Managed Care Pharmacy and Medical Drug Policies Archive (2022)

"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
2022-UHC-MED-136 Maximum dosage policy 12/15/22 1/29/23 Approved Maximum dosage policy
2022-UHC-MED-137 RNA-Targeted Therapies_Amvuttra nd Onpattro 12/15/22 1/29/23 Approved RNA-Targeted Therapies_Amvuttra nd Onpattro
2022-UHC-MED-134 Testosterone-replacement-supplementation therapy 12/15/22 1/29/23 Approved Testosterone-replacement-supplementation therapy
2022-HB-MED-232 Amvuttra 12/12/22 1/26/23 Approved Amvuttra
2022-HB-MED-220 Blenrep 12/12/22 1/26/23 Approved Blenrep
2022-HB-MED-225 Vidaza 11/21/22 1/5/23 Approved Vidaza
2022-HB-MED-226 Jemperli 11/21/22 1/5/23 Approved Jemperli
2022-HB-MED-227 Lumoxiti 11/21/22 1/5/23 Approved Lumoxiti
2022-HB-MED-228 Zepzelca 11/21/22 1/5/23 Approved Zepzelca
2022-HB-MED-229 Ryplazim 11/21/22 1/5/23 Approved Ryplazim
2022-HB-MED-230 Somatuline Depot 11/21/22 1/5/23 Approved Somatuline Depot
2022-HB-MED-231 Octreotide Agents 11/21/22 1/5/23 Approved Octreotide Agents
2022-HB-MED-233 Naltrexone Implantable Pellets 11/21/22 1/5/23 Approved Naltrexone Implantable Pellets
2022-HB-MED-234 Vyvgart 11/21/22 1/5/23 Approved Vyvgart
2022-HB-MED-235  Implantable and ER buprenorphine containing agents 11/21/22 1/5/23 Approved Implantable and ER buprenorphine containing agents
2022-HB-MED-236 Imcivree 11/21/22 1/5/23 Approved Imcivree
2022-HB-MED-237 Testosterone Injectable 11/21/22 1/5/23 Approved Testosterone Injectable
2022-HB-MED-238 Subcutaneous Hormonal Implants 11/21/22 1/5/23 Approved Subcutaneous Hormonal Implants
2022-HB-MED-239 Trastuzumab Agents 11/21/22 1/5/23 Approved Trastuzumab Agents
2022-ACLA-MED-50 Insulin Pumps 11/21/22 1/5/23 Approved Insulin Pumps
2022-HB-MED-211 Keytruda 11/18/22 1/2/23 Approved Keytruda
2022-HB-MED-212 Iron Agents 11/18/22 1/2/23 Approved Iron Agents
2022-HB-MED-213 Rituximab agents for non-oncologic indications 11/18/22 1/2/23 Approved Rituximab agents for non-oncologic indications
2022-HB-MED-214 Rituximab agents for oncologic indications step therapy 11/18/22 1/2/23 Approved Rituximab agents for oncologic indications step therapy
2022-HB-MED-215 Bevacizumab for non-ophthalmologic indications 11/18/22 1/2/23 Approved Bevacizumab for non-ophthalmologic indications
2022-HB-MED-216 Opdualag 11/18/22 1/2/23 Approved Opdualag
2022-HB-MED-217 Levoleucovorin 11/18/22 1/2/23 Approved Levoleucovorin
2022-HB-MED-218 Istodax 11/18/22 1/2/23 Approved Istodax
2022-HB-MED-219 Beleodaq 11/18/22 1/2/23 Approved Beleodaq
2022-HB-MED-221 Monjuvi 11/18/22 1/2/23 Approved Monjuvi
2022-HB-MED-222 Pepaxto 11/18/22 1/2/23 Approved Pepaxto
2022-HB-MED-223 Enhertu 11/18/22 1/2/23 Approved Enhertu
2022-HB-MED-224 Zylonta 11/18/22 1/2/23 Approved Zylonta
2022-PHARM-96 Anticonvulsants 11/16/22 12/31/22 Approved Anticonvulsants
2022-PHARM-97 Asthma/COPD - Inhaled Glucocorticoids 11/16/22 12/31/22 Approved Asthma/COPD - Inhaled Glucocorticoids
2022-PHARM-98 Dermatology - AD Immunomodulators 11/16/22 12/31/22 Approved Dermatology - AD Immunomodulators
2022-PHARM-99 Neuropathic Pain 11/16/22 12/31/22 Approved Neuropathic Pain
2022-PHARM-100 Oncology, Oral - Hematologic 11/16/22 12/31/22 Approved Oncology, Oral - Hematologic
2022-PHARM-101 Oncology, Oral - Renal Cell 11/16/22 12/31/22 Approved Oncology, Oral - Renal Cell
2022-PHARM-102 Ophthalmic - Anti-inflammatory Immunomodulators 11/16/22 12/31/22 Approved Ophthalmic - Anti-inflammatory Immunomodulators
2022-PHARM-103 Ophthalmic - Glaucoma Agents 11/16/22 12/31/22 Approved Ophthalmic - Glaucoma Agents
2022-PHARM-104 PDL 11/16/22 12/31/22 Approved PDL
2022-ACLA-MED-48 Complement Inhibitors 11/15/22 12/30/22 Approved Complement Inhibitors
2022-UHC-MED-131 Oncology Medication Clinical Coverage Policy 11/15/22 12/30/22 Approved Oncology Medication Clinical Coverage Policy
2022-UHC-MED-132 Somatostatin analogs 11/15/22 12/30/22 Approved Somatostatin analogs
2022-HUMANA-MED-1 Abecma 11/9/22 12/24/22 Approved Abecma
2022-HUMANA-MED-2 Abraxane 11/9/22 12/24/22 Approved Abraxane
2022-HUMANA-MED-3 Beovu 11/9/22 12/24/22 Approved Beovu
2022-HUMANA-MED-4 Breyanzi 11/9/22 12/24/22 Approved Breyanzi
2022-HUMANA-MED-5 Carvykti 11/9/22 12/24/22 Approved Carvykti
2022-HUMANA-MED-7 Eylea 11/9/22 12/24/22 Approved Eylea
2022-HUMANA-MED-8 Jemperli 11/9/22 12/24/22 Approved Jemperli
2022-HUMANA-MED-9 Kymriah 11/9/22 12/24/22 Approved Kymriah
2022-HUMANA-MED-10 Levoleucovorin 11/9/22 12/24/22 Approved Levoleucovorin
2022-HUMANA-MED-11 Opdualag 11/9/22 12/24/22 Approved Opdualag
2022-HUMANA-MED-12 Signifor LAR 11/9/22 12/24/22 Approved Signifor LAR
2022-HUMANA-MED-13 Tecartus 11/9/22 12/24/22 Approved Tecartus
2022-HUMANA-MED-14 Vabysmo 11/9/22 12/24/22 Approved Vabysmo
2022-HUMANA-MED-15 Yescarta   11/9/22 12/24/22 Approved Yescarta  
2022-ACLA-MED-47 Rituximab 11/7/22 12/22/22 Approved Rituximab
2022-ACLA-MED-52 BCMA CAR-T 11/7/22 12/22/22 Approved BCMA CAR-T
2022-HB-MED-210 Carvykti  11/7/22 12/22/22 Approved Carvykti 
2022-ACLA-MED-49 Anti-FGF23 Monoclonal Antibodies 11/7/22 12/22/22 Approved Anti-FGF23 Monoclonal Antibodies
2022-PHARM-78 Antidepressants, Other 11/2/22 12/17/22 Approved Antidepressants, Other
2022-PHARM-79 Bile Acid Salts 11/2/22 12/17/22 Approved Bile Acid Salts
2022-PHARM-80 Camzyos 11/2/22 12/17/22 Approved Camzyos
2022-PHARM-81 Cystic Fibrosis, Oral 11/2/22 12/17/22 Approved Cystic Fibrosis, Oral
2022-PHARM-82 Cytokine/CAM Antagonists 11/2/22 12/17/22 Approved Cytokine/CAM Antagonists
2022-PHARM-83 Evrysdi 11/2/22 12/17/22 Approved Evrysdi
2022-PHARM-84 ICD-10 Chart 11/2/22 12/17/22 Approved ICD-10 Chart
2022-PHARM-85 Immunomodulators, Lupus 11/2/22 12/17/22 Approved Immunomodulators, Lupus
2022-PHARM-86 Multiple Sclerosis Agents 11/2/22 12/17/22 Approved Multiple Sclerosis Agents
2022-PHARM-87 POS Amvuttra 11/2/22 12/17/22 Approved POS Amvuttra
2022-PHARM-88 POS Camzyos 11/2/22 12/17/22 Approved POS Camzyos
2022-PHARM-89 POS Igalmi 11/2/22 12/17/22 Approved POS Igalmi
2022-PHARM-90 POS Opiate Dependence Agents 11/2/22 12/17/22 Approved POS Opiate Dependence Agents
2022-PHARM-91 POS Pulmonary Arterial Hypertension 11/2/22 12/17/22 Approved POS Pulmonary Arterial Hypertension
2022-PHARM-92 POS Sedative Hypnotics 11/2/22 12/17/22 Approved POS Sedative Hypnotics
2022-PHARM-93 Urea Cycle Disorder 11/2/22 12/17/22 Approved Urea Cycle Disorder
2022-PHARM-94 Uterine Disorder Treatments 11/2/22 12/17/22 Approved Uterine Disorder Treatments
2022-PHARM-95 Vivjoa 11/2/22 12/17/22 Approved Vivjoa
2022-UHC-MED-126 Medical therapies enzyme deficiencies 10/7/22 11/21/22 Approved Medical therapies enzyme deficiencies
2022-UHC-MED-127 Brineura-cerliponase-alfa 10/7/22 11/21/22 Approved Brineura-cerliponase-alfa
2022-UHC-MED-128 RNA-targeted Therapies Amvuttra and Onpattro 10/7/22 11/21/22 Approved RNA-targeted Therapies Amvuttra and Onpattro
2022-UHC-MED-129 Complement inhibitors 10/7/22 11/21/22 Approved Complement inhibitors
2022-UHC-MED-130 Gonadotropin-releasing hormone analogs 10/7/22 11/21/22 Approved Gonadotropin-releasing hormone analogs
2022-ACLA-MED-46 ACLA HCPCS PA List 2Q22 9/29/22 11/13/22 Approved ACLA HCPCS PA List 2Q22
2022-HB-MED-202 Amvuttra 9/29/22 11/13/22 Approved Amvuttra
2022-HB-MED-203 Kymriah 9/29/22 11/13/22 Approved Kymriah
2022-HB-MED-204 Nulojix 9/29/22 11/13/22 Approved Nulojix
2022-HB-MED-205 Opdivo 9/29/22 11/13/22 Approved Opdivo
2022-HB-MED-206 Vidaza 9/29/22 11/13/22 Approved Vidaza
2022-HB-MED-207 VEGF Inhibitors 9/29/22 11/13/22 Approved VEGF Inhibitors
2022-HB-MED-208 Yervoy 9/29/22 11/13/22 Approved Yervoy
2022-HB-MED-209 Xipere 9/29/22 11/13/22 Approved Xipere
2022-LHCC-MED-143 Xiaflex 9/15/22 10/30/22 Approved Xiaflex
2022-LHCC-MED-144 Alpha 1-Proteinase Inhibitors 9/15/22 10/30/22 Approved Alpha 1-Proteinase Inhibitors
2022-LHCC-MED-145 Thyrotropin alfa 9/15/22 10/30/22 Approved Thyrotropin alfa
2022-LHCC-MED-146 Mogamulizumab-kpkc 9/15/22 10/30/22 Approved Mogamulizumab-kpkc
2022-LHCC-MED-147 Ramucirumab 9/15/22 10/30/22 Approved Ramucirumab
2022-LHCC-MED-148 Deferoxamine 9/15/22 10/30/22 Approved Deferoxamine
2022-LHCC-MED-149 Baclofen 9/15/22 10/30/22 Approved Baclofen
2022-LHCC-MED-150 Levoleucovorin 9/15/22 10/30/22 Approved Levoleucovorin
2022-LHCC-MED-151 Sebelipase alfa 9/15/22 10/30/22 Approved Sebelipase alfa
2022-LHCC-MED-152 Epoprostenol 9/15/22 10/30/22 Approved Epoprostenol
2022-LHCC-MED-153 Belatacept 9/15/22 10/30/22 Approved Belatacept
2022-LHCC-MED-154 Cosyntropin 9/15/22 10/30/22 Approved Cosyntropin
2022-LHCC-MED-155 Trabectedin 9/15/22 10/30/22 Approved Trabectedin
2022-LHCC-MED-156 Erwinia Aspariginase 9/15/22 10/30/22 Approved Erwinia Aspariginase
2022-HB-MED-200 Opdualag 9/15/22 10/30/22 Approved Opdualag
2022-HB-MED-201 Yescarta 9/15/22 10/30/22 Approved Yescarta
2022-UHC-MED-121 Maximum dosage policy 9/15/22 10/30/22 Approved Maximum dosage policy
2022-HB-MED-189 Ketamine injection  9/9/22 10/24/22 Approved Ketamine injection 
2022-HB-MED-190 Doxorubicin liposome 9/9/22 10/24/22 Approved Doxorubicin liposome
2022-HB-MED-191 Torisel 9/9/22 10/24/22 Approved Torisel
2022-HB-MED-192 Polivy 9/9/22 10/24/22 Approved Polivy
2022-HB-MED-193 Somatuline Depot 9/9/22 10/24/22 Approved Somatuline Depot
2022-HB-MED-194 Darzalex 9/9/22 10/24/22 Approved Darzalex
2022-HB-MED-195 Rybrevant 9/9/22 10/24/22 Approved Rybrevant
2022-HB-MED-196 Phesgo 9/9/22 10/24/22 Approved Phesgo
2022-HB-MED-197 Yervoy 9/9/22 10/24/22 Approved Yervoy
2022-HB-MED-198 Bevacizumab for non-ophthalmologic ind. 9/9/22 10/24/22 Approved Bevacizumab for non-ophthalmologic ind.
2022-HB-MED-199 Radioimmunotherapy 9/9/22 10/24/22 Approved Radioimmunotherapy
2022-UHC-MED-119 Alpha 1-proteinase-inhibitors 9/9/22 10/24/22 Approved Alpha 1-proteinase-inhibitors
2022-UHC-MED-122 Erythropoiesis-stimulating agents 9/9/22 10/24/22 Approved Erythropoiesis-stimulating agents
2022-UHC-MED-123 Gonadotropin-releasing hormone analogs 9/9/22 10/24/22 Approved Gonadotropin-releasing hormone analogs
2022-UHC-MED-124 Nplate 9/9/22 10/24/22 Approved Nplate
2022-UHC-MED-125 Benlysta-belimumab 9/9/22 10/24/22 Approved Benlysta-belimumab
2022-HB-MED-185 Dihydroergotamine (DHE) injection 9/2/22 10/17/22 Approved Dihydroergotamine (DHE) injection
2022-HB-MED-187 Gamifant 9/2/22 10/17/22 Approved Gamifant
2022-HB-MED-188 Trastuzumab Agents 9/2/22 10/17/22 Approved Trastuzumab Agents
2022-HB-MED-175 Adcetris 9/2/22 10/17/22 Approved Adcetris
2022-HB-MED-176 Velcade 9/2/22 10/17/22 Approved Velcade
2022-HB-MED-177 Erbitux 9/2/22 10/17/22 Approved Erbitux
2022-HB-MED-178 Vectibix 9/2/22 10/17/22 Approved Vectibix
2022-HB-MED-179 Synribo 9/2/22 10/17/22 Approved Synribo
2022-HB-MED-180 Provenge 9/2/22 10/17/22 Approved Provenge
2022-HB-MED-181 Jevtana 9/2/22 10/17/22 Approved Jevtana
2022-HB-MED-182 Bendamustine 9/2/22 10/17/22 Approved Bendamustine
2022-HB-MED-183 Sarclisa 9/2/22 10/17/22 Approved Sarclisa
2022-HB-MED-184 Libtayo 9/2/22 10/17/22 Approved Libtayo
2022-HB-MED-186 Imcivree 9/2/22 10/17/22 Approved Imcivree
2022-UHC-MED-116 Immune globulin ivig scig 8/31/22 10/15/22 Approved Immune globulin ivig scig
2022-UHC-MED-117 Tepezza 8/31/22 10/15/22 Approved Tepezza
2022-UHC-MED-118 Vyvgart 8/31/22 10/15/22 Approved Vyvgart
2022-HB-MED-170 Tecentriq 8/19/22 10/3/22 Approved Tecentriq
2022-HB-MED-171 Trodelvy 8/19/22 10/3/22 Approved Trodelvy
2022-HB-MED-172 Cosela 8/19/22 10/3/22 Approved Cosela
2022-HB-MED-173 Tepezza 8/19/22 10/3/22 Approved Tepezza
2022-HB-MED-174 Keytruda 8/19/22 10/3/22 Approved Keytruda
2022-LHCC-MED-134 Degarelix 8/19/22 10/3/22 Approved Degarelix
2022-LHCC-MED-135 Alglucosidase 8/19/22 10/3/22 Approved Alglucosidase
2022-LHCC-MED-136 Iron Sucrose 8/19/22 10/3/22 Approved Iron Sucrose
2022-LHCC-MED-137 Hemin 8/19/22 10/3/22 Approved Hemin
2022-LHCC-MED-139 Ranibizumab 8/18/22 10/2/22 Approved Ranibizumab
2022-LHCC-MED-140 Verteporfin 8/18/22 10/2/22 Approved Verteporfin
2022-LHCC-MED-141 Ibandronate 8/18/22 10/2/22 Approved Ibandronate
2022-LHCC-MED-142 Bendamustine 8/18/22 10/2/22 Approved Bendamustine
2022-ACLA-MED-40 Insulin Pumps PA Criteria 8/11/22 9/25/22 Approved Insulin Pumps PA Criteria
2022-PHARM-59 Atopic Dermatitis - Immunomodulators 8/10/22 9/24/22 Approved Atopic Dermatitis - Immunomodulators
2022-PHARM-60 Cibinqo 8/10/22 9/24/22 Approved Cibinqo
2022-PHARM-61 Cytokine/CAM Antagonists 8/10/22 9/24/22 Approved Cytokine/CAM Antagonists
2022-PHARM-62 Evrysdi 8/10/22 9/24/22 Approved Evrysdi
2022-PHARM-63 ICD-10 Chart 8/10/22 9/24/22 Approved ICD-10 Chart
2022-PHARM-64 POS Acne Agents 8/10/22 9/24/22 Approved POS Acne Agents
2022-PHARM-65 POS Besremi 8/10/22 9/24/22 Approved POS Besremi
2022-PHARM-66 POS Camcevi 8/10/22 9/24/22 Approved POS Camcevi
2022-PHARM-67 POS H2 Blockers 8/10/22 9/24/22 Approved POS H2 Blockers
2022-PHARM-68 POS Incretin Mimetics 8/10/22 9/24/22 Approved POS Incretin Mimetics
2022-PHARM-69 POS Norliqva 8/10/22 9/24/22 Approved POS Norliqva
2022-PHARM-70 POS Opiate Dependence Agents 8/10/22 9/24/22 Approved POS Opiate Dependence Agents
2022-PHARM-71 POS Pyrukynd 8/10/22 9/24/22 Approved POS Pyrukynd
2022-PHARM-72 POS Radicava 8/10/22 9/24/22 Approved POS Radicava
2022-PHARM-73 POS SGLT2 Inhibitors 8/10/22 9/24/22 Approved POS SGLT2 Inhibitors
2022-PHARM-74 POS Short-Acting Narcotics 8/10/22 9/24/22 Approved POS Short-Acting Narcotics
2022-PHARM-75 Releuko 8/10/22 9/24/22 Approved Releuko
2022-PHARM-76 Repository Corticotropin 8/10/22 9/24/22 Approved Repository Corticotropin
2022-PHARM-77 Vijoice 8/10/22 9/24/22 Approved Vijoice
2022-ACLA-MED-39 Dendritic Cell Tumor Peptide Immunotherapy 8/4/22 9/18/22 Approved Dendritic Cell Tumor Peptide Immunotherapy
2022-ACLA-MED-41 PLD1 Criteria 8/4/22 9/18/22 Approved PLD1 Criteria
2022-ACLA-MED-42 VEGF Inhibitors for Ophthalmic Conditions 8/4/22 9/18/22 Approved VEGF Inhibitors for Ophthalmic Conditions
2022-ACLA-MED-44 Vyvgart Criteria 8/4/22 9/18/22 Approved Vyvgart Criteria 
2022-PHARM-58 Synagis 6/20/22 N/A Approved Synagis Met Imminent Peril Justification
2022-UHC-MED-108 Tezspire 6/15/22 7/30/22 Approved Tezspire
2022-UHC-MED-109 Korsuva 6/15/22 7/30/22 Approved Korsuva
2022-UHC-MED-110 Gonadotropin Releasing Hormone Analogs 6/15/22 7/30/22 Approved Gonadotropin Releasing Hormone Analogs
2022-UHC-MED-111 Oncology Medication Clinical Coverage Policy For Louisiana 6/15/22 7/30/22 Approved Oncology Medication Clinical Coverage Policy For Louisiana
2022-UHC-MED-113 Botulinum toxins a and B 6/15/22 7/30/22 Approved Botulinum toxins a and B
2022-UHC-MED-114 Drug IV Iron Replacement Therapy 6/15/22 7/30/22 Approved Drug IV Iron Replacement Therapy
2022-UHC-MED-115 UHC Complement Inhibitors 6/15/22 7/30/22 Approved UHC Complement Inhibitors
2022-PHARM-57 Antipsychotics 6/13/22 7/28/22 Approved Antipsychotics
2022-LHCC-MED-120  Soliris   6/8/22 7/23/22 Approved Soliris 
2022-LHCC-MED-121  Bevacizumab    6/8/22 7/23/22 Approved Bevacizumab  
2022-LHCC-MED-122  Actimmune  6/8/22 7/23/22 Approved Actimmune
2022-LHCC-MED-123  Synribo  6/8/22 7/23/22 Approved Synribo
2022-LHCC-MED-124  Provenge  6/8/22 7/23/22 Approved Provenge 
2022-LHCC-MED-125  Opdivo  6/8/22 7/23/22 Approved Opdivo 
2022-LHCC-MED-126  Feraheme  6/8/22 7/23/22 Approved Feraheme 
2022-LHCC-MED-127  Fabrazyme  6/8/22 7/23/22 Approved Fabrazyme
2022-LHCC-MED-128  Eylea  6/8/22 7/23/22 Approved Eylea 
2022-LHCC-MED-129 Trastuzumab Biosimilars  6/8/22 7/23/22 Approved Trastuzumab Biosimilars 
2022-LHCC-MED-130  Kadcyla  6/8/22 7/23/22 Approved Kadcyla
2022-LHCC-MED-131 Adcetris  6/8/22 7/23/22 Approved Adcetris
2022-LHCC-MED-132 Imfinzi 6/8/22 7/23/22 Approved Imfinzi 
2022-LHCC-MED-133 Zinecard Totect  6/8/22 7/23/22 Approved Zinecard Totect 
2022-HB-MED-157 Radioimmunotherapy 5/31/22 7/15/22 Approved Radioimmunotherapy
2022-HB-MED-158 Xofigo 5/31/22 7/15/22 Approved Xofigo
2022-HB-MED-159 Cyramza 5/31/22 7/15/22 Approved Cyramza
2022-HB-MED-160 Besponsa 5/31/22 7/15/22 Approved Besponsa
2022-HB-MED-161 Gazyva 5/31/22 7/15/22 Approved Gazyva
2022-HB-MED-162 Zaltrap 5/31/22 7/15/22 Approved Zaltrap
2022-HB-MED-163 Melanoma Vaccines 5/31/22 7/15/22 Approved Melanoma Vaccines
2022-HB-MED-164 Empliciti 5/31/22 7/15/22 Approved Empliciti
2022-HB-MED-165 Sylvant 5/31/22 7/15/22 Approved Sylvant
2022-HB-MED-166 Jelmyto 5/31/22 7/15/22 Approved Jelmyto
2022-HB-MED-167 Mozobil 5/31/22 7/15/22 Approved Mozobil
2022-HB-MED-168 Margenza 5/31/22 7/15/22 Approved Margenza
2022-HB-MED-169 Keytruda  5/31/22 7/15/22 Approved Keytruda 
2022-HB-MED-149 Imfinzi  5/25/22 7/9/22 Approved Imfinzi 
2022-HB-MED-150 Elzonris 5/25/22 7/9/22 Approved Elzonris
2022-HB-MED-151 Abraxane 5/25/22 7/9/22 Approved Abraxane
2022-HB-MED-152 Docetaxel 5/25/22 7/9/22 Approved Docetaxel
2022-HB-MED-153 Pemetrexed Agents   5/25/22 7/9/22 Approved Pemetrexed Agents  
2022-HB-MED-154 Lartruvo 5/25/22 7/9/22 Approved Lartruvo
2022-HB-MED-155 Vidaza  5/25/22 7/9/22 Approved Vidaza 
2022-HB-MED-156 Zilretta   5/25/22 7/9/22 Approved Zilretta  
2022-PHARM-56 POS Opiate Dependence Agents 5/19/22 7/3/22 Approved POS Opiate Dependence Agents
2022-LHCC-MED-110 Hyaluronate Derivatives 5/17/22 7/1/22 Approved Hyaluronate Derivatives
2022-LHCC-MED-113 Xgeva 5/17/22 7/1/22 Approved Xgeva
2022-LHCC-MED-114 Perjeta 5/17/22 7/1/22 Approved Perjeta
2022-LHCC-MED-115 Rituximab 5/17/22 7/1/22 Approved Rituximab
2022-LHCC-MED-116 Darzalex 5/17/22 7/1/22 Approved Darzalex
2022-LHCC-MED-117 Yervoy 5/17/22 7/1/22 Approved Yervoy
2022-LHCC-MED-118 Yescarta 5/17/22 7/1/22 Approved Yescarta
2022-LHCC-MED-119 Enhertu 5/17/22 7/1/22 Approved Enhertu
2022-HB-MED-135 Carvykti 5/17/22 7/1/22 Approved Carvykti
2022-HB-MED-136 Kimmtrak 5/17/22 7/1/22 Approved Kimmtrak
2022-HB-MED-137 Enjaymo 5/17/22 7/1/22 Approved Enjaymo
2022-HB-MED-138 Yervoy 5/17/22 7/1/22 Approved Yervoy
2022-HB-MED-139 Kyprolis 5/17/22 7/1/22 Approved Kyprolis
2022-HB-MED-140 Blincyto 5/17/22 7/1/22 Approved Blincyto
2022-HB-MED-141 Bavencio 5/17/22 7/1/22 Approved Bavencio
2022-HB-MED-142 Ixempra 5/17/22 7/1/22 Approved Ixempra
2022-HB-MED-143 Perjeta 5/17/22 7/1/22 Approved Perjeta
2022-HB-MED-144 Kadcyla 5/17/22 7/1/22 Approved Kadcyla
2022-HB-MED-145 Halaven 5/17/22 7/1/22 Approved Halaven
2022-HB-MED-146 Mylotarg 5/17/22 7/1/22 Approved Mylotarg
2022-HB-MED-147 Arzerra 5/17/22 7/1/22 Approved Arzerra
2022-HB-MED-148          Enhertu 5/17/22 7/1/22 Approved Enhertu
2022-PHARM-45 Anticonvulsants 5/13/22 6/27/22 Approved Anticonvulsants
2022-PHARM-46 Antimigraine - Triptans 5/13/22 6/27/22 Approved Antimigraine - Triptans
2022-PHARM-47 Antipsychotics 5/13/22 6/27/22 Approved Antipsychotics
2022-PHARM-48 Enzyme Replacement Agents 5/13/22 6/27/22 Approved Enzyme Replacement Agents
2022-PHARM-49 Hypertension - Sympatholytics 5/13/22 6/27/22 Approved Hypertension - Sympatholytics
2022-PHARM-50 LA Medicaid PDL 5/13/22 6/27/22 Approved LA Medicaid PDL
2022-PHARM-51 Multiple Sclerosis Agents 5/13/22 6/27/22 Approved Multiple Sclerosis Agents
2022-PHARM-52 Oncology - Renal Cell 5/13/22 6/27/22 Approved Oncology - Renal Cell
2022-PHARM-53 POS Opiate Dependence Agents 5/13/22 6/27/22 Approved POS Opiate Dependence Agents
2022-PHARM-54 Pulmonary Arterial Hypertension Agents 5/13/22 6/27/22 Approved Pulmonary Arterial Hypertension Agents
2022-PHARM-55 Smoking Cessation Products 5/13/22 6/27/22 Approved Smoking Cessation Products
2022-HB-MED-133 Opdivo 5/13/22 6/27/22 Approved Opdivo
2022-HB-MED-131 Jetrea 5/12/22 6/26/22 Approved Jetrea
2022-HB-MED-132 Kanuma 5/12/22 6/26/22 Approved Kanuma
2022-HB-MED-134 Scenesse 5/12/22 6/26/22 Approved Scenesse
2022-PHARM-44 Vyondys 53 5/4/22 6/18/22 Approved Vyondys 53
2022-PHARM-43 Viltepso 5/4/22 6/18/22 Approved Viltepso
2022-PHARM-42 Tramadol - Age-Related Criteria 5/4/22 6/18/22 Approved Tramadol - Age-Related Criteria
2022-PHARM-41 Tezspire 5/4/22 6/18/22 Approved Tezspire
2022-PHARM-40 Sickle Cell Anemia 5/4/22 6/18/22 Approved Sickle Cell Anemia
2022-PHARM-39 POS Sickle Cell Anemia 5/4/22 6/18/22 Approved POS Sickle Cell Anemia
2022-PHARM-38 POS Short-Acting Narcotics 5/4/22 6/18/22 Approved POS Short-Acting Narcotics
2022-PHARM-37 POS Opiate Dependence Agents 5/4/22 6/18/22 Approved POS Opiate Dependence Agents
2022-PHARM-36 POS Long-Acting Narcotics 5/4/22 6/18/22 Approved POS Long-Acting Narcotics
2022-PHARM-35 POS Hyperlipidemia -Lipotropics, other 5/4/22 6/18/22 Approved POS Hyperlipidemia -Lipotropics, other
2022-PHARM-34 POS Cytokine/CAM Antagonists 5/4/22 6/18/22 Approved POS Cytokine/CAM Antagonists
2022-PHARM-33 POS Anxiolytics 5/4/22 6/18/22 Approved POS Anxiolytics
2022-PHARM-32 POS Antipsychotics -Oral/Transdermal 5/4/22 6/18/22 Approved POS Antipsychotics -Oral/Transdermal
2022-PHARM-31 POS Anticonvulsants 5/4/22 6/18/22 Approved POS Anticonvulsants
2022-PHARM-30 POS Anticoagulants 5/4/22 6/18/22 Approved POS Anticoagulants
2022-PHARM-29 POS Acne Agents 5/4/22 6/18/22 Approved POS Acne Agents
2022-PHARM-28 Nuedexta 5/4/22 6/18/22 Approved Nuedexta
2022-PHARM-27 ICD-10 Chart 5/4/22 6/18/22 Approved ICD-10 Chart
2022-PHARM-26 Hyperlipidemia -Lipotropics, other 5/4/22 6/18/22 Approved Hyperlipidemia -Lipotropics, other
2022-PHARM-25 Growth Factors 5/4/22 6/18/22 Approved Growth Factors
2022-PHARM-24 Exondys 51 5/3/22 6/17/22 Approved Exondys 51
2022-PHARM-23 Cytokine/CAM Antagonists 5/3/22 6/17/22 Approved Cytokine/CAM Antagonists
2022-PHARM-22 Adbry 5/3/22 6/17/22 Approved Adbry
2022-PHARM-21 Acne Agents 5/3/22 6/17/22 Approved Acne Agents
2022-LHCC-MED-112 Paclitaxel protein-bound (Abraxane) 5/3/22 6/17/22 Approved Paclitaxel protein-bound (Abraxane)
2022-LHCC-MED-111 Octreotide (Sandostatin, Sandostatin LAR, Bynfezia)  5/3/22 6/17/22 Approved Octreotide (Sandostatin, Sandostatin LAR, Bynfezia) 
2022-UHC-MED-107 Vyvgart 5/3/22 6/17/22 Approved Vyvgart
2022-HB-MED-126         Fyarro 4/21/22 6/5/22 Approved Fyarro
2022-HB-MED-127        Besremi  4/21/22 6/5/22 Approved Besremi 
2022-HB-MED-128        Vyvgart 4/21/22 6/5/22 Approved Vyvgart
2022-HB-MED-129        Adbry 4/21/22 6/5/22 Approved Adbry
2022-HB-MED-130        Asparagine Specific Enzymes 4/21/22 6/5/22 Approved Asparagine Specific Enzymes
2022-ACLA-MED-37 Emergency Use Authorization COVID-19 4/12/22 5/27/22 Approved Emergency Use Authorization COVID-19
2022-HB-MED-124          Leqvio 4/11/22 5/26/22 Approved Leqvio
2022-HB-MED-125          Selective VEGF Inhibitor 4/11/22 5/26/22 Approved Selective VEGF Inhibitor
2022-HB-PHARM-5 Continuous Glucose Monitors 4/6/22 5/21/22 Approved Continuous Glucose Monitors
2022-UHC-MED-104 Crysvita 4/5/22 5/20/22 Approved Crysvita
2022-UHC-MED-105 Enjaymo 4/5/22 5/20/22 Approved Enjaymo
2022-UHC-MED-106 Evkeeza 4/5/22 5/20/22 Approved Evkeeza
2022-HB-MED-118 Keytruda 4/5/22 5/20/22 Approved Keytruda
2022-HB-MED-119 Trastuzumab Agents 4/5/22 5/20/22 Approved Trastuzumab Agents
2022-HB-MED-120 Infertility and HCG Agents 4/5/22 5/20/22 Approved Infertility and HCG Agents
2022-HB-MED-121 Tecartus  4/5/22 5/20/22 Approved Tecartus 
2022-HB-MED-122 Oxlumo 4/5/22 5/20/22 Approved Oxlumo
2022-HB-MED-123 Relizorb 4/5/22 5/20/22 Approved Relizorb
2022-LHCC-PHARM-7 Specialty Pharmacy Program 3/28/22 5/12/22 Approved Specialty Pharmacy Program
2022-LHCC-MED-108 Ultomiris 3/23/22 5/7/22 Approved Ultomiris
2022-HB-MED-117 Ethyol 3/23/22 5/7/22 Approved Ethyol
2022-LHCC-MED-109 Keytruda  3/21/22 5/5/22 Approved Keytruda 
2022-HB-MED-113 Rituxan/Riabni Med Step Therapy/Criteria 3/21/22 5/5/22 Approved Rituxan/Riabni Med Step Therapy/Criteria
2022-HB-MED-114 Rituximab Agents for Oncologic Indications Step Therapy 3/21/22 5/5/22 Approved Rituximab Agents for Oncologic Indications Step Therapy
2022-HB-MED-115 Empaveli 3/21/22 5/5/22 Approved Empaveli
2022-HB-MED-116 Prialt 3/21/22 5/5/22 Approved Prialt
2022-UHC-MED-101 Amondys 3/21/22 5/5/22 Approved Amondys
2022-UHC-MED-102 Botutlinum toxins a and b 3/21/22 5/5/22 Approved Botutlinum toxins a and b
2022-UHC-MED-103 Tepezza 3/21/22 5/5/22 Approved Tepezza
2022-ACLA-MED-36 ACFC Safety Edit Exception 3/11/22 4/25/22 Approved ACFC Safety Edit Exception
2022-HB-MED-110 Sarclisa 3/9/22 4/23/22 Approved Sarclisa
2022-HB-MED-111 Bendamustine Agents 3/9/22 4/23/22 Approved Bendamustine Agents
2022-HB-MED-112 Levoleucovorin Agents 3/9/22 4/23/22 Approved Levoleucovorin Agents
2022-ACLA-MED-38 Insulin Pumps 3/9/22 4/23/22 Approved Insulin Pumps
2022-UHC-MED-99 Vyvgart 3/9/22 4/23/22 Approved Vyvgart
2022-ACLA-MED-28 Alpha 1 Proteinase Inhibitors 2/18/22 4/4/22 Approved Alpha 1 Proteinase Inhibitors
2022-ACLA-MED-29 VEGF Inhibitors for Ophthalmic Conditions 2/18/22 4/4/22 Approved VEGF Inhibitors for Ophthalmic Conditions
2022-ACLA-MED-24 Specialty Drugs PA Criteria 2/17/22 4/3/22 Approved Specialty Drugs PA Criteria
2022-ACLA-MED-30 Fabrazyme 2/17/22 4/3/22 Approved Fabrazyme
2022-ACLA-MED-31 Veklury 2/17/22 4/3/22 Approved Veklury
2022-ACLA-MED-32 Anti-CD19 CAR-T innumotherapies 2/17/22 4/3/22 Approved Anti-CD19 CAR-T innumotherapies
2022-ACLA-MED-33 ACFC Oncology Drugs 2/17/22 4/3/22 Approved ACFC Oncology Drugs
2022-ACLA-MED-34 Blincyto 2/17/22 4/3/22 Approved Blincyto
2022-ACLA-MED-35 HCPCS PA List 2/17/22 4/3/22 Approved HCPCS PA List
2022-UHC-MED-89 Ryplazim 2/3/22 3/20/22 Approved Ryplazim
2022-PHARM-1 Cytokine/CAM Agents 2/2/22 3/19/22 Approved Cytokine/CAM Agents
2022-PHARM-2 Hepatitis C DAA Agents 2/2/22 3/19/22 Approved Hepatitis C DAA Agents
2022-PHARM-3 Hyperlipidemia-Lipotropics, Other 2/2/22 3/19/22 Approved Hyperlipidemia-Lipotropics, Other
2022-PHARM-4 ICD-10 Chart 2/2/22 3/19/22 Approved ICD-10 Chart
2022-PHARM-5 POS ADD/ADHD 2/2/22 3/19/22 Approved POS ADD/ADHD
2022-PHARM-6 POS Anxiolytics 2/2/22 3/19/22 Approved POS Anxiolytics
2022-PHARM-7 POS Aspirin 2/2/22 3/19/22 Approved POS Aspirin
2022-PHARM-8 POS CGRP Agents 2/2/22 3/19/22 Approved POS CGRP Agents
2022-PHARM-9 POS Empaveli 2/2/22 3/19/22 Approved POS Empaveli
2022-PHARM-10 POS Hepatitis C DAA Agents 2/2/22 3/19/22 Approved POS Hepatitis C DAA Agents
2022-PHARM-11 POS HIV/AIDS 2/2/22 3/19/22 Approved POS HIV/AIDS
2022-PHARM-12 POS Immunomodulators-Atopic Dermatitis 2/2/22 3/19/22 Approved POS Immunomodulators-Atopic Dermatitis
2022-PHARM-13 POS Injectable Antipsychotic Agents 2/2/22 3/19/22 Approved POS Injectable Antipsychotic Agents
2022-PHARM-14 POS Long-Acting Narcotic Agents 2/2/22 3/19/22 Approved POS Long-Acting Narcotic Agents
2022-PHARM-15 POS Oral/Transdermal Antipsychotic Agents 2/2/22 3/19/22 Approved POS Oral/Transdermal Antipsychotic Agents
2022-PHARM-16 POS Orlistat 2/2/22 3/19/22 Approved POS Orlistat
2022-PHARM-17 POS Short-Acting Narcotic Agents 2/2/22 3/19/22 Approved POS Short-Acting Narcotic Agents
2022-PHARM-18 Qulipta 2/2/22 3/19/22 Approved Qulipta
2022-PHARM-19 Rezurock 2/2/22 3/19/22 Approved Rezurock
2022-PHARM-20 Skytrofa 2/2/22 3/19/22 Approved Skytrofa
2022-UHC-MED-98 Saphnelo 2/1/22 3/18/22 Approved Saphnelo
2022-UHC-MED-97 Benlysta 2/1/22 3/18/22 Approved Benlysta
2022-UHC-MED-96 Tezspire 2/1/22 3/18/22 Approved Tezspire
2022-UHC-MED-95 Inclisiran 1/4/22 2/18/22 Approved Inclisiran
2022-UHC-MED-94 IV Iron Replacement Therapy 1/4/22 2/18/22 Approved IV Iron Replacement Therapy

Related Info

Surgeon General Ralph L. Abraham, M.D.

Secretary Bruce D. Greenstein

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