Managed Care Pharmacy and Medical Drug Policies Archive (2023)

"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
2023-HUM-MED-78	Ferric Carboxymaltose, 1mg	12/22/23	2/5/23	Complete	Ferric Carboxymaltose, 1mg
2023-HB-MED-361	Zinplava	12/22/23	2/5/23	Complete	Zinplava
2023-HB-MED-363	Tecentriq	12/22/23	2/5/23	Complete	Tecentriq
2023-HB-MED-364	Trodelvy	12/22/23	2/5/23	Complete	Trodelvy
2023-LHCC-MED-398	Letermovir (Prevymis)	12/7/23	1/21/24	Complete	Letermovir (Prevymis)
2023-HB-MED-360	Testosterone, Injectable	12/7/23	1/21/24	Complete	Testosterone, Injectable
2023-UHC-MED-190	Reblozyl	12/7/23	1/21/24	Complete	Reblozyl
2023-UHC-MED-191	Krystexxa	12/7/23	1/21/24	Complete	Krystexxa
2023-UHC-MED-192	Denosumab-prolia-xgeva	12/7/23	1/21/24	Complete	Denosumab-prolia-xgeva
2023-MED-LHCC-394	Zinplava	12/7/23	1/21/24	Complete	Zinplava
2023-MED-LHCC-392	Keytruda	12/7/23	1/21/24	Complete	Keytruda
2023-MED-LHCC-393	Zemplar	12/7/23	1/21/24	Complete	Zemplar
2023-LHCC-MED-341	Off-Label Use	12/1/23	1/15/24	Complete	Off-Label Use
2023-LHCC-MED-342	No Coverage Criteria	12/1/23	1/15/24	Complete	No Coverage Criteria
2023-UHC-MED-184	Botulinum toxins a and b	11/28/23	1/12/24	Complete	Botulinum toxins a and b
2023-UHC-MED-185	Erythropoiesis Stimulating agents	11/28/23	1/12/24	Complete	Erythropoiesis Stimulating agents
2023-UHC-MED-187	Intracanalicular and intravitreal corticosteroid implants	11/28/23	1/12/24	Complete	Intracanalicular and intravitreal corticosteroid implants
2023-UHC-MED-188	Neonatal Fc Receptor blockers	11/28/23	1/12/24	Complete	Neonatal Fc Receptor blockers
2023-UHC-MED-189	Testosterone replacement supplementation therapy	11/28/23	1/12/24	Complete	Testosterone replacement supplementation therapy
2023-HB-MED-348	Ycanth	11/16/23	12/31/23	Complete	Ycanth
2023-HB-MED-350	Talvey	11/16/23	12/31/23	Complete	Talvey
2023-HB-MED-351	Elrexfio	11/16/23	12/31/23	Complete	Elrexfio
2023-HB-MED-352	Veopoz	11/16/23	12/31/23	Complete	Veopoz
2023-HB-MED-353	Iron Agents	11/16/23	12/31/23	Complete	Iron Agents
2023-HB-MED-354	Rebyota	11/16/23	12/31/23	Complete	Rebyota
2023-HB-MED-355	Octreotide Agents	11/16/23	12/31/23	Complete	Octreotide Agents
2023-HB-MED-356	Signifor LAR	11/16/23	12/31/23	Complete	Signifor LAR
2023-HB-MED-357	Somatuline Depot	11/16/23	12/31/23	Complete	Somatuline Depot
2023-HB-MED-358	Beyfortus	11/16/23	12/31/23	Complete	Beyfortus
2023-HB-MED-359	Subcutaneous Hormonal implants	11/16/23	12/31/23	Complete	Subcutaneous Hormonal implants
2023-HUMANA-MED-68	Nivolumab	11/15/23	12/30/23	Complete	Nivolumab
2023-HUMANA-MED-70	Rituximab	11/15/23	12/30/23	Complete	Rituximab
2023-HUMANA-MED-72	Vedolizumab	11/15/23	12/30/23	Complete	Vedolizumab
2023-PHARM-67	Anti-Allergens	11/8/23	12/23/23	Complete	Anti-Allergens
2023-PHARM-68	Anticonvulsants	11/8/23	12/23/23	Complete	Anticonvulsants
2023-PHARM-69	Asthma-COPD.Beta-Adrenergic.Bronchodilators	11/8/23	12/23/23	Complete	Asthma-COPD.Beta-Adrenergic.Bronchodilators
2023-PHARM-70	Asthma-COPD.Inhaled.Anticholinergic.Bronchodilators	11/8/23	12/23/23	Complete	Asthma-COPD.Inhaled.Anticholinergic.Bronchodilators
2023-PHARM-71	Asthma-COPD.Inhaled.Glucocorticoids	11/8/23	12/23/23	Complete	Asthma-COPD.Inhaled.Glucocorticoids
2023-PHARM-72	Cuvrior	11/8/23	12/23/23	Complete	Cuvrior
2023-PHARM-73	Cyltezo	11/8/23	12/23/23	Complete	Cyltezo
2023-PHARM-74	Digestive.Disorders.Bile.Acid.Salts	11/8/23	12/23/23	Complete	Digestive.Disorders.Bile.Acid.Salts
2023-PHARM-75	Elevidys	11/8/23	12/23/23	Complete	Elevidys
2023-PHARM-76	Hadlima	11/8/23	12/23/23	Complete	Hadlima
2023-PHARM-77	Heart.Disease.Hyperlipidemia.Lipotropics.Other	11/8/23	12/23/23	Complete	Heart.Disease.Hyperlipidemia.Lipotropics.Other
2023-PHARM-78	Hulio	11/8/23	12/23/23	Complete	Hulio
2023-PHARM-79	Hyrimoz	11/8/23	12/23/23	Complete	Hyrimoz
2023-PHARM-80	ICD-10 Chart	11/8/23	12/23/23	Complete	ICD-10 Chart
2023-PHARM-81	Idacio	11/8/23	12/23/23	Complete	Idacio
2023-PHARM-82	Imcivree	11/8/23	12/23/23	Complete	Imcivree
2023-PHARM-83	Immunosuppressives.Oral	11/8/23	12/23/23	Complete	Immunosuppressives.Oral
2023-PHARM-84	Litfulo	11/8/23	12/23/23	Complete	Litfulo
2023-PHARM-85	Louisiana Medicaid PDL	11/8/23	12/23/23	Complete	Louisiana Medicaid PDL
2023-PHARM-86	Ngenla	11/8/23	12/23/23	Complete	Ngenla
2023-PHARM-87	Ophthalmic Disorders Glaucoma Agents Intraocular Pressure Reducers	11/8/23	12/23/23	Complete	Ophthalmic Disorders Glaucoma Agents Intraocular Pressure Reducers
2023-PHARM-88	Ophthalmics Antibiotic-Steroid Combinations	11/8/23	12/23/23	Complete	Ophthalmics Antibiotic-Steroid Combinations
2023-PHARM-89	Otic Agents Antibiotics	11/8/23	12/23/23	Complete	Otic Agents Antibiotics
2023-PHARM-90	Pain Management Cytokine and CAM Antagonists	11/8/23	12/23/23	Complete	Pain Management Cytokine and CAM Antagonists
2023-PHARM-91	Pain Management Non Steroidal AntiInflammatory Agents	11/8/23	12/23/23	Complete	Pain Management Non Steroidal AntiInflammatory Agents
2023-PHARM-92	POS Androgenic Agents	11/8/23	12/23/23	Complete	POS Androgenic Agents
2023-PHARM-93	POS Brixadi	11/8/23	12/23/23	Complete	POS Brixadi
2023-PHARM-94	POS Cuvrior	11/8/23	12/23/23	Complete	POS Cuvrior
2023-PHARM-95	POS Digestive Disorders Antiemetic Antivertigo Agents	11/8/23	12/23/23	Complete	POS Digestive Disorders Antiemetic Antivertigo Agents
2023-PHARM-96	POS Estrogenic Agents and Combos	11/8/23	12/23/23	Complete	POS Estrogenic Agents and Combos
2023-PHARM-97	POS Pain Management Nonsteroidal Anti Inflammatory Drugs	11/8/23	12/23/23	Complete	POS Pain Management Nonsteroidal Anti Inflammatory Drugs
2023-PHARM-98	POS.Progestational.Agents	11/8/23	12/23/23	Complete	POS.Progestational.Agents
2023-PHARM-99	POS Progestational Agents Other		12/23/23	Complete	POS Progestational Agents Other
2023-PHARM-100	POS Prostate Benign Prostatic Hyperplasia Treatment	11/8/23	12/23/23	Complete	POS Prostate Benign Prostatic Hyperplasia Treatment
2023-PHARM-101	POS Rystiggo	11/8/23	12/23/23	Complete	POS Rystiggo
2023-PHARM-102	POS Skyclarys	11/8/23	12/23/23	Complete	POS Skyclarys
2023-PHARM-103	POS Spironolactone	11/8/23	12/23/23	Complete	POS Spironolactone
2023-PHARM-104	POS Testosterone Oral Injectable	11/8/23	12/23/23	Complete	POS Testosterone Oral Injectable
2023-PHARM-105	POS Vyvgart Vyvgart Hytrulo	11/8/23	12/23/23	Complete	POS Vyvgart Vyvgart Hytrulo
2023-PHARM-106	Roctavian	11/8/23	12/23/23	Complete	Roctavian
2023-PHARM-107	Skyclarys	11/8/23	12/23/23	Complete	Skyclarys
2023-PHARM-108	Urea Cycle Disorder	11/8/23	12/23/23	Complete	Urea Cycle Disorder
2023-PHARM-109	Vyjuvek	11/8/23	12/23/23	Complete	Vyjuvek
2023-PHARM-110	Yuflyma	11/8/23	12/23/23	Complete	Yuflyma
2023-PHARM-111	Yusimry	11/8/23	12/23/23	Complete	Yusimry
2023-PHARM-112	Zavzpret	11/8/23	12/23/23	Complete	Zavzpret
2023-LHCC-MED-389	Xgeva	11/7/23	12/22/23	Complete	Xgeva
2023-LHCC-MED-390	Opdivo	11/7/23	12/22/23	Complete	Opdivo
2023-LHCC-MED-391	Injectafer	11/7/23	12/22/23	Complete	Injectafer
2023-LHCC-MED-395	Alymsys, Avastin, Mvasi, Vegzelma, Zirabev	11/7/23	12/22/23	Complete	Alymsys, Avastin, Mvasi, Vegzelma, Zirabev
2023-LHCC-MED-396	Empliciti	11/7/23	12/22/23	Complete	Empliciti
2023-LHCC-MED-397	Kyprolis	11/7/23	12/22/23	Complete	Kyprolis
2023-HB-MED-346	Hydroxyprogesterone caproate	11/7/23	12/22/23	Complete	Hydroxyprogesterone caproate
2023-HB-MED-347	Qalsody	11/7/23	12/22/23	Complete	Qalsody
2023-UHC-MED-176	Ophthalmologic-complement inhibitors	11/6/23	12/21/23	Complete	Ophthalmologic-complement inhibitors
2023-UHC-MED-177	Tepezza	11/6/23	12/21/23	Complete	Tepezza
2023-UHC-MED-178	Luxturna-voretigene-neparvovec-rzyl	11/6/23	12/21/23	Complete	Luxturna-voretigene-neparvovec-rzyl
2023-UHC-MED-179	Syfovre-pegcetacoplan	11/6/23	12/21/23	Complete	Syfovre-pegcetacoplan
2023-UHC-MED-180	Medical therapies enzyme deficiencies	11/6/23	12/21/23	Complete	Medical therapies enzyme deficiencies
2023-UHC-MED-181	Rebyota	11/6/23	12/21/23	Complete	Rebyota
2023-UHC-MED-182	Somatostatin analogs	11/6/23	12/21/23	Complete	Somatostatin analogs
2023-UHC-MED-183	Veopoz-pozelimab-bbfg	11/6/23	12/21/23	Complete	Veopoz-pozelimab-bbfg
2023-LHCC-MED-399	Erbitux	11/3/23	12/18/23	Complete	Erbitux
2023-LHCC-MED-400	Blincyto	11/3/23	12/18/23	Complete	Blincyto
2023-LHCC-MED-401	Cubicin	11/3/23	12/18/23	Complete	Cubicin
2023-HUMANA-MED-67	Bendamustine, 1mg	11/3/23	12/18/23	Complete	Bendamustine, 1mg
2023-HUMANA-MED-69	Eculizumab, 10mg	11/3/23	12/18/23	Complete	Eculizumab, 10mg
2023-HUMANA-MED-71	Factor VIIa Antihemophilic Novoseven	11/3/23	12/18/23	Complete	Factor VIIa Antihemophilic Novoseven
2023-HUMANA-MED-73	Golimumab, 2mg	11/3/23	12/18/23	Complete	Golimumab, 2mg
2023-HUMANA-MED-76	Abatacept, 10mg	11/3/23	12/18/23	Complete	Abatacept, 10mg
2023-HUMANA-MED-27	Ustekinumab, 1mg	10/30/23	12/14/23	Complete	Ustekinumab, 1mg
2023-HUMANA-MED-52	Atezolizumab, 10mg	10/30/23	12/14/23	Complete	Atezolizumab, 10mg
2023-HUMANA-MED-48	HCPCS code J9299-Injection, Nivolumab, 1mg, when billed with HCPCS code J9228-ipilimumab, 1mg	10/30/23	12/14/23	Complete	HCPCS code J9299-Injection, Nivolumab, 1mg, when billed with HCPCS code J9228-ipilimumab, 1mg
2023-HUMANA-MED-46	Moderna Covid-19 Vaccine Administration	10/30/23	12/14/23	Complete	Moderna Covid-19 Vaccine Administration
2023-HUMANA-MED-56	Novavax Covid-19 Vaccine Administration	10/30/23	12/14/23	Complete	Novavax Covid-19 Vaccine Administration
2023-HUMANA-MED-55	Injection, octreotide, depot form for intramuscular injection, 1mg	10/30/23	12/14/23	Complete	Injection, octreotide, depot form for intramuscular injection, 1mg
2023-HUMANA-MED-58	Velaglucerase alfa	10/30/23	12/14/23	Complete	Velaglucerase alfa
2023-HUMANA-MED-54	Covid-19 Immunization and Administration	10/30/23	12/14/23	Complete	Covid-19 Immunization and Administration
2023-HUMANA-MED-61	Infliximab, 10mg	10/30/23	12/14/23	Complete	Infliximab, 10mg
2023-HUMANA-MED-62	Tocilizumab, 1mg	10/30/23	12/14/23	Complete	Tocilizumab, 1mg
2023-HUMANA-MED-77	HCPCS code J7300 for Prevention of Pregnancy	10/30/23	12/14/23	Complete	HCPCS code J7300 for Prevention of Pregnancy
2023-UHC-MED-170	Vyjuvek	10/24/23	12/8/23	Complete	Vyjuvek
2023-UHC-MED-171	Neonatal Fc receptor blockers	10/5/23	11/19/23	Complete	Neonatal Fc receptor blockers
2023-UHC-MED-172	Elevidys	10/5/23	11/19/23	Complete	Elevidys
2023-UHC-MED-173	Roctavian	10/5/23	11/19/23	Complete	Roctavian
2023-UHC-MED-174	Complement inhibitors	10/5/23	11/19/23	Complete	Complement inhibitors
2023-HB-MED-329	Vegzelma-LA	10/5/23	11/19/23	Complete	Vegzelma-LA
2023-HB-MED-330	Elfabrio	10/5/23	11/19/23	Complete	Elfabrio
2023-HB-MED-331	Vyjuvek	10/5/23	11/19/23	Complete	Vyjuvek
2023-HB-MED-332	Adstiladrin	10/5/23	11/19/23	Complete	Adstiladrin
2023-HB-MED-333	Rebyota	10/5/23	11/19/23	Complete	Rebyota
2023-HB-MED-334	Syfovre	10/5/23	11/19/23	Complete	Syfovre
2023-HB-MED-335	Lamzede	10/5/23	11/19/23	Complete	Lamzede
2023-HB-MED-336	Enjaymo	10/5/23	11/19/23	Complete	Enjaymo
2023-HB-MED-337	Bendamustine agents	10/5/23	11/19/23	Complete	Bendamustine agents
2023-HB-MED-338	Pemetrexed Agents	10/5/23	11/19/23	Complete	Pemetrexed Agents
2023-HB-MED-339	Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy	10/5/23	11/19/23	Complete	Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy
2023-HB-MED-340	Imcivree	10/5/23	11/19/23	Complete	Imcivree
2023-HB-MED-341	Epkinly	10/5/23	11/19/23	Complete	Epkinly
2023-HB-MED-342	Xipere	10/5/23	11/19/23	Complete	Xipere
2023-HB-MED-343	Zilretta	10/5/23	11/19/23	Complete	Zilretta
2023-HB-MED-344	Yescarta	10/5/23	11/19/23	Complete	Yescarta
2023-HB-MED-345	Phesgo	10/5/23	11/19/23	Complete	Phesgo
2023-LHCC-MED-388	Pharmacy Prior Authorization and Medical Necessity	9/11/23	10/26/23	Complete	Pharmacy Prior Authorization and Medical Necessity
2023-UHC-MED-169	Maximum Dosage	9/8/23	10/23/23	Complete	Maximum Dosage
2023-LHCC-MED-386	Epcoritamab-bysp (Epkinly)	9/6/23	10/21/23	Complete	Epcoritamab-bysp (Epkinly)
2023-LHCC-MED-387	Glofitamab-gxbm (Columvi)	9/6/23	10/21/23	Complete	Glofitamab-gxbm (Columvi)
2023-LHCC-MED-291	Baclofen (Feqsuvy, Gablofen, Lioresal, Lyvispah, Ozobax)	9/6/23	10/21/23	Complete	Baclofen (Feqsuvy, Gablofen, Lioresal, Lyvispah, Ozobax)
2023-LHCC-MED-327	Azacitidine (Onureg, Vidaza)	9/6/23	10/21/23	Complete	Azacitidine (Onureg, Vidaza)
2023-LHCC-MED-345	Sildenafil (Revatio)	9/6/23	10/21/23	Complete	Sildenafil (Revatio)
2023-LHCC-MED-384	Rolapitant (Varubi)	9/6/23	10/21/23	Complete	Rolapitant (Varubi)
2023-LHCC-MED-279	Interferon Gamma-1b (Actimmune)	8/28/23	10/12/23	Complete	Interferon Gamma-1b (Actimmune)
2023-LHCC-MED-284	Eculizumab (Soliris)	8/28/23	10/12/23	Complete	Eculizumab (Soliris)
2023-LHCC-MED-293	Agalsidase beta (Fabrazyme)	8/28/23	10/12/23	Complete	Agalsidase beta (Fabrazyme)
2023-LHCC-MED-304	Epoprostenol (Flolan, Veletri)	8/28/23	10/12/23	Complete	Epoprostenol (Flolan, Veletri)
2023-LHCC-MED-336	Ravulizumab-cwvz (Ultomiris)	8/28/23	10/12/23	Complete	Ravulizumab-cwvz (Ultomiris)
2023-LHCC-MED-367	Asfotase Alfa (Strensiq)	8/28/23	10/12/23	Complete	Asfotase Alfa (Strensiq)
2023-LHCC-MED-372	Cerliponase alfa (Brineura)	8/28/23	10/12/23	Complete	Cerliponase alfa (Brineura)
2023-LHCC-MED-373	Edaravone (Radicava)	8/28/23	10/12/23	Complete	Edaravone (Radicava)
2023-LHCC-MED-382	Patisiran (Onpattro)	8/28/23	10/12/23	Complete	Patisiran (Onpattro)
2023-LHCC-MED-383	Inotersen (Tegsidi)	8/28/23	10/12/23	Complete	Inotersen (Tegsidi)
2023-HB-MED-317	Adcetris	8/24/23	10/8/23	Complete	Adcetris
2023-HB-MED-318	Polivy	8/24/23	10/8/23	Complete	Polivy
2023-HB-MED-319	Torisel	8/24/23	10/8/23	Complete	Torisel
2023-HB-MED-320	Doxorubicin liposome	8/24/23	10/8/23	Complete	Doxorubicin liposome
2023-HB-MED-321	Jevtana	8/24/23	10/8/23	Complete	Jevtana
2023-HB-MED-322	Libtayo	8/24/23	10/8/23	Complete	Libtayo
2023-HB-MED-324	Rituximab Agents for Oncologic Indications	8/24/23	10/8/23	Complete	Rituximab Agents for Oncologic Indications
2023-HB-MED-325	Zynyz	8/24/23	10/8/23	Complete	Zynyz
2023-HB-MED-326	Provenge	8/24/23	10/8/23	Complete	Provenge
2023-HB-MED-327	Rituximab agents for Non-Oncologic Indications	8/24/23	10/8/23	Complete	Rituximab agents for Non-Oncologic Indications
2023-HB-MED-328	Rybrevant	8/24/23	10/8/23	Complete	Rybrevant
2023-LHCC-MED-366	Olaratumab (Lartruvo)	8/16/23	9/30/23	Complete	Olaratumab (Lartruvo)
2023-LHCC-MED-368	Siltuximab (Sylvant)	8/16/23	9/30/23	Complete	Siltuximab (Sylvant)
2023-LHCC-MED-369	Protein C Concentrate Human (Ceprotin)	8/16/23	9/30/23	Complete	Protein C Concentrate Human (Ceprotin)
2023-LHCC-MED-370	Pasireotide (Signifor, Signifor LAR)	8/16/23	9/30/23	Complete	Pasireotide (Signifor, Signifor LAR)
2023-LHCC-MED-371	Avelumab (Bavencio)	8/16/23	9/30/23	Complete	Avelumab (Bavencio)
2023-LHCC-MED-375	Daunorubicin-cytarabine (Vyxeos)	8/16/23	9/30/23	Complete	Daunorubicin-cytarabine (Vyxeos)
2023-LHCC-MED-376	Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas)	8/16/23	9/30/23	Complete	Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas)
2023-LHCC-MED-377	Copanlisib (Aliqopa)	8/16/23	9/30/23	Complete	Copanlisib (Aliqopa)
2023-LHCC-MED-378	Gemtuzumab (Mylotarg)	8/16/23	9/30/23	Complete	Gemtuzumab (Mylotarg)
2023-LHCC-MED-379	Inotuzumab Ozogamicin (Besponsa)	8/16/23	9/30/23	Complete	Inotuzumab Ozogamicin (Besponsa)
2023-LHCC-MED-380	Tisagenlecleucel (Kymriah)	8/16/23	9/30/23	Complete	Tisagenlecleucel (Kymriah)
2023-LHCC-MED-344	Burosumab-twza (Crysvita)	8/16/23	9/30/23	Complete	Burosumab-twza (Crysvita)
2023-LHCC-MED-346	Mitoxantrone	8/16/23	9/30/23	Complete	Mitoxantrone
2023-LHCC-MED-349	Irinotecan Liposome (Onivyde)	8/16/23	9/30/23	Complete	Irinotecan Liposome (Onivyde)
2023-LHCC-MED-350	Obinutuzumab (Gazyva)	8/16/23	9/30/23	Complete	Obinutuzumab (Gazyva)
2023-LHCC-MED-353	Belinostat (Beleodaq)	8/16/23	9/30/23	Complete	Belinostat (Beleodaq)
2023-LHCC-MED-355	Pralatrexate (Folotyn)	8/16/23	9/30/23	Complete	Pralatrexate (Folotyn)
2023-LHCC-MED-356	Romidepsin (Istodax)	8/16/23	9/30/23	Complete	Romidepsin (Istodax)
2023-LHCC-MED-357	Vincristine Liposome (Marqibo)	8/16/23	9/30/23	Complete	Vincristine Liposome (Marqibo)
2023-LHCC-MED-358	Cabazitaxel (Jevtana)	8/16/23	9/30/23	Complete	Cabazitaxel (Jevtana)
2023-LHCC-MED-360	Eribulin mesylate (Halaven)	8/16/23	9/30/23	Complete	Eribulin mesylate (Halaven)
2023-LHCC-MED-361	Necitumumab (Portrazza)	8/16/23	9/30/23	Complete	Necitumumab (Portrazza)
2023-LHCC-MED-362	Panitumumab (Vectibix)	8/16/23	9/30/23	Complete	Panitumumab (Vectibix)
2023-LHCC-MED-363	Plerixafor (Mozobil)	8/16/23	9/30/23	Complete	Plerixafor (Mozobil)
2023-LHCC-MED-364	Temsirolimus (Torisel)	8/16/23	9/30/23	Complete	Temsirolimus (Torisel)
2023-LHCC-MED-365	Ziv-afibercept (Zaltrap)	8/16/23	9/30/23	Complete	Ziv-afibercept (Zaltrap)
2023-LHCC-MED-329	Pegvisomant (Somavert)	8/16/23	9/30/23	Complete	Pegvisomant (Somavert)
2023-LHCC-MED-330	Lanreotide (Somatuline Depot)	8/16/23	9/30/23	Complete	Lanreotide (Somatuline Depot)
2023-LHCC-MED-331	Leucovorin Injection	8/16/23	9/30/23	Complete	Leucovorin Injection
2023-LHCC-MED-332	Cemiplimab-rwlc (Libtayo)	8/16/23	9/30/23	Complete	Cemiplimab-rwlc (Libtayo)
2023-LHCC-MED-333	Moxetumomab psaudotox-tdfk (Lumoxiti)	8/16/23	9/30/23	Complete	Moxetumomab psaudotox-tdfk (Lumoxiti)
2023-LHCC-MED-334	Emapalumab-lzsg (Gamifant)	8/16/23	9/30/23	Complete	Emapalumab-lzsg (Gamifant)
2023-LHCC-MED-335	Bortezomib (Velcade)	8/16/23	9/30/23	Complete	Bortezomib (Velcade)
2023-LHCC-MED-337	Dexrazoxane (Totect)	8/16/23	9/30/23	Complete	Dexrazoxane (Totect)
2023-LHCC-MED-338	Elapegademase-lvlr (Revcovi)	8/16/23	9/30/23	Complete	Elapegademase-lvlr (Revcovi)
2023-LHCC-MED-339	Fam-trastuzumab deruxtecan-nxki (Enhertu)	8/16/23	9/30/23	Complete	Fam-trastuzumab deruxtecan-nxki (Enhertu)
2023-LHCC-MED-340	Efgartigimod Alfa-fcab (Vyvgart)	8/16/23	9/30/23	Complete	Efgartigimod Alfa-fcab (Vyvgart)
2023-LHCC-MED-315	Brentuximab Vedotin (Adcetris)	8/16/23	9/30/23	Complete	Brentuximab Vedotin (Adcetris)
2023-LHCC-MED-316	Bendamustine (Belrapzo, Bendeka, Treanda, Vivimusta)	8/16/23	9/30/23	Complete	Bendamustine (Belrapzo, Bendeka, Treanda, Vivimusta)
2023-LHCC-MED-317	Daratumumab Daratumumab-Hyaluronidase fihj (Darzalex, Faspro)	8/16/23	9/30/23	Complete	Daratumumab Daratumumab-Hyaluronidase fihj (Darzalex, Faspro)
2023-LHCC-MED-318	Ipilimumab (Yervoy)	8/16/23	9/30/23	Complete	Ipilimumab (Yervoy)
2023-LHCC-MED-320	Durvalumab (Imfinzi)	8/16/23	9/30/23	Complete	Durvalumab (Imfinzi)
2023-LHCC-MED-321	Axicabtagene ciloleucel (Yescarta)	8/16/23	9/30/23	Complete	Axicabtagene ciloleucel (Yescarta)
2023-LHCC-MED-322	Pemetrexed (Alimta, Pemfexy)	8/16/23	9/30/23	Complete	Pemetrexed (Alimta, Pemfexy)
2023-LHCC-MED-323	Triamcinolone ER injection (Zilretta)	8/16/23	9/30/23	Complete	Triamcinolone ER injection (Zilretta)
2023-LHCC-MED-324	Voretigene Neparvovec-rzyl (Luxturna)	8/16/23	9/30/23	Complete	Voretigene Neparvovec-rzyl (Luxturna)
2023-LHCC-MED-325	Eteclacalcetide (Parsabiv)	8/16/23	9/30/23	Complete	Eteclacalcetide (Parsabiv)
2023-LHCC-MED-326	Lutetium Lu 177 Dotatate (Lutathera)	8/16/23	9/30/23	Complete	Lutetium Lu 177 Dotatate (Lutathera)
2023-LHCC-MED-328	Chloramphenicol Sodium Succinate	8/16/23	9/30/23	Complete	Chloramphenicol Sodium Succinate
2023-LHCC-MED-298	Paclitaxel protein-bound (Abraxane)	8/15/23	9/29/23	Complete	Paclitaxel protein-bound (Abraxane)
2023-LHCC-MED-299	Hemin (Panhematin)	8/15/23	9/29/23	Complete	Hemin (Panhematin)
2023-LHCC-MED-300	Aflibercept (Eylea)	8/15/23	9/29/23	Complete	Aflibercept (Eylea)
2023-LHCC-MED-301	Ranibizumab (Lucentis, Susvimo), Lucentis Biosimilars	8/15/23	9/29/23	Complete	Ranibizumab (Lucentis, Susvimo), Lucentis Biosimilars
2023-LHCC-MED-302	Verteporfin (Visudyne)	8/15/23	9/29/23	Complete	Verteporfin (Visudyne)
2023-LHCC-MED-303	Ibandronate injection (Boniva)	8/15/23	9/29/23	Complete	Ibandronate injection (Boniva)
2023-LHCC-MED-305	Belatacept (Nulojix)	8/15/23	9/29/23	Complete	Belatacept (Nulojix)
2023-LHCC-MED-306	Cosyntropin (Cortrosyn)	8/15/23	9/29/23	Complete	Cosyntropin (Cortrosyn)
2023-LHCC-MED-307	Trabectedin (Yondelis)	8/15/23	9/29/23	Complete	Trabectedin (Yondelis)
2023-LHCC-MED-308	Pertuzumab (Perjeta)	8/15/23	9/29/23	Complete	Pertuzumab (Perjeta)
2023-LHCC-MED-309	Trastuzumab Biosimilars Trastuzumab-Hyaluronidase	8/15/23	9/29/23	Complete	Trastuzumab Biosimilars Trastuzumab-Hyaluronidase
2023-LHCC-MED-310	Ado-trastuzumab (Kadcyla)	8/15/23	9/29/23	Complete	Ado-trastuzumab (Kadcyla)
2023-LHCC-MED-312	Atezolizumab (Tecentriq)	8/15/23	9/29/23	Complete	Atezolizumab (Tecentriq)
2023-LHCC-MED-313	Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela)	8/15/23	9/29/23	Complete	Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela)
2023-LHCC-MED-314	Erwinia Asparaginase (Erwinaze, Rylaze)	8/15/23	9/29/23	Complete	Erwinia Asparaginase (Erwinaze, Rylaze)
2023-LHCC-MED-277	Hyaluronate Derivatives	8/15/23	9/29/23	Complete	Hyaluronate Derivatives
2023-LHCC-MED-278	Octreotide Acetate (Sandostatin, Sandostatin LAR, Bynfezia, Mycapssa)	8/15/23	9/29/23	Complete	Octreotide Acetate (Sandostatin, Sandostatin LAR, Bynfezia, Mycapssa)
2023-LHCC-MED-281	Collagenase (Xiaflex)	8/15/23	9/29/23	Complete	Collagenase (Xiaflex)
2023-LHCC-MED-282	Alpha 1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira)	8/15/23	9/29/23	Complete	Alpha 1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira)
2023-LHCC-MED-283	Thyrotropin alfa (Thyrogen)	8/15/23	9/29/23	Complete	Thyrotropin alfa (Thyrogen)
2023-LHCC-MED-285	Omecetaxine (Synribo)	8/15/23	9/29/23	Complete	Omecetaxine (Synribo)
2023-LHCC-MED-286	Ramucirumab (Cyramza)	8/15/23	9/29/23	Complete	Ramucirumab (Cyramza)
2023-LHCC-MED-287	Sipuleucel-T (Provenge)	8/15/23	9/29/23	Complete	Sipuleucel-T (Provenge)
2023-LHCC-MED-289	Mogamulizumab-kpkc (Poteligeo)	8/15/23	9/29/23	Complete	Mogamulizumab-kpkc (Poteligeo)
2023-LHCC-MED-290	Deferoxamine (Desferal)	8/15/23	9/29/23	Complete	Deferoxamine (Desferal)
2023-LHCC-MED-292	Levoleucovorin (Fusilev, Khapzory)	8/15/23	9/29/23	Complete	Levoleucovorin (Fusilev, Khapzory)
2023-LHCC-MED-294	Sebelipase alfa (Kanuma)	8/15/23	9/29/23	Complete	Sebelipase alfa (Kanuma)
2023-LHCC-MED-295	Alglucosidase (Lumizyme)	8/15/23	9/29/23	Complete	Alglucosidase (Lumizyme)
2023-LHCC-MED-296	Ferumoxytol (Feraheme)	8/15/23	9/29/23	Complete	Ferumoxytol (Feraheme)
2023-LHCC-MED-297	Degarelix (Firmagon)	8/15/23	9/29/23	Complete	Degarelix (Firmagon)
2023-PHARM-67	POS Continuous Glucose Monitors	8/14/23	9/28/23	Complete	POS Continuous Glucose Monitors
2023-HUMANA-MED-25	Louisiana Medicaid NDC Requirement	8/14/23	9/28/23	Complete	Louisiana Medicaid NDC Requirement
2023-UHC-MED-159	Site of Care	8/2/23	9/16/23	Completed	Site of Care
2023-HUMANA-MED-18	Frequency Limitation for Vedolizumab	8/2/23	9/16/23	Complete	Frequency Limitation for Vedolizumab
2023-HUMANA-MED-19	Octreotide	8/2/23	9/16/23	Complete	Octreotide
2023-HUMANA-MED-20	Vedolizumab	8/2/23	9/16/23	Complete	Vedolizumab
2023-HUMANA-MED-21	Infliximab units per date of service	8/2/23	9/16/23	Complete	Infliximab units per date of service
2023-HUMANA-MED-22	Golimumab	8/2/23	9/16/23	Complete	Golimumab
2023-HUMANA-MED-23	Infliximab 10mg, and biosimilars	8/2/23	9/16/23	Complete	Infliximab 10mg, and biosimilars
2023-HUMANA-MED-24	Arformoterol	8/2/23	9/16/23	Complete	Arformoterol
2023-LHCC-MED-186	Polatuzumab Vedotin-piiq (Polivy)	8/2/23	9/16/23	Complete	Polatuzumab Vedotin-piiq (Polivy)
2023-LHCC-MED-191	Enfortumab Vedotin-ejfv (Padcev)	8/2/23	9/16/23	Complete	Enfortumab Vedotin-ejfv (Padcev)
2023-LHCC-MED-194	Teprotumumab (Tepezza)	8/2/23	9/16/23	Complete	Teprotumumab (Tepezza)
2023-LHCC-MED-199	Sacituzumab govitecan-hziy (Trodelvy)	8/2/23	9/16/23	Complete	Sacituzumab govitecan-hziy (Trodelvy)
2023-LHCC-MED-205	Setmelanotide (Imcivree)	8/2/23	9/16/23	Complete	Setmelanotide (Imcivree)
2023-LHCC-MED-211	Sultimlimab-jome (Enjaymo)	8/2/23	9/16/23	Complete	Sultimlimab-jome (Enjaymo)
2023-LHCC-MED-212	Antithymocyte Globulin (Atgam, Thymoglobulin)	8/2/23	9/16/23	Complete	Antithymocyte Globulin (Atgam, Thymoglobulin)
2023-LHCC-MED-246	Faricimab (Vabysmo)	8/2/23	9/16/23	Complete	Faricimab (Vabysmo)
2023-LHCC-MED-255	Tofersen (Qalsody)	8/2/23	9/16/23	Complete	Tofersen (Qalsody)
2023-LHCC-MED-256	Beremagene Geperpavec (Vyjuvek)	8/2/23	9/16/23	Complete	Beremagene Geperpavec (Vyjuvek)
2023-LHCC-MED-263	Trofinetide (Daybue)	8/2/23	9/16/23	Complete	Trofinetide (Daybue)
2023-HB-MED-299	Imfinzi	8/2/23	9/16/23	Complete	Imfinzi
2023-HB-MED-300	Cyramza	8/2/23	9/16/23	Complete	Cyramza
2023-HB-MED-301	Vidaza	8/2/23	9/16/23	Complete	Vidaza
2023-HB-MED-302	Carelon MSK Joint Surgery and Spine Codes	8/2/23	9/16/23	Complete	Carelon MSK Joint Surgery and Spine Codes
2023-HB-MED-303	Asparagine Specific Enzymes	8/2/23	9/16/23	Complete	Asparagine Specific Enzymes
2023-HB-MED-304	Trastuzumab Agents	8/2/23	9/16/23	Complete	Trastuzumab Agents
2023-HB-MED-305	Iron Agents	8/2/23	9/16/23	Complete	Iron Agents
2023-HB-MED-306	Bavencio	8/2/23	9/16/23	Complete	Bavencio
2023-HB-MED-307	Blincyto	8/2/23	9/16/23	Complete	Blincyto
2023-HB-MED-308	Kyprolis	8/2/23	9/16/23	Complete	Kyprolis
2023-HB-MED-309	Besponsa	8/2/23	9/16/23	Complete	Besponsa
2023-HB-MED-310	Enhertu	8/2/23	9/16/23	Complete	Enhertu
2023-HB-MED-311	Yervoy	8/2/23	9/16/23	Complete	Yervoy
2023-HB-MED-312	Erbitux	8/2/23	9/16/23	Complete	Erbitux
2023-HB-MED-313	Synribo	8/2/23	9/16/23	Complete	Synribo
2023-HB-MED-314	Vectibix	8/2/23	9/16/23	Complete	Vectibix
2023-HB-MED-315	Velcade	8/2/23	9/16/23	Complete	Velcade
2023-HB-MED-316	VEGF Inhibitors	8/2/23	9/16/23	Complete	VEGF Inhibitors
2023-UHC-MED-160	Qalsody	8/2/23	9/16/23	Completed	Qalsody
2023-UHC-MED-161	Immune Globulin IVIG	8/2/23	9/16/23	Completed	Immune Globulin IVIG
2023-UHC-MED-162	Medical Therapies for Enzyme Deficiencies	8/2/23	9/16/23	Completed	Medical Therapies for Enzyme Deficiencies
2023-UHC-MED-163	Syfovre	8/2/23	9/16/23	Completed	Syfovre
2023-UHC-MED-165	Scenesse	8/2/23	9/16/23	Completed	Scenesse
2023-UHC-MED-166	Intravenous Iron Replacement Therapy	8/2/23	9/16/23	Completed	Intravenous Iron Replacement Therapy
2023-UHC-MED-167	Rebyota	8/2/23	9/16/23	Completed	Rebyota
2023-PHARM-41	Aduhelm Form	8/2/23	9/16/23	Complete	Aduhelm Form
2023-PHARM-42	Alzheimer's Agents	8/2/23	9/16/23	Complete	Alzheimer's Agents
2023-PHARM-43	Antimigraine - CGRP Antagonists	8/2/23	9/16/23	Complete	Antimigraine - CGRP Antagonists
2023-PHARM-44	Continuous Glucose Monitors	8/2/23	9/16/23	Complete	Continuous Glucose Monitors
2023-PHARM-45	Cystic Fibrosis Agents	8/2/23	9/16/23	Complete	Cystic Fibrosis Agents
2023-PHARM-46	Cytokine/CAM Antagonists	8/2/23	9/16/23	Complete	Cytokine/CAM Antagonists
2023-PHARM-47	ICD-10 Chart	8/2/23	9/16/23	Complete	ICD-10 Chart
2023-PHARM-48	Leqembi Criteria	8/2/23	9/16/23	Complete	Leqembi Criteria
2023-PHARM-49	Leqembi Form	8/2/23	9/16/23	Complete	Leqembi Form
2023-PHARM-50	Lipotropics, Other	8/2/23	9/16/23	Complete	Lipotropics, Other
2023-PHARM-51	Movement Disorders	8/2/23	9/16/23	Complete	Movement Disorders
2023-PHARM-52	POS Altuviiio	8/2/23	9/16/23	Complete	POS Altuviiio
2023-PHARM-53	POS Antipsychotic, Injectable	8/2/23	9/16/23	Complete	POS Antipsychotic, Injectable
2023-PHARM-54	POS Benign Prostatic Hyperplasia	8/2/23	9/16/23	Complete	POS Benign Prostatic Hyperplasia
2023-PHARM-55	POS Daybue	8/2/23	9/16/23	Complete	POS Daybue
2023-PHARM-56	POS Elfabrio	8/2/23	9/16/23	Complete	POS Elfabrio
2023-PHARM-57	POS Joenja	8/2/23	9/16/23	Complete	POS Joenja
2023-PHARM-58	POS Lamzede	8/2/23	9/16/23	Complete	POS Lamzede
2023-PHARM-59	POS Movement Disorders	8/2/23	9/16/23	Complete	POS Movement Disorders
2023-PHARM-60	POS Proton Pump Inhibitors	8/2/23	9/16/23	Complete	POS Proton Pump Inhibitors
2023-PHARM-61	POS Pulmonary Arterial Hypertension	8/2/23	9/16/23	Complete	POS Pulmonary Arterial Hypertension
2023-PHARM-62	POS Qalsody	8/2/23	9/16/23	Complete	POS Qalsody
2023-PHARM-63	POS Relyvrio	8/2/23	9/16/23	Complete	POS Relyvrio
2023-PHARM-64	Sogroya	8/2/23	9/16/23	Complete	Sogroya
2023-PHARM-65	Tzield	8/2/23	9/16/23	Complete	Tzield
2023-PHARM-66	Vowst	8/2/23	9/16/23	Complete	Vowst
2023-PHARM-41	Antiemetic/Antivertigo Agents	8/1/23	N/A	Completed	Antiemetic/Antivertigo AgentsImminent Peril Justification
2023-LHCC-MED-208	Brixadi	7/7/23	8/21/23	Completed	Brixadi
2023-LHCC-MED-227	Melphalan flufenamide (Pepaxto)	7/7/23	8/21/23	Completed	Melphalan flufenamide (Pepaxto)
2023-LHCC-MED-228	Ophthalmic Riboflavin (Photrexa, Photrexa viscous)	7/7/23	8/21/23	Completed	Ophthalmic Riboflavin (Photrexa, Photrexa viscous)
2023-LHCC-MED-229	Loncastuximab tesirine-lpyl (Zynlonta)	7/7/23	8/21/23	Completed	Loncastuximab tesirine-lpyl (Zynlonta)
2023-LHCC-MED-230	Dostarlimab-gxly (Jemperli)	7/7/23	8/21/23	Completed	Dostarlimab-gxly (Jemperli)
2023-LHCC-MED-232	Talimogene laherparepvec (Imlygic)	7/7/23	8/21/23	Completed	Talimogene laherparepvec (Imlygic)
2023-LHCC-MED-233	Amivantamab-vmjw (Rybrevant)	7/7/23	8/21/23	Completed	Amivantamab-vmjw (Rybrevant)
2023-LHCC-MED-236	Vutrisiran (Amvuttra)	7/7/23	8/21/23	Completed	Vutrisiran (Amvuttra)
2023-LHCC-MED-237	Tisotumab vedotin-tftv (Tivdak)	7/7/23	8/21/23	Completed	Tisotumab vedotin-tftv (Tivdak)
2023-LHCC-MED-238	Allogenic processed thymus tissue-agdc (Rethymic)	7/7/23	8/21/23	Completed	Allogenic processed thymus tissue-agdc (Rethymic)
2023-LHCC-MED-239	Antithrombin III (ATryn, Thrombate III)	7/7/23	8/21/23	Completed	Antithrombin III (ATryn, Thrombate III)
2023-LHCC-MED-241	Ropeginterferon alfa-2b-njft (Besremi)	7/7/23	8/21/23	Completed	Ropeginterferon alfa-2b-njft (Besremi)
2023-LHCC-MED-243	Sirolimus Protein-bound Particles (Fyarro)	7/7/23	8/21/23	Completed	Sirolimus Protein-bound Particles (Fyarro)
2023-LHCC-MED-244	Tebentafusp-tebn (Kimmtrak)	7/7/23	8/21/23	Completed	Tebentafusp-tebn (Kimmtrak)
2023-LHCC-MED-247	Lutetium Lu 177 vipivotide tetraxetan (Pluvicto)	7/7/23	8/21/23	Completed	Lutetium Lu 177 vipivotide tetraxetan (Pluvicto)
2023-LHCC-MED-248	Sodium Phenylbutyrate-Taurursodiol (Relyvrio)	7/7/23	8/21/23	Completed	Sodium Phenylbutyrate-Taurursodiol (Relyvrio)
2023-LHCC-MED-250	Olipudase alfa-rpcp (Xenpozyme)	7/7/23	8/21/23	Completed	Olipudase alfa-rpcp (Xenpozyme)
2023-LHCC-MED-252	Nivolumab and Relatlimab (Opdualag)	7/7/23	8/21/23	Completed	Nivolumab and Relatlimab (Opdualag)
2023-LHCC-MED-267	Furosemide (Furoscix)	7/7/23	8/21/23	Completed	Furosemide (Furoscix)
2023-LHCC-MED-269	Sodium Thiosulfate (Pedmark)	7/7/23	8/21/23	Completed	Sodium Thiosulfate (Pedmark)
2023-LHCC-MED-270	Teclistamab-cqyv (Tecvayli)	7/7/23	8/21/23	Completed	Teclistamab-cqyv (Tecvayli)
2023-LHCC-MED-271	Tremelimumab-actl (Imjudo)	7/7/23	8/21/23	Completed	Tremelimumab-actl (Imjudo)
2023-LHCC-MED-272	Fecal microbiota, live-jslm (Rebyota)	7/7/23	8/21/23	Completed	Fecal microbiota, live-jslm (Rebyota)
2023-LHCC-MED-275	Mirvetuximab soravtansine-gynx (Elahere)	7/7/23	8/21/23	Completed	Mirvetuximab soravtansine-gynx (Elahere)
2023-LHCC-MED-276	Mosunetuzumab-axgb (Lunsumio)	7/7/23	8/21/23	Completed	Mosunetuzumab-axgb (Lunsumio)
2023-LHCC-MED-185	Metreleptin (Myalept)	7/6/23	8/20/23	Completed	Metreleptin (Myalept)
2023-LHCC-MED-187	Bremelanotide (Vyleesi)	7/6/23	8/20/23	Completed	Bremelanotide (Vyleesi)
2023-LHCC-MED-188	Valrubicin (Valstar)	7/6/23	8/20/23	Completed	Valrubicin (Valstar)
2023-LHCC-MED-189	Afamelanotide (Scenesse)	7/6/23	8/20/23	Completed	Afamelanotide (Scenesse)
2023-LHCC-MED-190	Brolucizumab (Beovu)	7/6/23	8/20/23	Completed	Brolucizumab (Beovu)
2023-LHCC-MED-192	Iobenguane I 131 (Azedra)	7/6/23	8/20/23	Completed	Iobenguane I 131 (Azedra)
2023-LHCC-MED-193	Nadofaragene firadenovec-vncg (Adstiladrin)	7/6/23	8/20/23	Completed	Nadofaragene firadenovec-vncg (Adstiladrin)
2023-LHCC-MED-196	Belantamab mafodotin (Blenrep)	7/6/23	8/20/23	Completed	Belantamab mafodotin (Blenrep)
2023-LHCC-MED-197	Brexucabtagene autoleucel (Tecartus)	7/6/23	8/20/23	Completed	Brexucabtagene autoleucel (Tecartus)
2023-LHCC-MED-200	Ferric Derisomaltose (Monoferric)	7/6/23	8/20/23	Completed	Ferric Derisomaltose (Monoferric)
2023-LHCC-MED-201	Idecabtagene vicleucel (Abecma)	7/6/23	8/20/23	Completed	Idecabtagene vicleucel (Abecma)
2023-LHCC-MED-202	Isatuximab-irfc (Sarclisa)	7/6/23	8/20/23	Completed	Isatuximab-irfc (Sarclisa)
2023-LHCC-MED-203	Lisocabtagene maraleucel (Breyanzi)	7/6/23	8/20/23	Completed	Lisocabtagene maraleucel (Breyanzi)
2023-HB-MED-284	Tecentriq	7/6/23	8/20/23	Completed	Tecentriq
2023-HB-MED-285	Trodelvy	7/6/23	8/20/23	Completed	Trodelvy
2023-HB-MED-286	Keytruda	7/6/23	8/20/23	Completed	Keytruda
2023-HB-MED-287	Docetaxel	7/6/23	8/20/23	Completed	Docetaxel
2023-HB-MED-288	Sarclisa	7/6/23	8/20/23	Completed	Sarclisa
2023-HB-MED-289	Abraxane	7/6/23	8/20/23	Completed	Abraxane
2023-HB-MED-290	Ixempra	7/6/23	8/20/23	Completed	Ixempra
2023-HB-MED-291	Lunsumio	7/6/23	8/20/23	Completed	Lunsumio
2023-HB-MED-292	Kadcyla	7/6/23	8/20/23	Completed	Kadcyla
2023-HB-MED-293	Darzalex	7/6/23	8/20/23	Completed	Darzalex
2023-HB-MED-294	Mylotarg	7/6/23	8/20/23	Completed	Mylotarg
2023-HB-MED-295	Opdivo	7/6/23	8/20/23	Completed	Opdivo
2023-HB-MED-296	Gazyva	7/6/23	8/20/23	Completed	Gazyva
2023-HB-MED-297	Perjeta	7/6/23	8/20/23	Completed	Perjeta
2023-HB-MED-298	Empliciti	7/6/23	8/20/23	Completed	Empliciti
2023-LHCC-MED-204	Bimatoprost implant (Durysta)	7/6/23	8/20/23	Completed	Bimatoprost implant (Durysta)
2023-LHCC-MED-207	Mitomycin for Pyelocalyceal Solution (Jelmyto)	7/6/23	8/20/23	Completed	Mitomycin for Pyelocalyceal Solution (Jelmyto)
2023-LHCC-MED-209	Lurbinectedin (Zepzelca)	7/6/23	8/20/23	Completed	Lurbinectedin (Zepzelca)
2023-LHCC-MED-210	Petruzumab-trastuzumab-hyaluronidate-zzxf (Phesgo)	7/6/23	8/20/23	Completed	Petruzumab-trastuzumab-hyaluronidate-zzxf (Phesgo)
2023-LHCC-MED-213	Tafasitamab-cxix (Monjuvi)	7/6/23	8/20/23	Completed	Tafasitamab-cxix (Monjuvi)
2023-LHCC-MED-216	Plasminogen (Ryplazim)	7/6/23	8/20/23	Completed	Plasminogen (Ryplazim)
2023-LHCC-MED-218	Avalglucosidate alfa-ngpt (Nexviazyme)	7/6/23	8/20/23	Completed	Avalglucosidate alfa-ngpt (Nexviazyme)
2023-LHCC-MED-219	Margetuximab-cmkb (Margenza)	7/6/23	8/20/23	Completed	Margetuximab-cmkb (Margenza)
2023-LHCC-MED-220	Naxitamab-gqgk (Danyelza)	7/6/23	8/20/23	Completed	Naxitamab-gqgk (Danyelza)
2023-LHCC-MED-222	Fibrinogen concentrate (human) (Fibryga, RiaSTAP)	7/6/23	8/20/23	Completed	Fibrinogen concentrate (human) (Fibryga, RiaSTAP)
2023-LHCC-MED-225	Ciltacabtagene Autoleucel (Carvykti)	7/6/23	8/20/23	Completed	Ciltacabtagene Autoleucel (Carvykti)
2023-LHCC-MED-174	Immunization Coverage	7/5/23	8/19/23	Completed	Immunization Coverage
2023-LHCC-MED-175	Imiglucerase (Cerezyme)	7/5/23	8/19/23	Completed	Imiglucerase (Cerezyme)
2023-LHCC-MED-177	Ferric Gluconate (Ferrlecit)	7/5/23	8/19/23	Completed	Ferric Gluconate (Ferrlecit)
2023-LHCC-MED-178	Treprostinil (Remodulin)	7/5/23	8/19/23	Completed	Treprostinil (Remodulin)
2023-LHCC-MED-179	Dornase alfa (Pulmozyme)	7/5/23	8/19/23	Completed	Dornase alfa (Pulmozyme)
2023-LHCC-MED-180	Desmopressin (DDAVP, Stimate,  Nocdurna)	7/5/23	8/19/23	Completed	Desmopressin (DDAVP, Stimate, Nocdurna)
2023-LHCC-MED-181	Parathyroid Hormone (Natpara)	7/5/23	8/19/23	Completed	Parathyroid Hormone (Natpara)
2023-LHCC-MED-182	Ofatumumab (Arzerra)	7/5/23	8/19/23	Completed	Ofatumumab (Arzerra)
2023-LHCC-MED-183	Testosterone (Testopel)	7/5/23	8/19/23	Completed	Testosterone (Testopel)
2023-LHCC-MED-184	Corticosteroids for ophthalmic injection  (Xipere)	7/5/23	8/19/23	Completed	Corticosteroids for ophthalmic injection  (Xipere)
2023-UHC-MED-152	Self-administered Medications C&S	6/15/23	7/30/23	Completed	Self-administered Medications C&S
2023-UHC-MED-158	Tepezza	6/15/23	7/30/23	Completed	Tepezza
2023-HB-MED-264	Prior authorization requirement changes	6/12/23	7/27/23	Completed	Prior authorization requirement changes
2023-UHC-MED-149	Somatostatin analogs	5/30/23	7/14/23	Completed	Somatostatin analogs
2023-UHC-MED-150	IV Enzyme replacement therapy for Gaucher disease	5/30/23	7/14/23	Completed	IV Enzyme replacement therapy (ERT) for Gaucher disease
2023-UHC-MED-153	Crysvita	5/30/23	7/14/23	Completed	Crysvita
2023-UHC-MED-154	Tzield	5/30/23	7/14/23	Completed	Tzield
2023-UHC-MED-155	Rituximab	5/30/23	7/14/23	Completed	Rituximab
2023-UHC-MED-156	Maximum dosage and frequency	5/30/23	7/14/23	Completed	Maximum dosage and frequency
2023-PHARM-40	Hemgenix	5/16/23	6/30/23	Completed	Hemgenix
2023-PHARM-33	Heart Disease - Anticoagulants	5/16/23	6/30/23	Completed	Heart Disease - Anticoagulants
2023-PHARM-34	Hyperlipidemia - Lipotropics, Other	5/16/23	6/30/23	Completed	Hyperlipidemia - Lipotropics, Other
2023-PHARM-35	Multiple Sclerosis Agents	5/16/23	6/30/23	Completed	Multiple Sclerosis Agents
2023-PHARM-36	PDL	5/16/23	6/30/23	Completed	PDL
2023-PHARM-37	POS Multiple Sclerosis	5/16/23	6/30/23	Completed	POS Multiple Sclerosis
2023-PHARM-38	POS Potassium Binders	5/16/23	6/30/23	Completed	POS Potassium Binders
2023-PHARM-39	Potassium Binders	5/16/23	6/30/23	Completed	Potassium Binders
2023-Humana-MED-16	Frequency limitation for ocrelizumab	5/11/23	6/25/23	Completed	Frequency limitation for ocrelizumab
2023-Humana-MED-17	Frequency limitation for golimumab	5/11/23	6/25/23	Completed	Frequency limitation for golimumab
2023-HB-MED-283	Quarterly Pharmacy Formulary Change	5/10/23	6/24/23	Completed	Quarterly Pharmacy Formulary Change
2023-PHARM-24	Amjevita	5/10/23	6/24/23	Completed	Amjevita
2023-PHARM-25	Antifungals, Oral	5/10/23	6/24/23	Completed	Antifungals, Oral
2023-PHARM-26	Briumvi	5/10/23	6/24/23	Completed	Briumvi
2023-PHARM-27	Cytokine/CAM Antagonists	5/10/23	6/24/23	Completed	Cytokine/CAM Antagonists
2023-PHARM-28	Hereditary Angioedema	5/10/23	6/24/23	Completed	Hereditary Angioedema
2023-PHARM-29	ICD-10 Chart	5/10/23	6/24/23	Completed	ICD-10 Chart
2023-PHARM-30	POS Diabetes - Incretin Mimetics	5/10/23	6/24/23	Completed	POS Diabetes - Incretin Mimetics
2023-PHARM-31	POS Pulmonary Arterial Hypertension	5/10/23	6/24/23	Completed	POS Pulmonary Arterial Hypertension
2023-PHARM-32	Stimufend	5/10/23	6/24/23	Completed	Stimufend
2023-LHCC-MED-173	Glycopyrronium (Qbrexza)	5/4/23	6/18/23	Completed	Glycopyrronium (Qbrexza)
2023-HB-MED-273	Zilretta	5/4/23	6/18/23	Completed	Zilretta
2023-HB-MED-275	Imfinzi	5/4/23	6/18/23	Completed	Imfinzi
2023-HB-MED-276	Xenpozyme	5/4/23	6/18/23	Completed	Xenpozyme
2023-HB-MED-277	Bevacizumab	5/4/23	6/18/23	Completed	Bevacizumab
2023-HB-MED-278	IV Iron Med Step Therapy	5/4/23	6/18/23	Completed	IV Iron Med Step Therapy
2023-HB-MED-279	Trastuzumab agents	5/4/23	6/18/23	Completed	Trastuzumab agents
2023-HB-MED-280	Rituximab Agents for Non-Oncologic Indications	5/4/23	6/18/23	Completed	Rituximab Agents for Non-Oncologic Indications
2023-HB-MED-281	Elahere	5/4/23	6/18/23	Completed	Elahere
2023-HB-MED-282	Rituximab Agents for Oncologic Indications	5/4/23	6/18/23	Completed	Rituximab Agents for Oncologic Indications
2023-ACLA-MED-62	HCPCS PA List	4/24/23	6/8/23	Completed	HCPCS PA List
2023-HB-MED-265	VEGF Inhibitors	4/24/23	6/8/23	Completed	VEGF Inhibitors
2023-HB-MED-266	Adcetris	4/24/23	6/8/23	Completed	Adcetris
2023-HB-MED-267	Imjudo	4/24/23	6/8/23	Completed	Imjudo
2023-HB-MED-268	Relizorb	4/24/23	6/8/23	Completed	Relizorb
2023-HB-MED-269	Libtayo	4/24/23	6/8/23	Completed	Libtayo
2023-HB-MED-270	Tecentriq	4/24/23	6/8/23	Completed	Tecentriq
2023-UHC-MED-148	Monoclonal Antibodies Directed Against Amyloid for AD	4/24/23	6/8/23	Completed	Monoclonal Antibodies Directed Against Amyloid for AD
2023-ACLA-MED-54	VEGF Inhibitor for Ophthalmic Conditions	4/24/23	6/8/23	Completed	VEGF Inhibitor for Ophthalmic Conditions
2023-ACLA-MED-55	Continuous Glucose Monitors	4/24/23	6/8/23	Completed	Continuous Glucose Monitors
2023-ACLA-MED-56	Blincyto	4/24/23	6/8/23	Completed	Blincyto
2023-ACLA-MED-57	Anti-CD19 CAR-T Immunotherapies	4/24/23	6/8/23	Completed	Anti-CD19 CAR-T Immunotherapies
2023-ACLA-MED-58	Alpha 1 Proteinase Inhibitors	4/24/23	6/8/23	Completed	Alpha 1 Proteinase Inhibitors
2023-ACLA-MED-59	Tzield	4/24/23	6/8/23	Completed	Tzield
2023-ACLA-MED-61	ACFC Safety Edit Exception Criteria	4/24/23	6/8/23	Completed	ACFC Safety Edit Exception Criteria
2023-UHC-MED-133	Buprenorphine-Probuphine	3/23/23	5/7/23	Completed	Buprenorphine-Probuphine
2023-HB-MED-263	LA Quarterly Rx Formulary Change Notice	3/14/23	4/28/23	Completed	LA Quarterly Rx Formulary Change Notice
2023-UHC-MED-141	Denosumab (Prolia, Xgeva)	2/16/23	4/2/23	Completed	Denosumab (Prolia, Xgeva)
2023-UHC-MED-142	Botulinum toxins a and B	2/16/23	4/2/23	Completed	Botulinum toxins a and B
2023-UHC-MED-143	Spevigo	2/16/23	4/2/23	Completed	Spevigo
2023-UHC-MED-144	Tzield	2/16/23	4/2/23	Completed	Tzield
2023-UHC-MED-145	Review at launch new to market medications	2/16/23	4/2/23	Completed	Review at launch new to market medications
2023-UHC-MED-146	RNA Targeted Therapies (Amvuttra, Onpattro)	2/16/23	4/2/23	Completed	RNA Targeted Therapies (Amvuttra, Onpattro)
2023-UHC-MED-147	Maximum Dosage policy	2/16/23	4/2/23	Completed	Maximum Dosage policy
2023-ACLA-PHARM-51	Continuous Glucose Monitors	2/16/23	4/2/23	Completed	Continuous Glucose Monitors
2023-HB-MED-251	Keytruda	2/16/23	4/2/23	Completed	Keytruda
2023-HB-MED-252	Hyaluronan Injections	2/16/23	4/2/23	Completed	Hyaluronan Injections
2023-HB-MED-253	Tzield	2/16/23	4/2/23	Completed	Tzield
2023-HB-MED-254	Imjudo	2/16/23	4/2/23	Completed	Imjudo
2023-HB-MED-255	Danyelza	2/16/23	4/2/23	Completed	Danyelza
2023-HB-MED-256	Ethyol	2/16/23	4/2/23	Completed	Ethyol
2023-HB-MED-257	Spevigo	2/16/23	4/2/23	Completed	Spevigo
2023-HB-MED-258	Tecartus	2/16/23	4/2/23	Completed	Tecartus
2023-HB-MED-259	Abecma	2/16/23	4/2/23	Completed	Abecma
2023-HB-MED-260	Aliqopa	2/16/23	4/2/23	Completed	Aliqopa
2023-HB-MED-261	Tecvayli	2/16/23	4/2/23	Completed	Tecvayli
2034-HB-MED-262	Pedmark	2/16/23	4/2/23	Completed	Pedmark
2023-LHCC-MED-158	Pemetrexed (Alimta, Pemfexy)	2/15/23	4/1/23	Completed	Pemetrexed (Alimta, Pemfexy)
2023-PHARM-1	Atopic Dermatitis Immunomodulators	2/6/23	3/23/23	Completed	Atopic Dermatitis Immunomodulators
2023-PHARM-2	CGRP Antagonists	2/6/23	3/23/23	Completed	CGRP Antagonists
2023-PHARM-3	Colony Stimulating Factors	2/6/23	3/23/23	Completed	Colony Stimulating Factors
2023-PHARM-4	Cytokine/CAM Antagonists	2/6/23	3/23/23	Completed	Cytokine/CAM Antagonists
2023-PHARM-5	Fylnetra	2/6/23	3/23/23	Completed	Fylnetra
2023-PHARM-6	Hemgenix	2/6/23	3/23/23	Completed	Hemgenix
2023-PHARM-7	Hyftor	2/6/23	3/23/23	Completed	Hyftor
2023-PHARM-8	ICD-10 Chart	2/6/23	3/23/23	Completed	ICD-10 Chart
2023-PHARM-9	Kuvan/Javygtor	2/6/23	3/23/23	Completed	Kuvan/Javygtor
2023-PHARM-10	Oxlumo	2/6/23	3/23/23	Completed	Oxlumo
2023-PHARM-11	POS Antipsychotic Agents - Injectable	2/6/23	3/23/23	Completed	POS Antipsychotic Agents - Injectable
2023-PHARM-12	POS CGRP Antagonists	2/6/23	3/23/23	Completed	POS CGRP Antagonists
2023-PHARM-13	POS Chorionic Gonadotropin	2/6/23	3/23/23	Completed	POS Chorionic Gonadotropin
2023-PHARM-14	POS Firdapse	2/6/23	3/23/23	Completed	POS Firdapse
2023-PHARM-15	POS Opiate Dependence	2/6/23	3/23/23	Completed	POS Opiate Dependence
2023-PHARM-16	POS Pulmonary Arterial Hypertension	2/6/23	3/23/23	Completed	POS Pulmonary Arterial Hypertension
2023-PHARM-17	POS Xenpozyme	2/6/23	3/23/23	Completed	POS Xenpozyme
2023-PHARM-18	POS Ztalmy	2/6/23	3/23/23	Completed	POS Ztalmy
2023-PHARM-19	Rolvedon	2/6/23	3/23/23	Completed	Rolvedon

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