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Medical Specialty Drug Policies: I-K

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Medical Specialty Drug Policies: I-K

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-CD-FG-HIJKL-NO-RS-UV-Z

 


 

I

Policy NameNoticesCurrent Effective DatePA Fax FormsPolicy NotesArchived Policies
1. Icatibant (Hereditary Angioedema Preferred Drug Program) (Commercial) 11/21/2025Refer below for icatibant Fax FormsHereditary Angioedema Preferred Drug ProgramARCHIVED - Hereditary Angioedema Preferred Drug Program
2. icatibant (generic) (Commercial and QUEST)01/01/2026Commercial Fax Form
QUEST Fax Form 		icatibant–Firazir-sajazir ARCHIVED - Icatibant (Comm-QUEST)

1. Idacio (adalimumab-aacf)

(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. Idacio
(adalimumab-aacf)
(Commercial)		05/25/2025Commercial Fax Form Humira (adalimumab)
Effective 12/1/2023		ARCHIVED - Adalimumab (Humira)
Idacio (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)04/01/2026 Adalimumab Preferred Drug Program (QUEST)ARCHIVED - Adalimumab Preferred Drug Program (QI)
Idelvion
[Factor IX (recombinant)]		Please contact HMSA at 
808-948-6464, option #4, for drug review		    
Ilaris (canakinumab)
(Commercial and QUEST)		10/01/2025Fax Form ARCHIVED - Ilaris (Comm-QI)
ARCHIVED - Ilaris
Ilaris (canakinumab)
(Medicare Advantage)		05/23/2025   ARCHIVED - Ilaris (MA)
ARCHIVED - Ilaris
1. Ilumya 
(tildrakizumab-asmn)
(Autoimmune Preferred Drug Program)  (Commercial)		01/01/2026Refer below for Ilumya Fax FormsCommercial plan members refer to the Preferred Drug Program policy firstARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Ilumya
(tildrakixumab-asmn)
(Commercial and QUEST)		 03/27/2026Commerical Fax Form
QUEST Fax Form		Specific drug criteria for Ilumya eff 10/1/2020

ARCHIVED - Ilumya (COMM-QI)

ARCHIVED - Ilumya

Ilumya
(tildrakixumab-asmn)
(Medicare Advantage)		 03/27/2026Medicare Advantage Fax Form ARCHIVED - Ilumya (MA)
Imaavy (nipocalimab-aahu)04/14/2026Fax Form
Medicare Advantage Fax Form		Specialty Drugs Requiring Precertification (SDRP)
Added effective 7/10/2023		ARCHIVED - SDRP
Imdelltra
(tarlatamab-dlle)		 04/14/2026Fax Form
Medicare Advantage Fax Form		Global OncologyARCHIVED - Global Oncology
Imfinzi
(durvalumab)		 04/14/2026Fax Form
Medicare Advantage Fax Form		Global OncologyARCHIVED - Global Oncology
Imjudo
(durvalumab)		 04/14/2026Fax Form
Medicare Advantage Fax Form		Global OncologyARCHIVED - Global Oncology
Imlygic
(talimogene laherparepvec)		04/14/2026Fax Form
Medicare Advantage Fax Form		Global OncologyARCHIVED - Global Oncology
1. Imuldosa (ustekinumab-srlf)
(Autoimmune Preferred Drug Program)  (Commercial)		01/01/2026See below for Imuldosa Fax FormsCommercial plan members refer to the Preferred Drug Program policy firstARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Imuldosa (ustekinumab-srlf) (Commercial)01/19/2026Commercial Fax Form

Stelara and Biosimilars 

Added eff 4/8/2025

ARCHIVED - Stelara and Biosimilars (Commercial)
Imuldosa (ustekinumab-srlf) (QUEST)01/19/2026QUEST Fax Form

Stelara and Biosimilars (QUEST)

ARCHIVED - Stelara and Biosimilars (QUEST)
Imuldosa (ustekinumab-srlf)
(Medicare Advantage)		04/01/2026Medicare Advantage Fax FormStelara and Biosimilars (Medicare Advantage)ARCHIVED - Stelara (MA)
1. Inflectra 
(Autoimmune Preferred Drug Program)  (Commercial)		01/01/2026See below for Inflectra Fax FormsCommercial plan members refer to the Preferred Drug Program policy firstARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Inflectra
(infliximab-dyyb)
(Commercial and QUEST)		04/01/2026Commercial Fax Form
QUEST Fax Form		Infliximab-Avsola-Inflectra-Remicade-Renflexis-Zymfentra

ARCHIVED - Infliximab (Comm-QUEST)

 

ARCHIVED - Infliximab

Inflectra (infliximab-dyyb) (QUEST)60-day provider notice 05/01/2026-06/30/2026, in effect 07/01/2026Infliximab-Avsola-Inflectra-Renflexis-Zymfentra (QUEST)

 

Inflectra
(infliximab-dyyb)
(Medicare Advantage)		12/19/2025Medicare Advantage Fax FormInfliximab-Avsola-Inflectra-Remicade-Renflexis MAARCHIVED - Infliximab (MA) 
Infliximab
(Commercial and QUEST)		04/01/2026Commercial Fax Form
QUEST Fax Form		Infliximab-Avsola-Inflectra-Remicade-Renflexis-Zymfentra

ARCHIVED - Infliximab (Comm-QUEST)

 

ARCHIVED - Infliximab

Infliximab (QUEST)60-day provider notice 05/01/2026-06/30/2026, in effect 07/01/2026Infliximab-Avsola-Inflectra-Renflexis-Zymfentra (QUEST)

 

Infliximab
(Medicare Advantage)		 12/19/2025Medicare Advantage Fax FormInfliximab-Avsola-Inflectra-Remicade-Renflexis MAARCHIVED - Infliximab (MA) 
Infugem
(gemcitabine)		 04/14/2026Fax Form
Medicare Advantage Fax Form		Global OncologyARCHIVED - Global Oncology
Inlexzo (gemcitabine) 04/14/2026Fax Form
Medicare Advantage Fax Form		Global OncologyARCHIVED - Global Oncology
Intravenous Immune Globulin (IVIG) (Commercial & QUEST) 07/25/2025Fax FormIntravenous Immune Globulin (IVIG)ARCHIVED - IVIG
Intravenous Immune Globulin (IVIG) (Medicare Advantage) 10/01/2025Medicare Advantage Fax FormIntravenous Immune Globulin (IVIG) - MAARCHIVED - IVIG (MA)
Istodax
(romidepsin)		 04/14/2026Fax Form
Medicare Advantage Fax Form		Global Oncology
Effective 8/1/2022		ARCHIVED - Global Oncology
Ivra (melphalan hydrochloride)04/14/2026Fax Form
Medicare Advantage Fax Form		Global Oncology
Added effective 3/23/2025		ARCHIVED - Global Oncology
Ixinity
[Factor IX (recombinant)]		Please contact HMSA at 
808-948-6464, option #4, for drug review		    
Izervay
(avacincaptad pegol intravitreal solution)		 04/14/2026Fax Form
Medicare Advantage Fax Form		Specialty Drugs Requiring Precertification (SDRP)
Effective 9/1/2023		ARCHIVED - SDRP

 

J

Policy NameNoticesCurrent Effective DatePA Fax FormsPolicy NotesArchived Policies
Jelmyto
(mitomycin)		 04/14/2026Fax Form
Medicare Advantage Fax Form		Global OncologyARCHIVED - Global Oncology
Jemperli
(dostarlimab-gxly)		 04/14/2026Fax Form
Medicare Advantage Fax Form		Global Oncology 
(eff 05/01/2021)		ARCHIVED - Global Oncology
Jetrea   No PA required as of 3/1/19 
Jivi
[Factor VIII (recombinant)]		Please contact HMSA at 
808-948-6464, option #4, for drug review		    
Jobevne (bevacizumab-nwgd) (Bevacizumab Preferred Drug Program policy Commercial)01/01/2026Commercial Fax FormBevacizumab Products - Preferred Drug Program Commercial 
Effective 1/1/2026		ARCHIVED - Bevacizumab Products (Commercial)
Jobevne (bevacizumab-nwgd) (Bevacizumab Preferred Drug Program policy Medicare Advantage)01/01/2026Medicare Advantage Fax FormBevacizumab Products - Preferred Drug Program Medicare Advantage
Effective 1/1/2026
ARCHIVED - Bevacizumab Products (MA)
Jobevne (bevacizumab-nwgd) (Bevacizumab Preferred Drug Program policy QUEST)01/01/2026Bevacizumab Products - Preferred Drug Program QUEST
Effective 1/1/2026
ARCHIVED - Bevacizumab Products (QUEST)
Jubbonti (denosumab-bbdz) (Commercial and QUEST)04/01/2026Commercial Fax Form
QUEST Fax Form		Prolia and Biosimilars (Commercial and QUEST)ARCHIVED - Prolia (Comm-QUEST)
Jubbonti (denosumab-bbdz) (Medicare Advantage)06/27/2025Medicare Advantage Fax FormProlia and Biosimilars (Medicare Advantage)
Added eff 6/27/2025		ARCHIVED - Prolia (MA)

 

K

Policy NameNoticesCurrent Effective DatePA Fax FormsPolicy NotesArchived Policies
Kadcyla
(ado-trastuzumab emtansine)		 04/14/2026Fax Form
Medicare Advantage Fax Form		Global OncologyARCHIVED - Global Oncology
1. Kalbitor (ecallantide) (Hereditary Angioedema Preferred Drug Program) (Commercial) 11/21/2025Refer below for Kalbitor Fax FormsHereditary Angioedema Preferred Drug Program
Added effective 2/1/2022		ARCHIVED - Hereditary Angioedema Preferred Drug Program
2. Kalbitor (ecallantide)
(Commercial and QUEST)		01/01/2026Fax Form
QUEST Fax Form		Specific drug criteria

ARCHIVED - Kalbitor (Comm-QUEST)

ARCHIVED - Kalbitor

Kalbitor (ecallantide)
(Medicare Advantage)		01/01/2026Medicare Advantage Fax Form ARCHIVED - Kalbitor (MA)
1. Kanjinti
(trastuzumab-anns)
(Trastuzumab Preferred Drug Program Commercial and QUEST)		01/01/2026Refer below for Kanjinti fax formsTrastuzumab Products - Preferred Drug Program Commercial
ARCHIVED - Trastuzumab Products (Commercial)
2. Kanjinti
(trastuzumab-anns)
(Commercial and QUEST)		 04/14/2026

Commercial Fax Form

QUEST Fax Form

Global OncologyARCHIVED - Global Oncology
1. Kanjinti
(trastuzumab-anns)
(Trastuzumab Preferred Drug Program Medicare Advantage)		01/01/2026Refer below for Kanjinti fax formsTrastuzumab Products - Preferred Drug Program MA
ARCHIVED - Trastuzumab Products (MA)
2. Kanjinti
(trastuzumab-anns)
(Medicare Advantage)		 04/14/2026Medicare Advantage Fax FormGlobal OncologyARCHIVED - Global Oncology
Kanuma (sebelipase alfa) 04/14/2026

Commercial Fax Form
QUEST Fax Form 
Medicare Advantage Fax Form

Specialty Drugs Requiring Precertification (SDRP)ARCHIVED - SDRP
Kepivance
(palifermin)		 04/14/2026Fax Form
Medicare Advantage Fax Form		Global Oncology
Added effective 11/28/2023		ARCHIVED - Global Oncology
Kesimpta (ofatumumab)04/14/2026Commercial Fax Form
QUEST Fax Form		Specialty Drugs Requiring Precertification (SDRP)ARCHIVED - SDRP
1. Kevzara 
(sarilumab)
(Autoimmune Preferred Drug Program)  (Commercial)		01/01/2026Refer below for Kevzara Fax FormsCommercial plan members refer to the Preferred Drug Program policy firstARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Kevzara (sarilumab)
(Commercial and QUEST)		04/01/2026

Commercial Fax Form

QUEST Fax Form

Specific drug criteria for Kevzara eff 10/1/2020ARCHIVED - Kevzara (Comm-QUEST)
Keytruda 
(pembrolizumab)		 04/14/2026Fax Form
Medicare Advantage Fax Form		Global OncologyARCHIVED - Global Oncology
Khapzory (levoleucovorin) 04/14/2026Fax Form
Medicare Advantage Fax Form		Global OncologyARCHIVED - Global Oncology
Kimmtrak
(tebentafusp-tebn)		04/14/2026Fax Form
Medicare Advantage Fax Form		Global Oncology
Added effective 4/1/2022		ARCHIVED - Global Oncology
1. Kineret 
(anakinra) (Autoimmune Preferred Drug Program)  (Commercial)		01/01/2026Refer below for Kineret Fax FormsCommercial plan members refer to the Preferred Drug Program policy firstARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Kineret (anakinra) (Commercial and QUEST)05/23/2025Fax FormSpecific drug criteria for KineretARCHIVED - Kineret
Kisunla
(donanemab-azbt)		Please contact HMSA at 
808-948-6464, option #4, for drug review		ARCHIVED - SDRP
Koate
[Factor VIII (plasma derived)]		Please contact HMSA at 
808-948-6464, option #4, for drug review		    
Kovaltry
Factor VIII (recombinant)]		Please contact HMSA at 
808-948-6464, option #4, for drug review		    
Krystexxa (pegloticase)
(Commercial and QUEST)		 05/23/2025Fax Form ARCHIVED - Krystexxa (Comm-QI)
ARCHIVED - Krystexxa
Krystexxa (pegloticase)
(Medicare Advantage)		 05/23/2025Medicare Advantage Fax Form ARCHIVED - Krystexxa (MA)
KymriahEffective 06/24/2019: Please contact HMSA at 808-948-6464, option #4, for drug review    
Kynamro (mipomersen)   No PA required as of 05/25/2021 
Kyprolis
(carfilzomib)		 04/14/2026Fax Form
Medicare Advantage Fax Form		Global OncologyARCHIVED - Global Oncology
Kyxata (carboplatin) 04/14/2026Fax Form
Medicare Advantage Fax Form		Global Oncology
Added effective 09/12/2025		ARCHIVED - Global Oncology


 
CVS Caremark® is an independent company providing pharmacy benefit management services on behalf of HMSA.
Rev#:Date:Nature of Change:
7.2205/07/2026

1100-1677778-1848950 Infliximab (QUEST) 60-day provider notice (05/01/2026-06/30/2026) in effect 07/01/2026 has been posted for the following drugs:
Inflectra (infliximab-dyyb) (QUEST)
Infliximab (QUEST)

7.2104/29/2026

1100-1677771-1838900 The Global Oncology policy effective 04/14/2026 has been posted for the following drugs covered under this policy.
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Inlexzo (gemcitabine)
Ivra (melphalan hydrochloride) 
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
2. Kanjinti (trastuzumab-anns)(Commercial and QUEST)
2. Kanjinti (trastuzumab-anns)(Medicare Advantage)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
Kyxata (carboplatin)

 

1100-1677771-1838900 The Global Oncology policy effective 04/14/2026 has been posted for the following drugs covered under this policy.
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Inlexzo (gemcitabine)
Ivra (melphalan hydrochloride) 
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
2. Kanjinti (trastuzumab-anns)(Commercial and QUEST)
2. Kanjinti (trastuzumab-anns)(Medicare Advantage)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
Kyxata (carboplatin)

 

1100-1677771-1837550 The SDRP policy eff 04/14/2026 has been posted for the following drugs covered under this policy. 
Imaavy (nipocalimab-aahu) 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)

7.2004/14/20261100-1677771-1821700 Updated the QUEST fax form link for Icatibant.
7.1904/13/20261100-1677771-1819705 The Prolia (denosumab) (Commercial and QUEST) policy effective 04/01/2026 has been posted for the following drug covered under this policy:
Jubbonti (denosumab-bbdz) (Commercial and QUEST)
7.1804/07/2026Typo edit.
7.1704/06/2026

1100-1677771-1805800 The following policies effective 03/27/2026 have been posted:
2. Ilumya (tildrakizumab-asmn) (Commercial and QUEST)
Ilumya (tildrakizumab-asmn) (Medicare Advantage)

1100-1677771-1805800 The SDRP policy eff 03/27/2026 has been posted for the following drugs covered under this policy. 
Imaavy (nipocalimab-aahu) 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)

7.1603/31/2026

1100-1677764-1802500 Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST) effective 04/01/2026, has been posted for the following drug covered under this policy. 
Idacio (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)

1100-1677764-1802500 The Stelara and Biosimilars (Medicare Advantage), effective 04/01/2026, has been posted for the following drug covered under this policy. 
Imuldosa (ustekinumab-srlf) (Medicare Advantage)

7.1503/30/2026

1100-1677764-1798661 Infliximab (Commercial and QUEST) effective 04/01/2026 has been posted to the following drugs covered under this policy:
2. Inflectra (infliximab-dyyb) (Commercial and QUEST) 
Infliximab (Commercial and QUEST) 

1100-1677764-1798661 2. Kevzara (sarilumab) (Commercial and QUEST) effective 04/01/2026 has been posted.

7.1403/25/20261100-1677764-1781156 The Stelara (Commercial) effective date for 2. Imuldosa (ustekinumab-srlf) (Commercial) has been corrected to 01/19/2026.
7.1303/23/2026

1100-1677764-1784008 The ustekinumab (Stelara) and Biosimilars (QUEST) policy effective 01/19/2026, has been posted for the following drug covered under this policy. ARCHIVED: policy effective 10/01/2025.
Imuldosa (ustekinumab-srlf) (QUEST) 

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.
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Inlexzo (gemcitabine)
Ivra (melphalan hydrochloride) 
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
2. Kanjinti (trastuzumab-anns)(Commercial)
2. Kanjinti (trastuzumab-anns)(Medicare Advantage)
Kanjinti (trastuzumab-anns)(QUEST)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
Kyxata (carboplatin)

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.
Imaavy (nipocalimab-aahu) 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)

7.1203/17/20261100-1677764-1781156 Stelara (Commercial), effective 01/09/2026, has been posted for the following drug covered under this policy. ARCHIVED: Policy eff 4/8/2025 v3
2. Imuldosa (ustekinumab-srlf) (Commercial) 
7.1102/24/20261100-1677757-1754350 The SDRP policy eff 02/23/2026 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 02/09/2026.
Imaavy (nipocalimab-aahu) 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
7.1002/17/2026

1100-1677757-1743054 Products Specialty Exceptions (Commercial) policy, effective 01/01/2026 v2, has been posted for the following drug covered under this policy. 
Jobevne (bevacizumab-nwgd) Preferred Drug Program policy (Commercial) (NEW) 

1100-1677757-1743054 Products Specialty Exceptions (Medicare Advantage) policy, effective 01/01/2026 v2, has been posted for the following drug covered under this policy. 
Jobevne (bevacizumab-nwgd) Preferred Drug Program policy (Medicare Advantage) (NEW) 

1100-1677757-1743054 Products Specialty Exceptions (QUEST) policy, effective 01/01/2026 v2, has been posted for the following drug covered under this policy. 
Jobevne (bevacizumab-nwgd) Preferred Drug Program policy (QUEST) (NEW) 

7.0902/10/2026

1100-1677757-1734650 The Intravenous Immune Globulin (IVIG) (Commercial & QUEST) current effective date has been updated to 07/25/2025.

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.
Imaavy (nipocalimab-aahu) 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)

7.0802/06/20261100-1677757-1723650 Policy notes updated for 2. Inflectra (infliximab-dyyb) (Commercial and QUEST) and 
2. Infliximab (Commercial and QUEST)
7.0702/05/20261100-1677757-1723601 Updated the policy notes and archived link name for Stelara and Biosimilars (QUEST).
7.0602/04/20261100-1677757-1723650 Infliximab (Commercial and QUEST) 60-day provider notice (02/01/2026-03/31/2026), effective 04/01/2026, has been posted for the following drug covered under this policy: 
2. Inflectra (infliximab-dyyb) (Commercial and QUEST)
2. Infliximab (Commercial and QUEST)
7.0502/03/2026

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 drug covered under this policy: 
Idacio (adalimumab-aacf) (Adalimumab Preferred Drug Program) (QUEST)

1100-1677757-1721600 The Stelara (Medicare Advantage) redlined 60-day provider notice (02/01/2026-03/31/2026), effective 4/01/2026, has been posted for the following drug covered under this policy:
Imuldosa (ustekinumab-srlf) (Medicare Advantage)

1100-1677757-1723601 The Kevzara (sarilumab) (Commercial and QUEST) 60-day provider notice (02/01/2026-03/31/2026), effective 4/01/2026, has been posted.

1100-1677757-1721150 The Prolia (denosumab) (Commercial and QUEST) 60-day provider notice 02/01/2026-03/31/2026, in effect 04/01/2026 has been posted for the following drug covered under this policy: 
Jubbonti (denosumab-bbdz) (Commercial and QUEST)

7.0401/20/20261100-1677750-1702005 Updated all instances of QUEST Integration to QUEST.
7.0301/16/20261100-1677750-1699604 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.
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Inlexzo (gemcitabine)
Ivra (melphalan hydrochloride) 
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
2. Kanjinti (trastuzumab-anns)(Commercial)
2. Kanjinti (trastuzumab-anns)(Medicare Advantage)
Kanjinti (trastuzumab-anns)(QUEST)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
Kyxata (carboplatin)
7.0201/08/2026

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.
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Inlexzo (gemcitabine)
Ivra (melphalan hydrochloride) 
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
2. Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
Kyxata (carboplatin)

1100-1677750-1684306 LOB edit to drug name links.

7.0101/05/2026

1100-1677750-1684300 Icatibant (Commercial and QUEST), effective 01/01/2026 has been posted for the following drugs covered under this policy. The policy effective 09/27/2024 has been archived.024 has been posted for the following drugs covered under this policy. The policy effective 10/27/2023 has been archived.
2. icatibant (generic) (Commercial and QUEST)

1100-1677750-1684306 The following policies effective 1/1/2026 have been posted:
2. Kalbitor (Commercial and QUEST)ARCHIVED: policy eff 9/27/2024
Kalbitor (Medicare Advantage); ARCHIVED: policy eff 3/20/2025

7.0001/02/20261100-1677750-1684314 The SDRP policy eff 01/01/2026 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 12/23/2025
Imaavy (nipocalimab-aahu) 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
6.4312/31/2025

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. Kanjinti (trastuzumab-anns) (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. Kanjinti (trastuzumab-anns) (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. Idacio (adalimumab-aacf) (Autoimmune Preferred Drug Program)
1. Ilumya (tildrakizumab-asmn) (Autoimmune Preferred Drug Program)
1. Imuldosa (ustekinumab-srlf) (Autoimmune Preferred Drug Program) 
1. Inflectra (infliximab) Infliximab (Autoimmune Preferred Drug Program)
1. Infliximab (Autoimmune Preferred Drug Program)
1. Kevzara (sarilumab) (Autoimmune Preferred Drug Program)
1. Kineret (anakinra) (Autoimmune Preferred Drug Program)

6.4212/30/20251100-1205577-1680803 The SDRP policy eff 12/23/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 11/18/2025
Imaavy (nipocalimab-aahu) 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
6.4112/23/2025

1100-1205577-1671755 Ilumya (MA) effective 12/19/2025 has been posted. Archived: policy eff 4/26/2025.

1100-1205577-1671755 Infliximab (Medicare Advantage) policies effective 12/19/2025 have been posted to the following drugs covered under these policies, as applicable. Archived: Policy effective 11/15/2024.
Inflectra (infliximab-dyyb) (Medicare Advantage)
Infliximab (Medicare Advantage)

6.4012/03/20251100-1205577-1642610 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.
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Inlexzo (gemcitabine)
Ivra (melphalan hydrochloride) 
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
2. Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
Kyxata (carboplatin)
6.3912/01/20251100-1205570-1634455 The Hereditary Angioedema (HAE) Preferred Drug Program (Commercial) policy effective 11/21/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 12/20/2024.
1. Icatibant (Hereditary Angioedema Preferred Drug Program) (Commercial)
1. Kalbitor (ecallantide) (Hereditary Angioedema Preferred Drug Program) (Commercial)
6.3811/24/20251100-1205570-1631470 The SDRP policy eff 11/18/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 10/10/2025
Imaavy (nipocalimab-aahu) 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
6.3711/20/20251100-1205570-1631260 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.
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Inlexzo (gemcitabine)
Ivra (melphalan hydrochloride) 
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
2. Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
Kyxata (carboplatin)
6.3611/10/2025

1100-1205570-1615650 Stelara + Biosimilars Fax Form links have been updated for the following drugs:
2. Imuldosa (ustekinumab-srlf) (Commercial) 
Imuldosa (ustekinumab-srlf) (QUEST)

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
Imaavy (nipocalimab-aahu) 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)

6.3511/05/20251100-1205570-1607700 The following drug names have been updated to:
1. Icatibant (Hereditary Angioedema Preferred Drug Program) (Commercial)
1. Kalbitor (ecallantide) (Hereditary Angioedema Preferred Drug Program) (Commercial)
6.3411/03/20251100-1205563-1603251 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
Imaavy (nipocalimab-aahu) 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
6.3310/30/20251100-1205563-1597750 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.
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Inlexzo (gemcitabine) (NEW)
Ivra (melphalan hydrochloride) 
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
2. Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
Kyxata (carboplatin)
6.3210/27/20251100-1205563-1592051 Stelara (Commercial), effective 04/08/2025 v3, has been posted. ARCHIVED: Policy eff 4/8/2025 v2
Imuldosa (ustekinumab-srlf) (Commercial) 
6.3110/23/2025

1100-1205563-1590053 The icatibant 60-day notice (Commercial and QUEST) has been posted for the following drugs covered under this policy. Provider notification period is 11/01/2025-12/31/2025. Policy effective date is 01/01/2026.
2. icatibant (generic) (Commercial and QUEST)

1100-1205563-1590053 The following 60-day notices have been posted:
2. Kalbitor (ecallantide) (Commercial and QUEST Integration)
Kalbitor (ecallantide) (Medicare Advantage)

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. Idacio (adalimumab-aacf) (Autoimmune Preferred Drug Program)
1. Ilumya (tildrakizumab-asmn) (Autoimmune Preferred Drug Program)
1. Imuldosa (ustekinumab-srlf) (Autoimmune Preferred Drug Program) 
1. Inflectra (infliximab) Infliximab (Autoimmune Preferred Drug Program)
1. Infliximab (Autoimmune Preferred Drug Program)
1. Kevzara (sarilumab) (Autoimmune Preferred Drug Program)
1. Kineret (anakinra) (Autoimmune Preferred Drug Program)

6.3010/20/20251100-1205563-1581802 The following updates were made:
Intravenous Immune Globulin (IVIG) (Medicare Advantage) - updated current effective date to 10/01/2025
6.2910/17/2025

1100-1205563-1579050 The SDRP policy eff 08/01/2025 v2 has been posted for the following drugs covered under this policy. 
Imaavy (nipocalimab-aahu) 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (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. Kanjinti (trastuzumab-anns) (Commercial and QUEST) 

1100-1205563-1574400 The Trastuzumab Products Specialty Exceptions (Medicare Advantage) policy effective 09/26/2025, has been posted for the following drug covered under this policy. ARCHIVED: Policy effective 01/01/2025.   
1. Kanjinti (trastuzumab-anns) (Medicare Advantage)

1100-1205563-1574454 The Prolia fax form links have been updated for Jubbonti (Commercial and QUEST)

6.2810/03/20251100-1205563-1551406 ustekinumab (Stelara) and Biosimilars (QUEST) archive folder link fix.
6.2710/02/2025

1100-1205563-1551406 Ilaris (canakinumab) (Commercial and QUEST), 10/1/2025 has been posted; ARCHIVED: 60-day notice and policy eff 5/24/2024

1100-1205563-1551406 The Prolia (denosumab) (Commercial and QUEST) policy effective 10/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: 60-day notice and policy eff 7/26/2024.
Jubbonti (denosumab-bbdz) (Commercial and QUEST)

1100-1205563-1551406 The ustekinumab (Stelara) and Biosimilars (QUEST) policy effective 10/01/2025, has been posted for the following drug covered under this policy. ARCHIVED: 60-day notice.
Imuldosa (ustekinumab-srlf) (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. Idacio (adalimumab-aacf) (Autoimmune Preferred Drug Program)
1. Ilumya (tildrakizumab-asmn) (Autoimmune Preferred Drug Program)
1. Imuldosa (ustekinumab-srlf) (Autoimmune Preferred Drug Program) 
1. Inflectra (infliximab) Infliximab (Autoimmune Preferred Drug Program)
1. Infliximab (Autoimmune Preferred Drug Program)
1. Kevzara (sarilumab) (Autoimmune Preferred Drug Program)
1. Kineret (anakinra) (Autoimmune Preferred Drug Program)

6.2609/22/2025

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.
Imaavy (nipocalimab-aahu) 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)

1100-1205556-1528350 The effective dates for the drugs covered under the Stelara (Medicare Advantage) policy has been corrected to 09/20/2025.

6.3509/19/20251100-1205556-1528350 The Stelara and Biosimilars (Medicare Advantage), effective 9/20/2025, has been posted for the following drug covered under this policy. ARCHIVED: policy eff 4/1/2025.
Imuldosa (ustekinumab-srlf) (Medicare Advantage) (NEW)
6.3409/17/20251100-1205556-1514402 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.
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Ivra (melphalan hydrochloride) 
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
Kyxata (carboplatin) (NEW)
6.3309/16/20251100-1205556-1518355 The SDRP policy eff 07/25/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 07/11/2025.
Imaavy (nipocalimab-aahu) 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
6.3209/15/2025

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.
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Ivra (melphalan hydrochloride) 
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis

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. Idacio (adalimumab-aacf) (Autoimmune Preferred Drug Program)
1. Ilumya (tildrakizumab-asmn) (Autoimmune Preferred Drug Program)
1. Imuldosa (ustekinumab-srlf) (Autoimmune Preferred Drug Program) 
1. Inflectra (infliximab) Infliximab (Autoimmune Preferred Drug Program)
1. Infliximab (Autoimmune Preferred Drug Program)
1. Kevzara (sarilumab) (Autoimmune Preferred Drug Program)
1. Kineret (anakinra) (Autoimmune Preferred Drug Program)

6.3109/03/2025

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.
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Ivra (melphalan hydrochloride) 
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis

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.
Imaavy (nipocalimab-aahu) 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)

6.3009/02/20251100-1205549-1486802 The QUEST fax form links for the following drugs have been updated: Kanuma, Kesimpta
6.2908/26/2025

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.
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Ivra (melphalan hydrochloride) 
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis

1100-1205549-1488650 The SDRP policy eff 07/01/2025-v2 has been posted for the following drugs covered under this policy.
Imaavy (nipocalimab-aahu) 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)

6.2808/12/2025

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.
Imaavy (nipocalimab-aahu) (NEW)
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (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.
Imaavy (nipocalimab-aahu) - removed - drug is covered under SDRP
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Ivra (melphalan hydrochloride) 
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis

6.2708/07/2025

1100-1205549-1463453 Kisnula: Removed the policy notes entry from the table.

1100-1205549-1463400 The Ilaris (canakinumab) (Commercial and QUEST) 60-day provider notice (8/1/2025-9/30/2025) eff 10/1/2025 has been posted.

1100-1205549-1463400 The Prolia (denosumab) (Commercial and QUEST) 60-day provider notice (08/01/2025-09/30/2025) eff 10/01/2025 has been posted for the following drugs covered under this policy: 
Jubbonti (denosumab-bbdz) (Commercial and QUEST) (NEW)

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. Idacio (adalimumab-aacf) (Autoimmune Preferred Drug Program)
1. Ilumya (tildrakizumab-asmn) (Autoimmune Preferred Drug Program)
1. Imuldosa (ustekinumab-srlf) (Autoimmune Preferred Drug Program) 
1. Inflectra (infliximab) Infliximab (Autoimmune Preferred Drug Program)
1. Infliximab (Autoimmune Preferred Drug Program)
1. Kevzara (sarilumab) (Autoimmune Preferred Drug Program)
1. Kineret (anakinra) (Autoimmune Preferred Drug Program)

6.2607/24/20251100-1205542-1427101 Prolia and Biosimilars (Medicare Advantage), 6/27/2025 has been posted for the following drug covered under this policy:
Jubbonti (denosumab-bbdz) (Medicare Advantage) (NEW)
6.2506/30/2025

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.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)

1100-1205535-138830 Stelara and Biosimilars (Commercial and QUEST), effective 04/08/2025 v2, has been posted for the following drug covered under this policy. ARCHIVED: policy eff 4/8/2025.
Imuldosa (ustekinumab-srlf) (Commercial and QUEST) 

6.2406/10/2025

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. Idacio (adalimumab-aacf) (Autoimmune Preferred Drug Program)
1. Ilumya (tildrakizumab-asmn) (Autoimmune Preferred Drug Program)
1. Imuldosa (ustekinumab-srlf) (Autoimmune Preferred Drug Program) (NEW)
1. Inflectra (infliximab) Infliximab (Autoimmune Preferred Drug Program)
1. Infliximab (Autoimmune Preferred Drug Program)
1. Kevzara (sarilumab) (Autoimmune Preferred Drug Program)
1. Kineret (anakinra) (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.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)

The following policies have been posted effective 5/23/2025: 
Ilaris (canakinumab) (Commercial and QUEST Integration), Archived: 9/27/2024
2. Ilumya (tildrakizumab-asmn) (Commercial and QUEST Integration), Archived: 4/26/2024
2. Kineret (anakinra) (Commercial and QUEST), Archived: 4/26/2024 
Krystexxa (pegloticase) (Commercial and QUEST), Archived: 4/26/2024
Krystexxa (pegloticase) (Medicare Advantage), Archived: 7/26/2024

6.2306/03/2025
1100-1205535-1358906
Stelara and Biosimilars (Commercial and QUEST), effective 04/08/2025 , has been posted for the following drug covered under this policy. Biosimilars added eff 4/8/2025.
Imuldosa (ustekinumab-srlf) (Commercial and QUEST) (NEW)
6.2205/22/2025
1100-1205528-1346450 Fax form links for the following have been updated:
2. Idacio (adalimumab-aacf) (Commercial)
1. Kanjinti (trastuzumab-anns) (Trastuzumab Preferred Drug Program Commercial and QUEST)
1. Kanjinti (trastuzumab-anns) (Trastuzumab Preferred Drug Program Medicare Advantage)
2. Kanjinti (trastuzumab-anns) (Commercial and QUEST)
2. Kanjinti (trastuzumab-anns) (Medicare Advantage)
6.2105/21/2025
1100-1205528-1349251
Adalimumab (Commercial) effective 5/25/2025, has been posted for the following drug covered under this policy. Archived: 60-day notice and policy eff 4/01/2025.
2. Idacio (adalimumab-aacf) (Commercial)
6.2005/19/2025
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.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part 
6.1905/14/2025
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.
Imaavy (nipocalimab-aahu) (NEW)
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Ivra (melphalan hydrochloride) 
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
6.1805/12/2025
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.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
6.1705/06/2025
1100-1205528-1332100 Kalbitor (ecallantide) (Medicare Advantage), 3/20/2025 has been posted. ARCHIVED: policy eff 12/20/2024 
1100-1205528-1330252 The SDRP policy eff 04/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 03/01/2025.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
6.1604/23/2025
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.
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Ivra (melphalan hydrochloride) (NEW)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
6.1504/22/2025
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.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
6.1404/15/2025
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.
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
6.1304/14/2025
1100-1205521-1305653


Adalimumab (Commercial) effective 4/01/2025, has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy eff 7/01/2024.
2. Idacio (adalimumab-aacf) (Commercial)

 

Adalimumab (QUEST) effective 04/01/2025, has been posted for the following drugs covered under this policy. ARCHIVED: 60-day notice and policy 5/03/2024.
Idacio (adalimumab-aacf) (QUEST)

 

Kineret (anakinra) (Commercial and QUEST) has been posted; ARCHIVED: 60-day notice and policy eff 2/1/2024

6.1204/07/2025
1100-1205521-1301650 The SDRP policy eff 02/01/2025 has been posted for the following drugs covered under this policy. 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
6.1103/24/2025
1100-1205514-1272756 Added the Infliximab (Comm-QUEST) archived folder for 
2. Infliximab (Commercial and QUEST)
2. Inflectra (infliximab-dyyb) (Commercial and QUEST)
6.1003/14/2025
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. Idacio (adalimumab-aacf) (Autoimmune Preferred Drug Program)
1. Ilumya (tildrakizumab-asmn)
1. Inflectra (infliximab) Infliximab (Autoimmune Preferred Drug Program)
1. Infliximab (Autoimmune Preferred Drug Program)
1. Kevzara (sarilumab)
1. Kineret (anakinra)
6.0903/13/2025
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.
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
 
Change history notes from 2020, 2021, and 2022 are archived and have been removed from this article.
6.0803/12/2025
1100-1205514-1261250 republished.
6.0703/11/2025
1100-1205514-1261250 The following edits were applied:
Deleted: Kanjinti (trastuzumab-anns) (QUEST Integration)
Updated:  2. Kanjinti (trastuzumab-anns) (Commercial and QUEST) 
6.06

03/10/2025

(published on 3/11/2025)
1100-1205514-1272756 Kevzara (sarilumab) (Commercial and QUEST), 03/01/2025 has been posted. ARCHIVED: 60-day notice and policy eff 4/1/2024.
1100-1205514-1272756 Infliximab (Commercial and QUEST) effective 3/1/2025 has been posted to the following drug covered under these policies, as applicable. ARCHIVED: 60-day notice and policy effective 1/1/2024.
2. Inflectra (infliximab-dyyb) (Commercial and QUEST) 
2. Infliximab (Commercial and QUEST) 
1100-1205514-1272761 The SDRP policy eff 01/01/2025, v2 has been posted for the following drugs covered under this policy. 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
6.0503/05/2025
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 drug covered under this policy: 
2. Idacio (adalimumab-aacf) (Commercial)
The Adalimumab redlined 60-day provider notice (02/01/2025-03/31/2025), effective 04/01/2025, has been posted for the following drug covered under this policy: 
Idacio (adalimumab-aacf) (QUEST)
The following redlined 60-day provider notices (02/01/2025-03/31/2025), effective 04/01/2025 have been posted: 
Kineret (anakinra) (Commercial and QUEST)
6.0403/03/2025
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.
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
6.0302/10/2025
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.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
6.0202/05/2025
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.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
6.0101/14/2025
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.
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
6.001/07/2025
1100-956557-1197451 Edit 2. Inflectra and 2. Kevzara links to 60-day provider notice (01/01/2025-02/28/2025) eff 03/01/2025

 
Rev#:Date:Nature of Change:
5.37. (v179)12/30/2024
1100-956557-1197451 Infliximab (Commercial and QUEST)  60-day provider notice (02/01/2023-03/31/2023), effective 12/01/2023, has been posted for the following drugs covered under this policy: 
2. Inflectra (infliximab-dyyb)
2. Infliximab
1100-956557-1197451 Kevzara (sarilumab) (Commercial and QUEST) 60-day provider notice (01/01/2025-02/28/2025), effective 03/01/2025 has been posted.
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. Kanjinti (trastuzumab-anns) (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. Kanjinti (trastuzumab-anns) (Medicare Advantage)  
5.36 (v178)12/23/2024
1100-956557-1204850 The following policies have been posted:
Kalbitor (ecallantide) (Medicare Advantage), 12/20/2024; ARCHIVED: policy eff 1/1/2024
The Hereditary Angioedema (HAE) Preferred Drug Program (Commercial) policy effective 12/20/2024 has been posted for the following drug covered under this policy. ARCHIVED: policy effective 11/17/2023.
1. Icatibant (Commercial)
1. Kalbitor (ecallantide) (Commercial)
5.35 (v177)12/03/2024
1100-956552-1182203 Refreshed the links for the following:
2. Inflectra (infliximab-dyyb) (Medicare Advantage)
2. Infliximab (Medicare Advantage)
5.34 (v176)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. Idacio (adalimumab-aacf) (Autoimmune Preferred Drug Program)
1. Ilumya (tildrakizumab-asmn)
1. Inflectra (infliximab)
1. Infliximab
1. Kevzara (sarilumab)
1. Kineret (anakinra)
1100-956552-1182203
Infliximab (Medicare Advantage) policies effective 11/15/2024 have been posted to the following drugs covered under these policies, as applicable. Archived: Policy effective 1/1/2024.
2. Inflectra (infliximab-dyyb) (Medicare Advantage)
2. Infliximab (Medicare Advantage)
The Global Oncology policy effective 11/15/2024 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 10/23/2024.
Imdelltra (tarlatamab-dlle)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
5.33 (v175)11/04/2024
1100-956547-1165170
The effective date for Kadcyla has been updated.
5.32 (v174)11/01/2024
1100-956547-1167950
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. Kanjinti (trastuzumab-anns) (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. Kanjinti (trastuzumab-anns) (Medicare Advantage)  
5.31 (v173)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.
Imdelltra (tarlatamab-dlle) (new)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
The SDRP policy eff 10/3/2024 v2 has been posted for the following drugs covered under this policy.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
Kisunla (donanemab-azbt)
5.30 (v172)10/21/2024
1100-956547-1156401
The following policy has been posted: 2. Kalbitor (ecallantide) (Commercial and QUEST), 09/27/2024. 
5.29 (v171)10/14/2024
1100-956547-1156413 
Updated Kisunla (donanemab-azbt): Please contact HMSA at 808-948-6464, option #4, for drug review.
5.28 (v170)10/11/2024
1100-956547-1156401
The following policies have been posted: Ilaris (canakinumab) (Medicare Advantage), 09/27/2024. Archived: 1/1/2024
2. Kalbitor (ecallantide) (Commercial and QUEST), 09/27/2024. Archived: 1/1/2024
Icatibant (generic) (Commercial and QUEST), effective 09/27/2024 has been posted for the following drugs covered under this policy. The policy effective 10/27/2023 has been archived.
2. icatibant (generic)  
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.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
Kisunla (donanemab-azbt)
5.27 (v169)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. Idacio (adalimumab-aacf) (Autoimmune Preferred Drug Program)
1. Ilumya (tildrakizumab-asmn)
1. Inflectra (infliximab)
1. Infliximab
1. Kevzara (sarilumab)
1. Kineret (anakinra)
5.26 (v168)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.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
Kisunla (donanemab-azbt)
5.25 (v167)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.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
Kisunla (donanemab-azbt)
5.24 (v166)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.
Imdelltra (tarlatamab-dlle) (new)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
5.23 (v165)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.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
Kisunla (donanemab-azbt)
5.22 (v164)08/06/20241100-956537-1104509
The following policies have been posted: 
Krystexxa (pegloticase) (Medicare Advantage), 07/26/2024. Archived: 1/1/2024
5.21 (v163)07/16/20241100-956532-1092301
Global Oncology 07/15/2024 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 05/17/2024.
Imdelltra (tarlatamab-dlle) (new)
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
The SDRP policy eff 7/01/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 6/17/2024.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
Kisunla (donanemab-azbt) (new)
5.20 (v162)06/25/20241100-956527-1081006
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. Idacio (adalimumab-aacf) (Autoimmune Preferred Drug Program)(new)
1. Ilumya (tildrakizumab-asmn)
1. Inflectra (infliximab)
1. Infliximab
1. Kevzara (sarilumab)
1. Kineret (anakinra)
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. Idacio (adalimumab-aacf) (Commercial)
5.19 (v161)06/24/20241100-956527-1079102
The SDRP policy eff 6/17/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 5/27/2024.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
5.18 (v160)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.
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
5.17 (v159)05/30/20241100-956522-1064600
The following policy has been posted: 
Ilaris (canakinumab) (Commercial and QUEST Integration), 5/24/2024. Archived: 4/1/2024
5.16 (v158)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. Idacio (adalimumab-aacf) (Autoimmune Preferred Drug Program)(new)
#1. Ilumya (tildrakizumab-asmn)
#1. Inflectra (infliximab)
#1. Infliximab
#1. Kevzara (sarilumab)
#1. Kineret (anakinra)
5.15 (v157)05/23/20241100-956522-1060150
The SDRP policy eff 5/27/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 5/12/2024.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
5.14 (v156)05/15/20241100-956522-1055200
The SDRP policy eff 5/12/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 4/1/2024.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
5.13 (v155)05/10/20241100-956522-1050250
Updated the Adalimumab Preferred Drug Program (QUEST Integration) archived folder link.
5.12 (v154)05/08/20241100-956522-1050250
Adalimumab Preferred Drug Program (QUEST Integration) effective 5/03/2024, has been posted for the following drug covered under this policy. Archived: policy eff 4/1/2024
Idacio (adalimumab-aacf) (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.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
5.11 (v153)05/02/20241100-956522-1046900
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. Ilumya (tildrakizumab-asmn)
#1. Inflectra (infliximab)
#1. Infliximab
#1. Kevzara (sarilumab)
#1. Kineret (anakinra)
1100-956522-1046905
The following policies have been posted: 
Ilumya (tildrakizumab-asmn) (Commercial and QUEST Integration), 4/26/2024. Archived: 2/1/2024
Ilumya (tildrakizumab-asmn) (Medicare Advantage), 4/26/2024. Archived: 1/1/2024
Krystexxa (Commercial and QUEST Integration), 4/26/2024. Archived: 4/1/2024
Intravenous Immune Globulin (IVIG) (Medicare Advantage) 4/26/2024 has been posted. Archived: policy eff 12/15/2023.
5.10 (v152)04/15/2024Humira (adalimumab) (Commercial) effective 04/01/2024, has been posted for the following drug covered under this policy. Archived: policy eff 12/1/2023
Idacio (adalimumab-aacf) (Commercial)
*Drug numbering has been removed.
5.9 (v151)03/31/2024Adalimumab Preferred Drug Program (QUEST Integration) effective 4/01/2024, has been posted for the following drug covered under this policy. Archived: 60-day notice.
1. Idacio (adalimumab-aacf) (QUEST Integration)
The following policies have been posted: 
Ilaris (Commercial and QUEST Integration), 4/1/2024. Archived: 1/1/2024
2. Kevzara (Commercial and QUEST Integration), 4/1/2024. Archived: 10/1/2023
Krystexxa (Commercial and QUEST Integration), 4/1/2024. Archived: 1/1/2024
5.8 (v150)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. 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
5.7 (v149)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. 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
5.6 (v148)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.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
5.5 (v147)02/05/2024The following policy has been reposted (no changes):
2. Ilumya (tildrakizumab-asmn), 2/1/2024 
4.3 (v146)02/01/202460-day notices have been posted for the following drugs. Provider notification period is 2/1/2024-3/31/2024.
Ilaris (Commercial and QUEST Integration)
2. Kevzara (Commercial and QUEST Integration)
Krystexxa (Commercial and QUEST Integration)
Adalimumab Preferred Drug Program (QUEST Integration) 60-day provider notice (02/01/2024-03/31/2024), effective 4/01/2024, has been posted for the following drugs covered under this policy:
1. Idacio (adalimumab-aacf) (QUEST Integration)
4.2 (v145)01/31/2024Updated fax form links for the following:
Kanjinti (new line for QI), Krystexxa
4.1 (v144)01/30/2024The following policies have been posted:
2. Ilumya (tildrakizumab-asmn), 2/1/2024; ARCHIVED: 60-day notice eff 2/1/24 and policy eff 1/1/2024; linked new COMM-QI archive folder
2. Kineret (anakinra), 2/1/2024; ARCHIVED: 60-day notice eff 2/1/24 and policy eff 9/1/2022
4.0 (v143)01/12/2024The 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.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B

 

Rev#:Date:Nature of Change:
3.33 (v142)12/28/2023The following policies effective 1/1/2024 have been posted:
Ilaris (canakinumab) (Commercial and QUEST Integration)
Ilaris (canakinumab) (Medicare Advantage)
2. Ilumya (tildrakizumab-asmn) (Commercial and QUEST Integration)
Ilumya (tildrakizumab-asmn) (Medicare Advantage)
2. Kalbitor (ecallantide) (Commercial and QUEST Integration)
Kalbitor (ecallantide) (Medicare Advantage)
Krystexxa (pegloticase) (Commercial and QUEST Integration)
Krystexxa (pegloticase) (Medicare Advantage)
The following policies have been archived: 
Ilaris (canakinumab), 12/16/2022 (for all LOBs) 
2. Ilumya (tildrakizumab-asmn), 09/01/2022 (for all LOBs) 
2. Kalbitor (ecallantide), 10/27/2023 (for all LOBs) 
Krystexxa (pegloticase), 04/01/2023 (for all LOBs) 
Infliximab (Commercial and QUEST Integration) and (Medicare Advantage) policies effective 1/1/2024 have been posted to the following drugs covered under these policies, as applicable. Archived: The policy effective 12/1/2023 (all LOBs) has been archived.
2. Inflectra (infliximab-dyyb) (Commercial and QUEST Integration)
2. Inflectra (infliximab-dyyb) (Medicare Advantage)
2. Infliximab (Commercial and QUEST Integration)
2. Infliximab (Medicare Advantage)
3.32 (v141)12/27/2023Trastuzumab 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. Kanjinti (trastuzumab-anns) (Commercial) (new)
Trastuzumab Products - Medicare Part B Preferred Drug Program policy, effective 01/01/2024, has been posted for the following drug covered under this policy. Archived: 60-day notice eff 1/1/2024.   
1. Kanjinti (trastuzumab-anns) (Medicare Advantage) (new) 
3.31 (v140)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.
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Kepivance (palifermin)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
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.  
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
3.30 (v139)12/18/2023Updated the current effective dates for 2. Kanjinti (trastuzumab-anns) and Kyprolis to 11/28/2023 (missed in last update)
Intravenous Immune Globulin (IVIG) (Medicare Advantage) eff 12/15/2023 has been posted. Archived: policy eff 9/1/2022.
3.29 (v138)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.
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Kepivance (palifermin) (new eff 11/28/2023)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
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. 
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (drug is not covered under Part B)
3.28 (v137)12/12/2023Updated the effective date for 1. Icatibant (Commercial) t0 11/17/2023. It is a drug covered under the Hereditary Angioedema (HAE) Acute Preferred Drug Program (Commercial) policy which was posted on 12/8/2023.
3.27 (v136)12/11/2023
The following policies have been posted:
2. Ilumya (tildrakizumab-asmn) redlined 60-day notice (12/1/23-1/31/24)
2. Kineret (anakinra) redlined 60-day notice (12/1/23-1/31/24)
3.26 (v135)12/08/2023Humira (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)
Idacio (adalimumab-aacf) (new eff 12/1/23) 
Infliximab effective 12/01/2023, has been posted for the following drugs covered under this policy. Archived: 60-day provider notice (10/01/2023-11/30/2023) and policy eff 9/1/2022
2. Inflectra (infliximab-dyyb)
2. Infliximab
The Hereditary Angioedema (HAE) Acute Preferred Drug Program (Commercial) policy effective 11/17/2023 has been posted for the following drug covered under this policy. The policy effective 10/28/2022 has been archived.
1. Kalbitor (ecallantide) (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.
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
3.25 (v134)11/20/2023The following policy has been posted:
2. Kalbitor (ecallantide), 10/27/2023; archived policy eff 2/1/2023
Icatibant, effective 10/27/2023 has been posted for the following drugs covered under this policy. The policy effective 02/01/2023 have been archived.
2. icatibant (generic) 
3.24 (v133)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.
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
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.
Izervay (avacincaptad pegol intravitreal solution)
Kanuma  
Kesimpta (ofatumumab) (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.
3.23 (v132)11/07/2023Links to applicable archived folders have been added to the following drugs:
1. Icatibant (Commercial)
2. Ilumya (tildrakixumab-asmn)
Intravenous Immune Globulin (IVIG) (Commercial & QUEST)
Intravenous Immune Globulin (IVIG) (Medicare Advantage)
1. Kalbitor (ecallantide) (Commercial)
2. Kineret (anakinra)
Added row: 2. Kanjinti - Global Oncology
3.22 (v131)11/01/2023Trastuzumab 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. Kanjinti (trastuzumab-anns) (Commercial) (new)
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 drug covered under this policy:  
1. Kanjinti (trastuzumab-anns) (Medicare Advantage) (new) 
3.21 (v130)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. .  
Izervay (avacincaptad pegol intravitreal solution)
Kanuma
Kesimpta (ofatumumab) (drug is not covered under Part B)  
3.20 (v129)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. Ilumya (tildrakizumab-asmn)
#1. Inflectra
#1. Kevzara (sarilumab)
#1. Kineret (anakinra)
3.19 (v128)10/01/2023Replaced SDRP drug name Ngenla with the correct SDRP drug name Izervay, effective date 9/5/2023.
3.18 (v127)09/29/2023Humira (adalimumab) redlined 60-day provider notice (10/01/2023-11/30/2023), effective 12/01/2023, has been posted for the following drugs covered under this policy: 
Idacio (adalimumab-aacf) (new eff 12/1/23) 
Infliximab redlined 60-day provider notice (02/01/2023-03/31/2023), effective 12/01/2023, has been posted for the following drugs covered under this policy: 
2. Inflectra (infliximab-dyyb)
2. Infliximab
3.17 (v126)09/28/2023The following policy has been posted:
#2. Kevzara (sarilumab), 10/1/2023; Archived: 60-day notice effective 10/1/23 and policy eff 12/16/2022
3.16 (v125)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.
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
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.  
Izervay (avacincaptad pegol intravitreal solution) (NEW eff 9/1/2023)
Kanuma
Kesimpta (ofatumumab) (drug is not covered under Part B)        
3.15 (v124)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.
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
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.  
Kanuma
Kesimpta (ofatumumab) (drug is not covered under Part B) 
3.14 (v123)07/31/2023The following policy has been posted:
#2. Kevzara (sarilumab), redlined 60-day notice effective 3/1/2023 (notification period: 01/01/2023-02/28/2023)
3.13 (v122)07/11/2023References 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.
3.12 (v121)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.
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
3.11 (v120)07/03/2023Autoimmune 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. Infliximab
3.10 (v120)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. 
Kanuma
Kesimpta (ofatumumab) (drug is not covered under Part B) 
Autoimmune Preferred Drug Program (Commercial) effective 07/01/2023 has been posted for the following drugs covered under this policy. The 60-day notice and policy effective 04/01/2023 have been archived.
#1. Ilumya (tildrakizumab-asmn)
#1. Inflectra
#1. Kevzara (sarilumab)
#1. Kineret (anakinra)
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.
Idelvion [Factor IX (recombinant)]
Ixinity [Factor IX (recombinant)]
Jivi [Factor VIII (recombinant)]
Koate [Factor VIII (plasma derived)]
Kovaltry [Factor VIII (recombinant)]
3.9 (v119)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. Ilumya (tildrakizumab-asmn)
#1. Inflectra (infliximab)
#1. Infliximab
#1. Kevzara (sarilumab)
#1. Kineret (anakinra)
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. 
Kanuma
Kesimpta (ofatumumab) (drug is not covered under Part B)  
3.8 (v118)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.
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
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. 
Kanuma
Kesimpta (ofatumumab) (drug is not covered under Part B)      
3.7 (v117)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. 
Kanuma
Kesimpta (ofatumumab) (drug is not covered under Part B)   
3.6 (v116)04/28/2023Autoimmune Preferred Drug Program (Commercial) redlined 60-day notice effective 7/1/2023 (notification period: 05/01/2023-06/30/2023) has been posted for the following drugs covered under this policy:
#1. Ilumya (tildrakizumab-asmn)
#1. Inflectra (infliximab)
#1. Infliximab
#1. Kevzara (sarilumab)
#1. Kineret (anakinra)
3.5 (v115)03/30/2023
Autoimmune Preferred Drug Program (Commercial) effective 04/01/2023 has been posted for the following drugs covered under this policy. The 60-day notice and policy effective 10/1/2022 has been archived.
#1. Ilumya (tildrakizumab-asmn)
#1. Inflectra
#1. Kevzara (sarilumab)
#1. Kineret (anakinra)
The following policy has been posted: 
Krystexxa (pegloticase), 4/1/2023; archived 60-day notice and policy eff 4/1/2022
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.  
Kanuma
Kesimpta (ofatumumab) (drug is not covered under Part B)    
3.4 (v114)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.  
Kanuma
Kesimpta (ofatumumab) (drug is not covered under Part B)  
3.3 (v113)03/20/2023Global 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.
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
3.2 (v112)02/23/2023The following links have been fixed:
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Fixed Current Date typo for Kimmtrak (tebentafusp-tebn)
3.1 (v111)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.
Imfinzi (durvalumab)
Imjudo (durvalumab)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Istodax (romidepsin)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Keytruda
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn)
Kyprolis
3.0 (v110)01/31/2023The following policy effective 2/1/2023 has been posted:
2. Kalbitor (ecallantide); archived 60-day notice effective 2/1/23 and policy effective 4/1/22
The icatibant 60-day notice has been posted for the following drugs covered under this policy. Provider notification period is 1/1/2023-2/28/2023. Policy effective date is 3/1/2023.
icatibant (generic) 
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. Ilumya (tildrakizumab-asmn)
#1. Inflectra
#1. Kevzara (sarilumab)
#1. Kineret (anakinra)
The following redlined 60-day notices effective 4/1/2023 (notification period: 02/01/2023-03/31/2023) have been posted:
Krystexxa (pegloticase)

 


 
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