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| Item Number | Policy/Procedure | Date Posted | Comment Period Closed | Status | Document Links |
|---|---|---|---|---|---|
| 2024-LHCC-MED-497 | Idecabtagene Vicleucel (Abecma) | 5/23/24 | 7/7/24 | Complete | Idecabtagene Vicleucel (Abecma) |
| 2024-LHCC-MED-428 | Ofatumumab (Arzerra) | 5/23/24 | 7/7/24 | Complete | Ofatumumab (Arzerra) |
| 2024-LHCC-MED-431 | Lisocabtagene maraleucel (Breyanzi) | 5/23/24 | 7/7/24 | Complete | Lisocabtagene maraleucel (Breyanzi) |
| 2024-LHCC-MED-481 | Levoleucovorin (Fusilev, Khapzory) | 5/23/24 | 7/7/24 | Complete | Levoleucovorin (Fusilev, Khapzory) |
| 2024-LHCC-MED-482 | Obinutuzumab (Gazyva) | 5/23/24 | 7/7/24 | Complete | Obinutuzumab (Gazyva) |
| 2024-LHCC-MED-483 | Eribulin Mesylate (Halaven) | 5/23/24 | 7/7/24 | Complete | Eribulin Mesylate (Halaven) |
| 2024-LHCC-MED-484 | Panitumumab (Vectibix) | 5/23/24 | 7/7/24 | Complete | Panitumumab (Vectibix) |
| 2024-LHCC-MED-485 | Temsirolimus (Torisel) | 5/23/24 | 7/7/24 | Complete | Temsirolimus (Torisel) |
| 2024-LHCC-MED-486 | Gemtuzumab Ozogamicin (Mylotarg) | 5/23/24 | 7/7/24 | Complete | Gemtuzumab Ozogamicin (Mylotarg) |
| 2024-LHCC-MED-487 | Inotuzumab Ozogamicin (Besponsa) | 5/23/24 | 7/7/24 | Complete | Inotuzumab Ozogamicin (Besponsa) |
| 2024-LHCC-MED-488 | Eteclacalcetide (Parsabiv) | 5/23/24 | 7/7/24 | Complete | Eteclacalcetide (Parsabiv) |
| 2024-LHCC-MED-489 | Leucovorin Injection | 5/23/24 | 7/7/24 | Complete | Leucovorin Injection |
| 2024-LHCC-MED-490 | Vincristine Sulfate Liposome Injection (Marqibo) | 5/23/24 | 7/7/24 | Complete | Vincristine Sulfate Liposome Injection (Marqibo) |
| 2024-LHCC-MED-491 | Lanreotide (Somatuline Depot and Unbranded) | 5/23/24 | 7/7/24 | Complete | Lanreotide (Somatuline Depot and Unbranded) |
| 2024-LHCC-MED-461 | Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispha, Ozabax) | 5/23/24 | 7/7/24 | Complete | Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispha, Ozabax) |
| 2024-LHCC-MED-462 | Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) | 5/23/24 | 7/7/24 | Complete | Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) |
| 2024-LHCC-MED-463 | Hyaluronate Derivatives | 5/23/24 | 7/7/24 | Complete | Hyaluronate Derivatives |
| 2024-LHCC-MED-464 | Burosumab-twza (Crysvita) | 5/23/24 | 7/7/24 | Complete | Burosumab-twza (Crysvita) |
| 2024-LHCC-MED-465 | Collagenase Clostridium Histolyticum (Xiaflex) | 5/23/24 | 7/7/24 | Complete | Collagenase Clostridium Histolyticum (Xiaflex) |
| 2024-LHCC-MED-466 | Thyrotropin Alfa (Thyrogen) | 5/23/24 | 7/7/24 | Complete | Thyrotropin Alfa (Thyrogen) |
| 2024-LHCC-MED-467 | Mogamulizumab-kpkc (Poteligeo) | 5/23/24 | 7/7/24 | Complete | Mogamulizumab-kpkc (Poteligeo) |
| 2024-LHCC-MED-468 | Degarelix Acetate (Firmagon) | 5/23/24 | 7/7/24 | Complete | Degarelix Acetate (Firmagon) |
| 2024-LHCC-MED-469 | Belinostat (Beleodaq) | 5/23/24 | 7/7/24 | Complete | Belinostat (Beleodaq) |
| 2024-LHCC-MED-470 | Pralatrexate (Folotyn) | 5/23/24 | 7/7/24 | Complete | Pralatrexate (Folotyn) |
| 2024-LHCC-MED-471 | Necitumumab (Portrazza) | 5/23/24 | 7/7/24 | Complete | Necitumumab (Portrazza) |
| 2024-LHCC-MED-472 | Ziv-aflibercept (Zaltrap) | 5/23/24 | 7/7/24 | Complete | Ziv-aflibercept (Zaltrap) |
| 2024-LHCC-MED-473 | Daunorubicin-cytarabine (Vyxeos) | 5/23/24 | 7/7/24 | Complete | Daunorubicin-cytarabine (Vyxeos) |
| 2024-LHCC-MED-474 | Copanlisib (Aliqopa) | 5/23/24 | 7/7/24 | Complete | Copanlisib (Aliqopa) |
| 2024-LHCC-MED-475 | Chloramphenicol Sodium Succinate | 5/23/24 | 7/7/24 | Complete | Chloramphenicol Sodium Succinate |
| 2024-LHCC-MED-476 | Pegvisomant (Somavert) | 5/23/24 | 7/7/24 | Complete | Pegvisomant (Somavert) |
| 2024-LHCC-MED-477 | Iobenguane I-131 (Azedra) | 5/23/24 | 7/7/24 | Complete | Iobenguane I-131 (Azedra) |
| 2024-LHCC-MED-478 | Isatuximab-irfc (Sarclisa) | 5/23/24 | 7/7/24 | Complete | Isatuximab-irfc (Sarclisa) |
| 2024-LHCC-MED-479 | Sirolimus Protein-Bound Particles (Fyarro) | 5/23/24 | 7/7/24 | Complete | Sirolimus Protein-Bound Particles (Fyarro) |
| 2024-LHCC-MED-480 | Sodium Phenylbutyrate-Taurursodiol (Relyvrio) | 5/23/24 | 7/7/24 | Complete | Sodium Phenylbutyrate-Taurursodiol (Relyvrio) |
| 2024-LHCC-MED-453 | Amivantamab-vmjw (Rybrevant) | 5/21/24 | 7/5/24 | Complete | Amivantamab-vmjw (Rybrevant) |
| 2024-LHCC-MED-458 | Cipaglucosidase alfa-atga--miglustat (Pombiliti-Opfolda) | 5/21/24 | 7/5/24 | Complete | Cipaglucosidase alfa-atga--miglustat (Pombiliti-Opfolda) |
| 2024-LHCC-MED-459 | Eplontersen (Wainua) | 5/21/24 | 7/5/24 | Complete | Eplontersen (Wainua) |
| 2024-LHCC-MED-460 | ADAMTS13, recombinant-krhn (Adzynma) | 5/21/24 | 7/5/24 | Complete | ADAMTS13, recombinant-krhn (Adzynma) |
| 2024-LHCC-MED-501 | Aflibercept (Eylea, Eylea HD) | 5/21/24 | 7/5/24 | Complete | Aflibercept (Eylea, Eylea HD) |
| 2024-LHCC-MED-502 | Romidepsin (Istodax) | 5/21/24 | 7/5/24 | Complete | Romidepsin (Istodax) |
| 2024-LHCC-MED-503 | Pasireotide (Signifor, Signifor LAR) | 5/21/24 | 7/5/24 | Complete | Pasireotide (Signifor, Signifor LAR) |
| 2024-LHCC-MED-504 | Avalglucosidase Alfa-ngpt (Nexviazyme) | 5/21/24 | 7/5/24 | Complete | Avalglucosidase Alfa-ngpt (Nexviazyme) |
| 2024-LHCC-MED-505 | Ropeginterferon Alfa-2b-njft (BESREMi) | 5/21/24 | 7/5/24 | Complete | Ropeginterferon Alfa-2b-njft (BESREMi) |
| 2024-LHCC-MED-506 | Olipudase Alfa-rpcp (Xenpozyme) | 5/21/24 | 7/5/24 | Complete | Olipudase Alfa-rpcp (Xenpozyme) |
| 2024-LHCC-MED-507 | Tofersen (Qalsody) | 5/21/24 | 7/5/24 | Complete | Tofersen (Qalsody) |
| 2024-LHCC-MED-492 | Treprostinil (Remodulin) | 5/21/24 | 7/5/24 | Complete | Treprostinil (Remodulin) |
| 2024-LHCC-MED-493 | Belatacept (Nulojix) | 5/21/24 | 7/5/24 | Complete | Belatacept (Nulojix) |
| 2024-LHCC-MED-494 | Mitoxantrone | 5/21/24 | 7/5/24 | Complete | Mitoxantrone |
| 2024-LHCC-MED-495 | Irinotecan Liposome (Onivyde) | 5/21/24 | 7/5/24 | Complete | Irinotecan Liposome (Onivyde) |
| 2024-LHCC-MED-496 | Plerixafor (Mozobil) | 5/21/24 | 7/5/24 | Complete | Plerixafor (Mozobil) |
| 2024-LHCC-MED-498 | Pertuzumab-Trastuzumab-Hyaluronidase-zzxf (Phesgo) | 5/21/24 | 7/5/24 | Complete | Pertuzumab-Trastuzumab-Hyaluronidase-zzxf (Phesgo) |
| 2024-LHCC-MED-499 | Antithymocyte Globulin (Atgam, Thymoglobulin) | 5/21/24 | 7/5/24 | Complete | Antithymocyte Globulin (Atgam, Thymoglobulin) |
| 2024-LHCC-MED-500 | Talimogene laherepvec (Imlygic) | 5/21/24 | 7/5/24 | Complete | Talimogene laherepvec (Imlygic) |
| 2024-UHC-MED-212 | Complement inhibitors | 5/21/24 | 7/5/24 | Complete | Complement inhibitors |
| 2024-UHC-MED-211 | Review at Launch New to Market Medications | 5/16/24 | 6/30/24 | Complete | Review at Launch New to Market Medications |
| 2024-PHARM-36 | Acne Agents | 5/15/24 | 6/29/24 | Complete | Acne Agents |
| 2024-PHARM-37 | Anticonvulsants | 5/15/24 | 6/29/24 | Complete | Anticonvulsants |
| 2024-PHARM-38 | Asthma-COPD, Beta-Adrenergic Bronchodilators | 5/15/24 | 6/29/24 | Complete | Asthma-COPD, Beta-Adrenergic Bronchodilators |
| 2024-PHARM-39 | Asthma-COPD, Inhaled Anticholinergic Bronchodilators | 5/15/24 | 6/29/24 | Complete | Asthma-COPD, Inhaled Anticholinergic Bronchodilators |
| 2024-PHARM-40 | Asthma-COPD, Inhaled Glucocorticoids | 5/15/24 | 6/29/24 | Complete | Asthma-COPD, Inhaled Glucocorticoids |
| 2024-PHARM-41 | Dermatology-Topical, Antiparasitic Agents | 5/15/24 | 6/29/24 | Complete | Dermatology-Topical, Antiparasitic Agents |
| 2024-PHARM-42 | Digestive Disorders, PPIs | 5/15/24 | 6/29/24 | Complete | Digestive Disorders, PPIs |
| 2024-PHARM-43 | Digestive Disorders, Ulcerative Colitis Agents | 5/15/24 | 6/29/24 | Complete | Digestive Disorders, Ulcerative Colitis Agents |
| 2024-PHARM-44 | GI Motility, Chronic | 5/15/24 | 6/29/24 | Complete | GI Motility, Chronic |
| 2024-PHARM-45 | Heart Disease, Anticoagulants | 5/15/24 | 6/29/24 | Complete | Heart Disease, Anticoagulants |
| 2024-PHARM-46 | Heart.Disease, Pulmonary Arterial Hypertension Agents | 5/15/24 | 6/29/24 | Complete | Heart.Disease, Pulmonary Arterial Hypertension Agents |
| 2024-PHARM-47 | Hemodialysis, Phosphate Binders | 5/15/24 | 6/29/24 | Complete | Hemodialysis, Phosphate Binders |
| 2024-PHARM-48 | Infectious Disorders, Hepatitis C DAA | 5/15/24 | 6/29/24 | Complete | Infectious Disorders, Hepatitis C DAA |
| 2024-PHARM-49 | Infectious Disorders-Antibiotics, Inhaled Antibiotics | 5/15/24 | 6/29/24 | Complete | Infectious Disorders-Antibiotics, Inhaled Antibiotics |
| 2024-PHARM-50 | Multiple Sclerosis Agents | 5/15/24 | 6/29/24 | Complete | Multiple Sclerosis Agents |
| 2024-PHARM-51 | Oncology Agents-Oral, Hematologic | 5/15/24 | 6/29/24 | Complete | Oncology Agents-Oral, Hematologic |
| 2024-PHARM-52 | Ophthalmic Disorders-Anti-Inflammatory, Immunomodulators | 5/15/24 | 6/29/24 | Complete | Ophthalmic Disorders-Anti-Inflammatory, Immunomodulators |
| 2024-PHARM-53 | Ophthalmic Disorders-Glaucoma.Agents, Intraocular Pressure Reducers | 5/15/24 | 6/29/24 | Complete | Ophthalmic Disorders-Glaucoma.Agents, Intraocular Pressure Reducers |
| 2024-PHARM-54 | Opiate Dependence Agents | 5/15/24 | 6/29/24 | Complete | Opiate Dependence Agents |
| 2024-PHARM-55 | PDL-July 1, 2024 | 5/15/24 | 6/29/24 | Complete | PDL-July 1, 2024 |
| 2024-PHARM-56 | POS Infectious Disorders-Hepatitis C Agents, Direct Acting Antiviral Agents | 5/15/24 | 6/29/24 | Complete | POS Infectious Disorders-Hepatitis C Agents, Direct Acting Antiviral Agents |
| 2024-PHARM-57 | Stimulants and Related Agents | 5/15/24 | 6/29/24 | Complete | Stimulants and Related Agents |
| 2024-PHARM-58 | Wegovy | 5/15/24 | 6/29/24 | Complete | Wegovy |
| 2024-PHARM-59 | Wegovy Patient Agreement | 5/15/24 | 6/29/24 | Complete | Wegovy Patient Agreement |
| 2024-UHC-MED-210 | Provider administered drugs-site of care | 5/6/24 | 6/20/24 | Complete | Provider administered drugs-site of care |
| 2024-PHARM-17 | Agamree | 4/25/24 | 6/9/24 | Complete | Agamree |
| 2024-PHARM-18 | Alzheimers | 4/25/24 | 6/9/24 | Complete | Alzheimers |
| 2024-PHARM-19 | Asthma Immunomodulators | 4/25/24 | 6/9/24 | Complete | Asthma Immunomodulators |
| 2024-PHARM-20 | Casgevy | 4/25/24 | 6/9/24 | Complete | Casgevy |
| 2024-PHARM-21 | Dermatology - Atopic.Dermatitis, Immunomodulators | 4/25/24 | 6/9/24 | Complete | Dermatology - Atopic.Dermatitis, Immunomodulators |
| 2024-PHARM-22 | Filsuvez | 4/25/24 | 6/9/24 | Complete | Filsuvez |
| 2024-PHARM-23 | H.pylori Treatment | 4/25/24 | 6/9/24 | Complete | H.pylori Treatment |
| 2024-PHARM-24 | Louisiana Medicaid ICD-10 Chart | 4/25/24 | 6/9/24 | Complete | Louisiana Medicaid ICD-10 Chart |
| 2024-PHARM-25 | Lyfgenia | 4/25/24 | 6/9/24 | Complete | Lyfgenia |
| 2024-PHARM-26 | Pain Management - Cytokine/CAM Antagonists | 4/25/24 | 6/9/24 | Complete | Pain Management - Cytokine/CAM Antagonists |
| 2024-PHARM-27 | POS Adzynma | 4/25/24 | 6/9/24 | Complete | POS Adzynma |
| 2024-PHARM-28 | POS Diabetes - Hypoglycemics/Incretin Mimetics | 4/25/24 | 6/9/24 | Complete | POS Diabetes - Hypoglycemics/Incretin Mimetics |
| 2024-PHARM-29 | POS Eohilia | 4/25/24 | 6/9/24 | Complete | POS Eohilia |
| 2024-PHARM-30 | POS Fabhalta | 4/25/24 | 6/9/24 | Complete | POS Fabhalta |
| 2024-PHARM-31 | POS H.Pylori Treatment | 4/25/24 | 6/9/24 | Complete | POS H.Pylori Treatment |
| 2024-PHARM-32 | POS Wainua | 4/25/24 | 6/9/24 | Complete | POS Wainua |
| 2024-PHARM-33 | POS Zilbrysq | 4/25/24 | 6/9/24 | Complete | POS Zilbrysq |
| 2024-PHARM-34 | Rivfloza | 4/25/24 | 6/9/24 | Complete | Rivfloza |
| 2024-PHARM-35 | Zymfentra | 4/25/24 | 6/9/24 | Complete | Zymfentra |
| 2024-UHC-MED-206 | Immune globulin IVIG-scig | 4/23/24 | 6/7/24 | Complete | Immune globulin IVIG-scig |
| 2024-UHC-MED-207 | Iron replacement therapy | 4/23/24 | 6/7/24 | Complete | Iron replacement therapy |
| 2024-UHC-MED-208 | Maximum dosage | 4/23/24 | 6/7/24 | Complete | Maximum dosage |
| 2024-UHC-MED-209 | Rituxan-Rituximab | 4/23/24 | 6/7/24 | Complete | Rituxan-Rituximab |
| 2024-LHCC-MED-427 | Immunization Coverage | 4/23/24 | 6/7/24 | Complete | Immunization Coverage |
| 2024-LHCC-MED-429 | Brexucabtagene Autoleucel (Tecartus) | 4/23/24 | 6/7/24 | Complete | Brexucabtagene Autoleucel (Tecartus) |
| 2024-LHCC-MED-430 | Ferric Derisomaltose (Monoferric) | 4/23/24 | 6/7/24 | Complete | Ferric Derisomaltose (Monoferric) |
| 2024-LHCC-MED-432 | Mitomycin for Pyelocalyceal Solution (Jelmyto) | 4/23/24 | 6/7/24 | Complete | Mitomycin for Pyelocalyceal Solution (Jelmyto) |
| 2024-LHCC-MED-433 | Tafasitamab-cxix (Monjuvi) | 4/23/24 | 6/7/24 | Complete | Tafasitamab-cxix (Monjuvi) |
| 2024-LHCC-MED-434 | Ciltacabtagene Autoleucel (Carvykti) | 4/23/24 | 6/7/24 | Complete | Ciltacabtagene Autoleucel (Carvykti) |
| 2024-LHCC-MED-435 | Lutetium Lu 177, vipivotide tetraxetan (Pluvicto) | 4/23/24 | 6/7/24 | Complete | Lutetium Lu 177, vipivotide tetraxetan (Pluvicto) |
| 2024-LHCC-MED-436 | Furosemide (Furoscix) | 4/23/24 | 6/7/24 | Complete | Furosemide (Furoscix) |
| 2024-LHCC-MED-442 | Metreleptin (Myalept) | 4/4/24 | 5/19/24 | Complete | Metreleptin (Myalept) |
| 2024-LHCC-MED-443 | Bremelanotide (Vyleesi) | 4/4/24 | 5/19/24 | Complete | Bremelanotide (Vyleesi) |
| 2024-LHCC-MED-444 | Valrubicin (Valstar) | 4/4/24 | 5/19/24 | Complete | Valrubicin (Valstar) |
| 2024-LHCC-MED-445 | Afamelanotide (Scenesse) | 4/4/24 | 5/19/24 | Complete | Afamelanotide (Scenesse) |
| 2024-LHCC-MED-446 | Brolucizumab-dbll (Beovu) | 4/4/24 | 5/19/24 | Complete | Brolucizumab-dbll (Beovu) |
| 2024-LHCC-MED-447 | Plasminogen, Human-tvmh (Ryplazim) | 4/4/24 | 5/19/24 | Complete | Plasminogen, Human-tvmh (Ryplazim) |
| 2024-LHCC-MED-448 | Margetuximab-cmkb (Margenza) | 4/4/24 | 5/19/24 | Complete | Margetuximab-cmkb (Margenza) |
| 2024-LHCC-MED-449 | Naxitamab-gqgk (Danyelza) | 4/4/24 | 5/19/24 | Complete | Naxitamab-gqgk (Danyelza) |
| 2024-LHCC-MED-450 | Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP) | 4/4/24 | 5/19/24 | Complete | Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP) |
| 2024-LHCC-MED-451 | Melphalan Flufenamide (Pepaxto) | 4/4/24 | 5/19/24 | Complete | Melphalan Flufenamide (Pepaxto) |
| 2024-LHCC-MED-452 | Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) | 4/4/24 | 5/19/24 | Complete | Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) |
| 2024-LHCC-MED-454 | Vutrisiran (Amvuttra) | 4/4/24 | 5/19/24 | Complete | Vutrisiran (Amvuttra) |
| 2024-LHCC-MED-455 | Tisotumab Vedotin-tftv (Tivdak) | 4/4/24 | 5/19/24 | Complete | Tisotumab Vedotin-tftv (Tivdak) |
| 2024-LHCC-MED-456 | Allogenic Processed Thymus Tissue-agdc (Rethymic) | 4/4/24 | 5/19/24 | Complete | Allogenic Processed Thymus Tissue-agdc (Rethymic) |
| 2024-LHCC-MED-457 | Antithrombin III (ATryn, Thrombate III) | 4/4/24 | 5/19/24 | Complete | Antithrombin III (ATryn, Thrombate III) |
| 2024-LHCC-MED-437 | Parathyroid Hormone (Natpara) | 4/3/24 | 5/18/24 | Complete | Parathyroid Hormone (Natpara) |
| 2024-LHCC-MED-438 | Belantamab Mafodotin-blmf (Blenrep) | 4/3/24 | 5/18/24 | Complete | Belantamab Mafodotin-blmf (Blenrep) |
| 2024-LHCC-MED-439 | Tebentafusp-tebn (Kimmtrak) | 4/3/24 | 5/18/24 | Complete | Tebentafusp-tebn (Kimmtrak) |
| 2024-LHCC-MED-440 | Nivolumab and Relatlimab-rmbw (Opdualag) | 4/3/24 | 5/18/24 | Complete | Nivolumab and Relatlimab-rmbw (Opdualag) |
| 2024-LHCC-MED-441 | Mosunetuzumab-axgb (Lunsumio) | 4/3/24 | 5/18/24 | Complete | Mosunetuzumab-axgb (Lunsumio) |
| 2024-HUMANA-MED-93 | 7266, J1602 Golimumab, 1mg | 4/3/24 | 5/18/24 | Complete | 7266, J1602 Golimumab, 1mg |
| 2024-HUMANA-MED-94 | 7264, J0585 Onobotulinumtoxin A | 4/3/24 | 5/18/24 | Complete | 7264, J0585 Onobotulinumtoxin A |
| 2024-HUMANA-MED-95 | 7269, J0585 Onobotulinumtoxin A | 4/3/24 | 5/18/24 | Complete | 7269, J0585 Onobotulinumtoxin A |
| 2024-HUMANA-MED-96 | 7234, J9312, Q5115, Q5119, Q5123 Rituximab, 10mg | 4/3/24 | 5/18/24 | Complete | 7234, J9312, Q5115, Q5119, Q5123 Rituximab, 10mg |
| 2024-UHC-MED-200 | Adzynma | 4/1/24 | 5/16/24 | Complete | Adzynma |
| 2024-UHC-MED-201 | Enjaymo-sutimlimab | 4/1/24 | 5/16/24 | Complete | Enjaymo-sutimlimab |
| 2024-UHC-MED-202 | Erythropoiesis-stimulating agents | 4/1/24 | 5/16/24 | Complete | Erythropoiesis-stimulating agents |
| 2024-UHC-MED-203 | Reblozyl | 4/1/24 | 5/16/24 | Complete | Reblozyl |
| 2024-UHC-MED-204 | Oncology medication | 4/1/24 | 5/16/24 | Complete | Oncology medication |
| 2024-UHC-MED-205 | Radicava | 4/1/24 | 5/16/24 | Complete | Radicava |
| 2024-ACLA-MED-71 | Inhibitors for Ophthalmic Conditions | 3/25/24 | 5/9/24 | Completed | Inhibitors for Ophthalmic Conditions |
| 2024-ACLA-MED-72 | Enzyme Replacement Therapies for Fabry Disease | 3/25/24 | 5/9/24 | Completed | Enzyme Replacement Therapies for Fabry Disease |
| 2024-LHCC-MED-422 | Pegunigalsidase alfa-iwxj (Elfabrio) | 3/25/24 | 5/9/24 | Completed | Pegunigalsidase alfa-iwxj (Elfabrio) |
| 2024-LHCC-MED-423 | Pegcetacoplan (Empaveli, Syfovre) | 3/25/24 | 5/9/24 | Completed | Pegcetacoplan (Empaveli, Syfovre) |
| 2024-LHCC-MED-424 | Velmanase Alfa-tycv (Lamzede) | 3/25/24 | 5/9/24 | Completed | Velmanase Alfa-tycv (Lamzede) |
| 2024-LHCC-MED-425 | Exagamglogene autotemcel (Casgevy) | 3/25/24 | 5/9/24 | Completed | Exagamglogene autotemcel (Casgevy) |
| 2024-LHCC-MED-426 | Zilucoplan (Zilbrysq) | 3/25/24 | 5/9/24 | Completed | Zilucoplan (Zilbrysq) |
| 2024-LHCC-MED-403 | Desmopressin (DDAVP, Stimate, Nocdurna) | 3/25/24 | 5/9/24 | Completed | Desmopressin (DDAVP, Stimate, Nocdurna) |
| 2024-LHCC-MED-404 | Polatuzumab Vedotin-piiq (Polivy) | 3/25/24 | 5/9/24 | Completed | Polatuzumab Vedotin-piiq (Polivy) |
| 2024-LHCC-MED-405 | Nadofaragene firadenovec-vncg (Adstiladrin) | 3/25/24 | 5/9/24 | Completed | Nadofaragene firadenovec-vncg (Adstiladrin) |
| 2024-LHCC-MED-406 | Lurbinectedin (Zepzelca) | 3/25/24 | 5/9/24 | Completed | Lurbinectedin (Zepzelca) |
| 2024-LHCC-MED-407 | Loncastuximab tesirine-lpyl (Zynlonta) | 3/25/24 | 5/9/24 | Completed | Loncastuximab tesirine-lpyl (Zynlonta) |
| 2024-LHCC-MED-408 | Dostablimab-gxly (Jemperli) | 3/25/24 | 5/9/24 | Completed | Dostablimab-gxly (Jemperli) |
| 2024-LHCC-MED-409 | Sodium thiosulfate (Pedmark) | 3/25/24 | 5/9/24 | Completed | Sodium thiosulfate (Pedmark) |
| 2024-LHCC-MED-410 | Teclistamab-cqyv (Tecvayli) | 3/25/24 | 5/9/24 | Completed | Teclistamab-cqyv (Tecvayli) |
| 2024-LHCC-MED-411 | Tremelimumab-actl (Imjudo) | 3/25/24 | 5/9/24 | Completed | Tremelimumab-actl (Imjudo) |
| 2024-LHCC-MED-412 | Fecal microbiota, live-jslm (Rebyota) | 3/25/24 | 5/9/24 | Completed | Fecal microbiota, live-jslm (Rebyota) |
| 2024-LHCC-MED-413 | Mirvetuximab soravtansine-gynx (Elahere) | 3/25/24 | 5/9/24 | Completed | Mirvetuximab soravtansine-gynx (Elahere) |
| 2024-LHCC-MED-402 | Glycopyrronium (Qbrexza) | 3/18/24 | 5/2/24 | Complete | Glycopyrronium (Qbrexza) |
| 2024-LHCC-MED-414 | DaxibotulinumtoxinA-lanm (Daxxify) | 3/18/24 | 5/2/24 | Complete | DaxibotulinumtoxinA-lanm (Daxxify) |
| 2024-LHCC-MED-415 | Elranatamab-bcmm (Elrexfio) | 3/18/24 | 5/2/24 | Complete | Elranatamab-bcmm (Elrexfio) |
| 2024-LHCC-MED-416 | Melphalan (Hepzato) | 3/18/24 | 5/2/24 | Complete | Melphalan (Hepzato) |
| 2024-LHCC-MED-417 | Motixafortide (Aphexda) | 3/18/24 | 5/2/24 | Complete | Motixafortide (Aphexda) |
| 2024-LHCC-MED-418 | Pozelimab-bbfg (Veopoz) | 3/18/24 | 5/2/24 | Complete | Pozelimab-bbfg (Veopoz) |
| 2024-LHCC-MED-419 | Avacincaptad pegol (Izervay) | 3/18/24 | 5/2/24 | Complete | Avacincaptad pegol (Izervay) |
| 2024-LHCC-MED-420 | Rozanolixizumab-noli (Rystiggo) | 3/18/24 | 5/2/24 | Complete | Rozanolixizumab-noli (Rystiggo) |
| 2024-LHCC-MED-421 | Talquetamab-tgvs (Talvey) | 3/18/24 | 5/2/24 | Complete | Talquetamab-tgvs (Talvey) |
| 2024-ACLA-MED-63 | Anti FGF23 Monoclonal Antibody | 3/18/24 | 5/2/24 | Complete | Anti FGF23 Monoclonal Antibody |
| 2024-ACLA-MED-64 | Complement Inhibitors | 3/18/24 | 5/2/24 | Complete | Complement Inhibitors |
| 2024-ACLA-MED-65 | Primary HLH | 3/18/24 | 5/2/24 | Complete | Primary HLH |
| 2024-ACLA-MED-66 | Qalsody | 3/18/24 | 5/2/24 | Complete | Qalsody |
| 2024-ACLA-MED-67 | IGF1R Antagonists thyroid eye disease | 3/18/24 | 5/2/24 | Complete | IGF1R Antagonists thyroid eye disease |
| 2024-ACLA-MED-68 | Rituximab | 3/18/24 | 5/2/24 | Complete | Rituximab |
| 2024-ACLA-MED-69 | Treatments for PLD1 | 3/18/24 | 5/2/24 | Complete | Treatments for PLD1 |
| 2024-ACLA-MED-70 | Vyvgart | 3/18/24 | 5/2/24 | Complete | Vyvgart |
| 2024-HUMANA-MED-91 | Infliximab, 10mg, Code 6965 | 3/18/24 | 5/2/24 | Complete | Infliximab, 10mg, Code 6965 |
| 2024-HUMANA-MED-92 | Hormone Pellet, Code 6992 | 3/18/24 | 5/2/24 | Complete | Hormone Pellet, Code 6992 |
| 2024-UHC-MED-198 | Neonatal Fc receptor blockers | 2/29/24 | 4/14/24 | Complete | Neonatal Fc receptor blockers |
| 2024-UHC-MED-199 | Ryplazim | 2/29/24 | 4/14/24 | Complete | Ryplazim |
| 2024-HB-MED-389 | Bevacizumab for non-ophthalmologic indications | 2/29/24 | 4/14/24 | Complete | Bevacizumab for non-ophthalmologic indications |
| 2024-HB-MED-390 | Loqtorzi | 2/29/24 | 4/14/24 | Complete | Loqtorzi |
| 2024-HB-MED-391 | Rivfloza | 2/29/24 | 4/14/24 | Complete | Rivfloza |
| 2024-HB-MED-392 | Rituximab agents for non-oncologic indications | 2/29/24 | 4/14/24 | Complete | Rituximab agents for non-oncologic indications |
| 2024-HB-MED-393 | Perjeta | 2/29/24 | 4/14/24 | Complete | Perjeta |
| 2024-HB-MED-394 | Keytruda | 2/29/24 | 4/14/24 | Complete | Keytruda |
| 2024-HB-MED-395 | Zilretta | 2/29/24 | 4/14/24 | Complete | Zilretta |
| 2024-HB-MED-396 | Jemperli | 2/29/24 | 4/14/24 | Complete | Jemperli |
| 2024-HB-MED-397 | Relizorb | 2/29/24 | 4/14/24 | Complete | Relizorb |
| 2024-HB-MED-398 | Tecvayli | 2/29/24 | 4/14/24 | Complete | Tecvayli |
| 2024-HB-MED-399 | Wainua | 2/29/24 | 4/14/24 | Complete | Wainua |
| 2024-HUMANA-MED-84 | 6728, 6816 Bendamustine HCL, 1mg Codes J9033, J9034 | 2/22/24 | 4/7/24 | Complete | 6728, 6816 Bendamustine HCL, 1mg Codes J9033, J9034 |
| 2024-HB-MED-378 | Polivy | 2/22/24 | 4/7/24 | Complete | Polivy |
| 2024-HB-MED-379 | Kymriah | 2/22/24 | 4/7/24 | Complete | Kymriah |
| 2024-HB-MED-380 | Yescarta | 2/22/24 | 4/7/24 | Complete | Yescarta |
| 2024-HB-MED-381 | Tecartus | 2/22/24 | 4/7/24 | Complete | Tecartus |
| 2024-HB-MED-382 | Abecma | 2/22/24 | 4/7/24 | Complete | Abecma |
| 2024-HB-MED-383 | Breyanzi | 2/22/24 | 4/7/24 | Complete | Breyanzi |
| 2024-HB-MED-384 | Fyarro | 2/22/24 | 4/7/24 | Complete | Fyarro |
| 2024-HB-MED-385 | Carvykti | 2/22/24 | 4/7/24 | Complete | Carvykti |
| 2024-HB-MED-386 | Imjudo | 2/22/24 | 4/7/24 | Complete | Imjudo |
| 2024-HB-MED-387 | Pedmark | 2/22/24 | 4/7/24 | Complete | Pedmark |
| 2024-HB-MED-388 | Elahere | 2/22/24 | 4/7/24 | Complete | Elahere |
| 2024-UHC-MED-197 | Maximum Dosage policy | 2/21/24 | 4/6/24 | Complete | Maximum Dosage policy |
| 2024-HB-MED-367 | Adzynma | 2/21/24 | 4/6/24 | Complete | Adzynma |
| 2024-HB-MED-368 | Aphexda | 2/21/24 | 4/6/24 | Complete | Aphexda |
| 2024-HB-MED-369 | Zilbrysq | 2/21/24 | 4/6/24 | Complete | Zilbrysq |
| 2024-HB-MED-370 | Octreotide Agents | 2/21/24 | 4/6/24 | Complete | Octreotide Agents |
| 2024-HB-MED-371 | Adcetris | 2/21/24 | 4/6/24 | Complete | Adcetris |
| 2024-HB-MED-372 | Keytruda | 2/21/24 | 4/6/24 | Complete | Keytruda |
| 2024-HB-MED-373 | Opdivo | 2/21/24 | 4/6/24 | Complete | Opdivo |
| 2024-HB-MED-374 | Darzalex | 2/21/24 | 4/6/24 | Complete | Darzalex |
| 2024-HB-MED-375 | Tecentriq | 2/21/24 | 4/6/24 | Complete | Tecentriq |
| 2024-HB-MED-376 | Imfinzi | 2/21/24 | 4/6/24 | Complete | Imfinzi |
| 2024-HB-MED-377 | Aliqopa | 2/21/24 | 4/6/24 | Complete | Aliqopa |
| 2024-PHARM-1 | Abrilada | 2/2/24 | 3/18/24 | Complete | Abrilada |
| 2024-PHARM-2 | Bimzelx | 2/2/24 | 3/18/24 | Complete | Bimzelx |
| 2024-PHARM-3 | Cytokine/CAM Antagonists | 2/2/24 | 3/18/24 | Complete | Cytokine/CAM Antagonists |
| 2024-PHARM-4 | Growth Factors | 2/2/24 | 3/18/24 | Complete | Growth Factors |
| 2024-PHARM-5 | ICD-10 Chart | 2/2/24 | 3/18/24 | Complete | ICD-10 Chart |
| 2024-PHARM-6 | Movement Disorders - VMAT2 Inhibitors | 2/2/24 | 3/18/24 | Complete | Movement Disorders - VMAT2 Inhibitors |
| 2024-PHARM-7 | Omvoh | 2/2/24 | 3/18/24 | Complete | Omvoh |
| 2024-PHARM-8 | POS Antipsychotic Agents, Injectable | 2/2/24 | 3/18/24 | Complete | POS Antipsychotic Agents, Injectable |
| 2024-PHARM-9 | POS Diabetes, Incretin Mimetics/Enhancers | 2/2/24 | 3/18/24 | Complete | POS Diabetes, Incretin Mimetics/Enhancers |
| 2024-PHARM-10 | POS Opvee | 2/2/24 | 3/18/24 | Complete | POS Opvee |
| 2024-PHARM-11 | POS Pombiliti/Opfolda | 2/2/24 | 3/18/24 | Complete | POS Pombiliti/Opfolda |
| 2024-PHARM-12 | POS Sohonos | 2/2/24 | 3/18/24 | Complete | POS Sohonos |
| 2024-PHARM-13 | POS Ycanth | 2/2/24 | 3/18/24 | Complete | POS Ycanth |
| 2024-PHARM-14 | Spinal Muscular Atrophy | 2/2/24 | 3/18/24 | Complete | Spinal Muscular Atrophy |
| 2024-PHARM-15 | Velsipity | 2/2/24 | 3/18/24 | Complete | Velsipity |
| 2024-PHARM-16 | Zurzuvae | 2/2/24 | 3/18/24 | Complete | Zurzuvae |
| 2024-HUMANA-MED-79 | Irinotecan, 20mg, 6737 | 1/30/24 | 3/15/24 | Complete | Irinotecan, 20mg, 6737 |
| 2024-HUMANA-MED-80 | Infliximab & Biosimilars, 6812 | 1/30/24 | 3/15/24 | Complete | Infliximab & Biosimilars, 6812 |
| 2024-HUMANA-MED-81 | Paclitaxel, 1mg, 6760 | 1/30/24 | 3/15/24 | Complete | Paclitaxel, 1mg, 6760 |
| 2024-HUMANA-MED-82 | Afibercept, 1mg, 6932 | 1/30/24 | 3/15/24 | Complete | Afibercept, 1mg, 6932 |
| 2024-HUMANA-MED-83 | Rituximab & Biosimilars, 6778 | 1/30/24 | 3/15/24 | Complete | Rituximab & Biosimilars, 6778 |
| 2024-HUMANA-MED-86 | Eculizumab, 10mg, 6731, 6735 | 1/30/24 | 3/15/24 | Complete | Eculizumab, 10mg, 6731, 6735 |
| 2024-HUMANA-MED-87 | Bendamustine, 1mg, 6777, 6781, 6783, 6785 | 1/30/24 | 3/15/24 | Complete | Bendamustine, 1mg, 6777, 6781, 6783, 6785 |
| 2024-HUMANA-MED-88 | Fam-Trastuzumab, 6876, 6878, 6880, 6882, 6884, 6886, 6888, 6890, 6892, 6894 | 1/30/24 | 3/15/24 | Complete | Fam-Trastuzumab, 6876, 6878, 6880, 6882, 6884, 6886, 6888, 6890, 6892, 6894 |
| 2024-HUMANA-MED-89 | Lanreotide, 1mg, 6382, 6385 | 1/30/24 | 3/15/24 | Complete | Lanreotide, 1mg, 6382, 6385 |
| 2024-HUMANA-MED-90 | Gemcitabine, 200mg, 6787, 6789, 6792, 6795, 6797, 6799, 6801 | 1/30/24 | 3/15/24 | Complete | Gemcitabine, 200mg, 6787, 6789, 6792, 6795, 6797, 6799, 6801 |
| 2024-UHC-MED-196 | Medical Therapies for Enzyme Deficiencies | 1/30/24 | 3/15/24 | Complete | Medical Therapies for Enzyme Deficiencies |
| 2024-UHC-MED-193 | Iron Replacement Therapy | 1/25/24 | 3/10/24 | Complete | Iron Replacement Therapy |
| 2024-UHC-MED-194 | Omvoh | 1/25/24 | 3/10/24 | Complete | Omvoh |
| 2024-UHC-MED-195 | Complement Inhibitors | 1/25/24 | 3/10/24 | Complete | Complement Inhibitors |
Medicaid Managed Care Policies & Procedures Archive - Pharmacy (2024) continued
"Policy or procedure" shall mean a requirement governing the administration of managed care organizations specific to billing guidelines, medical management and utilization review guidelines, case management guidelines, claims processing guidelines and edits, grievance and appeals procedures and process, other guidelines or manuals containing pertinent information related to operations and pre-processing claims, and core benefits and services.
Below are items previously posted for public comment:
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