Information

Title Medical Specialty Drug Policies: O-R

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

L-N

S-U

V-Z

O

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Ocrevus (ocrelizumab)		08/01/2025	Commercial Fax Form QUEST Fax Form	Drug specific criteria effective on 08/01/2025	ARCHIVED - Ocrevus ARCHIVED - SDRP
Ocrevus-Zunovo (ocrelizumab and hysluronidase-ocsq)		08/01/2025	Commercial Fax Form QUEST Fax Form	Drug specific criteria effective on 08/01/2025	ARCHIVED - Ocrevus ARCHIVED - SDRP
Octagam (human immunoglobulin) (Commercial & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG
Octagam (human immunoglobulin) (Medicare Advantage)		10/01/2025	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Off-Label (Commercial & QUEST)	Refer to Criteria Exception (Commercial & QUEST) policy				ARCHIVED - Off-Label (Commerical & QUEST)
Off-Label (Medicare Advantage)		09/26/2025			ARCHIVED - Off Label (MA)
1. Ogivri (trastuzumab-dkst) (Trastuzumab Preferred Drug Program Commercial and QUEST)		01/01/2026	Refer below for Ogivri fax forms	Trastuzumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Trastuzumab Products (Commercial)
2. Ogivri (trastuzumab-dkst) (Commercial and QUEST)		04/14/2026	Commercial Fax Form QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Ogivri (trastuzumab-dkst) (Trastuzumab Preferred Drug Program Medicare Advantage)		01/01/2026	Refer below for Ogivri fax forms	Trastuzumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Trastuzumab Products (MA)
2. Ogivri (trastuzumab-dkst) (Medicare Advantage)		04/14/2026	Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Omisirge (omidubicel-onlv)	Please contact HMSA at 808-948-6464, option #4, for drug review
Omlyclo (omalizumab-igec) (Commercial and QUEST)		12/19/2025	Commercial Fax Form QUEST Fax Form	Xolair Added effective 12/19/2025	ARCHIVED - Xolair (Comm-QUEST)
Omlyclo (omalizumab-igec) (Medicare Advantage)		01/19/2026	Medicare Advantage Fax Form	Xolair-Omlyclo	ARCHIVED - Xolair (MA)
Omnitrope^®(somatropin) (Commercial and QUEST)		01/01/2026	Fax Form	Growth Hormone	ARCHIVED - Growth Hormone
1. Omvoh (mirikizumab-mrkz) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Omvoh Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Omvoh (mirikizumab-mrkz)		04/14/2026	Commercial Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 11/1/2023	ARCHIVED - SDRP
Onapgo (apomorphine hydrochloride)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added eff 03/01/2025	ARCHIVED - SDRP
Onivyde (irinotecan hydrochloride)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Onpattro (patisiran)	Effective 02/15/2024: Please contact HMSA at 808-948-6464, option #4, for drug review			Effective 2/15/2024 PA review for Onpattro is moved from CVS to HMSA review	ARCHIVED - SDRP
1. Ontruzant (trastuzumab-dttb) (Trastuzumab Preferred Drug Program Commercial and QUEST)		01/01/2026	Refer below for Ontruzant fax forms	Trastuzumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Trastuzumab Products (Commercial)
2. Ontruzant (trastuzumab-dttb) (Commercial and QUEST)		04/14/2026	Commercial Fax Form QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Ontruzant (trastuzumab-dttb) (Trastuzumab Preferred Drug Program Medicare Advantage)		01/01/2026	Refer below for Ontruzant fax forms	Trastuzumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Trastuzumab Products (MA)
2. Ontruzant (trastuzumab-dttb) (Medicare Advantage)		04/14/2026	Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Opdivo (nivolumab)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Opdualag (nivolumab and relatlimab-rmbw)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Effective 4/1/2022	ARCHIVED - Global Oncology
1. Orencia (abatacept) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Orencia Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Orencia (abatacept) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Specific drug criteria for Orencia	ARCHIVED - Orencia (Comm-QUEST) ARCHIVED - Orencia
Orencia (abatacep) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form		ARCHIVED - Orencia (MA)
1. Orthovisc® (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Orthovisc® Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Orthovisc® (high molecular weight hyaluronan) (Commercial and QUEST)		04/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI) ARCHIVED - Hyaluronates (drug specific)
1. Orthovisc (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Orthovisc® Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program (MA)
2. Orthovisc® (high molecular weight hyaluronan) (Medicare Advantage)		03/13/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Osenvelt (denosumab-bmwo) (Commercial and QUEST)		06/27/2025	Commercial Fax Form QUEST Fax Form	Xgeva and Biosimilars (Commercial and QUEST) Added eff 6/27/2025	ARCHIVED - Xgeva (Comm-QUEST)
Osenvelt (denosumab-bmwo) (Medicare Advantage)		06/27/2025	Medicare Advantage Fax Form	Xgeva and Biosimilars (Medicare Advantage) Added eff 6/27/2025	ARCHIVED - Xgeva (MA)
Ospomyv (denosumab-dssb) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Prolia and Biosimilars (Commercial and QUEST)	ARCHIVED - Prolia (Comm-QUEST)
Ospomyv (denosumab-dssb) (Medicare Advantage)		06/27/2025	Medicare Advantage Fax Form	Prolia and Biosimilars (Medicare Advantage) Added eff 6/27/2025	ARCHIVED - Prolia (MA)
Osvyrti (denosumab-desu) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Prolia and Biosimilars (Commercial and QUEST)	ARCHIVED - Prolia (Comm-QUEST)
1. Otulfi (ustekinumab-aauz) (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. Otulfi (ustekinumab-aauz) (Commercial)		01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added eff 4/8/2025	ARCHIVED - Stelara and Biosimilars (Commercial)
Otulfi (ustekinumab-aauz) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
Otulfi (ustekinumab-aauz) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
Oxlumo (lumasiran)	Effective 02/15/2024: Please contact HMSA at 808-948-6464, option #4, for drug review			Effective 2/15/2024 PA review for Oxlumo is moved from CVS to HMSA review	ARCHIVED - SDRP

P

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Padcev (enfortumab vedotin-ejfv)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Palynziq (pegvaliase-pqpz)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Panzyga (immune globulin) (Commercial & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QI)
Panzyga (immune globulin) (Medicare Advantage		10/01/2025	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Papzimeos (zopapogene imadenovec-drba)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 09/12/2025	ARCHIVED - SDRP
Parsabiv (etelcalcetide)	No PA required as of 1/1/2024			New Medical Specialty policy effective 11/01/2019	ARCHIVED - Parsabiv
Pavblu (aflibercept-ayyh) (Commercial and QUEST)	No PA required
Pavblu (aflibercept-ayyh) (Medicare Advantage)	No PA required
PCSK9 Inhibitors Preferred Drug Program (Commercial)		11/21/2025		PCSK9 Inhibitors Preferred Drug Program	ARCHIVED - PCSK9 Inhibitors Preferred Drug Program
pemetrexed (generic)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Pemfexy (pemetrexed)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Pemrydi RTU (pemetrexed)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Pepaxto (melphalan flufenamide)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Perjeta (pertuzumab)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Phesgo pertuzumab, trastuzumab, hyaluronidase-zzxf)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Piasky (crovalimab-akkz)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Plegridy (peginterferon beta-1a) (Multiple Sclerosis Preferred Program) (Commercial)		11/21/2025	Commercial Fax Form	Multiple Sclerosis (MS) - Interferons Preferred Drug Program	ARCHIVED - Multiple Sclerosis (MS) – Preferred Drug Program
plerixafor (generic) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Mozobil (plerixafor) (Commercial and QUEST)	ARCHIVED - Mozobil (Comm-QUEST)
Polivy (polatuzumab vedotin-piiq)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Portrazza (necitumumab)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Poteligeo (mogamulizumab-kpkc)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Praluent (alirocumab) PCSK9 Inhibitors Preferred Program (Commercial)		11/21/2025	Refer below for Praluent Fax Forms	PCSK9 Inhibitors Preferred Drug Program	ARCHIVED - PCSK9 Inhibitors Preferred Drug Program
2. Praluent (alirocumab) (Commercial and QUEST)		12/19/2025	Commercial Fax Form QUEST Fax Form		ARCHIVED - Praluent
Privigen (human immunoglobulin) (Commercial & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QI)
Privigen (human immunoglobulin) (Medicare Advantage)		10/01/2025	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Probuphine				No PA required as of 09/01/2019
Procrit				No PA required as of 11/23/2015
Profilnine [Factor IX (plasma derived)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Prolastin-C (alpha1-proteinase inhibitor [human])		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Prolia (denosumab) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form		ARCHIVED - Prolia (Comm-QUEST) ARCHIVED - Prolia
Prolia (denosumab) (Medicare Advantage)		06/27/2025	Medicare Advantage Fax Form	Prolia and Biosimilars (Medicare Advantage) Added eff 6/27/2025	ARCHIVED - Prolia (MA)
Provenge (sipuleucel-T)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Purified Cortrophin Gel (repository corticotropin injection)		12/19/2025	Fax Form	H.P. Acthar Gel Effective 9/1/2022	ARCHIVED - HP Acthar Gel (Comm-QUEST)
1. Pyzchiva (ustekinumab-ttwe) (Autoimmune Preferred Drug Program)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Pyzchiva (ustekinumab-ttwe) (Commercial)		01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added eff 4/8/2025	ARCHIVED - Stelara and Biosimilars (Commerical)
Pyzchiva (ustekinumab-ttwe) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
Pyzchiva (ustekinumab-ttwe) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)

Q

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Qfitlia [Antithrombin Lowering Agent (fitusiran)]	Please contact HMSA at 808-948-6464, option #4, for drug review.

R

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Radicava (edaravone)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Rebif (interferon beta-1a) (Commercial)	No PA required	11/21/2025		Multiple Sclerosis (MS) - Interferons Preferred Drug Program	ARCHIVED - Multiple Sclerosis (MS) – Preferred Drug Program
Rebinyn [Factor IX (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Recombinate [Factor VIII (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Redemplo (plozasiran)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 12/23/2025	ARCHIVED - SDRP
Releuko (filgrastim-ayow) (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
Releuko (filgrastim-ayow) (CSF Short Acting Preferred Drug Program Medicare Advantage)		11/21/2025	Medicare Advantage Fax Form	Colony Stimulating Factors (CSF) –Short Acting Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - CSF Short Acting (Preferred Drug Program) (MA)
1. Remicade (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Remicade Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Remicade (infliximab) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Infliximab-Avsola-Inflectra-Remicade-Renflexis-Zymfentra	ARCHIVED - Infliximab (Comm-QUEST) ARCHIVED - Infliximab
Remicade (infliximab) (Medicare Advantage)		12/19/2025		Infliximab-Avsola-Inflectra-Remicade-Renflexis MA	ARCHIVED - Infliximab (MA)
Remodulin (treprostinil) (Commercial and QUEST)	60-day provider notice 04/01/2026-05/31/2026 in effect 06/01/2026	12/19/2025	Fax Form		ARCHIVED - Remodulin (Comm-QUEST) ARCHIVED - Remodulin
Remodulin (treprostinil) (Medicare Advantage)		11/21/2025	Medicare Advantage Fax Form		ARCHIVED - Remodulin (MA)
1. Renflexis (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Renflexis Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Renflexis (infliximab-abda) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Infliximab-Avsola-Inflectra-Remicade-Renflexis-Zymfentra	ARCHIVED - Infliximab (Comm-QUEST) ARCHIVED - Infliximab
Renflexis (infliximab-abda) (QUEST)	60-day provider notice 05/01/2026-06/30/2026, in effect 07/01/2026			Infliximab-Avsola-Inflectra-Renflexis-Zymfentra (QUEST)
Renflexis (infliximab-abda) (Medicare Advantage)		12/19/2025		Infliximab-Avsola-Inflectra-Remicade-Renflexis MA	ARCHIVED - Infliximab (MA)
1. Repatha (evolocumab) PCSK9 Inhibitors Preferred Program (Commercial)		11/21/2025		PCSK9 Inhibitors Preferred Drug Program	ARCHIVED - PCSK9 Inhibitors Preferred Drug Program
2. Repatha (evolocumab) (Commercial and QUEST)		12/19/2025	Fax Form		ARCHIVED - Repatha
Retinal Disorders Preferred Drug Program (Commercial)	No PA required				ARCHIVED - Retinal Disorders Preferred Drug Program (Commercial)
Retinal Disorders Preferred Drug Program (Medicare Advantage)	No PA required as of 01/01/2024			Retinal Disorders Preferred Drug Program	ARCHIVED - Retinal Disorders Preferred Drug Program (MA)
Revatio (sildenafil)	No PA required as of 01/01/2024				ARCHIVED - Revatio
Revcovi (elapegademase-ivir)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
1. Riabni (rituximab-arrx) (Rituximab Preferred Drug Program Commercial)		01/01/2026	Commercial Fax Form	Rituximab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Rituximab Products (Commercial)
2. Riabni (rituximab-arrx) (Commercial)		04/14/2026		Global Oncology	ARCHIVED - Global Oncology
1. Riabni (rituximab-arrx) (Rituximab Preferred Drug Program Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Rituximab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Rituximab Products (MA)
2. Riabni (rituximab-arrx) (Medicare Advantage)		04/14/2026		Global Oncology	ARCHIVED - Global Oncology
Riabni (rituximab-arrx) (QUEST)		04/14/2026	QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
Riabni (rituximab-arrx) (Non-oncology) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Rituximab-Riabni-Rituxan-Ruxience-Truxima	ARCHIVED - Rituximab (non-oncology) (Comm-QI) ARCHIVED - Rituximab
Riabni (rituximab-arrx) (Non-oncology) (Medicare Advantage)		12/19/2025		Rituximab-Riabni-Rituxan-Ruxience-Truxima MA	ARCHIVED - Rituximab (non-oncology) (MA)
1. Rituxan (rituximab) (Rituximab Preferred Drug Program Commercial)		01/01/2026	Commercial Fax Form	Rituximab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Rituximab Products (Commercial)
2. Rituxan (rituximab) (Oncology) (Commercial)		04/14/2026		Global Oncology	ARCHIVED - Global Oncology
1. Rituxan (rituximab) (Rituximab Preferred Drug Program Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Rituximab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Rituximab Products (MA)
2. Rituxan (rituximab) (Oncology) (Medicare Advantage)		04/14/2026		Global Oncology	ARCHIVED - Global Oncology
Rituxan (rituximab) (QUEST)		04/14/2026	QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
Rituxan (rituximab) (Non-oncology) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Rituximab-Riabni-Rituxan-Ruxience-Truxima	ARCHIVED - Rituximab (non-oncology) (Comm-QI) ARCHIVED - Rituximab
Rituxan (rituximab) (Non-oncology) (Medicare Advantage)		12/19/2025		Rituximab-Riabni-Rituxan-Ruxience-Truxima MA	ARCHIVED - Rituximab (non-oncology) (MA)
1. Rituxan Hycela (rituximab and hyaluronidase human) (Rituximab Preferred Drug Program Commercial)		01/01/2026	Commercial Fax Form	Rituximab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Rituximab Products (Commercial)
2. Rituxan Hycela (rituximab and hyaluronidase human) (Commercial)		04/14/2026	Commercial Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Rituxan Hycela (rituximab and hyaluronidase human) (Rituximab Preferred Drug Program Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Rituximab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Rituximab Products (MA)
2. Rituxan Hycela (rituximab and hyaluronidase human) (Medicare Advantage)		04/14/2026	Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Rituxan Hycela (rituximab and hyaluronidase human (QUEST)		04/14/2026	Fax Form	Global Oncology	ARCHIVED - Global Oncology
Rituximab Preferred Drug Program (Commercial)		01/01/2026	Commercial Fax Form	Rituximab Products - Preferred Drug Program Commercial	ARCHIVED - Rituximab Products (Commercial)
Rituximab (non-oncology) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Rituximab-Riabni-Rituxan-Ruxience-Truxima	ARCHIVED - Rituximab (non-oncology) (Comm-QI) ARCHIVED - Rituximab
1. Rituximab Preferred Drug Program (Medicare Advantage)		01/01/2026		Rituximab Products - Preferred Drug Program MA	ARCHIVED - Rituximab Products (MA)
2. Rituximab (non-oncology) (Medicare Advantage)		12/19/2025	Medicare Advantage Fax Form	Rituximab-Riabni-Rituxan-Ruxience-Truxima MA	ARCHIVED - Rituximab (non-oncology) (MA)
Rivfloza (nedosiran)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 1/1/2024	ARCHIVED - SDRP
Rixubis [Factor IX (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Roctavian (valoctocogene roxaparvovec-rvox)	Please contact HMSA at 808-948-6464, option #4, for drug review
Rolvedon (eflapegrastimxnst) (Commercial)		01/01/2026	Commercial Fax Form	Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CSF Long Acting Preferred Drug Program
Rolvedon (eflapegrastimxnst) (Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CFS Long Acting Preferred Drug Program (MA)
romidepsin		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Ruconest (C1 esterase inhibitor [recombinant]) (Hereditary Angioedema Preferred Drug Program) (Commercial)		11/21/2025	Refer below for Ruconest Fax Forms	Hereditary Angioedema Preferred Drug Program	ARCHIVED - Hereditary Angioedema Preferred Drug Program
2. Ruconest (recombinant C1 esterase inhibitor) (Commercial and QUEST)		01/01/2026	Fax Form		ARCHIVED - Ruconest (Comm-QUEST) ARCHIVED - Ruconest
Ruconest (recombinant C1 esterase inhibitor) (Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form		ARCHIVED - Ruconest (MA)
1. Ruxience (rituximab-pvvr) (Rituximab Preferred Drug Program Commercial)		01/01/2026	Commercial Fax Form	Rituximab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Rituximab Products (Commercial)
2. Ruxience (rituximab-pvvr) (oncology) (Commercial)		04/14/2026		Global Oncology	ARCHIVED - Global Oncology
1. Ruxience (rituximab-pvvr) (Rituximab Preferred Drug Program Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Rituximab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Rituximab Products (MA)
2. Ruxience (rituximab-pvvr) (oncology) (Medicare Advantage)		04/14/2026		Global Oncology	ARCHIVED - Global Oncology
Ruxience (rituximab-pvvr) (oncology) (QUEST)		04/14/2026	QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
Ruxience (rituximab-pvvr) (Non-oncology) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Rituximab-Riabni-Rituxan-Ruxience-Truxima	ARCHIVED - Rituximab (non-oncology) (Comm-QI) ARCHIVED - Rituximab
Ruxience (rituximab-pvvr) (Non-oncology) (Medicare Advantage)		12/19/2025		Rituximab-Riabni-Rituxan-Ruxience-Truxima MA	ARCHIVED - Rituximab (non-oncology) (MA)
Rybrevant (amivantamab-vmjw)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Rybrevant Faspro (amivantamab and hyaluronidase-lpuj)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 3/13/2026	ARCHIVED - Global Oncology
Rylaze (asparaginase erwinia chrysanthemi (recombinant) -rywn)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Ryoncil (remestemcel-L-rknd)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) added eff 03/01/2025	ARCHIVED - SDRP
Ryplazim (plasminogen, human-tvmh)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 4/1/2022	ARCHIVED - SDRP
Rystiggo (rozanolixizumab-noli)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 7/1/2023	ARCHIVED - SDRP
Rytelo (imetelstat sodium)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Ryzneuta (efbemalenograstim alfa-vuxw)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 07/01/2025	ARCHIVED - SDRP

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

Change History

Rev#:	Date:	Nature of Change:
6.27	05/07/2026	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 drug: Renflexis (infliximab-abda) (QUEST)
6.26	04/29/2026	1100-1677771-1838900 The Global Oncology policy effective 04/14/2026 has been posted for the following drugs covered under this policy. 2. Ogivri (trastuzumab-dkst)(Commercial and QUEST) 2. Ogivri (trastuzumab-dkst)(Medicare Advantage) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb)(Commercial and QUEST) 2. Ontruzant (trastuzumab-dttb)(Medicare Advantage) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) pemetrexed (generic) Pemrydi RTU (pemetrexed) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr)(Commercial) 2. Riabni (rituximab-axxr)(Medicare Advantage) Riabni (rituximab-axxr)(QUEST) 2. Rituxan 2. Rituxan(Medicare Advantage) Rituxan(QUEST) 2. Rituxan Hycela (rituximab and hyaluronidase human)(Commercial) 2. Rituxan Hycela (rituximab and hyaluronidase human)(Medicare Advantage) Rituxan Hycela (rituximab and hyaluronidase human)(QUEST) romidepsin 2. Ruxience (rituximab-pvvr)(Commercial) 2. Ruxience (rituximab-pvvr)(Medicare Advantage) Ruxience (rituximab-pvvr)(QUEST) Rybrevant (amivantamab-vmjw) Rybrevant Faspro (amivantamab and hyaluronidase-lpuj) (NEW) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Rytelo (imetelstat sodium) 1100-1677771-1837550 Rituximab Products - Preferred Drug Program Medicare Advantage effective 01/01/2026 v2, has been posted for the following drugs covered under this policy. (LOB has been corrected.) 1. Riabni (rituximab-arrx) (Medicare Advantage) 1. Rituxan (rituximab) (Medicare Advantage) 1. Rituximab Preferred Drug Program (Medicare Advantage) 1. Rituxan Hycela (rituximab and hyaluronidase human) (Medicare Advantage) 1. Ruxience (rituximab-pvvr) (Medicare Advantage) 1100-1677771-1837550 The SDRP policy eff 04/14/2026 has been posted for the following drugs covered under this policy. 2. Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Palynziq Papzimeos (zopapogene imadenovec-drba) Piasky (crovalimab-akkz) Prolastin-C Radicava Redemplo (plozasiran) Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli) Ryzneuta (efbemalenograstim alfa-vuxw) Change history from 2023 has been removed.
6.25	04/20/2026	1100-1677771-1819704 Minor copy edit. 1100-1677771-1831000 Remodulin (Commercial-QUEST) 60-day provider notice 04/01/2026-05/31/2026 in effect 06/01/2026, has been posted for the following drug covered under this policy: Remodulin (treprostinil) (Commercial-QUEST)
6.24	04/16/2026	Edited the spelling for the following: 1100-1677771-1819705 Opsomyv (Commercial and QUEST) to Ospomyv (Commercial and QUEST) and re-alphabetize. Also updated and moved Ospomyv (Medicare Advantage).
6.23	04/14/2026	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. Orthovisc® (high molecular weight hyaluronan) (Commercial and QUEST)
6.22	04/13/2026	1100-1677771-1819704 The following drug has been added: Qfitlia [Antithrombin Lowering Agent (fitusiran) 1100-1677771-1819705 The Prolia (denosumab) (Commercial and QUEST) policy effective 04/01/2026 has been posted for the following drugs covered under this policy: Ospomyv (denosumab-dssb) (Commercial and QUEST) Osvyrti (denosumab-desu) (Commercial and QUEST) Prolia (denosumab) (Commercial and QUEST)
6.21	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.
6.20	04/06/2026	1100-1677771-1805800 The SDRP policy eff 03/27/2026 has been posted for the following drugs covered under this policy. 2. Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Palynziq Papzimeos (zopapogene imadenovec-drba) Piasky (crovalimab-akkz) Prolastin-C Radicava Redemplo (plozasiran) Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli) Ryzneuta (efbemalenograstim alfa-vuxw)
6.19	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. Orthovisc® (high molecular weight hyaluronan) (Medicare Advantage)
6.18	03/31/2026	1100-1677764-1802500 The Stelara and Biosimilars (Medicare Advantage), effective 04/01/2026, has been posted for the following drug covered under this policy. ARCHIVED: policy eff 4/1/2025. Otulfi (ustekinumab-aauz) (Medicare Advantage) Pyzchiva (ustekinumab-ttwe) (Medicare Advantage)
6.17	03/30/2026	1100-1677764-1798661 Infliximab (Commercial and QUEST) effective 04/01/2026 has been posted to the following drugs covered under this policy: 2. Remicade (infliximab) (Commercial and QUEST) 2. Renflexis (infliximab-abda) (Commercial and QUEST) 1100-1677764-1798661 The following policies effective 04/01/2026 have been posted: 2. Orencia (abatacept) (Commercial and QUEST) Orencia (abatacept) (Medicare Advantage) 1100-1677764-1798661 Mozobil (plerixafor) (Commercial and QUEST) effective 04/01/2026 has been posted for the following drug covered under this policy. plerixafor (generic) (Commercial and QUEST) 1100-1677764-1798661 Rituximab (non-oncology) (Commercial and QUEST), effective 4/01/2026, has been posted for the following drugs covered under this policy. Riabni (rituximab-arrx) (non-oncology)(Commercial and QUEST) Rituxan (rituximab) (non-oncology)(Commercial and QUEST) Rituximab (non-oncology)(Commercial and QUEST) Ruxience (rituximab-pvvr) (non-oncology)(Commercial and QUEST)
6.16	03/25/2026	1100-1677764-1781156 The Stelara (Commercial) effective date has been correceted to 01/19/2026 for the following drugs covered under this policy: 2. Otulfi (ustekinumab-aauz) (Commercial) 2. Pyzchiva (ustekinumab-ttwe) (Commercial) 1100-1677764-1784003 The effective dates for the following drugs covered under the Global Oncology policy have been updated to 03/13/2026: 2. Ogivri (trastuzumab-dkst)(Commercial) 2. Ogivri (trastuzumab-dkst)(Medicare Advantage) Ogivri (trastuzumab-dkst)(QUEST) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb)(Commercial) 2. Ontruzant (trastuzumab-dttb)(Medicare Advantage) Ontruzant (trastuzumab-dttb)(QUEST) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw)
6.15	03/23/2026	1100-1677764-1784008 The ustekinumab (Stelara) and Biosimilars (QUEST) policy effective 01/19/2026, has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 10/01/2025. Otulfi (ustekinumab-aauz) (QUEST) Pyzchiva (ustekinumab-ttwe) (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. 2. Ogivri (trastuzumab-dkst)(Commercial) 2. Ogivri (trastuzumab-dkst)(Medicare Advantage) Ogivri (trastuzumab-dkst)(QUEST) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb)(Commercial) 2. Ontruzant (trastuzumab-dttb)(Medicare Advantage) Ontruzant (trastuzumab-dttb)(QUEST) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) pemetrexed (generic) Pemrydi RTU (pemetrexed) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr)(Commercial) 2. Riabni (rituximab-axxr)(Medicare Advantage) Riabni (rituximab-axxr)(QUEST) 2. Rituxan 2. Rituxan(Medicare Advantage) Rituxan(QUEST) 2. Rituxan Hycela (rituximab and hyaluronidase human)(Commercial) 2. Rituxan Hycela (rituximab and hyaluronidase human)(Medicare Advantage) Rituxan Hycela (rituximab and hyaluronidase human)(QUEST) romidepsin 2. Ruxience (rituximab-pvvr)(Commercial) 2. Ruxience (rituximab-pvvr)(Medicare Advantage) Ruxience (rituximab-pvvr)(QUEST) Rybrevant (amivantamab-vmjw) Rybrevant Faspro (amivantamab and hyaluronidase-lpuj) (NEW) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Rytelo (imetelstat sodium) 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. 2. Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Palynziq Papzimeos (zopapogene imadenovec-drba) Piasky (crovalimab-akkz) Prolastin-C Radicava Redemplo (plozasiran) Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli) Ryzneuta (efbemalenograstim alfa-vuxw)
6.14	03/17/2026	1100-1677764-1781156 Stelara (Commercial), effective 01/09/2026, has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 4/8/2025 v3 2. Otulfi (ustekinumab-aauz) (Commercial) 2. Pyzchiva (ustekinumab-ttwe) (Commercial)
6.13	02/25/2026	1100-1677757-1756800 Xolair (Medicare Advantage), effective 01/19/2026, has been posted for the following drug covered under this policy. Omlyclo (omalizumab-igec) (Medicare Advantage) (NEW)
6.12	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. 2. Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Palynziq Papzimeos (zopapogene imadenovec-drba) Piasky (crovalimab-akkz) Prolastin-C Radicava Redemplo (plozasiran) Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
6.11	02/23/2026	1100-1677757-1751350 The Remodulin (treprostinil) (Commercial and QUEST) 60-day provider notice (02/01/2026-03/31/2026), effective 4/01/2026 has been removed. The policy effective 12/19/2025 will continue as the current policy until further notice for the following drug: Remodulin (treprostinil) (Commercial and QUEST)
6.10	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. 2. Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Palynziq Papzimeos (zopapogene imadenovec-drba) Piasky (crovalimab-akkz) Prolastin-C Radicava Redemplo (plozasiran) Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli) Ryzneuta (efbemalenograstim alfa-vuxw)
6.09	02/06/2026	1100-1677757-1723650 Policy notes updated for 2. Remicade (infliximab) (Commercial and QUEST) and 2. Renflexis (infliximab-abda) (Commercial and QUEST)
6.08	02/05/2026	1100-1677757-1723601 Updated the policy notes and archived link name for Stelara and Biosimilars (QUEST).
6.07	02/04/2026	1100-1677757-1723650 Infliximab (Commercial and QUEST) 60-day provider notice (02/01/2026-03/31/2026), effective 04/01/2026, has been posted for the following drugs covered under this policy: 2. Remicade (infliximab) (Commercial and QUEST) 2. Renflexis (infliximab-abda) (Commercial and QUEST) 1100-1677757-1723650 The Rituximab (non-oncology) (Commercial and QUEST) 60-day provider notice (02/01/2026-03/31/2026), effective 4/01/2026, has been posted for the following drugs covered under this policy: Riabni (rituximab-arrx) (non-oncology)(Commercial and QUEST) Rituxan (rituximab) (non-oncology)(Commercial and QUEST) Rituximab (non-oncology)(Commercial and QUEST) Ruxience (rituximab-pvvr) (non-oncology)(Commercial and QUEST)
6.06	01/30/2026	1100-1677750-1720704 Removed "Growth Hormone Preferred Drug Program" from the following drug links: Omnitrope (somatropin) (Commercial and 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 drugs covered under this policy: Otulfi (ustekinumab-aauz) (Medicare Advantage) Pyzchiva (ustekinumab-ttwe) (Medicare Advantage) 1100-1677757-1723601 The following 60-day provider notices (02/01/2026-03/31/2026), effective 4/01/2026, have been posted. Orencia (abatacept) (Commercial and QUEST) Orencia (abatacept) (Medicare Advantage) Remodulin (treprostinil) (Commercial-QUEST) 1100-1677757-1721150 The Prolia (denosumab) (Commercial and QUEST) 60-day provider notice 02/01/2026-03/31/2026, in effect 04/01/2026 has been posted for the following drugs covered under this policy: Opsomyv (denosumab-dssb) (Commercial and QUEST) Osvyrti (denosumab-desu) (Commercial and QUEST) (NEW) Prolia (denosumab) (Commercial and QUEST)
6.05	01/20/2026	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. 2. Ogivri (trastuzumab-dkst)(Commercial) 2. Ogivri (trastuzumab-dkst)(Medicare Advantage) Ogivri (trastuzumab-dkst)(QUEST) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb)(Commercial) 2. Ontruzant (trastuzumab-dttb)(Medicare Advantage) Ontruzant (trastuzumab-dttb)(QUEST) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) pemetrexed (generic) Pemrydi RTU (pemetrexed) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr)(Commercial) 2. Riabni (rituximab-axxr)(Medicare Advantage) Riabni (rituximab-axxr)(QUEST) 2. Rituxan 2. Rituxan(Medicare Advantage) Rituxan(QUEST) 2. Rituxan Hycela (rituximab and hyaluronidase human)(Commercial) 2. Rituxan Hycela (rituximab and hyaluronidase human)(Medicare Advantage) Rituxan Hycela (rituximab and hyaluronidase human)(QUEST) romidepsin 2. Ruxience (rituximab-pvvr)(Commercial) 2. Ruxience (rituximab-pvvr)(Medicare Advantage) Ruxience (rituximab-pvvr)(QUEST) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Rytelo (imetelstat sodium)
6.03	01/01/2026	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 Omnitrope (somatropin) (Growth Hormone Preferred Drug Program) (Commercial and QUEST)
6.02	01/08/2026	1100-1677750-1690700 The Global Oncology policy effective 12/23/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 11/21/2025. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) pemetrexed (generic) Pemrydi RTU (pemetrexed) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Rytelo (imetelstat sodium) 1100-1205577-1682550 Edits to LOB in drug link name. 1100-1677750-1684306 Edits to LOB in drug link name.
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. Omnitrope (somatropin) (Commercial and QUEST) 1100-1677750-1684306 The following policies effective 1/1/2026 have been posted: 2. Ruconest (Commercial and QUEST)ARCHIVED: policy eff 9/27/2024 Ruconest (Medicare Advantage); ARCHIVED: policy eff 3/20/2025
6.00	01/02/2026	1100-1677750-1684703 Rituximab Products - Preferred Drug Program Commercial effective 01/01/2026, has been posted for the following drugs covered under this policy. Archived: 60-day provider notice eff 1/1/26 and policy eff 1/1/25. 1. Riabni (rituximab-arrx) (Commercial) 1. Rituxan (rituximab) (Commercial) 1. Rituxan Hycela (rituximab and hyaluronidase human) (Commercial) 1. Rituximab Preferred Drug Program (Commercial) 1. Ruxience (rituximab-pvvr) (Commercial) 1100-1677750-1684703 Rituximab Products - Preferred Drug Program Medicare Advantage effective 01/01/2026, has been posted for the following drugs covered under this policy. Archived: 60-day provider notice and policy eff 1/1/25. 1. Riabni (rituximab-arrx) (Medicare Advantage) 1. Rituxan (rituximab) (Medicare Advantage) 1. Rituximab Preferred Drug Program (Medicare Advantage) 1. Rituxan Hycela (rituximab and hyaluronidase human) (Medicare Advantage) 1. Ruxience (rituximab-pvvr) (Medicare Advantage) 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 2. Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Palynziq Papzimeos (zopapogene imadenovec-drba) Piasky (crovalimab-akkz) Prolastin-C Radicava Redemplo (plozasiran) Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli) Ryzneuta (efbemalenograstim alfa-vuxw)
5.70	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 Rolvedon (eflapegrastimxnst) (Commercial) 1100-1205577-1681552 Colony Stimulating Factors (CSF) – Long Acting Specialty Exceptions(Medicare Advantage), effective 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 09/26/2025. Rolvedon (eflapegrastimxnst) (Medicare Advantage) 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. Ogivri (trastuzumab-dkst) (Commercial and QUEST) 1. Ontruzant (trastuzumab-dttb) (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. Ogivri (trastuzumab-dkst) (Medicare Advantage) 1. Ontruzant (trastuzumab-dttb) (Medicare Advantage) 1100-1205577-1681563 The Hyaluronates Specialty Exceptions(Commercial and QUEST) policy effective 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 09/26/2025. 1. Orthovisc (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. Orthovisc (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. Omvoh (mirikizumab-mrkz) (Autoimmune Preferred Drug Program) 1. Orencia (abatacept) (Autoimmune Preferred Drug Program) 1. Otulfi (ustekinumab-aauz) (Autoimmune Preferred Drug Program) 1. Pyzchiva (ustekinumab-ttwe) (Autoimmune Preferred Drug Program) 1. Remicade (infliximab) Infliximab (Autoimmune Preferred Drug Program) 1. Renflexis (infliximab) Infliximab (Autoimmune Preferred Drug Program)
5.69	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 2. Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Palynziq Papzimeos (zopapogene imadenovec-drba) Piasky (crovalimab-akkz) Prolastin-C Radicava Redemplo (plozasiran) (NEW) Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli) Ryzneuta (efbemalenograstim alfa-vuxw)
5.68	12/24/2025	1100-1205577-1675357 Remodulin (Commercial-QUEST) policy, effective 12/19/2025 has been posted. ARCHIVED: policy effective 12/20/2024.
5.67	12/23/2025	1100-1205577-1671755 HP Acthar Gel (repository corticotropin injection) (Commercial and QUEST), effective 12/19/2025 has been posted for the following drug. ARCHIVED: policy effective 9/27/2024 Purified Cortrophin Gel (repository corticotropin injection) (Commercial and QUEST) 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. Remicade (infliximab) (Medicare Advantage) Renflexis (infliximab-abda) (Medicare Advantage) 1100-1205577-1671755 The Hyaluronates Medicare Part B policy effective 12/19/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 12/20/2024. 2. Orthovisc® (high molecular weight hyaluronan) (Medicare Advantage) 1100-1205577-1672050 Praluent (alirocumab) (Commercial and QUEST) effective 12/19/2025 has been posted. ARCHIVED: policy eff 12/20/2024. 1100-1205577-1672050 Repatha (evolocumab) (Commercial and QUEST) effective 12/19/2025 has been posted. ARCHIVED: policy eff 7/26/2024. 1100-1205577-1672050 Rituximab (non-oncology) (Medicare Advantage) effective 12/19/2025, has been posted for the following drugs covered under this policy. Archived: policy eff 04/26/2024. Riabni (non-oncology) (Medicare Advantage) Rituxan (non-oncology) (Medicare Advantage) Rituximab (non-oncology) (Medicare Advantage) Ruxience (non-oncology) (Medicare Advantage) 1100-1205577-1672050 Xolair (Commercial and QUEST), effective 12/19/2025, has been posted for the following drug covered under this policy. ARCHIVED: policy eff 4/01/2025. Omlyclo (omalizumab-igec) (Commercial and QUEST) (NEW)
5.66	12/19/2025	1100-1205577-1670253 The fax form link for the following have been updated. plerixafor (generic) (Commercial) plerixafor (generic) (QUEST)
5.65	12/04/2025	1100-1205577-1642516 Updated the following link names: 1. Praluent (alirocumab) PCSK9 Inhibitors Preferred Program (Commercial) 1. Repatha (evolocumab) PCSK9 Inhibitors Preferred Program (Commercial)
5.64	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. Releuko (filgrastim-ayow) (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. Releuko (filgrastim-ayow) 1100-1205577-1642516 Remodulin (Medicare Advantage) policy, effective 11/21/2025 has been posted. ARCHIVED: policy effective 3/1/2025. 1100-1205577-1642516 PCSK9 Inhibitors Preferred Drug Program (Commercial) policy effective 11/21/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 10/25/2024. PCSK9 Inhibitors Preferred Drug Program (Commercial) 1. Praluent (alirocumab) (Commercial) 1. Repatha (evolocumab) (Commercial) 1100-1205577-1642610 The Global Oncology policy effective 11/21/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 11/18/2025. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) pemetrexed (generic) Pemrydi RTU (pemetrexed) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Rytelo (imetelstat sodium)
5.63	11/26/2025	1100-1205570-1634455 The Hereditary Angioedema (HAE) Preferred Drug Program (Commercial) policy effective 11/21/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 12/20/2024. 1. Ruconest (C1 esterase inhibitor [recombinant]) (Hereditary Angioedema Preferred Drug Program) (Commercial) 1100-1205570-1634458 Multiple Sclerosis (MS) Preferred Drug Program (Commercial) effective 11/21/2025, has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 10/25/2024. Plegridy (peginterferon beta-1a) (Multiple Sclerosis Preferred Program) (Commercial) Rebif (interferon beta-1a) (Commercial) - No PA required
5.62	11/24/2025	1100-1205570-1615650 Posted the following fax form updates: Ocrevus - removed the Medicare fax form link. The policy only applies to Commercial and QUEST. Ocrevus Zunovo - removed the Medicare fax form link. The policy only applies to Commercial and QUEST. 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 2. Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Palynziq Papzimeos (zopapogene imadenovec-drba) Piasky (crovalimab-akkz) Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli) Ryzneuta (efbemalenograstim alfa-vuxw)
5.61	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. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) pemetrexed (generic) Pemrydi RTU (pemetrexed) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Rytelo (imetelstat sodium)
5.60	11/10/2025	1100-1205570-1615650 Stelara + Biosimilars Fax Form links have been updated for the following drugs: 2. Otulfi (ustekinumab-aauz) (Commercial) Otulfi (ustekinumab-aauz) (QUEST) 2. Pyzchiva (ustekinumab-ttwe) (Commercial) Pyzchiva (ustekinumab-ttwe) (QUEST) 1100-1205570-1615650 Ocrevus (Commercial and QUEST) fax form link has been updated. 1100-1205570-1615650 Ocrevus Zunovo (Commercial and QUEST) fax form link has been updated. 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 Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Palynziq Papzimeos (zopapogene imadenovec-drba) (NEW) Piasky (crovalimab-akkz) Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli) Ryzneuta (efbemalenograstim alfa-vuxw)
5.59	11/05/2025	1100-1205570-1607700 The following drug name has been updated to: 1. Ruconest (C1 esterase inhibitor [recombinant]) (Hereditary Angioedema Preferred Drug Program) (Commercial)
5.58	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 Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Palynziq Papzimeos (zopapogene imadenovec-drba) (NEW) Piasky (crovalimab-akkz) Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli) Ryzneuta (efbemalenograstim alfa-vuxw)
5.57	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. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) pemetrexed (generic) Pemrydi RTU (pemetrexed) (NEW) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Rytelo (imetelstat sodium)
5.56	10/29/2025	1100-1205563-1590900 The links to Rituximab Products - Preferred Drug Program Medicare Advantage 60-day provider notice (11/01/2025-12/31/2025) eff 1/1/2026 have been updated: 1. Rituxan Hycela (rituximab and hyaluronidase human) (Medicare Advantage) 1. Ruxience (rituximab-pvvr) (Medicare Advantage) Removed 60-day notice from 2. Ruxience (rituximab-pvvr) (oncology) (Medicare Advantage) as it was incorrectly placed.
5.55	10/27/2025	1100-1205563-1592051 Stelara (Commercial), effective 04/08/2025 v3, has been posted. ARCHIVED: Policy eff 4/8/2025 v2 2. Otulfi (ustekinumab-aauz) (Commercial) 2. Pyzchiva (ustekinumab-ttwe) (Commercial) 1100-1205563-1590900 Rituximab Products - Preferred Drug Program Commercial 60-day provider notice (11/01/2025-12/31/2025) eff 1/1/2026, has been posted for the following drugs covered under this policy: 1. Riabni (rituximab-arrx) (Commercial) 1. Rituxan (rituximab) (Commercial) 1. Rituxan Hycela (rituximab and hyaluronidase human) (Commercial) 1. Ruxience (rituximab-pvvr) (Commercial) 1100-1205563-1590900 Rituximab Products - Preferred Drug Program Medicare Advantage 60-day provider notice (11/01/2025-12/31/2025) eff 1/1/2026, has been posted for the following drugs covered under this policy: 1. Riabni (rituximab-arrx) (Medicare Advantage) 1. Rituxan (rituximab) (Medicare Advantage) 1. Rituxan Hycela (rituximab and hyaluronidase human) (Medicare Advantage) 1. Ruxience (rituximab-pvvr) (Medicare Advantage 1100-1205563-1596453 Ocrevus and Ocrevus-Zunovo: Removed SDRP from the policy notes.
5.54	10/23/2025	1100-1205563-1590053 The following 60-day notices have been posted: Ruconest (recombinant C1 esterase inhibitor) (Commercial and QUEST) Ruconest (recombinant C1 esterase inhibitor) (Medicare Advantage) 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: Omnitrope® (somatropin) 1100-1205563-1589400 The Autoimmune Preferred Drug Program (Commercial) 60-day provider notice (11/01/2025-12/31/2025) effective 01/01/2026, has been posted for the following drugs covered under this policy: 1. Omvoh (mirikizumab-mrkz) (Autoimmune Preferred Drug Program) 1. Orencia (abatacept) (Autoimmune Preferred Drug Program) 1. Otulfi (ustekinumab-aauz) (Autoimmune Preferred Drug Program) 1. Pyzchiva (ustekinumab-ttwe) (Autoimmune Preferred Drug Program) 1. Remicade (infliximab) Infliximab (Autoimmune Preferred Drug Program) 1. Renflexis (infliximab) Infliximab (Autoimmune Preferred Drug Program)
5.53	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 drug covered under this policy. ARCHIVED: Policy eff 01/01/2025 Rolvedon (eflapegrastimxnst) (Commercial) 1100-1205563-1574400 Colony Stimulating Factors (CSF) – Long Acting Specialty Exceptions (Medicare Advantage), effective 09/26/2025, has been posted for the following drug covered under this policy. ARCHIVED: Policy eff 01/01/2025. Rolvedon (eflapegrastimxnst) (Medicare Advantage)
5.52	10/20/2025	1100-1205563-1581802 The 60-day notices were removed and current date updated to 10/01/2025 for the following drugs covered under the IVIG (MA) policy: Octagam (human immunoglobulin) (Medicare Advantage) Panzyga (immune globulin) (Medicare Advantage Privigen (human immunoglobulin) (Medicare Advantage)
5.51	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. Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Palynziq Piasky (crovalimab-akkz) Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli) Ryzneuta (efbemalenograstim alfa-vuxw) 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. Ogivri (trastuzumab-dkst) (Commercial and QUEST) 1. Ontruzant (trastuzumab-dttb) (Commercial and QUEST) 1100-1205563-1574400 The Trastuzumab Products Specialty Exceptions (Medicare Advantage) policy effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 01/01/2025. 1. Ogivri (trastuzumab-dkst) (Medicare Advantage) 1. Ontruzant (trastuzumab-dttb) (Medicare Advantage) 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. Orthovisc (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. Orthovisc (Medicare Advantage) 1100-1205563-1574454 The Prolia fax form links have been updated for Opsomyv (Commercial and QUEST) and Prolia (Commercial and QUEST)
5.50	10/03/2025	1100-1205563-1551406 ustekinumab (Stelara) and Biosimilars (QUEST) archive folder link fix.
5.49	10/02/2025	1100-1205563-1551406 The Prolia (denosumab) (Commercial and QUEST) policy effective 10/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: 60-day notice and policy eff 7/26/2024. Opsomyv (denosumab-dssb) (Commercial and QUEST) Prolia (denosumab) (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. Otulfi (ustekinumab-aauz) (QUEST) Pyzchiva (ustekinumab-ttwe) (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. Omvoh (mirikizumab-mrkz) (Autoimmune Preferred Drug Program) 1. Orencia (abatacept) (Autoimmune Preferred Drug Program) 1. Otulfi (ustekinumab-aauz) (Autoimmune Preferred Drug Program) 1. Pyzchiva (ustekinumab-ttwe) (Autoimmune Preferred Drug Program) 1. Remicade (infliximab) Infliximab (Autoimmune Preferred Drug Program) 1. Renflexis (infliximab) Infliximab (Autoimmune Preferred Drug Program)
5.48	09/30/2025	1100-1205556-1544400 The following policy has been posted: Off-Label Drug Use (Medicare Advantage), 09/26/2025; ARCHIVED policy eff 9/27/24
5.47	09/25/2025	1100-1205556-1538050 The following drugs were added to the table: Pavblu (aflibercept-ayyh) (Commercial and QUEST Integration) - No PA required Pavblu (aflibercept-ayyh) (Medicare Advantage) - No PA required
5.46	09/22/2025	1100-1205556-1524002 Refreshed all Global Oncology policy links for drugs in the "O" section. 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. Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Palynziq Piasky (crovalimab-akkz) Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli) Ryzneuta (efbemalenograstim alfa-vuxw) 1100-1205556-1528350 The effective dates for the drugs covered under the Stelara (Medicare Advantage) policy has been corrected to 09/20/2025.
5.45	09/19/2025	1100-1205556-1528350 The Stelara and Biosimilars (Medicare Advantage), effective 9/20/2025, has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 4/1/2025. Otulfi (ustekinumab-aauz) (Medicare Advantage) (NEW) Pyzchiva (ustekinumab-ttwe) (Medicare Advantage) (NEW)
5.43	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. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) pemetrexed (generic) Pemrydi RTU (pemetrexed) (NEW) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Rytelo (imetelstat sodium)
5.42	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. Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Palynziq Piasky (crovalimab-akkz) Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli) Ryzneuta (efbemalenograstim alfa-vuxw)
5.41	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. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) pemetrexed (generic) Pemrydi RTU (pemetrexed) (NEW) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Rytelo (imetelstat sodium) 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. Omvoh (mirikizumab-mrkz) (Autoimmune Preferred Drug Program) 1. Orencia (abatacept) (Autoimmune Preferred Drug Program) 1. Otulfi (ustekinumab-aauz) (Autoimmune Preferred Drug Program) 1. Pyzchiva (ustekinumab-ttwe) (Autoimmune Preferred Drug Program) 1. Remicade (infliximab) Infliximab (Autoimmune Preferred Drug Program) 1. Renflexis (infliximab) Infliximab (Autoimmune Preferred Drug Program) 1100-1205556-1514402 Spelling correction on the following: 2. Riabni (rituximab-arrx) (Oncology) (Commercial) 2. Riabni (rituximab- arrx) (Oncology) (Medicare Advantage) Riabni (rituximab- arrx) (Oncology) (QUEST)
5.40	09/04/2025	1100-1205549-1486802 The QUEST fax form link for the following drug has been updated: Palynziq
5.39	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. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) pemetrexed (generic) Pemrydi RTU (pemetrexed) (NEW) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Rytelo (imetelstat sodium) 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. Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Palynziq Piasky (crovalimab-akkz) Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli) Ryzneuta (efbemalenograstim alfa-vuxw)
5.38	09/02/2025	1100-1205549-1486802 The QUEST fax form links for the following drugs have been updated: Ocrevus, Palynziq, Prolastin-C, Radicava, Revcovi, Osenvelt
5.37	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. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) pemetrexed (generic) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Rytelo (imetelstat sodium) 1100-1205549-1488650 The SDRP policy eff 07/01/2025-v2 has been posted for the following drugs covered under this policy. Ocrevus Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Ocrevus-Zunovo Palynziq Piasky (crovalimab-akkz) Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli) Ryzneuta (efbemalenograstim alfa-vuxw)
5.36	08/18/2025	1100-1205549-1463454 Ryzneuta (efbemalenograstim alfa-vuxw) - revised policy note to "Added Effective 07/01/2025"
5.35	08/14/2025	1100-1205549-1463450 Link fix for Octagam (Commercial and QUEST)
5.34	08/12/2025	1100-1205549-1463454 The SDRP policy eff 07/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 06/01/2025. Ocrevus Ocrevus-Zunovo (ocrelizumab and hysluronidase-ocsq) Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Palynziq Piasky (crovalimab-akkz) Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli) Ryzneuta (efbemalenograstim alfa-vuxw) (NEW) 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. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) pemetrexed (generic) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Rytelo (imetelstat sodium)
5.33	08/11/2025	1100-1205549-1463450 Intravenous Immune Globulin (IVIG) (Commercial and QUEST) effective 7/25/2025, has been posted for the following drugs covered under this policy. Archived: policy eff 5/23/2025. Octagam (Commercial and QUEST) Panzyga (Commercial and QUEST) Privigen (Commercial and QUEST)
5.32	08/07/2025	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: Opsomyv (denosumab-dssb) (Commercial and QUEST) (NEW) Prolia (denosumab) (Commercial and QUEST) 1100-1205549-1463400 The Intravenous Immune Globulin (IVIG) (Medicare Advantage) 60-day provider notice (08/01/2025-09/30/2025) eff 10/01/2025 has been posted for the following drugs covered under this policy. Octagam (human immunoglobulin) (Medicare Advantage) Panzyga (immune globulin) (Medicare Advantage) Privigen (human immunoglobulin) (Medicare Advantage) 1100-1205549-1463400 The ustekinumab (Stelara) and Biosimilars (QUEST) 60-day provider notice (8/01/2025-9/30/2025) effective 10/01/2025, has been posted for the following drugs covered under this policy: Otulfi (ustekinumab-aauz) (QUEST) (NEW) Pyzchiva (ustekinumab-ttwe) (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. Omvoh (mirikizumab-mrkz) (Autoimmune Preferred Drug Program) 1. Orencia (abatacept) (Autoimmune Preferred Drug Program) 1. Otulfi (ustekinumab-aauz) (Autoimmune Preferred Drug Program) 1. Pyzchiva (ustekinumab-ttwe) (Autoimmune Preferred Drug Program) 1. Remicade (infliximab) Infliximab (Autoimmune Preferred Drug Program) 1. Renflexis (infliximab) Infliximab (Autoimmune Preferred Drug Program)
5.31	08/05/2025	1100-1205549-1457500 The OCREVUS (ocrelizumab) (Commercial and QUEST) effective 8/1/2025 has been posted for the following drugs covered under this policy; ARCHIVED: 60-day notice. Ocrevus (ocrelizumab) (Commercial and QUEST) Ocrevus-Zunovo (ocrelizumab and hyaluronidase-ocsq) (Commercial and QUEST)
5.30	07/24/2025	1100-1205542-1427101 Prolia and Biosimilars (Medicare Advantage), 6/27/2025 has been posted for the following drugs covered under this policy: Opsomyv (denosumab-dssb) (Medicare Advantage) (NEW) Prolia (Medicare Advantage); ARCHIVED policy eff 1/1/2025 1100-1205542-1427101 Xgeva and Biosimilars (Commercial and QUEST), 6/27/2025 has been posted for the following drug covered under this policy: Osenvelt (denosumab-bmwo) (Commercial and QUEST) (NEW) 1100-1205542-1427101 Xgeva and Biosimilars (Medicare Advantage), 6/27/2025 has been posted for the following drug covered under this policy: Osenvelt (denosumab-bmwo) (Medicare Advantage) (NEW)
5.29	06/30/2025	1100-1205535-1366050 The SDRP policy eff 06/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 05/23/2025. Ocrevus Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Ocrevus-Zunovo (ocrelizumab and hysluronidase-ocsq) (NEW) Palynziq Piasky (crovalimab-akkz) Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli) 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. Otulfi (ustekinumab-aauz) (Commercial and QUEST) Pyzchiva (ustekinumab-ttwe) (Commercial and QUEST)
5.28	06/23/2025	1100-1205535-1368400 Added a 2 before Pyzchiva (Commercial and QUEST)
5.27	06/16/2025	1100-1205535-1366050 Octagam (Commercial and QUEST): Corrected the effective date to 05/23/2025
5.26	06/10/2025	1100-1205535-1368400 Autoimmune (AI) Preferred Drug Program (Commercial) effective 6/07/2025 has been posted for the following drugs covered under this policy. ARCHVIED: Policy effective 2/14/2025. 1. Omvoh (mirikizumab-mrkz) (Autoimmune Preferred Drug Program) 1. Orencia (abatacept) (Autoimmune Preferred Drug Program) 1. Otulfi (ustekinumab-aauz) (Autoimmune Preferred Drug Program) (NEW) 1. Pyzchiva (ustekinumab-ttwe) (Autoimmune Preferred Drug Program) (NEW) 1. Remicade (infliximab) Infliximab (Autoimmune Preferred Drug Program) 1. Renflexis (infliximab) Infliximab (Autoimmune Preferred Drug Program) 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. Omvoh (mirikizumab-mrkz) (Autoimmune Preferred Drug Program) 1. Orencia (abatacept) (Autoimmune Preferred Drug Program) 1. Otulfi (ustekinumab-aauz) (Autoimmune Preferred Drug Program) (NEW) 1. Pyzchiva (ustekinumab-ttwe) (Autoimmune Preferred Drug Program) (NEW) 1. Remicade (infliximab) Infliximab (Autoimmune Preferred Drug Program) 1. Renflexis (infliximab) Infliximab (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. Ocrevus Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Ocrevus-Zunovo (ocrelizumab and hysluronidase-ocsq) (NEW) Palynziq Piasky (crovalimab-akkz) Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli) 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. Orthovisc® (high molecular weight hyaluronan) (Commercial and QUEST Integration) Intravenous Immune Globulin (IVIG) (Commercial and QUEST) effective 5/23/2025, has been posted for the following drugs covered under this policy. Archived: policy eff 12/20/2024. Octagam (Commercial and QUEST) Panzyga (Commercial and QUEST) Privigen (Commercial and QUEST)
5.25	06/03/2025	1100-1205535-1358906 Stelara and Biosimilars (Commercial and QUEST), effective 04/08/2025 , has been posted for the following drugs covered under this policy. Biosimilars added eff 4/8/2025. Otulfi (ustekinumab-aauz) (Commercial and QUEST) (NEW) Pyzchiva (ustekinumab-ttwe) (Commercial and QUEST) (NEW) 1100-1205535-1358909 The OCREVUS (ocrelizumab) (Commercial and QUEST) 60-day provider notice (6/01/2025-7/31/2025), effective 8/1/2025 has been posted for the following drugs covered under this policy: Ocrevus (ocrelizumab) (Commercial and QUEST) Ocrevus-Zunovo (ocrelizumab and hyaluronidase-ocsq) (Commercial and QUEST)
5.24	05/22/2025	1100-1205528-1346450 Fax form links for the following have been update: 1. Ogivri (trastuzumab-dkst) (Trastuzumab Preferred Drug Program Commercial and QUEST) 1. Ogivri (trastuzumab-dkst) (Trastuzumab Preferred Drug Program Medicare Advantage) 2. Ogivri (trastuzumab-dkst) (Commercial and QUEST) 2. Ogivri (trastuzumab-dkst) (Medicare Advantage) 1. Ontruzant (trastuzumab-dttb) (Trastuzumab Preferred Drug Program Commercial and QUEST) 1. Ontruzant (trastuzumab-dttb) (Trastuzumab Preferred Drug Program Medicare Advantage) 2. Ontruzant (trastuzumab-dttb) (Commercial and QUEST) 2. Ontruzant (trastuzumab-dttb) (Medicare Advantage) 2. Omvoh (mirikizumab-mrkz) 2. Rituxan Hycela (rituximab and hyaluronidase human)
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. Ocrevus Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Ocrevus-Zunovo (ocrelizumab and hysluronidase-ocsq) (NEW) Palynziq Piasky (crovalimab-akkz) Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
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. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) pemetrexed (generic) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Rytelo (imetelstat sodium)
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. Ocrevus Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) Ocrevus-Zunovo (ocrelizumab and hysluronidase-ocsq) (NEW) Palynziq Piasky (crovalimab-akkz) Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
5.20	05/08/2025	1100-1205528-1315150 The following fax form links have been updated or added: Releuko (filgrastim-ayow) (CSF Short Acting Preferred Drug Program Commercial and QUEST) - QUEST Rolvedon (eflapegrastimxnst) (Medicare Advantage) - MA 1100-1205528-1330252 Edit the SDRP current effective date to 04/01/2025 as applicable.
5.19	05/06/2025	1100-1205528-1332100 Ruconest (recombinant C1 esterase inhibitor) (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. Ocrevus Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) (NEW) Palynziq Piasky (crovalimab-akkz) Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) (NEW) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
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. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) pemetrexed (generic) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Rytelo (imetelstat sodium)
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. Ocrevus Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Onapgo (apomorphine hydrochloride) (NEW) Palynziq Piasky (crovalimab-akkz) Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryoncil (remestemcel-L-rknd) (NEW) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
5.16	04/21/2025	1100-1205521-1305653 The following edit was applied: 2. Orencia (Commercial and QUEST) - Removed the 60-day provider notice and updated the Current Effective Date to 04/01/2025.
5.15	04/15/2025	1100-1205521-1305678 The Global Oncology policy effective 02/28/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 02/03/2025. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) pemetrexed (generic) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Rytelo (imetelstat sodium)
5.14	04/14/2025	1100-1205521-1305653 The following policies effective 04/01/2025 have been posted: Orencia (abatacept) (Commercial and QUEST); ARCHIVED: 60-day notice and policy eff 4/1/2024 Orencia (abatacept) (Medicare Advantage); ARCHIVED: 60-day notice and policy eff 1/1/2024 Rituximab (non-oncology) (Commercial and QUEST), effective 4/01/2025, has been posted for the following drugs covered under this policy. ARCHIVED: 60-day notice and policy eff 4/01/2024. Riabni (rituximab-arrx) (non-oncology)(Commercial and QUEST) Rituxan (rituximab) (non-oncology)(Commercial and QUEST) Rituximab (non-oncology)(Commercial and QUEST) Ruxience (rituximab-pvvr) (non-oncology)(Commercial and QUEST) Growth Hormone Therapy, 4/01/2025, has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy effective 10/01/2024. Omnitrope (somatropin)
5.13	04/07/2025	1100-1205521-1301650 The SDRP policy eff 02/01/2025 has been posted for the following drugs covered under this policy. Ocrevus Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Palynziq Piasky (crovalimab-akkz) Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
5.12	03/24/2025	1100-1205514-1272756 Added the Infliximab (Comm-QUEST) archived folder for 2. Remicade (infliximab) (Commercial and QUEST) 2. Renflexis (infliximab-abda) (Commercial and QUEST)
5.11	03/14/2025	1100-1205514-1280502 Autoimmune (AI) Preferred Drug Program (Commercial) effective 2/14/2025 has been posted for the following drugs covered under this policy. ARCHVIED: Policy effective 11/18/2024. 1. Omvoh (mirikizumab-mrkz) (Autoimmune Preferred Drug Program) 1. Orencia (abatacept) 1. Remicade (infliximab) Infliximab (Autoimmune Preferred Drug Program) 1. Renflexis (infliximab) Infliximab (Autoimmune Preferred Drug Program)
5.10	03/13/2025	1100-1205514-1278952 The Global Oncology policy effective 02/03/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 01/15/2025. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) pemetrexed (generic) (NEW) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Rytelo (imetelstat sodium) Change history notes from 2020, 2021, and 2022 are archived and have been removed from this article.
5.09	03/11/2025	1100-1205514-1261250 The following has been added: Rituxan Hycela (rituximab and hyaluronidase human) (QUEST Integration) The following have been deleted: Ogivri (trastuzumab-dkst) (QUEST Integration), Ontruzant (trastuzumab-dttb) (QUEST Integration) The following have been updated: 2. Ogivri (trastuzumab-dkst) (Commercial and QUEST), 2. Ontruzant (trastuzumab-dttb) (Commercial and QUEST)
5.08	03/10/2025	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. Remicade (infliximab) (Commercial and QUEST) 2. Renflexis (infliximab-abda) (Commercial and QUEST) 1100-1205514-1272756 Remodulin (Medicare Advantage) policy, effective 3/1/2025 has been posted. ARCHIVED: 60-day notice and policy effective 1/1/2024. 1100-1205514-1272761 The SDRP policy eff 01/01/2025, v2 has been posted for the following drugs covered under this policy. Ocrevus Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Palynziq Piasky (crovalimab-akkz) (new) Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
5.07	03/05/2025	1100-1205514-1265700 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: Omnitrope (somatropin) The following redlined 60-day provider notices (02/01/2025-03/31/2025), effective 04/01/2025 have been posted: Orencia (abatacept) (Commercial and QUEST) Orencia (abatacept) (Medicare Advantage) The Rituximab (non-oncology) (Commercial and QUEST) redlined 60-day provider notice (02/01/2025-03/31/2025), effective 4/01/2025, has been posted for the following drug covered under this policy: Riabni (rituximab-arrx) (non-oncology)(Commercial and QUEST) Rituxan (rituximab) (non-oncology)(Commercial and QUEST) Rituximab (non-oncology)(Commercial and QUEST) Ruxience (rituximab-pvvr) (non-oncology)(Commercial and QUEST)
5.06	03/03/2025	1100-1205514-1261250 The Global Oncology policy effective 01/15/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 12/01/2024. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) pemetrexed (generic) (NEW) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Rytelo (imetelstat sodium)
5.05	02/24/2025	1100-1205507-1235400 Typographical edits. 1100-1205507-1254950 Fax form link have been updated for the following drugs: Octagam (Commercial & QUEST) Octagam (Medicare Advantage) Panzyga (Commercial & QUEST) Panzyga (Medicare Advantage) Privigen (Commercial & QUEST) Privigen (Medicare Advantage)

Rev#:	Date:	Nature of Revision:
5.04	02/05/2025	1100-1205507-1235400 The SDRP policy eff 12/16/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 10/3/2024. Ocrevus Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Palynziq Piasky (crovalimab-akkz) (new) Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
5.03	02/03/2025	1100-1205500-1214101 Formatting edit.
5.02	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: 2. Ogivri (Commercial) 2. Ogivri (Medicare Advantage) Ogivri (QUEST) Onivyde 2. Ontruzant (Commercial) 2. Ontruzant (Medicare Advantage) Ontruzant (QUEST) Opdivo (nivolumab) Opdualag The Global Oncology policy effective 12/01/2024 has been posted for the following drug covered under this policy. Rytelo
5.01	01/14/2025	1100-1205500-1214101 The Global Oncology policy effective 12/01/2024 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 11/15/2024.. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn)
5.00	01/07/2025	1100-956557-1197451 Edits: 2. Remicade, 2. Renflexis, 2. Remodulin links to 60-day provider notice (01/01/2025-02/28/2025) eff 03/01/2025

Rev#:	Date:	Nature of Change:
4.42 (v215)	12/30/2024	1100-956557-1197456 The following policy has been posted: Prolia (Medicare Advantage), 1/1/2025; ARCHIVED: 60-day notice effective 1/1/2025 and policy effective 7/26/2024 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. Remicade (infliximab) 2. Renflexis (infliximab-abda) 1100-956557-1197451 Remodulin (Medicare Advantage) 60-day provider notice (01/01/2025-02/28/2025), effective 03/01/2025, has been posted. Remodulin (treprostinil) (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. Rolvedon (eflapegrastimxnst) (Commercial) 1100-956557-1197456 Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Medicare Advantage), effective 1/1/2025, has been posted for the following drugs covered under this policy. ARCHIVED: The 60-day notice eff 1/1/2025. Rolvedon (eflapegrastimxnst) (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. Releuko (filgrastim-ayow) (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. Releuko (filgrastim-ayow) 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. Orthovisc (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. Orthovisc (Medicare Advantage) 1100-956557-1197456 Mozobil (plerixafor) (Commercial and QUEST) effective 1/1/2025 has been posted for the following drug covered under this policy. ARCHIVED: 60-day notice eff 1/1/2025. plerixafor (generic) Rituximab Products - Commercial Preferred Drug Program 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. Riabni (rituximab-arrx) (Commercial) 1. Rituxan (rituximab) (Commercial) 1. Rituxan Hycela (rituximab and hyaluronidase human) (Commercial) 1. Ruxience (rituximab-pvvr) (Commercial) Rituximab Products - Medicare Part B Preferred Drug Program 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. Riabni (rituximab-arrx) (Medicare Advantage) 1. Rituxan (rituximab) (Medicare Advantage) 1. Rituxan Hycela (rituximab and hyaluronidase human) (Medicare Advantage) 1. Ruxience (rituximab-pvvr) (Medicare Advantage) 1100-956557-1197456 Trastuzumab Products - Commercial and QUEST Preferred Drug Program policy effective 01/01/2025, has been posted for the following drugs covered under this policy. Archived: 60-day provider notice eff 1/1/25 and policy eff 1/1/24 1. Ogivri (trastuzumab-dkst) (Commercial and QUEST) 1. Ontruzant (trastuzumab-dttb) (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. Ogivri (trastuzumab-dkst) (Medicare Advantage) 1. Ontruzant (trastuzumab-dttb) (Medicare Advantage)
4.41 (v214)	12/23/2024	The Remodulin (treprostinil) (Commercial and QUEST)policy eff 12/20/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 1/1/2024 Remodulin (Commercial and QUEST) treprostinil (generic) (Commercial and QUEST) The following policies have been posted: Praluent (alirocumab) (Commercial and QUEST), 12/20/2024; ARCHIVED: policy eff 8/25/2023 Ruconest (recombinant C1 esterase inhibitor) (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. Ruconest (C1 esterase inhibitor [recombinant]) (Commercial) The Hyaluronates Medicare Part B policy effective 12/20/2024 has been posted for the following drug covered under this policy. ARCHIVED: policy effective 5/30/2024. 2. Orthovisc® (high molecular weight hyaluronan) (Medicare Advantage) Intravenous Immune Globulin (IVIG) (Commercial and QUEST) effective 12/20/2024, has been posted for the following drugs covered under this policy. Archived: policy eff 4/01/2024. Octagam (Commercial and QUEST) Panzyga (Commercial and QUEST) Privigen (Commercial and QUEST)
4.40 (v213)	12/17/2024	1100-956557-1197150The SDRP policy eff 10/3/2024 has been posted for the following drug covered under this policy: Piasky (crovalimab-akkz) (new)
4.39 (v212)	12/03/2024	1100-956557-1188100 The Hyaluronate Products (Commercial and QUEST Integration) effective 11/29/2024, has been posted for the following drugs covered under this policy. Archived: Policy eff 4/1/2024. 2. Orthovisc® (high molecular weight hyaluronan) (Commercial and QUEST Integration)
4.38 (v211)	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. Omvoh (mirikizumab-mrkz) (Autoimmune Preferred Drug Program) 1. Orencia (abatacept): 1. Remicade (infliximab) 1. Renflexis (infliximab) 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. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn)
4.37 (v210)	11/05/2024	1100-956547-1165170 Minor typo edit.
4.36 (v209)	11/04/2024	1100-956547-1165170 The effective date for Riabni, covered under the Global Oncology policy, has been updated. 1100-956552-1168730 Multiple Sclerosis (MS) Preferred Drug Program (Commercial) effective 10/25/2024, has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 11/17/2023. Plegridy (peginterferon beta-1a) (Commercial) Rebif (interferon beta-1a) (Commercial) PCSK9 Inhibitors Preferred Drug Program (Commercial) policy effective 10/25/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 11/17/2023 . PCSK9 Inhibitors Preferred Drug Program (Commercial) 1. Praluent (alirocumab) (Commercial) 1. Repatha (evolocumab) (Commercial)
4.35 (v208)	11/01/2024	1100-956547-1167950 Prolia (Medicare Advantage) 60-day provider notice (11/01/2024-12/31/2024) eff 1/1/2025 has been posted. Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial) 60-day provider notice (11/01/2024-12/31/2024) eff 1/1/2025, has been posted for the following drugs covered under this policy. Rolvedon (eflapegrastimxnst) (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. Rolvedon (eflapegrastimxnst) (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. Releuko (filgrastim-ayow) (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. Releuko (filgrastim-ayow) (Medicare Advantage) 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. Orthovisc (Commercial and QUEST) 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. Orthovisc (Medicare Advantage) Mozobil (plerixafor) (Commercial and QUEST) 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: plerixafor (generic) Rituximab Products - Commercial 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. Riabni (rituximab-arrx) (Commercial) 1. Rituxan (rituximab) (Commercial) 1. Rituxan Hycela (rituximab and hyaluronidase human) (Commercial) 1. Ruxience (rituximab-pvvr) (Commercial) Rituximab Products - Medicare Part B 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. Riabni (rituximab-arrx) (Medicare Advantage) 1. Rituxan (rituximab) (Medicare Advantage) 1. Rituxan Hycela (rituximab and hyaluronidase human) (Medicare Advantage) 1. Ruxience (rituximab-pvvr) (Medicare Advantage) 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. Ogivri (trastuzumab-dkst) (Commercial and QUEST) 1. Ontruzant (trastuzumab-dttb) (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. Ogivri (trastuzumab-dkst) (Medicare Advantage) 1. Ontruzant (trastuzumab-dttb) (Medicare Advantage)
4.34 (v207)	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. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) The SDRP policy eff 10/3/2024 v2 has been posted for the following drugs covered under this policy. Ocrevus Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Palynziq Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
4.33 (v206)	10/21/2024	1100-956547-1156413 The effective date for Ocrevus and 2. Omvoh have been updated to 10/03/2024.
4.32 (v205)	10/11/2024	1100-956547-1156401 The following policies have been posted: Off-Label Drug Use (Medicare Advantage), 09/27/2024. Archived: 08/25/2023 2. Ruconest (recombinant C1 esterase inhibitor) (Commercial and QUEST), 09/27/2024. Archived: 1/1/2024 The following policies have been posted:HP Acthar Gel (repository corticotropin injection) (Commercial and QUEST), effective 9/27/2024 has been posted for the following drug. ARCHIVED: policy effective 10/27/2023 Purified Cortrophin Gel (repository corticotropin injection) (Commercial and QUEST). 1100-956547-1156413 The SDRP policy eff 10/3/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 9/27/2024. Ocrevus Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Palynziq Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
4.31 (v204)	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. Omvoh (mirikizumab-mrkz) (Autoimmune Preferred Drug Program) 1. Orencia (abatacept): 1. Remicade (infliximab) 1. Renflexis (infliximab)
4.30 (v203)	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. Ocrevus Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Palynziq Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
4.29 (v202)	09/30/2024	1100-956542-1145350 Updated the following effective dates to 9/10/2024 as they were missed in the previous update: Radicava, Revcovi, Rivfloza (nedosiran), Ryplazim (plasminogen, human-tvmh), Rystiggo (rozanolixizumab-noli) 1100-956542-1148056 Growth Hormone Therapy, 10/01/2024, has been posted for the following drug covered under this policy. Archived: 60-day notice and policy effective 12/15/2023. Omnitrope (somatropin)
4.28 (v201)	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 8/25/2024. Ocrevus Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Palynziq Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
4.27 (v200)	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. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn)
4.26 (v199)	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. Ocrevus Omvoh (mirikizumab-mrkz) (subcutaneous formulation is not covered under Part B) Palynziq Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
4.25 (v198)	08/06/2024	1100-956537-1104509 The following policies have been posted: Prolia (denosumab) (Commercial and QUEST Integration), 07/26/2024. Archived: 1/1/2024 Prolia (denosumab) (Medicare Advantage), 07/26/2024. Archived: 1/1/2024 2. Repatha (evolocumab) (Commercial and QUEST Integration), 07/26/2024. Archived: 08/25/2023
4.24 (v197)	08/05/2024	1100-956537-1104504 Growth Hormone Therapy 60-day provider notice (08/01/2024-09/30/2024), effective 10/01/2024, has been posted for the following drug covered under this policy: Omnitrope (somatropin)
4.23 (v196)	07/25/2024	1100-956532-1092301 Minor type edit.
4.22 (v195)	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. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) The SDRP policy eff 7/01/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 6/17/2024. Ocrevus Omvoh (mirikizumab-mrkz) (drug is not covered under Part B) Palynziq Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
4.21 (v194)	06/25/2024	1100-956527-1081006 Autoimmune (AI) Preferred Drug Program (Commercial) effective 07/01/2024 has been posted for the following drugs covered under this policy. ARCHVIED: The 60-day notice and policy effective 09/01/2023. 1. Omvoh (mirikizumab-mrkz) (Autoimmune Preferred Drug Program)(new) 1. Orencia (abatacept): 1. Remicade (infliximab) 1. Renflexis (infliximab)
4.20 (v193)	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. Ocrevus Omvoh (mirikizumab-mrkz) (drug is not covered under Part B) Palynziq Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
4.19 (v192)	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. 2. Ogivri (trastuzumab-dkst) Onivyde (irinotecan hydrochloride) 2. Ontruzant (trastuzumab-dttb) Opdivo (nivolumab) Opdualag (nivolumab and relatlimab-rmbw) Padcev (enfortumab vedotin-ejfv) Pemfexy (pemetrexed) Pepaxto (melphalan flufenamide) Perjeta Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) Polivy (polatuzumab vedotin-piiq) Portrazza (necitumumab) Poteligeo (mogamulizumab-kpkc) Provenge 2. Riabni (rituximab-axxr) 2. Rituxan 2. Rituxan Hycela (rituximab and hyaluronidase human) romidepsin 2. Ruxience (rituximab-pvvr) Rybrevant (amivantamab-vmjw) Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn)
4.18 (v191)	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. Orthovisc® (high molecular weight hyaluronan) (Medicare Advantage)
4.17 (v190)	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. Omvoh (mirikizumab-mrkz) (Autoimmune Preferred Drug Program)(new) #1. Orencia (abatacept): #1. Remicade (infliximab) #1. Renflexis (infliximab)
4.16 (v189)	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. Ocrevus Omvoh (mirikizumab-mrkz) (drug is not covered under Part B) Palynziq Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli
4.15 (v188)	05/15/2024	1100-956522-1055200 The SDRP policy eff 5/12/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 4/1/2024. Ocrevus Omvoh (mirikizumab-mrkz) (drug is not covered under Part B) Palynziq Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
4.14 (v187)	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. Ocrevus Omvoh (mirikizumab-mrkz) (drug is not covered under Part B) Palynziq Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
4.13 (v186)	05/06/2024	1100-956522-1046905 Rituximab (non-oncology) (Medicare Advantage) effective 04/26/2024, v2, has been posted for the following drugs covered under this policy. Effective date typo fix. Riabni (non-oncology) (Medicare Advantage) Rituxan (non-oncology) (Medicare Advantage) Rituximab (non-oncology) (Medicare Advantage) Ruxience (non-oncology) (Medicare Advantage)
4.12 (v185)	05/02/2024	1100-956522-1046900 Autoimmune Preferred Drug Program (Commercial) revised redlined 60-day notice effective 7/1/2024 (notification period: 05/01/2024-06/30/2024) has been posted for the following drugs covered under this policy: #1. Orencia (abatacept): #1. Remicade (infliximab) #1. Renflexis (infliximab) 1100-956522-1046905 Intravenous Immune Globulin (IVIG) (Medicare Advantage) eff 4/26/2024 has been posted for the following drugs covered under this policy. Archived: policy eff 12/15/2023. Octagam (human immunoglobulin) (Medicare Advantage) Panzyga (immune globulin) (Medicare Advantage) Privigen (human immunoglobulin) (Medicare Advantage) Rituximab (non-oncology) (Medicare Advantage) effective 04/26/2024, has been posted for the following drugs covered under this policy. Archived: policy eff 1/1/2024. Riabni (non-oncology) (Medicare Advantage) Rituxan (non-oncology) (Medicare Advantage) Rituximab (non-oncology) (Medicare Advantage) Ruxience (non-oncology) (Medicare Advantage)
4.11 (v184)	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: Orthovisc (high molecular weight hyaluronan)
4.10 (v183)	04/05/2024	The following have been added to the applicable tables: Omisirge (omidubicel-onlv) Roctavian (valoctocogene roxaparvovec-rvox)
4.9 (v182)	03/31/2024	The following policy has been posted: 2. Orencia (Commercial and QUEST Integration), 4/1/2024. Archived: 1/1/2024 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. Orthovisc® (high molecular weight hyaluronan) (Commercial and QUEST Integration) Intravenous Immune Globulin (IVIG) (Commercial and QUEST Integration) effective 4/01/2024, has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy eff 9/1/2022. Octagam (Commercial and QUEST Integration) Panzyga (Commercial and QUEST Integration) Privigen (Commercial and QUEST Integration) Rituximab (non-oncology) (Commercial and QUEST Integration) effective 4/01/2024, has been posted for the following drug covered under this policy: Riabni (rituximab-arrx) (non-oncology) (Commercial and QUEST Integration) Rituxan (rituximab) (non-oncology) (Commercial and QUEST Integration) Rituximab (non-oncology) (Commercial and QUEST Integration) Ruxience (rituximab-pvvr) (non-oncology) (Commercial and QUEST Integration)
4.8 (v181)	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. Ocrevus Omvoh (mirikizumab-mrkz) (drug is not covered under Part B) Palynziq Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
4.7 (v180)	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. Ocrevus Omvoh (mirikizumab-mrkz) Onpattro - Effective 2/15/2024 PA review for Onpattro is moved from CVS to HMSA review Oxlumo - Effective 2/15/2024 PA review for Oxlumo is moved from CVS to HMSA review Palynziq Prolastin-C Radicava Revcovi Rivfloza (nedosiran) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
4.6 (v179)	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. Ocrevus Omvoh (mirikizumab-mrkz) Onpattro Oxlumo (lumasiran) Palynziq Prolastin-C Radicava Revcovi Rivfloza (nedosiran) (NEW effective 1/1/2024) Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)
4.5 (v178)	02/08/2024	Relinked 2. Orencia (Commercial and QUEST Integration) 60-day notice. Removed "2." from the following rows: Riabni (Commercial and QUEST Integration) (non-oncology) Riabni (Medicare Advantage) (non-oncology) Rituxan (Commercial and QUEST Integration) (non-oncology) Rituxan (Medicare Advantage) (non-oncology) Ruxience (Commercial and QUEST Integration) (non-oncology) Ruxience (Medicare Advantage) (non-oncology)
4.4 (v177)	02/05/2024	Updated fax form links for the following: Riabni (QUEST Integration) oncology and non-oncology Rituxan (QUEST Integration) oncology and non-oncology Rituximab (QUEST Integration) non-oncology Ruxience (QUEST Integration) oncology and non-oncology
4.3 (v176)	02/02/2024	Fax form link removed from Probuphine. The drug no longer requires PA.
4.2 (v175)	02/01/2024	60-day notice has been posted for the following drug. Provider notification period is 2/1/2024-3/31/2024. 2. Orencia (Commercial and QUEST Integration) The Hyaluronate Products (Commercial and QUEST Integration) 60-day notice has been posted for the following drugs covered under this policy. Provider notification period is 2/1/2024-3/31/2024. Policy effective date is 4/1/2024. 2. Orthovisc® (high molecular weight hyaluronan) (Commercial and QUEST Integration) Intravenous Immune Globulin (IVIG) (Commercial and QUEST Integration) 60-day provider notice (02/01/2024-03/31/2024), effective 4/01/2024, has been posted for the following drug covered under this policy: Octagam (Commercial and QUEST Integration) Panzyga (Commercial and QUEST Integration) Privigen (Commercial and QUEST Integration) Rituximab (non-oncology) (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. Riabni (rituximab-arrx) (non-oncology) 2. Rituxan (rituximab) (non-oncology) Rituximab (non-oncology) 2. Ruxience (rituximab-pvvr) (non-oncology)
4.1 (v174)	01/31/2024	Updated fax form links for the following: Ogivri (new line for QI), Ontruzant (new line for QI), Prolia, Releuko, Remodulin, Riabni (new line for QI), Rituxan (new line for QI), Rituximab, Ruconest, Ruxience
4.0 (v173)	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. Ocrevus Omvoh (mirikizumab-mrkz) Onpattro Oxlumo (lumasiran) Palynziq Prolastin-C Radicava Revcovi Ryplazim (plasminogen, human-tvmh) Rystiggo (rozanolixizumab-noli)

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