Information

Title Medical Specialty Drug Policies: S-U

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

O-R

V-Z

S

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Saizen^® (somatropin) (Commercial and QUEST)		01/01/2026	Fax Form	Growth Hormone	ARCHIVED - Growth Hormone
sajazir (icatibant) (Commercial and QUEST)		01/01/2026	Commercial Fax Form QUEST Fax Form	icatibant–Firazir-sajazir	ARCHIVED - Icatibant (Comm-QUEST)
Saphnelo (anifrolumab-fnia)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) (effective 12/10/2021)	ARCHIVED - SDRP
Sarclisa (isatuximab-irfc)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Scenesse (afamelanotide)	No PA required as of 1/1/2024				ARCHIVED - Scenesse
1. Selarsdi (ustekinumab-aekn) (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. Selarsdi (ustekinumab-aekn) (Commercial)		01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added eff 4/8/2025	ARCHIVED - Stelara and Biosimilars (Commercial)
Selarsdi (ustekinumab-aekn) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
Selarsdi (ustekinumab-aekn) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
Serostim (somatropin) (Commercial and QUEST)		01/01/2026	Fax Form	Growth Hormone	ARCHIVED - Growth Hormone
Sevenfact [Factor VIIA (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Signifor (pasireotide)		09/26/2025	Fax Form		ARCHIVED - Signifor (Comm-QUEST)
Signifor LAR (pasireotide long acting)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
1. Siliq (brodalumab) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Siliq Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Siliq (brodalumab) (Commercial and QUEST)		10/27/2025	Commerical Fax Form QUEST Fax Form	Specific drug criteria for Siliq eff 10/1/2020	ARCHIVED - Siliq
1. Simlandi (adalimumab-ryvk) (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. Simlandi (adalimumab-ryvk) (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 7/1/2024	ARCHIVED - Adalimumab (Humira)
Simlandi (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QI)
1. Simponi (golimumab for subcutaneous injection) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Simponi Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2 Simponi (golimumab for subcutaneous injection) (Commercial and QUEST)		05/25/2025	Fax Form	Specific drug criteria for Simponi	ARCHIVED - Simponi
1. Simponi Aria (golimumab for subcutaneous injection) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Simponi Aria Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2 Simponi Aria (golimumab injection for intravenous use) (Commercial and QUEST)		05/25/2025	Fax Form QUEST Fax Form	Specific drug criteria for Simponi Aria	ARCHIVED - Simponi Aria (COMM-QI) ARCHIVED - Simponi Aria
Simponi Aria (golimumab injection for intravenous use) (Medicare Advantage)		03/27/2026	Medicare Advantage Fax Form		ARCHIVED - Simponi Aria (MA)
1. Skyrizi (risankizumab-rzaa) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Skyrizi Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Skyrizi (risankizumab-rzaa) (Commercial and QUEST)		12/19/2025	Commercial Fax Form QUEST Fax Form	Specific drug criteria for Skyrizi	ARCHIVED - Skyrizi
Skyrizi (risankizumab-rzaa) (Medicare Advantage)	60-day provider notice 04/01/2026-05/31/2026, in effect 06/01/2026
Skysona (elivaldogene autotemcel)	Please contact HMSA at 808-948-6464, option #4, for drug review
Skytrofa (lonapegsomatropin-tcgd)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 12/10/2021	ARCHIVED - SDRP
Sogroya somapacitan-beco)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 5/1/2023	ARCHIVED - SDRP
Soliris (eculizumab) (Commercial and QUEST)		12/19/2025	Fax Form		ARCHIVED - Soliris (Comm-QUEST) ARCHIVED - Soliris
Soliris (eculizumab) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Soliris-Bkemy-Epysqli	ARCHIVED - Soliris (MA)
Somatuline Depot (lanreotide) (Non-oncology) (Commercial and QUEST)		09/26/2025	Fax Form	Somatuline Depot-Lanreotide	ARCHIVED - Lanreotide (Comm-QI) ARCHIVED - Somatuline Depot
Somatuline Depot (lanreotide) (Non-oncology) (Medicare Advantage)		10/27/2025	Medicare Advantage Fax Form	Somatuline Depot-Lanreotide MA	ARCHIVED - Lanreotide (MA)
Specialty Drugs Requiring Precertification (SDRP)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Spevigo (spesolimab-sbzo)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 11/1/2022	ARCHIVED - SDRP
Spinraza (nusinersen) (Commercial and QUEST)		09/26/2025	Commercial Fax Form QUEST Fax Form		ARCHIVED - Spinraza (Comm-QUEST) ARCHIVED - Spinraza
Spinraza (nusinersen) (Medicare Advantage)		09/26/2025	Medicare Advantage Fax Form		ARCHIVED - Spinraza (MA)
Spravato (esketamine) This policy can be accessed from the HMSA Medical Policies - CURRENT article under Intranasal Esketamine for Major Depressive Disorder with Acute Suicidality and Treatment-Resistant Depression	Please contact HMSA at 808-948-6464, option #4, for drug review
1. Starjemza (ustekinumab-hmny) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026			ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Starjemza (ustekinumab-hmny) (Commercial)		01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added eff 4/8/2025	ARCHIVED - Stelara and Biosimilars (Commercial)
Starjemza (ustekinumab-hmny) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
Starjemza (ustekinumab-hmny) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
1. Stelara (ustekinumab) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Stelara Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Stelara (ustekinumab) (Commercial)		01/19/2026	Commercial Fax Form	Stelara (Commercial) Added Biosimilars effective 4/8/2025	ARCHIVED - Stelara and Biosimilars (Commercial) ARCHIVED - Stelara
Stelara (ustekinumab) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
Stelara (ustekinumab) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
1. Steqeyma (ustekinumab-stba) (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. Steqeyma (ustekinumab-stba) (Commercial)		01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added eff 4/8/2025	ARCHIVED - Stelara and Biosimilars (Commercial)
Steqeyma (ustekinumab-stba) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
Steqeyma (ustekinumab-stba) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
Strensiq (asfotase alfa)		04/14/2026	Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Stimufend (pegfilgrastim-fpgk) (Commercial)		01/01/2026	Commercial Fax Form	Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CSF Long Acting Preferred Drug Program
Stimufend (pegfilgrastim-fpgk) (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)
Stoboclo (denosumab-bmwo) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Prolia and Biosimilars (Commercial and QUEST) Added eff 10/01/2025	ARCHIVED - Prolia (Comm-QUEST)
Stoboclo (denosumab-bmwo) (Medicare Advantage)		06/27/2025	Medicare Advantage Fax Form	Prolia and Biosimilars (Medicare Advantage) Added eff 6/27/2025	ARCHIVED - Prolia (MA)
Sublocade (buprenorphine)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
1. Supartz FX® (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Supartz FX® Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Supartz FX® (sodium hyaluronate) (Commercial and QUEST)		04/12/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI) ARCHIVED - Hyaluronates (drug specific)
1. Supartz FX® (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Supartz FX® Commercial Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program (MA)
2. Supartz FX® (sodium hyaluronate) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Supprelin LA (histrelin acetate implant)		01/01/2026	Fax Form		ARCHIVED - Supprelin LA
Syfovre (pegcetacoplan)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added to policy on 3/6/2023	ARCHIVED - SDRP
Sylvant (siltuximab)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Synagis (palivizumab				Discontinued by manufacturer effective 12/31/2025	ARCHIVED - Synagis
Synribo (omacetaxine mepesuccinate)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Synojoynt (1% sodium hyaluronate) (Commercial and QUEST)		04/12/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI)
Synojoynt (1% sodium hyaluronate) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA)
1. Synvisc® (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Synvisc Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Synvisc® (hylan G-F 20) (Commercial and QUEST)		04/12/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI) ARCHIVED - Hyaluronates (drug specific)
1. Synvisc (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Synvisc Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program (MA)
2. Synvisc® (hylan G-F 20) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
1. Synvisc One® (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Synvisc One Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Synvisc One® (hylan G-F 20) (Commercial and QUEST)		04/12/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI) ARCHIVED - Hyaluronates (drug specific)
1. Synvisc One® (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Synvisc One Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (MA)
2. Synvisc One® (hylan G-F 20) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)

T

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Takhzyro (lanadelumab-flyo)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
1. Taltz (ixekizumab) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Taltz Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Taltz (ixekizumab) (Commercial and QUEST)		12/19/2025	Commercial Fax Form QUEST Fax Form	Specific drug criteria for 11/18/2025Taltz eff 10/1/2020	ARCHIVED - Taltz
Talvey (talquetamab-tgvs)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Effective 9/5/2023	ARCHIVED - Global Oncology
Tecartus (brexucabtagene autoleucel)	Effective 07/31/2020: Please contact HMSA at 808-948-6464, option #4, for drug review
Tecentriq (atezolizumab)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Tecvayli (teclistamab-cqyv)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Tegsedi (inotersen)	Effective 9/27/2024 Tegsedi is discontinued.			Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
temsirolimus (generic)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Tepezza (teprotumumab-trbw)		09/26/2025	Commercial Fax Form QUEST Fax Form	Drug specific Effective 1/1/2025 Specialty Drugs Requiring Precertification (SDRP) Effective 1/1/25: Removed from SDRP policy	ARCHIVED - Tepezza (Comm-QUEST) ARCHIVED - SDRP
Tepylute (thiotepa)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
teriparatide (generic)		06/27/2025	Fax Form	Forteo (teriparatide) Effective 4/1/2023	ARCHIVED - Forteo
Tevimbra (tislelizumab-jsgr)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Effective 9/10/2024	ARCHIVED - Global Oncology
Tezspire (tezepelumab-ekko)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 4/1/2022	ARCHIVED - SDRP
Tivdak (tisotumab vedotin-tftv)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Tofidence (tocilizumab-bavi) (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. Tofidence (tocilizumab-bavi)(Commercial)		04/01/2026	Commercial Fax Form	Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (COMM-QI)
Tofidence (tocilizumab-bavi)(QUEST)		04/01/2026		Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (COMM-QI)
Tofidence (tocilizumab-bavi) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (MA)
Torisel (temsirolimus)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Trastuzumab Preferred Drug Program (Commercial and QUEST)		01/01/2026		Trastuzumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Trastuzumab Products (Commercial)
Trastuzumab Preferred Drug Program (Medicare Advantage)		01/01/2026		Trastuzumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Trastuzumab Products (MA)
1. Trazimera (trastuzumab-qyyp) (Trastuzumab Preferred Drug Program Commercial and QUEST)		01/01/2026	Refer below for Trazimera fax forms	Trastuzumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Trastuzumab Products (Commercial)
2. Trazimera (trastuzumab-qyyp) (Commercial and QUEST)		04/14/2026	Commercial Fax Form QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Trazimera (trastuzumab-qyyp) (Trastuzumab Preferred Drug Program Medicare Advantage)		01/01/2026	Refer below for Trazimera fax forms	Trastuzumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Trastuzumab Products (MA)
2. Trazimera (trastuzumab-qyyp) (Medicare Advantage)		04/14/2026	Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Tremfya (guselkumab) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Tremfya Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Tremfya (guselkumab) (Commerical and QUEST)		02/23/2026	Commercial Fax Form QUEST Fax Form	Specific drug criteria for Tremfya eff 10/1/2020	ARCHIVED - Tremfya (Comm-QUEST)
Tremfya IV (guselkumab) (Medicare Advantage)		10/01/2025			ARCHIVED - Tremfya IV (MA)
treprostinil (generic) (Commercial and QUEST)	60-day provider notice 04/01/2026-05/31/2026 in effect 06/01/2026	12/19/2025	Fax Form	Remodulin	ARCHIVED - Remodulin (Comm-QUEST) ARCHIVED - Remodulin
treprostinil (generic) (Medicare Advantage)		11/21/2025	Medicare Advantage Fax Form	Remodulin	ARCHIVED - Remodulin (MA)
1. Triluron (sodium hyaluronate) (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Triluron Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Triluron (sodium hyaluronate) (Commercial and QUEST)		04/12/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI) ARCHIVED - Hyaluronates (drug specific)
1. Triluron (sodium hyaluronate) (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Triluron Commercial Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program (MA)
2. Triluron (sodium hyaluronate) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Triptodur (triptorelin pamoate)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Trisenox (arsenic trioxide)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Trivisc® (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Trivisc Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Trivisc® (sodium hyaluronate) (Commercial and QUEST)		04/12/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI) ARCHIVED - Hyaluronates (drug specific)
1. Trivisc® (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Trivisc Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program (MA)
2. Trivisc® (sodium hyaluronate) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Trodelvy (sacituzumab govitecan-hziy)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Truxima (rituximab-abbs) (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. Truxima (rituximab-abbs) (Commercial)		04/14/2026		Global Oncology	ARCHIVED - Global Oncology
1. Truxima (rituximab-abbs) (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. Truxima (rituximab-abbs) (Medicare Advantage)		04/14/2026		Global Oncology	ARCHIVED - Global Oncology
Truxima (rituximab-abbs) (QUEST)		04/14/2026	QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
Truxima (rituximab-abbs) (Non-oncology) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Rituximab-Rituxan-Ruxience-Truxima	ARCHIVED - Rituximab (non-oncology) (Comm-QI) ARCHIVED - Rituximab
Truxima (rituximab-abbs) (Non-oncology) (Medicare Advantage)		12/19/2025		Rituximab-Rituxan-Ruxience-Truxima MA	ARCHIVED - Rituximab (non-oncology) (MA)
Tryngolza (olezarsen sodium)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
1. Tyenne (tocilizumab-aazg) (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. Tyenne (tocilizumab-aazg) (Commercial)		04/01/2026	Commercial Fax Form	Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (COMM-QI)
Tyenne (tocilizumab-aazg) (QUEST)		04/01/2026	Commercial Fax Form	Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (COMM-QI)
Tyenne (tocilizumab-aazg) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (MA)
Tymlos (abaloparatide)		06/27/2025	Commercial Fax Form QUEST Fax Form	Effective 4/1/23: Drug specific policy Effective 4/1/23: Removed from SDRP policy. Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - Tymlos ARCHIVED - SDRP Refer to policies eff 3/1/2023 and earlier
Tzield (teplizumab-mzwv)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 12/1/2022	ARCHIVED - SDRP

U

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Udenyca (pegfilgrastim-cbqv) (Commercial)		01/01/2026	Commercial Fax Form	Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CSF Long Acting Preferred Drug Program
Udenyca (pegfilgrastim-cbqv) (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)
Ultomiris (ravulizumab-cwvz)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Unituxin (dinutuximab)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Unloxcyt (cosibelimab-ipdl)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Uplizna (ineblizumab-cdon)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
ustekinumab (unbranded Stelara) (Commercial)		01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added effective 01/19/2026	ARCHIVED - Stelara and Biosimilars (Commercial)
Ustekinumab (Stelara and Biosimilars) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
ustekinumab (unbranded Stelara) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
ustekinumab-aauz (unbranded Otulfi) (Commercial)		01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added effective 01/19/2026	ARCHIVED - Stelara and Biosimilars (Commercial)
ustekinumab-aauz (unbranded Otulfi) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
ustekinumab-aauz (unbranded Otulfi) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
1. ustekinumab-aekn (unbranded Selarsdi) (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. ustekinumab-aekn (unbranded Selarsdi) (Commercial)		01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added eff 4/8/2025	ARCHIVED - Stelara and Biosimilars (Commercial)
ustekinumab-aekn (unbranded Selarsdi) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
ustekinumab-aekn (unbranded Selarsdi)(Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
ustekinumab-JJ (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026			ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
ustekinumab-stba (unbranded Steqeyma) (Commercial)		01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added effective 01/19/2026	ARCHIVED - Stelara and Biosimilars (Commercial)
ustekinumab-stba (unbranded Steqeyma) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
ustekinumab-stba (unbranded Steqeyma) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
1. ustekinumab-ttwe (unbranded Pyzchiva) (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. ustekinumab-ttwe (unbranded Pyzchiva) (Commercial)		01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added eff 4/8/2025	ARCHIVED - Stelara and Biosimilars (Commercial)
ustekinumab-ttwe (unbranded Pyzchiva) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
ustekinumab-ttwe (unbranded Pyzchiva) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)

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

Change History

Rev#:	Date:	Nature of Change:
6.31	05/04/2026	1100-1677771-1838900 The effective date for the following drugs covered under the Global Oncology policy have been updated to 04/14/2026: 2. Truxima (Medicare Advantage) Truxima (QUEST) Unituxin Unloxcyt
6.30	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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tepylute (thiotepa) Tevimbra (tislelizumab-jsgr) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp)(Commercial and QUEST) 2. Trazimera (trastuzumab-qyyp)(Medicare Advantage) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima(Commercial) 2. Truxima(Medicare Advantage) Truxima(QUEST) Unituxin (dinutuximab) Unloxcyt (cosibelimab-ipdl) 1100-1677771-1837550 Rituximab Products - Preferred Drug Program Medicare Advantage effective 01/01/2026 v2, has been posted for the following drug covered under this policy. (LOB has been corrected.) 1. Truxima (rituximab-abbs) (Medicare Advantage) 1100-1677771-1837550 The SDRP policy eff 04/14/2026 has been posted for the following drugs covered under this policy. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna
6.29	04/20/2026	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: treprostinil (generic) (Commercial-QUEST)
6.28	04/16/2026	updated the Skyrizi (Medicare Advantage) provider notice link to 04/01/2026-05/31/2026, in effect 06/01/2026
6.27	04/14/2026	1100-1677771-1821700 Updated the QUEST fax form link for Sajazir and Simponi Aria. 1100-1677771-0820850 The Hyaluronate Products (Commercial and QUEST) effective 04/12/2026 has been posted for the following drugs covered under this policy: 2. Supartz FX® (sodium hyaluronate) (Commercial and QUEST) Synojoynt (1% sodium hyaluronate) (Commercial and QUEST) (new) 2. Synvisc® (hylan G-F 20) (Commercial and QUEST) 2. Synvisc One® (hylan G-F 20) (Commercial and QUEST) 2. Triluron (sodium hyaluronate) (Commercial and QUEST) 2. Trivisc® (sodium hyaluronate) (Commercial and QUEST)
6.26	04/13/2026	1100-1677771-1819701 Skyrizi (risankizumab-rzaa) (Medicare Advantage) 60-day notice eff 6/1/2026 has been posted. 1100-1677771-1819705 The Prolia (denosumab) (Commercial and QUEST) policy effective 04/01/2026 has been posted for the following drug covered under this policy: Stoboclo (denosumab-bmwo) (Commercial and QUEST)
6.24	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. 1100-1205556-1528350 The effective date for ustekinumab-ttwe (unbranded (Pyzchiva) (Medicare Advantage) has been updated to 4/1/2026
6.23	04/06/2026	1100-1677771-1805800 Simponi Aria (golimumab) (Medicare Advantage) effective 03/27/2026 has been posted. 1100-1677771-1805800 The SDRP policy eff 03/27/2026 has been posted for the following drugs covered under this policy. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna
6.22	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. Supartz FX ® (sodium hyaluronate) (Medicare Advantage) Synojoynt (1% sodium hyaluronate) (Medicare Advantage) 2. Synvisc® (hylan G-F 20) (Medicare Advantage) 2. Synvisc One® (hylan G-F 20) (Medicare Advantage) 2. Triluron (sodium hyaluronate) (Medicare Advantage) 2. Trivisc® (sodium hyaluronate) (Medicare Advantage)
6.21	03/31/2026	1100-1677764-1798651 The Actemra (Commercial and QUEST) policy, effective 04/01/2026, has been posted for the following drugs covered under this policy. 2. Tofidence (tocilizumab-bavi) (Commercial) Tofidence (tocilizumab-bavi) (QUEST) 2. Tyenne (tocilizumab-aazg) (Commercial) Tyenne (tocilizumab-aazg) (QUEST) 1100-1677764-1798651 The Actemra (Medicare Advantage) policy, effective 04/01/2026, has been posted for the following drug covered under this policy. Tofidence (tocilizumab-bavi)(Medicare Advantage) 2. Tyenne (tocilizumab-aazg) (Medicare Advantage) 1100-1677764-1802500 Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST) effective 04/01/2026, has been posted for the following drug covered under this policy. Simlandi (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST) 1100-1677764-1802500 The Stelara and Biosimilars (Medicare Advantage), effective 04/01/2026, has been posted for the following drug covered under this policy. Stelara (ustekinumab) (Medicare Advantage) Selarsdi (ustekinumab-aekn) (Medicare Advantage) Starjemza (ustekinumab-hmny) (Medicare Advantage) Steqeyma (ustekinumab-stba) (Medicare Advantage) ustekinumab (unbranded Stelara) (Medicare Advantage) ustekinumab-aauz (unbranded Otulfi) (Medicare Advantage) ustekinumab-aekn (unbranded Selarsdi) (Medicare Advantage) ustekinumab-stba (unbranded Steqeyma) (Medicare Advantage) ustekinumab-ttwe (unbranded (Pyzchiva) (Medicare Advantage)
6.20	03/30/2026	1100-1677764-1798661 Rituximab (non-oncology) (Commercial and QUEST), effective 4/01/2026, has been posted for the following drugs covered under this policy. Truxima (rituximab-abbs)(Commercial and QUEST) 1100-1677764-1798661 Soliris (Medicare Advantage), effective 04/01/2026, has been posted.
6.19	03/26/2026	1100-1677764-1784008 Effective date for Steqeyma (ustekinumab-stba) (QUEST) has been updated to 01/19/2026.
6.18	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; adding four new drugs as indicated below: 2. Selarsdi (ustekinumab-aekn) (Commercial) 2. Starjemza (ustekinumab-hmny) (Commercial) (NEW) 2. Stelara (ustekinumab) (Commercial) 2. Steqeyma (ustekinumab-stba) (Commercial) ustekinumab (unbranded Stelara) (Commercial) (NEW) 2. ustekinumab-aauz (unbranded Otulfi) (Commercial) (NEW) 2. ustekinumab-aekn (unbranded Selarsdi) (Commercial) 2. ustekinumab-stba (unbranded Steqeyma) (Commercial) (NEW) 2. ustekinumab-ttwe (unbranded Pyzchiva) (Commercial)
6.17	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. Selarsdi (ustekinumab-aekn) (QUEST) Starjemza (ustekinumab-hmny) (QUEST) (new) Stelara (ustekinumab) (QUEST) Steqeyma (ustekinumab-stba) (QUEST) ustekinumab (Stelara) and Biosimilars (QUEST) ustekinumab-aauz (unbranded Otulfi) (QUEST) (new) ustekinumab-aekn (unbranded Selarsdi) (QUEST) ustekinumab-stba (unbranded Steqeyma) (QUEST) (new) ustekinumab-ttwe (unbranded Pyzchiva) (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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tepylute (thiotepa) Tevimbra (tislelizumab-jsgr) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp)(Commercial) 2. Trazimera (trastuzumab-qyyp)(Medicare Advantage) Trazimera (trastuzumab-qyyp)(QUEST) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima(Commercial) 2. Truxima(Medicare Advantage) Truxima(QUEST) Unituxin (dinutuximab) Unloxcyt (cosibelimab-ipdl) 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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna
6.16	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. Selarsdi (ustekinumab-aekn) (Commercial) 2. Stelara (ustekinumab) (Commercial) 2. Steqeyma (ustekinumab-stba) (Commercial) 2. ustekinumab-aekn (unbranded Selarsdi) (Commercial) 2. ustekinumab-ttwe (unbranded Pyzchiva) (Commercial)
6.15	03/13/2026	1100-1677764-1781150 Tremfya (Comm-QUEST) eff 2/23/2026 has been posted. ARCHIVED: policy eff 11/30/2025.
6.14	02/26/2026	1100-1677757-1758252 The Simponi Aria (golimumab injection for intravenous use) (Medicare Advantage) policy effective 3/1/2026 has been posted. ARCHIVED: 60-day notice and policy eff 1/1/2025. Change history notes from 2023 are archived and have been removed from this article.
6.13	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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna
6.12	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: Treprostinil (generic) (Commercial and QUEST)
6.11	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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna
6.10	02/05/2026	1100-1677757-1723601 Updated the policy notes and archived link name for Stelara and Biosimilars (QUEST).
6.09	02/04/2026	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 drug covered under this policy: Truxima (rituximab-abbs)(Commercial and QUEST)
6.08	02/03/2026	1100-1677757-1721600 The Actemra (Commercial and QUEST) policy, redlined 60-day notice effective 04/01/2026, has been posted for the following drugs covered under this policy. Tofidence (tocilizumab-bavi)(Commercial and QUEST) 2. Tyenne (tocilizumab-aazg) (Commercial and QUEST) 1100-1677757-1721600 The Actemra and Biosimilars (Medicare Advantage) policy, redlined 60-day notice effective 04/01/2026, has been posted for the following drugs covered under this policy. Tofidence (tocilizumab-bavi)(Medicare Advantage) Tyenne (tocilizumab-aazg) (Medicare Advantage) (NEW) 1100-1677757-1721600 The Adalimumab Preferred Drug Program (QUEST) redlined 60-day provider notice (02/01/2026-03/31/2026), effective 04/01/2026, has been posted for the following drug covered under this policy: Simlandi (adalimumab-ryvk) (QUEST) 1100-1677757-1721600 The Soliris (Medicare Advantage) redlined 60-day provider notice (02/01/2026-03/31/2026), effective 4/01/2026, has been posted. 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: Selarsdi (ustekinumab-aekn) (Medicare Advantage) Starjemza (ustekinumab-hmny) (Medicare Advantage) (NEW) Stelara (ustekinumab) (Medicare Advantage) Steqeyma (ustekinumab-stba) (Medicare Advantage) ustekinumab (unbranded Stelara) (Medicare Advantage) (NEW) ustekinumab-aauz (unbranded Otulfi) (Medicare Advantage) (NEW) ustekinumab-aekn (unbranded Selarsdi) (Medicare Advantage) ustekinumab-stba (unbranded Steqeyma) (Medicare Advantage) (NEW) ustekinumab-ttwe (unbranded Pyzchiva) (Medicare Advantage) 1100-1677757-1723601 Drug name edit: ustekinumab (Stelara) and Biosimilars (QUEST) 1100-1677757-1721607 Remodulin (Commercial-QUEST) 60-day provider notice (01/01/2025-02/28/2025), effective 03/01/2025, has been posted for the following drug covered under this policy: treprostinil (generic) (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 drug covered under this policy: Stoboclo (denosumab-bmwo) (Commercial and QUEST)
6.07	01/30/2026	1100-1677750-1720704 Removed "Growth Hormone Preferred Drug Program" from the following link: Saizen (somatropin) (Commercial and QUEST) Serostim (somatropin) (Commercial and QUEST)
6.06	01/20/2026	1100-1677750-1699604 Updated missed Global Oncology drugs to effective date 01/13/2026. 1100-1677750-1702005 Updated all instances of QUEST Integration to QUEST.
6.05	01/16/2026	1100-1677750-1699604 The Global Oncology policy effective 01/13/2026 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 12/23/2025. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tepylute (thiotepa) Tevimbra (tislelizumab-jsgr) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp)(Commercial) 2. Trazimera (trastuzumab-qyyp)(Medicare Advantage) Trazimera (trastuzumab-qyyp)(QUEST) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima(Commercial) 2. Truxima(Medicare Advantage) Truxima(QUEST) Unituxin (dinutuximab) Unloxcyt (cosibelimab-ipdl)
6.04	01/15/2026	1100-1677750-1694000 Growth Hormone Therapy, 01/01/2026 v2, has been posted for the following drugs covered under this policy. Archived: policy effective 01/01/2026 Saizen (somatropin) (Growth Hormone Preferred Drug Program) (Commercial and QUEST) Serostim (somatropin) (Growth Hormone Preferred Drug Program) (Commercial and QUEST)
6.03	01/09/2026	1100-1205577-1672050 Skyrizi: Added LOB and updated link.
6.02	01/08/2026	1100-1677750-1690703 Synagis (palivizumab) has been discontinued by the manufacturer effective 12/31/2025. The policy eff 08/01/2024 has been archived. 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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tepylute (thiotepa) Tevimbra (tislelizumab-jsgr) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab) Unloxcyt (cosibelimab-ipdl) 1100-1677750-1684314 Effective dates for the SDRP drugs in the T and U sections were updated to 01/01/2026. 1100-1205577-1682550 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. Saizen (somatropin) (Commercial and QUEST) Serostim (somatropin) (Commercial and QUEST) 1100-1677750-1684300 Icatibant (Commercial and QUEST), effective 01/01/2026 has been posted for the following drugs covered under this policy. The policy effective 09/27/2024 has been archived. sajazir (icatibant) (Commercial and QUEST) 1100-1677750-1684306 Supprelin LA (Commercial and QUEST) eff 1/1/2026 has been posted. ARCHIVED: policy eff 7/26/2024
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. Truxima (rituximab-abbs) (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. Truxima (rituximab-abbs) (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 Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna
5.61	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 Stimufend (pegfilgrastim-fpgk) (Commercial) Udenyca (pegfilgrastim-cbqv) (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. Stimufend (pegfilgrastim-fpgk) (Medicare Advantage) Udenyca (pegfilgrastim-cbqv) (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. Trastuzumab Preferred Drug Program (Commercial and QUEST) 1. Trazimera (trastuzumab-qyyp) (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. Trastuzumab Preferred Drug Program (Medicare Advantage) 1. Trazimera (trastuzumab-qyyp) (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. Supartz FX (Commercial and QUEST) 1. Synvisc (Commercial and QUEST) 1. Synvisc One (Commercial and QUEST) 1. Triluron (Commercial and QUEST) 1. Trivisc (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. Supartz FX (sodium hyaluronate) (Medicare Advantage) 1. Synvisc (Medicare Advantage) 1. Synvisc One (Medicare Advantage) 1. Triluron (sodium hyaluronate) (Medicare Advantage) 1. Trivisc (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. Selarsdi (ustekinumab-aekn) (Autoimmune Preferred Drug Program) 1. Siliq (brodalumab) (Autoimmune Preferred Drug Program) 1. Simlandi (adalimumab-ryvk) (Autoimmune Preferred Drug Program) 1. Simponi (golimumab for subcutaneous injection) 1. Simponi Aria (golimumab for subcutaneous injection) 1. Skyrizi (risankizumab-rzaa) (Autoimmune Preferred Drug Program) Starjemza SQ (ustekinumab-hmny) (Autoimmune Preferred Drug Program) 1. Stelara (ustekinumab) (Autoimmune Preferred Drug Program) 1. Steqeyma (ustekinumab-stba) (Autoimmune Preferred Drug Program) 1. Taltz (ixekizumab) (Autoimmune Preferred Drug Program) 1. Tofidence (tocilizumab-bavi) (Autoimmune Preferred Drug Program) 1. Tremfya (guselkumab) (Autoimmune Preferred Drug Program) 1. Tyenne (tocilizumab-aazg) (Autoimmune Preferred Drug Program) 1. ustekinumab-aekn (unbranded Selarsdi) (Autoimmune Preferred Drug Program) ustekinumab-JJ (Autoimmune Preferred Drug Program) 1. ustekinumab-ttwe (unbranded Pyzchiva) (Autoimmune Preferred Drug Program)
5.60	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 Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna
5.59	12/29/2025	1100-1205577-1679550 The Simponi Aria (Medicare Advantage) 60-day provider notices 01/01/2026-02/28/2026, in effect 03/01/2026 have been posted.
5.58	12/24/2025	1100-1205577-1675357 Remodulin (Commercial-QUEST) policy, effective 12/19/2025 has been posted for the following drug covered under this policy. ARCHIVED: policy effective 12/20/2024. treprostinil injection (generic) (Commercial-QUEST)
5.57	12/23/2025	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. Supartz FX ® (sodium hyaluronate) (Medicare Advantage) Synojoynt (1% sodium hyaluronate) (Medicare Advantage) (new) 2. Synvisc® (hylan G-F 20) (Medicare Advantage) 2. Synvisc One® (hylan G-F 20) (Medicare Advantage) 2. Triluron (sodium hyaluronate) (Medicare Advantage) 2. Trivisc® (sodium hyaluronate) (Medicare Advantage) 1100-1205577-1672050 Skyrizi (risankizumab-rzaa) (Commercial and QUEST) (Commercial and QUEST) effective 12/19/2025 has been posted. ARCHIVED: policy eff 1/1/2025. 1100-1205577-1672050 Taltz (ixekizumab) (Commercial and QUEST) effective 12/19/2025 has been posted. ARCHIVED: policy eff 2/22/2025. 1100-1205577-1672050 Rituximab (non-oncology) (Medicare Advantage) effective 12/19/2025, has been posted for the following drug covered under this policy. Archived: policy eff 04/26/2024. Truxima (non-oncology) (Medicare Advantage) 1100-1205577-1672050 Soliris (Commercial and QUEST), effective 12/19/2025, has been posted. ARCHIVED: policy eff 4/01/2025 v2.
5.56	12/03/2025	1100-1205577-1642516 Remodulin (Medicare Advantage) policy, effective 11/21/2025 has been posted for the following drug covered under this policy. ARCHIVED: policy effective 3/1/2025. treprostinil injection (generic) (Medicare Advantage) 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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tepylute (thiotepa) Tevimbra (tislelizumab-jsgr) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab) Unloxcyt (cosibelimab-ipdl)
5.55	12/02/2025	1100-1205577-1639572 Tremfya, eff 11/30/2025, has been posted. ARCHIVED: policy eff 4/01/2025.
5.54	11/26/2025	1100-1205570-1636950 The information in the following row has been updated: Ustekinumab Preferred Program (QUEST)
5.53	11/18/2025	1100-1205570-1631470 The SDRP policy eff 11/18/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 10/10/2025 Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna
5.52	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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tepylute (thiotepa) Tevimbra (tislelizumab-jsgr) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab) Unloxcyt (cosibelimab-ipdl)
5.51	11/10/2025	1100-1205570-1615650 Stelara + Biosimilars Fax Form links have been updated for the following drugs: 2. Selarsdi (ustekinumab-aekn) (Commercial) Selarsdi (QUEST) 2. Stelara (ustekinumab) (Commercial) Stelara (QUEST) 2. Steqeyma (ustekinumab-stba) (Commercial) Steqeyma (QUEST) 2. ustekinumab-aekn (unbranded Selarsdi) (Commercial) ustekinumab-aekn (unbranded Selarsdi) (QUEST) 2. ustekinumab-ttwe (unbranded Pyzchiva) (Commercial) ustekinumab-ttwe (unbranded Pyzchiva) (QUEST) 1100-1205570-1613562 The SDRP policy eff 10/10/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 09/12/2025 Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna
5.50	11/04/2025	1100-1205563-1604101 Updated drug name to: 2. Siliq (brodalumab) (Commercial and QUEST)
5.49	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 Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna 1100-1205563-1604101 The Lanreotide Injection/Somatuline Depot (MA) policy, effective 10/27/2025 has been posted for the following drug covered under this policy. ARCHIVED: 9/26/2025. Somatuline Depot (lanreotide) (Non-oncology) (Medicare Advantage) 1100-1205563-1604101 The Siliq (Commercial and QUEST) policy effective 10/27/2025 has been posted. ARCHIVED: 9/26/2025
5.48	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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tepylute (thiotepa) Tevimbra (tislelizumab-jsgr) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab) Unloxcyt (cosibelimab-ipdl)
5.47	10/28/2025	1100-1205563-1594410 Supprelin LA (histrelin acetate implant) 60-day provider notice 11/01/2025-12/31/2025 effective 01/01/2026 has been posted.
5.46	10/27/2025	1100-1205563-1592051 Stelara (Commercial), effective 04/08/2025 v3, has been posted. ARCHIVED: Policy eff 4/8/2025 v2 2. Selarsdi (ustekinumab-aekn) (Commercial) 2. Stelara (ustekinumab) (Commercial) 2. Steqeyma (ustekinumab-stba) (Commercial) 2. ustekinumab-aekn (unbranded Selarsdi) (Commercial) 2. ustekinumab-ttwe (unbranded Pyzchiva) (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. Truxima (rituximab-abbs) (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. Truxima (rituximab-abbs) (Medicare Advantage)
5.45	10/23/2025	1100-1205563-1590053 The icatibant 60-day notice (Commercial and QUEST) has been posted for the following drugs covered under this policy. Provider notification period is 11/01/2025-12/31/2025. Policy effective date is 01/01/2026. sajazir (icatibant) (Commercial and QUEST) 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 drugs covered under this policy: Saizen® (somatropin) Serostim (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. Selarsdi (ustekinumab-aekn) (Autoimmune Preferred Drug Program) 1. Siliq (brodalumab) (Autoimmune Preferred Drug Program) 1. Simlandi (adalimumab-ryvk) (Autoimmune Preferred Drug Program) 1. Simponi (golimumab for subcutaneous injection) 1. Simponi Aria (golimumab for subcutaneous injection) 1. Skyrizi (risankizumab-rzaa) (Autoimmune Preferred Drug Program) Starjemza SQ (ustekinumab-hmny) (Autoimmune Preferred Drug Program) 1. Stelara (ustekinumab) (Autoimmune Preferred Drug Program) 1. Steqeyma (ustekinumab-stba) (Autoimmune Preferred Drug Program) 1. Taltz (ixekizumab) (Autoimmune Preferred Drug Program) 1. Tofidence (tocilizumab-bavi) (Autoimmune Preferred Drug Program) 1. Tremfya (guselkumab) (Autoimmune Preferred Drug Program) 1. Tyenne (tocilizumab-aazg) (Autoimmune Preferred Drug Program) 1. ustekinumab-aekn (unbranded Selarsdi) (Autoimmune Preferred Drug Program) ustekinumab-HIKMA (Autoimmune Preferred Drug Program) (REMOVED) ustekinumab-JJ (Autoimmune Preferred Drug Program) 1. ustekinumab-ttwe (unbranded Pyzchiva) (Autoimmune Preferred Drug Program)
5.44	10/21/2025	The following were posted on 10/17/2025: 1100-1205563-1574400 Colony Stimulating Factors (CSF) – Long Acting Specialty Exceptions(Commercial), effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 01/01/2025 Stimufend (pegfilgrastim-fpgk) (Commercial) Udenyca (pegfilgrastim-cbqv) (Commercial) 1100-1205563-1574400 Colony Stimulating Factors (CSF) – Long Acting Specialty Exceptions (Medicare Advantage), effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 01/01/2025. Stimufend (pegfilgrastim-fpgk) (Medicare Advantage) Udenyca (pegfilgrastim-cbqv) (Medicare Advantage)
5.43	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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna 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. Trastuzumab Preferred Drug Program (Commercial and QUEST) 1. Trazimera (trastuzumab-qyyp) (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. Trastuzumab Preferred Drug Program (Medicare Advantage) 1. Trazimera (trastuzumab-qyyp) (Medicare Advantage) 1100-1205563-1574400 The Hyaluronates Preferred Drug Program (Commercial and QUEST) policy effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 01/01/2025. 1. Supartz FX (Commercial and QUEST) 1. Synvisc (Commercial and QUEST) 1. Synvisc One (Commercial and QUEST) 1. Triluron (Commercial and QUEST) 1. Trivisc (Commercial and QUEST) 1100-1205563-1574400 The Hyaluronates Specialty Exceptions(Medicare Advantage) policy effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 01/01/2025. 1. Supartz FX (sodium hyaluronate) (Medicare Advantage) 1. Synvisc (Medicare Advantage) 1. Synvisc One (Medicare Advantage) 1. Triluron (sodium hyaluronate) (Medicare Advantage) 1. Trivisc (Medicare Advantage) 1100-1205563-1574454 The Prolia fax form links have been updated for Stoboclo (Commercial and QUEST) Corrected the drug name entry for Starjemza (ustekinumab-hmny) (Autoimmune Preferred Drug Program)
5.42	10/03/2025	1100-1205563-1551406 ustekinumab (Stelara) and Biosimilars (QUEST) archive folder link fix.
5.41	10/02/2025	1100-1205563-1551406 Tremfya IV (guselkumab) (Medicare Advantage), 10/1/2025 has been posted; ARCHIVED: 60-day notice 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. Stoboclo (denosumab-bmwo) (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. Selarsdi (ustekinumab-aekn) (QUEST) Stelara (ustekinumab) (QUEST) Steqeyma (ustekinumab-stba) (QUEST) ustekinumab (Stelara) and Biosimilars (QUEST) ustekinumab-aekn (unbranded Selarsdi) (QUEST) ustekinumab-ttwe (unbranded Pyzchiva) (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. Selarsdi (ustekinumab-aekn) (Autoimmune Preferred Drug Program) 1. Siliq (brodalumab) (Autoimmune Preferred Drug Program) 1. Simlandi (adalimumab-ryvk) (Autoimmune Preferred Drug Program) 1. Simponi (golimumab for subcutaneous injection) 1. Simponi Aria (golimumab for subcutaneous injection) 1. Skyrizi (risankizumab-rzaa) (Autoimmune Preferred Drug Program) Starjemza SQ (ustekinumab-hmny) (Autoimmune Preferred Drug Program) 1. Stelara (ustekinumab) (Autoimmune Preferred Drug Program) 1. Steqeyma (ustekinumab-stba) (Autoimmune Preferred Drug Program) 1. Taltz (ixekizumab) (Autoimmune Preferred Drug Program) 1. Tofidence (tocilizumab-bavi) (Autoimmune Preferred Drug Program) 1. Tremfya (guselkumab) (Autoimmune Preferred Drug Program) 1. Tyenne (tocilizumab-aazg) (Autoimmune Preferred Drug Program) 1. ustekinumab-aekn (unbranded Selarsdi) (Autoimmune Preferred Drug Program) ustekinumab-HIKMA (Autoimmune Preferred Drug Program) (REMOVED) ustekinumab-JJ (Autoimmune Preferred Drug Program) 1. ustekinumab-ttwe (unbranded Pyzchiva) (Autoimmune Preferred Drug Program)
5.40	09/30/2025	1100-1205556-1544400 The following policies have been posted: Signifor (pasireotide), 09/26/2025; ARCHIVED policy eff 9/27/24 2. Siliq (brodalumab), 09/26/2025; ARCHIVED policy eff 12/20/24 Spinraza (nusinersen) (Commercial and QUEST), 09/26/2025; ARCHIVED policy eff 4/1/25 Spinraza (nusinersen) (Medicare Advantage), 09/26/2025; ARCHIVED policy eff 3/20/25 Tepezza (teprotumumab-trbw), 09/26/2025; ARCHIVED policy eff 1/1/25 1100-1205556-1545954 Lanreotide (Commercial and QUEST) effective 09/26/2025 has been posted for the following drug covered under this policy. Archived: 07/26/2024. Somatuline Depot (lanreotide) (Commercial and QUEST) Lanreotide (Medicare Advantage) effective 09/26/2025 has been posted for the following drug covered under this policy. Archived: 07/26/2024. Somatuline Depot (lanreotide) (Medicare Advantage)
5.39	09/22/2025	1100-1205556-1528353 The SDRP policy eff 08/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 07/25/2025. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna 1100-1205556-1528350 The effective dates for the drugs covered under the Stelara (Medicare Advantage) policy has been corrected to 09/20/2025.
5.38	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. Selarsdi (ustekinumab-aekn) (Medicare Advantage) (NEW) Stelara (ustekinumab) (Medicare Advantage) Steqeyma (ustekinumab-stba) (Medicare Advantage) (NEW) ustekinumab-aekn (unbranded Selarsdi) (Medicare Advantage) (NEW) ustekinumab-ttwe (unbranded Pyzchiva) (Medicare Advantage) (NEW) 1100-1205556-1514402 The Global Oncology policy effective 09/12/2025 has been posted for the following drug covered under this policy: Unloxcyt (cosibelimab-ipdl) (NEW)
5.37	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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tepylute (thiotepa) (NEW) Tevimbra (tislelizumab-jsgr) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab)
5.36	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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna
5.35	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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tepylute (thiotepa) (NEW) Tevimbra (tislelizumab-jsgr) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab) 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. Selarsdi (ustekinumab-aekn) (Autoimmune Preferred Drug Program) 1. Siliq (brodalumab) (Autoimmune Preferred Drug Program) 1. Simlandi (adalimumab-ryvk) (Autoimmune Preferred Drug Program) 1. Simponi (golimumab for subcutaneous injection) 1. Simponi Aria (golimumab for subcutaneous injection) 1. Skyrizi (risankizumab-rzaa) (Autoimmune Preferred Drug Program) Starjemza SQ (ustekinumab-hmny) (Autoimmune Preferred Drug Program) 1. Stelara (ustekinumab) (Autoimmune Preferred Drug Program) 1. Steqeyma (ustekinumab-stba) (Autoimmune Preferred Drug Program) 1. Taltz (ixekizumab) (Autoimmune Preferred Drug Program) 1. Tofidence (tocilizumab-bavi) (Autoimmune Preferred Drug Program) 1. Tremfya (guselkumab) (Autoimmune Preferred Drug Program) 1. Tyenne (tocilizumab-aazg) (Autoimmune Preferred Drug Program) 1. ustekinumab-aekn (unbranded Selarsdi) (Autoimmune Preferred Drug Program) ustekinumab-HIKMA (Autoimmune Preferred Drug Program) (REMOVED) ustekinumab-JJ (Autoimmune Preferred Drug Program) 1. ustekinumab-ttwe (unbranded Pyzchiva) (Autoimmune Preferred Drug Program)
5.34	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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tepylute (thiotepa) (NEW) Tevimbra (tislelizumab-jsgr) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab) 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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna
5.33	09/02/2025	1100-1205549-1486802 The QUEST fax form links for the following drugs have been updated: Saphnelo, Signifor LAR, Skytrofa, Specialty Drugs Requiring Percert (SDRP), Spevigo, Sublocade, Takhzyro, Tezspire, Triptodur, Tzield, Ultomiris, Uplizna
5.32	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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tepylute (thiotepa) (NEW) Tevimbra (tislelizumab-jsgr) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab) 1100-1205549-1488650 The SDRP policy eff 07/01/2025-v2 has been posted for the following drugs covered under this policy. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna
5.31	08/18/2025	1100-1205549-1463454 Removed Tepylute (thiotepa) (SDRP). It was incorrectly added as a drug covered under SDRP.
5.30	08/12/2025	1100-1205549-1463454 The SDRP policy eff 07/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 06/01/2025. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tepylute (thiotepa) (NEW) Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna 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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tepylute (thiotepa) (NEW) Tevimbra (tislelizumab-jsgr) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab) 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: Stoboclo (denosumab-bmwo) (Commercial and QUEST) 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. Simlandi (adalimumab-ryvk) (Autoimmune Preferred Drug Program) 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 additional drugs covered under this policy: 1. Tofidence (tocilizumab-bavi) (Autoimmune Preferred Drug Program) (NEW) ustekinumab-HIKMA (Autoimmune Preferred Drug Program) (NEW) ustekinumab-JJ (Autoimmune Preferred Drug Program) (NEW)
5.29	08/07/2025	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: Selarsdi (ustekinumab-aekn) (QUEST) (NEW) Stelara (ustekinumab) (QUEST) (NEW) Steqeyma (ustekinumab-stba) (QUEST) (NEW) ustekinumab (Stelara) and Biosimilars (QUEST) (NEW) ustekinumab-aekn (unbranded Selarsdi) (QUEST) (NEW) ustekinumab-ttwe (unbranded Pyzchiva) (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. Selarsdi (ustekinumab-aekn) (Autoimmune Preferred Drug Program) 1. Siliq (brodalumab) (Autoimmune Preferred Drug Program) 1. Simlandi (adalimumab-ryvk) (Autoimmune Preferred Drug Program) 1. Simponi (golimumab for subcutaneous injection) 1. Simponi Aria (golimumab for subcutaneous injection) 1. Skyrizi (risankizumab-rzaa) (Autoimmune Preferred Drug Program) 1. Stelara (ustekinumab) (Autoimmune Preferred Drug Program) 1. Steqeyma (ustekinumab-stba) (Autoimmune Preferred Drug Program) 1. Taltz (ixekizumab) (Autoimmune Preferred Drug Program) 1. Tremfya (guselkumab) (Autoimmune Preferred Drug Program) 1. Tyenne (tocilizumab-aazg) (Autoimmune Preferred Drug Program) (NEW) 1. ustekinumab-aekn (unbranded Selarsdi) (Autoimmune Preferred Drug Program) ustekinumab-HIKMA (Autoimmune Preferred Drug Program) (NEW) ustekinumab-JJ (Autoimmune Preferred Drug Program) (NEW) 1. ustekinumab-ttwe (unbranded Pyzchiva) (Autoimmune Preferred Drug Program)
5.28	07/28/2025	1100-1205535-138830 Added a "2." in front of the Stelara and Biosimilars drugs below: ustekinumab-aekn (unbranded Selarsdi) (Commercial and QUEST) ustekinumab-ttwe (unbranded Pyzchiva) (Commercial and QUEST)
5.27	07/24/2025	1100-1205542-1427101 Forteo (teriparatide), 06/27/2025 has been posted for the following drug covered under this policy. ARCHIVED: policy effective 07/26/2024. teriparatide (generic) 1100-1205542-1427101 Prolia and Biosimilars (Medicare Advantage), 6/27/2025 has been posted for the following drug covered under this policy: Stoboclo (denosumab-bmwo) (Medicare Advantage) (NEW) 1100-1205542-1427101 The following drug policy effective 6/27/2025 has been posted: Tymlos (Commercial and QUEST); ARCHIVED: policy eff 7/26/2024
5.26	06/30/2025	1100-1205535-1366050 The SDRP policy eff 06/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 05/23/2025. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna 1100-1205535-138830 Soliris (Commercial and QUEST), effective 4/01/2025 v2, has been posted. ARCHIVED: policy eff 4/01/2025. 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. Selarsdi (ustekinumab-aekn) (Commercial and QUEST) 2. Stelara (ustekinumab) (Commercial and QUEST) Steqeyma (ustekinumab-stba) (Commercial and QUEST) ustekinumab-aekn (unbranded Selarsdi) (Commercial and QUEST) ustekinumab-ttwe (unbranded Pyzchiva) (Commercial and QUEST)
5.25	06/10/2025	1100-1205535-1368400 Autoimmune (AI) Preferred Drug Program (Commercial) effective 6/07/2025 has been posted for the following drugs covered under this policy. ARCHVIED: Policy effective 2/14/2025. 1. Selarsdi (ustekinumab-aekn) (Autoimmune Preferred Drug Program) (NEW) 1. Siliq (brodalumab) (Autoimmune Preferred Drug Program) 1. Simlandi (adalimumab-ryvk) (Autoimmune Preferred Drug Program) 1. Simponi (golimumab for subcutaneous injection) 1. Simponi Aria (golimumab for subcutaneous injection) 1. Skyrizi (risankizumab-rzaa) (Autoimmune Preferred Drug Program) 1. Stelara (ustekinumab) (Autoimmune Preferred Drug Program) 1. Steqeyma (ustekinumab-stba) (Autoimmune Preferred Drug Program) (NEW) 1. Taltz (ixekizumab) (Autoimmune Preferred Drug Program) 1. Tremfya (guselkumab) (Autoimmune Preferred Drug Program) 1. ustekinumab-aekn (unbranded Selarsdi) (Autoimmune Preferred Drug Program) (NEW) 1. ustekinumab-ttwe (unbranded Pyzchiva) (Autoimmune Preferred Drug Program) (NEW) 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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna The Hyaluronate Products (Commercial and QUEST Integration) effective 5/23/2025, has been posted for the following drugs covered under this policy. Archived: Policy eff 11/29/2024 2. Supartz FX® (sodium hyaluronate) (Commercial and QUEST Integration) Synojoynt (1% sodium hyaluronate) (Commercial and QUEST) (new) 2. Synvisc® (hylan G-F 20) (Commercial and QUEST Integration) 2. Synvisc One® (hylan G-F 20) (Commercial and QUEST Integration) 2. Triluron (sodium hyaluronate) (Commercial and QUEST Integration) 2. Trivisc® (sodium hyaluronate) (Commercial and QUEST Integration)
5.24	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. Selarsdi (ustekinumab-aekn) (Commercial and QUEST) (NEW) 2. Stelara (ustekinumab) (Commercial and QUEST) ARCHIVED: Stelara Policy eff 2/22/2025 Steqeyma (ustekinumab-stba) (Commercial and QUEST) (NEW) ustekinumab-aekn (unbranded Selarsdi) (Commercial and QUEST) (NEW) ustekinumab-ttwe (unbranded Pyzchiva) (Commercial and QUEST) (NEW)
5.23	05/22/2025	1100-1205528-1346450 Fax form links for the following have been update: 2. Simlandi (adalimumab-ryvk) (Commercial) 1. Trazimera (trastuzumab-qyyp) (Trastuzumab Preferred Drug Program Commercial and QUEST) 1. Trazimera (trastuzumab-qyyp) (Trastuzumab Preferred Drug Program Medicare Advantage) 2. Trazimera (trastuzumab-qyyp) (Commercial and QUEST) 2. Trazimera (trastuzumab-qyyp) (Medicare Advantage)
5.22	05/21/2025	1100-1205528-1349251 The following drugs have been posted: Simponi (golimumab for subcutaneous injection) (Commercial and QUEST), 5/25/2025. ARCHIVED: policy eff 8/1/2024 Simponi Aria (golimumab injection for intravenous use) (Commercial and QUEST), 5/25/2025. ARCHIVED: policy eff 8/1/2024 Adalimumab (Commercial) effective 5/25/2025, has been posted for the following drug covered under this policy. Archived: 60-day notice and policy eff 4/01/2025. 2. Simlandi (adalimumab-ryvk) (Commercial)
5.21	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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna Change history posted on 5/14/25 was incorrect. The correct revision edits are as follows: 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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tepylute (thiotepa) (NEW) (added to grid on 5/19/25) Tevimbra (tislelizumab-jsgr) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab)
5.20	05/16/2025	1100-1205528-1345204 Updated the Tepezza Fax Form links.
5.19	05/15/2025	1100-1205528-1344351 The following fax form links have been updated: Spinraza (nusinersen) (Commercial and QUEST Integration) 2. Tremfya (guselkumab) (Commercial and QUEST Integration)
5.18	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)
5.17	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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna
5.16	05/08/2025	1100-1205528-1315150 The following fax form links have been updated or added: Stimufend (pegfilgrastim-fpgk) (Medicare Advantage) - MA Tofidence (tocilizumab-bavi) (Commercial and QUEST Integration) - Commercial Udenyca (pegfilgrastim-cbqv) (Medicare Advantage) - MA Tyenne (tocilizumab-aazg) (Commercial and QUEST) - Commercial 1100-1205528-1330252 Edited the SDRP current effective date to 04/01/2025 as applicable.
5.15	05/06/2025	1100-1205528-1332100 Spinraza (nusinersen) (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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna
5.14	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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tevimbra (tislelizumab-jsgr) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab)
5.13	04/22/2025	1100-1205521-1305678 Tivdak: Corrected the current eff date to 02/28/2025. 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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna
5.12	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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tevimbra (tislelizumab-jsgr) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab)
5.11	04/14/2025	1100-1205521-1305653 The Actemra (Commercial and QUEST) policy, effective 04/01/2025, has been posted for the following drugs covered under this policy. ARCHIVED: 60-day notice and policy eff 2/1/2024. Tofidence (tocilizumab-bavi) (Commercial and QUEST) Tyenne (tocilizumab-aazg) (Commercial and QUEST) Adalimumab (Commercial) effective 4/01/2025, has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy eff 7/01/2024. 2. Simlandi (adalimumab-ryvk) (Commercial) Adalimumab (QUEST) effective 04/01/2025, has been posted for the following drugs covered under this policy. ARCHIVED: 60-day notice and policy 5/03/2024. Simlandi (adalimumab-ryvk) (QUEST)The following policies effective 04/01/2025 have been posted: Spinraza (nusinersen) (Commercial and QUEST); ARCHIVED: 60-day notice and policy eff 4/1/2024 Tremfya (guselkumab) (Commercial and QUEST); ARCHIVED: 60-day notice and policy eff 2/1/2024 Stelara (ustekinumab) (Medicare Advantage), effective 4/01/2025, has been posted. ARCHIVED: 60-day notice and policy eff 1/01/2024. Soliris (Commercial and QUEST), effective 4/01/2025, has been posted. ARCHIVED: 60-day notice and policy eff 1/01/2024 Rituximab (non-oncology) (Commercial and QUEST), effective 4/01/2025, has been posted for the following drug covered under this policy. ARCHIVED: 60-day notice and policy eff 4/01/2024. Truxima (rituximab-abbs)(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. Saizen (somatropin) Serostim (somatropin)
5.10	04/07/2025	1100-1205521-1301650 The SDRP policy eff 02/01/2025 has been posted for the following drugs covered under this policy. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) Tzield (teplizumab-mzwv) Ultomiris Uplizna
5.09	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. Siliq (brodalumab) 1. Simlandi (adalimumab-ryvk) 1. Simponi (golimumab for subcutaneous injection) 1. Simponi Aria (golimumab for subcutaneous injection) 1. Skyrizi (risankizumab-rzaa) 1. Stelara (ustekinumab) 1. Taltz (ixekizumab) 1. Tremfya (guselkumab) 1100-1205514-1272761 Link fix: Tryngolza (olezarsen sodium)
5.08	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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) (new eff 10/23/2024) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tevimbra (tislelizumab-jsgr) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab) Change history notes from 2020, 2021, and 2022 are archived and have been removed from this article.
5.07	03/11/2025	1100-1205514-1261250 The following edits were applied: Deleted: Trazimera (trastuzumab-qyyp) (QUEST Integration) Updated: 2. Kanjinti (trastuzumab-anns) (Commercial and QUEST)
5.06	03/10/2025	1100-1205514-1272752 The following drug policies have been posted: Taltz (ixekizumab) (Commercial and QUEST), effective 2/22/2025; ARCHIVED: Policy eff 2/1/2024 Stelara (Commercial and QUEST), effective 2/22/2025; ARCHIVED: Policy eff 2/1/2024 1100-1205514-1272756 Remodulin (Medicare Advantage) policy, effective 3/1/2025 has been posted. ARCHIVED: 60-day notice and policy effective 1/1/2024. treprostinil injection (generic) (Medicare Advantage) 1100-1205514-1272761 The SDRP policy eff 01/01/2025, v2 has been posted for the following drugs covered under this policy. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tryngolza (olezarsen sodium) (NEW) Tzield (teplizumab-mzwv) Ultomiris Uplizna
5.05	03/05/2025	1100-1205514-1265700 The Actemra (Commercial and QUEST) redlined 60-day provider notice (02/01/2025-03/31/2025), effective 04/01/2025, has been posted for the following drugs covered under this policy: Tofidence (tocilizumab-bavi) (Commercial and QUEST) (NEW) Tyenne (tocilizumab-aazg) (Commercial and QUEST) (NEW) The Adalimumab redlined 60-day provider notice (02/01/2025-03/31/2025), effective 04/01/2025, has been posted for the following drug covered under this policy: 2. Simlandi (adalimumab-ryvk) (Commercial) The Adalimumab redlined 60-day provider notice (02/01/2025-03/31/2025), effective 04/01/2025, has been posted for the following drug covered under this policy: Simlandi (adalimumab-ryvk) (QUEST) Growth Hormone Therapy 60-day provider notice (2/1/25-3/31/25), effective 04/01/2025, have been posted for the following drugs covered under this policy: Saizen (somatropin) Serostim (somatropin) The following redlined 60-day provider notices (02/01/2025-03/31/2025), effective 04/01/2025 have been posted: Soliris (Commercial and QUEST) Spinraza (nusinersen) (Commercial and QUEST) Tremfya (guselkumab) (Commercial and QUEST) The Rituximab (non-oncology) (Commercial and QUEST Integration) 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: Truxima (rituximab-abbs)(Commercial and QUEST) The Stelara (Medicare Advantage) 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: Stelara (ustekinumab) (Medicare Advantage)
5.04	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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) (new eff 10/23/2024) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tevimbra (tislelizumab-jsgr) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab)
5.03	02/10/2025	1100-1205507-1238900 The SDRP policy eff 01/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 12/16/2024. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tezspire (tezepelumab-ekko) Triptodur Tzield (teplizumab-mzwv) Ultomiris Uplizna

Rev#:	Date:	Nature of Change:
5.02	02/05/2025	1100-1205507-1235400 The SDRP policy eff 12/16/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 10/3/2024. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tepezza Tezspire (tezepelumab-ekko) Triptodur Tzield (teplizumab-mzwv) Ultomiris Uplizna
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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) (new eff 10/23/2024) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tevimbra (tislelizumab-jsgr) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab)
5.00	01/07/2025	1100-956557-1197451 Edit treprostinil (generic) link to 60-day provider notice (01/01/2025-02/28/2025) eff 03/01/2025
4.37 (v234)	12/30/2024	1100-956557-1197451 Remodulin (Medicare Advantage) 60-day provider notice (01/01/2025-02/28/2025), effective 03/01/2025, has been posted for the following drug covered under this policy: treprostinil (generic) (Medicare Advantage) 1100-956557-1197456 The following policies have been posted: Simponi Aria (golimumab injection for intravenous use) (Medicare Advantage), 1/1/2025; ARCHIVED: 60-day notice effective 1/1/2025 and policy effective 1/1/2024 Skyrizi (risankizumab-rzaa), 1/1/2025; ARCHIVED: 60-day notice effective 1/1/2025 and policy effective 12/1/2023 Tepezza (teprotumumab-trbw) (Commercial and QUEST), 1/1/2025; ARCHIVED: 60-day notice effective 1/1/2025 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. Stimufend (pegfilgrastim-fpgk) (Commercial) Udenyca (pegfilgrastim-cbqv) (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. Stimufend (pegfilgrastim-fpgk) (Medicare Advantage) Udenyca (pegfilgrastim-cbqv) (Medicare Advantage) 1100-956557-1197456 The Hyaluronates Preferred Drug Program (Commercial and QUEST) policy effective 1/1/2025, has been posted for the following drugs covered under this policy. Archived: 60-day provider notice effective 1/1/2025 and policy effective 1/1/2024. 1. Supartz FX (Commercial and QUEST) 1. Synvisc (Commercial and QUEST) 1. Synvisc One (Commercial and QUEST) 1. Triluron (Commercial and QUEST) 1. Trivisc (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. Supartz FX (sodium hyaluronate) (Medicare Advantage) 1. Synvisc (Medicare Advantage) 1. Synvisc One (Medicare Advantage) 1. Triluron (sodium hyaluronate) (Medicare Advantage) 1. Trivisc (Medicare Advantage) 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. Truxima (rituximab-abbs) (Commercial) Rituximab Products - Medicare Part B Preferred Drug Program effective 01/01/2025, has been posted for the following drug covered under this policy. Archived: 60-day provider notice eff 1/1/25 and policy eff 1/1/24. 1. Truxima (rituximab-abbs) (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 Trastuzumab Preferred Drug Program (Commercial and QUEST) 1. Trazimera (trastuzumab-qyyp) (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. Trastuzumab Preferred Drug Program (Medicare Advantage) 1. Trazimera (trastuzumab-qyyp) (Medicare Advantage)
4.36 (v233)	12/23/2024	1100-956557-1204850 The Actemra (tocilizumab) (Medicare Advantage) policy effective 12/20/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 1/1/2024 Tofidence (tocilizumab-bavi) (Medicare Advantage) (new) 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 treprostinil (generic) (Commercial and QUEST) The following policies have been posted: Siliq (brodalumab) (Commercial and QUEST), 12/20/2024; ARCHIVED: policy eff 2/1/2024 Soliris (eculizumab) (Medicare Advantage), 12/20/2024; ARCHIVED: policy eff 1/1/2024 Spinraza (nusinersen) (Medicare Advantage), 12/20/2024; ARCHIVED: policy eff 1/1/2024 The Hyaluronates Medicare Part B policy effective 12/20/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 5/30/2024. 2. Supartz FX ® (sodium hyaluronate) (Medicare Advantage) Synojoynt (1% sodium hyaluronate) (Medicare Advantage) (new) 2. Synvisc® (hylan G-F 20) (Medicare Advantage) 2. Synvisc One® (hylan G-F 20) (Medicare Advantage) 2. Triluron (sodium hyaluronate) (Medicare Advantage) 2. Trivisc® (sodium hyaluronate) (Medicare Advantage)
4.35 (v232)	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. Supartz FX® (sodium hyaluronate) (Commercial and QUEST Integration) Synojoynt (1% sodium hyaluronate) (Commercial and QUEST) (new) 2. Synvisc® (hylan G-F 20) (Commercial and QUEST Integration) 2. Synvisc One® (hylan G-F 20) (Commercial and QUEST Integration) 2. Triluron (sodium hyaluronate) (Commercial and QUEST Integration) 2. Trivisc® (sodium hyaluronate) (Commercial and QUEST Integration)
4.34 (v231)	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. Siliq (brodalumab) 1. Simlandi (adalimumab-ryvk) 1. Simponi (golimumab for subcutaneous injection) 1. Simponi Aria (golimumab for subcutaneous injection) 1. Skyrizi (risankizumab-rzaa) 1. Stelara (ustekinumab) 1. Taltz (ixekizumab) 1. Tremfya (guselkumab) 1100-956552-1182203 The Global Oncology policy effective 11/15/2024 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 10/23/2024. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) (new eff 10/23/2024) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tevimbra (tislelizumab-jsgr) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab)
4.33 (v230)	11/01/2024	1100-956547-1167950 60-day provider notices (11/01/2024-12/31/2024) eff 1/1/2025 have been posted for the following drugs: Simponi Aria (golimumab injection for intravenous use) (Medicare Advantage) 2. Skyrizi (risankizumab-rzaa) Tepezza (teprotumumab-trbw) (Commercial and QUEST) 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. Stimufend (pegfilgrastim-fpgk) (Commercial) Udenyca (pegfilgrastim-cbqv) (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. Stimufend (pegfilgrastim-fpgk) (Medicare Advantage) Udenyca (pegfilgrastim-cbqv) (Medicare Advantage) The Hyaluronates Preferred Drug Program (Commercial and QUEST) 60-day provider notice (11/01/2024-12/31/2024), effective 01/01/2025, has been posted for the following drugs covered under this policy: 1. Supartz FX (Commercial and QUEST) 1. Synvisc (Commercial and QUEST) 1. Synvisc One (Commercial and QUEST) 1. Triluron (Commercial and QUEST) 1. Trivisc (Commercial and QUEST) The Hyaluronates Medicare Part B Preferred Drug Program 60-day provider notice (11/01/2024-12/31/2024), effective 01/01/2025, has been posted for the following drugs covered under this policy: 1. Supartz FX (sodium hyaluronate) (Medicare Advantage) 1. Synvisc (Medicare Advantage) 1. Synvisc One (Medicare Advantage) 1. Triluron (sodium hyaluronate) (Medicare Advantage) 1. Trivisc (Medicare Advantage) Rituximab 60-day provider notice (11/01/2024-12/31/2024) eff 1/1/2025, has been posted for the following drug covered under this policy: 1. Truxima (rituximab-abbs) (Commercial) Rituximab 60-day provider notice (11/01/2024-12/31/2024) eff 1/1/2025, has been posted for the following drug covered under this policy: 1. Truxima (rituximab-abbs) (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: Trastuzumab Preferred Drug Program (Commercial and QUEST) 1. Trazimera (trastuzumab-qyyp) (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: Trastuzumab Preferred Drug Program (Medicare Advantage) 1. Trazimera (trastuzumab-qyyp) (Medicare Advantage)
4.32 (v229)	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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) (new eff 10/23/2024) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tevimbra (tislelizumab-jsgr) (new eff 9/10/2024) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab) The SDRP policy eff 10/3/2024 v2 has been posted for the following drugs covered under this policy. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tegsedi (Discontinued effective 9/27/2024) Tepezza Tezspire (tezepelumab-ekko) Triptodur Tzield (teplizumab-mzwv) Ultomiris Uplizna
4.31 (v228)	10/21/2024	1100-956547-1156401 Correction: Effective date for sajazir (generic), 9/27/2024
4.30 (v227)	10/11/2024	1100-956547-1156401 Signifor (pasireotide) (Commercial and QUEST Integration), 09/27/2024 has been posted. Archived: 08/25/2023 Icatibant (generic) (Commercial and QUEST), effective 09/27/2024 has been posted for the following drug covered under this policy. The policy effective 10/27/2023 has been archived. sajazir (generic) 1100-956547-1156413 The SDRP policy eff 10/3/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 9/27/2024. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tegsedi (Discontinued effective 9/27/2024) Tepezza Tezspire (tezepelumab-ekko) Triptodur Tzield (teplizumab-mzwv) Ultomiris Uplizna
4.29 (v226)	10/10/2024	1100-956547-1150004 Corrected the effective date to 9/27/2024 for Ultomiris and Uplizna 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. Siliq (brodalumab) 1. Simlandi (adalimumab-ryvk) (Autoimmune Preferred Drug Program)(new) 1. Simponi (golimumab for subcutaneous injection) 1. Simponi Aria (golimumab for subcutaneous injection) 1. Skyrizi (risankizumab-rzaa) 1. Stelara (ustekinumab) 1. Taltz (ixekizumab) 1. Tremfya (guselkumab)
4.28 (v225)	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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tegsedi (Discontinued effective 9/27/2024) Tepezza Tezspire (tezepelumab-ekko) Triptodur Tzield (teplizumab-mzwv) Ultomiris Uplizna
4.27 (v224)	09/30/2024	1100-956542-1148056 Growth Hormone Therapy, 10/01/2024, has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy effective 12/15/2023. Saizen (somatropin) Serostim (somatropin)
4.36 (v223)	09/25/2024	1100-956542-1145350 The SDRP policy eff 9/10/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 8/23/2024. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tegsedi Tepezza Tezspire (tezepelumab-ekko) Triptodur Tzield (teplizumab-mzwv) Ultomiris Uplizna
4.35 (v222)	09/18/2024	1100-956542-1140010 The Synagis (palivizumab policy eff 8/1/2024 has been posted. ARCHIVED: Policy eff 9/13/2024. Commercial and QUEST fax form link have been posted effective, 09/2024.
4.34 (v221)	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.. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tevimbra (tislelizumab-jsgr) (new eff 9/10/2024) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab)
4.33 (v220)	09/11/2024	1100-956542-1133403 The Synagis policy eff 9/13/2024 has been posted. ARCHIVED: policy effective 8/1/2023.
4.32 (v219)	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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tegsedi Tepezza Tezspire (tezepelumab-ekko) Triptodur Tzield (teplizumab-mzwv) Ultomiris Uplizna
4.31 (v218)	08/08/2024	1100-956537-1105000 1100-956537-1104509 Minor typo fixes.
4.30 (v217)	08/06/2024	1100-956537-1105000 The following policies have been posted: 2. Simponi (golimumab for subcutaneous injection) (Commercial and QUEST Integration), 8/1/2024; ARCHIVED: 60-day notice and poicy eff 12/1/2023 2. Simponi Aria (golimumab for subcutaneous injection) (Commercial and QUEST Integration), 8/1/2024; ARCHIVED: 60-day notice and poicy eff 2/1/2024 1100-956537-1104509 The following policies have been posted: Supprelin LA (histrelin acetate implant) (Commercial and QUEST Integration), 07/26/2024. Archived: 12/15/2023 Tymlos (abaloparatide) (Commercial and QUEST Integration), 07/26/2024. Archived: 1/1/2024 Forteo (teriparatide), 07/26/2024 has been posted for the following drug covered under this policy. Archived: 3/22/2024. teriparatide (generic) Lanreotide (Commercial and QUEST Integration) effective 07/26/2024 has been posted for the following drug covered under this policy. Archived: 04/01/2024. Somatuline Depot (lanreotide) (Commercial and QUEST Integration) Lanreotide (Medicare Advantage) effective 07/26/2024 has been posted for the following drug covered under this policy. Archived: 01/01/2024. Somatuline Depot (lanreotide) (Medicare Advantage)
4.29 (v216)	08/05/2024	1100-956537-1104504 Growth Hormone Therapy 60-day provider notice (08/01/2024-09/30/2024), effective 10/01/2024, have been posted for the following drugs covered under this policy: Saizen (somatropin) Serostim (somatropin)
4.28 (v215)	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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab) 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)
4.28 (v214)	06/27/2024	1100-956527-10802405 The following note has been added to Tegsedi (inotersen): Effective 9/27/2024 Tegsedi will be discontinued. PA requests will be redirected back to the provider for an alternative product.
4.27 (v213)	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. Siliq (brodalumab) 1. Simlandi (adalimumab-ryvk) (Autoimmune Preferred Drug Program)(new) 1. Simponi (golimumab for subcutaneous injection) 1. Simponi Aria (golimumab for subcutaneous injection) 1. Skyrizi (risankizumab-rzaa) 1. Stelara (ustekinumab) 1. Taltz (ixekizumab) 1. Tremfya (guselkumab) Humira (adalimumab) (Commercial) effective 07/01/2024, has been posted for the following drugs covered under this policy. Archived: policy eff 04/01/2024. 2. Simlandi (adalimumab-ryvk) (Commercial) (new)
4.26 (v212)	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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tegsedi Tepezza Tezspire (tezepelumab-ekko) Triptodur Tzield (teplizumab-mzwv) Ultomiris Uplizna
4.25 (v211)	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. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tivdak (tisotumab vedotin-tftv) Torisel 2. Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab)
4.24 (v210)	06/06/2024	1100-956527-1069655 The following redlined 60-day notices (06/01/2024-07/31/2024) have been posted: 2. Simponi (golimumab for subcutaneous injection) (Commercial and QUEST Integration) 2. Simponi Aria (golimumab for subcutaneous injection) (Commercial and QUEST Integration)
4.23 (v209)	05/31/2024	1100-956522-1064200 Minor typographical fix.
4.22 (v208)	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. Supartz FX ® (sodium hyaluronate) (Medicare Advantage) Synojoynt (1% sodium hyaluronate) (Medicare Advantage) (new) 2. Synvisc® (hylan G-F 20) (Medicare Advantage) 2. Synvisc One® (hylan G-F 20) (Medicare Advantage) 2. Triluron (sodium hyaluronate) (Medicare Advantage) 2. Trivisc® (sodium hyaluronate) (Medicare Advantage)
4.21 (v207)	05/24/2024	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. Siliq (brodalumab) #1. Simlandi (adalimumab-ryvk) (Autoimmune Preferred Drug Program)(new) #1. Simponi (golimumab for subcutaneous injection) #1. Simponi Aria (golimumab for subcutaneous injection) #1. Skyrizi (risankizumab-rzaa) #1. Stelara (ustekinumab) #1. Taltz (ixekizumab) #1. Tremfya (guselkumab)
4.20 (v206)	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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tegsedi Tepezza Tezspire (tezepelumab-ekko) Triptodur Tzield (teplizumab-mzwv) Ultomiris Uplizna
4.19 (v205)	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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tegsedi Tepezza Tezspire (tezepelumab-ekko) Triptodur Tzield (teplizumab-mzwv) Ultomiris Uplizna
4.18 (v204)	05/13/2024	1100-956522-1053152 Updated the Commercial and QUEST Integration fax form links for Skyrizi.
4.17 (v203)	05/10/2024	1100-956522-1050250 Updated the Adalimumab Preferred Drug Program (QUEST Integration) archived folder link.
4.16 (v202)	05/08/2024	1100-956522-1050250 Adalimumab Preferred Drug Program (QUEST Integration) effective 5/03/2024, has been posted for the following drug covered under this policy. Archived: policy eff 4/1/2024 Simlandi (adalimumab-ryvk) (new eff 5/1/2024) 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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tegsedi Tepezza Tezspire (tezepelumab-ekko) Triptodur Tzield (teplizumab-mzwv) Ultomiris Uplizna
4.15 (v201)	05/07/2024	1100-956522-1048951 Text edit to Spravato information.
4.14 (v200)	05/06/2024	1100-956522-1046905 Rituximab (non-oncology) (Medicare Advantage) effective 04/26/2024, v2, has been posted for the following drug covered under this policy. Effective date typo fix. Truxima (non-oncology) (Medicare Advantage)
4.13 (v199)	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. Siliq (brodalumab) #1. Simponi (golimumab for subcutaneous injection) #1. Simponi Aria (golimumab for subcutaneous injection) #1. Skyrizi (risankizumab-rzaa) #1. Stelara (ustekinumab) #1. Taltz (ixekizumab) #1. Tremfya (guselkumab) 1100-956522-1046903 Spravato (esketamine): Added a link to the medical policy Intranasal Esketamine for Major Depressive Disorder with Acute Suicidality and Treatment-Resistant Depression, located on Medical Policies - CURRENT. 1100-956522-1046905 Rituximab (non-oncology) (Medicare Advantage) effective 04/26/2024, has been posted for the following drug covered under this policy. Archived: policy eff 1/1/2024. Truxima (non-oncology) (Medicare Advantage)
4.12 (v198)	04/05/2024	Skysona (elivaldogene autotemcel) has been added to the applicable table.
4.11 (v197)	03/31/2024	The following policy has been posted: Spinraza (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 drugs covered under this policy. Archived: 60-day notice and policy eff 1/1/2024. 2. Supartz FX® (sodium hyaluronate) (Commercial and QUEST Integration) 2. Synvisc® (hylan G-F 20) (Commercial and QUEST Integration) 2. Synvisc One® (hylan G-F 20) (Commercial and QUEST Integration) 2. Triluron (sodium hyaluronate) (Commercial and QUEST Integration) 2. Trivisc® (sodium hyaluronate) (Commercial and QUEST Integration) Lanreotide (Commercial and QUEST Integration) effective 4/01/2024 has been posted for the following drug covered under this policy. Archived: 60-day notice and policy eff 1/1/2024. Somatuline Depot (lanreotide) (Non-oncology) (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: Truxima (rituximab-abbs) (non-oncology) (Commercial and QUEST Integration)
4.10 (v196)	03/28/2024	Forteo (teriparatide), 3/22/2024 has been posted for the following drug covered under this policy. The policy eff 7/28/2023 has been archived. teriparatide (generic)
4.9 (v195)	03/21/2024	Added the Medicare fax form link for Tzield.
4.8 (v194)	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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tegsedi Tepezza Tezspire (tezepelumab-ekko) Triptodur Tzield (teplizumab-mzwv) Ultomiris Uplizna
4.7 (v193)	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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tegsedi Tepezza Tezspire (tezepelumab-ekko) Triptodur Tzield (teplizumab-mzwv) Ultomiris Uplizna
4.6 (v192)	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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tegsedi Tepezza Tezspire (tezepelumab-ekko) Triptodur Tzield (teplizumab-mzwv) Ultomiris Uplizna
4.5 (v191)	02/08/2024	The following links were corrected: 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. Supartz FX® (sodium hyaluronate) (Commercial and QUEST Integration) 2. Synvisc® (hylan G-F 20) (Commercial and QUEST Integration) 2. Synvisc One® (hylan G-F 20) (Commercial and QUEST Integration) 2. Triluron (sodium hyaluronate) (Commercial and QUEST Integration) 2. Trivisc® (sodium hyaluronate) (Commercial and QUEST Integration) The "2." has been removed from the following rows: Truxima (Commercial and QUEST Integration) (non-oncology) Truxima (Medicare Advantage) (non-oncology)
4.4 (v190)	02/05/2024	Updated fax form links for the following: Truxima (QUEST Integration) oncology and non-oncology
4.3 (v189)	02/01/2024	60-day notice has been posted for the following drug. Provider notification period is 2/1/2024-3/31/2024. Spinraza (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. Supartz FX® (sodium hyaluronate) (Commercial and QUEST Integration) 2. Synvisc® (hylan G-F 20) (Commercial and QUEST Integration) 2. Synvisc One® (hylan G-F 20) (Commercial and QUEST Integration) 2. Triluron (sodium hyaluronate) (Commercial and QUEST Integration) 2. Trivisc® (sodium hyaluronate) (Commercial and QUEST Integration) Lanreotide (Commercial and QUEST Integration) 60-day provider notice (02/01/2024-03/31/2024), effective 4/01/2024, has been posted for the following drug covered under this policy: Somatuline Depot (lanreotide) (Non-oncology) 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. Truxima (rituximab-abbs)
4.2 (v188)	01/31/2024	Updated fax form links for the following: Simponi Aria, Soliris, Somatuline Depot, Spinraza, Stelara, Trazimera (new line for QI), Treprostinil, Truxima (new line for QI), Tymlos
4.1 (v187)	01/30/2024	The following policies have been posted: 2. Siliq (brodalumab), 2/1/2024; ARCHIVED: 60-day notice eff 2/1/24 and policy eff 10/22/2022 2. Simponi Aria (golimumab injection for intravenous use), 2/1/2024; ARCHIVED: 60-day notice eff 2/1/24 and policy eff 1/1/2024; linked new COMM-QI archive folder 2. Stelara (ustekinumab), 2/1/2024; ARCHIVED: 60-day notice eff 2/1/24 and policy eff 1/1/2024; linked new COMM-QI archive folder 2. Taltz (ixekizumab), 2/1/2024; ARCHIVED: 60-day notice eff 2/1/24 and policy eff 9/1/2022 2. Tremfya (guselkumab), 2/1/2024; ARCHIVED: 60-day notice eff 2/1/24 and policy eff 9/1/2022
4.0 (v186)	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. Saphnelo (anifrolumab-fnia) Signifor LAR Skytrofa (lonapegsomatropin-tcgd) Sogroya (somapacitan-beco) Specialty Drugs Requiring Precertification (SDRP policy) Spevigo (spesolimab-sbzo) Strensiq (drug is not covered under Part B) Sublocade Syfovre (pegcetacoplan) Takhzyro Tegsedi Tepezza Tezspire (tezepelumab-ekko) Triptodur Tzield (teplizumab-mzwv) Ultomiris Uplizna

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