Information

Title Medical Specialty Drug Policies: L-N

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

G-H

I-K

O-R

S-U

V-Z

L

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Lamzede (velmanase alfa-tycv)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 4/1/2023	ARCHIVED - SDRP
Lanreotide (lanreotide acetate injection) (non-oncology) (Commercial and QUEST)		09/26/2025		Somatuline Depot-Lanreotide	ARCHIVED - Lanreotide (Comm-QI)
Lanreotide (lanreotide acetate injection) (non-oncology) (Medicare Advantage)		10/27/2025		Somatuline Depot-Lanreotide MA	ARCHIVED - Lanreotide (MA)
Lantidra (donislecel-jujn)	Please contact HMSA at 808-948-6464, option #4, for drug review
Leqembi (lecanemab-irmb)		02/01/2025	Commercial Fax Form QUEST Fax Form		ARCHIVED - Leqembi
Leqvio (inclisiran)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 4/1/2022	ARCHIVED - SDRP
Leukine (sargramostim) (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
Leukine (sargramostim) (CSF Short Acting Preferred Drug Program Medicare Advantage)		11/21/2025	Medicare Advantage Fax Form	Colony Stimulating Factors (CSF) –Short Acting Preferred Drug Program	ARCHIVED - CSF Short Acting (Preferred Drug Program) (MA)
leuprolide acetate (generic) (Non-oncology) (Commercial and QUEST)		01/01/2026	Fax Form	Leuprolide-Lupron	ARCHIVED - Leuprolide (Comm-QUEST)
leuprolide acetate (generic) (Oncology)		04/14/2026	Fax Form	Global Oncology	ARCHIVED - Global Oncology
Libtayo (cemiplimab-rwlc)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Loqtorzi (toripalimab-tpzi)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology Effective 12/12/2023
Lucentis (ranibizumab) (Commercial and QUEST)	No PA required
Lucentis (ranibizumab) (Medicare Advantage)	No PA required as of 01/01/2024			Retinal Disorders Preferred Drug Program	ARCHIVED - Retinal Disorders Preferred Drug Program (MA)
Lumoxiti (moxetumomab pasudotox-TDFK)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Lunsumio (mosunetuzumab-axgb)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Effective 1/20/2023	ARCHIVED - Global Oncology
Lupaneta Pack (Non-oncology)	No PA required. Drug was discontinued as of 4/1/2024.			Lupron-Lupaneta	ARCHIVED - Lupron-Lupaneta
Lupron Depot (leuprolide acetate) (Commercial and QUEST)	No PA Required for Medicare Advantage	01/01/2026	Fax Form	Leuprolide-Lupron	ARCHIVED - Leuprolide (Comm-QUEST)
Lupron Depot (leuprolide acetate) (Oncology)	No PA Required for Medicare Advantage	04/14/2026	Fax Form	Global Oncology	ARCHIVED - Global Oncology
Lupron Depot-PED (leuprolide acetate) (Non-oncology) (Commercial and QUEST)		01/01/2026	Fax Form	Leuprolide-Lupron	ARCHIVED - Leuprolide (Comm-QUEST)
Lutathera	Effective 06/24/2019: Please contact HMSA at 808-948-6464, option #4, for drug review
Luxturna (voretigene neparvovec-rzyl)	Please contact HMSA at 808-948-6464, option #4, for drug review
Lyfgenia (lovotibeglogene autotemcel)	Please contact HMSA at 808-948-6464, option #4, for drug review
Lymphir (denileukin diftitox-cxdl)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 12/23/2025	ARCHIVED - Global Oncology
Lynozyfic (linvoseltamab-gcpt)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 07/17/2025	ARCHIVED - Global Oncology

M

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Macugen (pegaptanib sodium) (Commercial and QUEST)	No PA required				ARCHIVED - Retinal Disorders Preferred Drug Program
Macugen (pegaptanib sodium) (Medicare Advantage)	No PA required as of 02/01/2022			Retinal Disorders Preferred Drug Program	ARCHIVED - Retinal Disorders Preferred Drug Program (MA)
Makena (hydroxyprogesterone caproate injection)	As of 04/06/2023 this drug is no longer available				ARCHIVED - Makena
Margenza (margetuximab-cmkb)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Mepsevii (vestronidase alfa-vjbk)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Monjuvi (tafasitamab-cxix)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Mononine Factor IX (plasma derived)]	Please contact HMSA at 808-948-6464, option #4, for drug review
1. Monovisc™ (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Monovisc™ Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Monovisc™ (high molecular weight hyaluronan) (Commercial and QUEST)		04/12/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QUEST) ARCHIVED - Hyaluronates (drug specific)
1. Monovisc (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Monovisc™ Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program) (MA)
2. Monovisc™ (high molecular weight hyaluronan) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Mozobil (plerixafor) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Mozobil (plerixafor) (Commercial and QUEST)	ARCHIVED - Mozobil (Comm-QUEST)
Multiple Sclerosis (MS) – Interferons Preferred Drug Program (Commercial)		11/21/2025		Multiple Sclerosis (MS) – Interferons Preferred Drug Program	ARCHIVED - Multiple Sclerosis (MS) – Preferred Drug Program
1. Mvasi (bevacizumab-awwb) (Bevacizumab Preferred Drug Program Commercial)		01/01/2026	Commercial Fax Form	Bevacizumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Bevacizumab Products (Commercial)
2. Mvasi (bevacizumab-awwb) (Commercial)		04/14/2026	Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Mvasi (bevacizumab-awwb) (Bevacizumab Preferred Drug Program Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Bevacizumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Bevacizumab Products (MA)
2. Mvasi (bevacizumab-awwb) (Medicare Advantage)		04/14/2026		Global Oncology	ARCHIVED - Global Oncology
1. Mvasi (bevacizumab-awwb) (Bevacizumab Preferred Drug Program QUEST)		01/01/2026		Bevacizumab Products - Preferred Drug Program QUEST Effective 1/1/2025	ARCHIVED - Bevacizumab Products (QUEST)
2. Mvasi (bevacizumab-awwb) (QUEST)		04/14/2026	QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
Myalept (metreleptin)		09/26/2025	Fax Form		ARCHIVED - Myalept (Comm-QUEST)
Mylotarg (gemtuzumab ozogamicin)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Myobloc (rimabotulinumtoxinB)		04/01/2026	Fax Form QUEST Fax Form Medicare Advantage Fax Form	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY)	ARCHIVED - Botulinum Toxins
1. Myobloc (Botulinum Toxins Preferred Drug Program) (Medicare Advantage)		11/21/2025	Refer below for Myobloc Fax Forms	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY) Preferred Drug Program	ARCHIVED - Botulinum Toxins Preferred Drug Program MA
2. Myobloc (rimabotulinumtoxinB)		04/01/2026	Fax Form QUEST Fax Form Medicare Advantage Fax Form	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY)	ARCHIVED - Botulinum Toxins

N

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
1. Nemluvio (nemolizumab-ilto) (Atopic Dermatitis Preferred Program) (Commercial)		01/01/2026		Atopic Dermatitis Preferred Program Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Atopic Dermatitis (Commercial)
2. Nemluvio (nemolizumab-ilto)	60-day provider notice 05/01/2026-06/30/2026, in effect 07/01/2026	04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Nemluvio (nemolizumab-ilto) (QUEST)
Neulasta (including Onpro kit) (pegfilgrastim) (Commercial)	No PA required	01/01/2026		Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CSF Long Acting Preferred Drug Program
Neulasta (including Onpro kit) (pegfilgrastim) (Medicare Advantage)	No PA required	01/01/2026		Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CFS Long Acting Preferred Drug Program (MA)
Neupogen (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
Neupogen (filgrastim) (CSF Short Acting Preferred Drug Program Medicare Advantage)		11/21/2025	Medicare Advantage Fax Form	Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program	ARCHIVED - CSF Short Acting (Preferred Drug Program) (MA)
Nexviazyme (avalglucosidase alfa-ngpt)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Ngenla (somatrogon-ghla)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 9/1/2023	ARCHIVED - SDRP
Niktimvo (axatilimab-csfr)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Nivestym (filgrastim-aafi) (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
Nivestym (filgrastim-aafi) (CSF Short Acting Preferred Drug Program Medicare Advantage)		11/21/2025	Medicare Advantage Fax Form	Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program	ARCHIVED - CSF Short Acting (Preferred Drug Program) (MA)
Norditropin^® (somatropin) (Commercial and QUEST)		01/01/2026	Fax Form	Growth Hormone	ARCHIVED - Growth Hormone
NovoEight [Factor VIII (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
NovoSeven RT [Factor VIIA (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Nplate (romiplostim) (Commercial and QUEST)		11/21/2025	Fax Form		ARCHIVED - Nplate (Comm-QUEST) ARCHIVED - Nplate
Nplate (romiplostim) (Medicare Advantage)		11/21/2025	Medicare Advantage Fax Form		ARCHIVED - Nplate (MA)
Nucala (mepolizumab)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Nulibry (fosdenopterin)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Nutropin/Nutropin AQ (somatropin)	Effective 12/31/2024 Nutropin/Nutropin AQ is discontinued	10/01/2024	Fax Form	Growth Hormone Therapy Preferred Drug Program	ARCHIVED - Growth Hormone
Nuwiq [Factor VIII (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Nyvepria (pegfilgrastim-apgf) (Commercial)	No PA required	01/01/2026		Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CSF Long Acting Preferred Drug Program
Nyvepria (pegfilgrastim-apgf) (Medicare Advantage)	No PA required	01/01/2026		Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CFS Long Acting Preferred Drug Program (MA)

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

Change History

Rev#:	Date:	Nature of Change:
6.19	05/07/2026	1100-1677778-1848950 The Nemluvio (nemolizumab-ilto) (QUEST) 60-day provider notice (05/01/2026-06/30/2026) in effect 07/01/2026 has been posted.
6.18	04/14/2026	1100-1677771-1838900 The Global Oncology policy effective 04/14/2026 has been posted for the following drugs covered under this policy. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate)(Oncology) (No PA Required for Medicare Advantage) Lymphir (denileukin diftitox-cxdl) Lynozyfic (linvoseltamab-gcpt) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb)(Commercial) 2. Mvasi (bevacizumab-awwb)(Medicare Advantage) 2. Mvasi (bevacizumab-awwb)(QUEST) Mylotarg 1100-1677771-0820850 The Hyaluronate Products (Commercial and QUEST) effective 04/12/2026 has been posted for the following drug covered under this policy: 2. Monovisc™ (high molecular weight hyaluronan) (Commercial and QUEST) 1100-1677771-1837550 The SDRP policy eff 04/14/2026 has been posted for the following drugs covered under this policy. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii 2. Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin)
6.17	04/07/2026	1100-1677764-1802900: The effective date for drugs covered under the Hyaluronates (MA) policy has been corrected from 4/1/2026 to 03/13/2026.
6.16	04/06/2026	1100-1677771-1805800 The SDRP policy eff 03/27/2026 has been posted for the following drugs covered under this policy. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii 2. Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin)
6.15	04/02/2026	1100-1677764-1802900 The Hyaluronates (MA) policy effective 04/01/2026 has been posted for the following drugs covered under this policy. 2. Monovisc™ (high molecular weight hyaluronan) (Medicare Advantage)
6.14	03/31/2026	1100-1677764-1798651 Botulinum Toxins, eff 04/01/2026, has been posted for the following drugs covered under this policy. Myobloc (rimabotulinumtoxinB) 2. Myobloc
6.13	03/30/2026	1100-1677764-1798661 Mozobil (plerixafor) (Commercial and QUEST) effective 04/01/2026 has been posted.
6.12	03/23/2026	1100-1677764-1784003 The Global Oncology policy effective 03/13/2026 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 01/13/2026. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate)(Oncology) (No PA Required for Medicare Advantage) Lymphir (denileukin diftitox-cxdl) Lynozyfic (linvoseltamab-gcpt) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb)(Commercial) 2. Mvasi (bevacizumab-awwb)(Medicare Advantage) Mvasi (bevacizumab-awwb)(QUEST) Mylotarg 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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii 2. Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin)
6.11	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii 2. Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin)
6.10	02/17/2026	1100-1677757-1743054 Products Specialty Exceptions (Commercial) policy, effective 01/01/2026 v2, has been posted for the following drug covered under this policy. 1. Mvasi (bevacizumab-awwb) (Commercial) 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. 1. Mvasi (bevacizumab-awwb) (Medicare Advantage) 1100-1677757-1743054 Products Specialty Exceptions (QUEST) policy, effective 01/01/2026 v2, has been posted for the following drug covered under this policy. 1. Mvasi (bevacizumab-awwb) (QUEST)
6.09	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii 2. Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin)
6.08	02/03/2026	1100-1677757-1723601 Botulinum Toxins (Comm-QUEST-MA) 60-day provider notice 02/01/2026-03/31/2026, in effect 04/01/2026, has been posted for the following drug covered under this policy: 2. Myobloc (rimabotulinumtoxinB) 1100-1677757-1721607 Mozobil (plerixafor) (Commercial and QUEST) 60-day provider notice 02/01/2026-03/31/2026, in effect 04/01/2026, has been posted.
6.07	01/30/2026	1100-1677750-1720704 Removed "Growth Hormone Preferred Drug Program" from the following drug links: Norditropin (somatropin) (Commercial and QUEST)
6.06	01/21/2026	1100-1677750-1704852 Updated the policy notes for Myobloc.
6.05	01/20/2026	1100-1677750-1699604 Updated missed Global Oncology drugs to effective date 01/13/2026. 1100-1677750-1702005 Updated all instances of QUEST Integration to QUEST.
6.04	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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate)(Oncology) (No PA Required for Medicare Advantage) Lymphir (denileukin diftitox-cxdl) Lynozyfic (linvoseltamab-gcpt) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb)(Commercial) 2. Mvasi (bevacizumab-awwb)(Medicare Advantage) Mvasi (bevacizumab-awwb)(QUEST) Mylotarg
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 Norditropin (somatropin) (Growth Hormone Preferred Drug Program) (Commercial and QUEST)
6.02	01/08/2026	1100-1205577-1682553 Atopic Dermatitis Preferred Program has been added to the policy notes for the drugs covered under this policy. 1100-1677750-1690700 The Global Oncology policy effective 12/23/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 11/21/2025. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) (No PA Required for Medicare Advantage) Lymphir (denileukin diftitox-cxdl) (NEW) Lynozyfic (linvoseltamab-gcpt) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg 1100-1677750-1684306 LOB edit to drug name links.
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. Norditropin (somatropin) (Commercial and QUEST) 1100-1677750-1684306 Leuprolide (Commercial and QUEST) effective 07/26/2024 has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy eff 07/26/2024. Leuprolide acetate (generic) (Commercial and QUEST) Lupron Depot (leuprolide acetate) (Commercial and QUEST) Lupron Depot PED (leuprolide acetate) (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 Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii 2. Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin)
5.50	12/31/2025	1100-1205577-1681552 Colony Stimulating Factors (CSF) – Long Acting Specialty Exceptions (Commercial), effective 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 09/26/2025 Neulasta (including Onpro kit) (pegfilgrastim) (Commercial) - no PA required Nyvepria (pegfilgrastim-apgf) (Commercial) - no PA required 1100-1205563-1574400 Colony Stimulating Factors (CSF) – Long Acting Specialty Exceptions (Medicare Advantage), effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 01/01/2025. Neulasta (including Onpro kit) (pegfilgrastim) (Medicare Advantage) No PA required Nyvepria (pegfilgrastim-apgf) (Medicare Advantage) - No PA required 1100-1205577-1681556 Bevacizumab Products Specialty Exceptions (Commercial) policy, effective 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 09/26/2025 1. Mvasi (bevacizumab-awwb) (Commercial) 1100-1205577-1681556 Bevacizumab Products Specialty Exceptions (Medicare AdvantageMedicare Advantage) policy, effective 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 09/26/2025 1. Mvasi (bevacizumab-awwb) (Medicare Advantage) 1100-1205577-1681556 Bevacizumab Products Specialty Exceptions (QUEST) policy, effective 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 09/26/2025 1. Mvasi (bevacizumab-awwb) (QUEST) 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. Monovisc (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. Monovisc (Medicare Advantage) 1100-1205577-1682553 The Atopic Dermatitis (Commercial) 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: 60-day notice. Nemluvio (nemolizumab-ilto) (Atopic Dermatitis Preferred Program)
5.49	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 Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii 2. Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin)
5.48	12/23/2025	1100-1205577-1671755 The Hyaluronates Medicare Part B policy effective 12/19/2025 has been posted for the following drug covered under this policy. ARCHIVED: policy effective 12/20/2024. 2. Monovisc™ (high molecular weight hyaluronan) (Medicare Advantage)
5.47	12/18/2025	1100-1205577-1670253 The fax form link for the following have been updated. Mozobil (Commercial) Mozobil (QUEST)
5.46	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. Leukine (sargramostim) (Commercial and QUEST) Neupogen (filgrastim) (Commercial and QUEST) Nivestym (filgrastim-aaf) (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. Leukine (sargramostim) Neupogen (filgrastim) Nivestym (filgrastim-aafi) 1100-1205577-1642516 The following policies have been posted effective 11/21/2025; ARCHIVED: policy effective 4/01/2025. Nplate (romiplostim) (Commercial and QUEST) Nplate (romiplostim) (Medicare Advantage)
5.45	11/26/2025	1100-1205570-1634452 Botulinum Toxins Preferred Drug Program (Medicare Advantage) policy, eff 11/21/2025, has been posted for the following drugs covered under this policy. Archived: Policy eff 1/1/2025. 1. Myobloc (rimabotulinumtoxinB) (Botulinum Toxins Preferred Drug Program) (Medicare Advantage) 1100-1205570-1634458 Multiple Sclerosis (MS) Preferred Drug Program (Commercial) effective 11/21/2025, has been posted. ARCHIVED: policy effective 10/25/2024.
5.44	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 Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin)
5.43	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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) (No PA Required for Medicare Advantage) Lynozyfic (linvoseltamab-gcpt) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg
5.42	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 Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin)
5.41	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 Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin) 1100-1205563-1604101 The Lanreotide Injection/Somatuline Depot (MA) policy, effective 10/27/2025 has been posted. ARCHIVED: 9/26/2025. Lanreotide (lanreotide acetate injection) (non-oncology) (Medicare Advantage)
5.40	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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) (No PA Required for Medicare Advantage) Lynozyfic (linvoseltamab-gcpt) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg
5.39	10/29/2025	1100-1205563-1592054 The Atopic Dermatitis (Commercial) 60-day provider notice 11/01/2025-12/31/2025 effective 01/01/2026, has been posted for the following drug covered under this policy: Nemluvio (nemolizumab-ilto) (Atopic Dermatitis Preferred Program) (NEW)
5.38	10/28/2025	1100-1205563-1594410 Leuprolide (Commercial and QUEST) 60-day provider notice 11/01/2025-12/31/2025 effective 01/01/2026, has been posted for the following drug covered under this policy: Leuprolide acetate (generic) (non-oncology) (Commercial and QUEST) Lupron Depot (leuprolide acetate) (Commercial and QUEST) (No PA Required for Medicare Advantage) Lupron Depot PED (leuprolide acetate) (non-oncology) (Commercial and QUEST)
5.37	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: Norditropin® (somatropin)
5.36	10/21/2025	The following were posted on 10/17/2025: 1100-1205563-1574400 Colony Stimulating Factors (CSF) – Long Acting Specialty Exceptions (Commercial), effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 01/01/2025 Neulasta (including Onpro kit) (pegfilgrastim) (Commercial) - no PA required Nyvepria (pegfilgrastim-apgf) (Commercial) - no PA required 1100-1205563-1574400 Colony Stimulating Factors (CSF) – Long Acting Specialty Exceptions (Medicare Advantage), effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 01/01/2025. Neulasta (including Onpro kit) (pegfilgrastim) (Medicare Advantage) Nyvepria (pegfilgrastim-apgf) (Medicare Advantage)
5.35	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin) 1100-1205563-1574400 The Hyaluronates Preferred Drug Program (Commercial and QUEST) policy effective 09/26/2025, has been posted for the following drug covered under this policy. ARCHIVED: Policy effective 01/01/2025. 1. Monovisc (Commercial and QUEST) 1100-1205563-1574400 The Hyaluronates 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. Monovisc (Medicare Advantage) 1100-1205563-1574400 Bevacizumab Products Specialty Exceptions (Commercial) policy, effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 01/01/2025 1. Mvasi (bevacizumab-awwb) (Commercial) 1100-1205563-1574400 Bevacizumab Products Specialty Exceptions (Medicare AdvantageMedicare AdvantageMedicare Advantage) policy, effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 01/01/2025 1. Mvasi (bevacizumab-awwb) (Medicare Advantage) 1100-1205563-1574400 Bevacizumab Products Specialty Exceptions (QUEST) policy, effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 01/01/2025 1. Mvasi (bevacizumab-awwb) (QUEST)
5.34	09/30/2025	1100-1205556-1544400 The following policy has been posted: Myalept (metreleptin) (Comm-QUEST), 09/26/2025; ARCHIVED policy eff 9/27/24 1100-1205556-1545954 The following policies have been posted: Lanreotide (Commercial and QUEST), 09/26/2025. Archived: 07/26/2024. Lanreotide (Medicare Advantage), 09/26/2025. Archived: 07/26/2024.
5.33	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin)
5.32	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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) (No PA Required for Medicare Advantage) Lynozyfic (linvoseltamab-gcpt)(NEW) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg
5.31	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin)
5.30	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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) (No PA Required for Medicare Advantage) Lynozyfic (linvoseltamab-gcpt)(NEW) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg
5.29	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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) (No PA Required for Medicare Advantage) Lynozyfic (linvoseltamab-gcpt)(NEW) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg 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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin)
5.28	09/02/2025	1100-1205549-1486802 The QUEST fax form links for the following drugs have been updated: Leqvio , Mepsevii, Nexviazyme, Nucala, Nulibry, Mvasi 1100-1205549-1488650 Linked Lynozyfic (linvoseltamab-gcpt) to the Global Oncology policy eff 07/10/2025.
5.27	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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) (No PA Required for Medicare Advantage) Lynozyfic (linvoseltamab-gcpt)(NEW) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg 1100-1205549-1488650 The SDRP policy eff 07/01/2025-v2 has been posted for the following drugs covered under this policy. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin)
5.26	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin) 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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) (No PA Required for Medicare Advantage) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg
5.25	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin)
5.24	06/10/2025	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin) The Hyaluronate Products (Commercial and QUEST Integration) effective 5/23/2025, has been posted for the following drug covered under this policy. Archived: Policy eff 11/29/2024 2. Monovisc™ (high molecular weight hyaluronan) (Commercial and QUEST Integration)
5.23	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin)
5.22	05/14/2025	1100-1205528-1340903 The Global Oncology policy effective 05/08/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 03/23/2025. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) (No PA Required for Medicare Advantage) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg
5.21	05/12/2025	1100-1205528-1336050 The SDRP policy eff 04/01/2025, v2 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 04/01/2025. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin)
5.20	05/08/2025	1100-1205528-1315150 The following fax form links have been updated or added: Leukine (sargramostim) (CSF Short Acting Preferred Drug Program Commercial and QUEST) - QUEST Myobloc (rimabotulinumtoxinB) - QUEST 2. Myobloc (rimabotulinumtoxinB) - QUEST Neupogen (filgrastim) (CSF Short Acting Preferred Drug Program Commercial and QUEST) - QUEST Nivestym (filgrastim-aafi) (CSF Short Acting Preferred Drug Program Commercial and QUEST) - QUEST 1100-1205528-1315150 Update name of Leukine (sargramostim) (CSF Short Acting Preferred Drug Program Commercial) to Leukine (sargramostim) (CSF Short Acting Preferred Drug Program Commercial and QUEST)
5.19	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin)
5.18	04/23/2025	1100-1205521-1317159 The Global Oncology policy effective 03/23/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 02/28/2025. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) (No PA Required for Medicare Advantage) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg
5.17	04/22/2025	1100-1205521-1316800 The SDRP policy eff 03/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 02/01/2025. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) Nucala Nulibry (fosdenopterin)
5.16	04/21/2025	1100-1205521-1305653 The following edit was applied: Nplate (Commercial and QUEST) - watermark has been corrected. The policy remains unchanged.
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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) (No PA Required for Medicare Advantage) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg
5.14	04/14/2025	1100-1205521-1305653 The following policies effective 04/01/2025 have been posted: Nplate (romiplostim) (Commercial and QUEST); ARCHIVED: 60-day notice and policy eff 4/1/2024 Nplate (romiplostim) (Medicare Advantage); ARCHIVED: 60-day notice and policy eff 1/1/2024 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. Norditropin (somatropin) Botulinum Toxins, eff 04/01/2025, has been posted for the following drug covered under this policy. ARCHIVED: 60-day notice and policy eff 1/1/2025. Myobloc 2. Myobloc (Medicare Advantage)
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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Niktimvo (axatilimab-csfr) (NEW) Nucala Nulibry (fosdenopterin)
5.12	03/14/2025	1100-1205514-1265700 Corrected the link titles for Botulinum Toxins (Comm-QUEST-MA) redlined 60-day provider notice (02/01/2025-03/31/2025), effective 4/01/2025, and for the following drug covered under this policy: Myobloc (rimabotulinumtoxinB)
5.11	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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) (No PA Required for Medicare Advantage) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg Change history notes from 2020, 2021, and 2022 are archived and have been removed from this article.
5.10	03/11/2025	1100-1205514-1261250 Added "2" to 2. Mvasi (bevacizumab-awwb) (QUEST Integration)
5.09	03/10/2025	1100-1205514-1272761 The SDRP policy eff 01/01/2025, v2 has been posted for the following drugs covered under this policy. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin)
5.08	03/05/2025	1100-1205514-1265700 Botulinum Toxins (Comm-QUEST-MA) redlined 60-day provider notice (02/01/2025-03/31/2025), effective 4/01/2025, has been posted for the following drug covered under this policy: Myobloc (rimabotulinumtoxinB) Growth Hormone Therapy 60-day provider notice (2/1/25-3/31/25), effective 04/01/2025, have been posted for the following drug covered under this policy: Norditropin (somatropin) The following redlined 60-day provider notices (02/01/2025-03/31/2025), effective 04/01/2025 have been posted: Nplate (romiplostim) (Commercial and QUEST) Nplate (romiplostim) (Medicare Advantage)
5.07	03/03/2025	1100-1205514-1261250 The Global Oncology policy effective 01/15/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 12/01/2024. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) (No PA Required for Medicare Advantage) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg
5.06	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin)
5.05	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin)
5.04	02/04/2025	1100-1205507-1232803 Posted Leqembi (lecanemab-irmb), 2/1/2025. ARCHIVED: 60-day notice. Also added the links to the Commercial and QUEST PA Fax forms.
5.03	01/30/2025	1100-1205500-1214101 The following drugs current effective date has been updated to 12/01/2024 to match the current policy posted: leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) (No PA Required for Medicare Advantage)
5.02	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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) (No PA Required for Medicare Advantage) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg
5.01	01/09/2025	1100-956557-1197456 Removed policy links: Neulasta (Medicare Advantage) and Nyvepria (Medicare Advantage)
5.00	01/07/2025	1100-956557-1197456 Added: No PA required to Neulasta (Medicare Advantage) and Nyvepria (Medicare Advantage).

Rev#:	Date:	Nature of Change:
4.37 (V181)	12/30/2024	1100-956557-1197456 Bevacizumab Products - Commercial Preferred Drug Program policy, effective 01/01/2025, has been posted for the following drug covered under this policy. Archived: policy eff 1/1/24 and 60-day notice eff 1/1/25 1. Mvasi (bevacizumab-awwb) (Commercial) 1100-956557-1197456 Bevacizumab Products - Medicare Part B Preferred Drug Program policy effective 01/01/2025, has been posted for the following drugs covered under this policy. Archived: policy eff 1/1/24 and 60-day notice eff 1/1/25 1. Mvasi (bevacizumab-awwb) (Medicare Advantage) 1100-956557-1197456 Bevacizumab Products - QUEST Preferred Drug Program policy, effective 01/01/2025, has been posted for the following drug covered under this policy. Archived: 60-day notice eff 1/1/25 1. Mvasi (bevacizumab-awwb) (QUEST) 1100-956557-1197456 Botulinum Toxins, eff 01/01/2025, has been posted for the following drug covered under this policy. Archived: 60-day notice eff 1/1/25 and policy eff 4/1/24, v2. Myobloc (rimabotulinumtoxinB) 1100-956557-1197456 Botulinum Toxins Medicare Part B Preferred Drug Program policy, eff 1/1/2025, has been posted for the following drugs covered under this policy. Archived: 60-day notice eff 1/1/2025 and policy eff 1/1/2024. 1. Myobloc (rimabotulinumtoxinB) (Medicare Advantage) 1100-956557-1197456 Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial), effective 1/1/2025, has been posted for the following drugs covered under this policy. The 60-day notice eff 1/1/2025 and policy eff 1/1/2024 have been archived. Neulasta (including Onpro kit) (pegfilgrastim) (Commercial) - no PA required Nyvepria (pegfilgrastim-apgf) (Commercial) - no PA required 1100-956557-1197456 Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Medicare Advantage), effective 1/1/2025, has been posted for the following drugs covered under this policy. ARCHIVED: The 60-day notice eff 1/1/2025. Neulasta (including Onpro kit) (pegfilgrastim) (Medicare Advantage) Nyvepria (pegfilgrastim-apgf) (Medicare Advantage) 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. Leukine (sargramostim) (Commercial and QUEST) Neupogen (filgrastim) (Commercial and QUEST) Nivestym (filgrastim-aaf) (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. Leukine (sargramostim) Neupogen (filgrastim) Nivestym (filgrastim-aafi) 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. Monovisc (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. Monovisc (Medicare Advantage) 1100-956557-1197456 Mozobil (plerixafor) (Commercial and QUEST) effective 1/1/2025 has been posted. ARCHIVED: 60-day notice eff 1/1/2025.
4.36 (v180)	12/3\20/2024	1100-956557-1204850 The Hyaluronates Medicare Part B policy effective 12/20/2024 has been posted for the following drug covered under this policy. ARCHIVED: policy effective 5/30/2024. 2. Monovisc™ (high molecular weight hyaluronan) (Medicare Advantage)
4.35 (v179)	12/03/2024	1100-956557-1188105 Posted Leqembi (lecanemab-irmb) (Commercial and QUEST), 60-day notice (12/01/2024-01/31/2025) eff 2/1/2025 1100-956557-1188100The 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. Monovisc™ (high molecular weight hyaluronan) (Commercial and QUEST Integration)
4.34 (v178)	11/21/2024	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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) (No PA Required for Medicare Advantage) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg
4.33 (v177)	11/04/2024	1100-956552-1168730 Multiple Sclerosis (MS) Preferred Drug Program (Commercial) effective 10/25/2024, has been posted. ARCHIVED: policy effective 11/17/2023.
4.32 (v176)	11/01/2024	1100-956547-1167950 Bevacizumab Products - Commercial Preferred Drug Program 60-day provider notice (11/01/2024-12/31/20234), effective 01/01/2025, has been posted for the following drugs covered under this policy: 1. Mvasi (bevacizumab-awwb)(Commercial) Bevacizumab Products - Medicare Part B Preferred Drug Program 60-day provider notice (11/01/2024-12/31/20234), effective 01/01/2025, has been posted for the following drugs covered under this policy: 1. Mvasi (bevacizumab-awwb) (Medicare Advantage) Bevacizumab Products - QUEST Preferred Drug Program 60-day provider notice (11/01/2024-12/31/20234), effective 01/01/2025, has been posted for the following drugs covered under this policy: 1. Mvasi (bevacizumab-awwb) (Bevacizumab Preferred Drug Program Policy QUEST) (new) Botulinum Toxins (Comm-QUEST-MA) 60-day provider notice (11/01/2024-12/31/2024) eff 1/1/2025, has been posted for the following drug covered under this policy: Myobloc (rimabotulinumtoxinB) Botulinum Toxins Preferred Drug Program (Medicare Advantage) 60-day provider notice (11/01/2024-12/31/2024), effective 01/01/2025, has been posted for the following drugs covered under this policy: 1. Myobloc (rimabotulinumtoxinB) (Medicare Advantage) Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial) 60-day provider notice (11/01/2024-12/31/2024) eff 1/1/2025, has been posted for the following drugs covered under this policy. Neulasta (including Onpro kit) (pegfilgrastim) (Commercial) Nyvepria (pegfilgrastim-apgf) (Commercial) Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Medicare Advantage) 60-day provider notice (11/01/2024-12/31/2024) eff 1/1/2025, has been posted for the following drugs covered under this policy. Neulasta (including Onpro kit) (pegfilgrastim) (Medicare Advantage) Nyvepria (pegfilgrastim-apgf) (Medicare Advantage) 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. Leukine (sargramostim) (Commercial) Neupogen (filgrastim) (Commercial) Nivestym (filgrastim-aafi) (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. Leukine (sargramostim) (Medicare Advantage) Neupogen (filgrastim) (Medicare Advantage) Nivestym (filgrastim-aafi) (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. Monovisc (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. Monovisc (Medicare Advantage) Mozobil (plerixafor) (Commercial and QUEST) 60-day provider notice (11/01/2024-12/31/2024), effective 01/01/2025, has been posted.
4.31 (v175)	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. Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg The SDRP policy eff 10/3/2024 v2 has been posted for the following drugs covered under this policy. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin)
4.30 (v174)	10/23/2024	1100-956547-1163650 The 60-day notice for Leqembi (lecanemab-irmb) has been removed and archived.
4.29 (v173)	10/11/2024	1100-956547-1156401 Myalept (metreleptin) (Commercial and QUEST), 09/27/2024 has been posted. Archived: 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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin)
4.28 (v172)	10/08/2024	1100-956547-1154187 "No PA Required for Medicare Advantage" has been added to the notices section for Lupron Depot (leuprolide acetate) and Lupron Depot (leuprolide acetate) (oncology).
4.27 (v171)	10/04/2024	1100-956547-1152000 Leqembi - Posted 60-day notice, v2; Added a link to the Leqembi archived folder.
4.26 (v170)	10/02/2024	1100-956542-1148056 Norditropin (somatropin) - Removed 60-day notice link 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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin)
4.25 (v169)	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. Norditropin (somatropin) Nutropin/Nutropin AQ (somatropin) - Added notice: Effective 12/31/2024 Nutropin/Nutropin AQ is discontinued.
4.24 (v168)	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nemluvio (nemolizumab-ilto) (new effective 9/10/2024) Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin)
4.24 (v167)	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. Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg
4.23 (v166)	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin)
4.22 (v165)	08/30/2024	1100-956537-1123751 Posted the Leqembi (lecanemab-irmb) 60-day provider notice (09/01/2024-10/31/2024), effective 11/01/2024.
4.21 (v164)	08/09/2024	1100-956537-1104509 Minor typo fix.
4.20 (v163)	08/08/2024	1100-956537-1104509 Minor typo fix.
4.19 (v162)	08/06/2024	1100-956537-1104509 The following policies have been posted: Lanreotide (Commercial and QUEST Integration), 07/26/2024. Archived: 04/01/2024. Lanreotide (Medicare Advantage), 07/26/2024. Archived: 01/01/2024. Leuprolide (non-oncology) (Commercial and QUEST Integration) effective 07/26/2024 has been posted for the following drug covered under this policy. Archived: policy eff 4/1/2024. Leuprolide acetate (generic) (Commercial and QUEST Integration) Lupron Depot (leuprolide acetate) (Commercial and QUEST Integration) Lupron Depot PED (leuprolide acetate) (Commercial and QUEST Integration)
4.18 (v161)	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: Norditropin (somatropin) Nutropin/Nutropin AQ (somatropin) (to be removed 10/1)
4.17 (v160)	07/29/2024	1100-956532-1092301 2. Mvasi (bevacizumab-awwb) (Commercial) Global Oncology - corrected effective date to 7/15/2024.
4.16 (v159)	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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg The SDRP policy eff 7/01/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 6/17/2024. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin)
4.15 (v158)	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin)
4.14 (v157)	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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg
4.13 (v156)	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. Monovisc™ (high molecular weight hyaluronan) (Medicare Advantage)
4.12 (v155)	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin)
4.11 (v154)	05/08/2024	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin)
4.10 (v153)	05/08/2024	1100-956522-1049457 The SDRP policy eff 4/1/2024 has been posted for the following drugs covered under this policy. The SDRP policy effective 3/1/2024 has been archived. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin)
4.9 (v152)	04/15/2024	The Hyaluronates (drug specific policy) effective 2/1/2023 has been archived. The following drug covered under this policy has been archived and removed from the table: Monovisc (high molecular weight hyaluronan) The following links have been revised: Leuprolide acetate, Lupron Depot, Lupron Depot PED Botulinum Toxins (drug specific), eff 4/01/2024 v2, has been posted for the following drug covered under this policy. Archived: policy eff 4/01/2024. Myobloc (rimabotulinumtoxinB) 2. Myobloc (rimabotulinumtoxinB)
4.8 (v151)	04/05/2024	The following drugs have been added to the applicable tables: Lantidra (donislecel-jujn) Lyfgenia (lovotibeglogene autotemcel)
4.7 (v150)	04/01/2024	Added a note to Lupaneta Pack
4.6 (v149)	03/31/2024	Botulinum Toxins (drug specific), eff 4/01/2024, has been posted for the following drug covered under this policy. Archived: 60-day notice and policy eff 4/01/2023. Myobloc (rimabotulinumtoxinB) 2. Myobloc (rimabotulinumtoxinB) The Hyaluronate Products (Commercial and QUEST Integration) effective 4/01/2024, has been posted for the following drug covered under this policy. Archived: 60-day notice and policy eff 1/1/2024. 2. Monovisc™ (high molecular weight hyaluronan) (Commercial and QUEST Integration) Lanreotide (Commercial and QUEST Integration) effective 4/01/2024 has been posted for the following drug covered under this policy. Archived: 60-day notice and policy eff 1/1/2024. Lanreotide injection (lanreotide acetate injection) (Non-oncology) (Commercial and QUEST Integration) Leuprolide (Commercial and QUEST Integration) 60-day provider notice (02/01/2024-03/31/2024), effective 4/01/2024, has been posted for the following drug covered under this policy: Leuprolide acetate (generic) (Commercial and QUEST Integration) Lupron Depot (leuprolide acetate) (Commercial and QUEST Integration) Lupron Depot PED (leuprolide acetate) (Commercial and QUEST Integration)
4.5 (v148)	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin)
4.4 (v147)	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin)
4.3 (v146)	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin)
4.2 (v145)	02/08/2024	The following has been posted and moved to a new row: Botulinum Toxins (Commercial and QUEST Integration) 60-day provider notice (02/01/2024-03/31/2024), effective 4/01/2024, v2, has been posted for the following drug covered under this policy: Myobloc (rimabotulinumtoxinB)
4.1 (v144)	01/31/2024	Updated fax form links for the following: Leukine, Myasi (new line for QI), Neupogen, Nivestim, Nplate Botulinum Toxins (Commercial and QUEST Integration) 60-day provider notice (02/01/2024-03/31/2024), effective 4/01/2024, has been posted for the following drug covered under this policy: Myobloc (rimabotulinumtoxinB) 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 drug covered under this policy: 2. Monovisc™ (high molecular weight hyaluronan) (Commercial and QUEST Integration) Lanreotide (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: Lanreotide injection (lanreotide acetate injection) (Non-oncology) Leuprolide (Commercial and QUEST Integration) 60-day provider notice (02/01/2024-03/31/2024), effective 4/01/2024, has been posted for the following drug covered under this policy: Leuprolide acetate (generic) (Commercial and QUEST Integration) Lupron Depot (leuprolide acetate) (Commercial and QUEST Integration) Lupron Depot PED (leuprolide acetate) (Commercial and QUEST Integration)
4.0 (v143)	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin)

Rev#:	Date:	Nature of Change:
3.31 (v142)	12/28/2023	The following policy effective 1/1/2024 has been posted: Nplate (romiplostim) (Commercial and QUEST Integration) Nplate (romiplostim) (Medicare Advantage) The following policy has been archived: Nplate (romiplostim), 11/17/2022 (for all LOBs) The Hyaluronates (Commercial and QUEST Integration) and (Medicare Advantage) policies effective 01/01/2024 have been posted to the following drug covered under these policies, as applicable. Archived: Policy effective 2/1/2023 (all LOBs) 2. Monovisc (Commercial and QUEST Integration) 2. Monovisc (Medicare Advantage) Somatuline Depot (Lanreotide) (non-oncology) (Commercial and QUEST Integration) and (Medicare Advantage) policies effective 1/1/2024 have been posted for the following drugs covered under this policy. Archived: Policy effective 10/28/2022 (for all LOBs) Somatuline Depot (lanreotide) (non-oncology) (Commercial and QUEST Integration) Somatuline Depot (lanreotide) (non-oncology) (Medicare Advantage) The Retinal Disorders (Medicare Advantage) policy effective 10/01/2023 has been archived for the following drug covered under this policy. No PA is required as of 1/1/2024. 1. Lucentis (Medicare Advantage)
3.30 (v140)	12/27/2023	Bevacizumab Products - Commercial Preferred Drug Program policy, effective 01/01/2024, has been posted for the following drug covered under this policy. Archived: redlined 60-day provider notice effective 1/1/24. 1. Mvasi (bevacizumab-awwb) (Commercial) (new) Bevacizumab Products - Medicare Part B Preferred Drug Program policy effective 01/01/2024, has been posted for the following drugs covered under this policy. Archived: redlined 60-day provider notice effective 1/1/24. 1. Mvasi (bevacizumab-awwb) (Medicare Advantage) (new) Botulinum Toxins Medicare Part B Preferred Drug Program policy, eff 1/1/2024, has been posted for the following drugs covered under this policy. Archived: 60-day notice eff 1/1/2024 and policy eff 10/28/2022. 1. Myobloc (rimabotulinumtoxinB) (Medicare Advantage) Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial), effective 1/1/2024, has been posted for the following drugs covered under this policy. The 60-day notice eff 1/1/2024 and policy eff 3/1/2023 have been archived. Neulasta (including Onpro kit) (pegfilgrastim) (Commercial) - added "no PA required" Nyvepria (pegfilgrastim-apgf) (Commercial) - no PA required Colony Stimulating Factors (CSF) - Short Acting - Medicare Part B Preferred Drug Program 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 2/1/2023. Leukine (sargramostim) Neupogen (filgrastim) Nivestym (filgrastim-aafi) - removed "no PA required" 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. Monovisc (Commercial) The Hyaluronates Medicare Part B Preferred Drug Program policy effective 1/1/2024, has been posted for the following drug covered under this policy. Archived: 60-day notice eff 1/1/2024 and policy effective 1/1/2023 1. Monovisc (Hyaluronates Preferred Drug Program) (Medicare Advantage)
3.29 (v139)	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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Loqtorzi (toripalimab-tpzi) (NEW eff 12/12/2023) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg 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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin)
3.28 (v138)	12/18/2023	Growth Hormone Therapy, 12/15/2023, has been posted for the following drugs covered under this policy. Archived: policy effective 4/1/2023. Norditropin (somatropin) Nutropin/Nutropin AQ (somatropin)
3.27 (v137)	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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg 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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin)
3.26 (v136)	12/12/2023	Revised the archived folder link for Leukine (Commercial).
3.25 (v135)	12/08/2023	The following policy has been posted: Nplate (romiplostim), 11/17/2023; archived policy eff 4/1/2023 Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program (Commercial) 11/17/2023 has been posted for the following drugs covered under this policy. Archived: policy effective 10/1/2022. Leukine (sargramostim) (Commercial) Neupogen (filgrastim) (Commercial) Nivestym (filgrastim-aafi) (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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg
3.24 (v134)	11/20/2023	The following policies has been posted: Myalept (metreleptin), 10/27/2023; archived policy eff 2/1/2023 Multiple Sclerosis (MS) Preferred Drug Program (Commercial) effective 10/28/2022, has been posted. The policy eff 7/1/22 has been archived.
3.23 (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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) 2. Mvasi (bevacizumab-awwb) Mylotarg 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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Ngenla (somatrogon-ghla) Nucala Nulibry (fosdenopterin) 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 (v132)	11/07/2023	Links to applicable archived folders have been added to the following drugs: Leukine (sargramostim) (Medicare Advantage) Macugen (pegaptanib sodium) (Commercial and QUEST Integration ) Macugen (pegaptanib sodium) (Medicare Advantage) Multiple Sclerosis (MS) – Interferons Preferred Drug Program (Commercial) Myalept (metreleptin) Neupogen (filgrastim) (Commercial) Nivestym (filgrastim-aafi) (Commercial) Typo fixes. Added row: 2. Mvasi (bevacizumab-awwb) - Global Oncology.
3.20 (v131)	11/01/2023	Botulinum Toxins Medicare Part B Preferred Drug Program redlined 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024, has been posted for the following drugs covered under this policy: 1. Myobloc (rimabotulinumtoxinB) (Medicare Advantage) The Hyaluronates Preferred Drug Program (Commercial) 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024, has been posted for the following drugs covered under this policy: 1. Monovisc (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 drug covered under this policy: 1. Monovisc (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. Leukine (sargramostim) Neupogen (filgrastim) Nivestym (filgrastim-aafi) - no PA required Bevacizumab Products - Medicare Part B Preferred Drug Program redlined 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024, has been posted for the following drug covered under this policy: 1. Mvasi (bevacizumab-awwb) (Medicare Advantage) (new) Bevacizumab Products - Commercial Preferred Drug Program 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024, has been posted for the following drug covered under this policy: 1. Mvasi (bevacizumab-awwb) (Commercial) (new) Long-Acting Colony Stimulating Factors (CSF) – Commercial Preferred Drug Program 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024, has been posted for the following drugs covered under this policy: Neulasta (including Onpro Kit) (pegfilgrastim) (Commercial) Nyvepria (pegfilgrastim-apgf) (Commercial) No PA required
3.19 (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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Ngenla (somatrogon-ghla) Nexviazyme (avalglucosidase alfa-ngpt) Nucala Nulibry (fosdenopterin)
3.18 (v129)	09/28/2023	The Retinal Disorders Preferred Drug Program (Medicare Advantage) policy effective 10/01/2023 has been posted for the following drug covered under this policy. The 60-day notice eff 10/1/23 and policy effective 10/28/22 has been archived. Lucentis (Medicare Advantage)
3.17 (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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) Mvasi (bevacizumab-awwb) Mylotarg 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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Ngenla (somatrogon-ghla) (NEW eff 9/1/2023) Nexviazyme (avalglucosidase alfa-ngpt) Nucala Nulibry (fosdenopterin)
3.16 (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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) Mvasi (bevacizumab-awwb) Mylotarg 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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Nucala Nulibry (fosdenopterin)
3.15 (v125)	07/31/2023	The Retinal Disorders Preferred Drug Program (Medicare Advantage) redlined 60-day notice effective 10/1/2023 (notification period: 08/01/2023-09/30/2023) has been posted for the following drug covered under this policy: Lucentis (Medicare Advantage)
3.14 (v124)	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.
3.13 (v123)	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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) Mvasi (bevacizumab-awwb) Mylotarg
3.12 (v122)	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. . Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Nucala Nulibry (fosdenopterin) 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. Mononine [Factor IX (plasma derived)] NovoEight [Factor VIII (recombinant)] NovoSeven RT [Factor VIIA (recombinant)] Nuwiq [Factor VIII (recombinant)]
3.11 (v121)	06/14/2023	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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Nucala Nulibry (fosdenopterin)
3.10 (v120)	05/25/2023	Added the link to the archived Global Oncology folder for Lunsumio.
3.9 (v119)	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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) Lupron Depot (leuprolide acetate) (Oncology) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) Mvasi (bevacizumab-awwb) Mylotarg 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. Lamzede (velmanase alfa-tycv) Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Nucala Nulibry (fosdenopterin)
3.8 (v118)	05/11/2023	Added drug Lamzede (velmanase alfa-tycv) to the table as it was missed in the previous update.
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. Lamzede (velmanase alfa-tycv) - new eff 4/1/2023 Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Nucala Nulibry (fosdenopterin)
3.6 (v116)	04/06/2023	As of 4/6/2023, Makena (hydroxyprogesterone caproate injection) is no longer available. The policy has been archived. Minor typo fixes.
3.5 (v115)	03/30/2023	The following policies have been posted: Nplate (romiplostim), 4/1/2023; archived 60-day notice and policy eff 4/1/2022 Lupron-Lupaneta, eff 4/01/2023, has been posted for the following drugs covered under this policy. The 60-day notice and policy eff 4/1/2022 have been archived. Lupron Depot (leuprolide acetate) (non-oncology) Lupron Depot-PED (leuprolide acetate) (non-oncology) Lupaneta Pack (Leuprolide acetate/norethindrone) (non-oncology) Leuprolide acetate (generic) (non-oncology) 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. Norditropin (somatropin) Nutropin/Nutropin AQ (somatropin) Botulinum Toxins, eff 4/01/2023, has been posted for the following drug covered under this policy. Archived: 60-day notice and policy eff 1/1/2022. Myobloc (rimabotulinumtoxinB) 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. Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Nucala Nulibry (fosdenopterin)
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. Leqvio (inclisiran) Mepsevii Nexviazyme (avalglucosidase alfa-ngpt) Nucala Nulibry (fosdenopterin)
3.3 (v113)	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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) (new) Lupron Depot (leuprolide acetate) (Oncology) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) Mvasi (bevacizumab-awwb) Mylotarg
3.2 (v112)	02/24/2023	Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial) 60-day notice eff 3/1/22 and policy eff 10/01/2021 have been archived for the following drugs covered under this policy. Neulasta (including Onpro kit) (pegfilgrastim) Nyvepria (pegfilgrastim-apgf) - no PA required
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. leuprolide acetate (generic) (Oncology) Libtayo (cemiplimab-rwlc) Lumoxiti (moxetumomab pasudotox-TDFK) Lunsumio (mosunetuzumab-axgb) (new) Lupron Depot (leuprolide acetate) (Oncology) Margenza (margetuximab-cmkb) Monjuvi (tafasitamab-cxix) Mvasi (bevacizumab-awwb) Mylotarg
3.0 (v110)	01/31/2023	Colony Stimulating Factors (CSF) – Short-Acting Preferred Drug Program (Medicare Advantage) effective 02/01/2023 has been posted for the following drugs covered under this policy. The 60-day notice and policy effective 06/01/2021 have been archived. Leukine (sargramostim) (Medicare Advantage) Neupogen (filgrastim) (Medicare Advantage) Nivestym (filgrastim-aafi) (Medicare Advantage) - no PA required The Hyaluronates (drug specific policy) effective 02/01/2023 has been posted to the following drug covered under this policy. The 60-day notice and the policy effective 7/23/2021 have been archived. 2. Monovisc (Commercial, QUEST Integration and Medicare Part B policy) Botulinum Toxins 60-day provider notice (02/01/2023-03/31/2023), effective 4/01/2023, has been posted for the following drug covered under this policy: Myobloc (rimabotulinumtoxinB) Lupron-Lupaneta 60-day provider notice (02/01/2023-03/31/2023), effective 4/01/2023, has been posted for the following drug covered under this policy: Lupron Depot (leuprolide acetate) (non-oncology) Lupron Depot-PED (leuprolide acetate) (non-oncology) Lupaneta Pack (Leuprolide acetate/norethindrone) (non-oncology) Leuprolide acetate (generic) (non-oncology) 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: Norditropin (somatropin) Nutropin/Nutropin AQ (somatropin) The following redlined 60-day notices effective 4/1/2023 (notification period: 02/01/2023-03/31/2023) have been posted: Nplate (romiplostim)
2.45 (v109)	01/17/2023	Added Leqembi (lecanemab-irmb).

Details

URL Name Medical-Specialty-Drug-Policies-L-N