Medical Policies
- Alphabetical
-
Administrative Anesthesiology Allergy/Immunology Behavioral Health Cardiovascular Dermatology Durable Medical Equipment (DME) Ear, Nose, and Throat (ENT) Endocrinology Gastroenterology General Surgery Genetics Genitourinary Hematology/Oncology Infectious Diseases Laboratory/Pathology Nephrology Neurology/Neurosurgery Obstetrics and Gynecology Ophthalmology Oral maxillofacial Orthopedic Pediatrics Pharmacy Physical Medicine Preventive Medicine Pulmonary Radiology, diagnostic Radiation Therapy Transplant Women's Health
Administrative
Reimbursement Policies
Pharmacy
Dental
New Policies
Updated Policies
Upcoming Policies
For Advantage U Part D Requests, please visit: Advantage U Medicare Provider Documents & Forms
| Policy | Name | Effective Date | Revision Date | Next Review Date |
|---|---|---|---|---|
| ALL | ||||
| PHARM-PA | General Pharmacy Prior Authorization Form | N/A | N/A | N/A |
| PHARM-FE | Pharmacy Formulary Exception Request Form - Commercial and Individual | N/A | N/A | N/A |
| PHARM-HU-FE | Pharmacy Formulary Exception Request Form - Healthy U | N/A | N/A | N/A |
| PHARM-MHC-FE | MHC Pharmacy Formulary Exception Form | N/A | N/A | N/A |
| PHARM-MHCPA | MHC General Pharmacy Prior Authorization Form | N/A | N/A | N/A |
| A | ||||
| pharm-m033 | Abecma | June 1, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-M033 | Abecma - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-ma-M033 | Abecma - Medicare Advantage | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| Pharm-088 | Acute Migraine Medications - Commercial & Individual | December 01, 2022 | November 21, 2022 | November 21, 2023 |
| Pharm-hu-088 | Acute Migraine Medications - Healthy U | December 01, 2022 | November 21, 2022 | November 21, 2023 |
| pharm-001 | Acne Rosacea | October 01, 2022 | September 19, 2022 | September 19, 2023 |
| pharm-hu-001 | Acne Vulgaris and Rosacea - Healthy U | October 01, 2022 | September 19, 2022 | September 19, 2023 |
| pharm-002 | Alpha-1-Proteinase-Inhibitors | September 01, 2022 | August 24, 2022 | August 24, 2023 |
| pharm-hu-002 | Alpha-1-Proteinase-Inhibitors - Healthy U | September 01, 2022 | August 24, 2022 | August 24, 2023 |
| PHARM-003 | Ankylosing Spondylitis | September 01, 2022 | August 24, 2022 | August 24, 2023 |
| pharm-m018 | Ankylosing Spondylitis- Medical Infused Drugs | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| PHARM-HU-003 | Ankylosing Spondylitis - Healthy U | September 01, 2022 | August 24, 2022 | August 24, 2023 |
| pharm-004 | Anthelmintic | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| PHARM-HU-004 | Anthelmintics - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-006 | Antiemetics for Chemotherapy Induced Nausea and Vomiting | November 01, 2021 | October 13, 2021 | October 13, 2022 |
| pharm-m028 | Akynzeo | June 1, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-M028 | Akynzeo IV - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-ma-M028 | Akynzeo IV - Medicare Advantage | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-m017 | Antineoplastics - Medical Infused Drugs | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-007 | Antineoplastics - Retail | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-008 | Aranesp - Commercial & Individual | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-hu-008 | Aranesp - Healthy U | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-ma-008 | Aranesp - Medicare Advantage | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-009 | Eucrisa | October 01, 2022 | September 19, 2022 | September 19, 2023 |
| pharm-135 | Atopic Dermatitis: Biologics/JAK Inhibitors | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-135 | Brand Name Atopic Dermatitis Agents - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| B | ||||
| pharm-011 | Basal Insulin | October 01, 2022 | September 19, 2022 | September 19, 2023 |
| pharm-hu-011 | Basal Insulin - Healthy U | October 01, 2022 | September 19, 2022 | September 19, 2023 |
| pharm-012 | Biosimilar Policy | January 01, 2022 | August 18, 2021 | August 18, 2022 |
| PHARM-M030 | Medical Biosimilar Products | August 01, 2022 | May 18, 2022 | May 18, 2023 |
| PHARM-HU-M030 | Medical Biosimilar Products - Healthy U | August 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-013 | Brand Name Medications | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-081 | Benlysta | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| PHARM-HU-081 | Benlysta - Healthy U | April 1, 2022 | March 16, 2022 | March 16, 2023 |
| pharm-m006 | Branded Denosumab Products (Prolia, Xgeva) | July 1, 2022 | June 21, 2022 | June 21, 2023 |
| PHARM-HU-M006 | Branded Denosumab Products (Prolia, Xgeva) - Healthy U | July 01, 2022 | June 21, 2022 | June 21, 2023 |
| PHARM-MA-M006 | Branded Denosumab Products (Prolia, Xgeva) - Medicare Advantage | July 01, 2022 | June 21, 2022 | June 21, 2023 |
| pharm-m034 | Breyanzi | June 1, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-M034 | Breyanzi - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-ma-M034 | Breyanzi - Medicare Advantage | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-m014 | Brineura | January 1, 2022 | December 13, 2021 | December 13, 2022 |
| pharm-126 | Bylvay | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| pharm-hu-126 | Bylvay - Healthy U | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| C | ||||
| pharm-094 | Cablivi | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-094 | Cablivi - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-119 | Cabenuva and Vocabria - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-016 | Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist - Healthy U | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| pharm-hu-143 | Camyzos - Healthy U | September 01, 2022 | August 24, 2022 | August 24, 2023 |
| pharm-096 | Carisoprodol for Healthy U | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| PHARM-HU-M039 | Carvykti - Healthy U | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| PHARM-M039 | Carvykti | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| pharm-016 | Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists | November 01, 2021 | October 13, 2021 | October 13, 2022 |
| PHARM-HU-015 | Clostridium Difficile - Healthy U | April 1, 2022 | March 16, 2022 | March 16, 2023 |
| pharm-017 | Constipation | November 01, 2021 | October 13, 2021 | October 13, 2022 |
| pharm-108 | Continuous Glucose Monitor (CGM)- Retail Pharmacy | September 01, 2022 | August 24, 2022 | August 24, 2023 |
| pharm-hu-108 | Continuous Glucose Monitor (CGM)- Retail Pharmacy - Healthy U | September 01, 2022 | August 24, 2022 | August 24, 2023 |
| PHARM-129 | Cosentyx for ERA | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| PHARM-HU-129 | Cosentyx for ERA - Healthy U | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| pharm-019 | Crohn's Disease - Commercial Retail Drugs | October 01, 2022 | September 19, 2022 | September 19, 2022 |
| pharm-m019 | Crohn’s Disease - Medical Infused Drugs | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| PHARM-HU-019 | Crohn's Disease - Healthy U Retail and Medical Drugs | October 01, 2022 | September 19, 2022 | September 19, 2022 |
| pharm-098 | Cuvposa | August 10, 2020 | August 19, 2020 | August 19, 2021 |
| pharm-104 | Cystadrops and Cystaran for Ocular Cystinosis - Commercial & Individual | December 01, 2022 | November 21, 2022 | November 21, 2023 |
| pharm-hu-104 | Cystadrops and Cystaran for Ocular Cystinosis - Healthy U | December 01, 2022 | November 21, 2022 | November 21, 2023 |
| pharm-014 | Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Agents | January 23, 2020 | January 22, 2020 | January 23, 2021 |
| pharm-hu-014 | Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Agents - Healthy U | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| D | ||||
| pharm-020 | Daliresp | March 1, 2022 | February 14, 2022 | February 14, 2023 |
| pharm-020 | Daliresp - Healthy U | March 1, 2022 | February 14, 2022 | February 14, 2023 |
| pharm-111 | Descovy | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| PHARM-HU-111 | Descovy - Healthy U | April 1, 2022 | March 16, 2022 | March 16, 2023 |
| pharm-112 | Dojolvi | February 01, 2022 | January 19, 2022 | January 19, 2022 |
| pharm-hu-112 | Dojolvi - Healthy U | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| pharm-022 | Dupixent | September 01, 2022 | August 24, 2022 | August 24, 2023 |
| PHARM-HU-022 | Dupixent - Healthy U | September 01, 2022 | August 24, 2022 | August 24, 2023 |
| E | ||||
| pharm-024 | Epidiolex | March 1, 2022 | February 14, 2022 | February 14, 2023 |
| pharm-091 | Esbriet/OFEV - Commercial & Individual | December 01, 2022 | November 21, 2022 | November 21, 2023 |
| pharm-hu-091 | Esbriet/OFEV - Healthy U | December 01, 2022 | November 21, 2022 | November 21, 2023 |
| pharm-117 | Evrysdi - Commercial & Individual | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-hu-117 | Evrysdi - Healthy U | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| G | ||||
| pharm-026 | Gonadotropin Releasing Hormone (GnRH) Agonists and Antagonists | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-026 | GONADOTROPIN RELEASING HORMONE AGONISTS AND ANTAGONISTS – Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-027 | Growth Hormones- Adult | July 01, 2022 | June 21, 2022 | June 21, 2023 |
| PHARM-HU-027 | Growth Hormones: Adult - Healthy U | July 01, 2022 | June 21, 2022 | June 21, 2023 |
| pharm-028 | Growth Hormones- Child | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-028 | Growth Hormone - Child - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| H | ||||
| pharm-030 | Hepatitis C Direct Acting Antivirals | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| PHARM-HU-030 | Hepatitis C Direct Acting Antivirals - Healthy U | April 1, 2022 | March 16, 2022 | March 16, 2023 |
| pharm-110 | Hemophilia and Blood Products | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-031 | Hereditary Angioedema | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-hu-031 | Hereditary Angioedema - Healthy U | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| pharm-032 | Hidradenitis Suppurativa | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| pharm-m020 | Hidradenitis Supperativa- Medical Infused Drugs | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| PHARM-HU-032 | Hidradenitis Suppurativa - Healthy U | June 01, 2022 | April 01, 2022 | April 01, 2023 |
| pharm-101 | Humira for Uveitis - Commercial & Individual | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-hu-101 | Humira for Uveitis - Healthy U | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-033 | Hyperkalemia | March 1, 2022 | February 14, 2022 | February 14, 2023 |
| pharm-hu-033 | Hyperkalemia | March 1, 2022 | February 14, 2022 | February 14, 2023 |
| pharm-m001 | Hyaluronic Acid - Commercial & Individual | December 01, 2022 | November 21, 2022 | November 21, 2023 |
| pharm-ma-m001 | Hyaluronic Acid - Medicare Advantage | December 01, 2022 | November 21, 2022 | November 21, 2023 |
| I | ||||
| pharm-034 | Irritable Bowel Syndrome with Diarrhea (IBS-D) | March 1, 2022 | February 14, 2022 | February 14, 2023 |
| pharm-hu-034 | Irritable Bowel Syndrome with Diarrhea (IBS-D) - Healthy U | March 1, 2022 | February 14, 2022 | February 14, 2023 |
| pharm-035 | IL5 Receptor Antagonist for Asthma - Commercial & Individual | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-hu-035 | IL5 Receptor Antagonist for Asthma - Healthy U | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-036 | Increlex | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-036 | Increlex - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-039 | Interstitial Cystitis | March 1, 2022 | February 14, 2022 | February 14, 2023 |
| pharm-hu-039 | Interstitial Cystitis - Healthy U | March 1, 2022 | February 14, 2022 | February 14, 2023 |
| pharm-082 | Iron Chelation Therapy | October 01, 2022 | September 19, 2022 | September 19, 2023 |
| pharm-082 | Iron Chelation Therapy - Healthy U | October 01, 2022 | September 19, 2022 | September 19, 2023 |
| pharm-091 | Idiopathic Pulmonary Fibrosis | January 1, 2022 | December 13, 2021 | December 13, 2022 |
| pharm-m002 | Intravenous Iron | November 01, 2021 | October 13, 2021 | October 13, 2022 |
| pharm-105 | Isturisa | January 1, 2022 | December 13, 2021 | December 13, 2022 |
| pharm-hu-105 | Istursia - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| J | ||||
| pharm-041 | Juvenile Idiopathic Arthritis | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| pharm-m021 | Juvenile Idiopathic Arthritis - Medical Infused Drugs | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| PHARM-HU-041 | Juvenile Idiopathic Arthritis - Healthy U | June 01, 2022 | April 01, 2022 | April 01, 2023 |
| K | ||||
| PHARM-HU-124 | Kerendia - Healthy U | September 01, 2022 | August 24, 2022 | August 24, 2023 |
| pharm-m036 | Ketamine | October 01, 2022 | September 19, 2022 | September 19, 2023 |
| pharm-hu-m036 | Ketamine - Healthy U | October 01, 2022 | September 19, 2022 | September 19, 2023 |
| pharm-ma-m036 | Ketamine - Medicare Advantage | October 01, 2022 | September 19, 2022 | September 19, 2023 |
| pharm-m029 | Krystexxa | January 1, 2022 | December 13, 2021 | December 13, 2022 |
| pharm-hu-m029 | Krystexxa - Healthy U | September 01, 2022 | August 24, 2022 | August 24, 2023 |
| pharm-m003 | Kymriah - Commercial & Individual | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-hu-m003 | Kymriah - Healthy U | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| L | ||||
| PHARM-130 | Leqvio | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| PHARM-HU-130 | Leqvio - Healthy U | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| pharm-127 | Livtencity | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| pharm-hu-127 | Livtencity - Healthy U | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| PHARM-HU-133 | Livmarli - Healthy U | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| pharm-043 | Long Acting Tacrolimus | March 1, 2022 | February 14, 2022 | February 14, 2023 |
| pharm-118 | Lupkynis | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-118 | Lupkynis - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-m004 | Lutathera | July 01, 2022 | June 21, 2022 | June 21, 2023 |
| PHARM-HU-M004 | Lutathera - Healthy U | July 01, 2022 | June 21, 2022 | June 21, 2023 |
| PHARM-MA-M004 | Lutathera - Medicare Advantage | July 01, 2022 | June 21, 2022 | June 21, 2023 |
| M | ||||
| pharm-hu-123 | Myfembree - Healthy U | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| PHARM-044 | Multiple Sclerosis Agents | November 01, 2022 | August 24 , 2022 | August 24, 2023 |
| PHARM-HU-044 | Multiple Sclerosis Agents - Healthy U | November 01, 2022 | August 24 , 2022 | August 24, 2023 |
| N | ||||
| pharm-102 | Nayzilam® and Valtoco® Nasal Spray | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-102 | NAYZILAM and VALTOCO - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-113 | Nerlynx | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-hu-113 | Nerlynx - Healthy U | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| pharm-099 | Nexletol and Nexlizet | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-047 | Neupro | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-047 | Neupro - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-m027 | Neuromyelitis Optica Spectrum Disorder | June 1, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-M027 | Neuromyelitis Optica Spectrum Disorder (NMOSD) - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-ma-M027 | Neuromyelitis Optica Spectrum Disorder (NMOSD) - Medicare Advantage | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-142 | Non-Radiographic Axial Spondyloarthritis (nrx-SpA) | September 01, 2022 | August 24, 2022 | August 24, 2023 |
| pharm-hu-142 | Non-Radiographic Axial Spondyloarthritis (nrx-SpA) - Healthy U | September 01, 2022 | August 24, 2022 | August 24, 2023 |
| pharm-m041 | Non-Radiographic Axial Spondyloarthritis (nrx-SpA) - Medical Infused Drugs | September 01, 2022 | August 24, 2022 | August 24, 2023 |
| pharm-083 | Nuedexta - Commercial & Individual | December 01, 2022 | November 21, 2022 | November 21, 2023 |
| pharm-hu-083 | Nuedexta - Healthy U | December 01, 2022 | November 21, 2022 | November 21, 2023 |
| O | ||||
| pharm-068 | Ocaliva | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-049 | Off Label Use | June 1, 2021 | May 19, 2021 | May 19, 2022 |
| pharm-m005 | Ophthalmic VEGF Antagonists | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-050 | Opioid Dependence Agents | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-051 | Opioids - Chronic | March 1, 2022 | February 14, 2022 | February 14, 2023 |
| pharm-hu-051 | Opioids - Chronic - Healthy U | March 1, 2022 | February 14, 2022 | February 14, 2023 |
| pharm-052 | Acute Opioid Use Policy | September 01, 2022 | August 24, 2022 | August 24, 2023 |
| pharm-hu-052 | Acute Opioid Use Policy - Healthy U | September 01, 2022 | August 24, 2022 | August 24, 2023 |
| pharm-141 | Opzelura | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-054 | Osteoporosis Medications | July 01, 2022 | June 21, 2022 | June 21, 2023 |
| PHARM-HU-057 | Osteoporosis Medications - Healthy U | July 01, 2022 | June 21, 2022 | June 21, 2023 |
| pharm-m035 | Oxlumo | June 1, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-M035 | Oxlumo - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-ma-M035 | Oxlumo - Medicare Advantage | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-128 | Oxervate | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| pharm-hu-128 | Oxervate - Healthy U | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| P | ||||
| pharm-080 | Pancreatic Enzymes - Commercial & Individual | December 01, 2022 | November 21, 2022 | November 21, 2023 |
| pharm-hu-080 | Pancreatic Enzymes - Healthy U | December 01, 2022 | November 21, 2022 | November 21, 2023 |
| pharm-089 | Parkinson's Agents | January 1, 2022 | December 13, 2021 | December 13, 2022 |
| pharm-057 | Phosphodiesterase Type 5 (PDE-5) Inhibitor | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-103 | Pharmacy Continuity of Care | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-058 | Phenylbutyrates - Commercial & Individual | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-hu-058 | Phenylbutyrates - Healthy U | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-hu-058 | PHENYLBUTYRATES - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-059 | Phenylketonuria (PKU) | October 01, 2022 | September 19, 2022 | September 19, 2023 |
| pharm-hu-059 | Phenylketonuria (PKU) - Healthy U | October 01, 2022 | September 19, 2022 | September 19, 2023 |
| Pharm-M026 | Place of Service for Pharmaceutical Infusions | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-100 | Prevymis | October 01, 2022 | September 19, 2022 | September 19, 2023 |
| pharm-hu-100 | Prevymis - Healthy U | October 01, 2022 | September 19, 2022 | September 19, 2023 |
| pharm-056 | Prior Authorization and Medical Necessity Policy - Commercial & Individual | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-hu-056 | Prior Authorization and Medical Necessity Policy - Healthy U | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-060 | Promacta | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-060 | Promacta - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| PHARM-061 | Psoriasis | July 01, 2022 | May 01, 2022 | March 16, 2023 |
| PHARM-HU-061 | Psoriasis - Healthy U | June 01, 2022 | April 01, 2022 | April 01, 2023 |
| pharm-m022 | Psoriasis- Medical Infused Drugs | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| PHARM-062 | Psoriatic Arthritis | July 01, 2022 | May 01, 2022 | March 16, 2023 |
| PHARM-HU-062 | Psoriatic Arthritis - Healthy U | June 01, 2022 | April 01, 2022 | April 01, 2023 |
| pharm-m023 | Psoriatic Arthritis- Medical Infused Drugs | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| pharm-063 | Pulmonary Arterial Hypertension | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| pharm-045 | Pulmozyme ® | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-045 | Pulmozyme - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| R | ||||
| PHARM-064 | Revcovi | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| PHARM-131 | Rezurock | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| PHARM-HU-131 | Rezurock - Healthy U | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| pharm-065 | Rheumatoid Arthritis | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| PHARM-HU-065 | Rheumatoid Arthritis - Healthy U | June 01, 2022 | April 01, 2022 | April 01, 2023 |
| pharm-m024 | Rheumatoid Arthritis-Medical Infused Drugs | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| pharm-114 | Rocklatan and Rhopressa | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| pharm-hu-114 | Rocklatan and Rhopressa - Healthy U | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| pharm-084 | Ruzurgi- Firdapse | November 01, 2021 | October 13, 2021 | October 13, 2022 |
| S | ||||
| pharm-066 | Sandostation LAR | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-066 | Sandostatin LAR - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-ma-066 | Sandostatin LAR - Medicare Advantage | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-m037 | Saphnelo | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| pharm-ma-m037 | Saphnelo - Advantage U | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| pharm-hu-m037 | Saphnelo - Healthy U | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| pharm-067 | Savella | March 1, 2022 | February 14, 2022 | February 14, 2023 |
| pharm-hu-067 | Savella - Healthy U | March 1, 2022 | February 14, 2022 | February 14, 2023 |
| pharm-109 | Signifor | January 1, 2022 | December 13, 2021 | December 13, 2022 |
| pharm-m013 | Soliris & Ultomiris | November 01, 2021 | October 13, 2021 | October 13, 2022 |
| pharm-069 | Spravato | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-069 | Spravato - - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-m007 | Spinraza - Commercial & Individual | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-hu-m007 | Spinraza - Healthy U | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-071 | Brand Statins | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-071 | Brand Statins - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-115 | Step Therapy - Commercial & Individual | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-hu-115 | Step Therapy - Healthy U | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-070 | Subcutaneous Methotrexate | September 01, 2022 | August 24, 2022 | August 24, 2023 |
| pharm-hu-070 | Subcutaneous Methotrexate - Healthy U | September 01, 2022 | August 24, 2022 | August 24, 2023 |
| pharm-107 | Sunosi | January 1, 2022 | December 13, 2021 | December 13, 2022 |
| pharm-073 | Synagis | October 01, 2022 | September 19, 2022 | September 19, 2023 |
| pharm-hu-073 | Synagis - Healthy U | October 01, 2022 | September 19, 2022 | September 19, 2023 |
| T | ||||
| PHARM-HU-132 | Tavneous - Healthy U | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| pharm-m031 | Tecartus | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-ma-m031 | Tecartus - Advantage U | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| pharm-m016 | Tepezza | June 1, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-M016 | Tepezza - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-ma-M016 | Tepezza - Medicare Advantage | October 01, 2022 | September 19, 2022 | September 19, 2023 |
| pharm-m008 | Testopel | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| PHARM-HU-M038 | Tezspire - Healthy U | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| PHARM-M038 | Tezspire | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| pharm-074 | Topiramate ER Sprinkle Capsules | September 01, 2021 | August 18, 2021 | August 18, 2022 |
| U | ||||
| pharm-075 | Ulcerative Colitis | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| PHARM-HU-075 | Ulcerative Colitis - Healthy U | June 01, 2022 | April 01, 2022 | April 01, 2023 |
| pharm-m025 | Ulcerative Colitis - Medical Infused Drugs | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| PHARM-HU-M025 | Ulcerative Colitis Medical Infused Drugs - Healthy U | January 01, 2022 | January 01, 2022 | January 27, 2022 |
| V | ||||
| pharm-085 | Vasopressin Receptor Antagonists (VRA) | November 01, 2020 | October 28, 2020 | October 28, 2021 |
| pharm-hu-085 | Vasopressin Receptor Antagonists - Healthy U | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| pharm-090 | Vascepa | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-090 | Vascepa - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-077 | VMAT-2 Inhibitors | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-077 | VMAT - 2 Inhibitors - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-m032 | Vyepti | June 1, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-M032 | Vyepti - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| W | ||||
| pharm-125 | Wakix | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| pharm-hu-125 | Wakix - Healthy U | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| X | ||||
| pharm-078 | Xifaxan | July 01, 2021 | May 01, 2021 | April 19, 2022 |
| pharm-hu-078 | Xifaxan - Healthy U | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| pharm-ma-m011 | Xiaflex - Advantage U | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| pharm-079 | Xolair - Commercial & Individual | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-hu-079 | Xolair - Healthy U | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-086 | XHANCE | April 01, 2022 | March 16, 2022 | March 16, 2023 |
| PHARM-HU-086 | Xhance - Healthy U | April 1, 2022 | March 16, 2022 | March 16, 2023 |
| pharm-m011 | Xiaflex | February 01, 2021 | January 27, 2021 | January 27, 2022 |
| Y | ||||
| pharm-m009 | Yescarta | June 1, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-hu-M009 | Yescarta - Healthy U | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-ma-M009 | Yescarta - Medicare Advantage | June 01, 2022 | May 18, 2022 | May 18, 2023 |
| pharm-087 | Yupelri | December 01, 2020 | November 23, 2020 | November 23, 2021 |
| pharm-hu-087 | Yupelri - Healthy U | February 1, 2022 | January 19, 2022 | January 19, 2023 |
| Z | ||||
| pharm-m010 | Zilretta | July 01, 2022 | June 21, 2022 | June 21, 2023 |
| PHARM-MA-M010 | Zilretta - Medicare Advantage | July 01, 2022 | June 21, 2022 | June 21, 2023 |
| PHARM-HU-M010 | Zilretta - Healthy U | July 01, 2022 | June 21, 2022 | June 21, 2023 |
| pharm-m012 | Zolgensma - Commercial & Individual | November 01, 2022 | October 26, 2022 | October 26, 2023 |
| pharm-hu-m012 | Zolgensma - Healthy U | November 01, 2022 | October 26, 2022 | October 26, 2023 |