Information

Title Medical Specialty Drug Policies: V-Z

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

S-U

V

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Vabysmo (faricimab-svoa)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 4/1/2022	ARCHIVED - SDRP
Vectibix (Panitumumab)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Vegzelma (bevacizumab-adcd) (Bevacizumab Preferred Drug Program Commercial)		01/01/2026	Commercial Fax Form	Bevacizumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Bevacizumab Products (Commercial)
2. Vegzelma (bevacizumab-adcd) (Commercial)		04/14/2026		Global Oncology	ARCHIVED - Global Oncology
1. Vegzelma (bevacizumab-adcd) (Bevacizumab Preferred Drug Program Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Bevacizumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Bevacizumab Products (MA)
2. Vegzelma (bevacizumab-adcd) (Medicare Advantage)		04/14/2026		Global Oncology	ARCHIVED - Global Oncology
1. Vegzelma (bevacizumab-adcd) (Bevacizumab Preferred Drug Program policy QUEST)		01/01/2026		Bevacizumab Products - Preferred Drug Program QUEST Effective 1/1/2025	ARCHIVED - Bevacizumab Products (QUEST)
2. Vegzelma (bevacizumab-adcd) (QUEST)		04/14/2026	QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
Velcade (bortezomib)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Veletri (epoprostenol) (Commercial and QUEST)	60-day provider notice 04/01/2026-05/31/2026, in effect 6/1/2026	12/19/2025	Fax Form	Flolan; Veletri; epoprostenol (generic)	ARCHIVED - Flolan-Veletri-epoprostenol (Comm-QI) ARCHIVED - Flolan-Veletr
Veletri (epoprostenol) (Medicare Advantage)		12/19/2025	Medicare Advantage Fax Form	Flolan; Veletri; epoprostenol (generic)	ARCHIVED - Flolan-Veletri-epoprostenol (MA)
Veopoz (pozelimab-bbfg)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 9/1/2023	ARCHIVED - SDRP
Viltepso (viltolarsen)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Vimizim (elosulfase alfa) (Commercial and QUEST)		05/23/2025	Fax Form		ARCHIVED - Vimzim (Comm-QI) ARCHIVED - Vimizim
Vimizim (elosulfase alfa) (Medicare Advantage)		05/23/2025	Medicare Advantage Fax Form		ARCHIVED - Vimzim (MA)
1. Visco-3 ® (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Visco-3 Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Visco-3 ® (sodium hyaluronate) (Commercial and QUEST)		04/12/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI) ARCHIVED - Hyaluronates (drug specific)
1. Visco-3 (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Visco-3 Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program (MA)
2. Visco-3 ® (sodium hyaluronate) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Visudyne (verteporfin) (Commercial and QUEST)	No PA required				ARCHIVED - Retinal Disorders Preferred Drug Program
Visudyne (verteporfin) (Medicare Advantage)	No PA required as of 02/01/2022			Retinal Disorders Preferred Drug Program	ARCHIVED - Retinal Disorders Preferred Drug Program (MA)
Voxzogo (vosoritide)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 4/1/2022	ARCHIVED - SDRP
Voyxact (sibeprenlimab-szsi)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 12/23/2025	ARCHIVED - SDRP
VPRIV (velaglucerase) (Commercial and QUEST)		10/25/2024	Fax Form		ARCHIVED - VPRIV (Comm-QUEST) ARCHIVED - VPRIV
VPRIV (velaglucerase) (Medicare Advantage)		05/23/2025	Medicare Advantage Fax Form		ARCHIVED - VPRIV (MA)
Vyalev (foscarbidopa and foslevodopa)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Vyepti (eptinezumab-jjmr)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Vyjuvek (Beremagene geperpavec-svdt)	Effective 06/01/2024: Please contact HMSA at 808-948-6464, option #4, for drug review.
Vykoura (leucovorin calcium)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Vyloy (zolbetuximab-clzb)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Vyondys 53 (golodirsen)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Vyvgart (efgartigimod alfa-fcab)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 4/1/2022	ARCHIVED - SDRP
Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 7/1/2023	ARCHIVED - SDRP

W

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Wainua (eplontersen)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 1/1/2024	ARCHIVED - SDRP
1. Wezlana (ustekinumab-auub) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Wezlana fax forms.	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Wezlana (ustekinumag-auub) (Commercial)		01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial and QUEST)	ARCHIVED - Stelara and Biosimilars (Commercial)
Wezlana (ustekinumab-auub) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
Wezlana (ustekinumab-auub) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
Winrevair (sotatercept-csrk)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 5/17/2024	ARCHIVED - SDRP
Wyost (denosumab-bbdz) (Commercial and QUEST)		06/27/2025	Commercial Fax Form QUEST Fax Form	Xgeva and Biosimilars (Commercial and QUEST) Added eff 6/27/2025	ARCHIVED - Xgeva (Comm-QUEST)
Wyost (denosumab-bbdz) (Medicare Advantage)		06/27/2025	Medicare Advantage Fax Form	Xgeva and Biosimilars (Medicare Advantage) Added eff 6/27/2025	ARCHIVED - Xgeva (MA)

X

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Xembify (Immune Globulin Subcutaneous [Human] – klhw, 20%) (Commercial and QUEST)		10/01/2025	Commercial Fax Form QUEST Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED - SCIG (Comm-QUEST)
Xembify (Immune Globulin Subcutaneous [Human] – klhw, 20%) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED - SCIG (MA)
Xenpozyme (olipudase alfa-rpcp)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 11/1/2022	ARCHIVED - SDRP
Xeomin (incobotulinumtoxinA)		04/01/2026	Fax Form QUEST Fax Form Medicare Advantage Fax Form	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY)	ARCHIVED - Botulinum Toxins
1. Xeomin (Botulinum Toxins Preferred Drug Program) Medicare Advantage		11/21/2025	Refer below for Xeomin Fax Forms	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY) Preferred Drug Program	ARCHIVED - Botulinum Toxins Preferred Drug Program MA
2. Xeomin (incobotulinumtoxinA)		04/01/2026	Fax Form QUEST Fax Form Medicare Advantage Fax Form	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY)	ARCHIVED - Botulinum Toxins
Xgeva (denosumab) (Commercial and QUEST)		06/27/2025	Commercial Fax Form QUEST Fax Form	Xgeva and Biosimilars (Commercial and QUEST)	ARCHIVED - Xgeva (Comm-QUEST) ARCHIVED - Xgeva
Xgeva (denosumab) (Medicare Advantage)		06/27/2025	Medicare Advantage Fax Form	Xgeva and Biosimilars (Medicare Advantage)	ARCHIVED - Xgeva (MA)
Xolair (omalizumab) (Commercial and QUEST)		12/19/2025	Commercial Fax Form QUEST Fax Form		ARCHIVED - Xolair (Comm-QUEST) ARCHIVED - Xolair
Xolair (omalizumab) (Medicare Advantage)		01/19/2026	Medicare Advantage Fax Form	Xolair-Omlyclo	ARCHIVED - Xolair (MA)
Xybryk (denosumab-dssb) (Commercial and QUEST)		06/27/2025	Commercial Fax Form QUEST Fax Form	Xgeva and Biosimilars (Commercial and QUEST) Added eff 6/27/2025	ARCHIVED - Xgeva (Comm-QUEST)
Xybryk (denosumab-dssb) (Medicare Advantage)		06/27/2025	Medicare Advantage Fax Form	Xgeva and Biosimilars (Medicare Advantage) Added eff 6/27/2025	ARCHIVED - Xgeva (MA)
Xyntha [Factor VIII (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review

Y

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Yartemlea (narsoplimab-wuug)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Yervoy (ipilimumab)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Yescarta (axicabtagene ciloleucel)	Effective 06/24/2019: Please contact HMSA at 808-948-6464, option #4, for drug review
1. Yesintek (ustekinumab-kfce) (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. Yesintek (ust ekinumab-kfce (Commercial )		01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial-QUEST)	ARCHIVED - Stelara and Biosimilars (Commercial)
Yesintek (ustekinumab-kfce) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
Yesintek (ustekinumab-kfce) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
Yimmugo (Commercial and QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG) - Comm-QUEST	ARCHIVED - IVIG (Comm-QUEST)
Yimmugo (Medicare Advantage)		10/01/2025		Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Yondelis (trabectedin)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Yorvipath (palopegteriparatide)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
1. Yuflyma (adalimumab-aaty) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Yuflyma fax forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Yuflyma (adalimumab-aaty) (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 12/1/2023	ARCHIVED - Adalimumab (Humira)
Yuflyma (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QI)
1. Yusimry (adalimumab-aqvh) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Yusimry fax forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Yusimry (adalimumab-aqvh) (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 12/1/2023	ARCHIVED - Adalimumab (Humira)
Yusimry (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QI)
Yutiq (fluocinolone acetonide intravitreal implant)		04/14/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP

Z

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Zaltrap (ziv-aflibercept)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Zarxio (filgrastim-sndz) (Commercial and QUEST)	No PA required	11/21/2025		Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program	ARCHIVED - CSF Short Acting Preferred Drug Program
Zarxio (filgrastim-sndz) (Medicare Advantage)	No PA required	11/21/2025		CSF – Short Acting Preferred Drug Program MA	ARCHIVED - CSF Short Acting (Preferred Drug Program) (MA)
Zepzelca (lurbinectedin)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Ziextenzo (pegfilgrastim-bmez) (CSF Long Acting Preferred Drug Program Commercial)		01/01/2026	Fax Form	Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CSF Long Acting Preferred Drug Program
Ziextenzo (pegfilgrastim-bmez) (CSF Long Acting Preferred Drug Program 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)
Ziihera (zanidatamab-hrii)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Zilbrysq (zilucoplan)		04/14/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 1/1/2024	ARCHIVED - SDRP
1. Zirabev (bevacizumab-bvzr) (Bevacizumab Preferred Drug Program Commercial)		01/01/2026	Commercial Fax Form	Bevacizumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Bevacizumab Products (Commercial)
2. Zirabev (bevacizumab-bvzr) (Commercial)		04/14/2026		Global Oncology	ARCHIVED - Global Oncology
1. Zirabev (bevacizumab-bvzr) (Bevacizumab Preferred Drug Program Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Bevacizumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Bevacizumab Products (MA)
2. Zirabev (bevacizumab-bvzr) (Medicare Advantage)		04/14/2026		Global Oncology	ARCHIVED - Global Oncology
1. Zirabev (bevacizumab-bvzr) (Bevacizumab Preferred Drug Program policy QUEST)		01/01/2026		Bevacizumab Products - Preferred Drug Program QUEST Effective 1/1/2025	ARCHIVED - Bevacizumab Products (QUEST)
2. Zirabev (bevacizumab-bvzr) (QUEST)		04/14/2026	QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
Zolgensma (onasemnogene abeparvovec-xioi)	Effective 06/24/2019: Please contact HMSA at 808-948-6464, option #4, for drug review
Zomacton™ (somatropin) (Commercial and QUEST)		01/01/2026	Fax Form	Growth Hormone	ARCHIVED - Growth Hormone
Zorbtive^®(somatropin) (Commercial and QUEST)		01/01/2026	Fax Form	Growth Hormone	ARCHIVED - Growth Hormone
Zulresso (brexanolone)	Effective 06/24/2019: Please contact HMSA at 808-948-6464, option #4, for drug review
Zusduri (mitomycin)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 07/10/2025	ARCHIVED - Global Oncology
1. Zymfentra (infliximab-dyyb) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Zymfentra fax forms.	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Zymfentra (infliximab-dyyb) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Infliximab-Avsola-Inflectra-Remicade-Renflexis-Zymfentra	ARCHIVED - Infliximab (Comm-QUEST) ARCHIVED - Infliximab ARCHIVED - SDRP
Zymfentra (infliximab-dyyb) (QUEST)	60-day provider notice 05/01/2026-06/30/2026, in effect 07/01/2026			Infliximab-Avsola-Inflectra-Renflexis-Zymfentra (QUEST)
Zymfentra (infliximab-dyyb) (Medicare Advantage)	Drug is not covered under Medicare Part B effective 08/18/2024
Zynlonta (loncastuximab tesirine-lpyl)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 11/18/2025	ARCHIVED - Global Oncology
Zynteglo (betibeglogene autotemcel	Please contact HMSA at 808-948-6464, option #4, for drug review
Zynyz (retifanlimab-dlwr)		04/14/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Effective 5/10/2023	ARCHIVED - Global Oncology

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

Change History

Rev#:	Date:	Nature of Change:
6.28	05/07/2026	1100-1677778-1848950 Infliximab (QUEST) 60-day provider notice (05/01/2026-06/30/2026) in effect 07/01/2026 has been posted for the following drug: Zymfentra (infliximab-dyyb) (QUEST)
6.27	05/04/2026	1100-1677778-1846250 The fax form links for the following drugs have been updated: Xembify (Medicare Advantage)
6.26	04/29/2026	1100-1677771-1838900 The Global Oncology policy effective 04/14/2026 has been posted for the following drugs covered under this policy. Vectibix 2. Vegzelma (bevacizumab-adcd)(Commercial) 2. Vegzelma (bevacizumab-adcd)(Medicare Advantage) 2. Vegzelma (bevacizumab-adcd)(QUEST) Velcade Vykoura (leucovorin calcium) (NEW) Vyloy (zolbetuximab-clzb) Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Ziihera (zanidatamab-hrii) 2. Zirabev (bevacizumab-bvzr)(Commercial) 2. Zirabev (bevacizumab-bvzr)(Medicare Advantage) 2. Zirabev (bevacizumab-bvzr)(QUEST) Zusduri (mitomycin) Zynlonta (loncastuximab tesirine- lpyl) Zynyz (retifanlimab-dlwr) 1100-1677771-1837550 The SDRP policy eff 04/14/2026 has been posted for the following drugs covered under this policy. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Voyxact (sibeprenlimab-szsi) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yartemlea (narsoplimab-wuug) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B)
6.25	04/20/2026	1100-1677771-1831000 The epoprostenol-Flolan-Veletri (Commercial and QUEST) 60-day provider notice 04/01/2026-05/31/2026, in effect 06/01/2026, has been posted for the following drugs covered under this policy: Veletri (epoprostenol) (Commercial and QUEST)
6.24	04/14/2026	1100-1677771-0820850 The Hyaluronate Products (Commercial and QUEST) effective 04/12/2026 has been posted for the following drug covered under this policy: 2. Visco-3® (sodium hyaluronate) (Commercial and QUEST)
6.23	04/07/2026	1100-1677764-1802900: The effective date for drugs covered under the Hyaluronates (MA) policy has been corrected from 4/1/2026 to 03/13/2026.
6.22	04/06/2026	1100-1677771-1805800 The SDRP policy eff 03/27/2026 has been posted for the following drugs covered under this policy. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Voyxact (sibeprenlimab-szsi) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yartemlea (narsoplimab-wuug) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B)
6.21	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. Visco-3 (sodium hyaluronate) (Medicare Advantage)
6.20	03/31/2026	1100-1677764-1798651 Botulinum Toxins, eff 04/01/2026, has been posted for the following drugs covered under this policy. Xeomin (incobotulinumtoxinA) Xeomin 1100-1677764-1802500 Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST) effective 04/01/2026, has been posted for the following drugs covered under this policy. Yuflyma (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST) Yusimry (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. Wezlana (ustekinumab-auub) (Medicare Advantage) Yesintek (ustekinumab-kfce) (Medicare Advantage)
6.19	03/30/2026	1100-1677764-1798661 Infliximab (Commercial and QUEST) effective 04/01/2026 has been posted to the following drug covered under this policy: 2. Zymfentra (infliximab-dyyb) (Commercial and QUEST) relink from SDRP to Infliximab 1100-1677764-1798661 Subcutaneous Immunoglobulin (SCIG) (Medicare Advantage) effective 04/01/2026 has been posted for the following drugs. Xembify (Immune Globulin Subcutaneous [Human] – klhw, 20%) (Medicare Advantage)
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: 2. Wezlana (ustekinumab-auub) (Commercial) 2. Yesintek (ustekinumab-kfce) (Commercial) 1100-1677764-1784000 The SDRP drugs entries were updated to the current effective date 03/13/2026. 1100-1677764-1784003 The Global Oncology policy effective 03/13/2026 has been posted for the following drug covered under this policy. Vykoura (leucovorin calcium) (NEW)
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. Wezlana (ustekinumab-auub) (QUEST) Yesintek (ustekinumab-kfce) (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. Vectibix 2. Vegzelma (bevacizumab-adcd)(Commercial) 2. Vegzelma (bevacizumab-adcd)(Medicare Advantage) Vegzelma (bevacizumab-adcd)(QUEST) Velcade Vyloy (zolbetuximab-clzb) Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Ziihera (zanidatamab-hrii) 2. Zirabev (bevacizumab-bvzr)(Commercial) 2. Zirabev (bevacizumab-bvzr)(Medicare Advantage) Zirabev (bevacizumab-bvzr)(QUEST) Zusduri (mitomycin) Zynlonta (loncastuximab tesirine- lpyl) Zynyz (retifanlimab-dlwr) 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. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Voyxact (sibeprenlimab-szsi) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yartemlea (narsoplimab-wuug) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B)
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. Wezlana (ustekinumab-auub) (Commercial) 2. Yesintek (ustekinumab-kfce) (Commercial)
6.15	02/25/2026	1100-1677757-1756800 Xolair (Medicare Advantage), effective 01/19/2026, has been posted. ARCHIVED: policy eff 1/1/2025.
6.14	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. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Voyxact (sibeprenlimab-szsi) (NEW) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yartemlea (narsoplimab-wuug) (NEW) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B)
6.13	02/23/2026	1100-1677757-1751350 The epoprostenol-Flolan-Veletri (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: Veletri (epoprostenol) (Commercial and QUEST)
6.12	02/17/2026	1100-1677757-1743054 Products Specialty Exceptions (Commercial) policy, effective 01/01/2026 v2, has been posted for the following drugs covered under this policy. 1. Vegzelma (bevacizumab-adcd) (Commercial) 1. Zirabev (bevacizumab-bvzr) (Commercial) 1100-1677757-1743054 Products Specialty Exceptions (Medicare Advantage) policy, effective 01/01/2026 v2, has been posted for the following drugs covered under this policy. 1. Vegzelma (bevacizumab-adcd) (Medicare Advantage) 1. Zirabev (bevacizumab-bvzr) (Medicare Advantage) 1100-1677757-1743054 Products Specialty Exceptions (QUEST) policy, effective 01/01/2026 v2, has been posted for the following drugs covered under this policy. 1. Vegzelma (bevacizumab-adcd) (QUEST) 1. Zirabev (bevacizumab-bvzr) (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. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Voyxact (sibeprenlimab-szsi) (NEW) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yartemlea (narsoplimab-wuug) (NEW) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb)
6.10	02/06/2026	1100-1677757-1723650 Policy notes updated for Zymfentra (infliximab-dyyb) (Commercial and QUEST)
6.09	02/05/2026	1100-1677757-1723601 Updated the policy notes and archived link name for Stelara and Biosimilars (QUEST).
6.08	02/04/2026	1100-1677757-1723650 Infliximab (Commercial and QUEST) 60-day provider notice (02/01/2026-03/31/2026), effective 04/01/2026, has been posted for the following drug covered under this policy: Zymfentra (infliximab-dyyb) (Commercial and QUEST)
6.07	02/03/2026	1100-1677757-1721600 The Adalimumab Preferred Drug Program (QUEST) redlined 60-day provider notice (02/01/2026-03/31/2026), effective 04/01/2026, has been posted for the following drugs covered under this policy: Yuflyma (adalimumab-aaty) (Adalimumab Preferred Drug Program) (QUEST) Yusimry (adalimumab-aqvh) (QUEST) 1100-1677757-1721600 The Stelara (Medicare Advantage) redlined 60-day provider notice (02/01/2026-03/31/2026), effective 4/01/2026, has been posted for the following drugs covered under this policy: Wezlana (ustekinumab-auub) (Medicare Advantage) Yesintek (ustekinumab-kfce) (Medicare Advantage) 1100-1677757-1723601 Botulinum Toxins (Comm-QUEST-MA) 60-day provider notice 02/01/2026-03/31/2026, in effect 04/01/2026, has been posted for the following drug covered under this policy: 2. Xeomin (incobotulinumtoxinA) 1100-1205577-1675357 The epoprostenol-Flolan-Veletri (Commercial and QUEST) 60-day provider notice 02/01/2026-03/31/2026, in effect 04/01/2026, has been posted for the following drugs covered under this policy: Veletri (epoprostenol) (Commercial and QUEST) 1100-1677757-1721607 Subcutaneous Immunoglobulin (SCIG) (Medicare Advantage) 60-day provider notice 02/01/2026-03/31/2026, in effect 04/01/2026 has been posted for the following drugs covered under this policy: Xembify (Immune Globulin Subcutaneous [Human] – klhw, 20%) (Medicare Advantage)
6.06	01/30/2026	1100-1677750-1720704 Removed "Growth Hormone Preferred Drug Program" from the following links: Zomacton (somatropin) Zorbtive (somatropin)
6.05	01/21/2026	1100-1677750-1704852 Updated the policy notes for Xeomin.
6.04	01/16/2026	1100-1677750-1699604 The Global Oncology policy effective 01/13/2026 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 12/23/2025. Vectibix 2. Vegzelma (bevacizumab-adcd)(Commercial) 2. Vegzelma (bevacizumab-adcd)(Medicare Advantage) Vegzelma (bevacizumab-adcd)(QUEST) Velcade Vyloy (zolbetuximab-clzb) Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Ziihera (zanidatamab-hrii) 2. Zirabev (bevacizumab-bvzr)(Commercial) 2. Zirabev (bevacizumab-bvzr)(Medicare Advantage) Zirabev (bevacizumab-bvzr)(QUEST) Zusduri (mitomycin) Zynlonta (loncastuximab tesirine- lpyl) Zynyz (retifanlimab-dlwr)
6.03	01/15/2026	1100-1677750-1694000 Growth Hormone Therapy, 01/01/2026 v2, has been posted for the following drugs covered under this policy. Archived: policy effective 01/01/2026 Zomacton (Growth Hormone Preferred Drug Program) (somatropin) Zorbtive (Growth Hormone Preferred Drug Program) (somatropin)
6.02	01/08/2026	1100-1677750-1690700 The Global Oncology policy effective 12/23/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 11/21/2025. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Vyloy (zolbetuximab-clzb) Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Ziihera (zanidatamab-hrii) 2. Zirabev (bevacizumab-bvzr) Zusduri (mitomycin) Zynlonta (loncastuximab tesirine- lpyl) Zynyz (retifanlimab-dlwr)
6.01	01/05/2026	1100-1205521-1305653 Growth Hormone Therapy, 01/01/2026, has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy effective 4/01/2025. Zomacton (somatropin) Zorbtive (somatropin)
6.00	01/02/2026	1100-1677750-1684314 The SDRP policy eff 01/01/2026 has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 12/23/2025 Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Voyxact (sibeprenlimab-szsi) (NEW) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb)
5.59	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 Ziextenzo (pegfilgrastim-bmez) (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. Ziextenzo (pegfilgrastim-bmez) (Medicare Advantage) 1100-1205577-1681556 Bevacizumab Products Specialty Exceptions (Commercial) policy, effective 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 09/26/2025 1. Vegzelma (bevacizumab-adcd) (Commercial) 1. Zirabev (bevacizumab-bvzr) (Commercial) 1100-1205577-1681556 Bevacizumab Products Specialty Exceptions (Medicare AdvantageMedicare Advantage) policy, effective 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 09/26/2025 1. Vegzelma (bevacizumab-adcd) (Medicare Advantage) 1. Zirabev (bevacizumab-bvzr) (Medicare Advantage) 1100-1205577-1681556 Bevacizumab Products Specialty Exceptions (QUEST) policy, effective 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 09/26/2025 1. Vegzelma (bevacizumab-adcd) (QUEST) 1. Zirabev (bevacizumab-bvzr) (QUEST) 1100-1205577-1681563 The Hyaluronates Specialty Exceptions(Commercial and QUEST) policy effective 01/01/2026, has been posted for the following drugs covered under this policy. ARCHIVED: Policy effective 09/26/2025. 1. Visco-3 (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. Visco-3 (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. Wezlana (ustekinumab-auub) (Autoimmune Preferred Drug Program) 1. Yesintek (ustekinumab-kfce) (Autoimmune Preferred Drug Program) 1. Yuflyma (adalimumab-aaty) (Autoimmune Preferred Drug Program) 1. Yusimry (adalimumab-aqvh) (Autoimmune Preferred Drug Program) Zymfentra (infliximab-dyyb) (Autoimmune Preferred Drug Program)
5.58	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 Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Voyxact (sibeprenlimab-szsi) (NEW) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb)
5.57	12/23/2025	1100-1205577-1671755 Flolan-Veletri (Medicare Advantage) effective 12/19/2025, has been posted for the following drug covered under this policy. ARCHIVED: Policy 10/25/2024. Veletri (epoprostenol) (Medicare Advantage) 1100-1205577-1671755 The Hyaluronates Medicare Part B policy effective 12/19/2025 has been posted for the following drug covered under this policy. ARCHIVED: policy effective 12/20/2024. 2. Visco-3 (sodium hyaluronate) (Medicare Advantage) 1100-1205577-1672050 Xolair (Commercial and QUEST), effective 12/19/2025, has been posted. ARCHIVED: policy eff 4/01/2025.
5.56	12/03/2025	1100-1205577-1642506 Colony Stimulating Factors (CSF) – Short Acting Commercial and QUEST Preferred Drug Program effective 11/21/2025, has been posted for the following drug covered under this policy. Archived: policy effective 1/1/2025. Zarxio (filgrastim-sndz) (Commercial and QUEST) - no PA required 1100-1205577-1642506 Colony Stimulating Factors (CSF) – Short-Acting Medicare Advantage Preferred Drug Program effective 11/21/2025, has been posted for the following drug covered under this policy. Archived: policy effective 1/1/2025. Zarxio (filgrastim-sndz) - no PA required 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. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Vyloy (zolbetuximab-clzb) Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Ziihera (zanidatamab-hrii) 2. Zirabev (bevacizumab-bvzr) Zusduri (mitomycin) Zynlonta (loncastuximab tesirine- lpyl) Zynyz (retifanlimab-dlwr)
5.55	11/26/2025	1100-1205570-1634452 Botulinum Toxins Preferred Drug Program (Medicare Advantage) policy, eff 11/21/2025, has been posted for the following drugs covered under this policy. Archived: Policy eff 1/1/2025. 1. Xeomin (incobotulinumtoxinA) (Botulinum Toxins Preferred Drug Program) (Medicare Advantage)
5.54	11/24/2025	1100-1205570-1615650 Posted the fax form link for Wezlana (Medicare Advantage). 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 Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb)
5.53	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. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Vyloy (zolbetuximab-clzb) Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Ziihera (zanidatamab-hrii) 2. Zirabev (bevacizumab-bvzr) Zusduri (mitomycin) Zynlonta (loncastuximab tesirine- lpyl) (NEW) Zynyz (retifanlimab-dlwr)
5.52	11/10/2025	1100-1205570-1615650 Stelara + Biosimilars Fax Form links have been updated for the following drugs: 2. Wezlana (ustekinumab-auub) (Commercial) Wezlana (QUEST) 2. Yesintek (ustekinumab-kfce) (Commercial) Yesintek (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 Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B)
5.51	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 Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B)
5.50	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. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Vyloy (zolbetuximab-clzb) Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Ziihera (zanidatamab-hrii) 2. Zirabev (bevacizumab-bvzr) Zusduri (mitomycin) Zynyz (retifanlimab-dlwr)
5.49	10/27/2025	1100-1205563-1592051 Stelara (Commercial), effective 04/08/2025 v3, has been posted. ARCHIVED: Policy eff 4/8/2025 v2 2. Wezlana (ustekinumab-auub) (Commercial) 2. Yesintek (ustekinumab-kfce) (Commercial)
5.48	10/23/2025	1100-1205563-1590050 Growth Hormone Therapy (Commercial and QUEST) 60-day provider notice (11/01/25-12/31/25), effective 01/01/2025, have been posted for the following drugs covered under this policy: Zomacton™ (somatropin) Zorbtive® (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. Wezlana (ustekinumab-auub) (Autoimmune Preferred Drug Program) 1. Yesintek (ustekinumab-kfce) (Autoimmune Preferred Drug Program) 1. Yuflyma (adalimumab-aaty) (Autoimmune Preferred Drug Program) 1. Yusimry (adalimumab-aqvh) (Autoimmune Preferred Drug Program) Zymfentra (infliximab-dyyb) (Autoimmune Preferred Drug Program)
5.47	10/21/2025	The following were posted on 10/17/2025: 1100-1205563-1574400 Colony Stimulating Factors (CSF) – Long Acting Specialty Exceptions (Commercial), effective 09/26/2025, has been posted for the following drug covered under this policy. ARCHIVED: Policy eff 01/01/2025 Ziextenzo (pegfilgrastim-bmez) (Commercial) 1100-1205563-1574400 Colony Stimulating Factors (CSF) – Long Acting Specialty Exceptions (Medicare Advantage), effective 09/26/2025, has been posted for the following drug covered under this policy. ARCHIVED: Policy eff 01/01/2025. Ziextenzo (pegfilgrastim-bmez) (Medicare Advantage)
5.46	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. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B) 1100-1205563-1574400 The Hyaluronates Preferred Drug Program (Commercial and QUEST) policy effective 09/26/2025, has been posted for the following drug covered under this policy. ARCHIVED: Policy effective 01/01/2025. 1. Visco-3 (Commercial and QUEST) 1100-1205563-1574400 The Hyaluronates Specialty Exceptions (Medicare Advantage) policy effective 09/26/2025, has been posted for the following drug covered under this policy. ARCHIVED: Policy effective 01/01/2025. 1. Visco-3 (Medicare Advantage) 1100-1205563-1574400 Bevacizumab Products Specialty Exceptions (Commercial) policy, effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 01/01/2025 1. Vegzelma (bevacizumab-adcd) (Commercial) 1. Zirabev (bevacizumab-bvzr) (Commercial) 1100-1205563-1574400 Bevacizumab Products Specialty Exceptions (Medicare Advantage) policy, effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 01/01/2025 1. Vegzelma (bevacizumab-adcd) (Medicare Advantage) 1. Zirabev (bevacizumab-bvzr) (Medicare Advantage) 1100-1205563-1574400 Bevacizumab Products Specialty Exceptions (QUEST) policy, effective 09/26/2025, has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 01/01/2025 1. Vegzelma (bevacizumab-adcd) (QUEST) 1. Zirabev (bevacizumab-bvzr) (QUEST)
5.45	10/03/2025	1100-1205563-1551406 ustekinumab (Stelara) and Biosimilars (QUEST) archive folder link fix.
5.44	10/02/2025	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. Wezlana (ustekinumab-auub) (QUEST) Yesintek (ustekinumab-kfce) (QUEST) 1100-1205563-1551406 Subcutaneous Immunoglobulin (SCIG) (Commercial and QUEST) effective 10/01/2025 has been posted for the following drug covered under this policy. Archived: 60-day notice and policy eff 4/26/2024. Xembify (Immune Globulin Subcutaneous [Human] – klhw, 20%) (Commercial and QUEST) 1100-1205563-1551406 The Autoimmune Preferred Drug Program (Commercial) policy effective 10/1/2025, has been posted for the following drugs covered under this policy. ARCHIVED: 60-day notice and policy effective 6/7/2025 1. Wezlana (ustekinumab-auub) (Autoimmune Preferred Drug Program) 1. Yesintek (ustekinumab-kfce) (Autoimmune Preferred Drug Program) 1. Yuflyma (adalimumab-aaty) (Autoimmune Preferred Drug Program) 1. Yusimry (adalimumab-aqvh) (Autoimmune Preferred Drug Program) Zymfentra (infliximab-dyyb) (Autoimmune Preferred Drug Program)
5.43	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. Vabysmo (faricimab-svoa) Vafseo (vadadustat) (new) - pharmacy drug - remove Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B) 1100-1205556-1528350 The effective dates for the drugs covered under the Stelara (Medicare Advantage) policy has been corrected to 09/20/2025.
5.42	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. Wezlana (ustekinumab-auub) (Medicare Advantage) Yesintek (ustekinumab-kfce) (Medicare Advantage) (NEW)
5.41	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. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Vyloy (zolbetuximab-clzb) Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Ziihera (zanidatamab-hrii) 2. Zirabev (bevacizumab-bvzr) Zusduri (mitomycin) Zynyz (retifanlimab-dlwr)
5.40	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. Vabysmo (faricimab-svoa) Vafseo (vadadustat) (new) - pharmacy drug - remove Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B)
5.39	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. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Vyloy (zolbetuximab-clzb) Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Ziihera (zanidatamab-hrii) 2. Zirabev (bevacizumab-bvzr) Zusduri (mitomycin) Zynyz (retifanlimab-dlwr) 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. Wezlana (ustekinumab-auub) (Autoimmune Preferred Drug Program) 1. Yesintek (ustekinumab-kfce) (Autoimmune Preferred Drug Program) 1. Yuflyma (adalimumab-aaty) (Autoimmune Preferred Drug Program) 1. Yusimry (adalimumab-aqvh) (Autoimmune Preferred Drug Program) Zymfentra (infliximab-dyyb) (Autoimmune Preferred Drug Program)
5.38	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. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Vyloy (zolbetuximab-clzb) Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Ziihera (zanidatamab-hrii) 2. Zirabev (bevacizumab-bvzr) Zusduri (mitomycin) Zynyz (retifanlimab-dlwr) 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. Vabysmo (faricimab-svoa) Vafseo (vadadustat) (new) - pharmacy drug - remove Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B)
5.37	09/02/2025	1100-1205549-1486802 The QUEST fax form links for the following drugs have been updated: Vabysmo, Viltepso, Voxzogo, Vyepti, Vyondys, Vyvgart, Xenpozyme, Yutiq, Vegzelma, Zirabev, Wyost, Xbryk, Xgeva
5.36	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. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Vyloy (zolbetuximab-clzb) Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Ziihera (zanidatamab-hrii) 2. Zirabev (bevacizumab-bvzr) Zusduri (mitomycin) Zynyz (retifanlimab-dlwr) 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. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Vyloy (zolbetuximab-clzb) Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Ziihera (zanidatamab-hrii) 2. Zirabev (bevacizumab-bvzr) Zusduri (mitomycin) Zynyz (retifanlimab-dlwr)
5.35	08/18/2025	1100-1205549-1463454 Removed Vafseo (vadadustat) - It was added in error.
5.34	08/12/2025	1100-1205549-1463454 The SDRP policy eff 07/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 06/01/2025. Vabysmo (faricimab-svoa) Vafseo (vadadustat) (new) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B) 1100-1205549-1463454 The Global Oncology policy effective 07/10/2025 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 05/08/2025. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Vyloy (zolbetuximab-clzb) Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Ziihera (zanidatamab-hrii) 2. Zirabev (bevacizumab-bvzr) Zusduri (mitomycin) (NEW) Zynyz (retifanlimab-dlwr)
5.33	08/11/2025	1100-1205549-1463450 Intravenous Immune Globulin (IVIG) (Commercial and QUEST) effective 7/25/2025, has been posted for the following drug covered under this policy. Archived: policy eff 5/23/2025. Yimmugo (Commercial and QUEST)
5.32	08/07/2025	The Subcutaneous Immunoglobulin (SCIG) (Commercial and QUEST) 60-day provider notice (8/01/2025-9/30/2025) effective 10/01/2025 has been posted for the following drugs covered under this policy: Xembify (Commercial and QUEST) 1100-1205549-1463400 The Intravenous Immune Globulin (IVIG) (Medicare Advantage) 60-day provider notice (08/01/2025-09/30/2025) eff 10/01/2025 has been posted for the following drugs covered under this policy. Yimmugo (Medicare Advantage) (NEW) 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: Wezlana (ustekinumab-auub) (QUEST) (NEW) Yesintek (ustekinumab-kfce) (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: period: 05/01/2024-06/30/2024) has been posted for the following drugs covered under this policy: 1. Wezlana (ustekinumab-auub) (Autoimmune Preferred Drug Program) 1. Yesintek (ustekinumab-kfce) (Autoimmune Preferred Drug Program) 1. Yuflyma (adalimumab-aaty) (Autoimmune Preferred Drug Program) 1. Yusimry (adalimumab-aqvh) (Autoimmune Preferred Drug Program) Zymfentra (infliximab-dyyb) (Autoimmune Preferred Drug Program)
5.31	07/28/2025	1100-1205542-1427101 Updated the effective dates to 6/27/2025 for Xgeva (Commercial and QUEST) and Xgeva (Medicare Advantage)
5.30	07/24/2025	1100-1205542-1427101 Xgeva and Biosimilars (Commercial and QUEST), 6/27/2025 has been posted for the following drugs covered under this policy: Wyost (denosumab-bbdz) (Commercial and QUEST) (NEW) Xgeva (Commercial and QUEST); ARCHIVED: policy eff 12/20/2024 Xybryk (denosumab-dssb) (Commercial and QUEST) (NEW) 1100-1205542-1427101 Xgeva and Biosimilars (Medicare Advantage), 6/27/2025 has been posted for the following drugs covered under this policy: Wyost (denosumab-bbdz) (Medicare Advantage) (NEW) Xgeva (Medicare Advantage); ARCHIVED: policy eff 12/20/2024 Xybryk (denosumab-dssb) (Medicare Advantage) (NEW)
5.29	06/30/2025	1100-1205535-1366050 The SDRP policy eff 06/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 05/23/2025. Vabysmo (faricimab-svoa) Vafseo (vadadustat) (new) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B) 1100-1205535-138830 Stelara and Biosimilars (Commercial and QUEST), effective 04/08/2025 v2, has been posted for the following drug covered under this policy. ARCHIVED: policy eff 4/8/2025. Wezlana (ustekinumab-auub) (Commercial and QUEST) Yesintek (ustekinumab-kfce) (Commercial and QUEST)
5.28	06/23/2025	1100-1205535-1366050 Formatting edit: Move Yimmugo into alphabetical order. 1100-1205535-1368400 Link fix for: 1. Wezlana (Autoimmune Preferred Drug Program) and 1. Yesintek (Autoimmune Preferred Drug Program)
5.27	06/16/2025	1100-1205535-1366050 Intravenous Immune Globulin (IVIG) (Commercial and QUEST) effective 5/23/2025, has been posted for the following drugs covered under this policy. Yimmugo (Commercial and QUEST) (new) The effective dates of the following drugs were corrected to 05/23/2025: Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan)
5.26	06/10/2025	1100-1205535-1368400 Autoimmune (AI) Preferred Drug Program (Commercial) effective 6/07/2025 has been posted for the following drugs covered under this policy. ARCHVIED: Policy effective 2/14/2025. 1. Wezlana (ustekinumab-auub) (Autoimmune Preferred Drug Program) (NEW) 1. Yesintek (ustekinumab-kfce) (Autoimmune Preferred Drug Program) (NEW) 1. Yuflyma (adalimumab-aaty) (Autoimmune Preferred Drug Program) 1. Yusimry (adalimumab-aqvh) (Autoimmune Preferred Drug Program) Zymfentra (infliximab-dyyb) (Autoimmune Preferred Drug Program) 1100-1205535-1366050 The SDRP policy eff 05/23/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 05/15/2025, v2. Vabysmo (faricimab-svoa) Vafseo (vadadustat) (new) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B) The Hyaluronate Products (Commercial and QUEST Integration) effective 5/23/2025, has been posted for the following drug covered under this policy. Archived: Policy eff 11/29/2024 2. Visco-3® (sodium hyaluronate) (Commercial and QUEST Integration) The following policies have been posted effective 5/23/2025: Vimizim (elosulfase alfa) (Commercial and QUEST Integration), Archived: 5/24/2024 Vimizim (elosulfase alfa) (Medicare Advantage), Archived: 5/24/2024 Vpriv (velaglucerase) (Medicare Advantage), Archived: 10/25/2024
5.25	06/03/2025	1100-1205535-1358906 Stelara and Biosimilars (Commercial and QUEST), effective 04/08/2025, has been posted for the following drugs covered under this policy. Biosimilars added eff 4/8/2025. Wezlana (ustekinumab-auub) (Commercial and QUEST) ARCHIVED: Stelara Policy eff 2/22/2025 Yesintek (ustekinumab-kfce) (Commercial and QUEST) (NEW)
5.24	05/22/2025	1100-1205528-1346450 Fax form links for the following have been update: 2. Yuflyma (adalimumab-aaty) (Commercial) 2. Yusimry (adalimumab-aqvh) (Commercial) Zymfentra (infliximab-dyyb) (Commercial and QUEST)
5.23	05/21/2025	1100-1205528-1349251 Adalimumab (Commercial) effective 5/25/2025, has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy eff 4/01/2025. 2. Yuflyma (adalimumab-aaty) (Commercial) 2. Yusimry (adalimumab-aqvh) (Commercial)
5.22	05/19/2025	1100-1205528-1345201 The following drug was added: Zymfentra (infliximab-dyyb) (Medicare Advantage). This drug is not covered under Medicare Part B effective 08/18/2024. 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. Vabysmo (faricimab-svoa) Vafseo (vadadustat) (new) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B)
5.21	05/15/2025	1100-1205528-1344351 Fax form links for Xolair (omalizumab) (Commercial and QUEST Integration) have been updated.
5.20	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. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Vyloy (zolbetuximab-clzb) Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Ziihera (zanidatamab-hrii) 2. Zirabev (bevacizumab-bvzr) Zynyz (retifanlimab-dlwr)
5.19	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. Vabysmo (faricimab-svoa) Vafseo (vadadustat) (new) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B)
5.18	05/08/2025	1100-1205528-1315150 The following fax form links have been updated or added: Xeomin (incobotulinumtoxinA) - QUEST 2. Xeomin (incobotulinumtoxinA) - QUEST Ziextenzo (pegfilgrastim-bmez) (CSF Long Acting Preferred Drug Program Medicare Advantage) - MA
5.17	05/06/2025	1100-1205528-1330252 The SDRP policy eff 04/01/2025 has been posted for the following drugs covered under this policy. ARCHIVED: policy eff 03/01/2025. Vabysmo (faricimab-svoa) Vafseo (vadadustat) (new) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B)
5.16	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. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Vyloy (zolbetuximab-clzb) Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Ziihera (zanidatamab-hrii) 2. Zirabev (bevacizumab-bvzr) Zynyz (retifanlimab-dlwr)
5.15	04/22/2025	1100-1205521-1305678 Zepzelca: 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. Vabysmo (faricimab-svoa) Vafseo (vadadustat) (new) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B)
5.14	04/21/2025	1100-1205521-1305653 The following edit was applied: Xolair (Commercial and QUEST) - Added a link to the Xolair (Comm-QUEST) archived folder.
5.13	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. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Vyloy (zolbetuximab-clzb) Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Ziihera (zanidatamab-hrii) 2. Zirabev (bevacizumab-bvzr) Zynyz (retifanlimab-dlwr)
5.12	04/14/2025	1100-1205521-1305653 Adalimumab (Commercial) effective 4/01/2025, has been posted for the following drugs covered under this policy. Archived: 60-day notice and policy eff 7/01/2024. 2. Yuflyma (adalimumab-aaty) (Commercial) 2. Yusimry (adalimumab-aqvh) (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. Yuflyma (adalimumab-aaty) (QUEST) Yusimry (adalimumab-aqvh) (QUEST) Xolair (omalizumab) (Commercial and QUEST) has been posted; ARCHIVED: 60-day notice and policy eff 1/1/2024 Stelara (Medicare Advantage), effective 4/01/2025, has been posted for the following drug covered under this policy. ARCHIVED: 60-day notice and policy eff 1/01/2024. Wezlana (ustekinumab-auub) (Medicare Advantage) 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. Zomacton (somatropin) Zorbtive (somatropin) Botulinum Toxins, eff 04/01/2025, has been posted for the following drug covered under this policy. ARCHIVED: 60-day notice and policy eff 1/1/2025. Xeomin 2. Xeomin (Medicare Advantage)
5.11	04/07/2025	1100-1205521-1301650 The SDRP policy eff 02/01/2025 has been posted for the following drugs covered under this policy. Vabysmo (faricimab-svoa) Vafseo (vadadustat) (new) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyalev (foscarbidopa and foslevodopa) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B) Botulinum Toxins, eff 04/01/2025, has been posted for the following drug covered under this policy. ARCHIVED: 60-day notice and policy eff 1/1/2025. Xeomin 2. Xeomin (Medicare Advantage)
5.10	03/24/2025	1100-1205514-1272756 Added the Infliximab (Comm-QUEST) archived folder for Zymfentra (infliximab-dyyb) (Commercial and QUEST)
5.09	03/14/2025	1100-1205514-1265700 Corrected the link titles for Botulinum Toxins (Comm-QUEST-MA) redlined 60-day provider notice (02/01/2025-03/31/2025), effective 4/01/2025, and for the following drug covered under this policy: Xeomin (incobotulinumtoxinA) 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.as been posted for the following drugs covered under this policy. ARCHVIED: Policy effective 10/03/2024. 1. Yuflyma (adalimumab-aaty) (Autoimmune Preferred Drug Program) 1. Yusimry (adalimumab-aqvh) (Autoimmune Preferred Drug Program) Zymfentra (infliximab-dyyb) (Autoimmune Preferred Drug Program) 1100-1205514-1272761 Removed Velsipity (etrasimod) from the table as it is a Pharmacy drug.
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. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Vyloy (zolbetuximab-clzb) (NEW) Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Ziihera (zanidatamab-hrii) (NEW) 2. Zirabev (bevacizumab-bvzr) Zynyz (retifanlimab-dlwr) Change history notes from 2020, 2021, and 2022 are archived and have been removed from this article.
5.07	03/10/2025	1100-1205514-1272752 Stelara (Commercial and QUEST), effective 2/22/2025, has been posted for the following drug covered under this policy. ARCHIVED: Policy eff 2/1/2024 Wezlana (ustekinumab-auub) (Commercial and QUEST) (NEW) 1100-1205514-1272756 Infliximab (Commercial and QUEST) effective 3/1/2025 has been posted to the following drug covered under these policies, as applicable. ARCHIVED: 60-day notice and policy effective 1/1/2024. Zymfentra (infliximab-dyyb) 1100-1205514-1272761 The SDRP policy eff 01/01/2025, v2 has been posted for the following drugs covered under this policy. Vabysmo (faricimab-svoa) Vafseo (vadadustat) (new) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyalev (foscarbidopa and foslevodopa) (NEW eff 12/16/2024) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B)
5.06	03/05/2025	1100-1205514-1265700 The Adalimumab redlined 60-day provider notice (02/01/2025-03/31/2025), effective 04/01/2025, has been posted for the following drugs covered under this policy: 2. Yuflyma (adalimumab-aaty) (Commercial) 2. Yusimry (adalimumab-aqvh) (Commercial) The Adalimumab redlined 60-day provider notice (02/01/2025-03/31/2025), effective 04/01/2025, has been posted for the following drugs covered under this policy: 2. Yuflyma (adalimumab-aaty) (QUEST) 2. Yusimry (adalimumab-aqvh) (QUEST) Botulinum Toxins (Comm-QUEST-MA) redlined 60-day provider notice (02/01/2025-03/31/2025), effective 4/01/2025, has been posted for the following drug covered under this policy: Xeomin (incobotulinumtoxinA) 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: Zomacton (somatropin) Zorbtive (somatropin) The following redlined 60-day provider notice (02/01/2025-03/31/2025), effective 04/01/2025 have been posted: Xolair (omalizumab) (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: Wezlana (ustekinumab-auub) (Medicare Advantage) (NEW)
5.05	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. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Vyloy (zolbetuximab-clzb) (NEW) Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Ziihera (zanidatamab-hrii) (NEW) 2. Zirabev (bevacizumab-bvzr) Zynyz (retifanlimab-dlwr)
5.04	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. Vabysmo (faricimab-svoa) Vafseo (vadadustat) (new) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyalev (foscarbidopa and foslevodopa) (NEW eff 12/16/2024) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B)
5.03	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. Vabysmo (faricimab-svoa) Vafseo (vadadustat) (new) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyalev (foscarbidopa and foslevodopa) (NEW eff 12/16/2024) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B)
5.02	02/04/2025	1100-1205507-1235752 Updated the fax form links for the following drugs: Xembify (Commercial/QUEST/Medicare Advantage)
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. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Vyloy (zolbetuximab-clzb) (NEW) Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Ziihera (zanidatamab-hrii) (NEW) 2. Zirabev (bevacizumab-bvzr) Zynyz (retifanlimab-dlwr)
5.00	01/07/2025	1100-956557-1197456 Edits: Visco-3 Removed link to 60-day notice and updated effective date. 1100-956557-1197451 Edit 2. Zymfentra link to 60-day provider notice (01/01/2025-02/28/2025) eff 03/01/2025

Rev#:	Date:	Nature of Change:
4.43 (v185)	12/30/2024	1100-956557-1197451 Infliximab (Commercial and QUEST) 60-day provider notice (02/01/2023-03/31/2023), effective 12/01/2023, has been posted for the following drugs covered under this policy: Zymfentra (infliximab-dyyb) (new) 1100-956557-1197456 Bevacizumab Products - Commercial Preferred Drug Program policy, effective 01/01/2025, has been posted for the following drugs covered under this policy. Archived: policy eff 1/1/24 and 60-day notice eff 1/1/25 1. Vegzelma (bevacizumab-adcd) (Commercial) 1. Zirabev (bevacizumab-bvzr) (Commercial) 1100-956557-1197456 Bevacizumab Products - Medicare Part B Preferred Drug Program policy effective 01/01/2025, has been posted for the following drugs covered under this policy. Archived: policy eff 1/1/24 and 60-day notice eff 1/1/25 1. Vegzelma (bevacizumab-adcd) (Medicare Advantage) 1. Zirabev (bevacizumab-bvzr) (Medicare Advantage) 1100-956557-1197456 Bevacizumab Products - QUEST 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 1. Vegzelma (bevacizumab-adcd) (QUEST) 1. Zirabev (bevacizumab-bvzr) (QUEST) 1100-956557-1197456 Botulinum Toxins, eff 01/01/2025, has been posted for the following drug covered under this policy. Archived: 60-day notice eff 1/1/25 and policy eff 4/1/24, v2. Xeomin (incobotulinumtoxinA) 1100-956557-1197456 Botulinum Toxins Medicare Part B Preferred Drug Program policy, eff 1/1/2025, has been posted for the following drugs covered under this policy. Archived: 60-day notice eff 1/1/2025 and policy eff 1/1/2024. 1. Xeomin (incobotulinumtoxinA) (Medicare Advantage) 1100-956557-1197456 The following policy has been posted: Xolair (omalizumab) (Medicare Advantage), 1/1/2025; ARCHIVED: 60-day notice effective 1/1/2025 policy effective 1/1/2024 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. Ziextenzo (pegfilgrastim-bmez) (Commercial) 1100-956557-1197456Colony 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. T ARCHIVED: The 60-day notice eff 1/1/2025. Ziextenzo (pegfilgrastim-bmez) (Medicare Advantage) 1100-956557-1197456 Colony Stimulating Factors (CSF) – Short Acting Commercial and QUEST Preferred Drug Program effective 01/01/2025, has been posted for the following drug covered under this policy. Archived: 1/1/2025 and policy effective 11/17/2023. Zarxio (filgrastim-sndz) (Commercial and QUEST) - no PA required 1100-956557-1197456 Colony Stimulating Factors (CSF) – Short-Acting Medicare Advantage Preferred Drug Program effective 01/01/2025, has been posted for the following drug covered under this policy. Archived: 1/1/2025 and policy effective 1/1/2024. Zarxio (filgrastim-sndz) - no PA required 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. Visco-3 (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. Visco-3 (Medicare Advantage) Subcutaneous Immunoglobulin (SCIG) (Medicare Advantage) effective 1/1/2025 has been posted for the following drugs. Archived: 60-day notice eff 1/1/25 and policy eff 1/1/24. Xembify (Immune Globulin Subcutaneous [Human] – klhw, 20%) (Medicare Advantage)
4.42 (v184)	12/23/2024	1100-956557-1204850 The following policies have been posted: Xgeva (denosumabj) (Commercial and QUEST), 12/20/2024; ARCHIVED: policy eff 4/1/2024 Xgeva (denosumabj) (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 drug covered under this policy. ARCHIVED: policy effective 5/30/2024. 2. Visco-3 (sodium hyaluronate) (Medicare Advantage)
4.41 (v183)	12/17/2024	1100-956557-1197150 The SDRP policy eff 10/3/2024 has been posted for the following drug covered under this policy: Vafseo (vadadustat) (new)
4.40 (v182)	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. Visco-3® (sodium hyaluronate) (Commercial and QUEST Integration)
4.39 (v181)	11/21/2024	1100-956552-1168730 Added a link to VPRIV (Comm-QUEST) - Archived folder 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. Yuflyma (adalimumab-aaty) (Autoimmune Preferred Drug Program) 1. Yusimry (adalimumab-aqvh) (Autoimmune Preferred Drug Program) Zymfentra (infliximab-dyyb) (Autoimmune Preferred Drug Program) 1100-956552-1182203 The Global Oncology policy effective 11/15/2024 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 10/23/2024. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) 2. Zirabev (bevacizumab-bvzr) Zynyz (retifanlimab-dlwr)
4.38 (v180)	11/12/2024	1100-956552-1168730 Added a link to the archived folder for Veletri (epoprostenol) (Medicare Advantage).
4.37 (v179)	11/04/2024	1100-956552-1168730 Flolan-Veletri (Commercial and QUEST) effective 10/25/2024, has been posted for the following drug covered under this policy. ARCHIVED: Policy eff 4/1/2024. Veletri (epoprostenol) (Commercial and QUEST) Flolan-Veletri (Medicare Advantage) effective 10/25/2024, has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 1/1/2024. Veletri (epoprostenol) (Medicare Advantage) Vpriv (velaglucerase) (Commercial and QUEST), 10/25/2024, has been posted. ARCHIVED: 1/1/2024.
4.36 (v178)	11/01/2024	1100-956547-1167950 Bevacizumab Products - Commercial Preferred Drug Program 60-day provider notice (11/01/2024-12/31/20234), effective 01/01/2025, has been posted for the following drugs covered under this policy: 1. Vegzelma (bevacizumab-adcd) (Commercial) 1. Zirabev (bevacizumab-bvzr) (Commercial) Bevacizumab Products - Medicare Part B Preferred Drug Program 60-day provider notice (11/01/2024-12/31/20234), effective 01/01/2025, has been posted for the following drugs covered under this policy: 1. Vegzelma (bevacizumab-adcd) (Medicare Advantage) 1. Zirabev (bevacizumab-bvzr) (Medicare Advantage) Bevacizumab Products - QUEST Preferred Drug Program 60-day provider notice (11/01/2024-12/31/20234), effective 01/01/2025, has been posted for the following drugs covered under this policy: 1. Vegzelma (bevacizumab-adcd) (Bevacizumab Preferred Drug Program Policy QUEST) (new) 1. Zirabev (bevacizumab-bvzr) (Bevacizumab Preferred Drug Program Policy QUEST) (new) Botulinum Toxins (Comm-QUEST-MA) 60-day provider notice (11/01/2024-12/31/2024) eff 1/1/2025, has been posted for the following drug covered under this policy: Xeomin (incobotulinumtoxinA) Botulinum Toxins Preferred Drug Program (Medicare Advantage) 60-day provider notice (11/01/2024-12/31/2024), effective 01/01/2025, has been posted for the following drugs covered under this policy: 1. Xeomin (incobotulinumtoxinA) (Medicare Advantage) Xolair (omalizumab) (Medicare Advantage) 60-day provider notice (11/01/2024-12/31/2024) eff 1/1/2025 has been posted. Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial) 60-day provider notice (11/01/2024-12/31/2024) eff 1/1/2025, has been posted for the following drugs covered under this policy. Ziextenzo (pegfilgrastim-bmez) (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. Ziextenzo (pegfilgrastim-bmez) (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. Visco-3 (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. Visco-3 (Medicare Advantage) Subcutaneous Immunoglobulin (SCIG) (Medicare Advantage) (11/01/2024-12/31/2024) eff 1/1/2025 has been posted for the following drugs covered under this policy:. Xembify (Immune Globulin Subcutaneous [Human] – klhw, 20%) (Medicare Advantage)
4.35 (v177)	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. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) 2. Zirabev (bevacizumab-bvzr) Zynyz (retifanlimab-dlwr) The SDRP policy eff 10/3/2024 v2 has been posted for the following drugs covered under this policy. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide)(new eff 10/3/2024) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B)
4.34 (v176)	10/24/2024	1100-956547-1152003 The effective date for 1. Zymfentra (infliximab-dyyb) has been updated to 10/03/2024.
4.33 (v175)	10/21/2024	1100-956547-1156413 The effective dates for Wainua and Winrevair have been updated to 10/03/2024.
4.32 (v174)	10/11/2024	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. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yorvipath (palopegteriparatide)(new eff 10/3/2024) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B)
4.31 (v173)	10/10/2024	1100-956547-1152003 Autoimmune (AI) Preferred Drug Program (Commercial) effective 10/03/2024 has been posted for the following drugs covered under this policy. ARCHVIED: The 60-day notice and policy effective 07/01/2024. 1. Yuflyma (adalimumab-aaty) (Autoimmune Preferred Drug Program) 1. Yusimry (adalimumab-aqvh) (Autoimmune Preferred Drug Program) Zymfentra (infliximab-dyyb) (Autoimmune Preferred Drug Program)
4.30 (v172)	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. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B)
4.29 (v171)	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. Zomacton (somatropin) Zorbtive (somatropin)
4.28 (v170)	09/10/2024	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. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B)
4.27 (v169)	09/17/2024	1100-956542-1137967 The Global Oncology policy effective 09/10/2024 has been posted for the following drugs covered under this policy. ARCHIVED: Policy eff 07/15/2024. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) 2. Zirabev (bevacizumab-bvzr) Zynyz (retifanlimab-dlwr)
4.26 (v168)	09/10/2024	1100-956537-1131400 The SDRP policy eff 8/23/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 7/1/2024. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (drug is not covered under Part B); link to Medicare Advantage fax form has been removed
4.25 (v167)	08/05/2024	1100-956537-1104504 Growth Hormone Therapy 60-day provider notice (08/01/2024-09/30/2024), effective 10/01/2024, have been posted for the following drugs covered under this policy: Zomacton (somatropin) Zorbtive (somatropin)
4.24 (v166)	07/29/2024	1100-956532-1101501 The following drug has been added: Vyjuvek (Beremagene geperpavec-svdt)
4.23 (v165)	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. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) 2. Zirabev (bevacizumab-bvzr) Zynyz (retifanlimab-dlwr) The SDRP policy eff 7/01/2024 has been posted for the following drugs covered under this policy. ARCHIVED: policy effective 6/17/2024. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb)
4.22 (v164)	07/01/2024	1100-956527-1081006 Autoimmune (AI) Preferred Drug Program (Commercial) effective 07/01/2024 has been posted for the following drug covered under this policy 1. Velsipity (etrasimod) The SDRP policy eff 6/17/2024 has been posted for the following drug covered under this policy. 2. Velsipity (etrasimod)
4.21 (v163)	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. Yuflyma (adalimumab-aaty) (Autoimmune Preferred Drug Program)(new) 1. Yusimry (adalimumab-aqvh) (Autoimmune Preferred Drug Program)(new) Zymfentra (infliximab-dyyb) (Autoimmune Preferred Drug Program)(new) Humira (adalimumab) (Commercial) effective 07/01/2024, has been posted for the following drugs covered under this policy. Archived: policy eff 04/01/2024. 2. Yuflyma (adalimumab-aaty) (Commercial) 2. Yusimry (adalimumab-aqvh) (Commercial)
4.20 (v162)	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. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Winrevair (sotatercept-csrk) Xenpozyme (olipudase alfa-rpcp) Yutiq Zilbrysq (zilucoplan) 2. Zymfentra (infliximab-dyyb) (new 6/17/2024)
4.19 (v161)	06/18/2024	1100-956527-1071521 Updated the policy notes for Winrevair.
4.18 (v160)	06/13/2024	1100-956527-1075100 Removed Velsipity (etrasimod) (Autoimmune Preferred Drug Program policy) - It is a pharmacy specialty drug and will be moved to the Pharmacy Specialty drugs U-Z article.
4.17 (v159)	06/10/2024	1100-956527-1071521 The SDRP policy eff 5/27/2024 has been posted for the following drug covered under this policy. Winrevair (sotatercept-csrk) (new eff 5/27/24) Global Oncology 05/17/2024 has been posted for the following drugs covered under this policy. The policy effective 12/12/2023 has been archived. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) 2. Zirabev (bevacizumab-bvzr) Zynyz (retifanlimab-dlwr)
4.16 (v158)	05/30/2024	1100-956522-1064600 The following policies have been posted: Vimizim (elosulfase alfa) (Commercial and QUEST Integration), 5/24/2024. Archived: 1/1/2024 Vimizim (elosulfase alfa) (Medicare Advantage), 5/24/2024. Archived: 1/1/2024 Vpriv (velaglucerase) (Medicare Advantage), 5/24/2024. Archived: 1/1/2024 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. Visco-3 (sodium hyaluronate) (Medicare Advantage)
4.15 (v157)	05/28/2024	1100-956522-1060957 Autoimmune Preferred Drug Program (Commercial) revised redlined 60-day notice effective 7/1/2024, v2 (notification period: 05/01/2024-06/30/2024) has been posted for the following drugs covered under this policy: Velsipity (etrasimod) (Autoimmune Preferred Drug Program)(new) #1. Yuflyma (adalimumab-aaty) (Autoimmune Preferred Drug Program)(new) #1. Yusimry (adalimumab-aqvh) (Autoimmune Preferred Drug Program)(new) Zymfentra (infliximab-dyyb) (Autoimmune Preferred Drug Program)(new)
4.14 (v156)	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. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Xenpozyme (olipudase alfa-rpcp) Yutiq Zilbrysq (zilucoplan)
4.13 (155)	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. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Xenpozyme (olipudase alfa-rpcp) Yutiq Zilbrysq (zilucoplan)
4.12 (v154)	05/10/2024	1100-956522-1050250 Updated the Adalimumab Preferred Drug Program (QUEST Integration) archived folder links.
4.11 (v153)	05/08/2024	1100-956522-1050250 Adalimumab Preferred Drug Program (QUEST Integration) effective 5/03/2024, has been posted for the following drugs covered under this policy. Archived: policy eff 4/1/2024 Yuflyma (adalimumab-aaty) (QUEST Integration) Yusimry (adalimumab-aqvh) (QUEST Integration) 1100-956522-1049457 The SDRP policy eff 4/1/2024 has been posted for the following drugs covered under this policy. The SDRP policy effective 3/1/2024 has been archived. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Xenpozyme (olipudase alfa-rpcp) Yutiq Zilbrysq (zilucoplan)
4.10 (v152)	05/02/2024	1100-956522-1046905 Subcutaneous Immunoglobulin (SCIG) (Commercial and QUEST Integration) effective 4/26/2024 has been posted for the following drugs covered under this policy. Archived: 4/1/2024. Xembify (Immune Globulin Subcutaneous [Human] – klhw, 20%) (Commercial and QUEST Integration)
4.9 (v151)	04/15/2024	Humira (adalimumab) (Commercial) effective 04/01/2024, has been posted for the following drugs covered under this policy. Archived: policy eff 12/1/2023 Yuflyma (adalimumab-aaty) (Commercial) Yusimry (adalimumab-aqvh) (Commercial) *Drug numbering has been removed. Botulinum Toxins (drug specific), eff 4/01/2024 v2, has been posted for the following drug covered under this policy. Archived: policy eff 4/01/2024. Xeomin (incobotulinumtoxinA) 2. Xeomin (incobotulinumtoxinA)
4.8 (v150)	03/31/2024	Adalimumab Preferred Drug Program (QUEST Integration) effective 4/01/2024, has been posted for the following drugs covered under this policy. Archived: 60-day notice. 1. Yuflyma (adalimumab-aaty) (QUEST Integration) 1. Yusimry (adalimumab-aqvh) (QUEST Integration) The following policy has been posted: Xgeva (Commercial and QUEST Integration), 4/1/2024. Archived: 1/1/2024 Botulinum Toxins (drug specific), eff 4/01/2024, has been posted for the following drug covered under this policy. Archived: 60-day notice and policy eff 4/01/2023. Xeomin (incobotulinumtoxinA) 2. Xeomin (incobotulinumtoxinA) Flolan-Veletri (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 Veletri (epoprostenol) (Commercial and QUEST Integration) The Hyaluronate Products (Commercial and QUEST Integration) effective 4/01/2024, has been posted for the following drug covered under this policy. Archived: 60-day notice and policy eff 1/1/2024. 2. Visco-3® (sodium hyaluronate) (Commercial and QUEST Integration) Subcutaneous Immunoglobulin (SCIG) (Commercial and QUEST Integration) effective 4/1/2024 has been posted for the following drug covered under this policy. Archived: 60-day notice and policy eff 9/1/2022. Xembify (Immune Globulin Subcutaneous [Human] – klhw, 20%) (Commercial and QUEST Integration)
4.7 (v149)	03/21/2024	Added the Commercial and Medicare fax form links to Zilbrisq.
4.6 (v148)	03/20/2024	The SDRP policy eff 3/1/2024 has been posted for the following drugs covered under this policy. Omvoh is not covered under Part B. The SDRP policy effective 2/1/2024 has been archived. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Xenpozyme (olipudase alfa-rpcp) Yutiq Zilbrysq (zilucoplan)
4.5 (v147)	02/15/2024	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. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) Xenpozyme (olipudase alfa-rpcp) Yutiq Zilbrysq (zilucoplan)
4.4 (v146)	02/09/2024	The SDRP policy eff 1/1/2024, v2 has been posted for the following drugs covered under this policy. The SDRP policy effective 1/1/2024 has been archived. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Wainua (eplontersen) (NEW effective 1/1/2024) Xenpozyme (olipudase alfa-rpcp) Yutiq Zilbrysq (zilucoplan) (NEW effective 1/1/2024)
4.3 (v145)	02/08/2024	The following has been posted and moved to a new row: Botulinum Toxins (Commercial and QUEST Integration) 60-day provider notice (02/01/2024-03/31/2024), effective 4/01/2024, v2, has been posted for the following drug covered under this policy: Xeomin (incobotulinumtoxinA) The following link has been 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. Visco-3® (sodium hyaluronate) (Commercial and QUEST Integration)
4.2 (v144)	02/01/2024	60-day notice has been posted for the following drug. Provider notification period is 2/1/2024-3/31/2024. Xgeva (Commercial and QUEST Integration) Adalimumab Preferred Drug Program (QUEST Integration) 60-day provider notice (02/01/2024-03/31/2024), effective 4/01/2024, has been posted for the following drugs covered under this policy: 1. Yuflyma (adalimumab-aaty) (QUEST Integration) 1. Yusimry (adalimumab-aqvh) (QUEST Integration) Botulinum Toxins (Commercial and QUEST Integration) 60-day provider notice (02/01/2024-03/31/2024), effective 4/01/2024, has been posted for the following drug covered under this policy: Xeomin (incobotulinumtoxinA) (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: Veletri (epoprostenol) (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. Visco-3® (sodium hyaluronate) (Commercial and QUEST Integration) Intravenous Immune Globulin (SCIG) (Commercial and QUEST Integration) 60-day provider notice (02/01/2024-03/31/2024), effective 4/01/2024, has been posted for the following drug covered under this policy: Xembify (Commercial and QUEST Integration)
4.1 (v143)	01/31/2024	Updated fax form links for the following: Vegzelma (new line for QI), Veletri, Vimizim, Vpriv, Xgeva, Xolair, Ziextenzo, Zirabev (new line for QI)
4.0 (v142)	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. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Xenpozyme (olipudase alfa-rpcp) Yutiq

Rev#:	Date:	Nature of Change:
3.29 (v141)	12/29/2023	Fixed current policy link for Veletri (epoprostenol) (Commercial and QUEST Integration) Broken link fixes. Updated link to Xolair (MA).
3.28 (v140)	12/28/2023	The following policies effective 1/1/2024 have been posted: Vimizim (elosulfase alfa) (Commercial and QUEST Integration) Vimizim (elosulfase alfa) (Medicare Advantage) Vpriv (velaglucerase) (Commercial and QUEST Integration) Vpriv (velaglucerase) (Medicare Advantage) Xgeva (denosumabj) (Commercial and QUEST Integration) Xgeva (denosumabj) (Medicare Advantage) Xolair (omalizumab) (Commercial and QUEST Integration) Xolair (omalizumab) (Medicare Advantage) The following policies have been archived: Vimizim (elosulfase alfa), 06/23/2023 (for all LOBs) Vpriv (velaglucerase), 06/23/2023 (for all LOBs) Xgeva (denosumabj), 03/01/2023 (for all LOBs) Xolair (omalizumab), 08/25/2023 (for all LOBs) Flolan-Veletri (Commercial and QUEST Integration), eff 1/1/2024, has been posted for the following drugs covered under this policy. Archived: policy eff 3/1/2023 (all LOBs) has been archived Veletri (epoprostenol) (Commercial and QUEST Integration) Flolan-Veletri (Medicare Advantage), eff 1/1/2024, has been posted for the following drugs covered under this policy. Archived: policy eff 3/1/2023 (all LOBs) has been archived Veletri (epoprostenol) (Medicare Advantage) The Hyaluronates (Commercial and QUEST Integration) and (Medicare Advantage) policies effective 01/01/2024 have been posted to the following drug covered under these policies, as applicable. Archived: Policy effective 2/1/2023 (all LOBs) 2. Visco-3 (Commercial and QUEST Integration) 2. Visco-3 (Medicare Advantage) Subcutaneous Immunoglobulin (SCIG) (Medicare Advantage) effective 1/1/2024 has been posted for the following drugs. Archived: Policy effective 9/1/2022. Xembify (Immune Globulin Subcutaneous [Human] – klhw, 20%) (Medicare Advantage)
3.27 (v139)	12/27/2023	Bevacizumab Products - Commercial Preferred Drug Program policy, effective 01/01/2024, has been posted for the following drugs covered under this policy. Archived: redlined 60-day provider notice effective 1/1/24. 1. Vegzelma (bevacizumab-adcd) (Commercial) (new) 1. Zirabev (bevacizumab-bvzr) (Commercial) (new) Bevacizumab Products - Medicare Part B Preferred Drug Program policy effective 01/01/2024, has been posted for the following drugs covered under this policy. Archived: redlined 60-day provider notice effective 1/1/24. 1. Vegzelma (bevacizumab-adcd) (Medicare Advantage) (new) 1. Zirabev (bevacizumab-bvzr) (Medicare Advantage) (new) Botulinum Toxins Medicare Part B Preferred Drug Program policy, eff 1/1/2024, has been posted for the following drugs covered under this policy. Archived: 60-day notice eff 1/1/2024 and policy eff 10/28/2022. 1. Xeomin (incobotulinumtoxinA) (Medicare Advantage) Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial), effective 1/1/2024, has been posted for the following drugs covered under this policy. The 60-day notice eff 1/1/2024 and policy eff 3/1/2023 have been archived. Ziextenzo (pegfilgrastim-bmez) (Commercial) - removed "no PA required" Colony Stimulating Factors (CSF) - Short Acting - Medicare Part B Preferred Drug Program effective 01/01/2024, has been posted for the following drug covered under this policy. Archived: 60-day provider notice effective 1/1/2024 and policy effective 2/1/2023. Zarxio (filgrastim-sndz) - no PA required The Hyaluronates Preferred Drug Program (Commercial) policy effective 01/01/2024, has been posted for the following drugs covered under this policy. Archived: 60-day provider notice effective 1/1/2024 and policy effective 10/28/2022. 1. Visco-3 (Commercial) The Hyaluronates Medicare Part B Preferred Drug Program policy effective 1/1/2024, has been posted for the following drug covered under this policy. Archived: 60-day notice eff 1/1/2024 and policy effective 1/1/2023 1. Visco-3 (Hyaluronates Preferred Drug Program) (Medicare Advantage)
3.26 (v138)	12/19/2023	Global Oncology 12/12/2023 has been posted for the following drugs covered under this policy. The policy effective 11/28/2023 has been archived. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) 2. Zirabev (bevacizumab-bvzr) Zynyz (retifanlimab-dlwr) The SDRP policy eff 12/1/2023 has been posted for the following drugs covered under this policy. The SDRP policy effective 11/1/2023 has been archived. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Xenpozyme (olipudase alfa-rpcp)
3.25 (v137)	12/18/2023	Growth Hormone Therapy, 12/15/2023, has been posted for the following drugs covered under this policy. Archived: policy effective 4/1/2023. Zomacton (somatropin) Zorbtive (somatropin)
3.24 (v136)	12/13/2023	Global Oncology 11/28/2023 has been posted for the following drugs covered under this policy. The previous policy effective 11/17/2023 has been archived. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) 2. Zirabev (bevacizumab-bvzr) Zynyz (retifanlimab-dlwr) The SDRP policy eff 11/1/2023 has been posted for the following drugs covered under this policy. The SDRP policy effective 10/1/2023 v2 has been archived. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Xenpozyme (olipudase alfa-rpcp)
3.23 (v135)	12/08/2023	Humira (adalimumab) effective 12/01/2023, has been posted for the following drugs covered under this policy. Archived: 60-day provider notice (10/01/2023-11/30/2023) Yuflyma (adalimumab-aaty) (new eff 12/1/23) Yusimry (adalimumab-aqvh) (new eff 12/1/23) Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program (Commercial) 11/17/2023 has been posted for the following drug covered under this policy. Archived: policy effective 10/1/2022. Zarxio (filgrastim-sndz) (Commercial) (Preferred; No PA required) Global Oncology 11/17/2023 has been posted for the following drugs covered under this policy. The previous policy effective 10/11/2023 has been archived. Sarclisa (isatuximab-irfc) Sylvant Synribo Talvey (talquetamab-tgvs) Tecentriq (atezolizumab) Tecvayli (teclistamab-cqyv) temsirolimus (generic) Tivdak (tisotumab vedotin-tftv) Torisel Trazimera (trastuzumab-qyyp) Trisenox (arsenic trioxide) Trodelvy (sacituzumab govitecan-hziy) 2. Truxima Unituxin (dinutuximab)
3.22 (v134)	11/14/2023	Global Oncology 10/11/2023 has been posted for the following drugs covered under this policy. The previous policy effective 9/5/2023 has been archived. Vectibix 2. Vegzelma (bevacizumab-adcd) Velcade Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) 2. Zirabev (bevacizumab-bvzr) Zynyz (retifanlimab-dlwr) The SDRP policy eff 10/1/2023 v2 has been posted for the following drugs covered under this policy. The SDRP policy effective 10/1/2023 has been archived. No change to the policy - two drugs added: Aphexda and Daxxify. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Xenpozyme (olipudase alfa-rpcp) Effective 11/14/2023, Medical Specialty Archived policy articles will no longer be updated. The quick links to the archived policy pages have been removed. Archived policies can be accessed via the applicable links on this page, found in the Archived Policies column.
3.21 (v133)	11/07/2023	Links to applicable archived folders have been added to the following drugs: Visudyne (verteporfin) (Commercial) Visudyne (verteporfin) (Medicare Advantage) Xembify (Commercial & QUEST) Xembify (Medicare Advantage) Zarxio (filgrastim-sndz) (Commercial) Removed duplicate entry for Visco-3. Added rows: 2. Vegzelma (Commercial) - Global Oncology 2. Zirabev (Commercial) - Global Oncology
3.20 (v132)	11/01/2023	The Hyaluronates Preferred Drug Program (Commercial) 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024, has been posted for the following drugs covered under this policy: 1. Visco-3 (Commercial) The Hyaluronates Medicare Part B Preferred Drug Program 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024, has been posted for the following drug covered under this policy: 1. Visco-3 (Hyaluronates Preferred Drug Program) (Medicare Advantage) Botulinum Toxins Medicare Part B Preferred Drug Program redlined 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024, has been posted for the following drugs covered under this policy: 1. Xeomin (incobotulinumtoxinA) (Medicare Advantage) Short-Acting Colony Stimulating Factors (CSF) - Medicare Part B Preferred Drug Program redlined 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024, has been posted for the following drug covered under this policy. Zarxio (filgrastim-sndz) - no PA required Bevacizumab Products - Medicare Part B Preferred Drug Program redlined 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024, has been posted for the following drugs covered under this policy: 1. Vegzelma (bevacizumab-adcd) (Medicare Advantage) (new) 1. Zirabev (bevacizumab-bvzr) (Medicare Advantage) (new) Bevacizumab Products - Commercial Preferred Drug Program 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024, has been posted for the following drugs covered under this policy: 1. Vegzelma (bevacizumab-adcd) (Commercial) (new) 1. Zirabev (bevacizumab-bvzr) (Commercial) (new) Long-Acting Colony Stimulating Factors (CSF) – Commercial Preferred Drug Program 60-day provider notice (11/01/2023-12/31/2023), effective 01/01/2024, has been posted for the following drug covered under this policy: Ziextenzo (pegfilgrastim-bmez) (Commercial)
3.19 (v131)	10/23/2023	The SDRP policy eff 10/1/2023 has been posted for the following drugs covered under this policy. The SDRP policy effective 9/1/2023 has been archived. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Xdemvy (lotilaner ophthalmic solution) (removed eff 10/1/2023) Xenpozyme (olipudase alfa-rpcp) Yutiq
3.18 (v130)	09/29/2023	Humira (adalimumab) redlined 60-day provider notice (10/01/2023-11/30/2023), effective 12/01/2023, has been posted for the following drugs covered under this policy: Yuflyma (adalimumab-aaty) (new eff 12/1/23) Yusimry (adalimumab-aqvh) (new eff 12/1/23)
3.17 (v129)	09/11/2023	Global Oncology 9/5/2023 has been posted for the following drugs covered under this policy. The previous policy effective 7/21/2023 has been archived. Vectibix Vegzelma (bevacizumab-adcd) Velcade Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Zirabev (bevacizumab-bvzr) Zynyz (retifanlimab-dlwr) The SDRP policy eff 9/1/2023 has been posted for the following drugs covered under this policy. The SDRP policy effective 7/1/2023 (v2) has been archived. Vabysmo (faricimab-svoa) Veopoz (pozelimab-bbfg) (NEW eff 9/1/2023) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Vyondys 53 Xdemvy (lotilaner ophthalmic solution)(NEW eff 9/1/2023) Xenpozyme (olipudase alfa-rpcp) Yutiq
3.16 (v128)	08/30/2023	The following policy has been posted: Xolair (omalizumab), 08/25/2023; archived policy effective 04/01/2023
3.15 (v127)	08/12/2023	Vegzelma (bevacizumab-adcd): Added a link to the Global Oncology archived folder.
3.14 (v126)	08/08/2023	Global Oncology 7/21/2023 has been posted for the following drugs covered under this policy. The previous policy effective 7/1/2023 has been archived. Vectibix Vegzelma (bevacizumab-adcd) Velcade Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Zirabev (bevacizumab-bvzr) Zynyz (retifanlimab-dlwr) The SDRP policy eff 7/1/2023, v2 has been posted for the following drugs covered under this policy. The SDRP policy effective 7/1/2023 has been archived. Vabysmo (faricimab-svoa) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) (NEW eff 7/1/2023) Vyondys 53 Xenpozyme (olipudase alfa-rpcp) Yutiq
3.13 (v125)	07/11/2023	Zynyz (retifanlimab-dlwr): added a link to the Global Oncology archived folder. References to CVS and/or CVS Caremark have been removed or updated to "HMSA's pharmacy benefit manager" or "the pharmacy benefit manager." Minor proofreading edits, which did not affect context, were also applied.
3.12 (V124)	07/07/2023	Global Oncology 7/1/2023 has been posted for the following drugs covered under this policy. The previous policy effective 5/10/2023 has beeen archived. Vectibix Vegzelma (bevacizumab-adcd) Velcade Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Zirabev (bevacizumab-bvzr) Zynyz (retifanlimab-dlwr)
3.11 (v123)	06/29/2023	The SDRP policy eff 7/1/2023 has been posted for the following drugs covered under this policy. The SDRP policy effective 6/1/2023 has been archived. Vabysmo (faricimab-svoa) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyondys 53 Xenpozyme (olipudase alfa-rpcp) Yutiq The following drug is part of the Hemophilia Preferred Drug Program and has been added to the drug table. It applies only to Commercial and QUEST Integration members. Xyntha [Factor VIII (recombinant)]
3.10 (v122)	06/23/2023	The following policies have been posted: Vimizim (elosulfase alfa), 6/23/2023; archived policy eff 10/28/2022 VPRIV (velaglucerase), 6/23/2023; archived policy eff 10/28/2022 Added links to archived folders for both drug policies.
3.9 (v121)	06/14/2023	The SDRP policy eff 6/1/2023 has been posted for the following drugs covered under this policy. The SDRP policy effective 5/1/2023 has been archived. Vabysmo (faricimab-svoa) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyondys 53 Xenpozyme (olipudase alfa-rpcp) Yutiq
3.8 (v120)	05/19/2023	Global Oncology 5/10/2023 has been posted for the following drugs covered under this policy. The previous policy effective 3/6/2023 has beeen archived. Vectibix Vegzelma (bevacizumab-adcd) Velcade Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Zirabev (bevacizumab-bvzr) Zynyz (retifanlimab-dlwr) - NEW eff 5/10/2023 The SDRP policy eff 5/1/2023 has been posted for the following drugs covered under this policy. The SDRP policy effective 4/1/2023, v2 has been archived. Vabysmo (faricimab-svoa) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyondys 53 Xenpozyme (olipudase alfa-rpcp) Yutiq
3.7 (v119)	05/11/2023	The Yutiq link has been edited to target the current SDRP policy.
3.6 (v118)	05/10/2023	The SDRP policy eff 4/1/2023, version 2 has been posted for the following drugs covered under this policy. The SDRP policy effective 4/1/2023 has been archived. Vabysmo (faricimab-svoa) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyondys 53 Xenpozyme (olipudase alfa-rpcp) - added eff 11/1/2022 Yutiq
3.5 (v117)	03/29/2023	The following policies have been posted: Xolair (omalizumab), 4/1/2023; archived 60-day notice and policy eff 11/19/2021 Growth Hormone Therapy, 4/01/2023, has been posted for the following drugs covered under this policy. The 60-day notice and policy effective 4/1/2022 have been archived.. Zomacton (somatropin) Zorbtive (somatropin) Botulinum Toxins, eff 4/01/2023, has been posted for the following drug covered under this policy. Archived: 60-day notice and policy eff 1/1/2022. Xeomin (incobotulinumtoxinA) The SDRP policy eff 4/1/2023 has been posted for the following drugs covered under this policy. The SDRP policy effective 3/1/2023 has been archived. Vabysmo (faricimab-svoa) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyondys 53 Yutiq
3.4 (v116)	03/01/2023	The SDRP policy eff 3/1/2023 has been posted for the following drugs covered under this policy. The SDRP policy effective 12/1/2022 has been archived. Vabysmo (faricimab-svoa) Viltepso (viltolarsen) Voxzogo (vosoritide) Vyepti Vyvgart (efgartigimod alfa-fcab) Vyondys 53 Yutiq
3.3 (v115)	03/20/2023	Global Oncology 3/6/2023 has been posted for the following drugs covered under this policy. The previous policy effective 1/20/2023 has been archived. Vectibix Vegzelma (bevacizumab-adcd) - NEW eff 3/6/2023 Velcade Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Zirabev (bevacizumab-bvzr)
3.2 (v114)	02/24/2023	Flolan-Veletri-epopreostenol, eff 3/01/2023, has been posted for the following drugs covered under this policy. Archived: 60-day notice eff 3/1/23 and policy eff 3/1/2022 have been archived Veletri (epoprostenol) The following policy has been posted: Xgeva (denosumab), 3/1/2023. Archived: 60-day notice eff 3/1/23 and policy effective 04/21/2022 Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial), effective 3/01/2023, has been posted for the following drug covered under this policy. The 60-day notice eff 3/1/22 and policy eff 10/01/2021 have been archived. Ziextenzo (pegfilgrastim-bmez) - no PA required (but please add provider notice)
3.1 (v113)	02/03/2023	Global Oncology 1/20/2023 has been posted for the following drugs covered under this policy. The previous policy effective 12/2/2022 has beeen archived. Vectibix Velcade Yervoy Yondelis (trabectedin) Zaltrap Zepzelca (lurbinectedin) Zirabev (bevacizumab-bvzr)
3.0 (v112)	01/31/2023	Colony Stimulating Factors (CSF) – Short-Acting Preferred Drug Program (Medicare Advantage) effective 02/01/2023 has been posted for the following drugs covered under this policy. The 60-day notice and policy effective 06/01/2021 have been archived. Zarxio (filgrastim-sndz) (Medicare Advantage) - no PA required The Hyaluronates (drug specific policy) effective 02/01/2023 has been posted to the following drug covered under this policy. The 60-day notice and the policy effective 7/23/2021 have been archived. 2. Visco-3 (Commercial, QUEST Integration and Medicare Part B policy) Botulinum Toxins 60-day provider notice (02/01/2023-03/31/2023), effective 4/01/2023, has been posted for the following drug covered under this policy: Xeomin (incobotulinumtoxinA) Growth Hormone Therapy 60-day provider notice (02/01/2023-03/31/2023), effective 4/01/2023, has been posted for the following drug covered under this policy: Zomacton (somatropin) Zorbtive (somatropin) The following redlined 60-day notices effective 4/1/2023 (notification period: 02/01/2023-03/31/2023) have been posted: Xolair (omalizumab)

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