Managed Care Pharmacy and Medical Drug Policies Archive (2021)

"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:

Item Number	Policy/Procedure	Date Posted	Comment Period Closed	Status	Document Links
2021-HB-MED-104	LA 2Q21 Formulary Change Notice	12/14/21	1/28/22	Approved	LA 2Q21 Formulary Change Notice
2021-HB-MED-105	Bevacizumab	12/6/21	1/20/22	Approved	Bevacizumab
2021-HB-MED-106	Iron Agents	12/6/21	1/20/22	Approved	Iron Agents
2021-HB-MED-108	VEGF Inhibitors	12/6/21	1/20/22	Approved	VEGF Inhibitors
2021-UHC-MED-92	Onpattro	12/2/21	1/16/22	Approved	Onpattro
2021-UHC-MED-93	Crysvita	12/2/21	1/16/22	Approved	Crysvita
2021-UHC-MED-88	Evenity	11/19/21	1/3/22	Approved	Evenity
2021-UHC-MED-90	Vyepti	11/19/21	1/3/22	Approved	Vyepti
2021-UHC-MED-91	Max Dosage Policy	11/19/21	1/3/22	Approved	Max Dosage Policy
2021-LHCC-MED-68	Factor XIII-A-Subunit, Recombinant (Tretten)	11/19/21	1/3/22	Approved	Factor XIII-A-Subunit, Recombinant (Tretten)
2021-PHARM-132	Stimulants and Related Agents	11/16/21	12/31/21	Approved	Stimulants and Related Agents
2021-PHARM-131	Smoking Cessation	11/16/21	12/31/21	Approved	Smoking Cessation
2021-PHARM-130	POS Ophthalmic Cystinosis	11/16/21	12/31/21	Approved	POS Ophthalmic Cystinosis
2021-PHARM-129	POS Lupus Immunomodulators	11/16/21	12/31/21	Approved	POS Lupus Immunomodulators
2021-PHARM-128	Ophthalmic Cystinosis	11/16/21	12/31/21	Approved	Ophthalmic Cystinosis
2021-PHARM-127	Oncology - Renal	11/16/21	12/31/21	Approved	Oncology - Renal
2021-PHARM-126	Lupus Immunomodulators	11/16/21	12/31/21	Approved	Lupus Immunomodulators
2021-PHARM-125	January 1, 2022 PDL	11/16/21	12/31/21	Approved	January 1, 2022 PDL
2021-PHARM-124	ICD-10 Chart	11/16/21	12/31/21	Approved	ICD-10 Chart
2021-PHARM-123	Enzyme Replacements	11/16/21	12/31/21	Approved	Enzyme Replacements
2021-PHARM-122	Antipsychotics - Oral and Transdermal	11/16/21	12/31/21	Approved	Antipsychotics - Oral and Transdermal
2021-PHARM-121	Anticonvulsants	11/16/21	12/31/21	Approved	Anticonvulsants
2021-PHARM-120	Xyrem/Xywav	10/27/21	12/11/21	Approved	Xyrem/Xywav
2021-PHARM-119	Uterine Disorder Treatments	10/27/21	12/11/21	Approved	Uterine Disorder Treatments
2021-PHARM-118	Saphnelo	10/27/21	12/11/21	Approved	Saphnelo
2021-PHARM-117	POS Sedative/Hypnotics	10/27/21	12/11/21	Approved	POS Sedative/Hypnotics
2021-PHARM-116	POS Short-Acting Narcotics	10/27/21	12/11/21	Approved	POS Short-Acting Narcotics
2021-PHARM-115	POS CGRP Antagonists	10/27/21	12/11/21	Approved	POS CGRP Antagonists
2021-PHARM-114	POS Hyperlipidemia, Lipotropics Other	10/27/21	12/11/21	Approved	POS Hyperlipidemia, Lipotropics Other
2021-PHARM-113	Xenical	10/27/21	12/11/21	Approved	Xenical
2021-PHARM-112	Anti-Allergens	10/27/21	12/11/21	Approved	Anti-Allergens
2021-PHARM-111	POS SGLT2 Inhibitors	10/27/21	12/11/21	Approved	POS SGLT2 Inhibitors
2021-PHARM-110	Cytokine/CAM Agents	10/27/21	12/11/21	Approved	Cytokine/CAM Agents
2021-PHARM-109	CGRP Antagonists	10/27/21	12/11/21	Approved	CGRP Antagonists
2021-PHARM-108	Nulibry	10/27/21	12/11/21	Approved	Nulibry
2021-PHARM-107	Multiple Sclerosis	10/27/21	12/11/21	Approved	Multiple Sclerosis
2021-PHARM-106	ICD-10 Chart	10/27/21	12/11/21	Approved	ICD-10 Chart
2021-PHARM-105	Kerendia	10/27/21	12/11/21	Approved	Kerendia
2021-PHARM-104	Hyperlipidemia, Lipotropics Other	10/27/21	12/11/21	Approved	Hyperlipidemia, Lipotropics Other
2021-PHARM-103	Atopic Dermatitis Immunomodulators	10/27/21	12/11/21	Approved	Atopic Dermatitis Immunomodulators
2021-PHARM-102	Asthma Immunomodulators	10/27/21	12/11/21	Approved	Asthma Immunomodulators
2021-PHARM-101	Batch Pharmacy Encounter Systems Companion Guide, Section 7.1, 424-DO mandatory reporting requirement	10/11/21	11/25/21	Approved	Batch Pharmacy Encounter Systems Companion Guide
2021-UHC-MED-87	Review at Launch	10/7/21	11/21/21	Approved	Review at Launch
2021-UHC-MED-86	Krystexxa (pegloticase)	10/7/21	11/21/21	Approved	Krystexxa (pegloticase)
2021-ACLA-MED-25	Rituximab PA Criteria	9/28/21	11/12/21	Approved	Rituximab PA Criteria
2021-HB-PHARM-3	LA Diabetic Supplies Formulary Change Notice	9/24/21	11/8/21	Approved	LA Diabetic Supplies Formulary Change Notice
2021-HB-PHARM-4	Formulary Changes Regulatory Memo 2nd Quarter	9/24/21	11/8/21	Approved	Formulary Changes Regulatory Memo 2nd Quarter
2021-ACLA-MED-13	Insulin Pumps	9/22/21	11/6/21	Approved	Insulin Pumps
2021-UHC-MED-85	Medical Therapies for Enzyme Deficiencies	9/20/21	11/4/21	Approved	Medical Therapies for Enzyme Deficiencies
2021-UHC-MED-84	Complement Inhibitors	9/20/21	11/4/21	Approved	Complement Inhibitors
2021-UHC-MED-83	Erythropoiesis Stimulating Agents	9/20/21	11/4/21	Approved	Erythropoiesis Stimulating Agents
2021-ABH-PHARM-4	Diabetic Testing Supplies Supplement	9/14/21	10/29/21	Approved	Diabetic Testing Supplies Supplement
2021-PHARM-100	Aduhelm Form	9/13/21	N/A	Approved	Aduhelm Form Met Imminent Peril Policy
2021-PHARM-99	Aduhelm Criteria	9/13/21	N/A	Approved	Aduhelm Criteria Met Imminent Peril Policy
2021-ACLA-MED-27	B-Cell Maturation Antigen (BCMA) Directed Chimeric Antigen Receptor (CAR) T-Cell Therapy	9/10/21	10/25/21	Approved	B-Cell Maturation Antigen (BCMA) Directed Chimeric Antigen Receptor (CAR) T-Cell Therapy
2021-ACLA-MED-26	Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ophthalmic Conditions	9/10/21	10/25/21	Approved	Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ophthalmic Conditions
2021-ACLA-MED-23	Anti-CD19 CAR-T Immunotherapies	9/10/21	10/25/21	Approved	Anti-CD19 CAR-T Immunotherapies
2021-ACLA-MED-22	Complement Inhibitors	9/10/21	10/25/21	Approved	Complement Inhibitors
2021-ACLA-MED-21	Brineura	9/10/21	10/25/21	Approved	Brineura
2021-ACLA-MED-20	Dendritic Cell Tumor Peptide Immunotherapy	9/10/21	10/25/21	Approved	Dendritic Cell Tumor Peptide Immunotherapy
2021-ACLA-MED-19	HCPCS Prior Authorization List	9/10/21	10/25/21	Approved	HCPCS Prior Authorization List
2021-ACLA-MED-18	Primary Hemophagocytic Lymphohistiocytosis (HLH) Agents	9/10/21	10/25/21	Approved	Primary Hemophagocytic Lymphohistiocytosis (HLH) Agents
2021-ACLA-MED-17	Insulin-Like Growth Factor-1 Receptor (Igf-1r) Antagonists For Thyroid Eye Disease	9/10/21	10/25/21	Approved	Insulin-Like Growth Factor-1 Receptor (Igf-1r) Antagonists For Thyroid Eye Disease
2021-ACLA-MED-16	Blincyto	9/10/21	10/25/21	Approved	Blincyto
2021-ACLA-MED-15	Alpha-1 Proteinase Inhibitors (Human)	9/10/21	10/25/21	Approved	Alpha-1 Proteinase Inhibitors (Human)
2021-ACLA-MED-14	Fabrazyme	9/10/21	10/25/21	Approved	Fabrazyme
2021-ACLA-MED-00	Site of Care Medical Pharmacy Policy	9/10/21	10/25/21	Approved	Site of Care Medical Pharmacy Policy
2021-UHC-MED-78	Maximum Dosage Medical Drug Policy	9/10/21	10/25/21	Approved	Maximum Dosage Medical Drug Policy
2021-UHC-MED-79	Oncology Medication Clinical Coverage	9/10/21	10/25/21	Approved	Oncology Medication Clinical Coverage
2021-UHC-MED-82	Gonadotropin-Releasing Hormone analogs	9/10/21	10/25/21	Approved	Gonadotropin-Releasing Hormone analogs
2021-UHC-MED-81	Saphnelo	9/10/21	10/25/21	Approved	Saphnelo
2021-UHC-MED-80	Ryplazim	9/10/21	10/25/21	Approved	Ryplazim
2021-PHARM-98	Uterine Disorder	8/6/21	9/19/21	Approved	Uterine Disorder
2021-PHARM-97	POS Uterine Disorder	8/6/21	9/19/21	Approved	POS Uterine Disorder
2021-PHARM-96	POS Sedative Hypnotics	8/6/21	9/19/21	Approved	POS Sedative Hypnotics
2021-PHARM-95	POS HIV/AIDS	8/6/21	9/19/21	Approved	POS HIV/AIDS
2021-PHARM-94	POS Pulmonary Arterial Hypertension	8/6/21	9/19/21	Approved	POS Pulmonary Arterial Hypertension
2021-PHARM-93	POS Lipotropics, Other	8/6/21	9/19/21	Approved	POS Lipotropics, Other
2021-PHARM-92	POS Coronary Vasodilators	8/6/21	9/19/21	Approved	POS Coronary Vasodilators
2021-PHARM-91	POS ACE Inhibitors/Direct Renin Inhibitors	8/6/21	9/19/21	Approved	POS ACE Inhibitors/Direct Renin Inhibitors
2021-PHARM-90	POS Bronchodilator, Anticholinergics Inhalation	8/6/21	9/19/21	Approved	POS Bronchodilator, Anticholinergics Inhalation
2021-PHARM-89	POS Proton Pump Inhibitors	8/6/21	9/19/21	Approved	POS Proton Pump Inhibitors
2021-PHARM-88	POS SGLT2 Inhibitors	8/6/21	9/19/21	Approved	POS SGLT2 Inhibitors
2021-PHARM-87	POS ADD/ADHD	8/6/21	9/19/21	Approved	POS ADD/ADHD
2021-PHARM-86	Ponvory	8/6/21	9/19/21	Approved	Ponvory
2021-PHARM-85	Lupkynis	8/6/21	9/19/21	Approved	Lupkynis
2021-PHARM-84	Lipotropics, Other	8/6/21	9/19/21	Approved	Lipotropics, Other
2021-PHARM-83	ICD-10 Chart	8/6/21	9/19/21	Approved	ICD-10 Chart
2021-PHARM-82	Oxazolidinones	8/6/21	9/19/21	Approved	Oxazolidinones
2021-PHARM-81	Hepatitis C, DAA	8/6/21	9/19/21	Approved	Hepatitis C, DAA
2021-PHARM-80	Coronary Vasodilators	8/6/21	9/19/21	Approved	Coronary Vasodilators
2021-PHARM-79	Growth Hormones	8/6/21	9/19/21	Approved	Growth Hormones
2021-LHCC-MED-72	Enoxaparin (Lovenox)	8/5/21	9/18/21	Approved	Enoxaparin (Lovenox)
2021-LHCC-MED-71	Ferric Carboxymaltose (Injectafer)	8/5/21	9/18/21	Approved	Ferric Carboxymaltose (Injectafer)
2021-LHCC-MED-70	Fondaparinux (Arixtra)	8/5/21	9/18/21	Approved	Fondaparinux (Arixtra)
2021-LHCC-MED-69	Dalteparin (Fragmin)	8/5/21	9/18/21	Approved	Dalteparin (Fragmin)
2021-LHCC-MED-67	Factor XIII, Human (Corifact)	8/5/21	9/18/21	Approved	Factor XIII, Human (Corifact)
2021-LHCC-MED-66	Factor VIIa, Recombinant (Novoseven RT, SevenFact)	8/5/21	9/18/21	Approved	Factor VIIa, Recombinant (Novoseven RT, SevenFact)
2021-LHCC-MED-65	Factor IX Complex, Human (Profilnine)	8/5/21	9/18/21	Approved	Factor IX Complex, Human (Profilnine)
2021-LHCC-MED-64	Factor IX (Human, Recombinant)	8/5/21	9/18/21	Approved	Factor IX (Human, Recombinant)
2021-LHCC-MED-63	Anti-Inhibitor Coagulant Complex, Human (Feiba)	8/5/21	9/18/21	Approved	Anti-Inhibitor Coagulant Complex, Human (Feiba)
2021-LHCC-MED-62	Factor VIIII/von Willebrand Factor Complex (Human-Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant-Vonvendi)	8/5/21	9/18/21	Approved	Factor VIIII/von Willebrand Factor Complex (Human-Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant-Vonvendi)
2021-LHCC-MED-61	Factor VIII (Human, Recombinant)	8/5/21	9/18/21	Approved	Factor VIII (Human, Recombinant)
2021-LHCC-MED-60	Desmopressin Acetate (DDAVP)	8/5/21	9/18/21	Approved	Desmopressin Acetate (DDAVP)
2021-LHCC-MED-59	Trabectedin (Yondelis)	8/5/21	9/18/21	Approved	Trabectedin (Yondelis)
2021-LHCC-MED-58	Cosyntropin (Cortrosyn)	8/5/21	9/18/21	Approved	Cosyntropin (Cortrosyn)
2021-LHCC-MED-57	Treprostinil (Remodulin)	8/5/21	9/18/21	Approved	Treprostinil (Remodulin)
2021-LHCC-MED-56	Sildenafil (Revatio)	8/5/21	9/18/21	Approved	Sildenafil (Revatio)
2021-LHCC-MED-55	Epoprostenol (Flolan, Veletri)	8/5/21	9/18/21	Approved	Epoprostenol (Flolan, Veletri)
2021-LHCC-MED-54	Ibandronate Injection (Boniva)	8/5/21	9/18/21	Approved	Ibandronate Injection (Boniva)
2021-LHCC-MED-53	Verteporfin (Visudyne)	8/5/21	9/18/21	Approved	Verteporfin (Visudyne)
2021-LHCC-MED-52	Ranibizumab (Lucentis)	8/5/21	9/18/21	Approved	Ranibizumab (Lucentis)
2021-LHCC-MED-51	Pegaptanib (Macugen)	8/5/21	9/18/21	Approved	Pegaptanib (Macugen)
2021-LHCC-MED-50	Aflibercept (Eylea)	8/5/21	9/18/21	Approved	Aflibercept (Eylea)
2021-LHCC-MED-49	Hemin (Panhematin)	8/5/21	9/18/21	Approved	Hemin (Panhematin)
2021-LHCC-MED-48	Romiplostim (Nplate)	8/5/21	9/18/21	Approved	Romiplostim (Nplate)
2021-LHCC-MED-47	Ferumoxytol (Feraheme)	8/5/21	9/18/21	Approved	Ferumoxytol (Feraheme)
2021-LHCC-MED-46	Interferon Gamma-1b (Actimmune)	8/5/21	9/18/21	Approved	Interferon Gamma-1b (Actimmune)
2021-LHCC-MED-107	Fosnetupitant and Palonosetron (Akynzeo IV)	8/5/21	9/18/21	Approved	Fosnetupitant and Palonosetron (Akynzeo IV)
2021-LHCC-MED-106	Delafloxacin (Baxdela)	8/5/21	9/18/21	Approved	Delafloxacin (Baxdela)
2021-LHCC-MED-103	Tedizolid	8/5/21	9/18/21	Approved	Tedizolid
2021-LHCC-MED-102	Linezolid (Zyvox)	8/5/21	9/18/21	Approved	Linezolid (Zyvox)
2021-LHCC-MED-101	Teprotumumab (Tepezza)	8/5/21	9/18/21	Approved	Teprotumumab (Tepezza)
2021-LHCC-MED-100	Satralizumab-mwge (Enspryng)	8/5/21	9/18/21	Approved	Satralizumab-mwge (Enspryng)
2021-LHCC-MED-99	Iobenguane I-131 (Azedra)	8/5/21	9/18/21	Approved	Iobenguane I-131 (Azedra)
2021-LHCC-MED-96	Luspatercept-aamt (Reblozyl)	8/5/21	9/18/21	Approved	Luspatercept-aamt (Reblozyl)
2021-LHCC-MED-95	Brolucizumab-dbll (Beovu)	8/5/21	9/18/21	Approved	Brolucizumab-dbll (Beovu)
2021-LHCC-MED-94	Afamelanotide (Scenesse)	8/5/21	9/18/21	Approved	Afamelanotide (Scenesse)
2021-LHCC-MED-91	Bortezomib (Velcade)	8/5/21	9/18/21	Approved	Bortezomib (Velcade)
2021-LHCC-MED-90	Emapalumab-lzsg (Gamifant)	8/5/21	9/18/21	Approved	Emapalumab-lzsg (Gamifant)
2021-LHCC-MED-89	Chloramphenicol Sodium Succinate	8/5/21	9/18/21	Approved	Chloramphenicol Sodium Succinate
2021-LHCC-MED-88	Azacitidine (Vidaza)	8/5/21	9/18/21	Approved	Azacitidine (Vidaza)
2021-LHCC-MED-87	Voretigene Neparvovec-rzyl (Luxturna)	8/5/21	9/18/21	Approved	Voretigene Neparvovec-rzyl (Luxturna)
2021-LHCC-MED-86	Triamcinolone ER Injection (Zilretta)	8/5/21	9/18/21	Approved	Triamcinolone ER Injection (Zilretta)
2021-LHCC-MED-85	Emicizumab-kxwh (Hemlibra)	8/5/21	9/18/21	Approved	Emicizumab-kxwh (Hemlibra)
2021-LHCC-MED-84	Pemetrexed (Alimta, Pemfexy)	8/5/21	9/18/21	Approved	Pemetrexed (Alimta, Pemfexy)
2021-LHCC-MED-82	Tisagenlecleucel (Kymriah)	8/5/21	9/18/21	Approved	Tisagenlecleucel (Kymriah)
2021-LHCC-MED-81	Avelumab (Bavencio)	8/5/21	9/18/21	Approved	Avelumab (Bavencio)
2021-LHCC-MED-80	Protein C Concentrate, Human (Ceprotin)	8/5/21	9/18/21	Approved	Protein C Concentrate, Human (Ceprotin)
2021-LHCC-MED-79	Siltuximab (Sylvant)	8/5/21	9/18/21	Approved	Siltuximab (Sylvant)
2021-LHCC-MED-78	Olaratumab (Lartruvo)	8/5/21	9/18/21	Approved	Olaratumab (Lartruvo)
2021-LHCC-MED-76	Erwinia Asparaginase (Erwinaze)	8/5/21	9/18/21	Approved	Erwinia Asparaginase (Erwinaze)
2021-LHCC-MED-75	Bezlotoxumab (Zinplava)	8/5/21	9/18/21	Approved	Bezlotoxumab (Zinplava)
2021-LHCC-MED-74	Buprenorphine Implant/Injection (Probuphine, Sublocade)	8/5/21	9/18/21	Approved	Buprenorphine Implant/Injection (Probuphine, Sublocade)
2021-LHCC-MED-73	Etanercept (Enbrel)	8/5/21	9/18/21	Approved	Etanercept (Enbrel)
2021-ACLA-MED-12	Anti-amyloid Monoclonal Antibodies (Aduhelm)	8/4/21	N/A	Approved	Anti-amyloid Monoclonal Antibodies (Aduhelm) Immenint Peril Policy
2021-LHCC-MED-45	Aducanumab (Aduhelm)	8/4/21	N/A	Approved	Aducanumab (Aduhelm) Imminent Peril Policy
2021-UHC-MED-55	Evkeeza	7/26/21	9/8/21	Approved	Evkeeza
2021-UHC-MED-77	Brineura	7/12/21	8/25/21	Approved	Brineura
2021-UHC-MED-76	Rituxan_Rituximab	7/12/21	8/25/21	Approved	Rituxan_Rituximab
2021-UHC-MED-75	Scenesse	7/12/21	8/25/21	Approved	Scenesse
2021-UHC-MED-74	Viltepso	7/12/21	8/25/21	Approved	Viltepso
2021-UHC-MED-73	Intravitreal Corticosteroid Implants	7/9/21	8/23/21	Approved	Intravitreal Corticosteroid Implants
2021-UHC-MED-72	Reblozyl	7/8/21	8/22/21	Approved	Reblozyl
2021-PHARM-78	Synagis	7/8/21	N/A	Approved	Synagis Met Imminent Peril Justiication
2021-PHARM-77	Aduhelm	7/6/21	N/A	Approved	Aduhelm Met Imminent Peril Justification
2021-UHC-MED-71	Sodium Hyaluronate	6/23/21	8/7/21	Approved	Sodium Hyaluronate
2021-HB-MED-103	LA Specialty Pre Cert	6/23/21	8/7/21	Approved	LA Specialty Pre Cert
2021-UHC-MED-70	Parsabiv	6/21/21	8/5/21	Approved	Parsabiv
2021-UHC-MED-69	Gonadotropin Releasing Hormone Analogs	6/15/21	7/29/21	Approved	Gonadotropin Releasing Hormone Analogs
2021-UHC-MED-68	Off Label Unproven Specialty Drug Treatments	6/15/21	7/29/21	Approved	Off Label Unproven Specialty Drug Treatments
2021-UHC-MED-67	Maximum Dosage Medical Drug Policy	6/15/21	7/29/21	Approved	Maximum Dosage Medical Drug Policy
2021-UHC-MED-66	Oxlumo	6/15/21	7/29/21	Approved	Oxlumo
2021-UHC-MED-65	Medical Therapies for Enzyme Deficiencies	6/15/21	7/29/21	Approved	Medical Therapies for Enzyme Deficiencies
2021-ACLA-MED-11	Emergency Use Authorization Covid-19	6/8/21	7/22/21	Approved	Emergency Use Authorization Covid-19
2021-ACLA-MED-10	ALCA HCPCS PRIOR AUTHORIZATION LIST	6/8/21	7/22/21	Approved	ALCA HCPCS PRIOR AUTHORIZATION LIST
2021-PHARM-76	POS Hereditary Angioedema	6/2/21	7/17/21	Approved	POS Hereditary Angioedema
2021-PHARM-75	Hereditary Angioedema	6/2/21	7/17/21	Approved	Hereditary Angioedema
2021-PHARM-74	POS Colony Stimulating Factors	6/2/21	7/17/21	Approved	POS Colony Stimulating Factors
2021-PHARM-73	Colony Stimulating Factors	6/2/21	7/17/21	Approved	Colony Stimulating Factors
2021-PHARM-72	POS Cystic Fibrosis	6/2/21	7/17/21	Approved	POS Cystic Fibrosis
2021-PHARM-71	Cystic Fibrosis	6/2/21	7/17/21	Approved	Cystic Fibrosis
2021-PHARM-70	POS Multiple Sclerosis	6/2/21	7/17/21	Approved	POS Multiple Sclerosis
2021-PHARM-69	Multiple Sclerosis	6/2/21	7/17/21	Approved	Multiple Sclerosis
2021-PHARM-68	POS Methotrexate	6/2/21	7/17/21	Approved	POS Methotrexate
2021-PHARM-67	Methotrexate	6/2/21	7/17/21	Approved	Methotrexate
2021-UHC-MED-59	Oncology Medication	5/28/21	7/11/21	Approved	Oncology Medication
2021-UHC-MED-61	Tepezza	5/24/21	7/7/21	Approved	Tepezza
2021-UHC-MED-60	Complement Inhiibitors	5/20/21	7/3/21	Approved	Complement Inhiibitors
2021-UHC-MED-63	Xiaflex	5/20/21	7/3/21	Approved	Xiaflex
2021-UHC-MED-62	Nplate	5/20/21	7/3/21	Approved	Nplate
2021-PHARM-66	Potassium Binders	5/17/21	6/30/21	Approved	Potassium Binders
2021-PHARM-65	POS Potassium Binders	5/17/21	6/30/21	Approved	POS Potassium Binders
2021-PHARM-64	POS Pleuromutilins	5/17/21	6/30/21	Approved	POS Pleuromutilins
2021-PHARM-63	POS HIV / AIDS	5/17/21	6/30/21	Approved	POS HIV / AIDS
2021-PHARM-62	POS Hereditary Angioedema (HAE)	5/17/21	6/30/21	Approved	POS Hereditary Angioedema (HAE)
2021-PHARM-61	POS Hemophilia	5/17/21	6/30/21	Approved	POS Hemophilia
2021-PHARM-60	POS Growth Factors	5/17/21	6/30/21	Approved	POS Growth Factors
2021-PHARM-59	POS Glucagon Agents	5/17/21	6/30/21	Approved	POS Glucagon Agents
2021-PHARM-58	POS Multiple Sclerosis	5/17/21	6/30/21	Approved	POS Multiple Sclerosis
2021-PHARM-57	POS Colony Stimulating Factors	5/17/21	6/30/21	Approved	POS Colony Stimulating Factors
2021-PHARM-56	Pain Management Antimigraine Triptans	5/17/21	6/30/21	Approved	Pain Management Antimigraine Triptans
2021-PHARM-55	Multiple Sclerosis	5/17/21	6/30/21	Approved	Multiple Sclerosis
2021-PHARM-54	July 1, 2020 PDL	5/17/21	6/30/21	Approved	July 1, 2020 PDL
2021-PHARM-53	Infectious Disorders Antibiotics, Inhaled	5/17/21	6/30/21	Approved	Infectious Disorders Antibiotics, Inhaled
2021-PHARM-52	Immunosuppressives, Oral	5/17/21	6/30/21	Approved	Immunosuppressives, Oral
2021-PHARM-51	ICD-10 Chart	5/17/21	6/30/21	Approved	ICD-10 Chart
2021-PHARM-50	HIV / AIDS	5/17/21	6/30/21	Approved	HIV / AIDS
2021-PHARM-49	Hemodialysis Phosphate Binders	5/17/21	6/30/21	Approved	Hemodialysis Phosphate Binders
2021-PHARM-48	Heart Disease Pulmonary Arterial Hypertension	5/17/21	6/30/21	Approved	Heart Disease Pulmonary Arterial Hypertension
2021-PHARM-47	Growth Factors	5/17/21	6/30/21	Approved	Growth Factors
2021-PHARM-46	Glucagon Agents	5/17/21	6/30/21	Approved	Glucagon Agents
2021-PHARM-45	GI Motility, Chronic	5/17/21	6/30/21	Approved	GI Motility, Chronic
2021-PHARM-44	Digestive Disorders Ulcerative Colitis Agents	5/17/21	6/30/21	Approved	Digestive Disorders Ulcerative Colitis Agents
2021-PHARM-43	Digestive Disorders Proton Pump Inhibitors	5/17/21	6/30/21	Approved	Digestive Disorders Proton Pump Inhibitors
2021-PHARM-42	Digestive Disorders Antiemetic / Antivertigo Agents	5/17/21	6/30/21	Approved	Digestive Disorders Antiemetic / Antivertigo Agents
2021-PHARM-41	Diabetes Insulins & Related Agents	5/17/21	6/30/21	Approved	Diabetes Insulins & Related Agents
2021-PHARM-40	Anticonvulsants	5/17/21	6/30/21	Approved	Anticonvulsants
2021-PHARM-39	Acne Agents	5/17/21	6/30/21	Approved	Acne Agents
2021-PHARM-38	Medically Necessary	5/7/21	6/21/21	Approved	Medically Necessary
2021-PHARM-37	Cytokine and CAM Antagonists	5/7/21	6/21/21	Approved	Cytokine and CAM Antagonists
2021-PHARM-36	ICD-10 Chart	5/7/21	6/21/21	Approved	ICD-10 Chart
2021-PHARM-35	Urea Cycle Disorder	5/7/21	6/21/21	Approved	Urea Cycle Disorder
2021-PHARM-34	Trikafta	5/7/21	6/21/21	Approved	Trikafta
2021-PHARM-33	Sedative Hypnotics	5/7/21	6/21/21	Approved	Sedative Hypnotics
2021-PHARM-32	Diabetes– SGLT2	5/7/21	6/21/21	Approved	Diabetes– SGLT2
2021-PHARM-31	Diabetes – Incretin Mimetics/Enhancers	5/7/21	6/21/21	Approved	Diabetes – Incretin Mimetics/Enhancers
2021-PHARM-30	Orfadin/Nityr	5/7/21	6/21/21	Approved	Orfadin/Nityr
2021-PHARM-29	Multiple Sclerosis	5/7/21	6/21/21	Approved	Multiple Sclerosis
2021-PHARM-28	Lidocaine Patch Kits	5/7/21	6/21/21	Approved	Lidocaine Patch Kits
2021-PHARM-27	Cystic Fibrosis	5/7/21	6/21/21	Approved	Cystic Fibrosis
2021-PHARM-26	Benlysta	5/7/21	6/21/21	Approved	Benlysta
2021-PHARM-25	Asthma, Immunomodulators	5/7/21	6/21/21	Approved	Asthma, Immunomodulators
2021-PHARM-24	Amondys 45	5/7/21	6/21/21	Approved	Amondys 45
2021-PHARM-23	Antipsychotics Agents Oral / Transdermal	5/7/21	6/21/21	Approved	Antipsychotics Agents Oral / Transdermal
2021-LHCC-MED-41	Forteo	4/20/21	6/3/21	Approved	Forteo
2021-UHC-MED-58	Immune Globulin	4/8/21	5/23/21	Approved	Immune Globulin
2021-UHC-MED-57	Rituximab	4/8/21	5/23/21	Approved	Rituximab
2021-UHC-MED-56	Crysvita	4/8/21	5/23/21	Approved	Crysvita
2021-UHC-MED-54	Viltepso	4/8/21	5/23/21	Approved	Viltepso
2021-UHC-MED-53	Amondys 45	4/8/21	5/23/21	Approved	Amondys 45
2021-UHC-MED-52	Intravenous ERT	3/24/21	5/8/21	Approved	Intravenous ERT
2021-UHC-MED-51	Botulinum Toxins	3/24/21	5/8/21	Approved	Botulinum Toxins
2021-LHCC-MED-40	Actemra	3/19/21	5/3/21	Approved	Actemra
2021-LHCC-MED-39	Lemtrada	3/19/21	5/3/21	Approved	Lemtrada
2021-LHCC-MED-38	Immune Globulins	3/19/21	5/3/21	Approved	Immune Globulins
2021-LHCC-MED-37	Rituxan	3/18/21	5/2/21	Approved	Rituxan
2021-LHCC-MED-36	Tysabri	3/18/21	5/2/21	Approved	Tysabri
2021-LHCC-MED-35	Baclofen	3/18/21	5/2/21	Approved	Baclofen
2021-LHCC-PHARM-6	Preferred Drug List	3/18/21	5/2/21	Approved	Preferred Drug List
2021-LHCC-PHARM-5	Pharmacy Program	3/18/21	5/2/21	Approved	Pharmacy Program
2021-LHCC-MED-34	Valproate	3/17/21	4/30/21	Approved	Valproate
2021-LHCC-MED-33	Pegfilgrastim	3/17/21	4/30/21	Approved	Pegfilgrastim
2021-LHCC-MED-32	Triptorelin Pamoate	3/17/21	4/30/21	Approved	Triptorelin Pamoate
2021-LHCC-MED-31	Iron Sucrose	3/17/21	4/30/21	Approved	Iron Sucrose
2021-LHCC-MED-30	Ferric Gluconate	3/17/21	4/30/21	Approved	Ferric Gluconate
2021-LHCC-MED-29	Bevacizumab	3/17/21	4/30/21	Approved	Bevacizumab
2021-LHCC-MED-28	Denosumab	3/17/21	4/30/21	Approved	Denosumab
2021-LHCC-MED-27	Octreotide	3/17/21	4/30/21	Approved	Octreotide
2021-UHC-MED-48	Trogarzo	3/16/21	4/29/21	Approved	Trogarzo
2021-UHC-MED-47	Radicava	3/16/21	4/29/21	Approved	Radicava
2021-LHCC-MED-26	No Coverage	3/15/21	4/28/21	Approved	No Coverage
2021-LHCC-MED-25	Off-Label Use	3/15/21	4/28/21	Approved	Off-Label Use
2021-LHCC-MED-24	Aprepitant	3/15/21	4/28/21	Approved	Aprepitant
2021-LHCC-MED-23	Human Growth Hormone	3/15/21	4/28/21	Approved	Human Growth Hormone
2021-LHCC-MED-22	Valrubicin	3/15/21	4/28/21	Approved	Valrubicin
2021-LHCC-MED-21	Polatuzumab Vedotin-piiq	3/15/21	4/28/21	Approved	Polatuzumab Vedotin-piiq
2021-LHCC-MED-20	Metreleptin	3/15/21	4/28/21	Approved	Metreleptin
2021-LHCC-MED-19	Lanreotide	3/15/21	4/28/21	Approved	Lanreotide
2021-LHCC-MED-18	Testosterone	3/15/21	4/28/21	Approved	Testosterone
2021-LHCC-MED-17	Ocrelizumab	3/15/21	4/28/21	Approved	Ocrelizumab
2021-LHCC-MED-16	Pembrolizumab	3/15/21	4/28/21	Approved	Pembrolizumab
2021-LHCC-MED-15	Interferon Beta-1b	3/15/21	4/28/21	Approved	Interferon Beta-1b
2021-LHCC-MED-14	Infliximab	3/15/21	4/28/21	Approved	Infliximab
2021-LHCC-MED-13	Atezolizumab	3/15/21	4/28/21	Approved	Atezolizumab
2021-LHCC-MED-12	Histrelin	3/15/21	4/28/21	Approved	Histrelin
2021-LHCC-MED-11	Taliglucerase Alfa	3/15/21	4/28/21	Approved	Taliglucerase Alfa
2021-LHCC-MED-10	Nivolumab	3/15/21	4/28/21	Approved	Nivolumab
2021-LHCC-MED-9	Ramucirumab	3/15/21	4/28/21	Approved	Ramucirumab
2021-LHCC-MED-8	Naltrexone	3/15/21	4/28/21	Approved	Naltrexone
2021-LHCC-MED-7	Peginterferon Alfa-2a,b	3/15/21	4/28/21	Approved	Peginterferon Alfa-2a,b
2021-HB-MED-101	Specialty Rx PreCert	3/8/21	4/21/21	Approved	Specialty Rx PreCert
2021-HB-MED-100	Formulary Changes Regulatory Memo 4Q20	3/4/21	4/17/21	Approved	Formulary Changes Regulatory Memo 4Q20
2021-HB-MED-99	Specialty Rx PA Updates III	3/2/21	4/15/21	Approved	Specialty Rx PA Updates III
2021-HB-MED-98	Rx Iron Infusion Med Step Therapy	3/2/21	4/15/21	Approved	Rx Iron Infusion Med Step Therapy
2021-MED-HB-97	GnRH Analogs for the Treatment of Non-Oncologic Indications	2/24/21	4/9/21	Approved	GnRH Analogs for the Treatment of Non-Oncologic Indications
2021-MED-HB-96	Intravitreal Corticosteroid Implants	2/24/21	4/9/21	Approved	Intravitreal Corticosteroid Implants
2021-MED-HB-95	Kymriah	2/24/21	4/9/21	Approved	Kymriah
2021-MED-HB-94	Uplizna	2/24/21	4/9/21	Approved	Uplizna
2021-MED-HB-93	Lemtrada	2/24/21	4/9/21	Approved	Lemtrada
2021-MED-HB-92	Monoclonal Antibodies to Interleukin-17	2/24/21	4/9/21	Approved	Monoclonal Antibodies to Interleukin-17
2021-MED-HB-91	Durysta	2/24/21	4/9/21	Approved	Durysta
2021-MED-HB-90	Botulinum Toxin	2/24/21	4/9/21	Approved	Botulinum Toxin
2021-MED-HB-89	Givlaari	2/24/21	4/9/21	Approved	Givlaari
2021-MED-HB-88	Entyvio	2/24/21	4/9/21	Approved	Entyvio
2021-MED-HB-87	Adakveo	2/24/21	4/9/21	Approved	Adakveo
2021-MED-HB-86	Stelara	2/24/21	4/9/21	Approved	Stelara
2021-MED-HB-85	Monoclonal Interleukin-6	2/24/21	4/9/21	Approved	Monoclonal Interleukin-6
2021-MED-HB-84	Monoclonal Anti-Interleukin-23	2/24/21	4/9/21	Approved	Monoclonal Anti-Interleukin-23
2021-MED-HB-83	Interleukin-1 Inhibitors	2/24/21	4/9/21	Approved	Interleukin-1 Inhibitors
2021-ABH-PHARM-3	Diabetic Testing Supplies	2/24/21	4/9/21	Approved	Diabetic Testing Supplies
2021-HB-MED-82	Zilretta	2/24/21	4/9/21	Approved	Zilretta
2021-HB-MED-81	Zepzelca	2/24/21	4/9/21	Approved	Zepzelca
2021-HB-MED-80	Zaltrap	2/24/21	4/9/21	Approved	Zaltrap
2021-HB-MED-79	Xiaflex	2/24/21	4/9/21	Approved	Xiaflex
2021-HB-MED-78	Viltepso	2/24/21	4/9/21	Approved	Viltepso
2021-HB-MED-77	Veklury	2/24/21	4/9/21	Approved	Veklury
2021-HB-MED-76	Vectibix	2/24/21	4/9/21	Approved	Vectibix
2021-HB-MED-75	Trodelvy	2/24/21	4/9/21	Approved	Trodelvy
2021-HB-MED-74	Torisel	2/24/21	4/9/21	Approved	Torisel
2021-HB-MED-73	Tegsedi	2/24/21	4/9/21	Approved	Tegsedi
2021-HB-MED-72	Tecentriq	2/24/21	4/9/21	Approved	Tecentriq
2021-HB-MED-71	Tecartus	2/24/21	4/9/21	Approved	Tecartus
2021-HB-MED-70	Synribo	2/24/21	4/9/21	Approved	Synribo
2021-HB-MED-69	Sogroya	2/24/21	4/9/21	Approved	Sogroya
2021-HB-MED-68	Reblozyl	2/24/21	4/9/21	Approved	Reblozyl
2021-HB-MED-67	Provenge	2/24/21	4/9/21	Approved	Provenge
2021-HB-MED-66	Proleukin	2/24/21	4/9/21	Approved	Proleukin
2021-HB-MED-65	Phesgo	2/24/21	4/9/21	Approved	Phesgo
2021-HB-MED-64	Denosumab Agents	2/24/21	4/9/21	Approved	Denosumab Agents
2021-HB-MED-63	Alpha-1 Proteinase Inhibitor Therapy	2/24/21	4/9/21	Approved	Alpha-1 Proteinase Inhibitor Therapy
2021-HB-MED-62	Onpattro	2/24/21	4/9/21	Approved	Onpattro
2021-HB-MED-61	Mylotarg	2/24/21	4/9/21	Approved	Mylotarg
2021-HB-MED-60	Keytruda	2/24/21	4/9/21	Approved	Keytruda
2021-HB-MED-59	Jelmyto	2/24/21	4/9/21	Approved	Jelmyto
2021-HB-MED-58	Tepezza	2/24/21	4/9/21	Approved	Tepezza
2021-HB-MED-57	Gamastan	2/23/21	4/8/21	Approved	Gamastan
2021-HB-MED-56	ERT for Gaucher Disease	2/23/21	4/8/21	Approved	ERT for Gaucher Disease
2021-HB-MED-55	Erbitux	2/23/21	4/8/21	Approved	Erbitux
2021-HB-MED-54	Enspryng	2/23/21	4/8/21	Approved	Enspryng
2021-HB-MED-53	Duopa	2/23/21	4/8/21	Approved	Duopa
2021-HB-MED-52	Doxorubicin Liposome	2/23/21	4/8/21	Approved	Doxorubicin Liposome
2021-HB-MED-51	Blenrep	2/23/21	4/8/21	Approved	Blenrep
2021-HB-MED-50	Beleodaq	2/23/21	4/8/21	Approved	Beleodaq
2021-HB-MED-49	Abraxane	2/23/21	4/8/21	Approved	Abraxane
2021-HB-MED-48	Krystexxa	2/23/21	4/8/21	Approved	Krystexxa
2021-UHC-MED-48	Oxlumo	2/22/21	4/7/21	Approved	Oxlumo
2021-LHCC-PHARM-6	Pharmaceutical Management	2/19/21	4/4/21	Approved	Pharmaceutical Management
2021-HB-MED-47	Zaltrap	2/18/21	4/3/21	Approved	Zaltrap
2021-HB-MED-46	Yervoy	2/18/21	4/3/21	Approved	Yervoy
2021-HB-MED-45	Xofigo	2/18/21	4/3/21	Approved	Xofigo
2021-HB-MED-44	Scenesse	2/18/21	4/3/21	Approved	Scenesse
2021-HB-MED-43	Sarclisa	2/18/21	4/3/21	Approved	Sarclisa
2021-HB-MED-42	Reblozyl	2/18/21	4/3/21	Approved	Reblozyl
2021-HB-MED-41	Radioimmunotherapy	2/18/21	4/3/21	Approved	Radioimmunotherapy
2021-HB-MED-40	Radicava	2/18/21	4/3/21	Approved	Radicava
2021-HB-MED-39	Padcev	2/18/21	4/3/21	Approved	Padcev
2021-HB-MED-38	Opdivo	2/18/21	4/3/21	Approved	Opdivo
2021-HB-MED-37	Octreotide Agents	2/18/21	4/3/21	Approved	Octreotide Agents
2021-HB-MED-36	Melanoma Vaccines	2/18/21	4/3/21	Approved	Melanoma Vaccines
2021-HB-MED-35	Human Parathyroid Hormone Agents	2/18/21	4/3/21	Approved	Human Parathyroid Hormone Agents
2021-HB-MED-34	Gazyva	2/18/21	4/3/21	Approved	Gazyva
2021-HB-Med-33	Ethyol	2/18/21	4/3/21	Approved	Ethyol
2021-HB-MED-32	Enhertu	2/18/21	4/3/21	Approved	Enhertu
2021-HB-Med-31	Elzonris	2/18/21	4/3/21	Approved	Elzonris
2021-HB-MED-30	Cyramza	2/18/21	4/3/21	Approved	Cyramza
2021-HB-MED-29	Asparagine	2/18/21	4/3/21	Approved	Asparagine
2021-HB-MED-28	Alimta	2/18/21	4/3/21	Approved	Alimta
2021-PHARM-22	Pain Management Neuropathic Pain	2/11/21	3/27/21	Approved	Pain Management Neuropathic Pain
2021-UHC-MED-47	Maximum Dosage Policy	2/11/21	3/27/21	Approved	Maximum Dosage Policy
2021-UHC-MED-46	Complement Inhibitors	2/9/21	3/25/21	Approved	Complement Inhibitors
2021-UHC-MED-45	Benlysta	2/9/21	3/25/21	Approved	Benlysta
2021-UHC-MED-44	Rituxan	2/9/21	3/25/21	Approved	Rituxan
2021-PHARM-1	Cystic Fibrosis, Oral	2/4/21	3/20/21	Approved	Cystic Fibrosis, Oral
2021-PHARM-2	Cytokine and CAM Antagonists	2/4/21	3/20/21	Approved	Cytokine and CAM Antagonists
2021-PHARM-3	Cefiderocol	2/4/21	3/20/21	Approved	Cefiderocol
2021-PHARM-4	Hereditary Angioedema	2/4/21	3/20/21	Approved	Hereditary Angioedema
2021-PHARM-5	Immunomodulators, Asthma	2/4/21	3/20/21	Approved	Immunomodulators, Asthma
2021-PHARM-6	Nitisinone	2/4/21	3/20/21	Approved	Nitisinone
2021-PHARM-7	Acne Agents, Topical	2/4/21	3/20/21	Approved	Acne Agents, Topical
2021-PHARM-8	Dermatology – Atopic Dermatitis Immunomodulators	2/4/21	3/20/21	Approved	Dermatology – Atopic Dermatitis Immunomodulators
2021-PHARM-9	Select Skeletal Muscle Relaxants Criteria for Quantity Limit Override	2/4/21	3/20/21	Approved	Select Skeletal Muscle Relaxants Criteria for Quantity Limit Override
2021-PHARM-10	Sickle Cell Anemia	2/4/21	3/20/21	Approved	Sickle Cell Anemia
2021-PHARM-11	Viltolarsen	2/4/21	3/20/21	Approved	Viltolarsen
2021-PHARM-12	Sodium Oxybate (Xyrem®) and Calcium, Magnesium, Potassium and Sodium Oxybates (Xywav™)	2/4/21	3/20/21	Approved	Sodium Oxybate (Xyrem®) and Calcium, Magnesium, Potassium and Sodium Oxybates (Xywav™)
2021-PHARM-13	Multiple Sclerosis Agents	2/4/21	3/20/21	Approved	Multiple Sclerosis Agents
2021-PHARM-14	Growth Deficiency – Growth Hormones	2/4/21	3/20/21	Approved	Growth Deficiency – Growth Hormones
2021-PHARM-15	Infectious Disorders – Hepatitis C Agents – Direct Acting Antiviral Agents	2/4/21	3/20/21	Approved	Infectious Disorders – Hepatitis C Agents – Direct Acting Antiviral Agents
2021-PHARM-16	Opiate Dependence Agents	2/4/21	3/20/21	Approved	Opiate Dependence Agents
2021-PHARM-17	Asthma/COPD – Bronchodilator, Beta-Adrenergic Inhalation Agents	2/4/21	3/20/21	Approved	Asthma/COPD – Bronchodilator, Beta-Adrenergic Inhalation Agents
2021-PHARM-18	Pain Management – Skeletal Muscle Relaxants	2/4/21	3/20/21	Approved	Pain Management – Skeletal Muscle Relaxants
2021-PHARM-19	Medications Requiring ICD–10 Diagnosis Codes	2/4/21	3/20/21	Approved	Medications Requiring ICD–10 Diagnosis Codes
2021-PHARM-20	Anticonvulsants	2/4/21	3/20/21	Approved	Anticonvulsants
2021-PHARM-21	Point of Sale Edits Memo	2/4/21	3/20/21	Approved	Point of Sale Edits Memo
2021-UHC-MED-43	Gonadotropin Releasing Hormone Analogs	2/3/21	3/19/21	Approved	Gonadotropin Releasing Hormone Analogs
2021-ACLA-MED-8	Veklury	1/25/21	3/10/21	Approved	Veklury
2021-ACLA-MED-9	Emergency Use Authorization	1/25/21	3/10/21	Approved	Emergency Use Authorization
2021-UHC-MED-40	Testosterone Replacements	1/20/21	3/5/21	Approved	Testosterone Replacements
2021-UHC-MED-39	Scenesse	1/20/21	3/5/21	Approved	Scenesse
2021-UHC-MED-41	Uplizna	1/20/21	3/5/21	Approved	Uplizna
2021-UHC-MED-42	Viltepso	1/20/21	3/5/21	Approved	Viltepso
2021-HB-MED-28	Dupixent	1/7/21	2/20/21	Approved	Dupixent
2020-UHC-MED-35	Reblozyl	12/10/20	1/24/21	Approved	Reblozyl
2020-UHC-MED-36	Sodium Hyaluronate	12/10/20	1/24/21	Approved	Sodium Hyaluronate
2020-UHC-MED-37	Immune Globulins	12/10/20	1/24/21	Approved	Immune Globulins
2020-UHC-MED-38	Vyepti	12/10/20	1/24/21	Approved	Vyepti
2020-UHC-MED-34	Luxturna	12/4/20	1/17/21	Approved	Luxturna
2020-UHC-MED-33	Subcutaneous Implantable Naltrexone Pellets	12/4/20	1/17/21	Approved	Subcutaneous Implantable Naltrexone Pellets
2020-UHC-MED-32	Xiaflex	12/4/20	1/17/21	Approved	Xiaflex
2020-UHC-PHARM-31	UHC Off Label Unproven Specialty Drug Treatment	12/3/20	1/16/21	Approved	UHC Off Label Unproven Specialty Drug Treatment
2020-UHC-PHARM-30	UHC Review at Launch	12/3/20	1/16/21	Approved	UHC Review at Launch
2020-LHCC-PHARM-5	Octreotide	11/24/20	1/8/21	Approved	Octreotide
2020-ACLA-PHARM-7	Veklury	11/24/20	1/8/21	Approved	Veklury
2020-ACLA-PHARM-6	ACLA HCPCS PA List	11/24/20	1/8/21	Approved	ACLA HCPCS PA List
2020-UHC-PHARM-27	UHC Alpha-1 Proteinase Inhibitors	11/24/20	1/8/21	Approved	UHC Alpha-1 Proteinase Inhibitors
2020-UHC-PHARM-28	UHC Evenity	11/24/20	1/8/21	Approved	UHC Evenity
2020-UHC-PHARM-29	UHC Gamifant	11/24/20	1/8/21	Approved	UHC Gamifant
2020-HB-PHARM-26	HB Rituxan	11/24/20	1/8/21	Approved	HB Rituxan

---

---

---

---