B)
5.15	04/15/2025	1100-1205521-1305678 The Global Oncology policy effective 02/28/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 02/03/2025. Gazyva Global Oncology Grafapex (treosulfan) (NEW) 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Hercessi (trastuzumab-stfr) 2. Herzuma (trastuzumab-pkrb)
5.14	04/14/2025	1100-1205514-1265700 The Adalimumab redlined 60-day provider notice (02/01/2025-03/31/2025), effective 04/01/2025, has been posted for the following drugs covered under this policy: 2. Hadlima (adalimumab-bwwd) (Commercial) 2. Hulio (adalimumab-fkjp) (Commercial) 2. Humira (adalimumab) (Commercial) 2. Hyrimoz (adalimumab-adaz) (Commercial) The Adalimumab redlined 60-day provider notice (02/01/2025-03/31/2025), effective 04/01/2025, has been posted for the following drugs covered under this policy: Hadlima (adalimumab-bwwd) (QUEST) Hulio (adalimumab-fkjp) (QUEST) Humira (adalimumab) (QUEST) Hyrimoz (adalimumab-adaz) (QUEST) Growth Hormone Therapy, 4/01/2025, has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy effective 10/01/2024. Growth Hormone Therapy Genotropin (somatropin) Humatrope (somatropin)
5.13	04/07/2025	1100-1205521-1301650 The SDRP policy eff 02/01/2025 has been posted for the following drugs covered under this policy. Gamifant Haegarda (drug is not covered under Part B)
5.12	04/03/2025	1100-1205514-1278952 Current date edit to 2. Herzuma (trastuzumab-pkrb)
5.11	03/14/2025	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. Hadlima (adalimumab-bwwd) (Autoimmune Preferred Drug Program) 1. Hulio (adalimumab-fkjp) (Autoimmune Preferred Drug Program) 1. Humira (adalimumab) 1. Hyrimoz (adalimumab-adaz) (Autoimmune Preferred Drug Program)
5.10	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. Gazyva Global Oncology 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Hercessi (trastuzumab-stfr) 2. Herzuma (trastuzumab-pkrb) Change history notes from 2020, 2021, and 2022 are archived and have been removed from this article.
5.09	03/11/2025	1100-1205514-1261250 The following edits were applied: Deleted: Herceptin (trastuzumab) (QUEST Integration), Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (QUEST Integration), Herzuma (trastuzumab-pkrb) (QUEST Integration) Updated: 2. Herceptin (trastuzumab) (Commercial and QUEST), 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Commercial and QUEST), 2. Herzuma (trastuzumab-pkrb) (Commercial and QUEST)
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. Gamifant Haegarda (drug is not covered under Part B)
5.07	03/05/2025	1100-1205514-1265700 The Adalimumab redlined 60-day provider notice (02/01/2025-03/31/2025), effective 04/01/2025, has been posted for the following drugs covered under this policy: 2. Hadlima (adalimumab-bwwd) (Commercial) 2. Hulio (adalimumab-fkjp) (Commercial) 2. Humira (adalimumab) (Commercial) 2. Hyrimoz (adalimumab-adaz) (Commercial) The Adalimumab redlined 60-day provider notice (02/01/2025-03/31/2025), effective 04/01/2025, has been posted for the following drugs covered under this policy: Hadlima (adalimumab-bwwd) (QUEST) Hulio (adalimumab-fkjp) (QUEST) Humira (adalimumab) (QUEST) Hyrimoz (adalimumab-adaz) (QUEST) Growth Hormone Therapy 60-day provider notice (2/1/25-3/31/25), effective 04/01/2025, have been posted for the following drugs covered under this policy: Genotropin (somatropin) Growth Hormone Therapy Humatrope (somatropin)
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. Gazyva Global Oncology 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Hercessi (trastuzumab-stfr) (NEW) 2. Herzuma (trastuzumab-pkrb)
5.05	02/24/2025	1100-1205507-1254950 Fax form link have been updated for the following drugs: Gammagard Liquid (Commercial & QUEST) Gammagard Liquid (Medicare Advantage) Gammagard S/D (Commercial & QUEST) Gammagard S/D (Medicare Advantage) Gammaked (Commercial & QUEST) Gammaked (Medicare Advantage) Gammaplex (Commercial & QUEST) Gammaplex (Medicare Advantage) Gamunex-C (Commercial & QUEST) Gamunex-C (Medicare Advantage)
5.03	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. Gamifant Haegarda (drug is not covered under Part B)
5.02	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. Gamifant Haegarda (drug is not covered under Part B)
5.01	02/04/2025	1100-1205507-1235752 Updated the fax form links for the following drugs: Hizentra (Commercial/QUEST/Medicare Advantage) Hyqvia (Commercial/QUEST/Medicare Advantage)
5.00	01/14/2025	1100-1205500-1214101 The Global Oncology policy effective 12/01/2024 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 11/15/2024. Gazyva Global Oncology 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) 2. Herzuma (trastuzumab-pkrb)

Rev#:	Date:	Nature of Change:
4.36 (v182)	12/30/2024	1100-956557-1197456 Colony Stimulating Factors (CSF) – Short Acting Commercial and QUEST Preferred Drug Program effective 01/01/2025, has been posted for the following drug covered under this policy. Archived: 1/1/2025 and policy effective 11/17/2023. Granix (TBO-filgrastim) (Commercial and QUEST) 1100-956557-1197456 Colony Stimulating Factors (CSF) – Short-Acting Medicare Advantage Preferred Drug Program effective 01/01/2025, has been posted for the following drug covered under this policy. Archived: 1/1/2025 and policy effective 1/1/2024. Granix (TBO-filgrastim) 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. Gel-One (Commercial and QUEST) 1. Gelsyn-3 (Commercial and QUEST) 1. Genvisc 850 (Commercial and QUEST) 1. Hyalgan (Commercial and QUEST) 1. Hyaluronates Preferred Drug Program (Commercial and QUEST) 1. Hymovis (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. Gel-One (Medicare Advantage) 1. Gelsyn-3 (Medicare Advantage) 1. GenVisc 850 (Medicare Advantage) 1. Hyalgan (Medicare Advantage) Hyaluronates Preferred Drug Program (Medicare Advantage) 1. Hymovis (Medicare Advantage) Subcutaneous Immunoglobulin (SCIG) (Medicare Advantage) effective 1/1/2025 has been posted for the following drugs. Archived: 60-day notice eff 1/1/25 and policy eff 1/1/24. Hizentra (Immune Globulin Subcutaneous [Human], 20%) (Medicare Advantage) HyQvia (Immune Globulin Infusion 10% [Human] with Recombinant Human Hyaluronidase) (Medicare Advantage) 1100-956557-1197456 Trastuzumab Products - Commercial and QUEST Preferred Drug Program policy effective 01/01/2025, has been posted for the following drugs covered under this policy. Archived: 60-day provider notice eff 1/1/25 and policy eff 1/1/24. 1. Herceptin (trastuzumab) (Commercial and QUEST) 1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Commercial and QUEST) 1. Herzuma (trastuzumab-pkrb) (Commercial and QUEST) 1100-956557-1197456 Trastuzumab Products - Medicare Part B Preferred Drug Program policy, effective 01/01/2025, has been posted for the following drugs covered under this policy. Archived: 60-day notice eff 1/1/25 and policy eff 1/1/2024. 1. Herceptin (trastuzumab) (Medicare Advantage) 1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Medicare Advantage) 1. Herzuma (trastuzumab-pkrb) (Medicare Advantage)
4.35 (v181)	12/23/2024	1100-956557-1204850 The Hereditary Angioedema (HAE) Preferred Drug Program (Commercial) policy effective 12/20/2024 has been posted. ARCHIVED: policy effective 11/17/2023. Intravenous Immune Globulin (IVIG) (Commercial and QUEST) effective 12/20/2024, has been posted for the following drugs covered under this policy. Archived: policy eff 4/01/2024. Gammagard Liquid (Commercial and QUEST) Gammagard S/D (Commercial and QUEST) Gammaked (Commercial and QUEST) Gammaplex (Commercial and QUEST) Gamunex-C (Commercial and QUEST)
4.34 (v180)	12/03/2024	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. Gel-One® (cross-linked hyaluronate) (Commercial and QUEST Integration) 2. Gelsyn-3 (sodium hyaluronate 0.84%) (Commercial and QUEST Integration) 2. Genvisc 850 (sodium hyaluronate) (Commercial and QUEST Integration) 2. Hyalgan® (sodium hyaluronate) (Commercial and QUEST Integration) 2. Hymovis (high molecular weight viscoelastic hyaluronan) (Commercial and QUEST Integration)
4.33 (v179)	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. Hadlima (adalimumab-bwwd) (Autoimmune Preferred Drug Program) 1. Hulio (adalimumab-fkjp) (Autoimmune Preferred Drug Program) 1. Humira (adalimumab) 1. Hyrimoz (adalimumab-adaz) (Autoimmune Preferred Drug Program) 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. Gazyva Global Oncology 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) 2. Herzuma (trastuzumab-pkrb)
4.32 (v178)	11/04/2024	1100-956552-1168730 Gonal-f (follitropin-alfa), 10/25/2024, has been posted. ARCHIVED: policy effective 12/15/2023.
4.31 (v177)	11/01/2024	1100-956547-1167950 Colony Stimulating Factors (CSF) – Short Acting Commercial and QUEST Preferred Drug Program 60-day provider notice (11/01/2024-12/31/2024), effective 01/01/2025, has been posted for the following drug covered under this policy. Granix (TBO-filgrastim) (Commercial and QUEST) Colony Stimulating Factors (CSF) – Short-Acting Medicare Advantage Preferred Drug Program 60-day provider notice (11/01/2024-12/31/2024), effective 01/01/2025, has been posted for the following drug covered under this policy. Granix (TBO-filgrastim) (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. Gel-One (Commercial and QUEST) 1. Gelsyn-3 (Commercial and QUEST) 1. Genvisc 850 (Commercial and QUEST) 1. Hyalgan (Commercial and QUEST) 1. Hyaluronates Preferred Drug Program (Commercial and QUEST) 1. Hymovis (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. Gel-One (Medicare Advantage) 1. Gelsyn-3 (Medicare Advantage) 1. GenVisc 850 (Medicare Advantage) 1. Hyalgan (Medicare Advantage) Hyaluronates Preferred Drug Program (Medicare Advantage) 1. Hymovis (Medicare Advantage) Subcutaneous Immunoglobulin (SCIG) (Medicare Advantage) (11/01/2024-12/31/2024) eff 1/1/2025 has been posted for the following drugs covered under this policy: Hizentra (Immune Globulin Subcutaneous [Human], 20%) (Medicare Advantage) HyQvia (Immune Globulin Infusion 10% [Human] with Recombinant Human Hyaluronidase) (Medicare Advantage)
4.30 (v176)	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. Gazyva Global Oncology 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) 2. Herzuma (trastuzumab-pkrb) The SDRP policy eff 10/3/2024 v2 has been posted for the following drugs covered under this policy. Gamifant Haegarda (drug is not covered under Part B)
4.29 (v175)	10/11/2024	1100-956547-1156401 HP Acthar Gel (repository corticotropin injection) (Commercial and QUEST), effective 9/27/2024 has been posted. ARCHIVED: policy effective 10/27/2023 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. Gamifant Haegarda (drug is not covered under Part B)
4.28 (v174)	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. Hadlima (adalimumab-bwwd) (Autoimmune Preferred Drug Program) 1. Hulio (adalimumab-fkjp) (Autoimmune Preferred Drug Program) 1. Humira (adalimumab) 1. Hyrimoz (adalimumab-adaz) (Autoimmune Preferred Drug Program)
4.27 (v173)	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. Gamifant Haegarda (drug is not covered under Part B)
4.26 (V172)	09/30/2024	1100-956542-1148056 Growth Hormone Therapy, 10/01/2024, has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy effective 12/15/2023. Growth Hormone Therapy Genotropin (somatropin) Humatrope (somatropin)
4.25 (v171)	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. Gamifant Haegarda (drug is not covered under Part B)
4.24 (v170)	09/19/2024	1100-956542-1137967 Edited the effective dates of Gazyva and Global Oncology to 9/10/2024.
4.23 (v169)	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. Gazyva Global Oncology 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) 2. Herzuma (trastuzumab-pkrb)
4.22 (v168)	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. Gamifant Haegarda (drug is not covered under Part B)
4.21 (v167)	08/05/2024	1100-956537-1104504 Growth Hormone Therapy 60-day provider notice (08/01/2024-09/30/2024), effective 10/01/2024, have been posted for the following drugs covered under this policy: Genotropin (somatropin) Growth Hormone Therapy Humatrope (somatropin)
4.20 (v166)	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. Gazyva Global Oncology 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) 2. Herzuma (trastuzumab-pkrb) The SDRP policy eff 7/01/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 6/17/2024. Gamifant Haegarda (drug is not covered under Part B)
4.19 (v165)	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. Hadlima (adalimumab-bwwd) (Autoimmune Preferred Drug Program)(new) 1. Hulio (adalimumab-fkjp) (Autoimmune Preferred Drug Program)(new) 1. Humira (adalimumab) 1. Hyrimoz (adalimumab-adaz) (Autoimmune Preferred Drug Program)(new) Humira (adalimumab) (Commercial) effective 07/01/2024, has been posted for the following drugs covered under this policy. Archived: policy eff 04/01/2024. 2. Hadlima (adalimumab-bwwd) (Commercial) 2. Hulio (adalimumab-fkjp) (Commercial) 2. Humira (adalimumab) (Commercial) 2. Hyrimoz (adalimumab-adaz) (Commercial)
4.18 (v164)	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. Gamifant Haegarda (drug is not covered under Part B)
4.17 (v163)	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. Gazyva Global Oncology 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) 2. Herzuma (trastuzumab-pkrb)
4.16 (v162)	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. Gel-One® (cross-linked hyaluronate) (Medicare Advantage) 2. Gelsyn-3 (sodium hyaluronate 0.84%) (Medicare Advantage) 2. Genvisc 850 (sodium hyaluronate) (Medicare Advantage) 2. Hyalgan® (sodium hyaluronate) (Medicare Advantage) 2. Hyaluronates (Medicare Advantage) 2. Hymovis (high molecular weight viscoelastic hyaluronan) (Medicare Advantage)
4.15 (v161)	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. Hadlima (adalimumab-bwwd) (Autoimmune Preferred Drug Program)(new) #1. Hulio (adalimumab-fkjp) (Autoimmune Preferred Drug Program)(new) #1. Humira (adalimumab) #1. Hyrimoz (adalimumab-adaz) (Autoimmune Preferred Drug Program)(new)
4.14 (v160)	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. Gamifant Haegarda (drug is not covered under Part B)
4.13 (v159)	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. Gamifant Haegarda (drug is not covered under Part B)
4.12 (v158)	05/10/2024	1100-956522-1050250 Updated the Adalimumab Preferred Drug Program (QUEST Integration) archived folder links.
4.11 (v157)	05/08/2024	1100-956522-1050250 Adalimumab Preferred Drug Program (QUEST Integration) effective 5/03/2024, has been posted for the following drugs covered under this policy. Archived: policy eff 4/1/2024 Hadlima (adalimumab-bwwd) (QUEST Integration) Hulio (adalimumab-fkjp) (QUEST Integration) Humira (adalimumab) (QUEST Integration) Hyrimoz (adalimumab-adaz) (QUEST Integration) 1100-956522-1049457 The SDRP policy eff 4/1/2024 has been posted for the following drugs covered under this policy. The SDRP policy effective 3/1/2024 has been archived. Gamifant Haegarda (drug is not covered under Part B)
4.10 (v156)	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. Humira (adalimumab) 1100-956522-1046905 The following policy has been posted: Gattex (teduglutide) (Commercial and QUEST Integration), 4/26/2024. Archived: 1/1/20241100-956522-1046905 Intravenous Immune Globulin (IVIG) (Medicare Advantage) eff 4/26/2024 has been posted for the following drugs covered under this policy. Archived: policy eff 12/15/2023. Gammagard Liquid (human immunoglobulin) (Medicare Advantage) Gammagard S/D (immune globulin) (Medicare Advantage) Gammaked (immune globulin) (Medicare Advantage) Gammaplex (human immunoglobulin) (Medicare Advantage) Gamunex-C (human immunoglobulin) (Medicare Advantage) Subcutaneous Immunoglobulin (SCIG) (Commercial and QUEST Integration) effective 4/26/2024 has been posted for the following drugs covered under this policy. Archived: 4/1/2024. Hizentra (Immune Globulin Subcutaneous [Human], 20% Liquid) (Commercial and QUEST Integration) HyQvia (Immune Globulin Infusion 10% [Human] with Recombinant Human Hyaluronidase) (Commercial and QUEST Integration)
4.9 (v155)	04/16/2024	Added the effective date of 4/1/2024 to Hyrimoz (adalimumab-adaz) (Adalimumab Preferred Drug Program) (QUEST Integration). Effective date was missing from the table.
4.8 (v154)	04/15/2024	Humira (adalimumab) (Commercial) effective 04/01/2024, has been posted for the following drugs covered under this policy. Archived: policy eff 12/1/2023 Hadlima (adalimumab-bwwd) (Commercial) Hulio (adalimumab-fkjp) (Commercial) Humira (adalimumab) (Commercial) Hyrimoz (adalimumab-adaz) (Commercial) *Drug numbering has been removed. 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: Gel-One (cross-linked hyaluronate) Gelsyn-3 (sodium hyaluronate 0.84%) Genvisc 850 (sodium hyaluronate) Hyalgan (sodium hyaluronate) Hyaluronates (drug specific policy) Hymovis (high molecular weight viscoelastic hyaluronan)
4.7 (v153)	03/31/2024	Adalimumab Preferred Drug Program (QUEST Integration) effective 4/01/2024, has been posted for the following drugs covered under this policy. Archived: 60-day notice. 1. Hadlima (adalimumab-bwwd) (QUEST Integration) 1. Hulio (adalimumab-fkjp) (QUEST Integration) 1. Humira (adalimumab) (QUEST Integration) 1. Hyrimoz (adalimumab-adaz) (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. Gel-One® (cross-linked hyaluronate) (Commercial and QUEST Integration) 2. Gelsyn-3 (sodium hyaluronate 0.84%) (Commercial and QUEST Integration) 2. Genvisc 850 (sodium hyaluronate) (Commercial and QUEST Integration) 2. Hyalgan® (sodium hyaluronate) (Commercial and QUEST Integration) 2. Hymovis (high molecular weight viscoelastic hyaluronan) (Commercial and QUEST Integration) 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. Gammagard Liquid (Commercial and QUEST Integration) Gammagard S/D (Commercial and QUEST Integration) Gammaked (Commercial and QUEST Integration) Gammaplex (Commercial and QUEST Integration) Gamunex-C (Commercial and QUEST Integration) Subcutaneous Immunoglobulin (SCIG) (Commercial and QUEST Integration) effective 4/1/2024 has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy eff 9/1/2022. Hizentra (Immune Globulin Subcutaneous [Human], 20% Liquid) (Commercial and QUEST Integration) HyQvia (Immune Globulin Infusion 10% [Human] with Recombinant Human Hyaluronidase) (Commercial and QUEST Integration)
4.6 (v152)	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. Gamifant Haegarda (drug is not covered under Part B)
4.5 (v151)	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. Gamifant Givlaari - Effective 2/15/2024, PA review for Givlaari is moved from CVS to HMSA review Haegarda (drug is not covered under Part B)
4.4 (v150)	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. Gamifant Givlaari Haegarda (drug is not covered under Part B)
4.3 (v149)	02/08/2024	The following link has been added as it was missed in the previous update: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. Hymovis (high molecular weight viscoelastic hyaluronan) (Commercial and QUEST Integration)
4.2 (v148)	02/01/2024	Adalimumab Preferred Drug Program (QUEST Integration) 60-day provider notice (02/01/2024-03/31/2024), effective 4/01/2024, has been posted for the following drugs covered under this policy: 1. Hadlima (adalimumab-bwwd) (QUEST Integration) 1. Humira (adalimumab) (QUEST Integration) 1. Hulio (adalimumab-fkjp) (QUEST Integration) 1. Hyrimoz (adalimumab-adaz) (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) (Commercial and QUEST Integration) 2. Euflexxa® (1% sodium hyaluronate) (Commercial and QUEST Integration) 2. Gel-One® (cross-linked hyaluronate) (Commercial and QUEST Integration) 2. Gelsyn-3 (sodium hyaluronate 0.84%) (Commercial and QUEST Integration) 2. Genvisc 850 (sodium hyaluronate) (Commercial and QUEST Integration) 2. Hyalgan® (sodium hyaluronate) (Commercial and QUEST Integration) 2. Hymovis (high molecular weight viscoelastic hyaluronan) (Commercial and QUEST Integration) 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: Gammagard Liquid (Commercial and QUEST Integration) Gammagard S/D (Commercial and QUEST Integration) Gammaked (Commercial and QUEST Integration) Gammaplex (Commercial and QUEST Integration) Gamunex-C (Commercial and QUEST Integration) Intravenous Immune Globulin (SCIG) (Commercial and QUEST Integration) 60-day provider notice (02/01/2024-03/31/2024), effective 4/01/2024, has been posted for the following drug covered under this policy: Hizentra (Commercial and QUEST Integration) HyQvia (Commercial and QUEST Integration)
4.1 (v147)	01/31/2024	Updated fax form links for the following: Granix, Herceptin (new line for QI), Hercptin Hylecta (new line for QI), Herzuma (new line for QI)
4.0 (v146)	01/12/2024	The SDRP policy eff 1/1/2024 has been posted for the following drugs covered under this policy. The SDRP policy effective 12/1/2023 has been archived. Gamifant Givlaari Haegarda (drug is not covered under Part B)

Rev#:	Date:	Nature of Change:
3.32 (v145)	12/29/2023	Minor edit to the notice statement for Gattex and a typographcal correction.
3.31 (v144)	12/28/2023	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. Gel-One (Commercial and QUEST Integration) 2. Gel-One (Medicare Advantage) 2. Gelsyn-3 (Commercial and QUEST Integration) 2. Gelsyn-3 (Medicare Advantage) 2. GenVisc 850 (Commercial and QUEST Integration) 2. GenVisc 850 (Medicare Advantage) 2. Hyalgan (Commercial and QUEST Integration) 2. Hyalgan (Medicare Advantage) 2. Hyaluronates (Commercial and QUEST Integration) 2. Hyaluronates (Medicare Advantage) 2. Hymovis (Commercial and QUEST Integration) 2. Hymovis (Medicare Advantage) Subcutaneous Immunoglobulin (SCIG) (Medicare Advantage) effective 1/1/2024 has been posted for the following drugs. Archived: Policy effective 9/1/2022. Hizentra (Immune Globulin Subcutaneous [Human], 20%) (Medicare Advantage) HyQvia (Immune Globulin Infusion 10% [Human] with Recombinant Human Hyaluronidase) (Medicare Advantage) Gattex (teduglutide), 1/1/2024 has been posted. (No PA for Medicare Advantage effective 1/1/2024). ARCHIVED: Gattex (teduglutide), 10/1/2023 Trastuzumab Products - Commercial and QUEST Preferred Drug Program 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: 1. Herceptin (trastuzumab) (Commercial and QUEST) 1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Commercial and QUEST) 1. Herzuma (trastuzumab-pkrb) (Commercial and QUEST) Trastuzumab Products - 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. Herceptin (trastuzumab) (Medicare Advantage) 1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Medicare Advantage) 1. Herzuma (trastuzumab-pkrb) (Medicare Advantage)
3.30 (v143)	12/27/2023	Colony Stimulating Factors (CSF) - Short Acting - Medicare Part B Preferred Drug Program effective 01/01/2024, has been posted for the following drug covered under this policy. Archived: 60-day provider notice effective 1/1/2024 and policy effective 2/1/2023. Granix (TBO-filgrastim) 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. Gel-One (Commercial) 1. Gelsyn-3 (Commercial) 1. Genvisc 850 (Commercial) 1. Hyalgan (Commercial) 1. Hyaluronates Preferred Drug Program (Commercial) 1. Hymovis (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. Gel-One (Hyaluronates Preferred Drug Program) (Medicare Advantage) 1. Gelsyn-3 (Hyaluronates Preferred Drug Program) (Medicare Advantage) 1. GenVisc 850 (Hyaluronates Preferred Drug Program) (Medicare Advantage) 1. Hyalgan (Hyaluronates Preferred Drug Program) (Medicare Advantage) Hyaluronates Preferred Drug Program (Medicare Advantage) 1. Hymovis (Hyaluronates Preferred Drug Program) (Medicare Advantage) Trastuzumab Products - Commercial Preferred Drug Program policy effective 01/01/2024, has been posted for the following drugs covered under this policy. Archived: 60-day provider notice eff 1/1/24. 1. Herceptin (trastuzumab) (Commercial) (new) 1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Commercial) (new) 1. Herzuma (trastuzumab-pkrb) (Commercial) (new) Trastuzumab Products - Medicare Part B Preferred Drug Program policy, effective 01/01/2024, has been posted for the following drugs covered under this policy. Archived: 60-day notice eff 1/1/2024. 1. Herceptin (trastuzumab) (Medicare Advantage) (new) 1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Medicare Advantage) (new) 1. Herzuma (trastuzumab-pkrb) (Medicare Advantage) (new)
3.29 (v142)	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. Gazyva Global Oncology 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) 2. Herzuma (trastuzumab-pkrb) 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. Gamifant Givlaari Haegarda (drug is not covered under Part B)
3.28 (v141)	12/18/2023	Gonal-f (follitropin-alfa), 12/15/2023, has been posted. Archived: policy effective 12/16/2022. Growth Hormone Therapy, 12/15/2023, has been posted for the following drugs covered under this policy. Archived: policy effective 4/1/2023. Growth Hormone Therapy Genotropin (somatropin) Humatrope (somatropin) Intravenous Immune Globulin (IVIG) (Medicare Advantage) eff 12/15/2023 has been posted for the following drugs covered under this policy. Archived: policy eff 9/1/2022. Gammagard Liquid (human immunoglobulin) (Medicare Advantage) Gammagard S/D (immune globulin) (Medicare Advantage) Gammaked (immune globulin) (Medicare Advantage) Gammaplex (human immunoglobulin) (Medicare Advantage) Gamunex-C (human immunoglobulin) (Medicare Advantage)
3.27 (v140)	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. Gazyva Global Oncology 2. Herceptin (trastuzumab) 2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) 2. Herzuma (trastuzumab-pkrb) 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. Gamifant Givlaari Haegarda (drug is not covered under Part B)
3.26 (v139)	12/12/2023	Hulio (adalimumab-fkjp) - removed link to 60-day notice
3.25 (v138)	12/08/2023	Humira (adalimumab) effective 12/01/2023, has been posted for the following drugs covered under this policy. Archived: 60-day provider notice (10/01/2023-11/30/2023) Hadlima (adalimumab-bwwd) (new eff 12/1/23) Hulio (adalimumab-fkjp) (new eff 12/1/23) #2. Humira (adalimumab) Hyrimoz (adalimumab-adaz) (new eff 12/1/23) Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program (Commercial) 11/17/2023 has been posted for the following drug covered under this policy. Archived: policy effective 10/1/2022. Granix (TBO-filgrastim) (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. Gazyva Global Oncology Herceptin (trastuzumab) Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Herzuma (trastuzumab-pkrb) The Hereditary Angioedema (HAE) Preferred Drug Program (Commercial) policy effective 11/17/2023 has been posted. The policy effective 10/28/2022 has been archived.
3.24 (v137)	11/20/2023	HP Acthar Gel (repository corticotropin injection), effective 10/27/2023 has been posted. The policy effective 11/18/2022 has been archived.
3.23 (v136)	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. Gazyva Global Oncology Herceptin (trastuzumab) Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Herzuma (trastuzumab-pkrb) 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. Gamifant Givlaari Haegarda (drug is not covered under Part B) 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.
3.22 (v135)	11/07/2023	Links to applicable archived folders have been added to the following drugs: Gammagard Liquid (human immunoglobulin) (Commercial & QUEST) Gammagard Liquid (human immunoglobulin) (Medicare Advantage) Gammagard S/D (immune globulin) (Commercial & QUEST) Gammagard S/D (immune globulin) (Medicare Advantage) Gammaked (immune globulin) (Commercial & QUEST) Gammaked (immune globulin) (Medicare Advantage) Gammaplex (human immunoglobulin) (Commercial & QUEST) Gammaplex (human immunoglobulin) (Medicare Advantage) Gamunex-C (human immunoglobulin) (Commercial & QUEST) Gamunex-C (human immunoglobulin) (Medicare Advantage) Granix (TBO-filgrastim) (Commercial) Hereditary Angioedema (HAE) Acute Preferred Drug Program (Commercial) Hizentra (Immune Globulin Subcutaneous [Human], 20% Liquid) (Commercial and QUEST Integration) Hizentra (Immune Globulin Subcutaneous [Human], 20% Liquid) (Medicare Advantage) HP Acthar Gel (repository corticotropin injection) 1. Hymovis (Hyaluronates Preferred Drug Program) (Commercial) HyQvia (Immune Globulin Infusion 10% [Human] with Recombinant Human Hyaluronidase) (Commercial and QUEST Integration) HyQvia (Immune Globulin Infusion 10% [Human] with Recombinant Human Hyaluronidase) (Medicare Advantage) Added rows: 2. Herceptin - Global Oncology 1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Medicare Advantage) Trastuzumab Products - Medicare Part B Preferred Drug Program 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024 (missed previously) 1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Medicare Advantage) Trastuzumab Products - Commercial Preferred Drug Program 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024 (missed previously) 2. Herzuma - Global Oncology Removed duplicate rows: 1. Herceptin (trastuzumab) (Commercial) 1. Herceptin (trastuzumab) (Medicare Advantage)
3.21 (v134)	11/01/2023	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. Gel-One (Commercial) 1. Gelsyn-3 (Commercial) 1. Genvisc 850 (Commercial) 1. Hyalgan (Commercial) 1. Hyaluronates Preferred Drug Program (Commercial) 1. Hymovis (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. Gel-One (Hyaluronates Preferred Drug Program) (Medicare Advantage) 1. Gelsyn-3 (Hyaluronates Preferred Drug Program) (Medicare Advantage) 1. GenVisc 850 (Hyaluronates Preferred Drug Program) (Medicare Advantage) 1. Hyalgan (Hyaluronates Preferred Drug Program) (Medicare Advantage) Hyaluronates Preferred Drug Program (Medicare Advantage) 1. Hymovis (Hyaluronates Preferred Drug Program) (Medicare Advantage) Short-Acting Colony Stimulating Factors (CSF) - Medicare Part B Preferred Drug Program redlined 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024, has been posted for the following drug covered under this policy. Granix (TBO-filgrastim) Trastuzumab Products - 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. Herceptin (trastuzumab) (Medicare Advantage) (new) 1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Medicare Advantage) (new) 1. Herzuma (trastuzumab-pkrb) (Medicare Advantage) (new) Trastuzumab Products - Commercial Preferred Drug Program 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024, has been posted for the following drugs covered under this policy: 1. Herceptin (trastuzumab) (Commercial) (new) 1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Commercial) (new) 1. Herzuma (trastuzumab-pkrb) (Commercial) (new)
3.20 (v133)	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. Gamifant Givlaari Haegarda (drug is not covered under Part B)
3.19 (v132)	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. Humira (adalimumab)
3.18 (v131)	10/01/2023	Minor type fix.
3.17 (v130)	09/29/2023	Humira (adalimumab) 60-day provider notice (10/01/2023-11/30/2023), effective 12/01/2023, has been posted for the following drugs covered under this policy: Hadlima (adalimumab-bwwd) (new eff 12/1/23) Hulio (adalimumab-fkjp) (new eff 12/1/23) #2. Humira (adalimumab) Hyrimoz (adalimumab-adaz) (new eff 12/1/23) Idacio (adalimumab-aacf) (new eff 12/1/23)
3.16 (v129)	09/28/2023	The following policy has been posted: Gattex (teduglutide), 10/1/2023; Archived: 60-day notice effective 10/1/23 and policy eff 12/16/2022
3.15 (v128)	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. Gazyva Global Oncology Herceptin (trastuzumab) Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Herzuma (trastuzumab-pkrb) 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. Gamifant Givlaari Haegarda (drug is not covered under Part B)
3.14 (v127)	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. Gazyva Global Oncology Herceptin (trastuzumab) Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Herzuma (trastuzumab-pkrb) 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. Gamifant Givlaari Haegarda (drug is not covered under Part B)
3.13 (v126)	07/31/2023	The following policy has been posted: The Gattex (teduglutide), redlined 60-day notice effective 8/1/2023 (notification period: 08/01/2023-09/30/2023)
3.12 (v125)	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.
3.11 (v124)	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. Gazyva Global Oncology Herceptin (trastuzumab) Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Herzuma (trastuzumab-pkrb)
3.10 (v123)	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. Gamifant Givlaari Haegarda (drug is not covered under Part B) Autoimmune Preferred Drug Program (Commercial) effective 07/01/2023 has been posted for the following drug covered under this policy. The 60-day notice and policy effective 04/01/2023 have been archived. #1. Humira (adalimumab) 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. Hemlibra (emicizumab) Hemofil M [Factor VIII (plasma derived)] Humate P [Factor VIII (plasma derived)]
3.9 (v122)	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. Humira (adalimumab) 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. Gamifant Givlaari Haegarda (drug is not covered under Part B)
3.8 (v121)	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. Gazyva Global Oncology Herceptin (trastuzumab) Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Herzuma (trastuzumab-pkrb) 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. Gamifant Givlaari Haegarda (drug is not covered under Part B)
3.7 (v120)	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. Gamifant Givlaari Haegarda (drug is not covered under Part B)
3.6 (v119)	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 drug covered under this policy: #1. Humira (adalimumab)
3.5 (v118)	04/06/2023	As of 4/6/2023, Makena (hydroxyprogesterone caproate injection) is no longer available. The policy has been archived.
3.4 (v117)	03/30/2023	Autoimmune Preferred Drug Program (Commercial) effective 04/01/2023 has been posted for the following drug covered under this policy. The 60-day notice and policy effective 10/1/2022 has been archived.. #1. Humira (adalimumab) Growth Hormone Therapy, 4/01/2023, has been posted for the following drugs covered under this policy. The 60-day notice and policy effective 4/1/2022 have been archived. Growth Hormone Therapy Genotropin (somatropin) Humatrope (somatropin) 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. Gamifant Givlaari Haegarda (drug is not covered under Part B)
3.3 (v116)	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. Gamifant Givlaari Haegarda (drug is not covered under Part B)
3.2 (v115)	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. Gazyva Global Oncology Herceptin (trastuzumab) Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Herzuma (trastuzumab-pkrb)
3.1 (v114)	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. Gazyva Global Oncology Herceptin (trastuzumab) Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Herzuma (trastuzumab-pkrb)
3.0 (v113)	01/31/2023	Colony Stimulating Factors (CSF) – Short-Acting Preferred Drug Program (Medicare Advantage) effective 02/01/2023 has been posted for the following drug covered under this policy. The 60-day notice and policy effective 06/01/2021 have been archived. Granix (TBO-filgrastim) (Medicare Advantage) 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. Gel-One (Commercial, QUEST Integration and Medicare Part B policy) 2. Gelsyn-3 (Commercial, QUEST Integration and Medicare Part B policy) 2. GenVisc 850 (Commercial, QUEST Integration and Medicare Part B policy) 2. Hyalgan (Commercial, QUEST Integration and Medicare Part B policy) 2. Hyaluronates (Commercial, QUEST Integration and Medicare Part B policy) 2. Hymovis (Commercial, QUEST Integration and Medicare Part B policy) Growth Hormone Therapy 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: Genotropin (somatropin) Humatrope (somatropin) 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. Humira (adalimumab)

Details

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