Item Number and Policy
2025-HUMANA-MED-167 Paclitaxel – HCPCS code J9267 9208
2025-HUMANA-MED-168 carfilzomib, 1 mg – HCPCS code J9047 8997
2025-HUMANA-MED-169 ocrelizumab, 1 mg – HCPCS code J2350 9165
2025-HB-MED-642 Bynfezia Pen, Sandostatin and Sandostatin LAR (Octreotide) / Octreotide Agents
2025-HB-MED-643 Somatuline Depot (lanreotide)
2025-HB-MED-646 Bevacizumab for Non-Ophthalmologic Indications
2025-HB-MED-632 Ketamine Injection (Ketalar)
2025-HB-MED-635 Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)
2025-HB-MED-636 Epkinly (epcoritamab-bysp)
2025-HB-MED-637 Provenge (sipuleucel-T)
2025-HB-MED-638 Tevimbra (tislelizumab-jsgr)
2025-HB-MED-639 Asparagine Specific Enzymes
2025-HB-MED-640 Danyelza (naxitamab-gqgk)
2025-HB-MED-641 Pasireotide Agent: Signifor LAR (pasireotide)
2025-HB-MED-624 Emrelis (telisotuzumab vedotin-tllv)
2025-HB-MED-625 Penpulimab-kcqx
2025-HB-MED-626 Nulojix (belatacept)
2025-HB-MED-627 Drug Dosage, Frequency, and Route of Administration
2025-HB-MED-628 Off-Label Drug and Approved Orphan Drug Use
2025-HB-MED-630 Zynyz (retifanlimab-dlwr)
2025-HB-MED-614 Lynozyfic (linvoseltamab-gcpt)
2025-HB-MED-615 Zusduri (mitomycin intravesical solution)
2025-HB-MED-618 Rytelo (imetelstat)
2025-HB-MED-619 Columvi (glofitamab-gxbm)
2025-HB-MED-620 Keytruda (pembrolizumab)
2025-HB-MED-621 Levoleucovorin Agents
2025-HB-MED-622 Lymphir (denileukin difititox-cxdl)
2025-HB-MED-623 Istodax (romidepsin)
2025-HB-MED-604 Iron Agents
2025-HB-MED-605 Rituximab Agents for Non-Oncologic Indications
2025-HB-MED-606 Rituximab Agents for Oncologic Indications
2025-HB-MED-607 Beleodaq (belinostat)
2025-HB-MED-608 Monjuvi (tafasitamab-cxix)
2025-HB-MED-609 Datroway (datopotamab deruxtecan-dlnk)
2025-HB-MED-610 Opdivo (nivolumab)
2025-HB-MED-611 Opdivo Qvantig (nivolumab hyaluronidase-nvhy)
2025-HB-MED-612 Yervoy (ipilimumab)
2025-HB-MED-613 Tecelra (afamitresgene autoleucel)
2025-HB-MED-594 Opdualag (nivolumab and relatlimab-rmbw)
2025-HB-MED-595 Zynlonta (loncastuximab tesirine-lpyl)
2025-HB-MED-596 Rybrevant (amivantamab-ymjw)
2025-HB-MED-597 Jemperli (dostarlimab-gxly)
2025-HB-MED-598 Zepzelca (lurbinectedin)
2025-HB-MED-599 Ryplazim (plasminogen, human-tvmh)
2025-HB-MED-602 Human Parathyroid Hormone
2025-LHCC-MED-866 LInvoseltamab-gcpt (Lynozyfic) inject
2025-LHCC-MED-867 Remestemcel-L-rknd (Ryoncil)
2025-LHCC-MED-868 Encelto
2025-LHCC-MED-869 Blinatumomab(Blincyto)
2025-LHCC-MED-870 Eculizumab (Soliris), Eculizumab-aeeb (Bkemv), Eculizumab-aagh (Epysqli)
2025-LHCC-MED-871 Brentuximab Vedotin (Adcetris)
2025-UHC-MED-259 Brineura
2025-UHC-MED-260 FcRn-blockers
2025-PHARM-122 Amvuttra
2025-PHARM-123 Andembry
2025-PHARM-124 Colony Stimulating Factors
2025-PHARM-125 Dermatology - Atopic Dermatitis, Immunomodulators
2025-PHARM-126 Harliku
2025-PHARM-127 Heart Disease - Hypertension, Beta Blockers
2025-PHARM-128 Imuldosa
2025-PHARM-129 Kerendia
2025-PHARM-130 Leqselvi
2025-PHARM-131 Louisiana Medicaid ICD-10 Chart
2025-PHARM-132 Myalept
2025-PHARM-133 Onpattro
2025-PHARM-134 Pain Management - Cytokine/CAM Antagonists
2025-PHARM-135 POS Amvuttra
2025-PHARM-136 POS Brynovin
2025-PHARM-137 POS Dermatology - Atopic Dermatitis, Immunomodulators
2025-PHARM-138 POS Epysqli
2025-PHARM-139 POS Fabhalta
2025-PHARM-140 POS GI Motility, Chronic
2025-PHARM-141 POS Heart Disease - Hypertension, Beta Blocker Agents
2025-PHARM-142 POS Imaavy
2025-PHARM-143 POS Leqselvi
2025-PHARM-144 POS Merilog
2025-PHARM-145 POS Misoprostol
2025-PHARM-146 POS Onpattro
2025-PHARM-147 POS Qfitlia
2025-PHARM-148 POS Symbravo
2025-PHARM-149 POS Urology - Incontinence, Bladder Relaxant Preparations
2025-PHARM-150 POS Vanrafia
2025-PHARM-151 POS Wainua
2025-PHARM-152 POS Yutrepia
2025-PHARM-153 POS Zelsuvmi
2025-PHARM-154 POS Zepbound
2025-PHARM-155 Rivfloza
2025-PHARM-156 Ryzneuta
2025-PHARM-157 Wainua
2025-PHARM-158 Zepbound
2025-PHARM-159 Zepbound Patient Agreement
2025-PHARM-160 Zevaskyn
2025-HUM-MED-149 Panitumumab (HUM 8505)
2025-HUM-MED-155 Abatacept (HUM 8585)
2025-HB-MED-583 Keytruda (pembrolizumab)
2025-HB-MED-585 Imcivree (setmelanotide)
2025-HB-MED-587 Tepezza (teprotumumab-trbw)
2025-HB-MED-593 Kisunla
2025-HB-MED-572 Opdivo (nivolumab)
2025-HB-MED-573 Yervoy (ipilimumab)
2025-HB-MED-574 Opdivo Qvantig (nivolumab hyaluronidase-nvhy)
2025-HB-MED-575 Lunsumio (mosunetuzumab-axgb)
2025-HB-MED-576 Tevimbra (tislelizumab-jsgr)
2025-HB-MED-577 Bizengri (zenocutuzumab-zbco)
2025-HB-MED-578 Pemetrexed
2025-HB-MED-579 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin)
2025-HB-MED-580 Anktiva (nogapendekin alfa inbakicept-pmln)
2025-HB-MED-581 Imdelltra (tarlatamab-dlle)
2025-HB-MED-562 Synribo (omacetaxine mepesuccinate)
2025-HB-MED-563 Trastuzumab Agents
2025-HB-MED-564 Jevtana (cabazitaxel)
2025-HB-MED-565 Libtayo (cemiplimab-rwlc)
2025-HB-MED-566 GNRH Analogs for Oncologic Indications
2025-HB-MED-567 Gamifant (emapalumab)
2025-HB-MED-568 Rybrevant (amivantamab-ymjw)
2025-HB-MED-569 Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf)
2025-HB-MED-570 Imfinzi (durvalumab)
2025-HB-MED-571 Zynyz (retifanlimab-dlwr)
2025-HB-MED-553 Cosela (trilaciclib)
2025-HB-MED-554 Trodelvy (sacituzumab govitecan)
2025-HB-MED-555 Atezolizumab (Tecentriq, Tecentriq Hybreza)
2025-HB-MED-556 Doxorubicin Liposome (Doxil)
2025-HB-MED-557 Torisel (temsirolimus)
2025-HB-MED-558 Polivy (polatuzumab vedotin-piiq)
2025-HB-MED-559 Adcetris (brentuximab vedotin)
2025-HB-MED-560 Erbitux (cetuximab)
2025-HB-MED-561 Vectibix (panitumumab)
2025-LHCC-MED-854 Burosumab-twza (Crysvita)
2025-LHCC-MED-855 Deferoxamine (Desferal)
2025-LHCC-MED-856 Aflibercept (Eylea, Eylea HD, Opuviz, Yesafili, Ahzantive, Enzeevu, Pavblu)
2025-LHCC-MED-857 Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo)
2025-LHCC-MED-858 Lutetium Lu 177 Dotatate (Lutathera)
2025-LHCC-MED-859 Metreleptin (Myalept)
2025-LHCC-MED-860 Polatuzumab Vedotin-piiq (Polivy)
2025-LHCC-MED-861 Mitomycin for Pyelocalyceal Solution (Jelmyto)
2025-LHCC-MED-862 Pegcetacoplan (Empaveli, Syfovre)
2025-LHCC-MED-863 Epcoritamab-bysp (Epkinly)
2025-LHCC-MED-864 Glofitamab-gxbm (Columvi)
2025-LHCC-MED-865 Telisotuzumab Vedotin-tllv (Emrelis)
2025-UHC-MED-255 Gamifant-emapalumab
2025-UHC-MED-256 Complement inhibitors
2025-UHC-MED-257 Maximum Dosage and Frequency
2025-UHC-MED-258 Oncology medication clinical coverage
2025-ACLA-MED-112 Anti FGF23 Monoclonal Antibody
2025-ACLA-MED-113 BCMA Directed CAR T-cell Therapy
2025-ACLA-MED-114 Brineura
2025-ACLA-MED-115 Complement Inhibitors
2025-ACLA-MED-116 Encelto
2025-ACLA-MED-117 IGF1R Antagonists Thyroid Eye Disease
2025-ACLA-MED-118 Injectable Iron
2025-ACLA-MED-119 Myasthenia Gravis Agents
2025-ACLA-MED-120 Omisirge
2025-ACLA-MED-121 Enzyme Replacement Therapy for Fabry Disease
2025-ACLA-MED-122 Oncology
2025-ACLA-MED-123 Qalsody
2025-ACLA-MED-124 Rituximab
2025-ACLA-MED-125 Specialty Drugs
2025-ACLA-MED-126 VEGF Inhibitors for Ophthalmic Conditions
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