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| Item Number | Policy/Procedure | Date Posted | Comment Period Closed | Status | Document Links |
|---|---|---|---|---|---|
| 2025-HB-MED-594 | Opdualag (nivolumab and relatlimab-rmbw) | 10/6/25 | 11/20/25 | Pending | Opdualag (nivolumab and relatlimab-rmbw) |
| 2025-HB-MED-595 | Zynlonta (loncastuximab tesirine-lpyl) | 10/6/25 | 11/20/25 | Pending | Zynlonta (loncastuximab tesirine-lpyl) |
| 2025-HB-MED-596 | Rybrevant (amivantamab-ymjw) | 10/6/25 | 11/20/25 | Pending | Rybrevant (amivantamab-ymjw) |
| 2025-HB-MED-597 | Jemperli (dostarlimab-gxly) | 10/6/25 | 11/20/25 | Pending | Jemperli (dostarlimab-gxly) |
| 2025-HB-MED-598 | Zepzelca (lurbinectedin) | 10/6/25 | 11/20/25 | Pending | Zepzelca (lurbinectedin) |
| 2025-HB-MED-599 | Ryplazim (plasminogen, human-tvmh) | 10/6/25 | 11/20/25 | Pending | Ryplazim (plasminogen, human-tvmh) |
| 2025-HB-MED-602 | Human Parathyroid Hormone | 10/6/25 | 11/20/25 | Pending | Human Parathyroid Hormone |
| 2025-LHCC-MED-866 | LInvoseltamab-gcpt (Lynozyfic) inject | 10/6/25 | 11/20/25 | Pending | LInvoseltamab-gcpt (Lynozyfic) inject |
| 2025-LHCC-MED-867 | Remestemcel-L-rknd (Ryoncil) | 10/6/25 | 11/20/25 | Pending | Remestemcel-L-rknd (Ryoncil) |
| 2025-LHCC-MED-868 | Encelto | 10/6/25 | 11/20/25 | Pending | Encelto |
| 2025-LHCC-MED-869 | Blinatumomab(Blincyto) | 10/6/25 | 11/20/25 | Pending | Blinatumomab(Blincyto) |
| 2025-LHCC-MED-870 | Eculizumab (Soliris), Eculizumab-aeeb (Bkemv), Eculizumab-aagh (Epysqli) | 10/6/25 | 11/20/25 | Pending | Eculizumab (Soliris), Eculizumab-aeeb (Bkemv), Eculizumab-aagh (Epysqli) |
| 2025-LHCC-MED-871 | Brentuximab Vedotin (Adcetris) | 10/6/25 | 11/20/25 | Pending | Brentuximab Vedotin (Adcetris) |
| 2025-UHC-MED-259 | Brineura | 9/29/25 | 11/13/25 | Complete | Brineura |
| 2025-UHC-MED-260 | FcRn-blockers | 9/29/25 | 11/13/25 | Complete | FcRn-blockers |
| 2025-PHARM-122 | Amvuttra | 9/26/25 | 11/10/25 | Complete | Amvuttra |
| 2025-PHARM-123 | Andembry | 9/26/25 | 11/10/25 | Complete | Andembry |
| 2025-PHARM-124 | Colony Stimulating Factors | 9/26/25 | 11/10/25 | Complete | Colony Stimulating Factors |
| 2025-PHARM-125 | Dermatology - Atopic Dermatitis, Immunomodulators | 9/26/25 | 11/10/25 | Complete | Dermatology - Atopic Dermatitis, Immunomodulators |
| 2025-PHARM-126 | Harliku | 9/26/25 | 11/10/25 | Complete | Harliku |
| 2025-PHARM-127 | Heart Disease - Hypertension, Beta Blockers | 9/26/25 | 11/10/25 | Complete | Heart Disease - Hypertension, Beta Blockers |
| 2025-PHARM-128 | Imuldosa | 9/26/25 | 11/10/25 | Complete | Imuldosa |
| 2025-PHARM-129 | Kerendia | 9/26/25 | 11/10/25 | Complete | Kerendia |
| 2025-PHARM-130 | Leqselvi | 9/26/25 | 11/10/25 | Complete | Leqselvi |
| 2025-PHARM-131 | Louisiana Medicaid ICD-10 Chart | 9/26/25 | 11/10/25 | Complete | Louisiana Medicaid ICD-10 Chart |
| 2025-PHARM-132 | Myalept | 9/26/25 | 11/10/25 | Complete | Myalept |
| 2025-PHARM-133 | Onpattro | 9/26/25 | 11/10/25 | Complete | Onpattro |
| 2025-PHARM-134 | Pain Management - Cytokine/CAM Antagonists | 9/26/25 | 11/10/25 | Complete | Pain Management - Cytokine/CAM Antagonists |
| 2025-PHARM-135 | POS Amvuttra | 9/26/25 | 11/10/25 | Complete | POS Amvuttra |
| 2025-PHARM-136 | POS Brynovin | 9/26/25 | 11/10/25 | Complete | POS Brynovin |
| 2025-PHARM-137 | POS Dermatology - Atopic Dermatitis, Immunomodulators | 9/26/25 | 11/10/25 | Complete | POS Dermatology - Atopic Dermatitis, Immunomodulators |
| 2025-PHARM-138 | POS Epysqli | 9/26/25 | 11/10/25 | Complete | POS Epysqli |
| 2025-PHARM-139 | POS Fabhalta | 9/26/25 | 11/10/25 | Complete | POS Fabhalta |
| 2025-PHARM-140 | POS GI Motility, Chronic | 9/26/25 | 11/10/25 | Complete | POS GI Motility, Chronic |
| 2025-PHARM-141 | POS Heart Disease - Hypertension, Beta Blocker Agents | 9/26/25 | 11/10/25 | Complete | POS Heart Disease - Hypertension, Beta Blocker Agents |
| 2025-PHARM-142 | POS Imaavy | 9/26/25 | 11/10/25 | Complete | POS Imaavy |
| 2025-PHARM-143 | POS Leqselvi | 9/26/25 | 11/10/25 | Complete | POS Leqselvi |
| 2025-PHARM-144 | POS Merilog | 9/26/25 | 11/10/25 | Complete | POS Merilog |
| 2025-PHARM-145 | POS Misoprostol | 9/26/25 | 11/10/25 | Complete | POS Misoprostol |
| 2025-PHARM-146 | POS Onpattro | 9/26/25 | 11/10/25 | Complete | POS Onpattro |
| 2025-PHARM-147 | POS Qfitlia | 9/26/25 | 11/10/25 | Complete | POS Qfitlia |
| 2025-PHARM-148 | POS Symbravo | 9/26/25 | 11/10/25 | Complete | POS Symbravo |
| 2025-PHARM-149 | POS Urology - Incontinence, Bladder Relaxant Preparations | 9/26/25 | 11/10/25 | Complete | POS Urology - Incontinence, Bladder Relaxant Preparations |
| 2025-PHARM-150 | POS Vanrafia | 9/26/25 | 11/10/25 | Complete | POS Vanrafia |
| 2025-PHARM-151 | POS Wainua | 9/26/25 | 11/10/25 | Complete | POS Wainua |
| 2025-PHARM-152 | POS Yutrepia | 9/26/25 | 11/10/25 | Complete | POS Yutrepia |
| 2025-PHARM-153 | POS Zelsuvmi | 9/26/25 | 11/10/25 | Complete | POS Zelsuvmi |
| 2025-PHARM-154 | POS Zepbound | 9/26/25 | 11/10/25 | Complete | POS Zepbound |
| 2025-PHARM-155 | Rivfloza | 9/26/25 | 11/10/25 | Complete | Rivfloza |
| 2025-PHARM-156 | Ryzneuta | 9/26/25 | 11/10/25 | Complete | Ryzneuta |
| 2025-PHARM-157 | Wainua | 9/26/25 | 11/10/25 | Complete | Wainua |
| 2025-PHARM-158 | Zepbound | 9/26/25 | 11/10/25 | Complete | Zepbound |
| 2025-PHARM-159 | Zepbound Patient Agreement | 9/26/25 | 11/10/25 | Complete | Zepbound Patient Agreement |
| 2025-PHARM-160 | Zevaskyn | 9/26/25 | 11/10/25 | Complete | Zevaskyn |
| 2025-HUM-MED-149 | Panitumumab (HUM 8505) | 9/25/25 | 11/9/25 | Complete | Panitumumab (HUM 8505) |
| 2025-HUM-MED-155 | Abatacept (HUM 8585) | 9/25/25 | 11/9/25 | Complete | Abatacept (HUM 8585) |
| 2025-HB-MED-583 | Keytruda (pembrolizumab) | 9/25/25 | 11/9/25 | Complete | Keytruda (pembrolizumab) |
| 2025-HB-MED-585 | Imcivree (setmelanotide) | 9/25/25 | 11/9/25 | Complete | Imcivree (setmelanotide) |
| 2025-HB-MED-587 | Tepezza (teprotumumab-trbw) | 9/25/25 | 11/9/25 | Complete | Tepezza (teprotumumab-trbw) |
| 2025-HB-MED-593 | Kisunla | 9/25/25 | 11/9/25 | Complete | Kisunla |
| 2025-HB-MED-572 | Opdivo (nivolumab) | 9/18/25 | 11/2/25 | Complete | Opdivo (nivolumab) |
| 2025-HB-MED-573 | Yervoy (ipilimumab) | 9/18/25 | 11/2/25 | Complete | Yervoy (ipilimumab) |
| 2025-HB-MED-574 | Opdivo Qvantig (nivolumab hyaluronidase-nvhy) | 9/18/25 | 11/2/25 | Complete | Opdivo Qvantig (nivolumab hyaluronidase-nvhy) |
| 2025-HB-MED-575 | Lunsumio (mosunetuzumab-axgb) | 9/18/25 | 11/2/25 | Complete | Lunsumio (mosunetuzumab-axgb) |
| 2025-HB-MED-576 | Tevimbra (tislelizumab-jsgr) | 9/18/25 | 11/2/25 | Complete | Tevimbra (tislelizumab-jsgr) |
| 2025-HB-MED-577 | Bizengri (zenocutuzumab-zbco) | 9/18/25 | 11/2/25 | Complete | Bizengri (zenocutuzumab-zbco) |
| 2025-HB-MED-578 | Pemetrexed | 9/18/25 | 11/2/25 | Complete | Pemetrexed |
| 2025-HB-MED-579 | Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin) | 9/18/25 | 11/2/25 | Complete | Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin) |
| 2025-HB-MED-580 | Anktiva (nogapendekin alfa inbakicept-pmln) | 9/18/25 | 11/2/25 | Complete | Anktiva (nogapendekin alfa inbakicept-pmln) |
| 2025-HB-MED-581 | Imdelltra (tarlatamab-dlle) | 9/18/25 | 11/2/25 | Complete | Imdelltra (tarlatamab-dlle) |
| 2025-HB-MED-562 | Synribo (omacetaxine mepesuccinate) | 9/18/25 | 11/2/25 | Complete | Synribo (omacetaxine mepesuccinate) |
| 2025-HB-MED-563 | Trastuzumab Agents | 9/18/25 | 11/2/25 | Complete | Trastuzumab Agents |
| 2025-HB-MED-564 | Jevtana (cabazitaxel) | 9/18/25 | 11/2/25 | Complete | Jevtana (cabazitaxel) |
| 2025-HB-MED-565 | Libtayo (cemiplimab-rwlc) | 9/18/25 | 11/2/25 | Complete | Libtayo (cemiplimab-rwlc) |
| 2025-HB-MED-566 | GNRH Analogs for Oncologic Indications | 9/18/25 | 11/2/25 | Complete | GNRH Analogs for Oncologic Indications |
| 2025-HB-MED-567 | Gamifant (emapalumab) | 9/18/25 | 11/2/25 | Complete | Gamifant (emapalumab) |
| 2025-HB-MED-568 | Rybrevant (amivantamab-ymjw) | 9/18/25 | 11/2/25 | Complete | Rybrevant (amivantamab-ymjw) |
| 2025-HB-MED-569 | Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf) | 9/18/25 | 11/2/25 | Complete | Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf) |
| 2025-HB-MED-570 | Imfinzi (durvalumab) | 9/18/25 | 11/2/25 | Complete | Imfinzi (durvalumab) |
| 2025-HB-MED-571 | Zynyz (retifanlimab-dlwr) | 9/18/25 | 11/2/25 | Complete | Zynyz (retifanlimab-dlwr) |
| 2025-HB-MED-553 | Cosela (trilaciclib) | 9/18/25 | 11/2/25 | Complete | Cosela (trilaciclib) |
| 2025-HB-MED-554 | Trodelvy (sacituzumab govitecan) | 9/18/25 | 11/2/25 | Complete | Trodelvy (sacituzumab govitecan) |
| 2025-HB-MED-555 | Atezolizumab (Tecentriq, Tecentriq Hybreza) | 9/18/25 | 11/2/25 | Complete | Atezolizumab (Tecentriq, Tecentriq Hybreza) |
| 2025-HB-MED-556 | Doxorubicin Liposome (Doxil) | 9/18/25 | 11/2/25 | Complete | Doxorubicin Liposome (Doxil) |
| 2025-HB-MED-557 | Torisel (temsirolimus) | 9/18/25 | 11/2/25 | Complete | Torisel (temsirolimus) |
| 2025-HB-MED-558 | Polivy (polatuzumab vedotin-piiq) | 9/18/25 | 11/2/25 | Complete | Polivy (polatuzumab vedotin-piiq) |
| 2025-HB-MED-559 | Adcetris (brentuximab vedotin) | 9/18/25 | 11/2/25 | Complete | Adcetris (brentuximab vedotin) |
| 2025-HB-MED-560 | Erbitux (cetuximab) | 9/18/25 | 11/2/25 | Complete | Erbitux (cetuximab) |
| 2025-HB-MED-561 | Vectibix (panitumumab) | 9/18/25 | 11/2/25 | Complete | Vectibix (panitumumab) |
| 2025-LHCC-MED-854 | Burosumab-twza (Crysvita) | 9/17/25 | 11/1/25 | Complete | Burosumab-twza (Crysvita) |
| 2025-LHCC-MED-855 | Deferoxamine (Desferal) | 9/17/25 | 11/1/25 | Complete | Deferoxamine (Desferal) |
| 2025-LHCC-MED-856 | Aflibercept (Eylea, Eylea HD, Opuviz, Yesafili, Ahzantive, Enzeevu, Pavblu) | 9/17/25 | 11/1/25 | Complete | Aflibercept (Eylea, Eylea HD, Opuviz, Yesafili, Ahzantive, Enzeevu, Pavblu) |
| 2025-LHCC-MED-857 | Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo) | 9/17/25 | 11/1/25 | Complete | Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo) |
| 2025-LHCC-MED-858 | Lutetium Lu 177 Dotatate (Lutathera) | 9/17/25 | 11/1/25 | Complete | Lutetium Lu 177 Dotatate (Lutathera) |
| 2025-LHCC-MED-859 | Metreleptin (Myalept) | 9/17/25 | 11/1/25 | Complete | Metreleptin (Myalept) |
| 2025-LHCC-MED-860 | Polatuzumab Vedotin-piiq (Polivy) | 9/17/25 | 11/1/25 | Complete | Polatuzumab Vedotin-piiq (Polivy) |
| 2025-LHCC-MED-861 | Mitomycin for Pyelocalyceal Solution (Jelmyto) | 9/17/25 | 11/1/25 | Complete | Mitomycin for Pyelocalyceal Solution (Jelmyto) |
| 2025-LHCC-MED-862 | Pegcetacoplan (Empaveli, Syfovre) | 9/17/25 | 11/1/25 | Complete | Pegcetacoplan (Empaveli, Syfovre) |
| 2025-LHCC-MED-863 | Epcoritamab-bysp (Epkinly) | 9/17/25 | 11/1/25 | Complete | Epcoritamab-bysp (Epkinly) |
| 2025-LHCC-MED-864 | Glofitamab-gxbm (Columvi) | 9/17/25 | 11/1/25 | Complete | Glofitamab-gxbm (Columvi) |
| 2025-LHCC-MED-865 | Telisotuzumab Vedotin-tllv (Emrelis) | 9/17/25 | 11/1/25 | Complete | Telisotuzumab Vedotin-tllv (Emrelis) |
| 2025-UHC-MED-255 | Gamifant-emapalumab | 9/17/25 | 11/1/25 | Complete | Gamifant-emapalumab |
| 2025-UHC-MED-256 | Complement inhibitors | 9/17/25 | 11/1/25 | Complete | Complement inhibitors |
| 2025-UHC-MED-257 | Maximum Dosage and Frequency | 9/17/25 | 11/1/25 | Complete | Maximum Dosage and Frequency |
| 2025-UHC-MED-258 | Oncology medication clinical coverage | 9/17/25 | 11/1/25 | Complete | Oncology medication clinical coverage |
| 2025-ACLA-MED-112 | Anti FGF23 Monoclonal Antibody | 9/17/25 | 11/1/25 | Complete | Anti FGF23 Monoclonal Antibody |
| 2025-ACLA-MED-113 | BCMA Directed CAR T-cell Therapy | 9/17/25 | 11/1/25 | Complete | BCMA Directed CAR T-cell Therapy |
| 2025-ACLA-MED-114 | Brineura | 9/17/25 | 11/1/25 | Complete | Brineura |
| 2025-ACLA-MED-115 | Complement Inhibitors | 9/17/25 | 11/1/25 | Complete | Complement Inhibitors |
| 2025-ACLA-MED-116 | Encelto | 9/17/25 | 11/1/25 | Complete | Encelto |
| 2025-ACLA-MED-117 | IGF1R Antagonists Thyroid Eye Disease | 9/17/25 | 11/1/25 | Complete | IGF1R Antagonists Thyroid Eye Disease |
| 2025-ACLA-MED-118 | Injectable Iron | 9/17/25 | 11/1/25 | Complete | Injectable Iron |
| 2025-ACLA-MED-119 | Myasthenia Gravis Agents | 9/17/25 | 11/1/25 | Complete | Myasthenia Gravis Agents |
| 2025-ACLA-MED-120 | Omisirge | 9/17/25 | 11/1/25 | Complete | Omisirge |
| 2025-ACLA-MED-121 | Enzyme Replacement Therapy for Fabry Disease | 9/17/25 | 11/1/25 | Complete | Enzyme Replacement Therapy for Fabry Disease |
| 2025-ACLA-MED-122 | Oncology | 9/17/25 | 11/1/25 | Complete | Oncology |
| 2025-ACLA-MED-123 | Qalsody | 9/17/25 | 11/1/25 | Complete | Qalsody |
| 2025-ACLA-MED-124 | Rituximab | 9/17/25 | 11/1/25 | Complete | Rituximab |
| 2025-ACLA-MED-125 | Specialty Drugs | 9/17/25 | 11/1/25 | Complete | Specialty Drugs |
| 2025-ACLA-MED-126 | VEGF Inhibitors for Ophthalmic Conditions | 9/17/25 | 11/1/25 | Complete | VEGF Inhibitors for Ophthalmic Conditions |
| 2025-PHARM-121 | Palivizumab Criteria | 9/2/25 | 10/17/25 | Complete | Palivizumab Criteria |
| 2025-HUMANA-MED-129 | Pemetrexed, 10 mg – HCPCS codes J9292, J9294, J9305, J9322 and J9323 | 8/14/25 | 9/28/25 | Complete | Pemetrexed, 10 mg – HCPCS codes J9292, J9294, J9305, J9322 and J9323 |
| 2025-UHC-MED-251 | Encelto | 8/12/25 | 9/26/25 | Complete | Encelto |
| 2025-UHC-MED-252 | Denosumab-prolia-xgeva | 8/12/25 | 9/26/25 | Complete | Denosumab-prolia-xgeva |
| 2025-UHC-MED-253 | Reblozyl | 8/12/25 | 9/26/25 | Complete | Reblozyl |
| 2025-UHC-MED-254 | Rituxan-rituximab | 8/12/25 | 9/26/25 | Complete | Rituxan-rituximab |
| 2025-HB-MED-544 | Enhertu (fam-trastuzumab deruxtecan-nxki) | 8/12/25 | 9/26/25 | Complete | Enhertu (fam-trastuzumab deruxtecan-nxki) |
| 2025-LHCC-MED-852 | Nipocalimab-aahu (Imaavy) | 8/12/25 | 9/26/25 | Complete | Nipocalimab-aahu (Imaavy) |
| 2025-LHCC-MED-853 | Retifanlimab-dlwr (Zynyz) | 8/12/25 | 9/26/25 | Complete | Retifanlimab-dlwr (Zynyz) |
| 2025-HB-MED-545 | Imaavy (nipocalimab) | 8/12/25 | 9/26/25 | Complete | Imaavy (nipocalimab) |
| 2025-HB-MED-546 | Bevacizumab for Non-Ophthalmologic Indications | 8/12/25 | 9/26/25 | Complete | Bevacizumab for Non-Ophthalmologic Indications |
| 2025-HB-MED-547 | Denosumab | 8/12/25 | 9/26/25 | Complete | Denosumab |
| 2025-HB-MED-550 | Amvuttra (vutrisiran) | 8/12/25 | 9/26/25 | Complete | Amvuttra (vutrisiran) |
| 2025-HB-MED-551 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | 8/12/25 | 9/26/25 | Complete | Vascular Endothelial Growth Factor (VEGF) Inhibitors |
| 2025-LHCC-MED-823 | Datopotamab deruxtecan-dlnk (Datroway) | 8/12/25 | 9/26/25 | Complete | Datopotamab deruxtecan-dlnk (Datroway) |
| 2025-LHCC-MED-845 | Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) | 8/12/25 | 9/26/25 | Complete | Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) |
| 2025-LHCC-MED-846 | Pegunigalsidase alfa-iwxj (Elfabrio) | 8/12/25 | 9/26/25 | Complete | Pegunigalsidase alfa-iwxj (Elfabrio) |
| 2025-LHCC-MED-847 | Denosumab (Xgeva and Biosimilars) | 8/12/25 | 9/26/25 | Complete | Denosumab (Xgeva and Biosimilars) |
| 2025-LHCC-MED-848 | Rituximab (Rituxan), Rituximab-Hyaluronidase (Rituxan Hycela), and Biosimilars | 8/12/25 | 9/26/25 | Complete | Rituximab (Rituxan), Rituximab-Hyaluronidase (Rituxan Hycela), and Biosimilars |
| 2025-LHCC-MED-849 | Letermovir (Prevymis) | 8/12/25 | 9/26/25 | Complete | Letermovir (Prevymis) |
| 2025-LHCC-MED-850 | Desmopressin Acetate (DDAVP) | 8/12/25 | 9/26/25 | Complete | Desmopressin Acetate (DDAVP) |
| 2025-LHCC-MED-851 | Treprostinil (Orenitram, Remodulin, Tyvaso, Yutrepia) | 8/12/25 | 9/26/25 | Complete | Treprostinil (Orenitram, Remodulin, Tyvaso, Yutrepia) |
| 2025-UHC-MED-247 | Testosterone replacement or supplementation therapy | 8/7/25 | 9/21/25 | Complete | Testosterone replacement or supplementation therapy |
| 2025-HUMANA-MED-125 | Prior Authorization List-State Submission | 8/7/25 | 9/21/25 | Complete | Prior Authorization List-State Submission |
| 2025-HUMANA-MED-126 | Collagenase clostridium histolyticum – HCPCS code J0775 (8419) | 8/7/25 | 9/21/25 | Complete | Collagenase clostridium histolyticum – HCPCS code J0775 (8419) |
| 2025-HUMANA-MED-127 | Golimumab, 1 mg – HCPCS code J1602 (8515) | 8/7/25 | 9/21/25 | Complete | Golimumab, 1 mg – HCPCS code J1602 (8515) |
| 2025-HUMANA-MED-128 | esketamine nasal spray – HCPCS code S0013 (8502) | 8/7/25 | 9/21/25 | Complete | esketamine nasal spray – HCPCS code S0013 (8502) |
| 2025-PHARM-119 | Palivizumab Criteria | 8/4/25 | 9/18/25 | Complete | Palivizumab Criteria |
| 2025-PHARM-120 | Palivizumab Request Form | 8/4/25 | 9/18/25 | Complete | Palivizumab Request Form |
| 2025-LHCC-MED-831 | Nivolumab (Opdivo), Nivolumab Hyaluronidase-nvhy (Opdivo Qvantig) | 7/28/25 | 9/11/25 | Complete | Nivolumab (Opdivo), Nivolumab Hyaluronidase-nvhy (Opdivo Qvantig) |
| 2025-LHCC-MED-824 | Avacincaptad pegol (Izervay) | 7/25/25 | 9/8/25 | Complete | Avacincaptad pegol (Izervay) |
| 2025-LHCC-MED-825 | Hyaluronate Derivatives | 7/25/25 | 9/8/25 | Complete | Hyaluronate Derivatives |
| 2025-LHCC-MED-826 | Furosemide (Furoscix) | 7/25/25 | 9/8/25 | Complete | Furosemide (Furoscix) |
| 2025-LHCC-MED-827 | Efgartigimod Alfa-fcab (Vyvgart) | 7/25/25 | 9/8/25 | Complete | Efgartigimod Alfa-fcab (Vyvgart) |
| 2025-LHCC-MED-828 | Iptacopan (Fabhalta) | 7/25/25 | 9/8/25 | Complete | Iptacopan (Fabhalta) |
| 2025-LHCC-MED-829 | Dostarlimab-gxly (Jemperli) | 7/25/25 | 9/8/25 | Complete | Dostarlimab-gxly (Jemperli) |
| 2025-LHCC-MED-830 | Daptomycin (Cubicin, Cubicin RF, Dapzura RT) | 7/25/25 | 9/8/25 | Complete | Daptomycin (Cubicin, Cubicin RF, Dapzura RT) |
| 2025-LHCC-MED-832 | Ciltacabtagene Autoleucel (Carvykti) | 7/25/25 | 9/8/25 | Complete | Ciltacabtagene Autoleucel (Carvykti) |
| 2025-LHCC-MED-833 | Vutrisiran (Amvuttra) | 7/25/25 | 9/8/25 | Complete | Vutrisiran (Amvuttra) |
| 2025-UHC-MED-249 | Kebilidi | 7/24/25 | 9/7/25 | Complete | Kebilidi |
| 2025-UHC-MED-250 | FcRn-blockers | 7/24/25 | 9/7/25 | Complete | FcRn-blockers |
| 2025-LHCC-MED-834 | Omacetaxine (Synribo) | 7/24/25 | 9/7/25 | Complete | Omacetaxine (Synribo) |
| 2025-LHCC-MED-835 | Isatuximab-irfc (Sarclisa) | 7/24/25 | 9/7/25 | Complete | Isatuximab-irfc (Sarclisa) |
| 2025-LHCC-MED-836 | Ramucirumab (Cyramza) | 7/24/25 | 9/7/25 | Complete | Ramucirumab (Cyramza) |
| 2025-LHCC-MED-837 | Bevacizumab (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev) | 7/24/25 | 9/7/25 | Complete | Bevacizumab (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev) |
| 2025-LHCC-MED-838 | Inotuzumab Ozogamicin (Besponsa) | 7/24/25 | 9/7/25 | Complete | Inotuzumab Ozogamicin (Besponsa) |
| 2025-LHCC-MED-839 | Nadofaragene Firadenovec-vncg (Adstiladrin) | 7/24/25 | 9/7/25 | Complete | Nadofaragene Firadenovec-vncg (Adstiladrin) |
| 2025-LHCC-MED-840 | Amivantamab-vmjw (Rybrevant) | 7/24/25 | 9/7/25 | Complete | Amivantamab-vmjw (Rybrevant) |
| 2025-LHCC-MED-841 | Tremelimumab-actl (Imjudo) | 7/24/25 | 9/7/25 | Complete | Tremelimumab-actl (Imjudo) |
| 2025-LHCC-MED-842 | Paclitaxel, Protein-Bound (Abraxane) | 7/24/25 | 9/7/25 | Complete | Paclitaxel, Protein-Bound (Abraxane) |
| 2025-LHCC-MED-843 | Fam-Trastuzumab Deruxtecan-nxki (Enhertu) | 7/24/25 | 9/7/25 | Complete | Fam-Trastuzumab Deruxtecan-nxki (Enhertu) |
| 2025-LHCC-MED-844 | Pembrolizumab (Keytruda) | 7/24/25 | 9/7/25 | Complete | Pembrolizumab (Keytruda) |
| 2025-ACLA-MED-106 | Site of care medical-pharmacy | 7/9/25 | 8/23/25 | Complete | Site of care medical-pharmacy |
Medicaid Managed Care Policies & Procedures Archive - Pharmacy (2025)
"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: